Oneida County Hospital & Long Term Care Facility

Inspectors wroteBased on policy review, record review, and staff interview, it was determined the facility failed to ensure the residents and their representatives received assistance to exercise their right to formulate an Advanced Directive. This was true for 2 of 12 residents (Resident #4 and #19) whose records were reviewed for advanced directives. This deficient practice created the potential for harm or adverse outcomes if residents' wishes were not followed or documented regarding their advance care planning.

Inspectors wroteBased on policy review, record review, and staff interviews it was determined the facility failed to ensure appropriate discharge planning was documented in the resident's medical record and appropriate resident information was communicated to the resident's representative for 1 of 1 resident (Resident #27) reviewed for discharge. This deficient practice had the potential to result in adverse outcomes or harm if the resident did not receive appropriate care after discharge.

Inspectors wroteBased on record review, staff interviews, and policy review it was determined the facility failed to refer residents for recommended further evaluation when residents were diagnosed with a major mental illness. This was true for 1 of 2 residents (Resident #2) reviewed for Pre-admission Screening and Resident Review (PASRR) Level II evaluations. This deficient practice had the potential to cause harm if residents' PASRR Level II recommendations for specialized services needs were not referred for evaluation and incorporated in the resident's care.

Inspectors wroteBased on record review, interviews, and policy review it was determined the facility failed to refer residents for further evaluation when residents were diagnosed with a major mental illness. This was true for 1 of 2 residents (Resident #1) reviewed for Pre-admission Screening and Resident Review (PASRR) Level I and Level II evaluations. This deficient practice had the potential to cause harm if residents' specialized services for mental health needs were not evaluated by an appropriate state-designated authority.

Inspectors wroteBased on record review, observation, staff interviews, and policy review it was determined the facility failed to ensure that prior to the placement of bed rails, a resident assessment was completed that included alternatives to bed rail use were attempted and how the alternatives failed to meet the resident's assessed needs. This was true for 1 of 12 residents (Resident #3) reviewed for bed rails. This failure created the potential for harm due to the risk for injury, entrapment and/or death.

Inspectors wroteBased on staff interview and review of employee personnel files, it was determined the facility failed to ensure each CNA's annual performance review was completed at least once every 12 months for 2 of 2 CNAs (#1and #2) whose personnel records were reviewed for sufficient and competent staffing. This failure created the potential for incompetent CNAs providing care and increased the risk for harm for all residents living in the facility.

Inspectors wroteBased on observation, staff interviews, and the State Operations Manual, Appendix PP it was determined the facility failed to ensure nurse staffing information was accurate, posted daily for each shift, and included scheduled and actual hours. This failed practice had the potential to affect the 23 residents residing in the facility and their representatives, visitors, and others who wanted to review the facility's staffing levels.

Inspectors wroteBased on record review, observation, staff interview, and policy review it was determined the facility failed to ensure infection control prevention practices were maintained to provide a safe and sanitary environment. This was true for 1 of 5 residents (Resident #15) observed for infection control. These failures put residents at risk for cross contamination and infection.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure a Pre-admission Screening and Resident Review (PASARR) was accurately completed prior to admission for 1 of 3 residents (Resident #15), and when a new mental health diagnosis was identified for 2 of 3 residents (#10 and #11), whose records wer reviewed for PASARR screenings. These failures created the potential for harm if residents required, but did not receive, specialized services for mental health while residing in the facility.

Inspectors wroteBased on contract review, policy review, observation, and staff interview, it was determined the facility failed to ensure infection control surveillance was maintained for the contracted laundry services which processed residents' personal laundry. This deficient practice had the potential to impact 18 of 21 residents who had personal laundry services provided by the facility. This deficient practice placed residents at risk of infection from cross contamination.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure the resident's pulse was monitored appropriately for residents who received blood pressure medication. This was true for 1 of 5 residents (Resident #21) who were reviewed for unnecessary medications. This failure created the potential for harm if residents experienced adverse effects from blood pressure medication.

Inspectors wroteBased on policy review, record review, and staff interview, it was determined the facility failed to ensure residents were provided with the level of supervision necessary to prevent falls. This was true for 1 of 2 residents (Resident #14) reviewed for falls. This failure placed Resident #14 at risk of pain, bone fractures, brain damage, and other life changing injuries, as a result of falls.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure appropriate behavior and side effect monitoring was documented for residents receiving psychotropic medications. This was true for 2 of 5 residents (#5 and #21) reviewed for unnecessary medications and created the potential for harm if residents experienced adverse side effects or behaviors from unnecessary psychotropic medications.