Pih Health Good Samaritan Hospital D/P SNF

Inspectors wroteBased on observation, interview, and record review, the facility failed to document the removal or release of mittens and wrist restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for one out of one sampled resident (Resident 46). There was no evidence in Resident 46's record indicating that the restraints were removed or released for monitoring or assessment during the shift. Failure to document the removal or release of restraints (such as mittens or wrist restraints) violates the requirement for ongoing monitoring and documentation, which is essential to ensure the restraint is medically necessary and not used for convenience or discipline. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards of dialysis care for one of three sampled residents (Resident 34) by failing to ensure the provision of appropriate emergency equipment like hemodialysis emergency kit (Emergency bleeding control kit to control bleeding in the event of a dialysis-related complication ) is available at bedside for Resident 34 who had dialysis fistula (a surgically created connection between an artery and a vein, usually in the arm, to provide reliable, long-lasting access for dialysis). The kit typically includes critical items such as a tourniquet, pressure bandages, gauze, and a clamp or hemostat (a specialized clamp like pliers or scissors used to compress/pinch blood vessels), which are essential for immediate bleeding control. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident 1 was included in the discharge planning process. This failure had the potential to result in Resident 1's preferences not being incorporated in his own discharge plan. [...]

Inspectors wroteBased on interview and record review, the facility failed to submit their Payroll Based Journal (PBJ, information of the provider's daily staffing hours for the appropriate care of the residents) report to Center for Medicare Services (CMS) in a complete and accurate manner. This deficient practice prevented the provision of complete and accurate direct care staffing information to the public.

Inspectors wroteBased on interview and record review, the facility failed to ensure comprehensive, resident -centered care plans were developed for four of ten sampled residents (Residents 111, 115, 163 and 166). For Resident 111 the facility failed to develop a care plan to address the resident's non-compliance to take medications. -For Resident 115 the facility failed to develop a care plan with person centered interventions for psychotropic medication (medications that affect brain activities associated with mental processes and behavior) use. -For Resident 163 the facility failed to develop a care plan including measurable goals and interventions to monitor oxygen use. -For Resident 166 the facility failed to develop a care plan including measurable goals and interventions for the resident's multiple wounds. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' Minimum Data Set assessments (MDS, a federally mandated resident assessment tool) were transmitted timely to the Center for Medicare Services (CMS) system for two of 10 sampled residents (Resident 3 and Resident 4). This deficient practice had the potential to result in delayed services for Resident 3 and Resident 4.

Inspectors wroteBased on interview and record review, the facility failed to timely and accurately complete a discharge summary for two of four sampled residents (Resident 8 and Resident 9). For Resident 8, there was no discharge summary completed within 14 days of the resident being discharged . For Resident 9, the discharge summary did not include a final summary of the resident's status. These deficient practices caused an increased risk in the continuing care of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of ten sampled residents (Residents 166 ) received care and treatment to promote healing of wounds, as ordered by the physician. This deficient practice caused an increased risk of worsening of the wounds and potential infection for Resident 166.

Inspectors wroteBased on interview and record review, the facility failed to ensure one sampled resident(Resident 115), who was receiving nutrition by gastrostomy tube (GT- a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration), received appropriate care and services to prevent complications of enteral feeding (tube feeding, a way of delivering nutrition directly to your stomach or small intestine). This deficient practice had the potential to lead to the inadequate care of Resident 115 and place the resident at an increased risk for complications such as infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of five sampled residents (Residents 113 and 115) were free from unnecessary use of psychotropic drugs (any medication capable of affecting the mind, emotions, and behavior) in accordance with the facility policy and procedure. For Resident 115, there was no measurable target behaviors related to the use of three antipsychotic medications. For Resident 113, there was no measurable target behaviors related to the use of two antidepressant medications. These deficient practices had the potential to place Resident 113 and Resident 115 at risk for significant adverse consequence (unwanted, uncomfortable, or dangerous effects that a drug may have) from the use of unnecessary psychotropic drug, which could result to impairment or decline in the residents' mental, physical condition, functional, and psychosocial status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control measures for one of 10 sampled residents (Resident 63). For Resident 63, the intravenous catheter (IV, a soft, flexible tube placed inside a vein, usually in the hand or arm. A medical technique that administers medication, fluids, and/or nutrients directly into a person's vein) was not discontinued / removed when clinically indicated. This deficient practice caused an increased risk to infection control issues and the potential of the resident experiencing phlebitis (inflammation of the vein).

