Ascension Living Alexian Village Tennessee

In the surveyor’s words

From the most serious findings on record at Ascension Living Alexian Village Tennessee, in the surveyor’s own words.

• Immediate jeopardy, widespreadF658Oct 11, 2023

  Based on observation, interview, record review, and review of a facility document, the facility failed to ensure services were provided to meet acceptable professional standards for six out of six sampled residents (Resident (R) 4, R7, R8, R20, R21, and R22) reviewed for accidents, bowel monitoring, and supplemental oxygen therapy, out of a total sample of 35. On 07/30/23, R7 was found entrapped between the grab bar and mattress and sustained multiple fractures to his ribs. The nurse on duty assigned to R7 failed to complete a thorough assessment of R7 and failed to accurately report the incident to the resident's physician. Additionally, the facility failed to ensure R7 received supplemental oxygen therapy per the physician orders. […]

• Immediate jeopardy, widespreadF684Oct 11, 2023

  Based on interviews, record reviews, and review of the facility's policy, the facility failed to ensure six of six residents (Resident (R) 4, R7, R8, R20, R21, and R22) reviewed for bowel movement monitoring received the necessary care and treatment in accordance with professional standards of practice. On 07/30/23, R7 was transferred to the hospital after becoming entrapped in between his mattress and grab bar. While receiving treatment, it was discovered that R7 had a fecal impaction. Record review revealed there were no documented bowel movements for R7 for five days leading up to the fecal impaction diagnosis. Additional record reviews revealed the facility's systemic failure of ensuring residents' bowel movements were monitored to prevent constipation. […]

• Immediate jeopardy, widespreadF835Oct 11, 2023

  Based on interview, record review, and review of the facility's Administrator's and Director of Nursing's (DON) Job Descriptions, the facility failed to be administered in a manner that enabled effective use of its resources to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident in the facility. During an abbreviated survey, five Immediate Jeopardies were identified, with the highest scope and severity (S/S) of a L and four standard level tags were cited with the highest S/S being an F. […]

• Immediate jeopardy, isolatedF657Oct 11, 2023

  Based on interview, record review, review of the Hospitalists Discharge Summary, and review of the facility's policy, the facility failed to revise the Comprehensive Care Plan with newly identified problem areas and with new interventions for one of 35 sampled residents (Resident (R) 7). On 07/30/23, R7 was transferred to the hospital after he was discovered entrapped between his mattress and a grab bar attached to his bed. When R7 was readmitted to the facility on [DATE], his care plan was not revised to include updated interventions related to his entrapment. Additionally, while being treated at the hospital for the entrapment incident, it was discovered that R7 had a fecal impaction. […]

• Immediate jeopardy, isolatedF689Oct 11, 2023

  Based on observations, interviews, record reviews, and review of the facility's policies, the facility failed to ensure residents were free from accidents and hazards for one of three resident (Resident (R) 7) reviewed for accidents out of a sample of 35. On 07/30/23, R7 was discovered entrapped between his low air loss mattress and the grab bar attached to his bed. The resident sustained multiple fractures to his right and left ribs. Additionally, the facility failed to complete a timely and thorough investigation into the incident. An Immediate Jeopardy was identified on 09/26/23 and was determined to exist starting on 07/30/23, in S483.25(d) F689: Accidents. The Administrator was notified on 09/26/23 at 3:45 PM of the failure to prevent accidents and hazards for R7. […]