Harborview Health Center of Augusta

Inspectors wroteBased on observations, staff interviews, and review of facility policies titled, Infection Prevention and Control Program, and Laundry, the facility failed to use proper infection control practices in the laundry area, when storing wash basins on two of five halls and during the provision of tracheostomy care for one of three residents (R) (R5) reviewed with tracheostomies. The deficient practice increased the risk of cross contamination, spread of infection, and increased risk of adverse clinical outcomes.

Inspectors wroteBased on observations, staff interviews and review of facility policy titled, Preventative maintenance program, the facility failed to ensure residents were provided with a safe, clean, and comfortable environment, as evidenced by unclean Packaged Terminal Air Conditioner (PTAC) unit filters in three of nine rooms on 300 Hall (rooms [ROOM NUMBER]), two of 16 rooms on 400 Hall ( rooms [ROOM NUMBERS] ), and one of 16 rooms on the 500 hall (room [ROOM NUMBER]). This deficient practice had the potential to expose residents to poor air quality and contaminants throughout the environment. Findings Include: Review of facility policy titled, Preventive Maintenance Program. revealed 1. The maintenance director is responsible for developing and maintaining a schedule of maintenance services to ensure that the building's grounds and equipment are maintained in a safe and operable manner. 2. [...]

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility policy titled, Self-Administration of medication, the facility failed to ensure that one of 60 sampled residents (R) (R7) did not have unauthorized and unsecured medications at the bedside. This failure created the potential for medication errors and unauthorized access to medications by other residents.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled, Resident Assessment-Coordination with PASARR Program, the facility failed to assess and apply for PASARR II (Preadmission Screening and Resident Review) services for one of 60 sampled residents (R) (R1). This deficient practice had the potential for R1's mental health needs to go unmet.

Inspectors wroteBased on observations, record review, staff and resident interviews, and review of the facility policy titled, Activities of Daily Living, the facility failed to ensure that Activities of Daily Living care was provided for one dependent resident (R) (R28) related to bed baths and nail care. The deficient practice had the potential for to place R28 at risk of a diminished quality of life.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Medication Administration, the facility failed to discard expired medications on two of four medication carts reviewed. This deficient practice created the potential for expired, improperly stored medications to be used in resident care, placing residents at risk for compromised safety and potential adverse consequences.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure one of one Resident (R)107 reviewed for pain in the sample of 30 residents had his pain managed by ensuring the fentanyl transdermal patches had been available, his pain had been assessed in a consistent manner, and his physician had been notified of the missed pain management medication. This failure resulted in R107 experiencing pain when repositioned.

Inspectors wroteBased on observation and interview, the facility failed to ensure all items in the refrigerator, and freezer were sealed, labeled, and dated. These failures had the potential to affect 110 of 112 residents who received their meals from the kitchen at risk of foodborne illnesses.

Inspectors wroteBased on observation, interview, record review, review of the facility's policy titled, Medication Administration and review of the facility provided document titled Primary Pharmaceutical Provider Contract, the facility did not ensure medications were available for two of two Residents (R) (R107 and R220). This failure placed residents at risk for complications from missing medications.

Inspectors wroteBased on observation, interview, and review of the manufacturer's recommendations, the facility failed to ensure insulin pens or vials had pharmacy labels, were dated when opened, and were not used after the expiration date for two of two medication carts (100 hall and 200 hall). This deficient practice increased the risk of insulin used after the expiration date to be less effective which had the potential to cause high blood sugar levels.

Inspectors wroteBased on staff interview, record review, and review of the facility's policy titled Residents' Rights Regarding Treatment and Advance Directives, the facility failed to provide the resident and/or their representatives with written information of the right to accept or refuse medical or surgical treatment and/or formulate an advance directive for one of six Residents (R) (R59) reviewed for Advanced Directives. This failure created the potential the resident wishes would not be followed if the resident was unable to speak for themselves.

