BENTONVILLE MANOR NURSING HOME
LOCATED: 224 SOUTH MAIN STREET, BENTONVILLE, AR 72712
BENTONVILLE MANOR NURSING HOME was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies:
PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here.
FACILITY FAILED TO GIVE RESIDENTS PROPER TREATMENT TO PREVENT NEW BED (PRESSURE) SORES OR HEAL EXISTING BED SORES.
LEVEL OF HARM –IMMEDIATE JEOPARDY
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, record review and interview, the facility failed to ensure necessary treatment and services to promote healing of pressure sores, to prevent/decrease infection, and to prevent continued skin breakdown was provided to Residents #2 and #6. The facility failed to ensure intravenous (IV) antibiotics were administered as prescribed upon discharge from hospital for a wound infection for 1 (Resident #2) of 2 (Residents #2 and #6) case mix residents who had a pressure ulcer. The facility failed to ensure a thorough skin assessment was completed and documented upon admission/readmission and at least weekly to enable prompt identification and prompt consultation with physician regarding treatment of any existing or new skin breakdown for 1 (Resident #2) ) of 2 (Residents #2 and #6) case mix residents who had a pressure ulcer. The facility failed to ensure pressure ulcer treatments were provided as ordered by the physician to promote healing for 1 (Resident #2) of 2 (Residents #2 and #6) case mix residents who had a pressure ulcer.
The facility also failed to ensure correct technique was provided when cleansing a wound to prevent potential spread of infection for 1 [Resident #6] of 2 [Resident #2 and #6] case mix residents who had pressure sores.
The failures to ensure IV antibiotics were administered as prescribed and that orders for treatments were promptly obtained resulted in immediately jeopardy which caused or could have cause serious harm, injury, or death to Resident #2 who experienced further deterioration in his wounds resulting in hospitalization and had a potential to cause more than minimal harm to 3 residents with pressure sores according to a list provided by the Administrator on 3/24/15 at 11:40 a.m. The Administrator was informed of the Immediate Jeopardy on 3/24/15 at 11:40 a.m.
Continuing: The January 2015 Physician’s order sheet documented, ” …1/11/15: Send to wound care clinic for bilateral feet wounds.” The resident’s initial visit to the wound clinic was dated 2/5/15; 25 days after the order had been written.
Continuing: On 3/18/15 at 10:39 a.m., LPN #2 was asked about 2/28/14 when she sent (Resident #2) to the hospital. She stated, “He was running a temp, he was lethargic, his left face was drooping, his leg was swollen and his PICC was occluded.” LPN #2 was asked about the condition of the PICC line when the resident was sent out to the hospital. She stated, “…. The foot with the wound vac was terribly inflamed. [Physician] from the hospital called me really upset. She asked about the PICC. I told her I had been off. The Vanc was scheduled to be given that morning and I couldn’t give it because it was occluded. Then the doctor called back and asked about when the Invanz was hung. I went to the MAR and there was no Invanz. So I went to the chart and the first medication on the hospital discharge orders was Invanz. I don’t know how it got missed.” LPN #2 was asked to clarify if she saw the hospital discharge orders and that the Invanz was on the order sheet. She stated, “Yes. I saw them. They were in the miscellaneous section of the chart and Invanz was the first medication listed.” She was told the facility could not locate the hospital discharge orders now and she was asked if she had any idea where they might be. She stated, “I don’t understand that. They were in the chart. I looked at them ….”
Personal Note from NHAA Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect.
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