Transitional Care Services at Mercy Medical Center

Inspectors wroteBased on medical record review and staff interviews, it was determined that the facility failed to ensure the resident/responsible party was offered the opportunity to develop an advance directive for 4 (#18, #2, #12, #13) of 4 sampled residents for advance directives during the annual survey.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 2 (Residents #12, #9) of 4 residents reviewed for nutrition during the annual survey.

Inspectors wroteBased on medical record review and staff interview it was determined that the facility staff failed to ensure a resident had a baseline care plan created and initiated within 48 hours of admission to the facility. This was evident for 1 (Resident #12) out of 12 residents reviewed during the annual survey.

Inspectors wroteBased on medical record review and interview, the facility staff failed to thoroughly assess and monitor residents at risk for weight loss. This was evident for 3 (Resident #9, #36, #12) of 4 residents reviewed for nutrition during an annual survey.

Inspectors wroteBased on observation, medical record review, and interview, it was determined the facility staff failed to: 1) review and revise resident care plans to reflect accurate and current interventions, and 2) ensure the full interdisciplinary team including residents and/or their responsible parties were invited to the care plan meetings and 3) have care plan meetings for residents who had been in the facility 21 days or more. This was evident for 4 (#4, #12, #13, #15) of 27 residents reviewed during a recertification survey.

Inspectors wroteBased on observation and interview, it was determined the facility staff failed to treat each resident in a dignified manner by: 1) leaving a breakfast tray in the resident's closet, 2) leaving urinals hanging on the trash can in the resident's room, and 3) serving breakfast on a bedside table that had a urinal containing urine. This was evident for 2 (Resident #4, #12) of 27 residents reviewed during the survey.

Inspectors wroteBased on observation and interviews it was determined that the facility failed to maintain a comfortable homelike environment as evidenced of a resident having stained ceiling tile, rust near the trim in a resident's bathroom, fluid stains on the wall in a resident's room, and damaged drywall in a resident's room. This deficient practice was evidenced in 4 rooms of 8 rooms assessed for a homelike environment during the survey.

Inspectors wroteBased on medical record review and staff interview it was determined the facility failed to notify the resident/resident representative (RP) in writing of a transfer/discharge of a resident along with the reason for the transfer and failed to send a copy to the ombudsman. This was evident for 2 (#7, #17) of 2 residents reviewed for hospitalization during a recertification survey.

Inspectors wroteBased on medical record review and staff interview it was determined the facility failed to notify the resident/resident representative in writing of the bed-hold policy upon transfer of a resident to an acute care facility. This was evident for 2 (#7, #17) of 2 residents reviewed for hospitalization during a recertification survey.

Inspectors wroteBased on record review and interview it was determined that the facility failed to provide person centered Activities that incorporated the resident's interests. This deficient practice was evidenced in 3 (#8, #13, and #170) of 3 residents who verbalized they didn't know the facility offered Activities.

Inspectors wroteBased on observation, resident, and staff interviews, it was determined that the facility failed to develop, prepare, and distribute menus that reflect a resident's nutritional wishes. This was evident for 1 (#7) of 27 residents in the facility reviewed during a recertification survey.

Inspectors wroteBased on observations and interviews it was determined that the facility staff failed to use safe food practices while preparing lunch trays for the Transitional Care Unit and failed to store edible produce in the produce refrigerator located in the kitchen. This deficient practice was discovered during the survey.

Inspectors wroteBased on observation, medical record review, and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. Furthermore, the facility staff failed to assure the completeness and accuracy of documentation related to the route of medication administration. This was evident for 1 (Resident #4) of 27 residents reviewed during the recertification survey.

Inspectors wroteBased on observations and interviews it was determined that the facility staff failed to maintain infection control practices as evidenced by urinals hanging over residents' trash cans, a resident's wound vac machine was on the floor, and a urinal was on the bedside table near a resident's water and food tray. This was evident for 3 (Resident #170, #15, #171) of 27 residents reviewed during the survey.

Inspectors wroteBased on observation and record review it was determined the facility staff failed to ensure the dishwasher reached the final rinse temperature of 180' Fahrenheit.

Inspectors wroteBased on medical record review and interviews with facility staff it was determined the facility failed to report allegations of abuse in a timely manner. This was found to be evident for 1 (Resident # 24) of 1 abuse complaint reviewed during the survey.

Inspectors wroteBased on medical record review and interviews with facility staff it was determined the facility failed to ensure that a care plan was initiated to address the specific needs of a resident with a history of sexual assault allegations. This was found to be evident for 1 (Resident # 24) of 1 abuse complaint reviewed during the survey.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to provide the resident and their representative with a summary of the baseline care plan within 48 hours of admission to the facility. This was evident for 1 (Resident #2) of 19 residents reviewed during an annual recertification survey.