Inspectors wroteBased on interview and record review, the facility failed to complete and/or submit the Minimum Data Sets (MDS - a comprehensive standardized assessment and screening tool) within the required time frame for six of 19 sampled residents (Residents 8, 10, 13, 57, 110 and 111). This deficient practice had the potential to negatively affect the provision of necessary care and services for Residents 8, 10, 13, 57, 110 and 111.

Inspectors wroteBased on observation, interview and record review, the facility failed to post daily actual hours or projected hours worked by the licensed and unlicensed staff providing direct care to the residents per shift and failed to complete the Direct Care Service Hours Per Patient Day (DHPPD - refers to the actual hours of work performed per patient day by a direct caregiver) for 9/3/2023 to 10/4/2023. As a result, staffing information of the unit was not complete and accurate for residents and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to reasonably accommodate Resident 8's physical limitations by providing a soft bell call light within easy reach. This failure had the potential for Resident 8 to be unable to maintain or achieve independent functioning, dignity, and well-being.

Inspectors wroteBased on interview and record review, the facility failed to assist one of six sampled residents (Resident 57) in formulating an Advance Directive (a legal document that tells your doctor your wishes about your health care if you cannot make the decisions yourself). This deficient practice had the potential to inhibit Resident 57's right to communicate his healthcare wishes when he was unable to make or voice those decisions on his own.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 59) was provided with a Notice of Medicare Non-Coverage (NOMNC - a notice that is provided to beneficiaries that indicates when their Medicare covered services are ending). This deficient practice had the potential to result in the resident not being informed of their coverage end date and not being able to exercise their right to file an appeal.

Inspectors wroteBased on interview and record review, the facility failed to complete the Dialysis (the removing of waste, salt, and extra water to prevent build up in the body for residents who have loss of kidney function) Communication Record for one of 19 sampled residents (Resident 13). This deficient practice had a potential to place Resident 13 at risk for a delay in detecting complications related to dialysis including infections, pain, respiratory issues, and bleeding. Cross Reference:

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one sampled residedent (Resident 111) was free of any significant medication errors (incorrect medication administration that could cause the resident discomfort or jeopardizes his/her health and safety) according to professional standards of practice by failing to: -Ensure Resident 111's had ordered parameters for (nifedipine [Procardia] and valsartan [Diovan] for hypertension). -Ensure Licensed Vocational Nurse 1 (LVN 1) did not administer nifedipine [Procardia] or valsartan [Diovan] to Resident 111 without parameters. This deficient practice had the potential to lead to uncontrolled blood pressure which could in turn cause cardiac arrest, stroke, and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all opened food items stored in the freezer was labeled with the name of the food item, open date, and expiration date. This deficient practice placed the 17 facility residents at risk for foodborne illness which could lead to serious infections and death.

Inspectors wroteBased on interview and record review, the facility failed to conduct, develop, and revise annually a facility-wide assessment that included the resources needed to competently provide care to their residents. This deficient practice had a potential for the 17 facility residents to not receive comprehensive and specialized care placing them at risk for harm.

Inspectors wroteBased on interview record review, the facility failed to ensure their Payroll Based Journal (PBJ - information of the provider's daily staffing hours for the appropriate care of the residents) data had been submitted to the Center for Medicare and Medicaid Services (CMS) for two of four required quarters (1st fiscal quarter due 2/14/2023 and 2nd fiscal quarter due 5/15/2023) in 2023. This deficient practice had the potential to place the 17 facility residents at risk for delay in care, treatment, and services necessary to maintain physical and emotional wellbeing.

Inspectors wroteBased on interview and record review, the facility's Quality Assessment and Assurance Committee (required to meet at least quarterly to identify issues and to develop and implement plans of action to correct identified deficiencies and to coordinate and evaluate activities to include performance improvement projects) failed to ensure a policy and procedure (a set of rules and/or guidelines that tell facility staff how to care for residents with specific needs) was in place for dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). This deficient practice had the potential to inhibit dialysis residents in the facility from receiving high quality care and had the potential to create an unsafe environment for facility residents. Cross Reference: