Decatur Medical Lodge

In the surveyor’s words

From the most serious findings on record at Decatur Medical Lodge, in the surveyor’s own words.

• Immediate jeopardy, patternF684Aug 24, 2022

  Based on observation, interview, and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices for four (Residents #8, #9, #7, and #3) of ten residents reviewed for quality of care. 1. The facility failed to ensure Resident #8 did not develop blisters which then worsened to open sores on her back after she was left in a geri-chair for an extended period of time without a barrier between her and the chair. The facility also failed to ensure the correct treatment was applied to Resident #8's blisters on her back when they transitioned to open sores. 2. […]

• Immediate jeopardy, patternF686Aug 24, 2022

  Based on observation, interview, and record review, the facility failed to ensure that residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for five (Residents #1, #2, #6, #4, and #10) of ten residents reviewed for pressure ulcers. 1. The facility failed to follow Resident #1's treatment orders and care plan to ensure that new wounds did not develop and previously identified wounds did not worsen. 2. The facility failed to follow Resident #2's treatment orders and care plan to ensure that a dressing and treatment was applied to her wound. 3. […]

• Immediate jeopardy, isolatedF689Oct 11, 2023

  Based on observation, interview, and record review the facility failed to ensure the resident environment was free of accident and hazards as was possible for one resident (Resident #1) of three residents reviewed for accidents and hazards. Driver C failed to follow proper safety measures in securing Resident #1 in the van while driving the resident. An Immediate Jeopardy (IJ) was determined to have existed from [DATE] through [DATE]. The IJ was removed on [DATE] because the facility implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure placed residents at risk of severe injury or death. Findings include: Record review of Resident #1's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. […]

• Actual harm, patternF600Aug 24, 2022

  Based on observation, interview, and record review, the facility failed to ensure residents were free from neglect for two (Resident #7 and Resident #8) of five residents were reviewed for neglect. 1. The facility failed to ensure Resident #8 was not left in a geri-chair for an extended period of time which resulted in her developing blisters. The facility also failed to notify and obtain orders for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. The facility failed to ensure Resident #7 utilized a leg strap to decrease the tension from his indwelling foley catheter after it had to be surgically placed from when it was pulled out on 06/29/22. These failures placed residents at risk of abuse, neglect, decline in health, and being displaced or hospitalized . […]

• Actual harm, isolatedF690Aug 24, 2022

  Based on observation, interview, and record review, the facility failed to ensure a resident received appropriate treatment and services for one (Resident #7) of one residents observed for indwelling urinary catheters. The facility failed to ensure Resident #7 had a catheter strap to his leg after his catheter was dislodged on 06/29/22 resulting in him needing surgical intervention to implant it into his penis. This failure could place residents at risk for urethral tears, dislodging of the catheter, and urinary tract infections. Findings included: Review of Resident #7's face sheet, dated 08/06/22, reflected he was an [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]