West Suburban Medical Ctr

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide written notice of transfer/discharge to the resident and/or resident representative, including the reason, effective date, and location of transfer, for one of eight residents reviewed for discharge (R2). This failure resulted in R2, who has aphasia and resided on the same unit for over six years, being transferred to a local hospital emergency room without prior notification or opportunity for preparation. This deficient practice has the potential to cause R2 to experience fear, anxiety, and confusion related to unexpected transfer.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement an adequate plan for relocation and failed to provide written notification at least 60 days prior to closure to residents, resident representatives, and appropriate parties for eight of eight residents reviewed for facility closure (R1-R8). The facility closed abruptly without an approved closure plan or required notifications, resulting in uncoordinated and unsafe resident discharges. This deficient practice placed residents at risk for unsafe transfers, lack of continuity of care, and increased emotional distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that it was safe for one resident (R3) to self-administer medications and did not follow doctors order and facility policy prior to leaving inhaler medication at bedside. This failure affected one resident in a total sample of 15 residents.

Inspectors wroteBased on interview and record review, the facility failed to develop a person-centered care plan and interventions that meet the needs of a resident receiving dialysis treatment. This deficiency affects one (R65) of one resident in a sample of 15 reviewed for dialysis.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy related to ensuring flowsheets and dialysis communication forms are placed in chart on a resident on dialysis treatment. This deficiency affects one (R65) of one resident in a sample of 15 reviewed for dialysis.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control policies regarding 1. hand hygiene while passing meal trays 2. Droplet Plus isolation precautions, and 3. Legionella (water contamination) prevention; and failed to have a policy which includes COVID prevention. These failures have the potential to affect all seven residents residing on the subacute rehabilitation unit.

Inspectors wroteBased on observation and interview, the facility failed to maintain professional nursing standards of practice by not properly performing double nurse medication verification, in accordance with facility protocol, while administering cancer related medication and by preparing medications in advance of administering them. These failures applied to two (R6, R171) of eight residents reviewed for medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedures for providing assistance with activities of daily living by not ensuring resident nails were clean and cut, not ensuring a dependent resident's environment was clean and that he was was free of body odors, and failed to ensure a resident was raised out of bed for daily activities. These failures applied to five of five residents (R6, R7, R9, R18, and R68) reviewed for activities of daily living.

Inspectors wroteBased on interview and record review, the facility failed to follow their fall prevention policy and procedures by not ensuring a chair alarm intervention was in place as required for a resident at risk for falls resulting in an unwitnessed fall. This failure applied to one of one resident (R9) reviewed for accidents/falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a five percent (5%) or lower medication error rate. There were six medication errors out of 25 medication opportunities, resulting in a 24% medication error rate. This failure affected two of five residents observed during medication administration.

Inspectors wroteBased on interview and record review, the facility failed to follow their vaccine policy and procedures for flu and pneumonia vaccination by not ensuring a vaccine eligible long term care resident was offered and educated on or receiving a flu or pneumonia vaccination. This failure applied to one (R7) of five residents reviewed for vaccinations.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow their COVID-19 policy and procedures for COVID vaccination, by not ensuring a vaccine eligible long term care resident was offered and educated on or received a COVID vaccination. This failure applied to one (R7) of five residents reviewed for COVID vaccination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have an active order for oxygen administration for one resident (R9) prior to administration; failed to follow facility policy and accepted standards of care related to medication administration by not pulling residents' medications at the time of administration; and failed to safely secure controlled class drug medications. These failures apply to nine of nine (R8, R9, R10, R11, R109, R158, R159, R161, R209) residents reviewed for medication administration and storage, and has the potential to affect all 22 residents currently on the unit.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to ensure residents had Advanced Directives in place. This failure applied to six (R6, R7, R108, R109, R110, and R159) of six residents reviewed for advanced directives.