Southeast Colorado Hospital LTC

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#1) of three residents reviewed for accidents out of three sample residents. Specifically, the facility failed to: -Ensure Resident #1 had an individualized care plan with person-centered interventions to prevent elopement; and, -Ensure Resident #1 was provided with the supervision necessary to prevent an elopement.

Inspectors wroteBased on observations and interviews, the facility failed to maintain 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 infection. Specifically, the facility failed to: -Ensure residents were offered hand hygiene prior to eating; -Ensure hand hygiene was performed appropriately while serving meals and assisting residents with eating; -Ensure housekeeping staff disinfected high touch surfaces (call lights, bed controls, hand rails and light switches) in resident rooms; -Ensure gloves were changed and hand hygiene was performed appropriately when needed during the cleaning of residents' rooms.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the resident's right to receive services in the facility with reasonable accommodation of the resident's needs and preferences for two (#20 and #13) of five residents reviewed for accommodation of needs out of 22 sample residents. Specifically, the facility failed to ensure Resident #20 and Resident #13 were able to self-adjust the water coming out of the faucets in their room sinks to a safe and comfortable temperature for their personal use when completing activities of daily living (ADL), including hand hygiene and grooming tasks.

Inspectors wroteBased on interviews and record review, the facility failed to ensure one (#18) of one resident out of 22 sample residents was kept free from abuse. Specifically, the facility failed to identify a pattern of concerns regarding the care provided by certified nurse aide (CNA) #1 in order to prevent an incident of verbal abuse by CNA #1 toward Resident #18.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain proper nutrition and personal hygiene for three (#4 and #21) of three residents reviewed out of 22 sample residents. Specifically, the facility failed to: -Provide Resident #4, a resident assessed to need supervision, cueing, encouragement and occasional physical assistance with meals the necessary assistance to eat and maintain proper nutrition; and, -Provide Resident #21 with timely incontinence care.

Inspectors wroteBased on observations and interviews, the facility failed to ensure medications and biologicals were properly stored and labeled in accordance with professional standards in one of two medication carts and two of two medication storage rooms. Specifically, the facility failed to: -Ensure expired medications were removed from the medication carts and medication storage rooms; and, -Ensure the temperature of the medication storage refrigerator and the vaccine storage refrigerator were checked and recorded daily.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to ensure food was stored, prepared and served under sanitary conditions in one kitchen. Specifically, the facility failed to ensure: -Appropriate hand hygiene by food service staff; and, -Cutting boards were free from deep scratches and stains.

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain a sanitary, orderly, and comfortable environment for residents in eight of 35 resident rooms in two hallways. Specifically, the facility failed to ensure walls and doors were properly maintained.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that residents were free of unnecessary psychotropic medications for two (#32 and #29) of five residents out of 21 sample residents. Specifically, the facility failed to: -Evaluate the use of an as needed PRN antipsychotic medication by a physician within 14 days for Resident #38; -Provide non-pharmacological interventions for Resident #38 prior to administration of a PRN antipsychotic medication; -Identify and track behaviors for the use of psychotropic medications for Resident #38 and #29; -Monitor side effects of psychotropic medications for Resident #38 and #29; -Evaluate the use of an as needed PRN psychotropic medication by a physician within 14 days for Resident #29; and, -Provide non-pharmacological interventions for Resident #29 prior to administration of a PRN psychotropic medication.

Inspectors wroteBased on record review and interviews, the facility failed to coordinate assessments with the preadmission screening resident review (PASRR) program for one (#38) of five reviewed for PASRR out of 21 sample residents. Specifically, the facility failed to: -Take steps to ensure services were provided as recommended in the resident's PASRR level II for Resident #38; and, -Notify the State Mental Health Agency that recommendations could not be met for Resident #38.

Inspectors wroteBased on record review and interviews, the facility failed to develop and implement a comprehensive person-centered care plan, consistent resident rights, that included measurable objectives and timeframes to meet medical, nursing, mental and psychosocial needs for one (#27) of five residents reviewed for comprehensive care plans of 21 sample residents. Specifically, the facility failed to have a person-centered, resident-specific, vision care plan for Resident #27.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure dependant residents received services necessary to maintain or improve the ability to perform activities of daily living (ADLs) for one (#3) of four residents reviewed for ADLs out of 21 sample residents. Specifically, the facility failed to provide treatment and services for toileting, eating and repositioning consistent with needs and plan of care for Resident #3.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure resident care consistent with professional standards of practice, to prevent avoidable pressure ulcers for one (#30) of three residents reviewed out of 20 sample residents. Specifically, the facility failed to ensure the resident did not develop avoidable deep tissue injuries to his bilateral great toes by: -Ensuring the removal of the resident's socks while in bed, to prevent irritation/pressure to the bilateral great toes; -Ensuring the implementation of interventions to keep the resident's bed covers from touching the tips of the resident's bilateral great toes; and, -Updating the resident's care plan to include interventions for the resident's right great toe deep tissue injury. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents were as free from unnecessary psychotropic drugs as possible for two (#28, and #33) of five residents out of 20 total sample residents. Specifically, the facility failed to: -Ensure consent was obtained and residents and/or their responsible parties were informed of psychotropic medications with black box warnings (the Food and Drug Administration ' s strictest and most serious type of warning which describes a medication ' s serious or life-threatening side effects or risks) prior to the administration of the medication for Resident #28; -Consistently track behaviors to justify the use of an antipsychotic medication for a resident with dementia for Resident #28 and Resident #33; [...]