CANTERBURY HEALTH CARE FACILITY
LOCATED: 1720 KNOWLES ROAD, PHENIX CITY, AL 36869

CANTERBURY HEALTH CARE FACILITY 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 PROPER TREATMENT TO PREVENT NEW BED (PRESSURE) SORES OR HEAL EXISTING BED SORES.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of Resident Identifier (RI) #1’s medical record, review of www.webmd.com, the facility’s policies titled Care System Guideline Skin Care, Medication Policies Prescriber Medication Orders and Supplements and resident and staff interviews, the facility failed to:

1) complete an initial wound assessment of RI #1’s infected Stage IV sacral pressure ulcer. RI #1 was admitted to the facility on [DATE] with an infected Stage IV pressure ulcer to the sacral region. The admission nurse failed to  conduct an initial wound assessment of the resident’s pressure ulcer. The only wound/skin assessment found within RI #1’s medical record was a Skin Inspection Report dated 6/6/2017 that documented Skin Not Intact  Existing;

2) transcribe the admission wound care orders to change the wound vac on Mondays and Thursdays. RI #1’s wound care orders were not transcribed until 6/8/2017 with a start date of 6/12/2017. When questioned why the delay in wound care orders, the admission nurse, Employee Identifier (EI) #9 stated she forgot;

3) consistently change the wound vac as ordered. A review of the electronic Treatment Administration Record (eTAR) and staff interviews revealed, the resident’s wound vac was not changed as ordered by the physician;

4) conduct subsequent wound/skin assessments of RI #1’s infected Stage IV sacral pressure ulcer. During the course of RI #1’s stay at the nursing facility, from 6/5/2017 until 7/6/2017, there was no evidence the licensed nursing staff conducted weekly wound/skin assessments as listed in the facility’s policy and RI #1’s care plan. The weekly wound assessments, that was the responsibility of the Treatment Nurse, were not done. The facility’s Treatment Nurse left the facility on [DATE] and the administrative staff had no system in place to ensure wound/skin assessments were completed weekly; and

5) follow the Registered Dietician’s (RD) recommendation and physician’s orders [REDACTED].#1, to aid in the healing of the resident’s sacral pressure ulcer. The licensed nurse overlooked the order dated 6/19/2017, thus the resident never received the Juven and protein supplement that was recommended by the RD and ordered by the physician to aid in wound healing.

The facility further failed to ensure RI #1’s at risk for skin integrity care plan accurately reflected the resident’s status. RI #1’s care plan with a problem onset date of 6/5/2017 indicated the resident refused at times to be repositioned. Staff interviews revealed this was inaccurate. The facility also failed to ensure documentation contained within RI #1’s medical record was correct. The licensed nurse documented on 6/5/2017 that RI #1’s wound vac in progress; however, during interview she revealed the wound vac was not attached to the resident. These failures placed RI #1, one of nine sampled residents reviewed for pressure ulcer care in immediate jeopardy as it was likely to cause serious harm, injury or death.

Furthermore, the facility failed to conduct weekly wound/skin assessments of RI #2, a resident admitted to the facility with an unstageable sacral pressure ulcer from 5/1/2017 until 7/18/2017. This deficient practice affected RI #2, one of nine residents reviewed for pressure ulcer care.

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 or on the sidebar or call our toll free hot line number: 1-800-645-5262.

You can make a difference even if your loved one has already passed away.