Southwell Health and Rehabilitation

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to ensure the Wound Care Coordinator (WCC) followed infection control processes during wound care and supra-pubic catheter care for one of five residents (R) (R6) reviewed and observed for wound care and catheter care. This deficient practice had the potential to place R6 at risk of infection due to cross-contamination.

Inspectors wroteBased on staff and resident interviews, record review, and review of the facility's arbitration agreement, the facility failed to ensure three of three Residents (R) (R25, R80, R44) reviewed for arbitration agreements had agreements in place that provided the resident/responsible party a period of 30 days to rescind the agreement after it was signed. The facility's arbitration agreement provided a period of 10 days to rescind the agreement which had the potential to affect all residents of the facility. In addition, R80 and R44 had not been educated regarding the arbitration agreements and were not aware the arbitration agreements had been signed by their family members.

Inspectors wroteBased on staff interview, record review, and review of the facility's arbitration agreement, the facility failed to ensure three of three Residents (R25, R80, R44) reviewed for arbitration had arbitration agreements in place that allowed for a mutually agreed upon arbitrator and venue for arbitration. The facility's arbitration agreement delineated the specific arbitrator that would be used. This deficient practice had the potential to affect all residents in the facility.

Inspectors wroteBased on resident and staff interviews, record review, and review of the facility's policy titled, System Policy and Procedures Advance Directives, the facility failed to ensure they had a copy or had followed up to obtain the Advanced Directive for one out of 24 residents reviewed in the initial pool (Resident (R) R80). R80's Family Member (F)80 indicated, at the time of admission, that they had R80's advanced directive documentation; however, did not bring it into the facility at the time of admission.

Inspectors wroteBased on interviews, record review and review of the facility's policy titled, Compliance Investigations, the facility failed to protect the resident's right to be free from physical abuse by another resident for one of two residents (R) (R22) reviewed for abuse. Specifically, R22 alleged she was slapped hard on the hand by Certified Nurse Assistant (CNA) 1 and the allegation was substantiated by the facility, resulting in CNA 1's termination of employment.

Inspectors wroteBased on review of facility policy and interviews, the facility failed to ensure policies were in place to comprehensively address abuse prevention and investigation in the healthcare system's long-term care facility. The healthcare system's policies and procedures utilized to direct the facility's prevention and investigation of abuse did not specifically incorporate elements of the long-term care regulation set related to abuse/neglect.

Inspectors wroteBased on staff interviews, record review, review of the facility's abuse policies, and review of the facility's policy titled, Compliance Investigations, the facility failed to ensure an allegation of abuse by one resident (R) (R22) of two residents reviewed for abuse was thoroughly investigated. R22 alleged she was slapped hard on the hand by a Certified Nurse Aide (CNA) 1 and the investigation into the allegation did not include interviews with additional residents or staff members to ensure no other residents had been exposed to potential abuse by CNA 1.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled, System Policy and Procedures Behavioral Health, the facility failed to ensure one of three residents (R) (R36) who was reviewed for Pre-admission Screening and Resident Review (PASARR) services was referred to the state-designated authority for Level II PASARR after a new mental illness diagnosis of schizoaffective disorder was added during her stay.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to implement the comprehensive care plan for three residents (R) (R35, R71 and R25) of 21 sampled residents. Specifically, the failure created the potential for R25 to have inadequate care for an indwelling urinary catheter, and R35 and R71 to have inadequate care for edema in their lower extremities.

Inspectors wroteBased on observation, staff and resident interviews, and record review, the facility failed to ensure one of one resident (R) (R25) reviewed for indwelling urinary received appropriate care and services to prevent urinary tract infections (UTI). Specifically, there was no physician orders for the size of the indwelling urinary catheter and how often to change it and R25's catheter and/or tubing were observed resting on the floor for three out of four days of the survey. These failures created the potential for R25's catheter to become dislodged and for R25 to get a UTI. The sample size was 31 residents.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility's policy titled, Bed Rail Policy, the facility failed to ensure one of three Residents (R) (R27) reviewed for accidents had been assessed for the use of bed/side rails, had physicians orders for the bed/side rails, a care plan, and an informed consent from the resident for the use of the bed/side rails. Specifically, R27 had bilateral 1/3 bed/side rails applied to his bed and his bed/side rail assessment, physician orders, and care plan did not accurately reflect the resident's use of the bed/side rails. This failure created the potential for the resident to be injured related to the potentially unnecessary bed/side rails on his bed. The sample size was 31 residents.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Storage of Medication (SHR), the facility failed to ensure that one resident of 18 residents (R15) was administered insulin that was not expired; failed to ensure that one resident of 18 residents (R16) had prescribed Novolog insulin available for coverage; failed to ensure that two of three medications storage room were free of expired medications. The facility census is 80.

Inspectors wroteBased on record review and staff interview the facility failed to develop a comprehensive care plan for two residents ((R) R#1 and R#35) receiving oxygen therapy, and the facility failed to develop a care plan for psychotropic drug use for one resident R#60. This effected three of 38 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure psychotropic drug use was limited to 14 days unless the physician felt it was appropriate for the as needed (PRN) order to be extended beyond 14 days, documented the rational, and indicated the intended duration for the prn order, for two residents ((R) R#60 and R#81) of five reviewed for unnecessary medications, that had an order for PRN antianxiety medication beyond 14 days.

Inspectors wroteBased on record review and staff interview the facility failed ensure the Minimum Data Set (MDS) assessments were accurate for two ((R) R#1 and R#35) of eight residents receiving oxygen therapy. Findings Include: 1. Record review for R#1 revealed resident was admitted to the facility on [DATE] with diagnoses of Catatonic disorder, encephalopathy, epilepsy, chronic anticoagulation, Essential hypertension, Dysphagia, peripheral vascular diseases, asthma, diabetes mellitus, anemia, gastroesophageal reflux disease, schizophrenia, decubitus of the right ankle, gastrostomy status, peripheral vascular disease, major depressive disorder, sleep bruxism, and spasticity. Further review reveald orders for oxygen at 2 liters per minute (LPM) per nasal cannula routinely. Review of the MDS Quarterly assessment dated [DATE] revealed oxygen therapy was not indicated as in use for R#1. [...]

Inspectors wroteBased on observations, interviews, record reviews, and review of policy titled Respiratory Therapy, the facility failed to ensure that oxygen therapy was administered as ordered by Physician for one resident ((R) R#1) of eight residents receiving oxygen.

Inspectors wroteBased on observation and interviews, the facility failed to ensure two of two staff implemented standard precautions when providing care for one of 13 sampled residents as evidenced by staff failing to perform handwashing or hand hygiene with glove changes and sanitizing equipment after use.