Hazel Hawkins Memorial Hospital D/P SNF

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement individualized, resident-centered care plans for 24 of 36 residents (Residents 84, 22, 28, 97, 98, 9, 60, 2, 5, 10, 50, 54, 58, 83, 91, 80, 34, 33, 41, 75, 64, 20, 66, and 6) who used bed rails or side rails (adjustable rigid bars attached to the side of a bed). These failures had the potential of unmet care needs for Residents 84, 22, 28, 97, 98, 9, 60, 2, 5, 10, 50, 54, 58, 83, 91, 80, 34, 33, 41, 75, 64, 20, 66, and 6's use of bed rails.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure food was prepared in a manner which conserved flavor and nutritive value when: 1. Lunch was ready at 9:30 a.m. and was held at hot temperature for hours prior to meal service.2. The correct texture and recipe were not followed for pureed diet. These deficient practices had the potential to result in loss of nutrients and to decrease the food intake of residents and could negatively impact their nutritional status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when:1. Registered nurse A (RN A) did not remove dirty gloves, perform hand hygiene (the act of cleaning hands with soap and water or an alcohol-based hand sanitizer to remove germs and prevent the spread of infections) and don (put on) a new pair of gloves before doing Resident 65's finger stick test (method of drawing drops of blood, most commonly used by people with high blood sugar to check their levels), and RN A did not perform hand hygiene after she picked the glove that fell on the floor and before putting on clean gloves prior to medication preparation;2. Registered nurse E (RN E) did not perform hand hygiene prior to medication administration;3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 34) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behavior) when the physician did not document the reason a gradual dose reduction (GDR, stepwise tapering of a dose to determine if conditions can be managed by a lower dose or if the medication can be discontinued altogether) was contraindicated. This failure had the potential to result in unnecessary or prolonged use of the psychotropic medication, which could increase the resident's risk of experiencing side effects (undesirable effects from the medication).

Inspectors wroteBased on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS, an assessment tool) for one of 22 sampled residents (Resident 34) when Resident 34's MDS assessment did not reflect the use of antipsychotic medication (used to treat psychosis and other mental health disorders). This failure resulted in an inaccurate MDS assessment, which had the potential to affect the resident's care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a baseline care plan to include instructions on the care of bed rails or side rails (adjustable rigid bars attached to the side of a bed) use for one (Resident 99) of 36 residents (residents with bed rails or side rails). This failure resulted in the installation and use of Resident 99's bed rails without a plan of care. This failure had the potential to result in Resident 99's serious injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the proper use of side or bed rails (adjustable rigid bars attached to the side of a bed) for four (Residents 97, 99, 100, and 3) of 36 residents (residents who used bed or side rails) when:1. The physician's orders and informed consents (a process in which patients are given important information, including possible risks and benefits, about a medical procedure or treatment) were not obtained prior to use of bed or side rails for Resident 97 and Resident 99; and,2. Resident 100 and Resident 3 used side rails without a clinically appropriate indication. These failures had the potential to place Residents 97, 99, 100, and 3 at risk of entrapment and serious injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate accountability of medications and controlled substance (drug or other substance that can be easily abused and are under strict government control) for three of 13 randomly selected residents (Residents 56, 78 and 34) when: 1. Resident 56's Azithromycin (used to treat certain bacterial infections in many different parts of the body) antibiotic was not accounted for and reconciled accurately;2. Resident 78's Sulfamethoxazole -Trimethoprim (Cotrimazole, an antibiotic medication used to treat certain infections that are caused by bacteria) was not accounted for and reconciled accurately; and3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the pharmacist's medication regimen review (MRR) recommendations for one of 22 residents (Resident 34) were followed-up and acted upon. This failure had the potential for the resident to suffer unnecessary adverse side effects that could negatively impact her physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview, and document review, the facility failed to review and/or revise their policy and procedure in compliance with federal regulations and with accepted professional standards when the facility did not revise or update their side rail policy and procedure annually. This failure had the potential to compromise residents' health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice related to pain management for one of four sampled residents (Resident 1) when Resident 1 did not receive the right dosage of oxycodone (a controlled drug used to treat moderate to severe pain) to manage severe pain to right hip. This failure had the potential to affect Resident 1's well-being.

