Brian Center of Fincastle

In the surveyor’s words

From the most serious findings on record at Brian Center of Fincastle, in the surveyor’s own words.

• Immediate jeopardy, isolatedF695Dec 20, 2022

  Based on observations, interviews, document review, and in the course of a complaint investigation, the facility staff failed to provide respiratory therapy care and services to address the needs of four (4) of eight (8) sampled residents with ventilator orders (Resident #1, Resident #2, Resident #3, and Resident #4). For Resident #1, On [DATE] at 3:50 P.M., Immediate Jeopardy-Past Noncompliance was called, and lowered to a D. Resident #2, Resident #3, and Resident #4 were included in the Past non-compliance designation. The findings include: 1. The facility staff failed to implement Resident #1's medical provider's ventilator orders to ensure the resident was provided the necessary ventilation and oxygen. […]

• Actual harm, isolatedF695Mar 21, 2024

  Based on observation, staff interview, clinical record review, and facility document review, facility staff failed to ensure a ventilator dependent resident was provided with such care consistent with professional standards of practice resulting in death of the resident for 1 of 4 residents in the survey sample (Resident #1). Resident #1 was admitted to the facility with diagnoses which included acute and chronic respiratory failure with hypoxia, respiratory ventilator dependence, tracheostomy status, cerebral palsy, epilepsy, and dysphagia. On the most recent Minimum Data Set assessment, the resident was assessed as comatose/persistent vegetative state. Clinical record review revealed: On 3/13/2024, Resident #1 was found unresponsive and without pulse or respirations. […]

• No harm, potential for more than minimal, patternF908Dec 20, 2022

  Based on interviews and document review, the facility staff failed to ensure the facility's ventilators were maintained according to manufactures guidance for 36 of the 36 ventilators located at the facility. The findings include: Review of ventilator maintenance documents failed to provide evidence of the monthly changing of the ventilators air-inlet foam filter. The following information was found in the Clinical Manual for the type of ventilators used by the facility: The air-inlet foam filter is the gray foam located on the back panel. It protects (ventilator) from dirt and dust. […]

• No harm, potential for more than minimal, isolatedF842Dec 20, 2022

  Based on interviews, facility document review, and in the course of a complaint investigation, the facility staff failed to maintain complete and accurate clinical documentation for one (1) of eight (8) sampled residents (Resident #1). The findings include: Resident #1's clinical documentation failed to include the use of an automated external defibrillator (AED) when attempting to resuscitate the resident. Resident #1's clinical documentation included progress notes by a respiratory therapist (RT) whose electronic signature incorrectly identified the RT as a licensed practical nurse (LPN). Resident #1's minimum data set (MDS) assessment, with an assessment reference date (ARD) of [DATE], was dated as completed on [DATE]. […]

• No harm, potential for more than minimal, isolatedF684Aug 18, 2022

  Based on staff interview, clinical record review, and during a medication pass and pour observation the facility staff failed to follow the providers order in regards to administering the medication [MEDICATION(S)] for 1 of 3 residents observed during the medication pass and pour observation, Resident #44. The findings included: Resident #44's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Section C (cognitive patterns) of Resident #44's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 07/07/22 included a brief interview for mental status (BIMS) summary score of 15 out of a possible 15 points. Resident #44's care plan included the focus area requires assistance with oral care. Interventions included, but were not limited to, provide oral hygiene. […]