CHINLE, AZ- DR GUY GORMAN SR CARE HOME

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

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

Based on observation, interview, record review, and review of the facility’s policies, the facility failed to ensure seven residents (Resident (R) 99, R98, R24, R3, R39, and R36) received care and treatment in accordance with professional standards of practice.
1. The facility failed to perform Accuchecks (finger stick blood sugar checks) per the physician’s orders for eight days while continuing to administer scheduled insulin to R99;
2. and failed to notify R98’s Physician to obtain an order for Accuchecks after the resident was admitted to the facility with an order for insulin.
3. The facility failed to perform neuro checks after R39, R24, and R36 had sustained unwitnessed falls.
4. Additionally, the facility failed to ensure skin assessments and wound measurements were completed per the facility’s policy for R3.

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 and interview, the facility failed to develop a care plan for the problem of dehydration for one of one resident (R )15 in the sample of 17. Specifically, the resident was admitted to the hospital on two occassions for diagnosis of dehydration.

Assess the resident when there is a significant change in condition

Based on observation, interview, record review, and review of the facility policy, the facility failed to identify and complete a significant change in status Minimum Data Set (MDS) assessment for two (Residents (R) 3 and R36) in a total sample of 17. The facility failed to assess R3 for increased behaviors and declining cognition, and R36 for a significant decline in their physical condition which impacted their ability to perform activities of daily living (ADLs). This had the potential for care and services needed for R3 and R36 to reach their highest practical well-being not to be identified, assessed, planned, and provided. 

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

Based on interview, record review, and policy review, the facility failed to ensure one of two sampled residents recently admitted to the facility (Resident (R) 98), out of a sample of 17 residents, was provided with the written summary of the baseline care plan following admission. R98 stated she did not know what the services and treatments for her care entailed.

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

Based on interview, record review, and review of the facility’s policy, the facility failed to report
misappropriation of personal property, injuries of unknown source, and allegations of abuse to their
administrator and/or the Centers for Medicare & Medicaid Services (CMS) immediately, but not later than two hours for four of 11 sampled residents reviewed for abuse/neglect and injuries of unknown injuries (Resident (R)17, R22, R99 and R45). Failing to report timely has the potential to delay facility actions to protect residents from further potential abuse while the allegation is investigated.

Keep residents’ personal and medical records private and confidential.

Based on observation, interview, and record review, the facility failed to ensure that two residents (Resident (R) 348, R7) of eight residents observed during Medication Administration were provided with privacy during medication administration. Failure to respect privacy has the potential to erode trust, dignity, and a sense of well-being.

Protect each resident from the wrongful use of the resident’s belongings or money.

Based on interviews, record review, and facility policy review, the facility failed to ensure one resident (Resident (R) 17) of 17 sampled residents were free misappropriation of property by staff. This deficient practice had the potential to allow staff to take advantage of residents for personal gain.

Respond appropriately to all alleged violations.

Based on interview, record review, and review of the facility’s policy, the facility failed to investigate an injury of unknown origin for one resident (Resident (R) 1) of four residents reviewed for injury of unknown origin. In addition, the facility failed to implement their abuse policy and take steps to protect residents from the potential of further abuse by removing the alleged perpetrator from resident care, pending investigation for four residents (R3, R16, R17 and R45) of 11 residents reviewed for abuse. This failure had the potential to contribute to further abuse or psychosocial harm for residents.

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Based on interview and record review, the facility failed to ensure the resident and/or the resident
representative was provided with written transfer notices upon emergent transfer to the hospital for four out of five residents reviewed for hospitalization (Resident (R)15, R6, R298, and R36) out of a total sample of 17 residents. This had the potential for Residents and/or their representative to be unaware of their rights.

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 interview, record review and policy review, the facility failed to ensure four out of five sampled residents reviewed for hospitalization out of a total sample of 17 residents (Resident (R) 15, R6, R298, and R36) were provided with bed hold notices upon emergent transfer to the hospital.