Inspection Reports for Patriot Health and REhabilitation Center

The inspection was conducted based on complaints and concerns regarding resident dignity, pressure ulcer care, wound care management, food quality, supply shortages, and infection control practices.

The facility failed to ensure resident dignity for one resident related to inappropriate staff behavior during showering. The facility also failed to develop and implement adequate care plans and provide appropriate pressure ulcer care for multiple residents, resulting in wound deterioration and harm. Additionally, the facility did not ensure palatable and safe food temperatures, experienced shortages of essential supplies such as briefs, wipes, and coffee, and failed to maintain proper infection control practices during wound care.

The investigation was complaint-driven, focusing on allegations of dignity violations, inadequate wound care, poor food quality, supply shortages, and infection control breaches. Substantiation status is not explicitly stated.

The inspection was conducted due to a complaint investigation regarding a resident fall incident involving improper use of a Hoyer lift and failure to timely report the incident.

The facility failed to ensure residents were free from accidents when staff improperly used a Hoyer lift during a transfer, causing a resident to fall and hit his head. Additionally, a staff member failed to report the incident timely. The facility also failed to ensure that a Licensed Practical Nurse (LPN) had a current and valid Tennessee nursing license while working.

The complaint investigation involved Resident #1 who fell in the shower room on 4/18/2023 due to improper use of a Hoyer lift by CNA #1. The incident was not reported until the next day. CNA #1 was suspended and subsequently terminated. Interviews with Resident #1, CNAs, Staffing Coordinator, and Director of Nursing confirmed the incident and failure to report. The resident was sent to the ER for evaluation but was not hospitalized and sustained no injuries.

The inspection was conducted due to a complaint investigation regarding the facility's failure to complete a significant change Minimum Data Set (MDS) assessment within 14 days for the development of pressure ulcers and failure to provide appropriate pressure ulcer care and prevention for residents.

The facility failed to complete a significant change MDS assessment for a resident with pressure ulcers stage 2 or higher and failed to provide appropriate pressure ulcer care for a resident with a knee immobilizer, resulting in actual harm with the development of a Stage 3 pressure ulcer. Documentation and skin assessments related to the use of the immobilizer were inadequate.

The complaint investigation found substantiated deficiencies related to failure to complete significant change assessments and failure to provide adequate pressure ulcer prevention and care, resulting in actual harm to residents.

The inspection was conducted to investigate complaints regarding the facility's failure to include residents or their family members in Interdisciplinary Team (IDT) Care Plan meetings, ensure residents had alternative food and menu choices, and provide appropriate eating equipment and assistance.

The facility failed to include residents or their representatives in IDT Care Plan meetings for 2 of 12 sampled residents, failed to ensure 5 of 9 sampled residents had alternative food and menu choices, and failed to provide appropriate eating equipment for 1 of 5 sampled residents, resulting in minimal harm or potential for actual harm to a few residents.

The complaint investigation revealed that residents and/or their representatives were not invited to IDT Care Plan meetings since November 2021 and August 2021 for Residents #3 and #18 respectively. Residents reported lack of meal choices and menus, and one resident was unable to drink fluids independently due to lack of appropriate equipment.

The inspection was conducted to assess compliance with regulatory requirements related to resident care, assessments, care planning, pressure ulcer management, catheter care, and food handling practices at Patriot Health and Rehabilitation Center.

The facility was found deficient in multiple areas including failure to maintain resident dignity, incomplete and inaccurate Minimum Data Set (MDS) assessments, failure to develop comprehensive care plans for several residents, inadequate documentation and provision of pressure ulcer care, failure to monitor nephrostomy tube site as ordered, and improper food handling by staff.

The inspection was conducted to investigate complaints related to failure to provide timely notification to the Ombudsman of resident transfers, failure to ensure fall prevention measures, improper catheter care, and medication administration errors.

The facility failed to notify the Ombudsman timely of resident transfers for 2 of 6 sampled residents, failed to ensure fall prevention measures for 1 of 8 residents, failed to provide proper catheter care for 2 residents, and failed to administer insulin within the proper timeframe for 1 nurse, resulting in a significant medication error.

The visit was complaint-related, focusing on notification failures to the Ombudsman, fall prevention, catheter care, and medication administration errors. The Ombudsman notification failures were confirmed by interviews and lack of documentation.