cms_DC: 22
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 22 | WASHINGTON CTR FOR AGING SVCS | 95014 | 2601 18TH STREET NE | WASHINGTON | DC | 20018 | 2019-07-30 | 865 | F | 0 | 1 | BMNI11 | Based on record review and staff interviews, the facility staff failed to develop and implement an effective comprehensive quality assurance and performance improvement (QAPI) program inclusive of all systems by failing to implement systems to correct identified problems 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. There was failure 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 failure to ensure a process was in place to provide 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 facility census was 243 on the first day of the survey. Findings included . During the interview on (MONTH) 30, 2019 at approximately 10:40 AM, a review of the facility ' s quality assurance and performance improvement (QAPI) program was conducted with the facility's administration. The review of the program showed the facility failed to identify concerns, and develop and implement actions plans to correct identified areas of deficient practice in: 42 CFR 483.12 (c)(2)-(4), F610, Investigate/Prevent/Correct/Alleged Violation. Administration 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. Employee #5 stated, we review all allegations of resident. 42 CFR 483.25 (d)(1) Accidents -The environment remains as free of accident hazards as is possible; and 483.25 (d)(2) Each resident receives adequate supervision and assistive devices to prevent accidents. Employee #5 stated, resident falls were reviewed. I do a root cause analysis on all falls. The falls committee meets every 3 months, but we are now moving to monthly. We found that most falls occurred at night between 1:55 am to 5:30 AM. The nursing team does a huddle every shift to tell staff who are at risk of falls and the supervisor makes frequent rounds. We have no monitoring tool in place. We have someone in the solarium at all times when the resident are there. The Director of Nursing did a marathon inservice on falls in early (MONTH) (2019). Since then the number of falls reduced in (MONTH) 2019. 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. Employee #5 stated, we review all wounds, wounds associated from Foley catheter use was not a part of quality assurance program. Staff not reporting information on the 24-hour report- unit mangers not reporting information over to stand up. On (MONTH) 30, 2019, at 10:40 AM, Employee #5 stated the facility made good faith efforts to get things done based on what was reported and acknowledged the findings. | 2020-09-01 |