DIVERSICARE OF ST JOSEPH
LOCATED: 3002 NORTH 18TH ST, SAINT JOSEPH, MO 64505
DIVERSICARE OF ST JOSEPH 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 WRITE AND USE POLICIES THAT FORBID MISTREATMENT, NEGLECT AND ABUSE OF RESIDENTS AND THEFT OF RESIDENTS’ PROPERTY
LEVEL OF HARM –ACTUAL HARM
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to assure staff followed the facility policy for the prevention of skin breakdown and implement interventions to prevent the development of four pressure ulcers (a localized injury to the skin or underlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination with sheer) for one of 16 sampled residents (Resident #7). The facility census was 93.
During an interview on 2/1/16, at 9:30 A.M., while on the initial building tour, Licensed Practical Nurse (LPN) C said:
– The resident was non-verbal and not able to take food or fluids orally;
– Had a gastric tube (GT, a feeding tube inserted into the abdomen for administration of liquid nutritional supplements and medications);
– Incontinent of bowel and had a suprapubic urinary catheter;
– Sensitive skin, used a moisture barrier cream for skin protection, and had no skin breakdown.
Observation on 2/1/16, at 9:30 A.M., showed the resident, with multiple, severe contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) to all his/her joints, including both hands. He/she lay on his/her left side on a bed, which did not contain a therapeutic low air loss mattress, with the head of the bed (HOB) elevated to an approximately 45 degree angle. The resident did not have any type of supports or washcloths rolled in his/her hands to eliminate the worsening of his/her contractures.
Observation on 2/2/16, at 6:15 A.M., showed the resident lay on his/her left side on a bed with no low air loss mattress in place and the HOB elevated to an approximately 45 degrees. A small, round cushion supported the resident’s head under the left jaw. The resident did not have any type of supports or wash cloths rolled in his/her hands to prevent the worsening of his/her contractures.
Observation on 2/2/16, at 6:45 A.M., showed the resident with no change of position.
Observation on 2/2/16, at 6:50 showed Certified Nurse Aide (CNA) A entered the resident’s room, emptied the resident’s urinary catheter bag, did not change the resident’s position, or provide any type of ADL care to him/her.
Observation on 2/2/16, at 7:00 A.M., showed CMT A entered the resident’s room, spoke to the resident’s roommate, and did not change the resident’s position in bed.
Observation on 2/2/16, at 7:05 A.M., showed CNA C entered the resident’s room, placed a pillow under the resident’s roommate’s head, and did not change the position of the resident.
Observation on 2/2/16, at 7:20 A.M., showed MDS coordinator (MDSC) A and MDSC B entered the resident’s room, handed a wash cloth to the resident’s roommate to wash his/her face, and asked if the roommate wanted to get up for breakfast. MDSC A left the resident’s room to get a mechanical lift, while MDSC B stayed in the resident’s room to wait. MDSC B did not change the resident’s position or provide any ADL care for the resident. The roommate’s wheelchair sat, pushed against the resident’s bed. MDSC B left the room after a few minutes.
Observation on 2/2/16, at 7:30 A.M., showed MDSC A entered the resident’s room with the mechanical lift, and assisted the Activity Director (AD) with perineal care on the resident’s roommate. Staff did not provide any ADL care for the resident or change his/her position in the bed.
Observation on 2/2/16, at 7:45 A.M., showed MDSC A and AD completed perineal care on the roommate, transferred the roommate with the mechanical lift to a wheelchair, and wheeled the roommate out of the room. Neither staff provided any care or repositioned the resident before leaving the room.
Observation on 2/2/16, at 8:05 A.M., showed LPN B wheeled a medication cart to the doorway of the resident’s room to administer his/her medications. The resident remained in the same position. At 8:15 A.M., LPN B entered the resident’s room to administer medications, gave the resident’s medications and nutritional supplement though his/her GT, and left the room at 8:30 A.M. LPN B left the room without providing any ADL care or changing the resident’s position.
Observation on 2/2/16, at 10:55 A.M., showed the resident wore a new, clean gown, but appeared to have been left in the same position. He/she remained on his/her left side with his/her head supported by the round support cushion.
Observation on 2/2/16, at 11:30 A.M., showed the resident remained in the same position.
During an interview on 2/2/16, at 11:30 A.M., CNA E said:
– He/she did not know why the resident remained in the same position with his/her head to the left side with the round support in place under the chin.
– Staff instructed him/her to put the round support in that position, but he/she did not know why. That’s how staff told me to put it and he/she did not know why.
Personal Note from NHA – 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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