Morgan Health Center

Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice for 1 of 1 resident reviewed, who had nausea and vomiting for approximately 21 days and was later transferred and admitted to the hospital with renal failure (a condition in which the kidneys lose their ability to effectively filter waste products, excess fluids, and toxins from the blood. Common signs and symptoms of renal failure may include nausea, vomiting, abdominal pain and weight loss), Resident ID #1.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure that residents received care and services in accordance with professional standards of practice, resulting in Immediate Jeopardy. Specifically, for 3 of 3 residents reviewed who were prescribed anticoagulant (blood-thinning) medications and experienced falls, the facility failed to implement physician orders for post-fall care. This included failure to conduct timely and frequent neurological monitoring (e.g., every 15 minutes for the first hour) and/or the failure to transfer residents to the hospital as ordered. This deficient practice placed Resident IDs #1, #2, and #3 at risk for serious harm, serious impairment, serious injury or death.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure that a resident receives care, consistent with professional standards of practice, to promote wound healing and prevent new ulcers from developing for 1 of 2 residents reviewed with a pressure ulcer (a localized injury to the skin and/or underlying skin usually over a boney prominence), Resident ID #1.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice relative to following physician's orders for 1 of 3 residents reviewed, Resident ID #3.

Inspectors wroteBased on record review and staff interview, it has been determined that the pharmacist failed to report irregularities to the attending physician, the facility's Medical Director, and the Director of Nursing Services (DNS) for 1 of 3 residents reviewed, Resident ID #3.

Inspectors wroteBased on surveyor observation and staff interview, it has been determined that the facility failed to store and label drugs and biologicals in accordance with currently accepted professional principles for 2 of 3 units observed and for 1 of 1 resident observed with medications stored in their room, Resident ID #309.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that residents who are prescribed psychotropic medications (medications prescribed to affect behavior, mood, thoughts, or perception) receive gradual dose reductions (GDR), unless clinically contraindicated, in an effort to discontinue these medications, for 1 of 2 residents reviewed with a recommendation for a GDR, Resident ID #84.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to provide pharmaceutical services that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident related to antibiotic administration for 1 of 2 residents reviewed, Resident ID #49.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that each resident's medication regimen is free from a medication error rate of 5% or greater. Based on 27 opportunities for errors observed during the medication administration task, there were 2 errors resulting in an error rate of 7.41%, involving Resident ID #359.

Inspectors wroteBased on record review, staff and resident interview, it has been determined that the facility failed to ensure that each resident receives the necessary care and services to attain or maintain the highest practicable physical well-being for 2 of 3 residents reviewed relative to follow up appointments, Resident ID #s 1 and 2.

Inspectors wroteBased on record review, staff and resident interview, it has been determined that the facility failed to protect a resident's right to be free from abuse for 1 of 3 residents reviewed, Resident ID #1.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to promptly notify the ordering physician or a provider of laboratory results that fall outside of clinical reference ranges for 1 of 3 residents reviewed, Resident ID #1.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide a safe and sanitary environment to help prevent the transmission of infections related to implementing a water management program based upon industry standards and/or the Centers for Disease Control and Prevention (CDC) toolkit.

Inspectors wroteBased on surveyor observations, record review, staff, resident and resident representative interviews, it has been determined that the facility failed to treat each resident with respect and dignity, and is cared for in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life relative to assistance with toileting and communication with a resident whose primary language is not the dominant language of the facility, Resident ID #2.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that all alleged violations involving abuse, including injuries of unknown source are reported immediately, but not later than 2 hours after the allegation is made. If the events that cause the allegation involve abuse or no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to other officials (Rhode Island Department of Health;RIDOH), in accordance with State law, for 1 of 1 resident reviewed for an allegation of abuse, Resident ID #1.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to provide evidence that all alleged violations are thoroughly investigated for 1 of 1 resident reviewed for allegations of abuse, Resident ID #1.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that a resident's drug regimen is free from unnecessary drugs for 2 of 3 residents reviewed, Resident ID #s 1 and 2.

Inspectors wroteBased on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that a resident received incontinence care as per the resident's plan of care for 1 of 1 resident observed, Resident ID #1.

Inspectors wroteBased on surveyor observations, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases for 1 of 3 residents reviewed who tested positive for Influenza A, Resident ID #1.

Inspectors wroteBased on surveyor observation, record review, staff and resident interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections relative to staff entering a COVID-19 (SARS-CoV-2) positive room without wearing personal protective equipment (PPE) for 1 of 3 residents reviewed for COVID-19, Resident ID #4.

Inspectors wroteBased on surveyor observation, record review, resident, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice relative to 1 of 1 resident reviewed for a non-pressure related skin conditions, Resident ID #1.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety relative to the main kitchen and one of three nursing unit kitchenettes on the second floor.

Inspectors wroteBased on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that a resident who requires catheterization receives appropriate treatment and services for 1 of 1 residents reviewed relative to an indwelling catheter, Resident ID #47.

Inspectors wroteBased on surveyor observation and staff interview, it has been determined that the facility failed to store and label drugs and biological's in accordance with currently accepted professional principles for 1 of 2 medication storage rooms and 2 of 5 medication carts observed.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain medical records in accordance with professional standards and practices for 2 of 6 residents reviewed for nutritional intake, Resident ID #'s 30 and 357 and for 1 of 1 resident reviewed relative to indwelling catheters, Resident ID #47.