Avamere Rehabilitation of Burien

In the surveyor’s words

From the most serious findings on record at Avamere Rehabilitation of Burien, in the surveyor’s own words.

• Actual harm, isolatedF600Mar 27, 2024

  Based on observation, interview, and record review the facility failed to protect resident's rights to be free from abuse when facility policies and procedures to monitor and identify psychological harm were not implemented for 1 of 3 residents (Resident 2) reviewed for abuse. Resident 2 experienced psychological harm and fear when they were verbally abused by a staff member. This failure placed all residents at risk of psychological abuse, and a diminished quality of life. Findings included . Review of the facility Abuse Prevention Policy and Procedure, dated 07/01/2020, directed staff to initiate investigations as soon as a report of abuse was received to rule out or identify abuse and investigations would be completed within five days. […]

• Actual harm, isolatedF622Mar 27, 2024

  Based on interview and record review the facility failed to follow transfer and discharge requirements for 2 of 2 residents (Residents 4 & 3) reviewed for transfer and discharge requirements. The failure to identify a resident's inability to make complex decisions, coordinate care with the Resident Representative (RR), the physician, and the receiving hospital and provide adequate documents for a safe care transition, placed cognitively impaired residents at risk for harm, unmet care needs, delay in care, lack of advocacy from their RR, and diminished quality of life. […]

• Actual harm, isolatedF760Mar 27, 2024

  Based on interview and record review the facility failed to ensure 1 of 3 residents (Resident 3), reviewed for medication administration was free from a significant medication error. Resident 3 experienced harm when a staff nurse, who had not completed the facility required competency review for medication administration, did not follow standard practices for medication administration when they administered potent medications belonging to another resident to Resident 3 which resulted in the resident entering a comatose state (a life-threatening change of condition), emergency transfer to the hospital, and admission to the intensive care unit. These failures placed all residents at risk of harm, significant injury, and potential death. […]

• Actual harm, isolatedF684Feb 28, 2024

  Based on observation, interview, and record review, the facility failed to identify and provide care and services in accordance with the resident's goals and professional standards of practice in the areas of splint use and monitoring impacts of blood thinners and sleep medications for 4 of 20 residents (Residents 191, 60, 85, & 44) reviewed for quality of care. Resident 191 experienced harm when their left hand became swollen and self-reported a severe level of pain when the facility failed to implement measures to monitor the resident's circulation and blood flow to their broken left arm after wound treatment and reapplication of the hard splint. […]

• Actual harm, isolatedF686Feb 28, 2024

  Based on observation, interview, and record review the facility failed to ensure 3 of 5 sampled residents (Residents 32, 10, & 17) reviewed for Pressure Ulcers (PUs)/Pressure Injuries (PIs), received prescribed pressure reducing measures and repositioning on a consistent basis. Resident's 32 and 10 experienced harm when they developed facility acquired PUs. This failure placed all residents at risk for PI/PU development, and a diminished quality of life. Findings included . <PU Staging Guide> Review of the facility provided guided titled, Gentell PI Staging and Care Plan Considerations, dated 2019, showed a PI/PU was defined as damage to the skin and underlying tissue usually over a bony prominence. […]