D'Youville Care for Advanced Therapy

In the surveyor’s words

From the most serious findings on record at D'Youville Care for Advanced Therapy, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF677Apr 9, 2024

  Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required physical assistance from staff with toileting and hygiene, the Facility failed to ensure staff provided assistance in a timely manner, when after putting Resident #1 on the bed pan, the staff member left at the end of the shift, had not informed oncoming staff that Resident #1 was on the bed pan, and as a result his/her care needs went unattended for an extended period of time. Findings Include: Resident #1 was admitted to the Facility in December 2023, diagnoses included left femur (thigh bone) fracture, left lower radius (wrist) fracture, muscle weakness, difficulty walking, bilateral hearing loss, and history of falls. […]

• No harm, potential for more than minimal, isolatedF842Apr 9, 2024

  Based on records reviewed and interviews for one of three sampled residents (Resident #1) the Facility failed to ensure they maintained complete and accurate medical records when 1) Resident #1's Certified Nurse Aide (CNA) Activity of Daily Living (ADL) Flow Sheet documentation was not consistently completed each shift by CNAs and 2) Resident #1's Weekly Skin Check documentation was not accurately documented by nurses. Findings Include: The Facility Policy titled Documentation in the Medical Record, dated 11/30/23, indicated each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through accurate and timely documentation. […]

• No harm, potential for more than minimal, isolatedF694Oct 16, 2023

  Based on records reviewed and interviews for one of three sampled residents (Resident #1) who had a Physicians order for continuous intravenous (IV) fluid, the Facility failed to ensure intravenous fluids were administered as ordered, and as a result he/she went twenty-four hours without being administered IV fluids. Findings include: Review of the Facility policy titled Ordering Infusion Medications, dated June 2016, indicated infusion therapy is initiated upon a physician's order and a Facility nurse acting in conjunction with the Physician, may take a verbal or telephone order and initiate infusion therapy. […]

• No harm, potential for more than minimal, isolatedF554Aug 23, 2023

  Based on observation, record review and interview the facility failed to ensure one Resident (#1) was assessed for the ability to self-administer medications out of a total sample of 12 residents. Findings include: Review of the facility policy titled Self-Administration of Medications dated February 2019, indicated the following: -if the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive (including orientation of time), physical, and visual ability to carry out this responsibility during the care planning process. Resident #1 was admitted to the facility in August 2023 with diagnoses including fall with fracture and gastroesophageal reflux disease without esophagitis. […]

• No harm, potential for more than minimal, isolatedF759Aug 23, 2023

  Based on observation, interview and record review, the facility failed to ensure it was free from a medication error rate of greater than 5 percent. Two of three nurses observed made 15 errors in 33 opportunities on one of one unit, resulting in a medication error rate of 45.45%. These errors impacted two Residents (#283 and #231) out of 4 residents observed. Finding include: Review of the facility policy titled Medication Administration - General Guidelines dated as revised January 2018, indicated: -Medications are administered in accordance with written orders of the prescriber. -Medications are administered within sixty (60) minutes of scheduled time, except before, with or after meal orders, which are administered based on meal times. […]