Idaho State Veterans Home - Lewiston

Inspectors wroteBased on record review, staff interview, review of facility procedure and review of the Minimum Data Set (MDS) Resident Assessment Instrument (RAI) procedure, the facility failed to ensure the discharge and/or entry tracking records were complete as required for four (Resident (R)2, R21, R1, R22) of four residents reviewed for hospitalization. This failure had the potential to inaccurately identify a resident as receiving care in the facility after they had been admitted to the hospital, which could affect reimbursement and quality measures.

Inspectors wroteBased on interview, record review, review of facility procedure and review of the Resident Assessment Instrument (RAI), the facility failed to ensure the Minimum Data Set (MDS) accurately reflected the restraint status of five (Resident (R)20, R32, R3, R5, and R34) of five residents reviewed for restraint use out of a total sample of 18. These failures created a potential for an incomplete or ineffective plan of care related to bedrail/siderail and restraint use.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure one out of 18 sampled residents (Resident (R)32) was treated with dignity. R32's catheter bag, attached to his leg, was observed with urine in it for several hours while the resident was in the common areas with multiple residents and staff, and while attending an activity. Staff failed to intervene to ensure the catheter bag was covered. This created the potential for R32 and other residents to feel undignified.

Inspectors wroteBased on policy review, record review, review of the State Survey Agency's Long Term Care Reporting Portal, and resident and staff interview, it was determined the facility failed to ensure residents were free from abuse. This was true for 1 of 12 residents (Resident #25) reviewed for abuse. This deficient practice placed Resident #25 in immediate jeopardy of serious harm, impairment, or death when the facility did not protect him from physical and sexual abuse from Resident #52.

Inspectors wroteBased on policy review, record review, review of the the State Agency's Long Term Care Reporting Portal, and staff interview, it was determined the facility failed to ensure an allegation of resident abuse was reported to the State Survey Agency within 2 hours. This affected 1 of 12 residents (Resident #25) who were reviewed for abuse. This failure created the potential for residents to be subjected to ongoing abuse without detection and protective measures implemented by the facility.

Inspectors wroteBased on policy review, record review, review of the State Survey Agency's Long Term Care Reporting Portal, and staff interview, it was determined the facility failed to ensure allegations of abuse were thoroughly investigated. This was true for 1 of 12 residents (Resident #25) reviewed for abuse. This failure placed Resident #25 at risk for the potential of more than minimal harm when the facility did not protect him from physical and sexual abuse from Resident #52. This deficiency also created the potential for all residents residing in the facility to be subjected to ongoing abuse without detection and protective measures implemented by the facility.

Inspectors wroteBased on staff interview, record review, facility policy review, Incident and Accident Report review, Grievance Log review, and State Survey Agency Reportable Incidents Database review, it was determined the facility failed to ensure allegations of abuse were investigated and written allegations of abuse were not altered to minimize the severity of the allegations. This was true for 1 of 15 residents (Resident #3) reviewed for abuse. The health and safety of all residents residing in the facility were placed in immediate jeopardy when a) Resident #3 was at risk of ongoing abuse by facility staff and b) the other 56 residents residing in the facility were at risk of being subjected to abuse without detection and intervention.

Inspectors wroteBased on staff interview, record review, policy review, grievance log review, and review of Incident and Accident reports, it was determined the facility failed to ensure its policies were implemented to protect residents from potential physical abuse. This was true for 1 of 15 residents (Resident #3) reviewed for abuse. This deficient practice placed Resident #3, and the other 56 residents residing in the facility, at risk for physical and/or psychosocial harm.

Inspectors wroteBased on record review, observation, staff interview, and policy review, it was determined the facility failed to ensure specific target behaviors were identified and monitored for residents receiving psychotropic medications. This was true for 4 of 4 residents (#10, #36, #37, and #53) reviewed for psychotropic medications. This failed practice created the potential for harm should residents receive psychotropic medications that were unnecessary or ineffective.

Inspectors wroteBased on record review, staff interview, and policy review, it was determined the facility failed to ensure residents' care plans were revised as care needs changed. This was true for 1 of 2 residents (#108) reviewed for care plan revision and had the potential for harm if cares and/or services were not provided due to inaccurate information.

Inspectors wroteBased on observation, resident and staff interview, record review, and policy review, it was determined the facility failed to ensure residents were provided with bathing consistent with their needs. This was true for 1 of 15 (#7) residents reviewed for bathing. This failure created the potential for residents to experience embarrassment, a decreased sense of self-worth, skin impairment and compromised physical and psychosocial well-being.

Inspectors wroteBased on observation, staff interview, record review, and policy review, it was determined the facility failed to ensure professional standards of care were followed for 2 of 2 residents (#38 and #57) reviewed for transfers and respiratory care. These failed practices placed residents at risk of falls and adverse effects from inhaled medications.

Inspectors wroteBased on record review, observation, and staff interview, it was determined the facility failed to ensure bed rail consents were in place prior to the use of bed rails. This was true for 3 of 3 residents (#3, #36, and #55) reviewed for bed rail use. This failure created the potential for harm as it prevented the resident and/or resident representative's ability to make informed decisions related to the risk and benefits for bed rails.

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to ensure expired medications were removed from the medication cart and not available for administration to residents. This was true for 1 of 2 medication carts. This failed practice created the potential for adverse effects if residents received expired medications with decreased efficacy.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure infection control measures were consistently implemented and followed. This was true for 2 of 15 residents (#34 and #36) observed for infection prevention practices. This failure created the potential for harm by potentially exposing residents to the risk of infection and cross contamination.