Idaho State Veterans Home - Pocatello

Inspectors wroteBased on policy review, record review, and staff interview, it was determined the facility failed to ensure residents and their representative received assistance to exercise their right to formulate an Advance Directive. This was true for 10 of 54 residents (#1, #2, #4, #9, #19, #26, #27, #29, #46, and #55) whose records were reviewed for advance directives. This deficient practice created the potential for harm or adverse outcomes if the residents' wishes were not followed or documented regarding their advance care planning.

Inspectors wroteBased on the facility Bowel Management Protocol, record review and staff interview, it was determined the facility failed to follow the facility bowel care standing order of delivering specific medications when residents do not have BM within 72 hours for 5 of 16 Residents (#5, #9, #11, #26, and #35) who records were reviewed for bowel and bladder care. This failed practice created the potential for residents to experience discomfort when medications were not administered according to the physician's order.

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to treat each resident with respect and dignity. This was true for 1 of 4 residents (Residents #19) observed for covered urinary drainage bag. This deficient practice had the potential for residents to experience embarrassment, and low feelings of self-worth.

Inspectors wroteBased on policy review, record review, and staff interview, it was determined the facility failed to ensure resident's rights to be free from abuse were protected. This was true for 1 of 1 resident (Resident #61) whose record was reviewed for resident-to-resident abuse. This failure placed residents at risk for potential abuse and potential physical and psychosocial harm.

Inspectors wroteBased on review of the Resident Assessment Instrument (RAI), record review, and staff interview, the facility failed to ensure residents Minimum Data Set (MDS) had correct assessment information. This was true for 1 of 16 residents (Resident #46) reviewed for accuracy of MDS assessments. This deficient practice created the potential for residents to have their mental health needs not met due to inaccurate assessments.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to refer residents for further evaluation when residents were diagnosed with a major mental illness. This was true for 1 of 16 residents (Resident #35) reviewed for Pre-admission Screening and Resident Review (PASARR) Level II evaluations. This deficient practice had the potential to cause harm if residents' specialized services for mental health needs were not evaluated by an appropriate state-designated authority.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the resident's comprehensive person-centered care plan. This was true for 2 of 16 residents (#9 and #35) whose care plans were reviewed. This deficient practice of not following care plans placed residents at risk to their health and wellbeing with negative outcomes if services were not provided or provided incorrectly.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure accurate use of over the counter (OTC) medication left at bedside, and controlled medications were tracked and kept secure from potential theft and/or diversion. This was true for 1 of 16 residents (Resident #55) and the facility. This failure created the potential for undetected misuse of medications and/or diversion of controlled medications and had the potential to affect all residents who received medication in the facility.

Inspectors wroteBased on observations, and staff interviews it was determined the facility failed to ensure medications were stored and kept secure, and biologicals were labeled when opened. This was true for 1 of 16 Residents (Resident #46) and the facility. These deficient practices created the potential for theft or misuse of medication and the use of expired biologicals.

Inspectors wroteBased on observation, staff interview, and record review it was determined the facility failed to ensure infection control prevention practices were maintained to provide a safe and sanitary environment. This was true for 4 of 16 residents (#9, #21, #22, and #36) and the facility observed for infection control. These failures put residents at risk for cross contamination and infection.

Inspectors wroteBased on a facility reported investigation, policy review, and staff interview, the facility failed to ensure an allegation of sexual abuse was reported to the State Agency within two hours. This was true for 1 of 18 residents (Resident #149) reviewed for abuse. This failure resulted in Resident #149's allegation of sexual abuse not being acted on in a timely manner, investigated, and measures implemented to protect residents during the investigation, which placed all residents in the facility at risk of abuse.

Inspectors wroteBased on record review, facility investigation report, and resident and staff interview, it was determined the facility failed to ensure physician orders were followed for pain medication administration and a respiratory treatment. This was true for 1 of 18 residents (Resident #18) reviewed for quality of care. These failures created the potential to adversely affect Resident #18 whose care and services were not delivered according to physician orders.

