Sibley Mem Hosp Renaissance

Inspectors wroteResident #123 Abuse 08/13/24 09:20 AM #123 [NAME] DOB [DATE] DOA [DATE] Discharge [DATE] DX: - Rupture of Quadriplegic tendon - Lumbar Dengerative Disc Disease - Status Fall F610 The facility failed to ensure an alleged perpetrator did not have access to a resident who made an allegation of rough handling. Additionally, the facility failed to conduct a through investigation. As evidence by not having documented evidence of interview with the companion who was in the room on the night if the alleged incident of rough handling. OBSERVATION Unable to conduct observations, resident was discharged on [DATE] RECORD REVIEW MDS ADD Info see hard copy Care Plan- see hard copy 04/27/24 and 04/28/24 flow sheeted did not document any concerns or complaints from the resident. 04/28/24 at 8:37 AM [[NAME]'s (alleged perpetrator) Nursing Note] Pt. [...]

Inspectors wroteResident #17 Unnecessary Meds, Psychotropic Meds, and Med Regimen Review 08/12/24 09:58 AM #17 [NAME] DOB - [DATE] DOA - [DATE] DX: - Gram positive Bacteria -Anemia -Endocarditis -DVT -Thrombophilia -Insomnia [DATE] admission MDS C-11 I - Insomnia 483.45 Pharmacy (F756) - The physician failed to documented response to pharmacist recommendations. 08/12/24 10:01 AM OBSERVATION During an observation on 08/08/24 at 11:00 AM, the resident was observed lying in bed. A, OX 3, no bruising noted. RECORD REVIEW 07/16/23 - MMR Please monitor patient for additive CNS depressant effect and QTC prolongation due to DDI between Quetiapane and Mirtazine. The physcian failed to documented hi response. [DATE]- admission MDS C-11 I - Insomnia N- antipsychotics, anticoags. o 07/29/24 - Eliquis (anticoagulant) 5mg po BID for VTE Tx. [...]

Inspectors wrote2. Facility staff failed to ensure that their infection control policies were reviewed annually. During a review of the facility's infection control policies on 08/09/24 revealed a policy titled Mandatory COVID-19 Vaccination Policy - Policy Number ADMIN033 that documented Effective Date 11/10/2022 and Supersedes Date 09/23/2022. A face-to-face interview conducted on 08/09/24 at 12:50 PM, Employee #2 (Director of Nursing/DON) acknowledged the findings and stated, We adopt our policies from the hospital. We need to show that the policies are being reviewed annually and the review date should be reflected on the policy. Cross Reference: 22B DCMR Sec. [...]

Inspectors wroteBased on record review and staff interviews, for one (1) of five (5) sampled residents, facility staff failed to provide the necessary social and health care services to attain, maintain, or support the behavioral health (emotional and mental well-being) needs of Resident #1. Due to these failures, an Immediate Jeopardy (IJ-J) was identified on February 5, 2024 at 12:07 PM. During this survey, Immediate Jeopardy was identified at 42 CFR §483.40, Behavioral Health (F740), on February 5, 2024 at 12:07 PM. The facility's Administrator submitted a corrective action plan to the Survey Team that was accepted on February 5, 2024 at 7:52 PM. The Survey Team verified implementation of the corrective plan while onsite and the Immediate Jeopardy was lifted on February 6, 2024 at 2:15 PM. [...]

Inspectors wroteBased on record reviews and staff interviews, for one (1) of five (5) sampled residents, the facility's staff (Employee #5) failed to provide appropriate medically-related social services to meet Resident #1's needs, as evidenced by the employee's failure to conduct a follow-up assessment on 01/29/24 after the resident expressed that he wanted to die.

Inspectors wroteBased on record reviews and staff interviews for one (1) of five (5) sampled residents, the facility staff failed to maintain a complete medical record for Resident #1.

Inspectors wroteBased on observation of nine (9) nasal cannulas (delivers oxygen via the nose), facility staff failed to maintain respiratory/oxygen care equipment in accordance with the professional standards of practice.

Inspectors wroteBased on record review and staff interview, for one (1) of 16 sampled residents, facility staff failed to offer a resident or their representative the right to formulate or refuse an Advanced Directive (AD). Resident #79.

Inspectors wroteBased on observations and interview, facility staff failed to provide housekeeping services necessary to maintain a safe, clean, comfortable environment as evidenced by soiled bathroom vents in four (4) of eight (8) resident's rooms, and walls marred with peeling paint in three (3) of eight (8) resident's rooms.

Inspectors wroteBased on record review and staff interviews, for three (3) of 16 sampled residents, facility staff failed to implement its policies and procedures for reporting and investigating incidents involving abuse, neglect, and injuries of unknown origin. Residents' #81, #80 and #85.

Inspectors wroteBased on review of facility records, reported incidents, policies, and staff interview for four (4) of 16 sampled residents, facility staff failed to report the following incidents to the state agency in the required timeframes for one (1) resident who had a witnessed fall with staff that resulted in injury, one (1) residents with injuries of unknown origin, and one (1) resident with an allegation of abuse. (Residents' #81, #80, and #85)

Inspectors wroteBased on review of facility records, reported incidents, policies, and staff interviews for two (2) of 16 sampled residents, the facility's staff failed to show evidence of conducting thorough investigations for one (1) resident that had a fall with injury and one (1) resident with an injury of unknown origin. Residents' #81 and #80.

