FREDERICKSBURG, VA- WOODMONT CENTER

The Department of Health & Human Services conducted an inspection of the facility. The following  highlighted decencies listed below were all found in one inspection of the facility by a state surveyor.

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, clinical record review, staff interview and facility document review, it was determined that the facility staff failed to provide care and services for an indwelling urinary catheter (1) for one of 29 residents in the survey sample, Resident #245 (R245).

Employ staff that are licensed, certified, or registered in accordance with state laws.

Based on staff interview, facility document review and employee record review, it was determined that the facility staff failed to evidence maintenance of required certification for one of 25 employee record reviews.

The facility staff failed to provide the evidence of required certification for one CNA (certified nursing assistant) that was hired within the last two years, CNA #2.

Honor the resident’s right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to periodically review advance directives for two of 29 residents in the survey sample, Residents #51 (R51) and #2 (R2).

Immediately tell the resident, the resident’s doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Based on staff interview, facility document review and clinical record review, the facility staff failed to notify the physician of a significant change in health for one of 29 residents in the survey sample, Resident #49.

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

Based on staff interview, facility document review and clinical record review, the facility staff failed to implement the facility abuse policy for reporting the final results of an allegation of abuse to the State Agency (SA) for one of 29 residents in the survey sample, Resident #11.

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

Based on staff interview, facility document review and clinical record review, the facility staff failed to report the final results of an allegation of abuse to the State Agency (SA) within 5 working days, for one of 29 residents in the survey sample, Resident #11.

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence that bed hold notification was provided when two out of 29 residents in the survey sample were transferred to the hospital; Resident #18 and Resident #11.

Create and put into place a plan for meeting the resident’s most immediate needs within 48 hours of being admitted

Based on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to develop a baseline care plan for an indwelling urinary catheter (1) for one of 29 residents in the survey sample, Resident #245 (R245).

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

Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement the comprehensive care plan for 4 of 29 residents in the survey sample; Residents #47, #43, #4, and #51.

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to obtain weights as ordered for one of 29 residents in the survey sample, Resident #11.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Based on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to implement physician-ordered fall interventions per the plan of care for one of 29 residents in the survey sample; Resident #47.

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

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to provide respiratory care and services per physician’s order, for one of 29 residents in the survey sample, Resident #4.

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Based on observation, resident interview, facility document review and clinical record review, the facility staff failed to provide food to accommodate a resident’s preferences for one of 29 residents in the survey sample, Resident #43.

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Based on observation, staff interview and facility document review, it was determined that the facility staff failed to store, prepare and serve food in a sanitary manner in one of one facility kitchens and two of two facility unit pantries.

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure a complete and accurate clinical record for one of 29 residents in the survey sample; Resident #78.