Lynchburg Health & Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, patternF684Jul 1, 2021

  Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to ensure glucose-monitoring devices were calibrated and accurate on three of three units. A total of twelve glucose monitoring devices were located on nine medication carts and available for use on all three units. Review of the calibration logs for the devices revealed calibration had not been completed on a nightly basis per facility policy. All twelve devices were calibrated for accuracy by facility staff, and nine devices were out of range. […]

• Actual harm, isolatedF689Jul 6, 2022

  Based on staff interview, facility document review, clinical record review and complaint investigation, the facility staff failed to ensure safety while providing incontinence care for one of five residents in the survey sample. Resident #2, dependent upon staff for all mobility and personal care needs, fell from the bed when turned by a staff member during provision of incontinence care. Staff failed to follow the resident's plan of care for two-person assistance and failed to safely turn the resident in bed when the fall occurred. The resident experienced a goose egg and a bleeding abrasion/laceration to the forehead from the fall. […]

• Actual harm, isolatedF692Feb 10, 2022

  Based on staff interview, clinical record review, facility document review, and in the course of a complaint investigation, the facility failed to ensure one of fifty-eight residents in the survey sample did not have a significant weight loss, and failed to ensure six of fifty eight residents received tube feeding and flushes for hydration as ordered by the physician. Resident #204 lost a total of 57.7 pounds (23.89%) from the time of admission on 08/07/2021 until his hospital admission on 10/24/2021. The significant weight loss was not identified by facility staff and no nutrition interventions were put into place to prevent further loss, resulting in harm. Residents #208, #209, #210, #247, #201 and #222 did not receive tube feedings or flushes for hydration from 7:00 p.m. […]

• Actual harm, isolatedF600Nov 30, 2021

  Based on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to ensure fifty-four of 58 residents in the survey sample were free from neglect. Residents residing on the West unit that included Residents #201, #203, #205, #207 through #228 and #230 through #258, were not provided physician ordered medications and/or treatments during twelve consecutive hours starting on the evening of 2/7/22 due to no nurse working the unit. Facility staff, aware that no nurse was on the unit, made no attempt to ensure any medications/treatments were provided to the West unit residents during this 12-hour period. A nurse refused to administer Resident #207's pain medicines in response to the resident's verbal request for the medication. […]

• Actual harm, isolatedF686Nov 30, 2021

  Based on staff interview, family interview, clinical record review, and in the course of a complaint investigation, the facility staff failed to provide necessary care and treatment to promote the healing of a pressure ulcer, for one of four residents, Resident #1. The consultant wound nurse practitioner assessed the wound on 11/02/2021 and deemed it a Stage II pressure injury. Recommendations were not implemented, and further assessment was not conducted on the wound after two staff members identified a change, or prior to discharge to the hospital on 11/07/2021. At the time of admission to the hospital the wound was identified as a Stage III pressure ulcer. Findings were: Resident #1 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE]. […]