Walter Reed Post Acute

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to assist the resident to obtain vision services for 1 of 45 residents (Resident #85), in the survey sample.

Inspectors wroteBased on observation, staff interview, clinical record review, and review of facility documents, the facility's staff failed to ensure a leg strap was available to secure to a resident's leg to prevent the Foley (brand) catheter from dislodging or being pulled and the facility staff failed to date resident's Foley bag and Foley catheter for 1 of 45 residents (Resident #29), in the survey sample.

Inspectors wroteBased on observation and interviews, the facility failed to ensure food items were stored and served under sanitary conditions in that the facility failed to ensure dietary staff cleansed food preparation areas with an appropriate strength sanitizer, failed to change gloves and perform hand hygiene before touching clean dishes and before serving food. This deficient practice had the potential to affect all the residents in the facility.

Inspectors wroteBased on observations, record review and interviews, the facility failed to accommodate the need of one (Resident (R) 20 of two residents reviewed for accommodation of needs. Specifically, the facility failed to ensure R20, who had contractures of both hands, was provided with a call bell system that R20 could use to signal for assistance and that the call bell was within reach when in bed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the physician to obtain an order for treatment for one (Resident (R) 65) of one resident reviewed for the development of an open area on the sacrum.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure that one of five sampled residents reviewed for unnecessary medications was free from the use of a psychotropic medications (Resident (R) 61). R61 was restarted on olanzapine (medication used to treat certain mental/mood conditions and may be used with other medication to treat depression) at the Hospital and was re-admitted to the facility without clinical justification for the drug's use and continued drug use.

Inspectors wroteBased on observation, interview, and clinical record review the facility failed to provide dialysis services for 1 Resident (Resident #135) in a survey sample of 42 Residents resulting in harm. For Resident #135 the facility failed to ensure transportation to and from dialysis appointments which resulted in two back-to-back missed appointments. The missed appointments on 03/01/2018 (Thursday) and 03/03/2018 (Saturday) resulted in a new prescription for Ativan (a medication for anxiety) due to a panic attack. This resulted in harm. For the missed appointments on 04/28/2018 (Saturday) and 05/01/2018 (Tuesday), the resident was hospitalized . This also resulted in harm. These four missed appointments result in a pattern. [...]

Inspectors wroteBased on observation, staff interview and facility documentation review the facility staff failed to store and serve food in accordance with professional standards for food service safety. Facility staff failed to use correct handwashing procedures, hold food at appropriate temperature, and reheat food to appropriate temperature.

Inspectors wroteBased on observation and resident interview the facility failed to ensure food was served at a palatable temperature. Facility staff failed to ensure food was served hot.

Inspectors wroteBased on observations, staff interview, clinical record review, and facility policy review, the facility staff failed to meet professional standards by failing to secure a prescription for a controlled substance for one Resident (Resident # 101) in a survey sample of 42 residents.

Inspectors wroteBased on observations, staff interview, clinical record review, and facility policy review, the facility staff failed to provide care and service associated with Activities of Daily Living by not serving food in a scoop plate for one Resident (Resident # 101) in a survey sample of 42 residents.

Inspectors wroteBased on observations, family interview, staff interview, and clinical record review, the facility staff failed to provide hydration care and services for one resident (Resident # 94) in a survey sample of 42 residents. The facility staff failed to provide Resident #94 with water.

Inspectors wroteBased on staff interview and clinical record review the facility staff failed to ensure medications were available for administration for 1 resident (Resident #244) of 42 residents in the survey sample. For Resident #244 the facility staff failed to ensure Diazepam (for anxiety) was available for administration.

Inspectors wroteBased on observation, interview and clinical record review the facility failed to ensure 1 Resident (Resident #24) was free from unnecessary psychotropic medication in a survey sample of 42 Residents. For Resident # 24 the facility failed to ensure Resident was free from unnecessary psychotropic medication.

Inspectors wroteBased on staff interview and clinical record review the facility staff failed to ensure 2 resident (Resident #244 and #9) of 42 residents in the survey sample were free from significant medication errors. 1. For Resident #244 the facility staff failed to administer Diazepam (for anxiety) for five days. 2. For Resident #9, the facility failed to administer prn (as needed) Lasix per physician order on three occasions.

Inspectors wroteBased on observation and staff interview the facility staff failed to ensure meals were served according to the published menu. The food served for lunch on 8/22/18 did not reflect the foods listed on the published lunch menu.

Inspectors wroteBased on resident interview, staff interview, facility documentation and clinical record review Administration failed to use its resources to ensure the dialysis residents attain and maintain the highest practicable physical and psychosocial wellbeing. For Resident #135 the facility failed to ensure highest practicable wellbeing for dialysis patients by not utilizing its resources to transport dialysis patients to appointments. Resident # 135 a [AGE] year old female was admitted on [DATE] with diagnoses of but not limited to Diabetes, Diabetic neuropathy, CHF (Congestive Heart Failure), chronic pain of both lower extremities, generalized weakness, cellulitis of right lower extremity and ESRD (End stage renal disease) requiring dialysis three times weekly. [...]

Inspectors wroteBased on observation and staff interview the facility staff failed to implement an effective infection control program. The ice scoop was stored in the ice machine on the Ware unit.