St. John's Hospital Camarillo D/P SNF

Inspectors wroteBased on interview and record review, the facility staff failed to ensure the Physician was notified of a Weight variance of five pounds or more for 1 of 23 sampled residents (Resident 25's) when the weight record was examined and noted that the resident experienced a significant 14 percent weight loss in less than two months. This failure resulted in a delay in the need to alter treatment significantly to Resident 25.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure care plan interventions were implemented for one of 23 sampled residents (Resident 25). This failure had the potential to result in Resident 25 needs not being met.

Inspectors wroteThe facility failed to ensure medication is correctly labelled according to the physician's order and was sent to the pharmacy when medication discrepancy is found for 1 of 3 unsampled residents (Resident 64). This failure had the potential to result in a medication administration error.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain patient care equipment in safe operating condition when a residue build up was found inside of the ice machine panels. This failure had the potential for residents to Waterborne diseases (illnesses caused by consuming contaminated water).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe, functional, and comfortable environment for 1 out of 23 sampled residents (Resident 36). When an extension cord with six sockets was mounted on the right upper side rail, approximately 12 inches from Resident 36's head while lying in bed. This failure creates an unsafe environment for the resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident 1) was not exposed to pathogens carried by flies resulting to formation of maggots (the larvae of flies that are typically found in decaying organic matter). Maggots were found in the tracheostomy (an opening in the neck and into the windpipe to help a person breathe) site of the resident . This failure placed Resident 1 at risk for parasitic infection (Myiasis).

Inspectors wroteBased on interview and record review, the facility failed to provide evidence that an allegation of abuse was thoroughly investigated for one of three residents (Resident 1). This failure had the potential for further abuse to occur to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitary conditions within the food service operation when: 1. A nutrition assistant (NA 1) removed dirty gloves after handling dirty dishes, and put on a new pair of gloves, without washing her hands. 2. The high temperature dish machine manufacturer's guidelines were not followed. 3. Posted manufacturer's guidelines for contact time of food service equipment immersed in the sanitizer solution at the three (3) compartment sink was not followed. Failure to ensure proper hand washing and implementing manufacturer's guidelines for cleaning and sanitizing of the dishes had the potential to place five of 70 residents (Residents 52, 58, 61, 1, and 3) who received food from the kitchen at an increased risk of a foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to report to the California Department of Public Health (CDPH) a bruise on the forearm of unknown origin and allegation of abuse for one of one resident (Resident 22).within 2 hours of discovery. This failure had the potential to delay investigation and affect physical and psychosocial well-being of the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 72) had an accurate Minimum Data Set ((MDS) a standardized assessment tool designed to identify potential problems). This failure resulted in Resident 72 not having a care plan ((CP) a tool that outlines the interventions (actions) to be taken to meet the resident's needs) developed for their discharge goal of returning home.

Inspectors wroteBased on observation, interview and record review the facility failed to develop individualized care plans for 2 of 18 sampled residents (Residents 34 and 63): 1. For Resident 34, the facility failed to develop an individualized care plan that reflected specific target weight range with measurable goals and timeframe's, and failed to update and revise the care plan when there were changes to the tube feeding (providing nutrition through a tube to the stomach) order. 2. For Resident 63, the facility failed to develop an individualized care plan for a resident with a urinary catheter. This failure resulted in lack of individualized care plans that reflected specific care and measurable goals which impedes the IDT (interdisciplinary team) from effectively monitoring, evaluating and revising the care plan, as appropriate, to ensure care needs would not go unrecognized and unmet.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 72), had a care plan ((CP) a tool that outlines the interventions (actions) to be taken to meet the resident's needs) developed for their discharge goal of returning home.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 20 sampled residents (Resident 62), had their head of bed (HOB) elevated to 30 degrees or greater per physician order, due to being on a ventilator by a tracheostomy. This failure had the potential to result in respiratory distress.

Inspectors wroteThe facility failed to maintain the infection control program when staff left an unflushed suction catheter (a tube used to clear the airway by removing secretions from the oropharynx with the aid of a rigid suction tip) resulting in secretions dripped on top of the nightstand for one of six residents (Resident 50) with a tracheostomy tube. This failure placed Resident 50 at risk for the spread of healthcare-associated infection.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records for 1 of 3 sampled residents (Resident 1), who had a treatment consisting of ear irrigation for ear wax removal and the facility did not document the resident's response to treatment. This failure had the potential to result in complications in the resident's care as it was unknown if the outcome was desired or further intervention was required.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement their policy and procedure for posting the level of assistance required by one of two sampled residents (Resident 1) in such a way to communicate safe handling by the staff during position changes. This failure had the potential for physical injury to residents and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess and document 13 out of 18 sampled residents' (8, 71, 53, 59, 41, 4, 25, 65, 35, 63, 43, 34, and 48) Minimum Data Set (MDS- assessment tool to assess all residents' functional capabilities and facilitate care management in nursing homes) assessments for Section P (Physical Restraints) when quarter siderails were used and were coded as zero (not used). This facility failure resulted in inaccurate comprehensive assessments for 16 residents with restraints and had the potential for physical harm.

Inspectors wroteBased on observation, interview and record review, the facility failed to initiate and implement care plans for six out of 18 residents when: 1. Resident 35's care plan for position and mobility was not implemented. 2. Resident 35' has no careplan for the use of the medication Doxycline (an antibiotic/medication used to treat infections). 3. Resident 48's care plan for position and mobility was not implemented. 4. a.) Resident 4's care plan for pressure ulcer was not implemented. b.) Resident 25's care plan for pressure ulcer was not implemented. 5. Resident 48's care plan for refusal of SCDs (sequential compression device- wraps placed around the patient's lower legs in order to decrease the chance of blood clot formation) was not initiated. 6. Resident 8's and Resident 53's care plan for position and mobility was not implemented. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain safe food storage practices when food was available for use past the facility's use by date (a date determined by the facility to dispose of opened food items). This failure had the potential to result in foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure their policy and procedure for restraints use was followed for 14 of 18 sampled residents (Residents 63, 43, 8, 53, 1, 48, 25, 4, 35, 41, 34, 65 and 59) for the use siderails were with incomplete consents and no consent for siderail use on Resident 327. This facility failure placed residents at risk for being restrained with no proper and complete consents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS-a computerized assessment tool),was correctly coded for one of 18 sampled residents, (Resident 71), when the resident was reported to be taking insulin (hormone to lower glucose [sugar] in the blood) injections with no diagnosis with diabetes (a disease when your body does not make enough insulin) and not taking insulin. This failure resulted in the facility reporting inaccurate data on Resident 71 on medical status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician orders for two out of 18 sampled residents (Resident 4 and Resident 48) when: 1. Resident 4's Restorative Nursing Assistant (RNA) services were not done five times a week. 2. Resident 4's wound care treatments were not done twice a day. 3. Resident 48's tracheostomy (a hole that surgeons make through the front of the neck and into the windpipe, a tube is placed in the hole so a patient can breathe) care treatments were not getting done once a shift. 4. Resident 48 was not wearing an air boot (device to keep pressure off heels when residents spend time in bed). 5. Resident 48's infusion rate, for the water flush, did not match the physician's order. [...]