Inspectors wroteBased on observation, policy review, record review, and resident and staff interview, it was determined the facility failed to ensure alternatives to bed rails were attempted or were assessed for use of bed rails prior to placing bed rails on the residents' bed. This was true for 2 of 2 residents (#33 and #34) reviewed for bed rails. This failure created the potential for harm due to the risk of entrapment and injury.

Inspectors wrote4. Resident #38 was readmitted to the facility on [DATE], with multiple diagnoses including heart disease and congestive heart failure. A progress note, dated 8/6/19 at 12:30 PM, documented verbal communication from the physician to send Resident #38 to the hospital via emergent transport for evaluation and treatment. A progress note, dated 8/6/19 at 1:30 PM, documented Resident #38 was sent to the hospital ER for unresponsiveness, inability to follow commands, weakness, and bradypnea (abnormally slow breathing), after consulting with Resident #38's Durable Power of Attorney. Resident #38's record did not include documentation the required information was provided to the hospital to ensure a safe and effective transition of care. [...]

Inspectors wroteBased on observation, record review, policy review, and resident and staff interview, it was determined the facility failed to ensure the physician was notified when a resident's oxygen saturation (percentage of oxygen in the blood) was below prescribed parameters. This was true for 1 of 5 residents (Resident #37) reviewed for oxygen therapy, and created the potential for harm should the resident experience adverse consequences from lack of physician notification and intervention.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure bruises of unknown origin in suspicious areas of a resident's body were reported to the Administrator and State Survey Agency within 2 hours of when the bruises were identified by facility staff. This was true for 1 of 1 resident (Resident #31) reviewed for injuries of unknown origin. This failure created the potential harm if the injuries of unknown origin on Resident #31's thigh and breast were a result of abuse.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure bruises of unknown origin in suspicious areas of a resident's body were investigated. This was true for 1 of 1 resident (Resident #31) reviewed for injuries of unknown origin. This failure created the potential for Resident #31 to experience undetected abuse.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure residents' care plans were updated to accurately reflect their code status. This was true for 1 of 15 residents (Resident #37) whose care plans were reviewed. This failure created the potential for life sustaining treatment to be administer or withheld, contrary to residents wishes should they become incapacitated.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure the discharge summary included a reconciliation of residents' medications. This was true for 1 of 1 resident (Resident #61) reviewed for discharge from the facility. This failure created the potential for harm and inappropriate care due to incomplete documentation.

Inspectors wroteBased on policy review, record review, and staff interview, it was determined the facility failed to ensure professional standards of practice were maintained related to neurological assessments being completed following unwitnessed falls. This was true for 1 of 15 residents (Resident #44) reviewed for falls. These failures created the potential for harm if changes in residents' neurological status went undetected and untreated after falls.

Inspectors wroteBased on record review, review of Incident Reports, and staff interviews, it was determined the facility failed to ensure interventions were developed and implemented, and sufficient supervision was provided, to prevent resident falls. This was true for 1 of 2 residents (Resident #44) reviewed for falls. This failure placed Resident #44 at risk of bone fractures, brain damage, and other life changing injuries when she experienced a total of 7 unwitnessed falls in the facility in 42 days, 6 occurring within 15 days.

Inspectors wroteBased on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure the administration of oxygen consistent with the physician's order, and to ensure the tubing for respiratory equipment included the date it was last changed. This was true for 3 of 5 residents (Resident #24, #31, and #37) reviewed who received oxygen. This placed residents at risk of adverse effects from insufficient blood oxygen levels and respiratory infections due to the growth of pathogens (organisms that cause illness) in the tubing of respiratory equipment.

Inspectors wroteBased on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure appropriate infection control measures were maintained. This was true for 2 of 15 residents (Resident #31 and #43) reviewed for infection control. This deficient practice placed residents at risk for infection due to cross contamination.