Dooley Center

In the surveyor’s words

From the most serious findings on record at Dooley Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF851Feb 20, 2024

  The facility had a census of 33 residents. Based on interview and record review the facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ) when the facility failed to submit staffing hour data for all direct care personnel as required. This placed the residents at risk for impaired care due to unidentified staffing issues. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) 2023 Quarter 4 indicated data triggered for no registered nurse hours for four or more days during the quarter and was triggered for one staff rating. […]

• No harm, potential for more than minimal, widespreadF882Feb 20, 2024

  The facility identified a census of 33 residents. Based on record review and interviews, the facility failed to designate a staff member with the required qualification and certification as the Infection Preventionist, who was responsible for the facility's Infection Prevention and Control Program. This deficient practice placed all residents at risk for lack of identification, tracking/trending, and treatment of infections. Findings included: - A review of the Department Heads form dated 02/13/24 revealed the Infection Control Preventionist position was vacant. On 02/20/24 at 03:44 PM Administrative Nurse D stated the facility did not have a certified Infection preventionist at this time. […]

• No harm, potential for more than minimal, patternF755Feb 20, 2024

  The facility had a census of 33 residents. The sample included 12 residents and two medication carts. Based on observation, record review, and interview the facility failed to provide a consistent reconciliation of controlled drugs at the end of each work shift. This placed the 14 residents with controlled substances on the cart at risk for misappropriation of medications. Findings included: - On 02/19/24 at 08:14 AM, observation on the 100-200 hall medication cart revealed staff counted and signed the Controlled Drug Record flow sheet for one work shift on 02/05/24, 02/06/24, 02/08/24, 02/09/24, 02/14/24, 02/15/24, 02/17/24, and 02/18/24 (eight times out of a possible 38 work shifts). […]

• No harm, potential for more than minimal, patternF883Jul 21, 2022

  The facility identified a census of 31 residents. The sample included 12 residents with five reviewed for influenza and pneumococcal immunizations. Based on record review and interviews, the facility failed to provide pneumococcal vaccinations or informed refusals for Residents (R)2, R9, R15, and R23. This deficient practice placed the residents at risk for complication related to pneumonia. Findings included: - On 07/20/22 at 03:45 PM a review of Electronic Health Record (EHR) was completed for R2, R9, R15, and R23. The review revealed that R2, R9, R15, and R23 lacked documentation indicating that the four residents listed had been offered, consented, refused, or had received the pneumonia vaccination. […]

• No harm, potential for more than minimal, isolatedF657Feb 20, 2024

  The facility identified a census of 33 residents. The sample included 12 residents with one resident reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to revise the comprehensive care plan, to include oxygen therapy, for Resident (R) 20. This placed R20 at increased risk for respiratory infection and complications due to uncommunicated care needs. Findings included: - R20's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of weakness, respiratory disorders, dependence on supplemental oxygen (needs a constant supply of oxygen), and disorder of the nose and nasal sinuses. […]