Charlton Place Rehab and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Charlton Place Rehab and Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF760Nov 18, 2021

  Based on medical record review, interviews and review of a facility document titled, 10.2 Medication-Related Errors, the facility failed to ensure Resident Identifier (RI) #1's order for [MEDICATION(S)] 200 milligrams (MG) by mouth (PO) twice a day (BID) was administered from 9/17/2021 through 9/22/2021. This medication error was significant due to the drug's classification as an anticonvulsant and as a result of not receiving the prescribed medication, RI #1 had a Grand mal [CONDITION(S)] requiring hospitalization on [DATE]. This affected RI #1, one of four sampled residents reviewed for medication administration. Findings included: A review of a facility document titled, Medication-Related Errors, with Revision Date: 05/01/2010, documented: . Procedure: 1. […]

• No harm, potential for more than minimal, isolatedF609Jul 21, 2022

  Based on interviews, medical record review, and review of a facility policy titled, ABUSE, PREVENTION AND PROHIBITION POLICY, the facility failed to ensure an allegation of physical abuse, made by RI (Resident Identifer) #3, was reported to the State survey agency (SA) on 07/09/2022 within the two hour time frame. This had the potential to affect RI #3, for one of six abuse allegations reviewed. Findings include: The State agency received a complaint on 07/18/2022 regarding RI #3's allegation of abuse of being whipped with a wet wash cloth at the facility that caused bruises to RI #3's arms. A facility policy titled, ABUSE, PREVENTION AND PROHIBITION POLICY, with a reviewed date of 2021, documented: . Reporting/Response: . All alleged violations involving abuse, . […]

• No harm, potential for more than minimal, isolatedF656May 6, 2022

  Based on record review and interviews, the facility failed to ensure a plan of care was implemented for Resident Identifier (RI) #3's use of a Foley catheter. This affected RI #3, one of three residents whose plans of care were reviewed. Findings Include: A review of the medical record for RI #3 revealed a re-admitted [DATE] and an original admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Admission Minimum Data Set (MDS) for RI #3, with an Assessment Reference date of, 04/01/2022 shows the resident was coded to have an Indwelling Catheter. […]

• No harm, potential for more than minimal, isolatedF658May 6, 2022

  Based on interviews and record review, the facility failed to ensure a Physicians Order was obtained to insert a Foley catheter for Resident Identifier (RI) #1. This deficient practice affected RI #1, one of three residents sampled with Foley catheter's whose Physicians Orders were reviewed. Findings Include: RI #1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #1's care plans revealed RI #1 had a care plan, with an initiated date of 04/18/2022, for . The resident has Catheter . On 05/04/2022 at 2:24 PM, the surveyor conducted an interview with Employee Identifier (EI) #2, a RN (Registered Nurse)/supervisor. The surveyor asked EI #2 did RI #1 have a Foley catheter. […]

• No harm, potential for more than minimal, isolatedF842May 6, 2022

  Based on interviews, record review and review of facility policy titled CHARTING AND DOCUMENTATION, the facility failed to document the insertion of a Foley into Resident Identifer (RI) #1, due to [CONDITION(S)]. This deficient practice affected RI #1, one of three residents sampled for Foley catheters. Findings Include: Review of a facility policy titled CHARTING AND DOCUMENTATION, with a reviewed date of 02/2021, revealed the following: Policy 1. Chart all pertinent changes in the resident's condition, reaction to treatments . 2. Be concise, accurate, and complete . Document only the facts . Procedures . 3. Catheter Insertion a. Type of procedure (urethral catherization . etc ) and who performed it. b. Date and time the procedure was performed. c. Type and size of catheter used. […]