Inniswood Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Inniswood Health and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF692Feb 2, 2024

  Based on observation, medical record review, hospital record review, staff, physician and Registered Dietician (RD) interview, review of the Ohio Board of Dietetics (OBD) Standards of Practice in Nutrition Care, contract reviews, and facility policy review, the facility failed to ensure Resident #32, who was identified at nutritional risk, was provided a comprehensive and individualized nutritional plan to include monitoring weights and nutritional status, physician and dietitian notification for weight loss and implementation of nutrition interventions to prevent severe weight loss. […]

• Actual harm, isolatedF686Feb 2, 2024

  Based on observation, medical record review, interviews and facility policy review, the facility failed to implement adequate skin risk interventions for Resident #32 to prevent the development of a pressure ulcer. Actual harm occurred on 08/24/23 when Resident #32, who was readmitted to the facility on [DATE] with a displaced subtrochanteric fracture of right the femur with surgical repair and required extensive assistance with bed mobility for turning and repositioning developed a deep tissue injury (DTI) (A purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue.) to the right heel. […]

• Actual harm, isolatedF689Feb 2, 2024

  Based on record review, staff interview, hospital records review, Hoyer Lift user manual review and facility policy review, the facility failed to ensure Resident #87 was transferred in a safe manner using a mechanical (Hoyer) lift (a mechanical device with a sling used to transfer residents from one place to another). Actual Harm occurred on 10/18/23 when Resident #87, who was dependent on two staff for transfers using a Hoyer lift, sustained a fall out of the lift resulting in a hospitalization and diagnosis of cervicalgia (pain in the neck and shoulders that varies in intensity, and may feel achy or like an electric shock from the neck to the arm) with an order for a cervical collar to be worn at all times for four weeks. […]

• Actual harm, isolatedF697Feb 2, 2024

  Based on record review, interviews and facility policy review, the facility failed to provide adequate pain management for Resident #32 following an unwitnessed fall with pain to the right hip. Actual harm occurred on 07/31/23 when Resident #32 who was noted to have chronic hip pain and received scheduled Tylenol, was found on the floor screaming and pointing to her right leg at 4:30 A.M. The resident was assisted back into bed and continued to scream and point to her right leg for an additional two hours before Physician #502 was notified and an order was obtained for an x-ray. Additionally, the resident rated her pain as 7 out of 10 (zero being no pain and 10 being the worst pain possible) and was not given any pain medication until her scheduled Tylenol at 8:00 A.M. […]

• Actual harm, isolatedF686Jan 31, 2022

  Based on observation, record review, facility policy and procedure review and interview the facility failed to implement interventions to prevent the development of a pressure ulcer for Resident #82. Actual harm occurred on 01/18/22 when Resident #82, who required extensive assistance from two staff for bed mobility and had a known history of pressure ulcers was identified to have an unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcer to the coccyx. There was no evidence the facility had adequate interventions in place to prevent the development of the ulcer and to promote healing once the ulcer was identified. […]