Cape Cod Post Acute Care

In the surveyor’s words

From the most serious findings on record at Cape Cod Post Acute Care, in the surveyor’s own words.

• Actual harm, patternF580Mar 19, 2024

  Based on observations, interviews, record reviews, and policy review, the facility failed to notify the physician about a change in condition in order to re-evaluate the potential need to alter the treatment plan for two Residents (#2, #61), out of a total sample of 24 residents. Specifically, the facility failed: 1. For Resident #2, to notify the physician regarding a 12.66% severe significant weight loss in three months (11/21/23 to 2/3/24) and 5.39% in one month (2/3/24 to 3/8/24); and 2. […]

• Actual harm, patternF689Mar 19, 2024

  Based on observation, record review, policy review, and interview, the facility failed to ensure that four Residents (#24, #70, #226, and #2), out of a total sample of 24 residents, were provided an environment free from accident hazards. Specifically, the facility failed to ensure staff: Provided adequate supervision and/or followed their Falls Prevention and Management policy of investigating falls and initiating fall prevention interventions for: 1. Resident #24, who had six total falls, all related to toileting, one of which consisted of an acute left-sided 7th rib fracture, healing 5th and 6th rib fractures, and a closed head injury; 2. […]

• Actual harm, patternF692Mar 19, 2024

  Based on observations, interviews, record review, and policy review, the facility failed to monitor the nutritional status for two Residents (#2, #61) with an unplanned significant weight loss, out of a total sample of 24 residents. Specifically, the facility failed: 1. For Resident #2, to continue to monitor the Resident's nutritional status after they experienced a severe significant weight loss of 12.66% in three months (11/21/23 to 2/3/24), resulting in a continued significant weight loss of 5.39% in one month (2/3/24 to 3/8/24) which the facility did not identify or address; and 2. […]

• Actual harm, patternF689Aug 24, 2022

  Based on observations, interviews, record review, and policy review, the facility failed to ensure 11 Residents (#56, #82, #301, #81, #63, #79, #65, #26, #37, #71, #70), out of a total sample of 27 residents, were provided adequate supervision and assistance devices to prevent accidents. Specifically, the facility failed to: A. Follow their Falls Management and Prevention Policy of investigating falls and initiating fall prevention interventions for: 1.) Resident #56, resulting in nine falls, two falls resulting in major injury (hip fractures) 2.) Resident #82, resulting in 24 falls with one fall resulting in a cut/bruise between the resident's eyes, one fall resulting in a cut on the upper lip, and a third fall resulting in a skin tear. […]

• Actual harm, patternF692Aug 24, 2022

  Based on observation, interviews, record review, and policy review, the facility failed to ensure staff identified, addressed, and monitored significant weight changes for six Residents (#56, #71, #78, #79, #49, and #87) with unplanned, insidious (gradual), and/or significant weight changes, out of a total sample of 27 residents. In addition, the facility failed to weigh residents upon admission and not use hospital weights to conduct nutrition assessments, weigh residents according to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Specifically, the facility failed to: 1. Resident #56, reweigh the resident to ensure accurate weights, and failed to provide nutrition interventions when there was a significant weight loss; 2. […]