Intermountain Health Holy Rosary Hospital

Inspectors wroteBased on interview and record review, the facility neglected to ensure resident-specific care plan interventions were implemented requiring use of a gait belt and continuous physical support during transfers. for 1 (#1) of 3 residents sampled for falls. The failure resulted in the resident sustaining an uncontrolled fall with increased pain requiring emergency department evaluation and subsequent transition to palliative care for pain management.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of possible neglect involving 1 (#1) of 3 residents sampled for abuse and neglect was reported to the State Survey Agency within the required timeframe. The facility's failure delayed notification to the State Survey Agency and the agency's ability to determine whether additional oversight or investigation was warranted.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical director or his designee attended and/or participated in the Quality Assurance (QA) program at least quarterly. This deficient practice increased the risk of negative outcomes for residents with respect to quality assessment and assurance activities. The facility reported a census of 54 residents.

Inspectors wroteBased on interview and record review, the facility failed to provide required effective communication training to all direct care staff. This deficient practice had the potential to affect the care of all residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide required dementia training to include management of dementia related behaviors to all staff. This deficient practice had the potential to affect the care of residents with dementia health needs in the facility.

Inspectors wroteBased on interview and record review, the facility failed to report investigation findings to the State Survey Agency (SSA) within the required timeframe of 5 working days for 4 (#s 21, 29, 44, and 62) of 25 sampled and supplemental residents.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate allegations of abuse, failed to prevent further potential abuse, and failed to report the results of the investigation to the State Survey Agency (SSA) to verify corrective actions were taken for allegations of resident-to-resident abuse for 2 (#s 29 and 44); and the facility failed to document a thorough investigation of multiple elopements and identify the root-cause of the elopements for 3 (#s 21, 61, and 62) of 25 sampled and supplemental residents. These failures had the potential to cause the facility to miss key parts of the investigation and prevent further elopements or injuries to the residents and increased the risk for more than minimal harm by creating an environment that perpetuates a disrespectful situation between residents.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient supervision and interventions to prevent an elopement for 4 (#s 21, 38, 61, and 62) of 23 sampled residents, which led to a fall with minor injury for resident #62.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure a comprehensive grievance process was operationalized and followed effectively by staff for the resolution of a grievance related to the provision of personal resident care, for 1 (#5) of 23 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure pain was routinely assessed, and medication was given according to a physician's order for 1 (#3) of 23 sampled residents; this deficient practice had the potential for the resident to experience increased pain.

Inspectors wroteBased on interview and record review, the facility failed to implement a consistent antibiotic stewardship program, including infection surveillance and mapping, to identify trending of the locations of infections. This deficient practice increased the risk of a negative outcome related to residents taking antibiotics for infections and increased the incidence of adverse events associated with infections throughout the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe environment, free from elopements, for 4 (#s 16, 17, 18, and 24), and the facility failed to provide an environment free from accidents and hazards for 1 (#42) of 18 sampled and supplemental residents. This deficient practice had the potential to adversely affect the well-being and safety of all residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide COVID-19 vaccinations for 3 (#s 6, 17, and 35) of 14 sampled residents, and failed to document staff declinations and education regarding the COVID-19 vaccine for 2 (staff members M and N) of 2 sampled staff members.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide education and information to the residents or responsible party on the risks and benefits of psychotropic medication, so they were able to make an informed decision, and the facility did not have documentation to show the resident/responsible party consented to the use of the medications, for 3 (#s 6, 18, and 39) of 18 sampled and supplemental residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to review the risks and benefits of using a transfer rail, attached to the bed, for the resident and failed to obtain an informed consent prior to the installation of the transfer rail for 1 (#48) of 14 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide written notice of bed-hold information, which included the reserve bed payment amount, for 4 (#s 8, 35, 39, and 151) of 18 sampled and supplemental residents. The notice also failed to five the resident or responsible party the opportunity to select either to pay the reserve bed hold cost or no bed hold.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify root causes for falls, update care plans with interventions to prevent falls, and to decrease the risk for recurring falls, for 3 (#s 3, 271, and 109) of 5 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive, person-centered care plans, for 4 (#s 3, 21, 23, and 34) of 23 sampled residents. The failure had the potential to result in inadequate care and a lack of provision of services for the residents identified.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff were adequately trained, and a policy developed and implemented, for staff to follow and adhere to the infection control precautions and processes for the identified residents, for 3 (#s 7, 9 and 46) of 6 sampled residents, with catheters, gastric tubes, or wounds; and, the facility/staff failed to follow CDC recommendations for the precautions implemented by the facility. 1. During an observation on 2/13/24 at 3:19 p.m., staff member E was observed donning an isolation gown prior to entering resident #46's room. Staff member E stated she was planning to turn resident #46 onto his side. During an interview on 2/14/24 at 8:56 a.m., staff member J stated, We gown up for cares on anyone with a stomach tube or catheter because they are at higher risk (for infection). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately reflect the dental status on the Annual MDS assessment, for 1 (#3) of 6 sampled residents investigated for nutrition concerns.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient ADL assistance during mealtime, for 1 (#21) of 1 resident sampled for ADL concerns.

Inspectors wroteBased on observation, interview, and record review, facility staff failed to follow fall risk interventions identified and documented on the resident's care plan, for 1 (#21) of 23 sampled residents. This deficient practice increased the risk for falls for the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate staff cueing and assistance during meals for 1 (#21) of 5 residents sampled for nutrition concerns. This deficient practice contributed to, along with fluid retention, the resident's weight loss over five months.

Inspectors wroteBased on interview and record review, facility staff failed to identify and offer the necessary trauma services to maintain the highest practicable well-being, for 1 (#34) of 1 sampled resident, who had a diagnosis of post-traumatic stress disorder (PTSD).