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SIGNATURE HEALTHCARE AT HERITAGE HALL – NURSE AIDE FAILS TO REPORT FALL...

SIGNATURE HEALTHCARE AT HERITAGE HALL REHAB & WELLNESS CENTER LOCATED: 331 SOUTH MAIN STREET, LAWRENCEBURG, KY 40342 SIGNATURE HEALTHCARE AT HERITAGE HALL REHAB & WELLNESS CENTER 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 MAKE SURE THAT THE NURSING HOME AREA IS FREE FROM ACCIDENT HAZARDS AND RISKS AND PROVIDES SUPERVISION TO PREVENT AVOIDABLE ACCIDENTS. LEVEL OF HARM –ACTUAL HARM **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility’s policy, it was determined the facility failed to ensure one (1) of four (4) sampled residents (Resident #1) received adequate supervision and assistance devices to prevent a fall when one (1) staff member attempted to transfer the resident without assistance and without use of a mechanical lift as directed by the facility’s policy and the resident’s Comprehensive Care Plan. On 08/19/16, at approximately 5:00 AM, State Registered Nurse Aide (SRNA) #10 independently attempted to transfer Resident #1 from the bed to the wheelchair without requesting assistance and without utilizing a mechanical lift. Review of the facility’s investigation findings, revealed Resident #1 slid off the side of the bed onto the floor during the transfer. After Resident #1 sustained the fall, SRNA #10 failed to report the fall to the nurse in order for the resident to be assessed for injuries, and instead transferred the resident to the wheelchair with a gait belt, with the assistance of SRNA #7. The resident was not assessed for injuries until 08/19/16 at approximately 1:30 PM. an order for [REDACTED]. On 08/19/16 at 10:45 PM Emergency Medical Services (EMS) was contacted to transfer the resident to the local hospital emergency room and the resident was admitted to the hospital.   Review of Resident #1’s Diagnostic Imaging Report from the ED, dated 08/20/16, revealed a Intertrochanteric Left Femoral Neck Fracture of the Left Hip. Further interview with RN #2, revealed the ARNP was present in the facility at the time she assessed Resident #1, and she obtained orders from the ARNP for an X-ray at 2:00 PM; however, she stated at that point she had not been notified the resident had sustained a fall during the previous shift. She revealed she was notified by the Director of Nursing (DON) on the afternoon of 08/19/16,...

LAS PALOMAS CENTER– SANE EXAM SHOWED TRAUMA

LAS PALOMAS CENTER LOCATED: 8100 PALOMAS AVENUE, ALBUQUERQUE, NM 87109 LAS PALOMAS 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 PROTECT EACH RESIDENT FROM ALL ABUSE, PHYSICAL PUNISHMENT, AND BEING SEPARATED FROM OTHERS LEVEL OF HARM –ACTUAL HARM **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that residents were free from alleged sexual abuse for 1 (R #1) of 4 (R #1, 2, 3, 4) residents reviewed for abuse. This deficient practice resulted in R #1 experiencing feelings of anxiety, fear, discomfort and led to her having nightmares. The findings are: On 12/30/16 at 8:22 am, during an interview with the PTA (physical therapy assistant), she stated that R #1 came to therapy and told her that something strange happened. R #1 told PTA that on 09/12/16 she woke up to CNA #1 (certified nursing assistant) massaging her. PTA stated that R #1 told her that she woke up and CNA #1 was sitting on her bed and rubbing her. PTA also stated that R #1 was very concerned when telling her what happened. On 12/30/16 at 8:31 am, during an interview with the DON (Director of Nursing), she stated that R #1 told her that there was not penile penetration, but that CNA #1 did put his hand in R #1’s vagina. The DON stated that after R #1 disclosed this to her she (R #1) did agree to get a SANE (Sexual Assault Nursing Exam). On 12/30/16 at 10:10 am, during an interview with the SSD (social services director) she stated that she was the first person to interview R #1 regarding the alleged abuse. The SSD stated that R #1 informed her that the encounter took place after she (R #1) went to bed and lasted around thirty minutes. The SSD also stated that R #1 wasn’t able to pinpoint the exact time of the alleged abuse because it was very dark in the room at that time. R #1 told SSD #1 that CNA #1 was going to massage her leg and she told him that is not my leg. On 12/30/16 at 10:45 am, during an interview with CNA #1, he stated that he was called in by the Administrator...

