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Mission Palms Post Acute in Mesa Cited for Several Health Violations

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Mission Palms Post Acute Health and Rehabilitation center in Mesa, a recent acquisition of the Ensign Group, has been cited for several violations in DHHS / CMS reports published in 2019 and 2020. Below is a summary of the reports.

Failure to provide care and assistance to perform activities of daily living for any resident who is unable. (F 0677)

A resident who needed extensive help with hygiene and dressing did not receive showers as scheduled. Both staff and residents claimed that understaffing was the problem. The policy is that residents are to receive showers twice a week at minimum, and more often on request.

Failure to provide appropriate foot care. (F 0687)

Failure to provide proper foot care resulted in a serious infection for one resident’s toe. This happened despite the fact that the care plan specified that the resident needed podiatry support and regular nail cutting in order to limit skin breakdown. There was no policy at the facility specifically regarding foot care, and the patient was not on the podiatry list.

Failure to ensure that the nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F 0689)

A resident who needed maximum ADL assistance suffered a fall when a staff member (CNA) was washing the patient. The patient was sent to the hospital and injuries recorded.

Possible preventative actions could have been safety rails on the bed, and having a second person assist with the patient. Typically if a resident requires maximum assistance it means that more than one staff should be present for assistance. The patient was also a larger-bodied individual, which would be all the more reason to have more than one staff present.

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. (F 0725)

Multiple patient interviews revealed that there were not enough nursing staff on the premises to meet resident needs.

Areas of (potential) neglect included:

  • Waiting 30 minutes or more for help when call light was activated
  • Not having frequent enough showers
  • Waiting too long to get assistance with toilet or diaper change
  • Serious lack of staff on night shifts

Administration admitted to staff cutbacks and that showers sometimes need to be missed due to staff shortages.

Failure to 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. (F 0761)

Various bottles of expired drugs were found on the premises, and drugs were not secured properly per policy. This could result in expired medications being administered to residents, and residents accessing medications unsupervised.

Failure to procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (F 0812)

Improper storage of food and a failure to use sanitizer properly could have resulted in illness.

Failure to dispose of garbage and refuse properly. (F 0814)

The facility failed to ensure garbage was disposed of properly, resulting in possible contamination by pests.

Failure to provide and implement an infection prevention and control program. (F0880)

An RN was using her bare hands to dispense medication and put it into the medication cup. This deficient practice could result in cross contamination, spreading infections to others. Policy
dictates that gloves are to be used at all times when dispensing tablets.

Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities (F 0609); Failure to respond appropriately to all alleged violations. (F 0610)

The facility failed to ensure that an allegation of abuse for one resident was reported to the Administrator, AZDHS (Arizona Department of Health Services) and APS (Adult Protective Services) within the required time frame of two hours. IN addition, the accused employee was not removed immediately per policy, which could have posed a danger to other residents.

The facility failed to prevent further potential abuse by failing to remove from duty the accused staff member, which puts the other residents at risk of abuse.

This happened because staff failed to follow the appropriate reporting procedures about alleged abuse.

The facility has detailed policies regarding abuse and reporting, and one clearly states that an accused employee is to be immediately removed if accused of mistreatment.

Hygiene and Infections in Nursing Homes

Lack of adequate wound care will lead to infections. This might mean that a patient has severe bedsores, but also relates to routine processes like cutting nails.

The incident above where a patient ended up with a toe infection was probably due to a combination of issues, but the bottom line is that staff should be attending to basic hygiene issues.

Similarly, the fact that residents had to wait for assistance with hygiene issues such as showers and toileting is troubling. Diapers should be checked every two hour or else sores and infection can occur.

Neglect of seemingly simple activities like cutting nails can lead to disastrous results. Elderly people are more prone to skin breakdown which can lead to all kinds of infections.

Falls in Nursing Homes

The CDC estimates that 50-75% of nursing home residents may suffer at least one fall in a given year, leading to any number of injuries and even death.

One citation above points to several serious falls which may have been prevented with handrails and / or having more than one staff assist with the resident.

Falls themselves can obviously lead to injuries, but poor record-keeping in relation to these incidents, or a lack of immediacy in responding, can also be forms of neglect.

Lack of Staffing in Nursing Homes

Several violations listed above outline the different circumstances which can be behind neglect. In some cases it’s not clear why the neglect happened, but a lack of staff is clearly a contributing factor.

Every home should provide enough staff and properly qualified staff to meet the needs of residents and to meet standards of care required in both facility policy and state law.

If you are concerned about neglect or abuse in a certain nursing care home, let us know. We’re happy to help you understand the law, so that you can protect yourself and your loved ones.

Contact us today for a free consultation.

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