Pruitthealth - Old Capitol

Inspectors wroteBased on observations, staff interviews, and review of the facility's policies titled Labeling, Dating, and Storage, the facility failed to ensure that food was properly labeled and stored. This deficient practice had the potential to place the 88 residents receiving nutrition and hydration from the kitchen at increased risk of foodborne illness.

Inspectors wroteBased on observation, resident and staff interviews, record review, and review of the facility policy titled Self-Administration of Medication by Patients/Residents, the facility failed to ensure one of 34 sampled residents (R) (R43) was assessed for medication self-administration before allowing medications at the bedside. This deficient practice had the potential to place R43 at increased risk of medical complications related to medication use.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled Infection Prevention-Hand Hygiene, the facility failed to ensure infection control practices were followed during wound care for one of four residents (R) (R8) with wounds. This deficient practice had the potential to place R8 at increased risk for infection due to cross-contamination.

Inspectors wroteBased on interviews, record review, and a review of the facility policy titled Facility Assessment Tool, the facility failed to provide education for all nursing staff to possess the competencies and skill sets necessary to ensure residents were free of medication errors as well as ensure these competencies and skill sets were monitored on an ongoing basis. As a result, one of 26 residents (Resident (R) 50) out of a total sample of 83 residents was hospitalized after a nurse administered a benzodiazepine (an antianxiety drug that can cause sedation), which was not ordered by the physician, to the resident. [...]

Inspectors wroteBased on resident and staff interviews, record review, and a review of the facility policy titled Medication Administration: Oral Medications, the facility failed to ensure residents were free from significant medication errors for one of 26 sampled residents (Resident (R) 50) out of 83 total residents. R50 received a benzodiazepine (an antianxiety drug that can cause sedation), that was not ordered by the physician and contributed to her hospitalization. The facility's failure to ensure residents were free from significant medication errors presented a likelihood of serious harm, injury, impairment, or death to a resident. Immediate Jeopardy was identified on 5/22/2024 in the area of §483.45 Pharmacy Services F760 at a scope and severity (S/S) of J. [...]

Inspectors wroteBased on interviews, facility policy reviews, and job description reviews, the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to avoid significant medication errors during nursing medication administration. The facility failed to provide continued, effective oversight of the nursing staff's medication administration practices. This failure affected one of 26 residents out of 83 total residents (Resident (R) 50) when R50 received a benzodiazepine (an antianxiety drug that can cause sedation), which was not ordered by the physician and contributed to R50 hospitalization. The failure of the facility to provide continued, effective oversight of nursing staff's medication administration practices presented a likelihood of serious harm, injury, impairment, or death due to the significant medication error for R50. [...]

Inspectors wroteBased on resident and staff interviews, review of Resident Council Minutes, and review of the facility policy titled, Patient/Resident Council, the facility failed to ensure a response was provided to the members of the resident council when concerns were identified related to transportation accommodations for outings. During the resident council meeting four residents (R) (R30, R36, R54, and R78) had complaints of transportation not being provided for outings and had not received a response.

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled Controlled Substances for Healthcare Centers, the facility failed to ensure that controlled medications (drugs that can cause physical and mental dependence and have restrictions on how they can be filled and refilled) were stored separately from other medications and were stored under a double-lock system in two of two medication storage room refrigerators.

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled Labeling, Dating, and Storage, the facility failed to ensure food items were securely closed, labeled, and dated after opening. This had the potential to affect 75 of 83 residents who consumed food from the kitchen.

Inspectors wroteBased on interview, review of facility documentation, and review of facility policy, the Quality Assurance and Performance Improvement (QAPI) committee failed to ensure it developed and maintained a program to provide systematic analysis and systemic action aimed at performance improvement. This failure had the potential to affect all 83 residents who currently live in the facility.

Inspectors wroteBased on interview, review of facility documentation, and review of facility policy, the Quality Assurance and Performance Improvement (QAPI) committee failed to ensure the required members of the committee attended the quarterly meetings. This failure had the potential to affect all 83 residents who currently live in the facility.

Inspectors wroteBased on record review, interviews, and review of the policy titled, Freedom from Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property Mission Statement, the facility failed to ensure a thorough investigation was completed for an injury of unknown origin for one of 26 sampled residents (R) (R#14).

Inspectors wroteBased on observation, record review, and review of the facility policy titled Stop Orders-Healthcare Centers revealed the facility failed to ensure that a psychotropic medications/antianxiety medication was not ordered as needed (PRN) for more than 14 days unless clinically indicated for one of five residents (R) (R#64) reviewed for unnecessary medications. Fundings include: A review of the facility policy titled Stop Orders-Healthcare Centers reviewed 6/22/22 revealed: Policy Statement: It is the policy of the healthcare center to automatically stop medications after the indicated number of days, unless the prescriber specifies a different number of doses or duration of therapy given. Procedure: 1. [...]