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.

Ensure that residents are free from significant medication errors.

Based on observations, interviews and record review, the facility failed to ensure the Medication
Administration Record (MAR) was followed to prevent a significant medication error which could result in complications for 1 (Resident #43) of 1 sampled resident who received Metoprolol (a medication for high blood pressure, chest pain, and heart failure).

Make sure that a working call system is available in each resident’s bathroom and bathing area.

Based on observation, interview and record review, the facility failed to ensure call lights were in good working order for 1 (Resident #27) of 5 (Residents #20, #27, #35, #41, and #44) sampled residents who resided on the closed unit.

Honor the resident’s right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Based on observations, interviews, and record reviews, the facility failed to ensure staff did not stand over Residents while assisting them with eating for 1 (Resident #39), meal trays were removed from the serving tray and placed on the table for 2 (Residents #38 and #39) and residents who required assistance with eating were provided their meal at the same time as the other residents for 1 (Resident #44) of 3 (Residents #38, #39 and #44) sampled residents to promote dignity and respect.

Allow residents to self-administer drugs if determined clinically appropriate.

Based on observation, record review and interview, the facility failed to ensure before a resident was allowed to self-administer physician ordered liquid mouthwash for dry mouth, the interdisciplinary team (IDT) conducted an assessment to determine if this practice was safe, care planned, and a system was in place to assure the medication was safely and correctly utilized by the resident for 1 (Resident #43) of 1 sampled resident who self-administered a liquid mouthwash for dry mouth medication.

Keep residents’ personal and medical records private and confidential.

Based on observation, record review and interview, the facility failed to ensure privacy was provided to maintain dignity when flushing a percutaneous endoscopic gastrostomy (PEG) tube for 1 (Resident #52) of 1 sampled resident.

Plan the resident’s discharge to meet the resident’s goals and needs.

Based on record review and interview, the facility failed to ensure discharge planning was conducted to promote continuity of care after discharge for 1 (Resident #56) of 1 sampled resident who was discharged in the last 90 days.

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Based on record reviews, and interviews, the facility failed to formulate a discharge summary and provide the Resident and/or responsible party with a copy per the facility policy for 1 (Resident #56) of 1 sampled resident who was discharged from the facility in the last 90 days.

Provide care and assistance to perform activities of daily living for any resident who is unable.

Based on observations, interviews, and record reviews, the facility failed to ensure 1 (Resident (#46) of 1 sampled resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Based on interviews and record review, the facility failed to ensure a medication (Biotene, a liquid
mouthwash for dry mouth) was not left at the bedside for self-administration for 1 (Resident #43) of 1 sampled resident to prevent a potential for ingestion by other residents.