GRACE POINT, LLC
1700 EAST SHORT HILLSBORO, EL DORADO, AR 71730
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 APPROPRIATE CARE FOR RESIDENTS WHO ARE CONTINENT OR INCONTINENT OF BOWEL/BLADDER, APPROPRIATE CATHETER CARE, AND APPROPRIATE CARE TO PREVENT URINARY TRACT INFECTIONS
Based on observation, record review, and interview, the facility failed to ensure the necessary assessments, monitoring, treatment and services were provided for the management of bowel incontinence for Resident #1, as evidenced by: failure to ensure that before a rectal tube with fecal bag (Flexi-seal system) was initiated, the staff responsible for managing the device were knowledgeable and fully competent with doing so; failure to ensure nursing staff monitored the Flexi-seal system and fecal output, promptly addressed leakage of fecal material, kinks or blockage of the tubing, evaluated the positioning of the rectal tube for correct positioning in the rectum when the system continued to experience leakage of fecal material on an ongoing basis, and consulted the physician when the Flexi-seal system continued to be unsuccessful in preventing a Stage IV pressure ulcer from being repeatedly contaminated with fecal material, to prevent further infection and / or exacerbation of the pressure ulcer; and, failure to ensure all nursing staff involved with the resident’s care were aware of when to change the Flexi-seal bag and who was responsible for doing so, to ensure fecal material could evacuate from the bowel into the collection bag without impediment for 1 (Resident #1) of 1 case mix resident who had a Flexi-seal system in place.
These failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #1, who had a large Stage 4 pressure ulcer to the coccyx that deteriorated, developed maceration of the surrounding tissue. The failed practices also had the potential to cause more than minimal harm for 4 residents who had pressure ulcers, according to a list provided by the Administrator on 4/23/18. The Administrator and the Director of Nursing were informed of the Immediate Jeopardy condition on 4/20/18 at 4:10 p.m.
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 wellby 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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