Jackson Memorial Perdue Medical Center

Inspectors wroteF689Based on observations, record review and interviews the facility failed to provide an environment as free of accident hazards as possible for one (Resident # 45) out of two sampled residents who smoke as evidenced by observation of cigarettes and a lighter on the wheelchair in the room of Resident #45. There were 14 residents listed as smokers residing in the facility at the time of survey.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an accurate accounting of controlled substances on one of three medication carts reviewed as evidenced by two inaccurate controlled substance records identified for the North Wing's Red Medication Cart. The facility had a total of six medication carts at the time of survey.

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure kitchen staff were wearing a beard restraint. This has the potential for hair to come in contact with food.

Inspectors wroteBased on observations, interview and record review, the facility's Quality Assurance and Performance Improvement Activities (QAPI/QAA) failed to demonstrate an effective plan of action to correct repeated deficiencies in the problem area as evidenced by repeated deficient practices for F0689-Free of Accident and Hazards/Supervision/Devices and F0867; QAPI/QAA improvement activities. There were 147 residents residing in the facility at the time of survey.

Inspectors wroteBased on observations, interviews and record review, the facility failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F656 Develop/Implement Comprehensive Care Plans related to the facility failed to implement interventions of place bilateral floor mats by the bed for Resident # 78 and Resident #151 and F689 Free of Accidents Hazards/ Supervision/Devices related to the facility failure to ensure the safety measures were implemented for Resident #78, and Resident #151. there were 154 residents residing in the facility at the time of the survey.

Inspectors wroteBased on record review and interview, the facility failed to accurately code the Minimum Data Set (MDS) for one (Resident #158) out of 31 residents reviewed for resident assessments. As evidenced by inaccurate coding of MDS section for Discharge Status for Resident #158. The facility census was 154 residents at the time of the survey.

Inspectors wroteBased on record review and interview, the facility failed to accurately code the Minimum Data Set (MDS) for one (Resident #158) out of 31 residents reviewed for resident assessments. As evidenced by inaccurate coding of MDS section for Discharge Status for Resident #158. The facility census was 154 residents at the time of the survey.

Inspectors wroteBased on observation, interview and record review the facility failed to implement care plan interventions related to falls for two out of four residents reviewed (Resident #78 and Resident #151). As evidenced by, during several observations Resident #78 and #151 were in bed with only one fall mat on the floor of each resident's bedside. The findings Included: 1) Observation on 10/22/24 at 10:00 AM; Resident #78 was asleep in bed, one floor mat noted on floor next to the bed's right side. Observation on 10/23/24 at 08:02 AM; Resident #78 was asleep in bed, breakfast tray on overbed table, one floor mat noted on floor next to the bed's right side. Review of Resident #78's medical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Essential (primary) hypertension and Unspecified dementia with behavioral disturbance. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safety measures were implemented for two vulnerable residents (Resident #78 and Resident #151) out of four residents reviewed for falls. As evidenced by, during several observations Resident #78 and Resident #151 were observed in bed with only one floor mat (fall mats) on the floor of the residents' bedside. The findings Included: 1) Observation on 10/22/24 at 10:00 AM; Resident #78 was asleep in bed, one floor mat noted on floor next to the bed's right side. Observation on 10/23/24 at 08:02 AM; Resident #78 was asleep in bed, breakfast tray on overbed table, one floor mat noted on floor next to the bed's right side. Review of Resident #78's medical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: [...]

Inspectors wroteBased on observations, interviews and record review the facility failed to follow pharmacy procedure of less than 5% resulting in a of 6.25% medication error rate out of 31 opportunities; as evidenced by an observations of an inappropriate administration of a chewable form of aspirin, an omission of a magnesium 100 mg (milligram) capsule, and administration of insulin without providing privacy while another resident was in the room. There were 154 residents residing in the facility at the time of survey.

Inspectors wroteBased on observations, interviews and record review facility failed to ensure medication error rate was below 5% as evidenced by a medication error rate of 6.25% out of 31 opportunities which included an omission and an incorrect administration of a medication. There were 154 residents residing in the facility at the time of survey.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the safety and prevent bodily injury for one Resident (#1) out of 3 sampled residents and is determined to be at a level of harm, as evidenced by: Resident #1 sustaining first and second degree burns from hot coffee being spilled on the chest and abdominal area of his body. There were 153 residents residing at the facility at the time of the survey.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement care plan interventions related to bleeding precautions for two residents (#89, #93) and failed to develop and implement a comprehensive care plan related to a nephrostomy tube for one resident (#89) out of 30 residents sampled. This had the potential to affect the 150 residents residing in the facility receiving care at the time of this survey. The Findings Included: 1. During observation on 07/10/23 at 09:37 AM, Resident #89 was in bed awake, with a right side quarter side rail pad on the floor, and a left side quarter side rail pad was attached to the bed rail on the upper inside of the bed. The urinary tubing leading from the resident's left side to the drainage bag was attached to the lower bed rail. Resident #89 stated, he is doing great today. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to provide adequate and appropriate health care, related to occupational therapy services for two (Resident #65 and 88) out of two residents reviewed. There were no hand rolls observed in the residents hands.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe environment related to bed side rail pads to prevent accidents for one Resident (#89) out of one sampled resident. This had the potential to affect the 150 residents receiving care in the facility at the time of the survey. The Findings Included: During observation on 07/10/23 at 09:37 AM, Resident #89 was in bed awake, a right side quarter side rail pad was on the floor, the left side quarter side rail pad was attached to the bed rail on the upper inside of the bed, the bed was not in the lowest position. Resident #89 stated, he is doing great today. On 07/11/23 at 08:25 AM, Resident #89 was observed in the bed eating breakfast, no distress was noted, bilateral quarter rail pads were in place, the bed was not in the lowest position. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow doctor's orders related to Oxygen administration for one resident (Resident #77) out of two residents who were investigated for oxygen administration.