Idaho State Veterans Home - Post Falls

Inspectors wroteBased on observation, staff interview and record reviews, it was determined the facility failed to prevent the worsening of a pressure ulcer. This was true for 1 of 3 residents (Resident #1) reviewed for pressure ulcer. This deficient practice caused harm to Resident #1 when his pressure ulcer to his right heel deteriorated and became infected.

Inspectors wroteBased on observation, interviews, and record review, it was determined the facility failed to ensure resident was seen by a podiatry as ordered by the physician. This was true for 1 of 1 resident (Resident #1) reviewed for foot care. This deficient practice created the potential for Resident #1 to experience ongoing thickening of his toenails or other complications due to lack of foot care.

Inspectors wroteBased on record reviews, interviews, facility investigation, and policy review, the facility failed to ensure one of four residents (Resident (R) 4) was free from neglect when staff failed to provide timely and competent care in response to complaints of pain and decreased urinary output of 20 sample residents. As a result, R4, who had a neurogenic bladder and an indwelling catheter, experienced severe pain, and improper placement of an indwelling catheter.

Inspectors wroteBased on record review and interview, the facility failed to designate one or more qualified individuals as Infection Preventionists (IPs) who are responsible for the Infection Prevention and Control Program (IPCP) and who physically work onsite at the facility at least part-time. Failure to designate one or more qualified onsite IPs to oversee the implementation and monitoring of infection prevention practices has the potential to result in the inadequate identification, prevention, and control of infections within the facility, placing all 58 residents at increased risk for the transmission of communicable diseases and healthcare-associated infections.

Inspectors wroteBased on observation, interviews, and policy review, the facility failed to ensure expired medications were not available for use in one of one medication room reviewed for medication storage and labeling. Failure to ensure expired medications were not available for use had the potential to result in residents receiving expired medications, which may be ineffective or harmful, leading to adverse drug reactions, diminished therapeutic outcomes, and increased risk of complications or hospitalization.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure food temperatures were palatable for two out of 20 sample residents (Resident (R) 9 and R43) reviewed for palatability. This created the potential for meal dissatisfaction, decreased intake, and weight loss.

Inspectors wroteBased on observation, record review, and interview, the facility failed to honor one of one resident's (Resident (R) 43's) right to self-administer medications when clinically appropriate of 20 sample residents. Specifically, the facility did not conduct a comprehensive assessment of R43's ability to safely self-administer medications and failed to include all prescribed medications in the evaluation. When R43 did not take medications immediately upon staff offering, the medications were withheld, rather than allowing R43 to take them independently and without feeling rushed. This failure compromised R43's dignity and right to participate in decisions regarding their care.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure one of one resident reviewed for restraints (Resident (R) 2) was free of restraints of 20 sample residents. The therapy department failed to assess R2's wheelchair with seat belts in accordance with a physician's order, the facility failed to attempt less restrictive measures prior to restraint use, failed to assess and identify the belts as restraints, and failed to implement a plan to release the restraint having the potential for the resident to be at risk for negative outcomes (skin deterioration, discomfort, decreased quality of life etc.).

Inspectors wroteBased on observation, interview, record review, and procedure review, the facility failed to provide assistance with baths and shaving for one of one sample residents (Resident (R) 2) requiring substantial assistance from staff, reviewed for activities of daily living (ADLs) of 20 sample residents. This created the potential for discomfort and/or feeling unkempt.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a restorative nursing program recommended by physical therapy was implemented for one of two residents (Resident (R) 2) reviewed for range of motion of 20 sample residents. This created the potential that R2 would experience a decline in his abilities to perform activities of daily living (ADLs).

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure fall interventions were in place for one out of three residents (Resident (R) 2) reviewed for falls of 20 sample residents. Fall interventions such as mats on the floor, bed alarm, low bed, and a wedge were not consistently in place when R2 was in bed. This created the potential for significant injury from falls.

Inspectors wroteBased on observation, record review, interview, and policy review, the facility failed to ensure staff followed Enhanced Barrier Precautions (EBPs) for one of four residents (Resident (R) 8) reviewed for Transmission-Based Precautions of 20 sample residents. Failure to follow EBPs increases the potential for cross-contamination and transmission of infections to both staff and residents.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to implement an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. The facility's policy and protocols failed to address the duration of antibiotic use and address the prophylactic use of antibiotic medications. One of five residents reviewed for antibiotic medication use (Resident (R)4) failed to be assessed for continued antibiotic medication use by the nursing staff.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure one of three residents (Resident (R)23) reviewed for beneficiary notices out of a total sample of 23 residents received the Skilled Nursing Facility (SNF) Advanced Beneficiary Notice (ABN) of Non-Coverage form and/or the Notice of Medicare Non-coverage (NOMNC) form when skilled therapy was being discontinued. R23 had skilled days remaining and planned to remain in the facility. This failure did not allow R23/Representative to decide whether to continue with care that might not be paid for by Medicare and did allow for the option to file an appeal.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure that two (Residents (R)36 and R39) reviewed for abuse out of 23 sampled residents were free from resident to resident abuse.

Inspectors wroteBased on interviews, record review, and review of facility policy, the facility failed to notify the Ombudsman for one (Resident (R)24) of one resident reviewed for discharge. Specifically, the Ombudsman was never contacted and informed of R24's discharge plan.

Inspectors wroteBased on observations, interview, record review, and facility policy review, the facility failed to ensure residents who were dependent on staff for activities of daily living (ADL) assistance received services for one of three residents (Resident (R)23) reviewed for incontinence care in a total sample of 23 residents. This failure placed residents at risk for diminished self-worth, self-esteem, feelings of embarrassment, and/or medical issues.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure that one of two residents reviewed for insulin use (Resident (R)16) received nursing care and services to address hypoglycemia (low blood sugar) incidents. Specifically, there were instances in which R16's low blood sugars were either not rechecked or documented, and the Physician was not contacted according to the facility's hypoglycemia protocol. This created the potential for R16 to experience untreated hypoglycemia incidents putting her at risk for negative outcomes such as organ damage, coma, or death.

Inspectors wroteBased on interview, record review and policy review, the facility failed to ensure the needs of 1 out of 23 sampled residents (Resident (R)16) were accommodated. R16's call light was not placed within R16's reach. This created the potential for R16's physical, emotional and safety needs to be compromised.