Robertsdale Rehabilitation & Healthcare Ctr

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to notify the Ombudsman of hospital transfers in writing for three of three residents (Resident (R) 16, R38, and R93) out of a total sample of 35 residents reviewed for hospitalization. This had the potential for the residents to have no added protection if the residents were being inappropriately discharged or transferred so they could inform them of their rights and options.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to protect the resident's right to be free from abuse for seven of nine residents (Resident (R) 48, R83, R267, R15, R117, R76, and R80) reviewed for abuse. This failure had the potential to affect resident safety.

Inspectors wroteBased on interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, and facility policy review, the facility failed to ensure four of six residents (Resident (R) 15, R83, R93, and R94) reviewed for pneumococcal vaccines out of total sample of 35 residents were either offered pneumococcal vaccines or offered additional pneumococcal vaccines per CDC guidelines. Additionally, the facility failed to obtain consents and provide the risks and benefits to the residents and/or responsible party (RP) prior to administering pneumococcal vaccines. Additionally, the facility failed to ensure R93 was offered an influenza vaccine. The failure of not offering/providing pneumococcal vaccines increased the risk for residents to contract pneumonia. The failure for not offering influenza vaccine increased the risk for the resident to contract influenza.

Inspectors wroteBased on record review, observation, interview, and facility policy review, the facility failed to ensure one of two residents (Resident (R) 83) observed for dining out of 35 sample residents was positioned to ensure the resident could access their food without difficulty and at a comfortable position. This had the potential for the resident to have a decline in nutritional status and a negative dining experience.

Inspectors wroteBased on observations, record review, interview, and job description review, the facility failed to ensure two of four residents (Residents (R) 5 and R 37) reviewed for activities of daily living received adequate assistance with shaving. This failure had the potential to negatively impact the quality of life and self esteem for the affected residents.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure staff were providing appropriate and timely urinary catheter care for one of four residents (Resident (R) 5) reviewed for catheters and urinary tract infections of 35 sample residents. This failure placed the residents at risk for infection to the urinary tract and urethral trauma.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure ceiling vents did not drip condensation onto the tray line and scoops were stored appropriately. This deficient practice had the potential to affect 100 of 113 residents who received meals prepared in the facility's kitchen.

Inspectors wroteBased on interview and review of the facility's RECORD OF MEDICATION DISPOSAL forms, the facility failed to ensure the controlled drug destruction records had three required signatures. This was noted in 10/2018 and 5/2019, two of the six months of controlled drug destruction records reviewed. Findings Included: Review of the RECORD OF MEDICATION DISPOSAL forms, dated 10/16/18, revealed there were only two signatures present for the disposal of controlled medications. The section of the form for Signature of Witness (Only required for Controlled Drugs) was blank. Review of the RECORD OF MEDICATION DISPOSAL forms, dated 5/10/19, revealed there were only two signatures present for the disposal of controlled medications. The section of the form for Signature of Witness (Only required for Controlled Drugs) was blank. [...]

Inspectors wroteBased on interviews, medical record review and review of [NAME] and [NAME] Fundamentals of Nursing Ninth Edition, Chapter 23 Legal Implications in Nursing Practice, the facility failed to ensure a physician's order was accurately transcribed for Resident Identifier (RI) #175's bilateral lower extremity Doppler study. This affected RI #175, one of 27 sampled residents for whom medical records were reviewed. Findings Include: Review of [NAME] and [NAME] Fundamentals of Nursing Ninth Edition, Chapter 23 Legal Implications in Nursing Practice, copyright 2017, page 311, revealed the following: . Health Care Providers' Orders . Make sure that all health care provider orders are in writing . and transcribed correctly . RI #175 was re-admitted to the facility on [DATE]. RI #175 had diagnoses to include Cerebral Infarction, Surgical Aftercare following Surgery, and Hemiplegia. [...]

Inspectors wroteBased on interviews, review of Resident Identifier (RI) #25's medical record, the facility's investigation file and Employee Identifier (EI) #5's personnel file, EI #5, a CNA neglected to transfer RI #25 with a Hoyer lift and the assistance of another staff member on 5/17/2018. During the 3:00 PM to 11:00 PM shift on 5/17/2018, EI #5 failed to follow RI #25's plan of care when she transferred the resident by herself by picking the resident up and pivoting the resident to the bed. No Hoyer lift was used and no assistance was provided by another staff member. During the transfer the resident's right knee was twisted and the resident began to complain of pain. One day later, on 5/18/2018, RI #25's right leg between the knee and ankle was noted to be red, warm, swollen and painful. RI #25 was transferred to the local hospital for further evaluation. [...]

Inspectors wroteBased on interviews, review of Resident Identifier (RI) #25's medical record and the facility's investigation file, Employee Identifier (EI) #5, a Certified Nursing Assistant (CNA) failed to follow RI #25's plan of care when she transferred the resident by herself by picking the resident up and pivoting the resident to the bed. RI #25 is care planned for two person assist with transfers with the Hoyer lift. During the transfer the resident's right knee was twisted and the resident began to complain of pain. One day later, on 5/18/2018, RI #25's right leg between the knee and ankle was noted to be red, warm, swollen and painful. RI #25 was transferred to the local hospital for further evaluation. An X-ray showed a comminuted mildly displaced proximal tibia fracture as well as a proximal fibular fracture. This deficient practice affected RI #25, one of 39 sampled residents.

Inspectors wroteBased on interviews, review of Resident Identifier (RI) #25's medical record and the facility's investigation file, Employee Identifier (EI) #6, a Licensed Practical Nurse (LPN) failed to assess RI #25 for a complaint of leg pain during the 3:00 PM to 11:00 PM shift on 5/17/2018. During the 3:00 PM to 11:00 PM shift on 5/17/2018, EI #5, a Certified Nursing Assistant (CNA) failed to follow the resident's plan of care, when she transferred the resident to the bed. During the transfer the resident's right knee was twisted and the resident began to complain of pain. EI #6 administered an over-the-counter headache pain reliever, Excedrin, to the resident for the resident's complaint of pain; however, failed to assess the resident's complaint of leg pain. One day later, on 5/18/2018, RI #25's right leg between the knee and ankle was noted to be red, warm, swollen and painful. [...]

Inspectors wroteBased on interviews, review of Resident Identifier (RI) #25's medical record and the facility's investigation file, the facility failed to ensure Employee Identifier (EI) #5, a Certified Nursing Assistant (CNA) used a Hoyer lift and the assistance of another staff person, as determined by RI #25's assessment and plan of care, during a transfer on 5/17/2018. During the 3:00 PM to 11:00 PM shift on 5/17/2018, EI #5 failed to follow RI #25's plan of care when she transferred the resident by herself by picking the resident up and pivoting the resident to the bed. No Hoyer lift was used and no assistance was provided by another staff member. During the transfer the resident's right knee was twisted and the resident began to complain of pain. One day later, on 5/18/2018, RI #25's right leg between the knee and ankle was noted to be red, warm, swollen and painful. [...]

Inspectors wroteBased on observation, interview, review of facility's policy titled, FOOD STORAGE LABELING and the 2017 Food Code, the staff failed to ensure food was consistently covered and stored with labels to identify contents, date of preparation and use-by date. This had the potential to affect all residents for whom meals were prepared and served at the time of the survey.