Vanceburg Hills

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to notify the resident's physician to alter treatment when the resident's narcotic pain medication had a delay in delivery from the pharmacy for 1 of 28 sampled residents (Resident (R) 76). R76 received his last dose of his pain medication on 08/17/2024. Even though the resident was expressing verbal and nonverbal signs and symptoms of severe pain, the facility did not notify the resident's physician nor did the facility communicate with hospices services. The resident did not receive his pain medication until 08/19/2024. The facility was out of the resident's medication for 40 hours, and the medication was ordered to be administered every three hours as needed. [...]

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to develop and implement person centered comprehensive care plans for pain, activities, and a significant weight loss for 3 of 28 sampled residents, Resident (R) 76, R34, and R31. This placed the residents at risk for decreased quality of life, quality of care, and further exacerbation of an illness.

Inspectors wroteBased on interview, record review, and review of the facility's policies, the facility failed to ensure a resident, who was on end of life hospice services, pain was effectively managed per the physician orders for 1 of 2 residents reviewed for pain out of 28 sampled residents, Resident (R) 76. R76 was ordered Dilaudid (a narcotic pain medication used to treat severe pain) every three hours as needed. R76 was administered his last dose of Dilaudid on 08/17/2024 at 4:00 PM. The facility did not procure the resident's Dilaudid until 08/19/2024, and the medication was administered to the resident at 8:00 AM which indicated the resident went without the pain medication for 40 hours. This failure resulted in harm to R76 due to him experiencing severe pain.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to provide written notification of a facility-initiated transfer to the resident and responsible party (RP) for 2 (Resident (R) 27 and R46) of 4 residents reviewed for hospitalization in the sample of 28. The failure had the potential to affect the residents and/or their representatives concerning the reason for the transfer and the resident's appeal rights.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to ensure a resident who had a negative Preadmission Screening and Resident Review (PASARR) Level I and then later had a significant change in status and a new serious mental illness diagnosis was accurately and timely referred for a PASARR Level II referral for 1 of 6 residents (Resident (R) 32) reviewed for PASARRs out of 28 sampled residents. This failure placed the resident at risk of qualifying for specialized services but not receiving the services due to the inaccuracy of the PASARR Level II referral.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to ensure residents' Preadmission Screening and Resident Review (PASARR) Level I accurately reflected their current mental illness diagnoses for 3 of 6 residents (Resident (R) 32, R36, and R50) out of 28 sampled residents. This failure inaccurately produced negative PASARRs Level I and placed the residents at risk for unmet psychosocial needs and services had the PASARR triggered for a Level II referral.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to ensure 1 of 28 sampled resident, Resident (R) 31, was provided with activities of his interest. The failure to provide these activities placed R31 at risk for isolation.

Inspectors wroteBased on observation, interview, record review and review of the facility's policy, the facility failed to maintain acceptable nutritional parameters by not assessing the reason for significant weight loss for 1 of 6 sampled residents, Resident (R) 34, reviewed for nutrition in the sample of 28 residents. This had the potential to cause further weight loss without a root cause analysis and/or additional interventions put in place.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to ensure 2 out of the 3 residents with a gastrostomy tube (G-tube) had the tube placement verified and the residual determined prior to any fluids or medications being administered, Resident (R) 46 and R80. This failure had the potential for these residents to be at risk for aspiration pneumonia.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility's nursing staff failed to use appropriate Personal Protective Equipment (PPE) for 1 out of 28 sampled residents who were on Enhanced Barrier Precautions (EBP), Resident (R) 237. Specifically, nurses did not wear a gown when performing R237's wound treatment. This failure had the potential to cause an infection of the resident's wound.

Inspectors wroteBased on observation, interview, record review, and review of facility policies, it was determined 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 infections for three (3) of twenty-four (24) sampled residents (Resident #23, #69 and #75). Observation of Medication Administration for Resident #69, on 07/11/19, revealed Registered Nurse (RN) #1 handled pills and capsules with her bare hands. In addition, observation of Tracheostomy Care for Resident #75, on 07/11/19 , revealed RN #1 failed to ensure proper hand hygiene and glove usage prior to, during, and after the procedure. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's Policy, it was determined the facility failed to ensure daily quality controls were run on glucometers (a device utilized to obtain an immediate reading of the blood glucose) for eleven (11) dates on two (2) glucometers totaling twenty-two (22) events between 03/01/19 and 07/09/19. This affected fifteen (15) residents (Residents #1, #15, #16, #17, #20, #23, #31, #37, #50, #61, #66, #67,#73, #75, and #85) on the 100 and 300 Halls. Review on 07/10/19 of the Glucometer Control Logs, for the 100 and 300 Halls, revealed there were two (2) glucometers in use for fifteen (15) residents who were diagnosed with Diabetes Mellitus. Review of the Logs, revealed missing control results for the dates: 01/18/19, 01/19/19, 03/17/19, 04/28/19, 05/12/19, 05/30/19, 06/04/19, 06/05/19, 07/01/19, 07/02/19, and 07/03/19. [...]

Inspectors wroteBased on interview and record review, it was determined the facility failed to ensure the Office of the State Long Term Ombudsman was notified of a resident transfer/discharge for one (1) of three (3) sampled residents reviewed for discharge requirements out of a total sample of twenty-four (24) residents (Resident #95). Resident #95 was discharged to an acute care hospital on [DATE] with return anticipated; however, the resident did not return to the facility and was admitted to the hospital Hospice Unit. There was no documented evidence the State Long Term Care Ombudsman was notified of the transfer/discharge.

Inspectors wroteBased on observation interview, record review, and review of the facility's policies, it was determined the facility failed to ensure Tracheostomy Care (Trach Care) was provided in accordance with facility policy and professional standards of care for one (1) of one (1) sampled resident observed for Trach Care out of a total of twenty-four (24) sampled residents (Resident #75). Observation of Tracheostomy Care for Resident #75 on 07/11/19 , revealed Registered Nurse (RN) #1 did not follow the facility Infection Control Policy, Tracheostomy Care Procedure, or professional standards as the nurse failed to utilize proper hand hygiene and glove usage prior to, during, and after the procedure. In addition, RN #1 set up the trach kit for the procedure on the resident's abdomen instead of using a bedside table. [...]

Inspectors wroteBased on observation, interview, record review and review of the facility policies, it was determined the facility failed to implement procedures for acquiring, receiving, dispensing and administering medications for one (1) of twenty-four (24) sampled residents (Resident #75). Observation on 07/11/19 at 2:05 PM, revealed Resident #75 was administered a liquid per nebulizer treatment via tracheotomy by Registered Nurse (RN) #1, while the State Agency Representative was in Resident #75's room observing other care being provided. Interview with RN #1 at the time of administration, revealed she could not recall the name of the medication she had just administered. [...]