The Citadel Post Acute Rehabilitation Center in Mesa underwent a routine review by the HHS, and was cited for six separate violations per the 2019 report.
Failure to allow residents to self-administer drugs if determined clinically appropriate. (F 0554)
A resident was left to take medications on their own but this was not reviewed and instructed by the health care team or the physician’s order.
In this case, no actual harm was done to the patient, but a lack of staff observation in this context could result in serious harm, including (for instance) overdose or unsafe storage of medications.
The correct process for self-administration of medication is to have a patient’s status assessed by a care team, and then ensure that the patient is properly trained and clear on what they need to do.
Failure to ensure each resident receives an accurate assessment. (F 0641)
The facility failed to ensure that a patient MDS assessment accurately reflected the status of two different residents.
In one case, staff mistakenly documented an indwelling catheter. In another case, there was some confusion as to whether a pressure ulcer existed on admission or was acquired at the facility because of documentation problems.
The deficient practice could affect continuity of care.
Failure to provide appropriate treatment and care according to orders, resident’s preferences and goals. (F0684)
The facility failed to ensure medications were administered correctly for one resident, a situation which could lead to infections and other complications.
In this case, regular infusions of IV antibiotics were required to treat an abscess, but the doses appeared to have been missed over the course of several days. There was no indication as to why and no physician was consulted.
The policy for Administration of Medication clearly states that medications should be given per doctor’s orders at all times, and all times. If a patient refuses medication or there is some other reason a patient does not receive medication as directed, staff is to document this clearly.
Failure to provide safe, appropriate pain management for a resident who requires such services. (F 0697)
The facility failed to provide adequate pain management according to professional standards of practice for two residents.
One was in extreme pain and had to wait for hours, another requested a different medication but had to wait for the physician to change the pain medication.
The policy is to ensure residents’ well-being regarding pain management. But there is also the issue that doctors need to be the ones who make decisions to switch out medications or change doses.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (F 0755)
A blood glucose monitor control solution showed unusually high numbers, which indicates that it is not working correctly. However, it continued to be used.
The proper corrective action for this situation, according to both the facility policy and the manufacturer’s instructions, is that it should not be used if the control test is not in range.
This did not cause any direct harm to residents, however it could have resulted in inaccurate blood glucose readings.
Failure to provide and implement an infection prevention and control program. (F 0880)
The facility failed to implement infection control procedures for the handling of clean and soiled clothing and linens. The deficient practice could result in the spread of infection. Preventative measures are to ensure that staff is fully covered by a gown and protected with gloves.
Documentation and General Care
Sometimes this is the result of sloppy record-keeping and is not malicious but can do serious harm.
In general, patient records and care plans need to be thoroughly updated per regular assessments. This is important regarding even somewhat routine issues like taking non-narcotic medications, in part to ensure the safety of other residents.
The facility’s policy for accuracy of assessments stated that the MDS assessment should accurately reflect the resident’s status. Each individual who completed a portion of the assessment must sign and certify accuracy of that portion of the assessment.
Other Areas of Potential Neglect
Patients with diseases like diabetes need to be checked regularly, especially as they could have multiple illnesses which affect one another. Many have cognitive impairment, which means that they can no longer do regular activities like check their blood glucose.
All linens should be handled as if it were highly infectious. Healthcare workers play an important role in reducing the potential for transmission of infectious microorganisms.
Call Us For More Information on Nursing Home Neglect
Sometimes this is the result of sloppy record-keeping and is not malicious, but can do serious harm. Be wary of nursing homes which seem understaffed, or where the staff does not seem to be practicing due diligence.
If you’re concerned about nursing home neglect or abuse in the Phoenix area, don’t hesitate to reach out to us for a free consultation.