Pruitthealth- Conway at Conway Medical Center

Inspectors wroteBased on review of facility policy, record review and interview, the facility failed to develop a comprehensive care plan for Resident (R)25, for 1 of 37 sampled residents.

Inspectors wroteBased on review of facility policy, record review, observation, and interview, the facility failed to ensure respiratory equipment was maintained in a sanitary manner and in accordance with facility policy, and failed to ensure physician orders were in place for oxygen equipment maintenance for 1 of 12 residents reviewed who receive oxygen, Resident (R)25.

Inspectors wroteBased on observation, interview, facility policy review, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for five (5) out of five (5) sampled residents (Resident (R)33, R37, R73, R75 and R188).

Inspectors wroteBased on observation, interview, policy review, and record review, the facility failed to provide reasonable accommodation of resident needs and preferences for one (1) of 39 sampled residents, (Resident (R)39). The resident could not access his/her call light during three (3) different observations.

Inspectors wroteBased on observation, interview, facility policy review, and record review, the facility failed to protect the personal privacy and confidentiality of personal and medical records for two (2) of five (5) sampled residents, (Resident (R)37 and R73). Specifically, the Electronic Medication Administration Records (EMR) were not minimized and/or concealed while the medication cart was left unattended by a Registered Nurse (RN).

Inspectors wroteBased on review of facility policy, record review and interview, the facility failed to electronically transmit encoded, accurate, and complete Minimum Data Set (MDS) data to the CMS System for seven (7) out of 74 resident reviewed.

Inspectors wroteBased on observations, interviews, facility policy review, and record review, the facility failed to accurately reflect the resident's status for one (1) of five (5) sampled residents. Specifically, the Registered Nurse (RN) failed to accurately document an Accu-check (a device used to check blood sugars) result for Resident (R)73.

Inspectors wroteBased on observation, interview, facility policy review and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, Resident (R)39 did not have his/her call light within reach as outlined in the care plan. Additionally, R37 was not care planned for Enhanced Barrier Precautions (EBP). This affected two (2) of seven (7) sampled residents.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a Physician's Order was followed for the administration of a medication patch, Lidocaine (used for the treatment of pain). This affected one (1) of six (6) residents (Resident (R)75) observed during medication administration.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure that medications were properly stored for one (1) of six (6) residents (Resident (R)33) when staff left medications on top of a medication cart unattended and out of view.

Inspectors wroteBased on review of facility policy, observations and interviews, the facility failed to ensure that medications were secured, that outdated medications were removed from active storage and that medications were labeled as to opened and/or expiration date for 6 of 8 medication storage areas with expired medications and/or unlocked medication carts.

Inspectors wroteBased on observations, interviews, and review of the facility policy, the facility failed to ensure foods that are stored in the freezer, dry storage, emergency storage and resident dietary rooms were labeled with contents and open date and discarded after the manufacturer's expiration date. Findings Include: Review of the facility ' s policy titled, Food Ordering, Receiving, and Storage, with an effective date of 09/01/2001, reveals It is the policy of PruittHealth that food will be routinely ordered and received from approved corporate vendors who obtain food from regulated and reputable sources to ensure safety. Storage and Rotation Guidelines: FIFO: first in, first out. Stock should be rotated utilizing this principle. Old products should be moved to the front of the shelf, new products behind the old. Date all stock items with delivery date. [...]

Inspectors wroteBased on review of facility policy, observations, and interviews, the facility failed to ensure an excessive build-up of lint was removed from 2 of 2 clothes dryers.

Inspectors wroteBased on review of facility policy, interviews, record review, and observation, the facility failed to ensure sufficient nursing staff for 19 of 30 days reviewed for sufficient staff needed to maintain the highest practicable physical, mental, and psychosocial health and safety of each resident.

Inspectors wroteBased on review of facility policy, record reviews and interviews, the facility failed to ensure residents were offered the Pneumococcal Vaccinations, and to ensure residents had received the vaccination while a resident of the facility, if they chose to do so for 5 of 5 residents reviewed for immunizations.

Inspectors wroteBased on review of the facility policy, observations, interviews and record reviews, the facility failed to ensure that Resident (R)18 was provided a comfortable fitting bed for 1 of 1 residents reviewed for accommodation of needs.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that Resident (R)54 had an accurate Level 1 Preadmission Screening and Resident Review (PASARR), for 1 of 1 residents reviewed for PASARR.

Inspectors wroteBased on review of facility policy, observations, and interviews, the facility failed to follow procedure during wound care for Resident (R)12 to promote healing and to prevent or decrease the likelihood of infection for 1 of 2 residents reviewed with pressure ulcers.

Inspectors wroteBased on review of facility policy, observations, and interviews, the facility failed to follow procedure during suprapubic catheter care for Resident (R)12, to reduce the risk of infection for 1 of 3 residents reviewed for catheter care.

Inspectors wroteBased on record reviews, interviews, and review of facility policy, the facility failed to ensure Resident (R)24 received all doses of a drug prescribed for atrial fibrillation for 1 of 6 residents reviewed for unnecessary medications.

Inspectors wroteBased on review of facility, observations, and interviews, the facility failed to ensure proper hand washing during suprapubic catheter care and wound care for 1 of 1 residents reviewed for catheter care and wound care.