Inspectors wroteBased on record review and staff interviews, for two (2) of 16 sampled residents, facility staff failed to develop and implement comprehensive person-centered care plans with goals and approaches to address one (1) resident who is prescribed nine (9) prescribed medications; and one (1) resident who contracted COVID-19. Residents' #128 and #3.

Inspectors wroteBased on record review and staff interviews, for two (2) of 16 sampled residents, facility staff failed to revise/update the comprehensive care plan with new goals and approaches that addressed: one (1) resident's family bringing in foods from outside the facility; and one (1) resident's fall. Residents' #277 and #278.

Inspectors wroteBased on observations and staff interview, facility staff failed to distribute and serve foods under sanitary conditions as evidenced by: foods such as grilled chicken and beans that tested below 135 degrees Fahrenheit (F); inconsistent dish machine final rinse temperatures that were below 180 degrees Fahrenheit (F); and a crawling pest that was observed on the kitchen floor.

Inspectors wroteBased on observation, record review, and staff interview, for one (1) of 16 sampled residents, the facility's staff failed to maintain infection control policies and procedures as evidenced by: inappropriately transporting soiled linen; staff not performing hand hygiene and wearing a facemask inappropriately during meal tray distribution. Resident #1.

Inspectors wroteBased on observations and staff interview, facility staff failed to maintain essential equipment in safe condition as evidenced by dish machine final rinse temperatures that were below 180 degress Fahrenheit on January 4, 2023, at approximately 2:30 PM.

Inspectors wroteBased on observation and staff interview, facility staff failed to maintain an effective pest control program as evidenced by a crawling pest observed on the floor, around the flat grill, in dietary services.

Inspectors wroteBased on observation, record review, and resident and staff interview, facility staff failed to ensure that Resident #20, who was admitted to the facility with a bruise to the left heel received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent a deep tissue injury from developing for approximately 14 days, for one (1) of 17 sampled residents.

Inspectors wroteBased on observations and staff interview, facility staff failed to prepare and distribute foods under sanitary conditions as evidenced by one (1) of two (2) soiled convection oven in the bake shop area, two (2) of two (2) soiled convection ovens in the patient hotline area, and 32 of 33 food service trays that were cracked at both handles.

Inspectors wroteBased on observation and staff interview, facility staff failed to maintain essential equipment in good working condition as evidenced by two (2) of six (6) convection ovens with a loose door handle, and one (1) of two (2) steam kettles that intermittently blew out steam from its connection valve in the patient hotline area.

Inspectors wroteBased on observation, record review and staff interview, for one (1) of 17 sampled residents, facility staff failed to treat a resident with an indwelling catheter with respect and dignity as evidenced by his urinary collection bag being exposed while walking in the hallway. Resident #284.

Inspectors wroteBased on record review and staff interview, for one (1) of 17 sampled residents, facility staff failed to update the resident's code status and failed to address the resident's option to formulate an Advanced Directive. Resident #3.

Inspectors wroteBased on record review and staff interview, for one (1) of 17 sampled residents, the facility's staff failed to update/revise the compromised skin integrity care plan to address a resident's impaired skin integrity. Resident #20.

Inspectors wroteBased on one (1) of one (1) medication storage observation, facility staff failed to ensure that a syringe containing Neurontin (an anti-epileptic drug) was not stored for use beyond the expiration date.

Inspectors wroteBased on two (2) of two (2) observations, record review and staff interview, facility staff failed to maintain infection control prevention practices in accordance with standards of practice to minimize the potential spread of infections.

Inspectors wroteBased on record review and staff interviews, facility staff failed to act promptly upon the May and July 2019, grievances of the Resident Council concerning issues related to resident care and life in the facility. The resident census was 27 on the first day of the survey.

Inspectors wroteBased on observations and interview, it was determined that facility staff failed to store, prepare and distribute foods under sanitary conditions as evidenced by expired food items: 11 of 11 forty-six fluid ounce containers of cranberry juice cocktail and one (1) of three (3) plastic containers of ready-for-use vegetable broth, soiled equipment - four (4) of six (6) convection ovens and oven racks, one (1) of one (1) [NAME] Shaam brand food warmer, one (1) of one (1) Trauslen brand food warmer with shelves, 24 of 24 plastic containers of various sizes, and 40 of 80 food trays stored in the dishwashing area that were cracked at the handles.

Inspectors wroteBased on observation, record review and staff interview the facility staff failed to develop a system of surveillance to identify infections or communicable diseases; and failed to store drinkware under sanitary conditions as evidenced by 55 of 55 clean drinking cups were stacked wet in the dishwashing room. The census on the first day of survey was 27.

Inspectors wroteBased on an resident interviews during the group meeting, record review and staff interview for four (4) of 26 sampled residents, it was determined that facility staff failed to respond with timeliness to resident call lights when they request assistance. Residents' #1, 5, 29 and T1.

Inspectors wroteBased on observation, record reviews, and interviews, the facility's staff failed to ensure that three (3) of 26 sampled residents' Care Plans were patient-centered (Residents' #5, #18, and #90)

Inspectors wroteBased on record review and interview, the facility's nursing staff failed to appropriately and accurately assess a significant change of deep tissue wound for one (1) of 26 sampled residents (Resident #18).

Inspectors wroteBased on record review and interview, an attending physician failed to document the reason for the continued dose of a medication identified by the pharmacist to increase falls for one (1) of 26 sampled residents (Resident #18).

Inspectors wroteBased on record review and interview, the facility's staff failed to: monitor and document Resident #18's response to a PRN (as needed) medication for one (1) of 26 sampled residents. (Resident #18).