Rome Memorial Hospital, Inc - R H C F

Inspectors wroteThe facility failed to provide needed care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice. Specifically, Resident #1's advanced directives were Do Not Resuscitate (allow natural death) and when they became unresponsive, the staff did not verify the Resident #1's advance directives per facility policy, and initiated cardiopulmonary resuscitation for approximately three minutes.

Inspectors wroteBased on record review and interviews during the recertification and abbreviated (NY00362429) surveys conducted 1/2/2025-1/8/2025 the facility did not ensure the resident's physician was consulted and the resident's representative was notified when there was a need to alter treatment significantly for 1 of 1 resident (Resident #61) reviewed. Specifically, Resident #61 did not receive 5 doses of their Parkinson's disease (a progressive neurological disorder) medication (pramipexole dihydrochloride) and there was no documented evidence the physician or resident's representative were notified of the omission.

Inspectors wroteBased on record review and interviews during the recertification survey conducted 1/2/2025-1/8/2025, the facility did not ensure they assessed residents using the quarterly review instrument specified by the State and approved by the Centers for Medicare and Medicaid Services not less frequently than once every 3 months for 3 of 3 residents (Residents #28, #46, and #53) reviewed. Specifically, Residents #28's, #46's, and #53's Minimum Data Set assessments were completed later than 14 days after the Assessment Reference Date (the final day of the observation period to gathering information about a resident's condition when completing the assessment).

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 4/11/23-4/14/23, the facility failed to assess residents for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails with the resident or resident representative, and obtain informed consent prior to the installation of bed rails for 10 of 10 residents (Residents #9, 11, 14, 15, 16, 29, 32, 36, 37, and 38) reviewed. Specifically, for Residents #9, 11, 14, 15, 16, 29, 32, 36, 37, and 38 there was no documented evidence bed rail assessments were completed, and consents were obtained prior to bed rail installation; there was no documented evidence the risks and benefits of bed rails were explained to the residents or their representatives prior to bed rail use; and there were no care plans that included the use and monitoring of bed rails.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00307214) surveys conducted 4/11/23-4/14/23, the facility failed to ensure residents were free from abuse for 1 of 1 resident (Resident #38) reviewed. Specifically Resident #15 was witnessed by facility staff making inappropriate sexual contact with Resident #38 on 10/10/22, 11/18/22, and 12/16/22 and the facility did not have a plan in place to protect Resident #38 from Resident #15's advances. Additionally, the incidents on 10/7/22 and 11/18/22 were not reported to the New York State Department of Health (NYS DOH) as required.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 4/11/23-4/14/23, the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing for 1 of 2 residents (Resident #16) reviewed. Specifically, Resident #16 developed a Stage 2 pressure ulcer (partial-thickness skin loss), and the ulcer was not monitored, treatments were not completed as ordered, and the resident's plan of care was not followed. Additionally, the resident had a significant weight loss, and their nutritional needs were not reassessed after the development of the pressure ulcer and significant weight loss.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 4/11/23-4/14/23, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, and the comprehensive person-centered care plan for 1 of 3 residents (Resident #14) reviewed. Specifically, Resident #14 was observed receiving oxygen (O2) via a nasal cannula (NC, a tube delivering oxygen through the nose) and did not have a physician order or indications for use, and did not have ongoing assessments of respiratory status, and response to O2 therapy.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 4/11/23-4/14/23 the facility failed to ensure that licensed nurses had specific competencies and skill sets to provide nursing services to assure resident safety for 1 of 3 licensed nurses (licensed practical nurse [LPN]) #12 observed during medication administration. Specifically, LPN #12 was observed pre-pouring resident medications before the ordered times and placing them in plastic cups in the medication cart.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted [DATE]-[DATE], the facility failed to ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles and included the expiration date when applicable for 1 of 2 medication carts (Unit 3 East) reviewed. Specifically, the Unit 3 East medication cart contained an insulin pen for Resident # 9 that did not have an opened date.

Inspectors wroteBased on observation, interview and record review during the recertification and abbreviated surveys (NY00247612 and NY00249167) the facility did not ensure it maintained 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 2 of 2 nursing units (North/South and East) and 1 of 1 laundry room (first floor laundry room) reviewed. Specifically, dirty lunch trays were observed placed on top of multiple clean PPE (personal protective equipment) carts on 2 of 2 nursing units (North/South and East); and two drying tumblers and two front loading washer-extractors were not maintained per manufacturer instructions.

Inspectors wroteBased on observation and interview during the recertification survey, the facility did not store drugs and biologicals in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 3 medication carts (north hall medication carts #1 and #2) reviewed for medication storage and labeling. Specifically, multiple expired medications were observed stored in two north hall medication carts.