Queen Anne Nursing Home, Inc

Inspectors wroteBased on record review, document review, policy review, and interview, the facility failed to implement policies and procedures to ensure residents were properly screened for eligibility to receive the recommended pneumococcal vaccine, residents/residents' representatives were educated on the benefits and potential side effects of the vaccine, and were offered and administered (if applicable) the vaccine in a timely manner for four Residents (#1, #52, #49, and #278), out of a total sample size of five residents reviewed for immunizations.

Inspectors wroteBased on record review, document review, policy review, and interview, the facility failed to implement policies and procedures to ensure residents were properly screened for eligibility to receive the most up to date COVID-19 vaccine, residents/residents' representatives were educated on the benefits and potential side effects of the vaccine, and offered and administered (if applicable) the vaccine in accordance with CDC recommendations for three Residents (#52, #49, and #43), out of a total sample size of five residents reviewed for immunizations.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who had physicians orders for Lithium (chemical element, used to treat bipolar disorder), the Facility failed to ensure nursing notified his/her Physician and Family Representative when on 5/10/23, it was determined by nursing that Resident #1's new physicians order for Lithium that had been obtained on 5/04/23, (which decreased the total weekly amount of Lithium he/she was to be administered), had not been transcribed onto his/her Medication Administration Record (MAR), and he/she continued to receive the previously ordered dosage. Although Nurse #1 identified the transcription error and reported it to the (now Former) Director of Nurses at that time, neither the Physician or Resident #1's Family Representative were notified.

Inspectors wroteBased on records reviewed and interviews for two of three sampled residents (Resident #1 and Resident #3), the Facility failed to ensure they were free from significant medication errors, when 1) Resident #1's new physicians order obtained on 5/04/23 to decrease his/her dose of Lithium (chemical element, used to treat bipolar disorder) was not transcribed by nursing until a week later, resulting in his/her serum (blood) levels of Lithium to increase, and 2) Resident #3 who was newly admitted to the Facility in July 2023, and due to an error in medication reconciliation upon admission, he/she was administered only half the physician's order dosage of Eliquis (an anticoagulant that thins the blood), during his/her stay in the facility, placing him/her at risk for reoccurrence of blood clots. Findings Include: [...]

Inspectors wroteBased on records reviewed and interviews for two of three sampled residents (Resident #1 and Resident #3) the Facility failed to ensure they maintained complete and accurate medical/clinical records, including but not limited to their Medication Administration Records (MAR), the transcription of Physician's Orders and Medication Reconciliation, when 1) for Resident #1, who although nursing obtained a verbal order to change the dose and administration schedules of his/her Lithium (chemical element, used to treat bipolar disorder) the order was not transcribed by nursing until a week later, resulting in the incorrect dosage of Lithium being administered during that time period, and 2) for Resident #3 who was newly admitted to the Facility in July 2023, due to an error in medication reconciliation upon admission, he/she was administered half the physician's ordered dose of Eliquis [...]

Inspectors wroteBased on document review and interview, the facility failed to ensure the Facility Assessment was updated annually to accurately reflect the current status of the facility and to determine what resources are necessary to competently care for its residents during both day-to-day operations and emergencies.

Inspectors wroteBased on observations, interviews, policy review, and record review, the facility failed to ensure COVID-19 testing was conducted per facility policy and Centers for Disease Control and Prevention (CDC) guidance for two Residents (#43 and #55) with respiratory symptoms, in a total sample of 22 residents.

Inspectors wroteBased on interview, the facility failed to develop, implement, and maintain a comprehensive Compliance and Ethics program as required.

Inspectors wroteBased on observation, record review, policy review, and interview, the facility failed to ensure that staff provided care and treatment according to acceptable standards of clinical practice for six Residents (#244, #243, #69, #75, #85, and #246), out of a total sample of 24 residents. Specifically, the facility failed: 1. For Resident #244, to ensure that Lorazepam (anti-anxiety medication) was administered per the physician's orders; 2. For Resident #243, to ensure that medications were reconciled upon admission to the facility per the facility policy; 3. For Resident #69, to ensure that a change in the Resident's condition was further assessed and documented in the medical record within one hour of the identification of the change in condition; 4. [...]

