Aviata at Fletcher

In the surveyor’s words

From the most serious findings on record at Aviata at Fletcher, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Aug 21, 2024

  Based on interviews and record review, the facility failed to protect the resident's right to be free from deprivation of goods and services, by staff failing to provide one resident (#1) with Cardiopulmonary Resuscitation (CPR) per the resident's wishes out of eight residents sampled for advance directives. On [DATE] at approximately 3:00 a.m., Resident #1 became unresponsive during routine care. Nursing staff assessed Resident #1 and Emergency Medical Services (EMS) was called to the facility. Prior to EMS arrival, nursing staff reviewed the medical record and determined Resident #1 had a Do Not Resuscitate (DNR) order. Nursing staff provided oxygen at a high concentration via mask, and sternal rubs were intermittently applied with no response from the resident. […]

• Immediate jeopardy, isolatedF678Aug 21, 2024

  Based on interviews and record reviews, the facility failed to ensure cardiopulmonary resuscitation (CPR) was performed according to the resident's expressed Advance Directive to honor their rights and professional standards for one resident (#1) out of eight residents reviewed for advance directives. On [DATE] at approximately 3:00 a.m., Resident #1 became unresponsive during routine care. Nursing staff assessed Resident #1 and Emergency Medical Services (EMS) was called to the facility. Prior to EMS arrival, nursing staff reviewed the medical record and determined Resident #1 had a Do Not Resuscitate (DNR) order. Nursing staff provided oxygen at a high concentration via mask, and sternal rubs were intermittently applied with no response from the resident. […]

• Immediate jeopardy, isolatedF689Oct 20, 2022

  Based on observations, review of medical records, facility policies, interviews with facility staff, agency nursing staff, the Medical Director, and Advanced Registered Nurse Practitioners, the facility failed to provide supervision and services to prevent an unwitnessed exit from the facility for one resident (#1) of two residents sampled for high-risk of elopement. The facility failed to ensure frequent monitoring was provided for a resident known to wander, and failed to address frequent alarming of exit doors, resulting in the resident leaving the facility without staff intervention and failed to follow elopement policy and procedures by not doing an immediate head count following the incident. […]

• Immediate jeopardy, isolatedF726Oct 20, 2022

  Based on observations, review of medical records, facility policies, interviews with facility staff, agency nursing staff, the Medical Director, and Advanced Registered Nurse Practitioners, the facility failed to ensure nursing staff received adequate orientation and training to ensure competency in providing supervision to prevent an unwitnessed exit from the facility for one resident (#1) of two residents sampled for high-risk elopement. The facility failed to ensure agency staff were oriented and trained to the facility's alarm response protocols and failed to ensure staff provided an accurate assessment of Resident #1. […]

• Actual harm, isolatedF600Jul 13, 2022

  Based on observation, record review, and interviews, the facility failed to provide supervision to prevent resident to resident abuse for one (Resident # 12) of four residents reviewed for abuse allegations of a total of twenty-two sampled residents. Resident #12 was a victim of physical abuse which resulted in psychosocial harm as evidenced by pain, anxiety, and the feeling of being overwhelmed with an unsafe environment. Findings include: On 07/13/2022 at 12:47 p.m., a phone interview was conducted with Resident #12. He confirmed that he had resided in the facility and been placed in a room with Resident #8. He said, they did not tell me he was a mental case. The guy was crazy. They should have known he was not well. […]