Harborview Decatur

Inspectors wroteBased on interview and record review, and review of the facility's policy titled, Comprehensive Care Plans, the facility failed to provide information on the risks and benefits of prescribed psychotropic medications for one of five Residents (R) (R165) reviewed for unnecessary medications. This failure placed residents at risk of not knowing what their medications were and potential adverse side effects.

Inspectors wroteBased on interviews, record review, and review of the facility's policy titled, Comprehensive Care Plans, the facility failed to ensure one of 35 sampled Residents (R) (R165) reviewed for care planning was afforded the right to participate in their care planning process. This failure placed residents at risk of not being aware of the goals and outcomes of their care.

Inspectors wroteBased on record review, interview, and review of the facility policy titled, Transfer and Discharge (including AMA [Against Medical Advise]), the facility failed to ensure three of nine Residents (R) (R22, R25, and R40) and/or their Resident Representative (RR or Family Member (FM) received a written notice of transfer and/or a written bed hold notice that included all required information who were reviewed for hospitalization. This failure had the potential to affect the resident and their Resident Representative (RR or FM) by not having the knowledge of where and why a resident was transferred and/or how to appeal the transfer, if desired, and contribute to the possibility of denial of re-admission and loss of the resident's home following a hospitalization for residents transferred to the hospital.

Inspectors wroteBased on observation, interview, record review, and review of the RAI (Resident Assessment Instrument) Manual, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for two of three sampled Residents (R) (R1 and R43) reviewed for Preadmission admission Screening and Resident Review (PASARR). This failure had the potential to affect the care planning and provision of needed services.

Inspectors wroteBased on interviews, record review, review of the facility's policy titled, Comprehensive Care Plans, and the Resident Assessment Instrument (RAI) manual, the facility failed to develop a comprehensive care plan with a person-centered focus, measurable goal, and resident-specific interventions for one of 35 sampled Resident (R) (R 34). Specifically, the facility failed to develop a comprehensive care plan related to post-traumatic stress disorder (PTSD) for R34. This failure placed residents at risk of increased psychosocial distress and a diminished quality of life.

Inspectors wroteBased on interviews, record review, and review of the facility's policy titled, Comprehensive Care Plans, the facility failed to ensure the comprehensive care plan was revised/updated for two of 10 Residents (R) (R24 and R34) reviewed for pressure ulcers. The facility failed to revise the Skin Integrity Care Plan when R24 and R34 developed pressure ulcers. This failure placed residents at risk of unmet care needs.

Inspectors wroteBased on observations, interviews, and review of facility's policies titled, Wound Treatment Management, and Skin Assessments, the facility failed to provide care and services related to pressure ulcers for three of 10 Residents (R) (R214, R24, and R215) reviewed for pressure ulcers. Specifically, the facility failed to ensure a skin assessment was completed prior to R214's discharge to home where it was discovered he had a buttock pressure ulcer. In addition, the facility failed to ensure a low loss air mattress (a specialized medical mattress designed to prevent and treat pressure ulcers by providing constant airflow and alternating pressure) was placed on R24 and R215's bed per the wound care physician's order. These failures placed the residents at risk of unidentified and worsening wound care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure medically related social services were provided to meet the needs of two of 35 sampled Residents (R) (R116 and R54). This failure had the potential to affect the safety and well-being of the residents and their caregivers and help prevent re-admission.

Inspectors wroteBased on interviews and record review, the facility failed to maintain a complete medical record for three of 35 sampled Residents (R) (R164, R165, and R215). The failure placed the residents at risk of unmet care needs.

Inspectors wroteBased on observations, interviews, record review, and review of the facility's policy titled, Enhanced Barrier Precautions, the facility failed to ensure staff used proper personal protective equipment (PPE) with a resident who required enhanced barrier precautions (EBP) for one of three Residents (R) (R32) observed for medication administration. The deficient practice to not perform adequate infection control practices increases the risk of cross contamination and spread of infection.

Inspectors wroteBased on observations,staff interviews, and review of the facility's policy titled, 'Maintenance Inspection, the facility failed to ensure that the environment was safe, clean, and comfortable for residents, related to disrepair of residents' rooms and restrooms.

Inspectors wroteBased on observations, resident and staff interviews, record review, and the facility's policy titled, Oxygen (O2) Administration, the facility failed to provide Medical Doctor's (MD) orders for O2, to provide humidification to the O2 concentrator, and label/date O2 tubing for one of five Residents (R) (R#59) reviewed for O2 therapy. Also, the facility failed to provide a protective plastic bag to cover the Continuous Positive Airway Pressure (CPAP) mask and tubing for one of five Residents (R) (R#216) reviewed for respiratory treatment.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled, Storage of Medications, the facility failed to ensure one of three medication carts was locked and secured when the cart was unattended and not within eyesight of a nurse. The deficient practice placed residents, staff, and visitors at risk of having unauthorized access to residents' medications.

Inspectors wroteBased on observation, resident and staff interviews, and record review, the facility failed to ensure one of four sampled residents, (R)#41, was served a vegetarian diet ordered as ordered by the Physician.