Pruitthealth - Eastside

Inspectors wroteBased on record review, staff interviews, and review of the facility policy titled Medication Administration: Insulin Injections, the facility failed to ensure insulin was provided according to the blood sugar parameters on the sliding scale insulin physician order for one of five residents (Resident (R) 4), reviewed for unnecessary medications. This deficient practice had the potential to place R4 at increased risk of uncontrolled blood sugar levels.

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled Medication Delivery, the facility failed to ensure medications were stored securely and inaccessible to unauthorized individuals in two of four medication carts. This deficient practice created the potential for residents, unauthorized staff, and visitors to have access to medications and biologicals stored on the medication cart. The facility census was 83 residents.

Inspectors wroteBased on observations, staff interview, and review of the facility policy titled Hand Hygiene Policy, the facility failed to ensure staff properly performed hand hygiene and peri care for one of three residents (Resident (R)11) observed receiving care. This deficient practice had the potential to place R11 at increased risk of infection.

Inspectors wroteBased on staff and responsible party (RP) interviews, record review, and review of the facility's document titled Charge Nurse Workflow, the facility failed to notify one resident's (R) (R1) RP of a change in condition and transfer to the hospital. This failure had the potential to affect one of three residents reviewed for notification of change.

Inspectors wroteBased on observations, staff interviews, and review of the facility policies titled Foodborne Illnesses, Labeling, Dating, and Storage, Pot/Pan Washing and Sanitation, and Food Temperatures, the facility failed to thaw meat properly to prevent a foodborne illness, failed to clean a floor fan to prevent food contamination, failed to label and date opened food items, failed to discard leftover foods by the use by date, failed to demonstrate the proper usage of the three-compartment sink to prevent foodborne illness, and failed to properly maintain all food items on the steam table above 135 degrees Fahrenheit (F) to prevent bacteria growth. The deficient practices had the potential to place 78 residents who received an oral diet from the kitchen at risk of contracting a foodborne illness. The facility census was 79.

Inspectors wroteBased on observation, staff interviews, record review, and review of the facility policies titled Infection Control Precautions for Dressing Change, Clean Procedures, and Using the Treatment Cart and Infection Prevention-Hand Hygiene, the facility failed to ensure infection control practices were followed during wound care for one of two residents (R) (R28) reviewed for wound care. The deficient practice had the potential to increase the probability of R28 contracting an infection in his current wound.

Inspectors wroteBased on record review, staff interviews, and review of the facility policy titled Nutritional Screening and Assessments/Food Preferences, the facility failed to ensure the Registered Dietitian completed an annual nutritional assessment for one of 30 sampled residents (R) (R53). The deficient practice had the potential to place R53 at risk of unmet nutritional needs.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled Oxygen Administration, the facility failed to ensure respiratory equipment was maintained in a sanitary manner for three of 10 residents (R) who received oxygen (R64, R54, and R29). The deficient practice had the potential to place R64, R54, and R29 at an increased risk of respiratory complications and infection.

Inspectors wroteBased on observations, staff interviews, and resident interviews, the facility failed to ensure a functioning call system for one of 30 sampled residents (R) (R39). This failure placed R39 at risk of accident, injury, and/or unmet needs related to an inability to call for staff assistance.

Inspectors wroteBased on observations, staff interviews, and a review of the facility's policies titled, Labeling, Dating, Leftovers, Food Temperatures, Refrigeration/Freezer Temperatures, and Storage, and Pot/Pan Washing and Sanitation, the facility failed to ensure food items in the refrigerator were properly labeled, dated, and discarded; failed to ensure the dish machine had a final rinse temperature at or above 180 degrees for proper sanitization; failed to properly wash food processor bowl, lid, and blade between pureed food items to prevent cross contamination; failed to properly use the three-compartment sink to properly sanitize dishware; failed to ensure all food items on the steam table were held at or above 135 degrees to prevent foodborne illness; and failed to ensure all refrigerators containing food items had an internal temperature of 41 degrees or below to prevent bacterial growth. [...]

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled Nutritional Screening and Assessment/Food Preferences, the facility failed to complete a Comprehensive Nutritional Assessment for six of 27 residents (R) (R#72, R#37, #46, #36, #65, and #69) sampled.

Inspectors wroteBased on observations, staff interviews and a review of the policy titled Medication Storage in the Healthcare Setting, the facility failed to ensure that all drugs and biologicals were securely stored and not accessible by residents, unauthorized staff or visitors, specifically the facility failed to ensure that two of four medication carts were locked and secured when left unattended and out of eyesight of the nurse (West Wing Long Hall and East Wing A Hall carts); failed to ensure that all drugs and biologicals were appropriately labeled with an opened or discard date, specifically one tuberculin purified protein derivative 10 dose vial (an injectable solution used in a skin test to help diagnose tuberculosis); [...]

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to maintain dignity by ensuring a dignity bag was provided for one of seven residents (R) (R#69) who had an indwelling urinary catheter. This failure had the potential to diminish the resident's quality of life in an environment that promotes the maintenance or enhancement of each resident's quality of life.

Inspectors wroteBased on staff interviews, and record review, the facility failed to accurately code one of 27 resident (R) (#52) Quarterly Minimum Data Set (MDS) sampled. This failure has the potential to cause the Resident's medical record to reflect inaccurate data related to MDS coding.

Inspectors wrote2. Observation on 5/19/2023 at 2:35 p.m., and 5/20/2023 at 8:15 a.m. of R#69 revealed him to be sitting in a wheelchair with a urinary catheter drainage bag attached to the wheelchair without a privacy bag. The urine in the drainage bag was visible to other residents, staff, and visitors. Interview on 5/20/2023 at 10:40 a.m. with Certified Nursing Assistant (CNA) HH revealed CNAs were responsible for ensuring urinary catheter drainage bags were kept in privacy bags. She further revealed that she was unaware of what interventions were in the care plans. Interview on 5/20/2023 at 10:45 a.m. with LPN GG revealed that urinary drainage bags should be kept in privacy bags to prevent other residents and visitors from observing a resident's urine. [...]

Inspectors wroteBased on staff interviews, record review, and a review of the facility's policy, Significant Weight Changes, the facility failed to update the care plan with appropriate interventions for one resident (R) (#36) with significant weight loss. This failure had the potential for residents to not receive treatment and/or care according to their needs and place residents in a position for adverse consequences.

Inspectors wroteBased on staff interviews, and record review, the facility failed to provide appropriate care and services for one resident (R) (#61) with a diagnosis of Post-Traumatic Stress Disorder (PTSD). This failure had the potential to increase the risk for a resident with a mental illness diagnosis from not receiving specialized services.

Inspectors wroteBased on observation, staff interviews, and recipe review, the facility failed to ensure that dietary staff followed recipes for preparing pureed foods to avoid compromising the nutritive value, flavor, or appearance. This affected six of 73 residents receiving an oral diet.

Inspectors wroteBased on observations, staff interviews, and a review of the facility policy titled Infection Prevention and Control Plan, the facility failed to ensure resident basins and bedpans were labeled and covered for three of 54 rooms. These failures had the potential to expose patients to infections due to cross-contamination.