Baptist Homes, Tri-County

In the surveyor’s words

From the most serious findings on record at Baptist Homes, Tri-County, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Mar 15, 2023

  Based on interview and record review, the facility failed to provide adequate supervision and assistance for one resident (Resident #1), who utilized a Broda Chair (a type of wheelchair that tilts and reclines), was totally dependent on two or more staff for bed mobility and transfers, and had impaired range of motion on both sides of the upper and lower extremities. On approximately 2/24/23, the facility replaced the resident's air mattress but did not place bolsters on the bed. On the afternoon of 2/25/23, the resident fell out of bed and was transported by ambulance to the hospital. On the evening of 2/25/23, on-call transport Staff A arrived at the hospital to pick up the resident. Transport Staff A had difficulty getting the resident into and secured in the transport van. […]

• Immediate jeopardy, isolatedF678Mar 2, 2022

  Based on interview and record review, facility staff failed to implement their policy and failed to initiate cardiopulmonary resuscitation (CPR) (process of providing rescue ventilation and chest compressions to maintain circulation of blood) and call 911 for two residents (Resident #105 and #106) identified as having full code status (CPR required in the event of cardiac or respiratory arrest), when staff found the residents unresponsive and without a pulse. The facility census was 55. The administrator was notified on [DATE] at 2:30 P.M. of the Immediate Jeopardy (IJ), which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor onsite verification. […]

• Immediate jeopardy, isolatedF684Mar 2, 2022

  Based on interview and record review, the facility failed to communicate accurate and consistent information related to Resident #42's condition to the resident's physician, including the resident's variations in level of alertness and expressions of thirst. The facility failed to include hospice and the resident's family in an effective plan of care, to address the resident's needs after the facility received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had periods of fluctuating levels of alertness both before and after [DATE] when the NPO order began. Following the NPO order the resident verbalized thirst. The facility failed to ensure the resident was assessed and received appropriate interventions to address thirst, hydration and nutrition. […]

• Actual harm, isolatedF689Jul 19, 2023

  Based on interview and record review, the facility failed to provide adequate protective oversight for one resident (Resident #1), in a review of seven sampled residents. Staff failed to lower the height of the bed after providing care as directed by the care plan. The resident rolled off the bed onto the floor and sustained injury. Staff sent the resident to the hospital and where the resident was found to have an orbital fracture (fracture of one or more bones surrounding the eye) and a brain bleed. The facility census was 42. On 7/19/23, the administrator was notified of a Past Noncompliance related to a fall with injury which occurred on 7/4/23. […]

• Actual harm, isolatedF689Mar 2, 2022

  Based on observation, interview, and record review, the facility failed to provide adequate supervision and oversight to prevent falls for one resident, Resident #27, in a review of 19 sampled residents. The facility staff failed to implement fall prevention interventions as indicated on the resident's care plan, failed to provide safe transfers as directed by the resident's plan of care. Resident #27 had multiple falls with injuries including a subdural hematoma (pool of blood between the brain and its outermost covering). […]