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Olympia, WA – History of Poor Care; Falls, Neglect & Bedsores

EVERGREEN NURSING & REHAB CENTER

Located: 430 LILLY ROAD NORTHEAST, OLYMPIA, WA 98506

EVERGREEN NURSING & REHAB CENTER was cited between March of 2013 and January of 2014 on five (5) separate dates by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies.

The highlighted quotes listed here are only a portion of the full reports. The compete reports/surveys can be found here, here, here, here and here. The survey dates are listed on our website and are listed by name and date.

JANUARY 2014 – FAILURE TO PROVIDE PROPER TREATMENT TO PREVENT NEW BED (PRESSURE) SORES OR HEAL EXISTING BED SORES

Based on observation, interview and record review, the facility failed to follow and implement interventions consistent with recognized standards of practice as appropriate for 1 of 4 (#105) current sampled residents reviewed for pressure sores.

On observation during dressing change performed by LN H on 01/27/14 at 1:36 p.m., the following three breeches in practice were noted: first when removing dressing on left buttocks, rolling the outside of the dressing onto itself, secondly touching the spout of the spray bottle which contained the Wound Cleanser to the 4X4 sponge which was used to cleanse the inside of the open area on the left buttocks, and finally dragging the moist 4X4 sponge on the skin surface below the open area as the moist 4X4 was placed in the left buttocks open wound which was left in for the wound.

Continuing:  Multiple observations during survey found the resident in bed in the sitting position with head of bed elevated from 40 to 60 degrees. Heels were flat on bed and Resident #105 stated, The pillows they {staff} put under my lower legs are so thin and flat that my heels are on the bed anyways, so what’s the use.

Progress notes dated 10/14/13 reads that the Pt {patient} reviewed during Interdisciplinary Team meeting related to need for a repositioning/turning program. Pt cannot independently reposition self therefore staff needs to reposition Q 2 hr {every 2 hours}and PRN {as needed} to ensure good care.

01/27/14 at 2:40 p.m., when asked NA F if s/he repositioned Resident #105 every 2 hours on the night shift (approximately 10 p.m. to 6 a.m. timeframe), NA F stated, He {Resident #105} usually goes to sleep around 10:30 p.m. and then I go in around 2 a.m. and he is usually snoring on first round, so I empty his catheter and leave. NA F also stated that she usually does two rounds during the night shift, a first round at approximately 2:00 a.m. and a second round at approximately 5:00 a.m., and that Resident #105 is usually awake on second round when she empties his urinary catheter again.

SEPTEMBER 2013 ABUSE AND NEGLECT – FAILURE TO INVESTIGATE

Based on interview and record review, the facility failed to thoroughly investigate incidents to rule out abuse, neglect, or mistreatment in accordance with CFR 483.13( c)(2)(3)(4) for 3 of 5 current sampled residents (#s 1, 2, & 3) reviewed for incidents. This failure placed residents at risk of ongoing abuse and mistreatment. Findings include: All interviews took place on 9/17/13 unless otherwise indicated. <Resident #2> Resident #2 was admitted [DATE] to the facility with [DIAGNOSES REDACTED]. On 7/29/13, the resident stated to a staff person, his catheter had leaked, saturating his bed and he laid in it for several hours. Resident #2 stated when a nursing assistant (NA) had come to his room, he told her about being wet and instead of being changed, the NA opened the window and left the room.

Continuing: On 8/28/13, Resident #1 stated to staff she had to wait for 2 hours after activating her call light to summon help from staff. She also stated she had been left in a wet bed, had not been given proper food and had open sores from not receiving care. Resident #1 stated she had told staff her concerns, I don’t feel like I get quality care, they just do what they want to do, and that she wanted to discharge from the facility because of it. Resident Care Manager (RCM) A stated she was aware of Resident #1′s concerns about being neglected, but did not think an investigation was done because the resident did not give a specific date for when the neglect occurred. According to the facility State reporting incident log, the abuse/neglect allegation(s) had not been logged.

JUNE 2013 – FAILURE TO PREVENT FALLS AND AVOIDABLE ACCIDENTS

Based on observation, interview and record review, the facility failed to provide appropriate interventions, based on resident’s specific identified conditions, needs and potential for entrapment, to prevent accidents for 1 of 3 residents (#1) reviewed for accidents. This failure caused harm to Resident #1 who sustained injuries that required emergent care and treatment at a hospital.

Continuing:  On 5/4/13, according to the facility documentation, the resident was found by her family lying on the floor. Resident #1 stated she hit her head, and was observed with 2 x 3 inch hematoma (blood filled area under the skin) that she said caused her pain. On 5/5/13, a report of the injurious incident documented Resident #1 was positioned on her side too close to the edge of the bed, rather than the middle of the bed. The report documented patient (resident) is able to fidget and might have leaned over and with gravity, the patient rolled out of bed.

The resident was sent to a hospital for evaluation and emergent care for her injuries.

The bed rail had been identified as malfunctioning in the second fall. According to the facility investigative findings for each injury, improper care delivery or faulty equipment was identified as a contributing factor.

APRIL 2013 – FAILURE TO PROVIDE DIGNITY AND RESPECT

On 3/24/13 at 2:30 p.m., a entry in the progress notes documented that Resident #2 was observed with [Redacted] in her brief. The facility determined that she was not checked or changed for [Redacted] from the previous night shift. The progress note also documented Resident #2 was observed “visibly shaken and tearful.”

Continuing: Although there was a physician order to monitor the resident’s psycho-social reaction to the incident, there was no evidence the facility developed implementation of nursing and social services care plan to ensure Resident #2′s psychosocial well being was assessed or monitored to ensure harm did not occur.

MARCH 2013FAILURE TO PROVIDE CARE/SERVICES RELATED TO FALLS / ACCIDENTS

Based on observation, interview and record review, the facility failed to ensure residents received the necessary care and services to attain or maintain the highest level of physical mental and psychosocial well-being for 2 of 3 residents (#1 & 2) when assessments were not completed after fall incidents in accordance with facility protocol and physician direction regarding neurological checks. These failures placed residents at risk for not having their needs being met.

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.

You can make a difference. If you have a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately. We can help you file a state complaint, hire a specialized nursing home attorney or help you find a more suitable location for your loved one.

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Contact us through our CONTACT FORM located on our website here or call our toll free hot line number: 1-800-645-5262

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