Pruitthealth - Bethany

Inspectors wroteBased on staff interview, record review, and review of the facility policy titled Monitoring of Antipsychotics, the facility failed to monitor targeted behaviors for the use of an antidepressant medication for one of five residents reviewed for unnecessary medications (Resident (R )40) out of 23 sampled residents. This failure had the potential for residents to receive unnecessary medications.

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled Medication Administration: General Guidelines, the facility failed to ensure infection control was maintained for one of three residents (Resident (R) 20) observed during medication administration. Specifically, the facility failed to ensure that pills were not touched with bare hands or dropped during medication administration, which increased the risk for cross-contamination and infection.

Inspectors wroteBased on staff interviews, record review, review of the facility policy titled, Antibiotic Stewardship Program, and review of McGeer's criteria, the facility failed to have an Antibiotic Stewardship Program that followed current standards of practice for prescribing an antibiotic for two of three residents (Resident (R)13 and R15) reviewed for antibiotic stewardship out of total sample of 23. This failure had the potential to cause residents to be prescribed antibiotics that were potentially unnecessary.

Inspectors wroteBased on staff interviews, record review, review of the facility policy titled, Pneumococcal Vaccinations, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer or provide documentation of consent or refusal for three of five residents (Residents (R)13, R40, and R60) and/or their resident representatives the opportunity for the residents to receive influenza and/or pneumonia vaccines out of 23 sample residents. This failure had the potential to put these residents at an increased risk of developing influenza and/or pneumonia.

Inspectors wroteBased on record review, staff interviews, and review of the facility policy titled Abuse Prevention and Reporting, the facility failed to protect the resident's right to be free from neglect by staff for one of five sampled residents (R) (R1) during Activities of Daily Living (ADL) care. Specifically, the Certified Nursing Assistant (CNA) CC was providing ADL care to R1 unassisted when R1 rolled away from CNA CC, falling from the bed, landing face down on the floor with blood noted on the head with a large open area, 14 cenimeter (cm) head laceration, and the scalp was pulled away from the head, exposing the skull. R1 expired at the hospital 50 minutes post fall. On [DATE], it was determined that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. [...]

Inspectors wroteBased on record review, staff interviews, and review of the facility policy titled Care Plans, the facility failed to develop an accurate person-centered comprehensive care plan for one of five sampled residents (R) (R1) that specified the need for two-person assistance with Activities of Daily Living (ADL) care. On 7/9/2024, it was determined that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Senior Nurse Consultant (SNC) was informed of the Immediate Jeopardy on 7/9/2024 at 4:06 pm. The noncompliance related to the Immediate Jeopardy was determined to have existed on 6/30/2024.

Inspectors wroteBased on staff interviews and record review, the facility failed to provide adequate assistance for bed mobility for one of five residents (R) (R1) reviewed for falls. Specifically, R1 fell from the bed during Activities of Daily Living (ADL) care on [DATE], resulting in death within 50 minutes post-fall. On [DATE], it was determined that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Senior Nurse Consultant (SNC) was informed of the Immediate Jeopardy on [DATE] at 4:06 pm. The noncompliance related to the Immediate Jeopardy was determined to have existed on [DATE].

Inspectors wroteBased on record review, staff interviews, and review of the facility's Administrator and Director of Health Services (DHS) job descriptions, the facility Administration failed to ensure one of five sampled residents (R) (R1) was free from neglect during Activities of Daily Living (ADL) care. This failure resulted in R1 falling from the bed and expiring at the hospital 50 minutes post-fall. On 7/9/2024, it was determined that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Senior Nurse Consultant (SNC) was informed of the Immediate Jeopardy IJ on 7/9/2024 at 4:06 pm. The noncompliance related to the Immediate Jeopardy was determined to have existed on 6/30/2024.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents' rooms and bathrooms were safe and maintained to promote a pleasant and homelike environment in 24 of 53 rooms (101, 102, 103, 104, 105, 106, 107, 108, 110, 112, 115, 117, 118, 119, 120, 121, 122, 123, 124, 126, 127, 128, 130 and 132) observed.

Inspectors wroteBased on observation, staff interviews, record review, and a review of the facility policy titled, admission Orders, the facility failed to have a physician order for administering oxygen for one of two resident (R) (66) reviewed for oxygen and failed to have a physician order for the tracheostomy size and type for one of one (R81) resident reviewed for tracheostomy (a tube inside of the windpipe in the throat to allow for breathing) care. This placed R66 at risk for receiving too much or too little oxygen and placed R81 at risk of having respiratory issues related to the incorrect size or type of tracheostomy appliance.

Inspectors wroteBased on observations, interviews, record review, and facility policy, the facility failed to maintain oxygen equipment (including changing and dating oxygen tubing, cleaning oxygen concentrator filters, and storing nasal cannula tubing in clear bags) for three residents of four residents (Resident (R) 19, R43, and R47) reviewed for respiratory/oxygen therapy. Additionally, the facility failed to maintain emergency equipment for one resident of one resident (R7) with a tracheostomy. The deficient practice had potential to affect four of eleven residents receiving respiratory treatment by increasing respiratory germs exposure; cause R43 respiratory distress due to inaccurate oxygen flow rate; and the potential for the emergency tracheostomy kit to have outdated or missing supplies.

Inspectors wroteBased on observations, interviews, and review of facility policy, the facility failed to ensure proper consistency of the pureed meats for nine residents on pureed texture diets of 78 census residents. The deficient practice has the potential to create a choking risk and result in decreased resident intake.

Inspectors wroteBased on observations, interviews, record review, and facility policy, the facility failed to ensure one resident of 24 sampled residents (Resident (R) 14) had a physician's order and was screened/assessed for the self-administration of medications prior to medications being stored at the bedside and self-administered by the resident. The deficient practice created the potential for medication errors to occur.

Inspectors wroteBased on interview and record review, the facility failed to ensure that Minimum Data Set (MDS) assessments were encoded and transmitted for two of two residents (Resident (R) 1 and R2) reviewed for Resident Assessment. This failure creates a potential discrepancy or delay in benefits due to payor sources not notified of a resident's admission status.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight, for one of one resident (Resident (R) 18) reviewed for nutritional status; resulting in continued significant weight loss.