Mitchell County Hospital Health Systems Ltcu

Inspectors wroteThe facility had a census of 33 residents. Based on record review and interview, the facility failed to ensure the staff person designated as the Infection Preventionist, who was responsible for the facility's Infection Prevention and Control Program, completed the specialized training in infection prevention and control. This placed the residents at risk for lack of identification and treatment of infections.

Inspectors wroteThe facility had a census of 33 residents. The sample included 12 residents with two reviewed for bed rail use. Based on observation, interview, and record review the facility failed to provide bed rails with gaps less than four and three-quarters inches per Food and Drug Administration (FDA) guidelines for safety. This deficient practice placed Resident (R) 2 and R13 at risk for injury.

Inspectors wroteThe facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to thoroughly investigate two separate incidents of resident-to-resident incident between three sampled residents, Resident (R)26 and R8; R26 and R22 in another incident. This placed the residents at risk for further injury and unidentified abuse or mistreatment.

Inspectors wroteThe facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan that included Resident (R)17's history of bowel obstruction (a gastrointestinal condition in which digested material is prevented from passing normally through the bowel) and interventions to prevent constipation (difficulty passing stool). This placed the resident at risk for impaction (the condition of being or process of becoming impacted, especially of feces in the intestine) and bowel obstruction.

Inspectors wroteThe facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to revise, with person centered interventions for falls, the care plan for two sampled residents, Resident (R) 17 and R26, and lacked direction in the plan of care to staff for anticoagulant (blood thinner) medication for R8. This placed the residents at risk for uncommunicated and unmet care needs.

Inspectors wrote- R8's Electronic Medical Record documented diagnoses of osteoporosis (bone disease that develops when bone mineral density and bone mass decreases), cervicalgia (neck pain), hypertension (high blood pressure), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and atrial fibrillation (an irregular and often very rapid heart rhythm). The Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of six, indicating severely impaired cognition. The MDS documented R8 required supervision for eating and extensive assistance of two staff for all other activities of daily living (ADL). [...]

Inspectors wroteThe facility had a census of 31 residents. The sample included 12 residents with one reviewed for weight loss. Based on observation, interview, and record review the facility failed to implement interventions to prevent further weight loss after Resident (R)8 had a weight loss in February 2023 and continued to lose weight. This deficient practice placed R8 at risk for continued weight loss and malnutrition.

Inspectors wroteThe facility had a census of 31 residents. The sample included 12 residents, with two reviewed for dementia (progressive mental disorder characterized by failing memory, confusion) care. Based on observation, record review, and interview, the facility failed to provide the necessary dementia care and services for one sampled resident, Resident (R) 26, who had dementia related behaviors which significantly impacted R26 and other resident's quality of life. This placed the resident at risk for injury and unmet needs.

Inspectors wroteThe facility had a census of 31 residents. The sample included 12 residents with five residents reviewed for unnecessary drugs. Based on observation, interview, and record review the facility failed to ensure the consultant pharmacist identified and reported Resident (R) 16's as needed (prn) lorazepam (an antianxiety medication) lacked a stop date as required by Center for Medicare and Medicaid Services (CMS). This deficient practice placed R16 at risk for unnecessary medications.

Inspectors wroteThe facility had a census of 31 residents. The sample included 12 residents with five residents reviewed for unnecessary drugs. Based on observation, interview, and record review the facility failed to ensure Resident (R) 16's as needed (prn) lorazepam (an antianxiety medication) had a stop date as required by Center for Medicare and Medicaid Services (CMS). This deficient practice placed R16 at risk for adverse side effects related to psychotropic (altering mood or mind) medication use.

Inspectors wroteThe facility had a census of 27 residents. The sample included 12 residents of which one was reviewed for hospitalization. Based on observation, record review, and interview, the facility failed to provide a copy of the facility bed hold policy to Resident (R) 10 or her representative for her facility-initiated hospitalization.

Inspectors wroteThe facility had a census of 27 residents. The sample included 12 residents. Based on observation, interview and record review, the facility failed to assess one sampled Resident (R) 23, for bowel problems when the resident had no bowel movement (BM) for more than three days.

Inspectors wroteThe facility had a census of 27 residents. The sample included 12 residents with six reviewed for unnecessary medications. Based on observation, interview, and record review, the consultant pharmacist failed to notify the Director of Nursing, physician, and medical director of the requirement for a stop date for psychotropic medication (drug that affects behavior, mood, thoughts, or perception) ordered for Resident (R) 9.

Inspectors wroteThe facility had a census of 27 residents. The sample included 12 residents with six reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure one sampled Resident (R) 9 did not receive psychotropic medication (drug that affects behavior, mood, thoughts, or perception) without a stop date.