Inspectors wroteBased on observation, interview, and record review, the facility failed to update one of two Residents (R) R80 care plan interventions to include measures to prevent pressure ulcers. Specifically, R80 had acquired three pressure ulcers after readmission from the hospital and his care plan had not been revised with interventions to prevent the development of pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure one of five Residents (R) (R80) who was at risk for acquiring a pressure ulcer had preventative measures in place to avoid the development of pressure ulcers. Specifically, R80 acquired three pressure ulcers after his readmission to the facility.

Inspectors wroteBased on record review, and interviews, the facility failed to arrange podiatry services for two (residents (R) 15 and 33) of two residents reviewed in the sample of 30 residents. The facility failed to ensure at risk residents receive appropriate foot care services.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure residents respiratory equipment was maintained and stored appropriately for one of two resident (Resident (R) 83) reviewed for respiratory care out of 30 sampled residents. These failures placed the resident, who has a tracheostomy, at risk for environmental contamination which could lead to respiratory infections.

Inspectors wroteBased on observation, interview, and review of the facility's policies titled, Personal Protective Equipment and Handwashing/Hand Hygiene, the facility failed to ensure two of two staff (Certified Nursing Assistants (CNA) (CNA1 and CNA2) wore a gown and performed hand hygiene before, in-between, and after glove changes when they provided personal care to one Residents (R) (R107) who was on Enhanced Barrier Precautions (EBP); one of one Wound Care/Registered Nurse (WC/RN) failed to perform hand hygiene before, in-between, and after glove changes during wound care for R97; and two of two Certified Medication Aides (CMA) (CMA1 and CMA2) failed to sanitize the wrist blood pressure (B/P) cuffs between residents' use for R72 and R82.

Inspectors wroteBased on observation, staff interviews, and review of the facility's policies titled, Resident Rights and Confidentiality of Personal and Medical Records, the facility failed to ensure personal information was kept confidential for two residents (R) (R19 and R20) of 20 sampled residents. Specifically, the residents' medication cards containing resident information were left unattended on top of the 400-unit Medication Cart.

Inspectors wroteBased on interviews, record review, and review of the facility's policy titled Resident and Family Grievances, the facility failed to ensure their grievance procedures were followed for one of one resident (R) (R 3) reviewed for grievances of 20 sampled residents.

Inspectors wroteBased on observation, staff interviews, record review, and review of the facility's policy titled Pressure Injury/Wound Treatment Management, the facility failed to ensure that one of two Resident (R) (R 16) observed for pressure ulcer treatment, had a dressing maintained for a stage IV sacral ulcer. Specifically, there was no dressing covering R16's sacral pressure ulcer leaving it exposed to urine and feces.

Inspectors wroteBased on staff interview, record review, and review of a policy provided by the facility titled Maintenance of Clinical Records, the facility failed to ensure that clinical records were complete and contained accurate documentation for three Residents (R) (R 3, R1, and R4) out of 20 sampled residents.

Inspectors wroteBased on observations, interviews, record reviews, and review of the facility's policy titled, Resident Self-Administration of Medication, the facility failed to assess one of 20 Residents (R) (R11) receiving topical medications for wound care, for the ability to self-administer a topical medication. This failure had the potential for medication error and to alter the effectiveness of the medication.

Inspectors wroteBased on interviews and record review, the facility failed to honor reasonable accommodations for preferences related to bathing for one of 36 sampled Residents (R) (R64).

Inspectors wroteBased on observation, staff interviews, record review, and review of the policy, Comprehensive Care Plans, the facility failed to ensure one of 36 Residents (R) (R86) reviewed for care plans were followed. Specifically, the facility failed to verify placement for R86's percutaneous endoscopic gastrostomy (PEG) tube used to receive medications, fluids, and nutrition as specified in the care plan.

Inspectors wroteBased on observation, staff interview, record review, and review of the facility's policy titled Medication Administration via Enteral Tube, the facility failed to properly utilize the percutaneous endoscopic gastrostomy (PEG) tube for one of seven Residents (R) (R86) that received medications, fluids, and nutrition via (by way of) a PEG tube.