Gibson Community HSP Annex

In the surveyor’s words

From the most serious findings on record at Gibson Community HSP Annex, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 5, 2023

  Based on observation, interview, and record review the facility failed to prevent elopement by failing to identify behaviors of wandering/exit seeking and elopement, re-evaluate for risk of elopement, notify the physician and family of exit seeking behaviors, and develop/implement targeted behavior tracking and person-centered interventions to address exit seeking behavior for one resident (R11) reviewed for elopement in the sample list of 14. This failure resulted in R11, a resident with a known history of exit seeking and diagnosis of Dementia, leaving the facility alone and unnoticed by climbing through a window. […]

• Actual harm, isolatedF689Mar 13, 2024

  Base on observation, interview and record review, the facility failed to complete a fall risk assessment quarterly and failed to ensure safety equipment was in use during a transfer for one of one residents (R5) reviewed for falls on the sample list of 12. This failure resulted in R5 falling and sustaining a four centimeter laceration requiring seven sutures to the forehead and a fractured humerus. Findings Include: R5's Fall Risk Assessments dated 8/16/23 and 1/29/24 document R5 is a high risk for falls. On 3/12/24 at 10:40 AM, V3 MDS (Minimum Data Set)/CP (Care Plan) Coordinator stated fall risk assessments are to be completed upon admission, with significant changes and quarterly. V3 confirmed R5 only has an August and January assessment completed. […]

• No harm, potential for more than minimal, widespreadF880Mar 13, 2024

  Based on interview and record review the facility failed to maintain complete and current resident and staff infection control logs, analyze infection data to identify trends, restrict staff from working while ill, and test symptomatic staff for COVID-19 (Human Coronavirus Infection). These failures affect eight (R1, R2, R4, R5, R6, R7, R11, R65) of eight residents reviewed for infection control and has the potential to affect all 12 residents in the facility Findings include: 1.) The Employee Illness Reports document the following: On 1/14/24 V20 Certified Nursing Assistant (CNA) called in sick due to sore throat, cough, and muscle aches. On 1/29/24 V12 CNA called in sick due to headache, runny/stuffy nose, body aches, and vomiting. […]

• No harm, potential for more than minimal, patternF881Mar 13, 2024

  Based on interview and record review the facility failed to follow their antimicrobial stewardship policy by failing to accurately document the status of obtaining residents urine cultures and identify/document organisms results. This failure affects five (R1, R2, R4, R5, R6) of eight residents reviewed for infection control in the sample list of 12. Findings include: The facility's Antimicrobial Stewardship policy with reviewed date May 2023 documents the purpose of this program is to ensure appropriate use of antimicrobials which includes selecting the appropriate antibiotic, dose, duration and route to decrease toxicity and antimicrobial resistance. This policy documents to collect, track, and analyze antibiotic use and resistance patterns. […]

• No harm, potential for more than minimal, patternF758Jun 5, 2023

  Based on interview and record review the facility failed to attempt Gradual Dose Reductions of psychotropic medications, document clinical rational why dose reductions were not attempted, and care plan nonpharmacological behavioral interventions for four (R4, R8, R9, R11) of five residents reviewed for unnecessary medications in the sample list of 14. Findings include: 1.) R4's Diagnoses List dated 6/1/23 documents R4 has Dementia and Major Depressive Disorder. R4's Physician Order dated 4/25/23 documents administer Lorazepam (antianxiety) 0.5 milligrams (mg) by mouth daily. R4's Physician Order dated 10/27/22 documents to administer Paxil 40 mg by mouth daily. R4's Care Plan dated 4/25/23 documents R4 receives Paxil for depression and symptoms include feeling down and increased fatigue. […]