DE QUEEN, AR- BEAR CREEK HEALTHCARE

The Department of Health & Human Services conducted an inspection of the facility. The following highlighted decencies listed below were found in a public survey. 

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Based on record review and interview, the facility failed to ensure the facility abuse policies and procedures were implemented, as evidenced by failure to ensure an injury of unknown origin and an unwitnessed fall resulting in a fracture for 1 (Resident #16) was immediately reported to the Administrator, thoroughly investigated, evidence gathered, and findings reported to the state agency to rule out the possibility of abuse and or neglect. The failed practice resulted in Immediate Jeopardy (IJ). On 10/19/22 at 1:50 pm, the facility Owner and the DON were notified of the IJ.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Based on record review and interview, the facility failed to ensure that an injury of unknown origin was investigated and reported to the Office of Long Term Care (OLTC) and other agencies in accordance with state law, to enable those agencies to provide any necessary oversight of the facility’s investigations and protective measures for 1 Resident #16 of 5 residents sampled (Residents #16, #30, #33, #36 and #255) of residents who were reviewed for abuse/neglect.

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Based on record review, and interview the facility failed to obtain the completed Preadmission Assessment and Record Review (PASARR) level II evaluation from the State Agency in order in order incorporate the recommendations from the PASARR Level II evaluation report into the Residents Assessment, Care Plan and Transition of Care for 2 (Resident #20 and R#38) or 21 (Resident #7, #12, #13, #16, #20, #22,#23, #26, #30,#31, #33, #34, #36, #38,# 41 #42, #46, #49, #50#51,#255) sampled residents that were admitted to the facility and had mental health diagnosis.

Develop and implement a complete care plan that meets all the resident’s needs, with timetables and actions that can be measured.

Based on record review, observation, and interview the facility failed to ensure the Comprehensive Care Plan contained the necessary information to fully provide and coordinate care and services for a resident with Physician’s Orders for Anticoagulant Medication for 1 (Resident #36) of 3 (Resident #20, #33 and #36) sampled residents with orders for Anticoagulant Medications. The failed practice had the potential to affect 9 residents that had orders for Anticoagulant Medication according to a list provided by the Medical Records/Infection Prevention Nurse

Provide safe and appropriate respiratory care for a resident when needed.

Based on observation, record review, and interview, the facility failed to ensure oxygen tubing was properly labeled for 1 (Resident #30) sample mix resident, failed to ensure oxygen tubing, nebulizer mask and tubing were properly stored when not in use for 2 residents (Residents #30 and #49) to prevent potential contamination that could result in respiratory infection for 7 (Residents #20, #23, #30, #31, #34, #46, and #49) sampled residents who had Physician Orders for oxygen therapy and nebulizer treatments.

Keep all essential equipment working safely.

Based on observation, and interview the facility failed to ensure 1 of 2 commercial clothes dryers remained free of lint build up to decrease the potential for fire and loss of laundry services for 1 of 1 Laundry Room. This failed practice had the potential to affect 50 residents according to the resident Census and Condition form provided by the Director of Nursing (DON)