Chatham Health & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Chatham Health & Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF760Jun 11, 2024

  Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure residents were free of significant medication errors for 1 of 6 sampled residents resulting in a transfer to a higher level of care (Resident #1). The findings included: For Resident #1, the facility staff administered another resident's medication which included five (5) medications used to lower blood pressure, two (2) medications used to lower blood sugar levels, a medication used to prevent blood clots, and an over-the-counter Aspirin resulting in the resident being transferred to a higher level of care with a subsequent 3-day hospital stay including overnight in the intensive care unit (ICU). This was a closed record review. […]

• No harm, potential for more than minimal, isolatedF759Jun 11, 2024

  Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure a medication error rate of less than 5%. There were 3 medication errors in 34 opportunities for a medication error rate of 8.82%. These medication errors affected Resident #3 and #4. The findings included: 1. For Resident #3, the facility staff administered the incorrect dosage of a topical Lidocaine medicated patch and failed to administer a multivitamin with iron according to the medical provider's order. […]

• No harm, potential for more than minimal, isolatedF880Jun 11, 2024

  Based on observation, staff interview, and facility document review, the facility staff failed to maintain an infection prevention and control program to provide a safe, sanitary environment and help prevent the development and transmission of communicable disease or infections on 1 of 2 resident care units (200 Hall). The findings included: During a medication pass and pour observation, the facility staff failed to perform hand hygiene, administered a tablet that had been dropped on the top of the medication cart, and touched two medications with their bare hands. […]

• No harm, potential for more than minimal, isolatedF641Mar 21, 2024

  Based on staff interview and clinical record review, the facility staff failed to accurately complete a discharge Minimum Data Set (MDS) assessment for 1 of 5 closed record reviews, Resident #80. The findings included: The facility staff coded Resident #80's discharge MDS assessment as if they had discharged to a hospital. Resident #80 had discharged home. Resident #80's diagnoses included, but were not limited to, acute respiratory failure with hypoxia, acute pulmonary edema, and diabetes. Section C (cognitive patterns) of Resident #80's discharge MDS assessment with an Assessment Reference Date (ARD) of 02/20/24 included a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points. […]

• No harm, potential for more than minimal, isolatedF695Mar 21, 2024

  Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to provide respiratory care consistent with the comprehensive person-centered care plan for one of 18 residents in the survey sample, resident # 56. The findings included: For resident # 56 the facility staff failed to administer oxygen as ordered by the physician and according to the residents comprehensive person-centered care plan. Diagnoses for resident # 56 included but were not limited to, chronic obstructive pulmonary disease (COPD), hypertension (HTN), history of cerebrovascular accident (CVA) with left hemiplegia, atrial fibrillation A-fib, anxiety and major depressive disorder. […]