O'Connor Hospital D/P SNF

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure needed care and services were provided in accordance with professional standards of practice for four residents (Resident 3, 5, 12, 16) when:1. Resident 3 had a rectal tube (a flexible tube inserted into the rectum to manage bowel issues, such as channeling loose stool or gas into a collection bag) without a Physician Order,2. For Resident 5 and Resident 12, licensed staff did not administer a water flush prior to medication administration,3. For Resident 16, licensed staff did not use two resident identifiers to verify the resident's identity (ID) before medication administration. These failures resulted in insertion of a rectal tube into a Resident without physician orders, and the potential for errors in administering medications to the wrong Resident.

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 8.1% when three medication errors occurred out of 37 opportunities during the medication administration observation for three out of nine residents (Residents 5, 12, and 16) when:1. Nursing staff did not flush Resident 5 and 12's gastrostomy tube (G-tube; a tube surgically inserted through the abdomen into the stomach to administer nutrition and medications) prior to medication administration, 2. Nursing staff did not use two resident identifiers before administering medication to Resident 16. These failures had the potential for complications, such as clogging of the G-tube, for the residents, and potential errors in administering medications to the wrong Resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper use of side rails (or bed rails, adjustable rigid bars attached to the side of a bed [examples include safety rails, grab bars, and assist bars]) for 23 of 23 residents (Residents 1, 14, 21, 15, 10, 13, 11, 2, 7, 3, 22, 8, 19, 5, 9, 4, 6, 12, 16, 17, 18, 20, and 23), when 1. For Residents 4 and 23, the Siderail Assessment indicated side rails were not required, though the residents were observed to have side rails. 2. The facility failed to offer/or attempt alternatives prior to the use of side rails and no documentation indicated alternatives were offered and/or attempted prior to using side rails for 23 of 23 residents with side rails (Residents 1, 14, 21, 15, 10, 13, 11, 2, 7, 3, 22, 8, 19, 5, 9, 4, 6, 12, 16, 17, 18, 20, and 23). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that proper care and treatment services for the use of oxygen (O2, colourless, odourless, tasteless gas essential to living organisms; it is not flammable but causes other materials that burn to ignite more easily and to burn far more rapidly, that a fire involving oxygen can appear explosive-like) were provided for 19 of 19 sampled residents (Residents 2, 3, 11, 6, 15, 21, 10, 22, 12, 18, 13, 20, 1, 19, 23, 16, 5, 8, and 9) as there were no Oxygen In Use signs at these 19 residents' doors. This deficient practice had the potential to harm residents receiving O2 therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the call light within resident's reach for one of 12 sampled residents (Resident 22). This failure had the potential to negatively affect the resident's safety and delay the care and services to the residents in the facility.

Inspectors wroteBased on observations, interview, and record review, the facility failed to apply the right hand splint (a semi-rigid device to prevent or maintain a body part in a functional position) to one of 12 sampled residents (Resident 7) for contracture (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) management as ordered by the physician. This failure had the potential to worsen contractures in Resident 7's right hand.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate accountability of controlled medication (medication with high potential for abuse and addiction) when random controlled medication use audit for one of two residents (Resident 2) did not reconcile. The medication was signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Record (MAR, used to document medications taken by each individual) to indicate they were administered to the resident. The failure resulted in inaccurate accountability and had the potential for misuse or diversion of controlled medications.

Inspectors wroteBased on interview and record review, the facility failed to monitor side effects of anticoagulant (medicines that help prevent blood clots) medication for two of 12 sampled residents (Residents 7 and 1) reviewed. This failure had the potential to put the residents at risk for complications and adverse effects from the medication.

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 8% when two medication errors occurred out of 25 opportunities during the medication administration for two of eight residents (Residents 14 and 12). The failure resulted in medications not given as per accepted professional standards of practice and had the potential for residents not receiving the full therapeutic effects of medications which may negatively affect the residents' health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control and prevention practices when: 1. Licensed vocational nurse (LVN) E did not remove gloves, sanitize (to reduce or remove pathogenic agents) hands and put on new gloves after touching and removing the electrical fan on top of the bedside table before administering the medications using the gastrostomy tube (G-tube, a feeding tube used to deliver nourishment, liquid, and medication into the stomach) for Resident 11. 2. Licensed vocational nurse (LVN) F did not remove gloves, sanitize (to reduce or remove pathogenic agents) hands and put on new gloves after moving the bedside table to the side of the bed before administering the medications using the gastrostomy tube for Resident 9. These failures had the potential to compromise the health and well-being of the residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five residents (Residents 19) were offered and/or received pneumococcal (common bacteria that can affect different parts of the body) vaccinations. This failure increased the potential for residents to have inadequate immunity to pneumococcal infections (also known as pneumonia, an infection of one or both lungs).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the facility is free from flies and spiders. These failures could potentially lead to the transmission of diseases carried by pests to residents, their family members, staff and visitors who come to the activity room.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide proper pharmaceutical services when: 1. Medications were unavailable and were not administered as ordered for six of 12 residents (Residents 2, 3, 9, 12, 20, and 22); and, 2. The disposition of two of five discontinued narcotic medications (controlled substance medications, drugs with high potential for abuse or addiction) were not documented. These failures resulted in six residents not receiving medications as ordered by the physicians and had the potential to result in misuse of narcotic medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) program implemented their policy. 1. A performance indicator, medication error, did not capture medication omissions. 2. A performance indicator, Medication Management, did not monitor gradual dose reduction (GDR) of psychoactive medications and implementation of the consultant pharmacist (CP)'s recommendations from Medication Regimen Review (MRR, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication). Those failures had the potential to miss opportunities for identifying issues and improving the selected indicators for quality care of residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. A licensed nurse did not change gloves and perform hand hygiene between tasks; 2. Staff used gloves to cover respiratory tubing; and 3. Multiple face masks were hanging by the bed. These failures had the potential for development and transmission of communicable diseases and infections in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure privacy of one of 12 residents (Resident 75) while providing care. This failure had the potential to cause emotional distress to the resident.

Inspectors wroteBased on interview and record review, the facility failed to notify the responsible party (RP, the designated person who makes medical decisions for the resident) for one of two residents (Resident 17) when Resident 17 was transferred to an emergency department. This failure had the potential to compromise the residents' admission, transfer, and discharge rights.

Inspectors wroteBased on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for two of 12 residents (Residents 3 and 12), when licensed nurses did not notify the attending physicians regarding medications that were not administered. These failures had the potential to compromise the residents' health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure informed consents related to the use of side rails were completed for three of 12 residents (Residents 12, 22, and 73). This failure had the potential to put the residents at risk for entrapment and serious injury due to not being aware of the risks and benefits of bed rails.

Inspectors wroteBased on interview and record review, the facility failed to ensure the consultant pharmacist (CP)'s recommendations were acted upon for one of 12 residents (Resident 1). This failure had the potential to put the resident at risk for complications and adverse effects from the medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of six sampled residents (Residents 15 and 16) were free from unnecessary psychotropic medication (drugs that affects brain activities associated with mental processes and behavior) when Residents 15 and 16 received psychotropic medication without gradual dose reductions (GDR, a tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued); and there was no documented clinical rationale by the physician for why an attempted GDR was not indicated. These failures had the potential to put the residents at risk for experiencing adverse effects from unnecessary psychotropic medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored securely when one of three medication carts was left unlocked and unattended. This failure had the potential to result in the access of medications by unauthorized personnel.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) program implemented their policy to have a quarterly QAPI meeting. This failure have the potential to miss opportunities for identifying issues and improving the selected indicators for quality care of residents.