Bedford Care Ctr-Monroe Hall

In the surveyor’s words

From the most serious findings on record at Bedford Care Ctr-Monroe Hall, in the surveyor’s own words.

• Actual harm, isolatedF600Apr 28, 2022

  Based on interviews, record review, and facility policy review, the facility neglected to ensure an assistive device was used during a transfer, causing a resident to be lowered to the floor by staff which resulted in multiple fractures for one (1) of four (4) residents sampled. Resident #1. (See F689 for additional information.) Findings include: A record review of the facility's policy Safe Transfer and Lifting of Residents with a revised date of 09/2013 revealed Policy Statement In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Policy Interpretation and Implementation .II. Assessment Guidelines .10. […]

• Actual harm, isolatedF609Apr 28, 2022

  Based on interviews, record review and facility policy review, the facility staff failed to report a fall with major injury which occurred during a transfer in which the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: A record review of the facility's policy Accidents and Incidents-Investigation and Reporting with a revised date of 9/21 revealed, Policy Statement All accidents or incidents involving residents shall be investigated and reported to the Director of Nursing and the Administrator. Policy Interpretation and Implementation .1. The Nurse Supervisor/Charge Nurse, or License Practical Nurse (LPN) shall promptly initiate and document investigation of the accident or incident by completing an Incident/Accident form in the electronic medical record. […]

• Actual harm, isolatedF656Apr 28, 2022

  Based on staff interview, record review and facility policy review, the facility failed to ensure a resident's care plan was implemented related to the use of an assistive device when a resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1. Findings include: A record review of the facility's policy Care Plans-Comprehensive, with a revised date of January 2013 revealed, Policy Statement, an individual Comprehensive Person-Centered Care Plan that includes measurable objectives and timetable to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Policy Interpretation and Implementation revealed, .1. […]

• Actual harm, isolatedF689Apr 28, 2022

  Based on interviews, record review, and facility policy review, the facility failed to ensure an assistive device was used during a transfer, causing a resident to be lowered to the floor by staff which caused multiple fractures for one (1) of four (4) residents sampled. Resident #1 (See F600 for additonal information.) Findings include: A record review of the facility's policy Safe Transfer and Lifting of Residents with a revised date of 09/2013 revealed Policy Statement In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Policy Interpretation and Implementation .II. Assessment Guidelines .10. […]

• No harm, potential for more than minimal, patternF677Jan 27, 2023

  Based on observations, interviews, record review, and facility policy review, the facility failed to ensure residents, who were unable to carry out Activities of Daily Living (ADLs), received the necessary services to maintain grooming and personal hygiene for four (4) of seven (7) sampled residents. Resident #1, Resident #3, Resident #5, and Resident #7. Findings include: Record review of the facility's policy, Care of Fingernails/Toenails, revised 8/2/22, revealed, The purposes of this procedure are to clean the nail bed, to keep nails trimmed .1. Nail care includes daily cleaning and regular trimming .13. Trim fingernails in an oval shape and toenails straight across. 14. Smooth the nails with a nail file or emery board . […]