Presbyterian Intercomm Hosp Dp/SNF

Inspectors wroteBased on observation, interview and record review, the facility failed to promote dignity and respect when a care view camera (a specialized camera designed for patient monitoring in healthcare setting that allows healthcare professionals to remotely observe residents and intervene if necessary, typically for safety purposes like fall prevention) was placed in the resident's room for four (4) of eight (8) sampled residents (Residents 33, 49, 60 and 64). This failure resulted in Resident 33, 49, 60 and 64 experiencing feelings of discomfort and not having any personal privacy.1. During a review of Resident 49’s admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of septic discitis (infection discitis; [...]

Inspectors wroteBased on interview and record review, the facility failed to follow its policy titled, Resident Assessment Instrument (RAI - a standardized process used in nursing homes to collect information about residents' needs and strengths, enabling the creation of individualized care plans) Process, for two (2) of six (6) sampled residents (Residents 46 and 57) by not ensuring the comprehensive resident assessment was completed within 14 calendar days of resident's admission. This failure had the potential to result in Residents 46 and 57 not having an individualized care plan, which could negatively affect the residents' over all wellbeing.1. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete and transmit a discharge tracking assessment (a type of assessment conducted when a resident leaves a nursing home, which includes clinical items for quality monitoring as well as discharge tracking and is transmitted to the Centers for Medicare and Medicaid Services [CMS; a United States government agency that administers healthcare programs]) for one (1) of five (5) sampled residents (Resident 57). This failure had the potential to result in the facility's inaccurate quality monitoring data at transition points, such as when residents enter or leave the facility. During a review of Resident 57's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of pyelonephritis (a type of urinary tract infection [UTI; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of 1 sampled Resident (Resident 65) who was receiving nutrition by nasogastric tube feeding (NGT - a method of providing nutrition and medication directly into the stomach through a tube inserted through the nose) was provided care to prevent aspiration by failing to ensure the resident's head of the bed was elevated during feeding in accordance with the facility's policy. This deficient practice placed Resident 65 at risk of aspiration (feeding could enter the windpipe and lungs) that could lead to lung problems such as pneumonia (an infection/inflammation of the lungs).

Inspectors wroteBased on interview and record review, the facility failed to administer a medication for one (1) of seven (7) sampled residents (Resident 5) as indicated on the physician's order. This failure had the potential to place Resident 5 at risk for developing a Urinary Tract Infection (UTI; an infection in the bladder/urinary tract) due to not receiving her Estradiol (hormone medication used for regulating various bodily processes). During a review of Resident 5's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD; a chronic lung disease causing difficulty in breathing) and coronary artery disease (CAD; a condition where the blood vessels that supply the heart become narrowed or blocked). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have accurate and complete medical records for one (1) of seven (7) sampled residents (Residents 60) by failing to document the Nurse Practitioner (NP, a registered nurse with advanced education and training, holding a master's or doctoral degree in nursing) notification of Resident 60's refusal to take Atenolol (drug used to treat high blood pressure) in accordance with the facility's policy. This deficient practice resulted in the inaccurate representation of care provided which could delay the provision of necessary care and services needed for Resident 60's wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report an allegation of abuse to the Department of Health Services (DHS a government agency that promotes and protects the health of all people and their communities) and the state agencies within the two-hour time frame as indicated in the facility's policy and procedure for one of two sampled residents (Resident 69). The Licensed Vocational Nurse (LVN) 2 did not report to the Director of Nursing (DON) when Resident 69 reported to LVN 2 that a staff member (unknown) yelled and was mean to Resident 69. This deficient practice violated the resident's rights to be free from any form of abuse and the potential for Resident 69 not to be protected and to further experience mental and emotional abuse that could lead to a psychosocial (mental and emotional being) and decline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were maintained in the kitchen. During initial tour of the kitchen, an opened container of salad was observed unlabeled with the name of the food item and dated of when the food was prepared or to be discarded. This failure had the potential for improper food storage, which could lead to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins).

Inspectors wroteBased on observation, interview and record review, the facility failed to promote care that maintained dignity and respect for one of one sampled residents (Resident 11) by failing to ensure Resident 11's drainage bag (a tube that removes fluid from the body into a collection bag connected to the resident that stored body fluids) from the stomach that was hanging from on the resident's bed frame was not exposed to the public and uncovered. This deficient practice had the potential to affect the resident's psychosocial (emotional and mental status) being and deprive the resident from dignity.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two closed sampled residents (Resident 13), received notification of the transfer/discharge from the facility and the reasons for the move in writing. As a result of this failure the facility deprived Resident 13 the right to be informed regarding transfer and discharge from the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess the risk for accidental choking for one of one sampled resident (Resident 116), for the ability to chew food and safely eat a regular textured diet (all food textures that people with no chewing or swallowing issues eat) who had missing top teeth and dentures. This failure had the potential for Resident 116 to choke on her food and result in accidental death.

