Sierra View Medical Center

Inspectors wroteBased on interview and record review the facility failed to implement their policy and procedure for INFECTION CONTROL GUIDELINE FOR PEOPLE WITH HEAD LICE (PEDICULUS HUMANUS CARPITIS- tiny, wingless, blood-feeding insects that live on the human scalp and hair) for one of three sampled residents (Resident 1). This failure resulted in delayed treatment for Resident 1 and had the potential for lice to spread throughout the facility affecting other residents, staff, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure five of 28 sampled resident's (Resident 184, Resident 20, Resident 9, Resident 6, and Resident 134) head of bed (HOB) was elevated during G-tube feeding (gastrostomy tube - G tube a small flexible to tube surgical inserted through the abdomen and placed into the stomach to deliver nutrition, fluids, and medication directly into stomach). This failure had the potential to cause aspiration (liquid or food enters into the lungs instead of the stomach) and choking for Resident 184, Resident 20, Resident 9, Resident 6, and Resident 134.

Inspectors wroteBased on interview and record review, the facility failed to ensure their Policy and Procedure (P&P) titled, Medication Storage was followed when four of six sampled [facility name] Narcotic count check sheets [NCCS-requires two licensed nurses to sign and verify count accuracy], were not consistently completed. This failure had the potential for narcotic count errors, narcotic diversion [illegal use of controlled substance] or theft to not be identified.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pre-made food items were labeled with the use-by date and opened food items were labeled with the opened date. These failures had the potential to result in decreased palatability (tastiness) and foodborne illnesses for residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow standard practice for infection control when: 1. Water in the facility was not tested for legionella (bacteria found in various water sources and can pose a health risk when the bacteria grows and is inhaled by humans). 2. One of One Licensed Vocational Nurses (LVN) 2 did not wear proper Personal Protective Equipment (PPE-garment or device worn to shield an individual from potential harm) while providing respiratory care for one of two sampled residents (Resident 18) who were on contact precaution (Isolation of a resident when there is a high chance to spread contagious bacteria). These failures had the potential to spread disease causing organisms to residents, staff, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Crash Cart (emergency cart used to transport and store emergency medications and supplies) used for 30 of 30 sampled residents, was inspected daily. This failure had the potential to result in necessary supplies and medications to be unavailable in an emergency.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of 30 sampled residents (Resident 2 and Resident 7) were represented with an individual or entity other than the facility's Interdisciplinary Team (IDT- group of health care professionals including doctors, nurses, pharmacists, social workers, and dieticians who coordinate care). This failure resulted in Resident 2's and Resident 7's right to have a surrogate decision-maker not being honored.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled Respiratory Care Practitioners (RCP 1 and RCP 2) were competent to set up and manage respiratory care equipment for three of six residents (Resident 8, Resident 6, and Resident 10) according to facility policy. This failure had the potential to result in contaminated respiratory equipment being used and respiratory infections to develop in residents with compromised respiratory systems.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow standard infection control practices when staff did not: 1. Change the suction canister liner (containing respiratory secretions) when over three quarters full for one of six sampled residents (Resident 21). 2. Change the Yaunker (suction catheter used to clear excess secretions from the mouth) per policy for one of six sampled residents (Resident 9). 3. Discard an unlabeled, undated, and contaminated T-piece (connection device used in oxygen delivery) for one of six sampled residents (Resident 10). 4. Store and secure aerosol tubing (oxygen delivery system) in a way that prevented contamination for three of six sampled residents (Resident 8, Resident 10, and Resident 6). 5. Discard and replace contaminated aerosol tubing before reconnecting for two of three sampled residents (Resident 6 and Resident 10). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to re-evaluate the need for a left-hand mitten (physical restraint used to prevent a person from scratching or pulling at life sustaining equipment) after 90 days per physician's order for one of four sampled residents (Resident 14). This failure had the potential to result in Resident 14 being physically restrained without a physician's authorization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the head of bed was raised at least 35 degrees while receiving gastrostomy tube (g-tube - tube inserted directly into the stomach through the abdominal wall, for administration of nutrition and medication) feedings for one of eight sampled residents (Resident 22). This failure had the potential for aspiration (inhaling into lungs) of stomach contents and risk for developing a respiratory infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician's ordered medication was available for administration to one of 30 sampled residents (Resident 17). This failure resulted in Resident 17 not receiving medication to reduce excessive stomach acid.

Inspectors wroteBased on interview and record review, the facility failed to ensure the required language was written into signed arbitration agreements for two of 30 sampled residents (Resident 10 and Resident 12). This failure had the potential for Resident 10, Resident 12, and their representatives to not be aware of their rights to communicate with federal, state, or local officials such as federal and state surveyors, other federal or state health department employees and representative of the Office of the State Long Term Care Ombudsman.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer ordered medication for two of eight sampled residents (Resident 1, Resident 2). This failure had the potential for adverse effects.

Inspectors wroteBased on interview and record review, the facility failed to ensure a qualified professional directed the activities program from 5/21/22 through the recertification survey, which concluded on 12/8/22 (six and a half months). This failure resulted in 34 of 34 sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, Resident 11, Resident 12, Resident 13, Resident 14, Resident 15, Resident 16, Resident 17, Resident 18, Resident 19, Resident 20, Resident 21, Resident 22, Resident 23, Resident 24, Resident 25, Resident 26, Resident 27, Resident 28, Resident 29, Resident 30, Resident 31, Resident 32, Resident 33, Resident 334) not receiving activities directed by a qualified professional.

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive activities assessment was conducted and activities care plan developed specific to the preferences of four of 33 sampled Residents (Resident 334, Resident 29, Resident 28, and Resident 30). This failure resulted in Resident 334, Resident 29, Resident 28, and Resident 30 not receiving activities specific to their preference or choice.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards during medication administration when physician orders were not followed for two of five sampled residents (Resident 28 and Resident 30). This failure had the potential to result in adverse drug interactions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure it was free from a medication error rate of five percent (%) or greater during the medication pass observation. The facility had a cumulative medication rate of 7.14% consisting of two errors in a sample size of 28 opportunities for error. The medication errors consisted of giving two residents (Resident 28 and Resident 30) medications through their Gastric Tubes (Tube going directly into the stomach) without flushing with 15 milliliter (ml-unit of measure) water in between each medication. These failures had the potential to result in adverse drug interactions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices when Licensed Vocational Nurse (LVN) 1 did not change her gloves and perform hand hygiene before giving eye drop medication and after giving medication through Gastric tube (Tube going directly into the stomach) for one of five sampled residents (Resident 31). This failure had the potential for transmission of infection to Resident 31.