| 21 |
WASHINGTON CTR FOR AGING SVCS |
95014 |
2601 18TH STREET NE |
WASHINGTON |
DC |
20018 |
2019-07-30 |
837 |
F |
0 |
1 |
BMNI11 |
Based on staff interview, Governing Body failed to ensure that action plans were developed and implemented to ensure that facility staff thoroughly investigated the incident which caused Resident #1 to sustained an orbital fracture and multiple bruises during am care as a potential for abuse, neglect. The Governing Body failed to ensure facility staff implemented measures to prevent further potential abuse, neglect from occurring to other residents within the facility; and as a result of their investigation appropriate corrective action was not taken in accordance with the facility's Abuse policy. Also, the Governing Body failed to ensure that the facility staff provided adequate supervision to prevent an accident for Resident #182 who had a fall with an injury and to provide appropriate and sufficient catheter care and assessments and reassessments to prevent Harm for Resident #58 who was admitted with an indwelling Foley catheter which resulted in penile erosion and laceration. The census on the first day of survey was 243. Based on record review and staff interview for two (2) of 56 sampled residents facility staff failed to ensure one (1) resident who had a fall with an injury received adequate supervision to prevent an accident. Resident #182 Findings included . 1.In the area of 42 CFR 483.12 (c)(2)-(4), F610, Investigate/Prevent/Correct/Alleged Violation. The Governing Body failed to thoroughly investigate the incident which caused Resident #1 to sustained an orbital fracture and multiple bruises during am care as a potential for abuse, neglect. In addition, the facility failed implement measures to prevent further potential abuse, neglect from occurring to other residents within the facility; and as a result of their investigation appropriate corrective action was not taken in accordance with the facility's Abuse policy. On (MONTH) 23, 2019, at 11:09 AM an Immediate Jeopardy (IJ)-L was identified at 42 CFR 483.12 (c)(2)-(4), F610, Investigate/Prevent/Correct/Alleged Violation. During the face-to-face interview on (MONTH) 23, 2019 approximately at 2:15 PM, Employees' #1 and #2 acknowledged the findings. Cross reference 42 CFR 483.12 (c)(2)-(4), F610, Investigate/Prevent/Correct/Alleged Violation. 2. In the area of 42 CFR 483.25(d)(1)(2), F689 Free of Accident Hazards/Supervision/Devices, the Governing Body failed to ensure that the facility staff provided adequate supervision to prevent an accident for Resident #182 who had a fall with an injury. During a face-to-face interview with Employee #13 on 7/26/19, at 1:44 PM, he acknowledged the findings and stated, The staff assigned to the solarium left to help a coworker although we educate them not to leave residents in the solarium alone. Cross reference 42 CFR 483.25(d)(1)(2), F689 Free of Accident Hazards/Supervision/Devices 3. In the area of 42 CFR 483.25(e)(1)-(3), F690 Bowel/bladder/Incontinence, Catheter, UTI, the Governing Body failed to ensure facility staff provided appropriate and sufficient catheter care and assessments and reassessments to prevent Harm for Resident #58 who was admitted with an indwelling Foley catheter which resulted in penile erosion and laceration. The findings were acknowledged on (MONTH) 29, 2019, at 10:00 AM during a face-to-face interview with Employee #3 (Unit manager) who stated she did not know what erosion was and would look it up on the internet. Cross reference 42 CFR 483.25(e)(1)-(3), F690 Bowel/bladder/Incontinence, Catheter, UTI |
2020-09-01 |