Mount St. Rita Health Centre

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the correct use and ongoing reassessment of bed siderails for one of one resident, Resident ID #1 reviewed for the use of bed siderails. The facility failed to reassess the continued need for and safety of the resident's bed siderails for approximately 15 months, despite the resident's severely impaired cognition, total dependence for bed mobility, and continued use of the device. Consequently, the facility failed to identify that the bed siderails had become unsafe and were no longer clinically appropriate. As a result, Resident ID #1 sustained a traumatic posterior (the back) dislocation of the right shoulder and significant bruising. Following the injury, the facility's bed siderail assessment determined that the bed siderails were no longer indicated because they created a safety hazard for the resident.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure that an allegation involving an accident resulting in serious injury was reported to the appropriate authorities, including the State Survey Agency, as required by State law. This deficient practice was identified for 1 of 3 residents reviewed, Resident ID #1.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure that an injury of unknown origin was thoroughly investigated in accordance with federal regulations for 1 of 1 resident reviewed for who was discovered to have bruising to his/her right armpit and was subsequently diagnosed with a closed traumatic right posterior dislocation of the shoulder joint, Resident ID #1.

Inspectors wroteBased on surveyor observation, record review, and staff interview, the facility failed to provide a sanitary and comfortable environment for residents, staff and the public relative to stained ceiling tiles observed on 2 of 3 floors in the building.

Inspectors wroteBased on surveyor observation, review of the clinical record, and staff interviews, the facility failed to ensure adequate supervision to prevent an accident for 1 of 1 resident reviewed. The resident disengaged the alarm system, exited the facility, remained outside for an unknown period of time, sustained an unwitnessed fall, and was unable to re-enter the building, resulting in hospital admission for treatment of frostbite to the resident's bilateral hands, Resident ID #1.

Inspectors wroteBased on surveyor observation, clinical record review, and staff interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, for 1 of 1 resident reviewed with a standing physician's order for insulin with special instructions, Resident ID #9, and for 1 of 1 resident reviewed for off-loading heels, Resident ID #47.

Inspectors wroteBased on surveyor observation, clinical record review, and staff interview, the facility failed to ensure that resident records are complete and accurately documented relative to 1 of 1 resident observed for wound care, Resident ID #11, and 1 of 1 resident reviewed for off-loading heels, Resident ID #47.

Inspectors wroteBased on surveyor observation, clinical record review, and staff interview, the facility failed to ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection for 1 of 1 resident observed for wound care, Resident ID #11.

Inspectors wroteBased on surveyor observation, clinical record review, and staff interview, the facility failed to ensure that staff were competent to provide nursing and related services to assure resident safety to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as a nurse did not follow proper infection control practices or follow a physician's order during a resident's wound treatment and had not completed a facility provided competency for clean dressing changes, for 1 of 3 Licensed Practical Nurses (LPN) reviewed, LPN, Staff C.

Inspectors wroteBased on surveyor observation, clinical record review, and staff interview, the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections, relative to staff wearing the appropriate personal protective equipment (PPE), for 1 of 1 resident observed on contact precautions (an infection control measure used in healthcare settings to prevent the spread of germs that can be transmitted by direct or indirect contact with a resident or their environment), Resident ID #18.

Inspectors wroteBased on surveyor observation, record review, resident and staff interviews, 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 the use of a wanderguard bracelet (an electronic device used to alert staff of a potential elopement attempt) for 1 of 1 resident reviewed, Resident ID #56, and 2 of 2 residents reviewed for a change in condition, Resident ID #s 60 and 280.

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 1 of 3 medication carts reviewed and 3 of 3 medication rooms.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that a resident with pressure ulcers receives the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 1 newly admitted resident reviewed with a pressure ulcer, Resident ID #280.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 1 of 3 residents reviewed on antibiotics, Resident ID #280.

Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to keep residents free from significant medication errors for 1 of 2 residents reviewed who were receiving morphine (a medication used to treat pain), Resident ID #1.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents who are trauma survivors receive trauma informed care in accordance with professional standards of practice and accounting for the resident's experiences and preferences for 1 of 3 residents reviewed, Resident ID #23.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that food is stored and distributed in accordance with professional standards for food service safety, relative to the main kitchen and 2 out of 4 kitchenettes observed.

Inspectors wroteBased on surveyor observations, record review, and staff interview, it has been determined that the facility failed to follow standard precautions to prevent the spread of infection for 1 of 2 residents observed for wound care, Resident ID #57; 1 of 1 resident observed related to glucometer monitoring, Resident ID #223; and 2 of 2 residents observed on transmission based precautions, Resident ID #s 30 and 222.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to have sufficient staff who provide direct services to residents with the appropriate behavioral health training as determined by the facility assessment.

Inspectors wroteBased on surveyor observation, record review and staff interview it has been determined that the facility failed to respect the residents right to personal privacy for 1 of 2 residents observed during a wound dressing change, Resident ID #222 and 1 of 1 resident observed during blood glucose monitoring and insulin administration, Resident ID #223.

Inspectors wroteBased on surveyor observation, record review and staff interview, it has been determined that the facility failed to meet professional standards of quality relative to failure to follow physician's orders for 1 of 6 residents reviewed relative to the use of an air mattress, Resident ID #57.

Inspectors wroteBased on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that a resident receives treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan, for 1 of 1 resident observed relative to non-pressure wounds, Resident ID #57.

Inspectors wroteBased on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that residents that are fed through a feeding tube receive the appropriate treatment and services to prevent complications for 1 of 1 resident reviewed receiving nutrition and medications via a gastrostomy tube (G-tube-gives direct access to the stomach for supplemental feeding, hydration or medicine), Resident ID #222.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that pain management was provided to a resident who required such services, consistent with the comprehensive person-centered care plan, for 1 of 2 residents observed during a dressing change, Resident ID #57.

Inspectors wroteBased on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure nursing staff have the appropriate competencies and skill sets to provide nursing and related services to assure resident safety as identified in the plan of care for 1 of 1 nurse observed performing blood glucose testing, Licensed Practical Nurse (LPN), Staff C, for 1 of 1 nurse observed administering medications through a g-tube, Staff C, 1 nurse observed related to the setting of an air mattress LPN, Staff D and Registered Nurse, Staff E, and for 1 of 2 nurses observed completing a dressing change, LPN, Staff D.

Inspectors wroteBased on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that residents are free from any significant medication errors for 1 of 4 resident's observed for medication administration during medication pass Resident ID #18.

Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to provide a resident with access to personal and medical records pertaining to him or herself, upon an oral or written request for 1 of 1 resident reviewed for medical records requests, Resident ID #2.

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

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to provide care consistent with professional standards of practice to promote wound healing and prevent new ulcers from developing for 1 of 2 residents reviewed who are at risk and who have actual pressure ulcers (localized damage to the skin and/or underlying soft tissue usually over a bony prominence), Resident ID #3.