Inspectors wroteBased observation, interview, and record review, the facility failed to provide care related to IV sites/therapy (Intravenous is a small plastic catheter placed through the skin into the vein used to give fluids and medications) based on to the professional standard of practice and the facility's policy and procedure for two of two sampled residents (Resident 63 and Resident 66). 1. Resident 63's, IV medication bag was not labeled with the date and time the antibiotic (medication used to treat infection) was administered. Resident 63's IV tubing was not labeled with the date and the tubing was first used. 2. Resident 66's IV site dressing/tape (plastic tape or gauze covering the IV) on the left arm was not labeled with date and time of when the IV site was dressing/tape was change. [...]

Inspectors wroteBased on interview and record review the facility did not conduct, document, and review a Annual Facility Assessment (a facility wide assessment of the facility that included plan that define the process of strategizing, or directing, and making decisions on allocating its resources to enable each nursing home to thoroughly assess the needs of their resident population and the required resources needed to provide the care and services that residents need) as described in the regulations for long term care facilities for 23 of 23 residents in the census. This deficient practice had the potential for the residents in the facility not to receive the care and services needed to achieve their highest potential.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow its policy and procedure to maintain and prevent the entrance and harborage (any condition or place where pest can obtain water or food, nest and obtain shelter) of vermin (pests that spread diseases or destroy crops or livestock) and other pest by failing to provide proof of the facility's pest control activities and with presence of vermin in the facility. 1. On 7/7/2023, a live cockroach was observed in the facility hallway, between Resident 61's room and an empty resident room, next to an exit door to stairwell. 2. On 7/9/2023, another live cockroach was observed inside the Shower room [ROOM NUMBER]. This deficient practice resulted in an ineffective pest control program that could result in pest infestation and result in widespread infection and diseases from the pest and cockroaches.

Inspectors wroteBased on observation, interview, and record review, facility failed to promote respect and dignity for one of two sampled residents (Resident 109) by failing to ensure, Resident 109's urinary catheter (a thin tube that goes in through the urethra [part of resident's anatomy of the urinary tract that connects the bladder with the outside of the body]) drainage bag was covered with a privacy bag. This failure had the potential to affect Resident's 109's psychosocial (mental, emotional, social interactions) wellbeing.

Inspectors wroteBased on interview and record review the facility failed to provide a written and verbal notification about Bed Hold (is when a nursing home holds a bed for you when you go into the hospital) to the resident and the resident's legal representative for one of two sampled resident's (Resident 7) who was transferred to the General Acute Care Hospital (GACH) due to a change in condition that required a higher level of care. This failure resulted in violation of the resident's rights to ensure the resident's and the legal representative could make informed decisions about the duration of Bed Hold and the resident's rights to return to the facility from the GACH.

Inspectors wroteBased on observation, interview, and record review the facility failed develop a comprehensive, resident specific plan of care for two of three sampled residents (Resident 117 and Resident 161) as indicated in the facility's policy and procedure. 1. For Resident 117 failure to develop an individualized plan of care with measurable goals, specific interventions and assessment that identifies who and when the interventions are to be implemented for the resident who was receiving hemodialysis (a medical procedure that removes the excess fluid and toxins in the blood with a specialized medical equipment). 2. For Resident 161 the facility did not develop a plan of care for the use of postural support.

Inspectors wroteBased on observation, interview, and record review, the facility failed ensure one of one sampled resident (Resident 161) who was at high risk for fall and accident due to impaired cognition (thought process and ability to reason), unsteady gate and restlessness was provided safety to prevent injuries by failing to: 1. ensure Resident 161 was assessed by the licensed staff and the physician prior to the use of Posey torso support belt (five-inch-wide belt with shoulder straps for wheelchairs or similar non-wheelchair applications) for the risk for accident and entrapment (the state of being caught in or as in a trap.). 2. a plan of care was developed with interventions that indicated how and who will assess and monitor Resident 161 while using the Posey torso support belt. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility's Transitional Care Unit Dialysis (is a life-support treatment that uses a special machine to filter harmful waste, salt, and excess fluid from your blood) Communication Record were completed on 6/28/2023 and 7/7/2023 for one of two sampled resident (Resident 117) who was receiving hemodialysis treatments. This deficient practice had the potential for the resident to have delayed or fail to receive necessary interventions when they experience complications related to dialysis such as bleeding on the dialysis access site (formed by the joining of a vein and an artery in an area in the body that connects to the dialysis machine), low blood pressure and low heart rate or severe weakness.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain and prevent the spread and transmission of herpes zoster (known as shingles is the same virus that causes chickenpox which can spread from spread from person to person though contact) infection for one of one sampled resident (Resident 59). Resident 59's family (FAM2) was observed in nursing station wearing an isolation gown (gown used to protect clothing from contaminants or contacting disease causing organism), facemask and gloves that was used while visiting Resident 59. FAM 2 was observed returning to Resident 59's room wearing the same gown. This deficient practice had the potential to spread the infection to the residents, staffs, and other visitors in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure facility staff received information on abuse prevention as indicated in the facility's policy and procedure. Three of four sampled staff were not able to state the different types of abuse and did not know the time-frame to report abuse allegations of abuse. This deficient practice had the potential for a delay to identify, report and investigate potential allegations of abuse and exposing residents to potential abuse.