Palm Garden of West Palm Beach

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure care and services to prevent pressure ulcers, as evidenced by no interventions ordered or in place to prevent, 1 of 3 sampled residents, Resident #3, from acquiring pressure ulcers.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure that 1of 3 sampled residents received a shower as evidenced by not providing a shower to Resident #48.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for 3 of 31 sampled residents, related to the comatose status for Resident #65, related to diagnosis and oxygen therapy for Resident #77, and related to diagnosis for Resident #96.

Inspectors wroteBased on interview and record review, the facility failed to develop care plans for 2 of 31 sampled residents, as evidenced by lack of care plans for Resident #8 regarding the administration of diuretics and anticoagulants, and Resident #31 related to assessed trauma.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide Activities of Daily Living (ADL) assistance for 4 of 5 sampled residents, Resident #22 who requested assistance; and failed to provide proper positioning in bed during mealtime for Residents #8, #41, and #98.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure care and services for 3 of 31 sampled residents as evidenced by the failure to timely assess and treat diarrhea for Resident #65, failure to ensure timely initiation of an antibiotic for a urinary tract infection (UTI) for Resident #96, and failure to assess Resident #48's blood pressure and heart rate prior to administration of an antihypertensive medication with physician ordered parameters.

Inspectors wroteBased on facility policy, observation, record review and interview, the facility failed to provide proper care and maintenance for indwelling catheters for 2 of 3 sampled residents, as evidenced by failure to ensure that the catheter was secured to prevent dislodgement and care was performed properly for Resident #5, and by failure to ensure that there were physician orders to provide catheter care and maintenance for Resident #160.

Inspectors wroteBased on facility policy, observation, record review and interviews, the facility failed to provide respiratory care and services for the administration of oxygen and nebulizer treatment for 4 of 5 sampled residents, as evidenced by failure to administer oxygen per physician orders for Resident #35 and failure to perform respiratory assessment post nebulizer treatment for Resident #5, #15 and #77.

Inspectors wroteBased on record reviews and interviews, the facility failed to properly document the removal of narcotics in the medication administration records (MARs) and the controlled medication utilization record (the narcotic record) for 3 of 6 sampled residents, Residents #52, #104, and #134.

Inspectors wroteBased on record review, the physician failed to provide a rationale for declining a pharmacy recommendation on a Medication Regimen Review (MRR) for Resident #8.

Inspectors wroteBased on observation, interview, policy review, and record review, the medication error rate was 7.41% percent. Two medication errors were identified while observing a total of 27 opportunities, affecting 2 of 10 residents observed during medication pass observation, Residents #72 and #96.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that laboratory services were done in a timely manner for 1 of 5 sampled residents as evidenced by the Valproic Acid level (blood level to monitor antiseizure medication) was not drawn for Resident #6.

Inspectors wroteBased on record review and interview, the facility failed to ensure it had he most recent hospice plan of care for 1 of 1 sampled resident (Resident #31)

Inspectors wroteBased on policy reviews, observations, interviews, and record reviews, the facility failed to ensure that Enhanced Barrier Precautions (EBP) were initiated for 2 of 42 residents recorded on the EBP List, Resident #159 and Resident #160; failed to ensure infection control practices were adhered to during wound care for 1 of 3 sampled residents, Resident #81; failed to ensure a glucometer was disinfected adequately for 1 of 3 residents observed during blood glucose monitoring, Resident #65; and failed to ensure a barrier was maintained for an eye drop bottle during administration for 1 of 1 resident observed during eye drop administration, Resident #96) who was on Contact Precautions.

Inspectors wroteBased on record review, interview, policy review, and surveillance camera review, the facility failed to ensure a resident's advance directive choices were honored for a resident's expressed wishes for a Do Not Resuscitate (DNR) order for 1 of 4 sampled residents reviewed for DNR status (Resident #1). The deficient practice caused Resident #1 to have likely suffered serious psychological harm by the facility's attempt to be resuscitated against his wishes. Resident #1 could not express his reaction to this event; therefore, the reasonable person concept was applied. Additionally, there was a likelihood that Resident #1 experienced severe physical pain; broken ribs; broken sternum and bleeding in the chest area from the resuscitation efforts (https://pubmed.ncbi.nlm.nih.gov/38206442/). The facility staff did not follow their procedure to verify code status prior to initiating CPR. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to accurately assess 2 of 33 sampled residents. The Minimum Data Set (MDS) assessment was inaccurate related to indwelling urinary catheter use for Resident #79 and related to the discharge status for Resident #141.

Inspectors wroteBased on observation, record review, and interview, the facility failed to develop a comprehensive care plan for 1 of 1 sampled resident reviewed with an indwelling urinary catheter (Resident #79).

Inspectors wroteBased on record review and interview, the facility failed to ensure ordered labs were completed timely for 1 of 5 sampled residents, Resident #194.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure accurate and complete resident records for 4 of 33 sampled residents, as evidenced by: the record for Resident #79 lacked an order for the indwelling urinary catheter; the record for Resident #36 lacked documentation related to a change in a code status; the record for Resident #57 had inaccurate documentation related to a dressing change; and the record for Resident #92 lacked documentation related to blood sugar monitoring.

Inspectors wroteBased on observation and interview, the facility failed to meet the needs and requests of residents to reasonably accommodate the residents needs for 4 of 4 sampled residents (Residents #81, #22, #81 and #79), as evidenced by failure of answer call lights timely, provide additional assistance, and unable to locate a staff member to assist residents.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure 6 of 28 sampled residents reviewed received treatment and care in accordance with professional standards of practice and the residents' comprehensive person-centered care plans as evidenced by the following: 1. Failure to provide barrier cream as ordered, and failure to conduct skin checks per facility protocol (Resident #20); 2. Failure to provide barrier cream, heel prep, and prescribed topical cream as ordered; failure to conduct skin checks per facility protocol (Resident #90); 3. Failure to conduct skin checks per protocol for Resident #59; 4. Failure to apply ordered geri-sleeves each day for Resident #98; 5. Failure to apply ordered hand split for Resident #107; and 6. Failure to provide medications as ordered for Resident #31.

Inspectors wroteBased on record review and interview, the facility failed to complete Dialysis Center Communication care forms for 4 of 4 sampled residents reviewed for dialysis, Residents #30, #118, #96 and #66.

Inspectors wroteBased on record review and interview, the facility failed to ensure the narcotic reconciliation was accurate for 2 of 6 sampled resident, Residents #28 and #31.

Inspectors wroteBased on record review, policy review and interview, the facility failed to ensure the medication review recommendations by the consultant pharmacist were addressed by the prescribing physician for 1 of 5 sampled resident reviewed for unnecessary medications. (Resident (#59)

Inspectors wroteBased on observation, interview and record review, the facility failed to have a medication error rate of less than 5%, as evidenced by the medication rate was 7.4% percent. Two (2) medication errors were identified while observing a total of 27 opportunities, affecting Residents #59 and #285.

Inspectors wroteBased on record review, observation and interview the facility failed to ensure accurate documentation for the care provided to residents for 5 of 28 sampled residents reviewed (Residents #12, #21, #59, #98, and #107).