Avalon Health & Rehabilitation Center - Pasco

In the surveyor’s words

From the most serious findings on record at Avalon Health & Rehabilitation Center - Pasco, in the surveyor’s own words.

• Actual harm, isolatedF684Mar 15, 2024

  46722 Based on interview and record review, the facility failed to ensure 1 of 4 residents (Resident 1) received treatment and care in accordance with professional standards of practice after the resident was found with medications in their bed and when a change of condition was not identified timely. Resident 1 experienced harm when their change of condition was not promptly identified, monitored by staff, and not reported timely to the medical provider for evaluation which delayed interventions and the resident being emergently transferred to the hospital. This failure placed Resident 1 and other residents at risk for unidentified care needs and poor clinical outcomes. […]

• Actual harm, isolatedF697Feb 14, 2024

  Based on interviews and record review, the facility failed to provide timely pain management to 1 of 3 residents (Resident 1) on comfort measures. This failed practice resulted in harm to Resident 1 when they experienced unrelieved pain when waiting a prolonged period of time for pain medication while on comfort measures during their active dying process. This failure placed other residents at risk for unrelieved pain and diminished quality of life. Findings included . <Resident 1> Review of the electronic medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses which included malnutrition, adult failure to thrive (condition with the associated symptoms of weight loss, decreased appetite, poor nutrition and inactivity) and anorexia (lack or loss of appetite). […]

• Actual harm, isolatedF684May 17, 2023

  Based on interview and record review the facility failed to ensure that 1 of 2 residents (Resident 8) reviewed for constipation were assessed daily for frequency of bowel movements, and signs and symptoms of impaction or obstruction in accordance with professional standards of practice. Resident 8 experienced actual harm and was hospitalized for fecal impaction (severe constipation resulting in hardened stool getting backed up into the colon (a tube like organ connected to the intestine in the stomach). Findings included . Record review of the facility's undated policy titled Bowel Protocol and Bowel Tracking showed If constipation was suspected, bowel movements would be assessed daily by the nurses for signs and symptoms of fecal impaction or obstruction. […]

• Actual harm, isolatedF697Nov 2, 2021

  Based on observation, interview, and record review, the facility failed to implement [MEDICATION(S)] and/or reduction interventions when one of three residents (30) experienced pain at a 10 out of 10 (on a scale of zero to 10, with zero being no pain and 10 being worst pain), when being weighed by the facility's mechanical lift. Failure to assess the pain resulted in actual harm to the resident when the same process to weigh the resident continued (seven weights obtained since admission) without pain control interventions. Findings included . Review of the facility's policy, Safe Lifting and Movement of Residents, dated 08/31/2018, showed that resident safety, dignity, comfort and medical condition would be incorporated into decisions regarding transfers. […]

• Actual harm, isolatedF757Nov 2, 2021

  Based on observation, interview, and record review, the facility failed to ensure adequate monitoring of an anti-coagulant ([MEDICATION(S)]) for one of one resident (2) for unnecessary medications; to clarify whether the anticoagulant medication had to be held for a period of time before and after significant dental surgery (extraction of five teeth). This failure resulted in harm to Resident 2 who experienced signs and symptoms of excessive bleeding from dental surgery. The resident was taken to the emergency room in less than 24 hours after the surgery and was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included . Resident 2. […]