Dr Guy Gorman SR Care Home

In the surveyor’s words

From the most serious findings on record at Dr Guy Gorman SR Care Home, in the surveyor’s own words.

• Immediate jeopardy, patternF684Sep 15, 2023

  Based on observation, interview, record review, and review of the facility's policies, the facility failed to ensure seven residents (Resident (R) 99, R98, R24, R3, R39, and R36) received care and treatment in accordance with professional standards of practice. 1. The facility failed to perform Accuchecks (finger stick blood sugar checks) per the physician's orders for eight days while continuing to administer scheduled insulin to R99; 2. and failed to notify R98's Physician to obtain an order for Accuchecks after the resident was admitted to the facility with an order for insulin. 3. The facility failed to perform neuro checks after R39, R24, and R36 had sustained unwitnessed falls. 4. […]

• Immediate jeopardy, patternF689Sep 27, 2021

  Based on observation, interview, and record review, the facility failed to have a system in place to ensure residents' environment remained as free of accident hazards as is possible. Specifically: 1. Postural support The facility failed to ensure one of three residents (Resident (R) 2) with orders for the postural support device was applied correctly. When staff secured the device behind R2's back and R2 repositioned themselves, the device became a strangulation threat posing a serious risk for death or serious harm due to potential for strangulation Furthermore, all three residents (R2, R7, and R31) were not assessed for appropriateness or safety of the device before implementation. This failure resulted in the identification of an Immediate Jeopardy. […]

• Immediate jeopardy, isolatedF689Aug 30, 2022

  Based on observation, interview, record review, and policy review the facility failed to provide supervision to prevent resident injury during assisted transfers utilizing a mechanical lift. The facility failed to develop and implement policies for safe use of mechanical lifts and failed to ensure staff were trained and competent prior to using the mechanical lifts. Three residents (R22, R32 and R34) who required mechanical lift transfer were at risk for serious injury or death during transfers. Direct observation identified unsafe practice when R32 was left unattended while suspended in the lift sling during mechanical lift transfer that placed R32 in immediate jeopardy for severe injury or death. […]

• Actual harm, patternF689Sep 27, 2024

  Based on observations, interviews, review of records, and policy, the facility failed to ensure that 3 of 6 residents reviewed for accidents (Residents (R) 207, R106, and R156) did not sustain preventable falls with major injuries. Specifically, 1) The facility failed to conduct neuro checks after an unwitnessed fall, ensure neuro checks conducted were consistent with their policy, implement fall interventions, and provide adequate supervision for R106. R106 had 16 falls during his four-month stay, including three falls where the facility recommended 1:1 monitoring which was not implemented. After the series of falls where 1:1 monitoring was recommended but not implemented, R106 had four additional unwitnessed falls. […]

• Actual harm, isolatedF600Sep 27, 2024

  Based on interview and record review, the facility failed to protect the resident's right to be free from neglect (R106) and failed to protect residents' right to be free from physical abuse by another resident for (R)(R2 and R27) for 7 sampled residents reviewed for abuse as evidenced by: 1. Failed to ensure resident-centered care and treatment was provided in accordance with professional standards of practice to 1 of 6 sampled residents (R) (R106) reviewed for accidents. Licensed Practical Nurse (LPN) 6 failed to conducted neuro checks to assess for neurological changes and ensure timely interventions after R106's unwitnessed fall, 2. […]