BARKLEY CENTER- RESIDENT FOUND UNRESPONSIVE

BARKLEY CENTER LOCATED: 4747 ALBEN BARKLEY DRIVE, PADUCAH, KY 42001 BARKLEY CENTER 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 PROVIDE NECESSARY CARE AND SERVICES TO MAINTAIN THE HIGHEST WELL BEING OF EACH RESIDENT LEVEL OF HARM –IMMEDIATE JEOPARDY **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of hospital reports, and review of the facility’s policy and procedure, it was determined the facility failed to ensure the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one (1) of four (4) sampled residents (Resident #1). On 08/27/16 at 8:00 PM, Resident #1 was identified as having an accu-check (blood sugar level) of approximately four-hundred forty-three (443) milligrams/deciliter {mg/dl} (normal: 70-100 mg/dl). The resident’s temperature ranged between 99 degrees F to 101 degrees Fahrenheit (normal 98.6 F). The resident had 100 milliliters (ml) of urinary output during the 3:00 PM-11:00 PM shift and no urinary output during the 11:00 PM-7:00 AM shift on 08/27/16. On 08/28/16 at 6:00 AM, the resident’s accu-check was four-hundred eighty-six (486) mg/dl; and, the resident had no urinary output during the 3:00 PM -11:00 PM shift. On 08/28/16, during the 3:00 PM-11:00 PM shift, the resident was identified as being non-responsive and two (2) licensed staff were made aware. However, there was no documented evidence the facility assessed the resident and the physician was notified related to the resident’s high blood sugar, no urinary output, and increased temperatures per facility policy and care plan. On 08/28/16 at 10:00 PM, Resident #1 was found unresponsive, had an accu-check of HI (above 600 mg/ml) and a temperature of 105.4 degrees Fahrenheit. The accu-check was supposed to have been completed at 8:00 PM on 08/28/16, but was not completed until 10:00 PM. Resident #1 was sent to the emergency room (ER) and admitted to the hospital, on 08/29/16, with [DIAGNOSES REDACTED]. Interview with the ER Director on 09/07/16 at 11:00 AM, revealed Resident #1 presented to the ER on [DATE] with a chief complaint of unresponsiveness. He stated this resident responded to painful stimuli only. The ER Director stated Resident #1 arrived to the ER with purulent thick green sputum...

Administrator states, “No evidence that the facility had tracked or trended falls for Resident #1.”...

WEST LIBERTY NURSING & REHABILITATION CENTER LOCATED: 774 LIBERTY ROAD, WEST LIBERTY, KY 41472 WEST LIBERTY NURSING & REHABILITATION CENTER 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 MAKE SURE THAT THE NURSING HOME AREA IS FREE FROM ACCIDENT HAZARDS AND RISKS AND PROVIDES SUPERVISION TO PREVENT AVOIDABLE ACCIDENTS LEVEL OF HARM –ACTUAL HARM **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and a review of the facility falls policy, it was determined the facility failed to ensure one (1) of three (3) sampled residents (Resident #1) received adequate supervision and assistive devices to prevent accidents. Resident #1 had a history of [REDACTED]. The facility failed to investigate the falls to determine the cause of the falls, and to prevent further falls. Resident #1 fell on [DATE] and sustained fractured ribs as a result of the fall. Review of the medical record for Resident #1 revealed the facility admitted the resident on 02/12/16 with [DIAGNOSES REDACTED]. The resident was assessed to be at risk for falls on the admission Minimum Data Set (MDS) assessment with a reference date of 02/19/16 and sustained three falls within five days of admission to the facility. Interview with the Assistant Administrator on 08/24/16 at 11:00 AM revealed that if a resident had a fall, the resident was assessed by the nurse and an incident report and fall investigation were initiated. The nurse was to try to determine the cause of the fall and implement interventions to try and prevent further falls. The Assistant Administrator stated the fall was reviewed the next working day in the morning meeting and interventions were reviewed. According to the Assistant Administrator, there was no evidence that the facility had tracked or trended falls for Resident #1. 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...

