Pass Christian Health and Rehabiliation Center

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to revise Resident #1's comprehensive, person-centered care plan to include individualized interventions for falls for one (1) of three (3) residents reviewed for care planning, Resident #1.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure medications were properly secured, safeguarded, and tracked to prevent misappropriation of resident property, resulting in a prescribed injectable medication pen being unaccounted for and lost for one (1) of four (4) residents reviewed for medication diversion. Resident #1.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure medications were documented in accordance with physician orders and professional standards of practice for one (1) of four (4) residents reviewed for receiving insulin. Nursing staff documented routine insulin as being administered several hours after the prescribed administration time. Resident #2.

Inspectors wroteBased on interviews, record reviews, and facility policy review, the facility failed to ensure a comprehensive, resident-centered care plan was developed to address a diagnosis of Type 2 Diabetes Mellitus for one (1) of (15) sampled residents (Resident #9).

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure a PRN (as needed) psychotropic medication order was limited to (14) days or that the prescribing practitioner documented the rationale for extending therapy, including the duration of use, as required, which resulted in a resident continuing to receive Lorazepam beyond the regulatory limit without appropriate justification, for one (1) of five (5) residents reviewed for unnecessary medications.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to administer intravenous (IV) antibiotics for Resident #1 as ordered for two (2) of three (3) scheduled doses. Findings Include: Review of the facility's policy, Physician Orders, revised 3/3/2021, revealed, .The center will ensure that Physician orders are appropriately and timely documented in the medical record . Review of the facility's policy, Administering Medications, revised April 2019, revealed, Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation .4. Medications are administered in accordance with prescriber orders, including any required time frame .7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified .21. [...]

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to notify the medical provider until the next day that Resident #1, who was prescribed apixaban (an anticoagulant medication), had a fall for one (1) of three (3) sampled residents (Resident #1).

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to ensure that resident records were complete and accurate, as evidenced by missing documentation of a post-fall assessment, including vital signs, for one (1) of three (3) sampled residents (Resident #1).

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure staff competency in medication reconciliation, which resulted in a nurse accessing the wrong resident's records and transcribing incorrect medication orders into the system without verification. This failure led to the prolonged administration of incorrect medications for one (1) of four (4) sampled residents reviewed for medication administration. Resident #1.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure a Registered Nurse (RN) was present at the facility for at least eight (8) consecutive hours a day for one (1) of eight (8) days reviewed.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to prevent significant medication errors, resulting in a resident receiving multiple unprescribed medications for up to eight (8) consecutive days, causing excessive sedation and the inability to participate in therapy (Resident #1), and failed to administer prescribed intravenous (IV) antibiotics on multiple occasions (Resident #4) for two (2) of four (4) sampled residents.

Inspectors wroteBased on observation, interviews, record review and facility policy review the facility failed to identify and treat two (2) new pressure ulcers (PUs) before they had deteriorated to Stage 3 pressure ulcers for one (1) of (2) residents reviewed for PU's. Resident #36.

Inspectors wroteBased on observation, interviews, record review and facility policy review the facility failed to develop a comprehensive care plan within 21 days of admission (Resident #22) and failed to implement a care plan intervention (Resident #32) for two (2) of 15 sampled residents.

Inspectors wroteBased on observation, interviews, record review and facility policy review the facility failed to prevent the potential for an accident as evidenced by, facility staff transferred a resident without using the physician ordered mechanical lift for one (1) of four (4) transfer observations.

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to store food in accordance with professional standards for food service safety related to food items not dated, mislabeled, exposed, expired, no identifying label, and spoiled produce for one (1) of two (2) kitchen observations. Findings Include: A review of the facility's policy, Food and Supply Storage, with an effective date of 11/30/14, revealed, Policy: Food and supplies will be stored under sanitary and secure conditions . Procedure: Food service products will be placed in appropriate storage . designated for each product .Food supplies must be dated .Rotation of stock/inventory .is essential to maintain quality . On 04/21/24 at 9:10 AM, an observation of the kitchen and interview with the Certified Dietary Manager (CDM), revealed the following: [...]

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure that care plan interventions were implemented to prevent complications by not aspirating to check peg tube placement prior to flushing for one (1) of two (2) sampled residents with feeding tubes.

Inspectors wroteBased on staff and resident interviews, record review, and facility policy review the facility failed to notify the resident and the Resident's Representative (RR) in writing the reason for a transfer to the hospital for two (2) of three (3) sampled residents for hospitalizations. (Resident #22 and Resident #35)

Inspectors wroteBased on observation, staff interviews, record review, and facility policy review, the facility failed to ensure Percutaneous Endoscopic Gastrostomy (PEG) tube placement was checked prior to flushing the tube for one (1) of two (2) residents observed with feeding tubes. Resident #15. Findings Include: Record review of the facility's Policies and Procedures with the Subject: Medication-Administration Via Enteral Tube, and a revision date 3/6/2019, revealed, .Procedure .Checking for placement of enteral tube .To confirm proper placement .Aspirate by gently pulling back on plunger of syringe to check for stomach contents . On 8/8/22 at 12:03 PM, the State Agency (SA) observed Registered Nurse (RN) #1 flush Resident #15's PEG tube. RN #1 used a syringe with the plunger removed to flush the enteral tube by gravity. [...]