State Findings:
Based on interviews and record review, the facility failed to ensure two (#12 and #24) out of four sample residents were kept free from abuse. Specifically, the facility failed to prevent a resident-to-resident altercation between Resident #12 and #24.
The incident dated 5/21/21 identified Resident #12 and Resident #24 were found to be fighting outside.
The investigation reported to the state reporting portal stated, According to witness, Resident #24 and Resident #12 began arguing. Resident #24 spit on Resident #12, Resident #12 sprayed water on Resident #24, Resident #24 hit Resident #12 on the head with a reacher, Resident #12 grabbed Resident #24 on the arms and they were separated by staff.
Facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents ‘ goals and preferences for two (#11 and #14) of five residents reviewed for oxygen therapy out of 25 sample residents.
Specifically, the facility failed to ensure oxygen was administered according to physician orders for Residents #11 and #14.
Registered nurse (RN) #2 was asked about the oxygen order for Resident #11. She looked in the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Upon further investigation, she found an active order from 6/11/21 for 2L/min by NC, may titrate oxygen to maintain sats greater than 90%. She said the order never made it to the MAR, but he did have an active order. She went into the residents room and said the concentrator was set at 1L, and it should have been 2L.
The director of nursing (DON) was interviewed on 6/16/21 at 5:20 p.m. She said Resident #11’s initial order should have been on the MAR.
Following the interview with RN #2, the oxygen orders were changed for Resident #11.
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NHAA is here to assist families, residents, and the community by sounding the alarm on issues like those found above. This nursing home and many others across the country are cited for abuse and neglect.
If you have or had 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.
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Please give us a call at 1-800-645-5262 or fill out our form detailing your experience.
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.
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