Lake Park Nursing & Rehab – State finds repeat problems at Indian Trail nursing home...

INDIAN TRAIL, N.C. – North Carolina Department of Health and Human Services investigators visited Lake Park Nursing and Rehabilitation Center three days after Channel 9 exposed allegations of patient abuse. Eyewitness News anchor John Paul poured over the state’s findings, which include repeat problems. Investigators spent four days at Lake Park nursing home and found repeat problems. Channel 9 uncovered two lawsuits against the facility that are alleging sexual assault and abuse. State officials said that their visit was in response to a new complaint in March and there is a corrective plan was put into place. The latest investigation found the facility failed to maintain implemented procedures. The investigation stated that a patient had not received a shower in two weeks and staff provided him with a washcloth to wash his face, “but that’s it.” The facility was also cited for “neglecting to feed and provide incontinence care for dependent residents.” The continued failure of the facility during three federal surveys of record show a pattern of the facility’s inability to sustain an effective Quality Assurance Program. Channel 9 contacted Lake Park Thursday, but did not hear back. In the report, the facility’s administrator seems to place blame on family members. “One of the biggest barriers to achieving substantial compliance is difficult families,” it read. Lake Park nursing is a special focus facility, one of only about 80 in the country, which means it has a history of persistent poor quality, according to Medicare. Medicare said the facility has shown ‘no improvement for 12 months. 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. 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 have helped many already and we can help you and your loved one as well by filing a state complaint, hiring a specialized nursing home attorney or helping you find a more suitable location for your loved one. Contact us through our CONTACT FORM located on our website here below...

RIVERSIDE CARE & REHABILITATION CENTER – CALHOUN, KY...

RIVERSIDE CARE & REHABILITATION CENTER LOCATED: 190 EAST HWY. 136, CALHOUN, KY 42327 RIVERSIDE CARE & REHABILITATION CENTER 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 MAKE SURE THAT RESIDENTS ARE SAFE FROM SERIOUS MEDICATION ERRORS. LEVEL OF HARM –IMMEDIATE JEOPARDY **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, review of hospital records, and review of the facility’s policy and procedure, it was determined the facility failed to have an effective system to ensure one (1) of three (3) sampled residents (Resident #1) was free of significant medication errors. Review of the physician’s orders [REDACTED]. However, review of Resident #1’s May 2016 EZMAR (Electronic Medication Administration Record) revealed the resident’s order for [MEDICATION NAME] 6 mg, give one (1) tablet daily, was discontinued after the 05/26/16 dose was administered. The facility’s failure resulted in Resident #1 not receiving seventeen (17) doses of [MEDICATION NAME]. Review of the Progress Notes, dated 06/12/16 at 9:37 AM, revealed Licensed Practical Nurse (LPN) #1 was called to Resident #1’s room due to Resident #1 acting different. Upon entering the room, LPN #1 observed Resident #1 with left sided weakness. The resident’s left pupil was pinpoint and nonreactive, and the resident was nonverbal. Resident #1 required assistance for most movements. LPN #1 tried to evaluate Resident #1’s grasp by instructing the resident to grasp both of her hands at the same time. Resident #1 would grasp one (1) hand, then release and grasp the other hand and release. Resident #1 was then instructed to grasp and hold LPN #1’s hands. When Resident #1 grasped both hands, his/her left sided grasp was noted to be weaker. While LPN #1 and the Charge Nurse were evaluating Resident #1, another Charge Nurse notified the Medical Doctor (MD) and Power of Attorney (POA), the State Guardian on call, and the Emergency Medical Systems (EMS). Review of the Facility Progress Notes, dated 06/12/16 at 12:33 PM, recorded by LPN #1, revealed the emergency room (ER) Physician called the facility at approximately 11:00 AM to question about Resident #1 receiving [MEDICATION NAME]. Review of the MAR revealed the last dose the resident received was on 05/26/16. LPN #1 called the hospital at approximately 11:30 AM and followed up with the ER Physician...