Inspectors wroteDuring an observation on 3/11/24 at 11:27 AM, Resident 69 was observed in bed, with the two upper siderails in the raised position. Review of Resident 69's face sheet indicated Resident 69 admitted to the facility on [DATE]. Review of Resident 69's physician order, dated 4/19/23, indicated Resident 69 had an order for bilateral (both sides) upper side rails to be up when in bed for bed mobility. A review of Resident 69's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation on 3/11/24 at 10:20 AM, Resident 16 was seen lying in bed, with the two upper siderails and two lower siderails in the raised position. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement, comprehensive, resident-centered, care plans for five out of twenty sampled residents, (Residents 51, 42, 47, 43 and 82), when the activity care plans of Residents 51, 42, 47, 43 and 82, were not comprehensive and resident-centered. These failures had the potential to result in the residents not receiving the interventions necessary to maintain their highest level of well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure sanitary practices of both kitchens and their foods were stored under sanitary conditions when: 1. A wilted head of lettuce, green onion, and cut salad were stored in a refrigerator; 2. No air gap (space between the top of the drain overflow and the discharge pipe or hose to prevent back flow of contaminated water) for a dishwasher, ice machine, 3-way sink (commercial and manual dishwashing sink), and food preparation sink in kitchen; 3. The egg salad stored in a refrigerator was measured at 44.5 degrees Fahrenheit (a unit of measurement of temperature) These failures had the potential to result in food borne illnesses among residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to refer 2 of 18 sampled residents (Resident 6 and 35) to the appropriate agency for a level two PASRR (pre-admission screening and resident review, a federal requirement to help ensure individuals are not inappropriately placed in nursing homes for long term care) evaluation when 1. Resident 6's PASRR Level one was positive, and 2. Resident 35 was diagnosed with schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality) not due to a substance or known physiological condition after admission. This failure had the potential to put the residents at risk of not receiving appropriate care and services.

Inspectors wroteBased on interview and record review, the facility failed to document care consistent with professional standards of practice, to prevent pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin) from possibly getting worse for one out of six residents (Resident 238) investigated with pressure ulcer, when staff did not document whether they turned and repositioned Resident 238 every two hours, from 6/23/23 to 6/27/23. This failure resulted in the lack of documentation for whether Resident 238 was turned and repositioned.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician's orders for oxygen (a component of air essential to living organisms) rate administration for 1 of 3 sampled resident (Resident 48). This failure had the potential to compromise Resident 48's health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 5.88% when two medication errors occurred out of 34 opportunities during the medication administration for two of 12 residents (Residents 30 and 31). Both residents did not receive their medications as ordered. The failures resulted in medications not given according to the physician's orders and had the potential for them not receiving the full therapeutic effects of the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were labeled and stored appropriately when insulin (medication to lower blood sugar) pens were not labeled with an expiration date when stored at room temperature; expired medications were identified in two of two medication carts, and in two of two medication rooms; and the temperature was not being monitored and maintained twice daily for two out of two medication refrigerators as per facility policy and procedures (P&P). This failure had the potential for the insulin to be administered past the 28-day expiration date; expired medications given to the residents; and loss of drug potency due to unmonitored temperatures.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure to accommodate food dislikes for one out of three sampled residents (Resident 58). This failure had the potential for decreased meal intake and negative effects on health and well-being for Resident 58.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control practice to prevent the spread of infection when: 1. A nasal cannula (NC: a medical device to provide supplemental oxygen to residents) tubing was on the floor, and dated 3/3; 2. A Foley catheter (F/C: a semi-flexible plastic tube, one end inserted into the bladder [body organ that stores urine] and the other end is attached to a bag that collects urine) drain bag's cover touched the floor; 3. Nursing staff failed to disinfect the shared blood pressure (BP) cuff (the device used to measure BP) before and after use for Resident 82. These failures had the potential for the spread of infections and communicable diseases among residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the minimum requirement to provide 3.5 Direct Care Service Hours Per Patient Day (DHPPD, it is the total number of actual direct care service hours performed by direct caregivers per patient day divided by the average patient census) for eight days for the month of August to meet the resident's needs for one of two residents (Residents 1). This failure had the potential to affect Resident 1 and other residents ' care and wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comfortable and safe temperature level for two of three sampled residents (Resident 59, and Resident 384 ) and in hallway temperature was not maintained in the range of 71 to 81 degrees Fahrenheit. This failure had the potential for the residents to have an uncomfortable environment.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to follow proper sanitation and food handling practices when: 1. Pans were stacked and stored wet; 2. There were undated, unlabeled, and outdated food items in the reach-in refrigerator and dry storage area; and 3. Colanders were stacked and stored wet. These failures had the potential to cause food contamination and food-borne illness to 83 of 85 residents who received their food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS, an assessment tool) for two of 20 sampled residents (Residents 31 and 8). Failure to accurately assess the residents had the potential to compromise the facility's ability to develop and implement resident-centered care plans and interventions.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one of 20 sampled residents (Resident 14) when nursing staff did not apply Resident 14's left hand brace as ordered. This failure had the potential to affect the resident's care, health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three out of 12 sampled residents (Residents 5, 31, and 46) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behaviors) when: 1. Resident 5 received lorazepam (brand name: Ativan; an anti-anxiety medication) without adequate indication for use, and without a gradual dose reduction (GDR, a tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) since April 2020 (more than 2 years ago); and trazodone (medication for depression) without a GDR since August 2018 (almost for 4 years ago); 2. Resident 31 received sertraline (brand name: Zoloft; medication for depression) since April 2021 without an attempted GDR; and 3. [...]

Inspectors wroteBased on observation, interview and facility document review, the facility failed to ensure food served was palatable and attractive. These deficient practices had the potential to impact the residents' nutritional status and not meet the residents' desire to be served food they felt was palatable and attractive.