Dove Healthcare - Lodi

In the surveyor’s words

From the most serious findings on record at Dove Healthcare - Lodi, in the surveyor’s own words.

• Immediate jeopardy, isolatedF686Aug 26, 2024

  Based on observation, interview, and record review, the facility did not ensure each resident receives cares, consistent with professional standards of practice to prevent pressure injuries (PIs) for 2 of 3 residents (R) sampled out of a total sample of 9 (R2 and R8). R8 was admitted on [DATE], without a pressure injury or catheter. R8 was hospitalized on [DATE], returning on [DATE] with a foley catheter in place. The facility did not develop a care plan addressing the catheter until [DATE], after erosion to the penis was identified.The facility failed to ensure interventions to prevent medically related pressure injuries (PI) were implemented correctly to prevent PI development, failed to complete weekly measurements and assessments, and failed to get orders for treatments. […]

• Immediate jeopardy, isolatedF580Mar 30, 2021

  Based on interview and record review, the facility did not promptly consult with the physician when 1 of 3 residents reviewed (R1) of a total sample of 5 residents had a significant change in condition following a fall from bed. On [DATE], R1 fell approximately four feet from his bed to the floor when a certified nursing assistant provided care without assistance of a second person, as directed in R1's care plan. The nurse failed to consult with an MD before moving R1 off of the floor or inform the physician of a change in R1's pain level compared to baseline. Later, when R1 experienced acute changes in mental status, pain, and oxygen saturation levels, the nurse failed to promptly consult with a physician. […]

• Immediate jeopardy, isolatedF684Mar 30, 2021

  Based on interview and record review, the facility did not ensure each resident received the necessary care and services in accordance with professional standards of practice to meet each resident's physical needs for 1 of 3 residents reviewed (R1) of a total sample of 5 residents. After R1 fell four feet from the bed to the floor, the licensed practical nurse (LPN) failed to follow professional standards of practice as outlined in N6, Wisconsin Nurse Practice Act. The LPN did not report the fall to a registered nurse (RN) so the RN could perform a complete comprehensive assessment before determining whether R1 could be moved off the floor and perform ongoing monitoring and assessment of R1's condition. […]

• Immediate jeopardy, isolatedF689Mar 30, 2021

  Based on observation, interview, and record review, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents in 1 of 3 residents reviewed for fall concerns, out of a total sample of 5 (R1). On [DATE] a certified nursing assistant attempted to provide care to R1 without waiting for a second person to assist, as directed in R1's care plan. R1 rolled off the bed and fell approximately 4 ft. to the floor. R1 suffered multiple fractures as a result of the fall and expired at the hospital. This created a finding of immediate jeopardy that began on [DATE]. The NHA A (Nursing Home Administrator) was informed of the Immediate Jeopardy on [DATE] at 11:00 AM. […]

• Actual harm, isolatedF689Oct 10, 2022

  Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistive devices to prevent accidents for 1 of 3 residents (R8) reviewed for wandering, 1 of 3 residents (R4) reviewed for abuse, and 2 of 4 residents (R1 and R6) reviewed for falls. R8 was assessed as a high risk to wander. R8's most recent Minimum Data Set (MDS), dated [DATE], indicated R8 wandered in the previous 1-3 days. R8 has long and short-term cognitive impairment and has severely impaired cognitive skills for daily decision making. R8 wore a Wander Guard bracelet. R8 was known to wander throughout the facility on a regular basis, especially on the PM shift. […]