Deficiencies (over last year)
Deficiencies (over last year)
20 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
355% worse than Tennessee average
Tennessee average: 4.4 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Enforcement
Capacity: 155
Deficiencies: 11
Date: Jun 6, 2018
Visit Reason
This document is a Consent Order issued by the Tennessee Board for Licensing Health Care Facilities following findings of noncompliance and disciplinary action against Midsouth Health & Rehabilitation Center.
Findings
The facility was found to have multiple violations including failure to prevent elopement of cognitively impaired residents, inadequate infection control practices, improper medication administration, failure to provide adequate supervision and care, and failure to comply with training and safety requirements. These violations resulted in immediate jeopardy and substandard quality of care.
Deficiencies (11)
The facility failed to ensure a safe environment preventing elopement for four cognitively impaired residents who exhibited elopement behaviors.
The Quality Assurance committee failed to ensure proper sanitization of a multi-use glucometer, risking cross contamination among residents, including those positive for HIV and hepatitis.
Licensed Practical Nurses were observed using bare hands to handle testing strips and failed to clean the glucometer properly between uses.
The facility failed to provide a sanitary environment for medication administration, including improper handling and administration of oral medications.
Respiratory Therapist changed gloves twice without handwashing during tracheostomy care for a resident.
The facility failed to properly assess and address significant weight loss in residents, resulting in actual harm to at least one resident.
Residents did not receive showers as scheduled, with documentation and interviews confirming inadequate bathing care.
The facility failed to investigate and take action on verbal abuse allegations by a Certified Nursing Assistant toward a resident.
The facility failed to provide adequate in-service training to Certified Nurse Aides related to their responsibilities.
The facility's equipment was in poor repair, including multiple resident beds with broken bed rails.
The facility failed to pay for the care of 22 residents transferred due to a gas leak, confirmed by surveyors and repair company.
Report Facts
Licensed Capacity: 155
Residents at risk: 4
Residents affected by glucometer issue: 20
Residents transferred due to gas leak: 22
Probation period: 6
Plan of Correction submission timeframe: 6
Work plan submission timeframe: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing #1 | Director of Nursing | Confirmed glucometer cleaning procedures and was involved in findings related to infection control. |
| LPN #1 | Licensed Practical Nurse | Observed failing to clean glucometer and improper medication administration. |
| LPN #9 | Licensed Practical Nurse | Observed failing to clean glucometer and improper handling of testing supplies. |
| LPN #7 | Licensed Practical Nurse | Observed improper medication administration and sanitization failures. |
| Respiratory Therapist #1 | Respiratory Therapist | Observed changing gloves without handwashing during tracheostomy care. |
| Certified Nursing Assistant #29 | Certified Nursing Assistant | Alleged verbally abusive to Resident #21; investigation was not completed. |
| Director of Nursing #2 | Director of Nursing | Confirmed lack of investigation into verbal abuse allegations and training failures. |
Inspection Report
Enforcement
Census: 134
Capacity: 155
Deficiencies: 9
Date: Mar 13, 2018
Visit Reason
The document is an Order of Summary Suspension issued by the Tennessee Board for Licensing Health Care Facilities due to serious deficiencies found during the facility's annual and complaint surveys conducted from March 13, 2018 through March 26, 2018. The suspension was based on threats to resident health, safety, and welfare.
Findings
Numerous deficiencies were found affecting the health, safety, and welfare of residents, including failure to supervise vulnerable residents, failure to prevent elopement, unsafe blood glucose monitoring practices, inadequate medication administration, and poor infection control. The facility was decertified by CMS effective April 5, 2018 and will not be recertified.
Deficiencies (9)
The facility failed to ensure adequate supervision to prevent elopement for four cognitively impaired residents exhibiting elopement behaviors.
The facility failed to properly sanitize a multi-use glucometer, risking cross contamination of blood borne pathogens to approximately twenty residents receiving blood glucose checks.
Licensed Practical Nurses failed to clean the glucometer between residents and used bare hands to handle testing strips, violating infection control protocols.
The facility failed to provide a sanitary environment for medication administration; a nurse crushed medications with bare hands and tablets fell onto the medication cart.
The facility failed to ensure residents at risk for weight loss were properly assessed, resulting in actual harm to a resident.
The facility failed to provide showers as scheduled for residents, including one resident who received only two showers in a month.
The facility failed to investigate and report verbal abuse allegations by staff toward a resident and did not take action to prevent further abuse.
The facility failed to provide required in-service training to Certified Nurse Aides on their responsibilities and abuse prevention.
The facility failed to pay for care of twenty-two residents transferred due to a gas leak and owed outstanding bed taxes totaling $361,075.40.
Report Facts
Residents present: 134
Total licensed beds: 155
Residents at risk of elopement: 4
Residents affected by unsafe blood glucose monitoring: 20
Outstanding nursing home assessments: 361075.4
Residents transferred due to gas leak: 22
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