Coos County Nursing Hospital

In the surveyor’s words

From the most serious findings on record at Coos County Nursing Hospital, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF908Nov 4, 2021

  Based on interview, observation, and review of manufacturer's instructions, the facility failed to ensure the mechanical lift slings were in safe working order for 1 of 1 residents reviewed for falls. (Resident identifier is #2.) Findings include: Review on 11/4/21 at approximately 10:00 a.m. of Resident #2's nurses note dated 10/24/21 revealed mechanical lift sling strap broke during a transfer causing Resident #2 to fall to the floor. Interview on 11/4/21 at approximately 11:00 a.m. of Staff C (Licensed Nursing Assistant) revealed that Resident #2 used a sit stand for transfers, but due to falling a mechanical hoyer lift was used to get Resident #2 off the floor on 10/24/21. […]

• No harm, potential for more than minimal, patternF880Oct 21, 2021

  Based on observations, interview and manufacturer's instruction review, it was determined that the facility failed to follow manufacturer's instructions for the thermometer used when screening visitors for COVID-19 upon entrance to the facility for 4 out of 4 visitors observed. Findings include: Observation on 10/19/21 at approximately 10:50 a.m. of Staff B (office staff) revealed that at the entrance of the facility Staff B took temperatures with the infrared thermometer on 4 out of 4 visitors observed by measuring the skin temperature on their neck and at their inner elbow. Interview on 10/19/21 at approximately 10:50 a.m. with Staff B confirmed the above observation. Staff B stated that they do Covid-19 screening for visitors on a routine basis. […]

• No harm, potential for more than minimal, isolatedF761Nov 17, 2023

  Based on observation, interview, and policies, it was determined that the facility failed to ensure that expired medications were removed from the emergency kit (E-kit) stored in the medication storage room on the first floor in 1 of 2 storage rooms observed. Findings include: Observation on 11/16/23 of the medication storage room on the first floor revealed an E-kit with a sticker on the top indicating an expiration date of 9/23; within the E-kit revealed six individual boxes with different medications. […]

• No harm, potential for more than minimal, isolatedF880Nov 17, 2022

  Based on observation, interview, and policy review, it was determined that the facility failed to ensure that staff demonstrated proper use of gloves and hand hygiene during a dressing change for 1 out of 1 resident observed (Resident identifier is #14). Findings include: Observation on 11/15/22 at 2:49 p.m. of Resident #14's dressing change on right foot #5 metatarsal head with Staff B (Registered Nurse) revealed Staff B donned gloves, moved a urinal on the nightstand, gave Resident #14 a cup of pills then proceeded to clean Resident #14's wound with wound wash on a gauze pad. Staff B removed foam dressing from the package and with the same gloves, prepared the dressing by cutting with scissors, placed a small piece of foam dressing onto the wound, and covered with another foam dressing. […]

• No harm, potential for minimal, patternF641Nov 17, 2023

  Based on interview and record review, it was determined that the facility failed to ensure that the residents' Minimum Data Set (MDS) accurately reflect the resident's status for 4 of 16 residents reviewed for MDS in a final sample of 16 residents. (Resident identifiers are #5, #19, #48, and #51). Findings include: Resident #5 Interview on 11/15/23 at 2:10 p.m. with Resident #5 revealed that he/she has not had a fall with any major injury. Review on 11/17/23 of Resident #5's quarterly MDS with an Assessment Reference Date (ARD) of 11/3/23 revealed that Item J1900C Number of falls since Admission or Prior Assessment - Major injury was coded as 1 or One. Review on 11/17/23 of Resident #5's medical record revealed that there had not been a fall with a major injury documented. […]