George Washington Health & Rehabilitation

In the surveyor’s words

From the most serious findings on record at George Washington Health & Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF686Aug 15, 2024

  Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed provide care and services for the treatment of pressure injuries for two of seven residents in the survey sample, Residents #3 and #6. The findings include: 1.a. For Resident #3(R3), the facility staff failed to implement treatments for four pressure injuries upon admission on 6/11/24 until 6/14/24. The Admission Assessment, dated 6/11/24, documented the following skin concerns: 1. Right trochanter (hip) - Pressure - 4 cm (centimeters) in length - 2.5 cm in width - no depth documented; no stage documented. 2. Left ankle (outer) - Pressure - 4 cm in length - 2.5 cm in width - no depth documented; no stage documented. 3. […]

• No harm, potential for more than minimal, patternF880Aug 15, 2024

  3. For Resident #6(R6), the facility staff failed to implement infection control practices during a wound treatment. Observation was made of LPN (licensed practical nurse) #1, on 8/14/24 at 10:55 a.m. performing wound care for R6. The resident had three wounds accessible for wound care treatments, left ischium, right buttock, sacrum and an old scar on right hip. LPN #1 removed all the dressings in place. Changed her gloves. She proceeded to use the same gloves to clean each wound, starting with the right hip, went to buttock wound, ischium wound and then sacral wound, all with the same gloves on. LPN #1 didn't have gloves on and dried the right hip and buttock wound with dry gauze. She then put gloves on and wiped the sacral wound with a dry gauze. […]

• No harm, potential for more than minimal, patternF686Jun 14, 2023

  Based on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide treatment to promote healing of a pressure injury for one of 29 residents in the survey sample, Resident #36. The findings include: For Resident #36 (R36), the facility staff failed to evidence treatment to a pressure injury (1) initially observed on 4/5/2023. A treatment was not started until 4/12/2023. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/30/2023, the resident scored 3 out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely impaired for making daily decisions. […]

• No harm, potential for more than minimal, patternF694Jun 14, 2023

  Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to provide monitoring of a resident receiving TPN (total parenteral nutrition) consistent with professional standards of practice for one of 29 residents in the survey sample, Resident #84. The findings include: For Resident #84 (R84), the facility staff failed to monitor blood glucose levels while receiving TPN (1). R84 was admitted on [DATE], hospitalized on [DATE], then readmitted and d/c'd on the same day 4/1/22. […]

• No harm, potential for more than minimal, patternF697Jun 14, 2023

  Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement a pain management program per physician orders, for one of 29 residents in the survey sample; Resident #72. The findings include: For Resident #72, the facility staff failed to implement parameters for an as-needed (PRN) pain medication that was ordered for severe pain. The facility staff administered the medication for pain levels that were less than severe (mild or moderate) on a pain scale of 0-10 with 10 being the most severe level of pain. […]