Missouri Slope

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 4 of 21 sampled residents (Resident #50, #61, #139, #154) and 1 supplemental resident (Resident #30) observed during cares. Failure to practice infection control standards related to glove use, hand hygiene, catheter care, equipment disinfection, and enhanced barrier precautions (EBP) has the potential to spread infection throughout the facility.

Inspectors wroteBased on observation, record review, review of facility policy and staff interview, the facility failed to ensure adequate assistance for 1 of 1 sampled resident (Resident #61) observed during a mechanical sit to stand lift transfer. Failure to secure the leg strap and the abdominal strap of the lift sling placed the resident at risk for falls.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure drugs and biologicals were stored securely for 1 of 35 sampled residents (Resident #24) and 1 supplemental resident (Resident #109) with medications at the bedside. Failure to securely store medications may result in unauthorized use, adverse reactions, or ineffective treatment.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to provide care in a manner and environment that maintains or enhances residents' quality of life for 5 of 9 residents (Residents #3, #44, #45, #70, and #112) observed during medication administration and in 3 of 8 dining rooms (1st floor C/D wing, 2nd floor C/D wing, and 4th floor C/D wing). Failure to refer to residents by their preferred name and dispose of bags containing trash/dirty linens prior to entering dining rooms does not promote resident dignity or respect.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure food is stored in accordance with professional standards for food service sanitation in 6 of 8 nutrition stations (first floor A/B and C/D, second floor A/B and C/D, and third floor A/B and C/D). Failure to ensure food is safe from contamination by resident ice packs has the potential to result in a foodborne illness or adverse effects for residents, visitors, and staff.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to ensure the interdisciplinary team assessed the appropriateness to self-administer medications (SAM) for 1 of 9 residents (Resident #70) observed during medication administration. Failure to determine whether SAM is a safe practice has the potential to result in a medication error and/or harm to a resident.

Inspectors wroteBased on observation, record review, policy review, professional reference, and staff interview, the facility failed to follow professional standards of practice for medication administration for 1 of 9 resident's observed during medication administration. Failure to document medications after administration, does not reflect the actual time of administration or any refusals which may cause adverse effects for the resident.

Inspectors wroteBased on observation, review of facility policy, review of manufacturer's instructions, and staff interview, the facility failed to ensure a medication error rate of less than five percent for 2 of 9 residents (Resident #44 and #70) observed during medication administration. Four medication errors occurred during staff administration of 41 medications, resulting in a nine percent error rate. Failure to properly prepare and administer medications may inhibit the effectiveness of the medication and may have a negative impact on the resident's overall health.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 2 of 14 sampled residents (Resident #116 and #164) requiring enhanced barrier precautions (EBP). Failure to practice infection control standards related to EBP and hand hygiene has the potential to spread infection throughout the facility.

Inspectors wroteBased on review of the facility reported incident and investigation reports, record review, review of facility policy, and staff interview, the facility failed to ensure residents remained free from mental and/or physical abuse for 1 of 1 sampled resident (Resident #1) who was witnessed receiving physical and verbal abuse. Failure of facility staff to immediately report a witnessed incident of staff to resident abuse to the appropriate supervisor delayed the removal of the accused abuser, the start of the facility investigation, and assessment of the resident for injury. This delay placed Resident #1 at risk for further abuse, fear, anxiety, and/or psychosocial harm and placed other residents at risk for abuse.

Inspectors wroteBased on record review, review of the facility reported incident (FRI), review of facility policy, and resident and staff interviews, the facility failed to prevent accidents for 1 of 1 sampled resident (Resident #1) who sustained a fall with fracture. Failure to utilize the whirlpool seat belt resulted in an avoidable fall and fracture for Resident #1 and placed all residents at risk for falls and/or injuries. This citation is considered past non-compliance based on review of the corrective actions the facility implemented immediately following the incident.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to review and revise the comprehensive care plan to reflect the current status for 2 of 36 sampled resident (Resident #69 and #138). Failure to review and revise the care plan limited staff's ability to communicate needs and ensure continuity of care.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to ensure appropriate care and services for 1 of 1 sampled resident (Resident #379) with orders for a knee immobilizer. Failure to follow physician's orders and the care plan for application, and report refusals of application, placed Resident #379 at risk for falls and discomfort/pain.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure 1 of 1 sampled resident (Resident #138) reviewed for restorative therapy received the services developed by the therapy staff. Failure to follow up on a request to the provider for restorative nursing/therapy services may adversely affect the resident's ability to maintain range of motion (ROM), strength, and mobility.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to provide appropriate and sufficient supervision for 2 of 6 sampled residents (Resident #135 and #166) observed for safe transfers. Failure to provide appropriate and sufficient supervision during mechanical lift transfers (Resident t#166) and follow fall interventions (Resident #135) placed residents at risk for accidents, falls, and/or injuries.

Inspectors wroteBased on observation, record review, review of facility policy, and resident and staff interviews, the facility failed to provide respiratory care for 1 of 11 sampled residents (Resident #163) receiving oxygen by nasal cannula. Failure to administer oxygen according to the physician's order may result in complications and compromise the residents' respiratory status.

Inspectors wroteBased on record review, policy review, and resident and staff interview, the facility failed to provide care and services to control pain for 1 of 3 sampled residents (Resident #17) investigated for pain management. Failure to administer pain medication as scheduled may have contributed to Resident #17 experiencing increased and/or unresolved pain.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to ensure residents remained free from unnecessary psychotropic medications for 1 of 2 sampled residents (Resident #286) who received an as needed (PRN) psychotropic. Failure to limit PRN psychotropic use to 14 days unless reevaluated by a practitioner placed the resident as risk of receiving unnecessary medications and experiencing adverse drug effects.

Inspectors wroteBased on record review, review of facility policy, and staff and family interviews the facility failed to provide the required specialized rehabilitative services for 1 of 6 sampled residents (Resident #156) with orders for physical therapy evaluation and treatment. Failure to provide physical therapy services as ordered for Resident #156 may result in impaired strength, impaired mobility, and increased pain.

Inspectors wroteBased on observation, record review, review of facility policy and staff interview, the facility failed to follow standards of infection control for 1 of 1 sampled resident (Resident #138) observed for medication administration via feeding tube and 1 of 1 sampled resident (Resident #91) on transmission-based precautions (TBP). Failure to follow infection control standards during medication administration and with TBP has the potential to transmit infections to residents, staff, and visitors.