COLORADO SPRINGS, CO- LIFE CARE CENTER OF COLORADO SPRINGS

Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for six (#13, #272, #61, #17, #44 and #21) of seven residents reviewed out of 42 sample residents.

Specifically, the facility failed to ensure:
-Residents #13, #272 and #61 received assistance with showers as scheduled; and
-Residents #17, #44 and #21 were repositioned in their wheelchairs timely.

Registered nurse (RN) #3 was interviewed on 12/13/21 at 12:37 p.m. The RN was notified the resident had not been repositioned in over four hours. She said she was not aware of how frequently the resident needed to be repositioned. She said he was at risk for pressure ulcers.

The resident was interviewed on 10/13/21 at 2:10 p.m. The resident said that she was upset that she had not received her shower as scheduled. She said that she was supposed to have a shower on 10/6/21 and 10/9/21 and she was hoping that she would get her shower today. The resident said that when her shower was skipped it made her feel as if she was not important. She said that when she complained she was told it was due to staffing.

Based on record review, observations and interviews, the facility failed to ensure six (#70, #25, #52, #43, #17 and #26) of 10 residents reviewed for respiratory care were provided such care in accordance with professional standards of practice out of 42 sample residents.

Based on observations, interviews, and record review, the facility failed to have an effective infection control program.

Specifically, the facility failed to:
-Ensure staff offered hand sanitation prior to resident meals;
-Perform appropriate source control for staff and visitors; and,
-Ensure housekeeping staff completed proper hand hygiene during cleaning of resident rooms

Based on observations, and interviews, the facility failed to ensure medication error rate was not greater than five percent. Specifically, the facility failed to administer heart failure medication to Resident #16, and failed to complete a safety check/priming of the needle prior to insulin administration to Resident #16 out of 25 opportunities, resulting in a medication error rate of eight percent.

During insulin administration, RN #1 prepared to administer 14 units of insulin to the resident. She turned the dial on the [MEDICATION(S)] flex pen to 14 units, attached the needle and administered the insulin. She did not conduct the safety test by priming the insulin needle. Cross-reference F760 for significant medication error.

The unit manager/LPN #2 was interviewed on 10/13/21 at 8:50 p.m. She said the insulin needle had to be primed prior to insulin injection to ensure that the resident received the appropriate amount of insulin. She said she would provide immediate education to all nurses on the floor and for oncoming shifts as well, and she would contact the resident’s physician to report the inaccurate insulin administration.