Inspectors wroteBased on observation, record review, policy review, and interview, the facility failed to ensure that care and treatment of a peripherally inserted central catheter (PICC- intravenous catheter inserted into a vein in the upper arm and is advanced until the internal tip of the catheter is in the superior vena cava which is one of the central venous system veins that carries blood to the heart) was provided in accordance with current standards of practice and the facility policy/protocols for 4 of 4 Residents (#244, #243, #75, and #85) with PICCs in place, out of a total sample of 22 residents. Specifically, the facility failed to ensure that: 1. For Resident #244, a. The IV administration set/tubing was changed every 24 hours, b. The needleless connector was changed on admission and every 7 days thereafter, c. [...]

Inspectors wroteBased on observation, interview, policy review, and record review the facility failed to ensure all nurses (staff or agency) providing care to 4 of 4 Residents (#75, #85, #243 and #244) with PICC lines, had completed training and competencies for Intravenous (IV) Therapy and for care and management of Peripherally Inserted Central Catheter (PICC)/Midlines.

Inspectors wroteBased on interview, policy review, and record review, the facility failed to ensure for four Residents (#294, #293, #245, and #44), out of a total sample of 22 residents, that each resident's drug regimen was free from unnecessary drugs. Specifically, the facility failed to monitor for potential adverse consequences related to the use of anticoagulant (blood thinner) medications.

Inspectors wroteBased on observations, interviews, policy review, and record review, the facility failed to ensure staff implemented infection prevention and control practices and policies. Specifically, the facility failed to: 1. Monitor respiratory symptoms and implement transmission-based precautions for two Residents (#43 and #55); 2. Follow infection control standards during a medication pass, including hand hygiene; and 3. Follow infection control practices during a wound dressing change for Resident #294.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to notify the physician of changes in the health condition of one Resident (#69), out of a total sample of 22 residents.

Inspectors wroteBased on interview, record review, and policy review, the facility failed for one Resident (#30), out of a total sample of 22 residents, to develop and implement a comprehensive behavior care plan with measurable goals and individualized interventions to address behaviors exhibited towards a roommate.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure activity of daily living (ADL) care was provided to maintain good personal grooming for one Resident (#43), in a total sample of 22 residents. Specifically, the facility failed to ensure nail care was performed for Resident #43.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one Resident (#294), out of a total sample of 22 residents, received care and treatment to promote healing of pressure injuries. Specifically, the facility failed to ensure the Resident's air mattress was set per physician's orders and ensure pressure related interventions were consistently implemented to promote wound healing.

Inspectors wroteBased on record review and interview, the facility failed to provide care and service for an indwelling Foley catheter (urinary catheter which remains in the bladder to provide continuous urine drainage. A balloon inflated at the catheter's distal end prevents it from slipping out of the bladder after insertion) for one Resident (#244), out of a total sample of 22 residents. Specifically, for Resident #244, the facility failed to ensure the physician's order for changing/inserting the Foley catheter included catheter size/type and balloon size.

Inspectors wroteBased on observation, interview, policy review, and record review, the facility failed to monitor the nutritional status of one Resident (#14), out of a total sample of 22 residents. Specifically, the facility failed to ensure a reweigh was obtained within 24 hours to verify a significant weight change in one month, to ensure weekly weights were obtained as ordered, and to ensure the Resident's significant weight loss was addressed in a timely manner.

Inspectors wroteBased on record review and interview, the facility failed to ensure that PRN (as needed) orders for psychotropic medications were limited to 14 days and were not renewed unless the attending physician or prescribing practitioner evaluated the Resident for the appropriateness of that medication for one Resident (#244), in a sample of 22 residents.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure medications were stored safely and securely. Specifically, the facility failed to: a. Ensure a medication cart was only accessible to the licensed nurse responsible for those medications; and b. Ensure a treatment cart was locked and the consultant wound physician's medical bag was secured.