Accura Healthcare of South Des Moines

In the surveyor’s words

From the most serious findings on record at Accura Healthcare of South Des Moines, in the surveyor’s own words.

• Immediate jeopardy, patternF600Dec 21, 2023

  Based on observation, record review, resident, staff interviews, and facility policy review the facility failed to implement safety measures and interventions to protect residents on the CCDI (Chronic Confusion and Dementing Illness) unit from resident to resident physical abuse from Resident #2. On 11/26/23 during the lunch meal Resident #2 pushed a table into Resident #3 who responded by throwing cooled coffee on Resident #2. Later that same shift Resident #2 verbally threatened Resident #3 that she was going to get her. The facility separated the residents but failed to implement any measures to prevent further aggression. At approximately 7:00 p.m. that same day, a staff person responded to a commotion in Resident #3's room. Resident #2 and #3 were both in the room. […]

• Immediate jeopardy, isolatedF600Apr 25, 2024

  Based on observation, clinical record review, documentation from the facility self-report, staff interviews and facility policy the facility failed to provide an environment free from sexual abuse for 1 of 2 residents reviewed for sexual abuse. (Resident #1). Resident #2, the aggressor was well known for sexual behavior and comments toward other females. Resident #1 experienced unwanted sexual touching on 3/16/24. On 4/23/24, Resident #2 was observed sitting by Resident #4 who had poor cognitive status, and was unsupervised by staff for over two minutes. A serious adverse outcome was likely to occur as the facility failed to provide proper supervision of Resident#2, which put Resident#4 and any other vulnerable residents at risk for unwanted sexual advances. […]

• Immediate jeopardy, isolatedF689May 1, 2023

  Based on clinical record review, hospital record review, staff interview, policy review and observations, the facility failed to ensure the safety of residents during a mechanical lift transfer (Hoyer lift) for 1 of 3 residents reviewed for safe transfers (Resident #1). On April 26, 2023 at 2:00 p.m., the State Survey Agency informed the facility the staff's failure to ensure the proper sling was used for a Hoyer transfer of a resident created an Immediate Jeopardy situation, which began on April 18, 2023. The facility staff removed the immedicacy on April 18, 2023, when the facility staff implemented the following Corrective Actions: a. Hoyer transfer education provided immediately to the staff involved in the transfer which resulted in a fall. b. […]

• Immediate jeopardy, isolatedF692Apr 19, 2021

  Based on record review and staff and family interviews the facility failed to provide adequate nutrition and hydration for 1 of 2 sampled (Resident #1) who had weight loss. The facility failed to implement effective interventions for Resident #1 disconnecting his tube feeding at night. The facility failed to carry out a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to adequately assess Resident #1 prior to hospitalization on [DATE]. Resident #1 admitted to the Intensive Care Unit with profound dehydration and an elevated sodium level of 175 (normal 135-145). The facility reported a census of 48 residents. Findings include: Resident #1's Minimum Data Set (MDS) dated of 3/5/21 listed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Immediate jeopardy, isolatedF760Apr 19, 2021

  Based on observation, record review and staff & physician interview the facility failed to perform a Prothrombin Time (PT) and International Normalized Ratio (INR) lab draw for 1 of 2 residents (Resident #4) on an anticoagulant medication. PT & INR labs are done to determine blood clotting time when taking blood thinning medications. The Physician ordered a PT and INR on 3/15/21. On 3/26/21, Resident #4 transferred to the emergency room with a PT greater than 120 (normal 12.2-15.1) and an INR unable to be calculated due to the elevated PT value (normal 2-3). Resident #4 experienced bloody noses for 2 days prior to hospitalization without physician notification or intervention. Resident #4 admitted to the Intensive Care Unit on 3/26/21. The facility reported a census of 48 residents. […]