Harborview Health Center West Altamonte

Inspectors wroteBased on interview, and record review, the facility failed to ensure implementation of their Quality Assurance and Performance Improvement (QAPI) program by failing to obtain feedback and data to identify issues and concerns with facility systems, as well as opportunities for improvement.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the resident's representative was informed of a change in condition for 2 of 2 residents reviewed for change in condition, (#1, and #4), and failed to notify the physician of the change in condition which had the potential to delay medical evaluation and treatment for 1 of 2 residents reviewed for notification of changes, (#4) .

Inspectors wroteBased on interview, and record review, the facility failed to ensure the baseline care plan was effectively implemented to include a plan for staff to provide effective and person-centered care, for 2 of 2 residents reviewed for respiratory care, (#1, and #3), and failed to ensure the resident or representative received a summary of the baseline care plan with the required information, for 1 of 2 residents reviewed for baseline care plans, (#1), of a total sample of 4 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan to address oxygen use which placed the resident at risk for potential respiratory complications, for 1 of 1 residents reviewed for Comprehensive Assessment, of a total sample of 4 residents, (#2).

Inspectors wroteBased on interview, and record review, the facility failed to maintain complete, accurate, and consistent clinical records, compromising the reliability of the clinical record and the ability to ensure appropriate assessment, treatment, and continuity of care for 2 of 2 residents reviewed for resident records, of a total sample of 4 residents, (#1, #4).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide immediate and thorough nursing assessment and treatment services related to burns for 1 of 2 residents, (#27), and failed to obtain an order for treatment and date a treatment dressing for 1 of 2 residents reviewed for pressure wounds, (#84), of a total sample of 37 residents. The facility's failure to ensure a complete and timely assessment including accurate identification of burns resulted in actual harm. Resident #27 was transferred to a higher level of care initially for treatment and was transferred again to another hospital with a specialized burn unit. Resident #27 was admitted to the stepdown trauma unit with second degree burns to her left arm, left hand, abdomen and left thigh. She remained there for 5 days.

Inspectors wroteBased on interview and record review the facility failed to prevent an avoidable accident for a resident by not checking the temperature of microwaved noodles provided by staff for 1 of 2 residents reviewed for accidents, of a total sample of 37 residents, (#27). The facility's failure to provide a policy and ensure all staff were educated regarding the heating and reheating of resident food resulted in actual harm. Resident #27 was transferred to a higher level of care, then transferred again to another hospital with a specialized burn unit. Resident #27 was admitted to the stepdown trauma unit with second degree burns to her left arm, left hand, abdomen and left thigh. She remained in the hospital for 5 days.

Inspectors wroteBased on interview, and record review, the facility failed to provide a policy or training to staff regarding reheating of food for residents. This lack of instruction caused the resident to receive second degree burns when her food was heated in the microwave, for 1 of 1 resident reviewed for burns, of a total sample of 39 residents, (#27).

Inspectors wroteBased on observation, interview, and record review the facility failed to treat residents with dignity and care to promote quality of life by standing while feeding them and referring to residents as feeders for 2 of 6 residents reviewed for assisted dining, of a total sample of 37, (#15 and #29).

Inspectors wroteBased on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) Level I evaluation was completed, (#33), and failed to request a Level I and/or Level II PASARR evaluation after a new major mental disorder diagnosis, (#65), for 2 of 2 residents reviewed for PASARR, of a total sample of 37.

Inspectors wroteBased on interview, record review, and facility's policy review, the facility failed to ensure care and services consistent with professional standards of practice to prevent pressure ulcers was provided, by failing to follow physician's order for weekly skin sweeps for 1 of 4 residents reviewed for pressure ulcer, of a total sample of 37 residents, (#42).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory therapy was provided as per physician orders for 1 out of 1 resident reviewed for respiratory care, of a total sample of 37 residents, (#93).

Inspectors wroteBased on observation, interview, and record review the facility failed to follow proper infection control practices to prevent cross-contamination during wound care for 1 of 1 resident reviewed for pressure ulcers, of a total sample of 37 residents, (#33).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a call device to allow residents to call for staff assistance for 2 of 18 residents observed for call lights, of a total sample of 37, (#30 and 55).

Inspectors wroteBased on interview and record review the facility failed to provide showers as scheduled, and as per resident's preference for 2 of 2 dependent residents reviewed for Activities of Daily Living (ADL), of a total sample of 6 residents, (#1, and #5).

Inspectors wroteBased on interview and record review, the facility failed to develop and implement appropriate interventions to include provision of adequate supervision to prevent a fall with major injury for 1 of 1 resident reviewed for accidents, of a total sample of 31 residents, (#11). The facility's failure to increase supervision for a resident with a history of repeated falls resulted in actual harm for resident #11.

Inspectors wroteBased on interview and record review, the facility failed to implement its policies and procedures to prevent Neglect related to investigation of a fall with major injury for 1 of 1 resident reviewed for accidents, from a total sample of 31 residents, (#11).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow pharmaceutical procedures to ensure proper administration and accurate documentation of medications for 1 of 5 residents reviewed for medication administration, of a total sample of 31 residents, (#81).

Inspectors wroteBased on record review and interview, the facility failed to ensure pharmacy recommendations that resulted from monthly Medication Regimen Reviews (MRRs) were addressed and signed by the physician for 2 of 5 residents reviewed for Unnecessary Medications, of a total sample of 31 residents, (#66 & #78).