THE SPRINGS, A GRACE LIVING CENTER COMMUNITY
LOCATED: 5800 WEST OKMULGEE, MUSKOGEE, OK 74401
THE SPRINGS, A GRACE LIVING CENTER COMMUNITY 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 –IMMEDIATE JEOPARDY
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
On 10/06/16, an Immediate Jeopardy (IJ) was determined to exist due to the facility’s failure to provide adequate supervision to prevent accidents for residents #1, #2, #3, #4, #5, and #6.
Residents #1, #2, #3, #4, #5, and #6 had resided in the facility on the 200 hall behind two locked doors and without supervision or staff present at all times.
On 10/06/16 at 8:32 p.m., the IJ situation was verified with the Oklahoma State Department of Health.
On 10/06/16 at 8:50 p.m., the director of nurses (DON) stated prior to 10/03/16 she was not aware of dedicated staff assigned to the 200 hall. The DON stated as of 10/03/16 a certified nurse aide (CNA) was assigned to the 200 hall during the day shift only.
On 10/06/16 at 9:07 p.m., the administrator and the director of nurses (DON) were notified of the IJ situation related to failure to provide supervision to prevent accidents on the 200 hall.
On 10/06/16 at 10:52 p.m., the plan of removal for the Immediate Jeopardy pertaining to supervision to prevent accidents was accepted.
Based on observation, interview, and record review, it was determined the facility failed to provide supervision to prevent accidents for six (#1, #2, #3, #4, #5, and #6) of six sampled residents reviewed for supervision to prevent accidents. The facility failed to provide consistent supervision to prevent accidents for the residents who resided on the 200 hall. The facility identified six residents had resided on the 200 hall since the opening of the hall for resident care on 09/22/16.
On 10/06/16 at 5:17 p.m., resident #1 stated she came to live at the facility the previous week. The resident stated staff was good, but did not always answer the call lights timely. The resident stated she had verbalized the concern to the administrator and staff. The resident stated she was fearful to be on the hall without staff present because she might fall or become ill without someone knowing. The resident stated no staff present on the hall was a dangerous situation. The resident stated she had to be careful in the bathroom to keep from falling. The resident stated she was ill at 2:00 a.m. one morning and was already in the bathroom before staff arrived to help. The resident stated she would obtain her own ice from the dining room and rarely saw staff present. The resident stated she felt alone. A nurse note, dated 10/06/16, documented the resident was moved to room 314 with permanent supervision for her safety.
On 10/10/16 at 9:53 a.m., the DON was asked if concerns had been voiced related to supervision on the 200 hall. The DON stated the staff voiced concerns the first day a resident was admitted to the 200 hall due to staff not being present on the hall at all times. The DON stated all staff assigned to the 200 hall had voiced concerns. The DON stated the concerns were taken to the administrator. The DON stated the administrator had no response.
On 10/10/16 at 11:27 a.m., the DON was asked if residents were safe when left unsupervised for up to two hours on the 200 hall. The DON stated she had concerns. The DON stated staffing had not changed when residents were admitted to the 200 hall.
On 10/06/16 at 6:55 p.m., CNA #1 was asked about the staffing on the 200 hall. The CNA stated she worked the 100 and 200 hall and was assigned to provide supervision most nights. The CNA stated she couldn’t just sit over there on the 200 hall. The CNA stated she made rounds on the 200 hall every 2 hours and answered the call lights as soon as she could. The CNA was asked would she be able to hear if a resident residing on the 200 hall called out for help. The CNA stated she would not be able to hear a resident if they called out for help on the 200 hall. The CNA was asked how she would know if a resident had a fall. The CNA stated she would find them when she made rounds. The CNA was asked if she was able to meet resident needs on the 200 hall. The CNA stated not all resident needs may be meet on the 200 hall. The CNA was asked if residents on the 200 hall had voiced any concerns. The CNA stated one resident verbalized she did not like being on the 200 hall alone. The CNA stated staffing was not increased when residents were admitted to the 200 hall.
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.
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