Monument Healthcare American Fork

In the surveyor’s words

From the most serious findings on record at Monument Healthcare American Fork, in the surveyor’s own words.

• Actual harm, isolatedF684Dec 6, 2023

  Based on observation, interview, and record review it was determined that, for 4 of 47 sampled residents, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive assessment, the comprehensive person-centered care plan, and the residents' choice. Specifically, a resident with an identified mass was not evaluated as requested by the resident representative; a resident was hospitalized after a failure to identify a change of condition in a timely manner; a resident's blood sample was not obtained per protocol which resulted in an emergency room visit; and a resident received medication in error and one medication rectally when oral medication was available. […]

• Actual harm, isolatedF689Dec 6, 2023

  Based on observation, interview, and record review it was determined, for 6 of 47 sampled residents, that the facility did not ensure that the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistive devices to prevent accidents. Specifically, the facility did not provide adequate supervision to prevent a resident with previous falls from falling and sustaining a head laceration and neurological (neuro) checks were not completed as indicated. This deficiency was identified to have occurred at a harm level for resident 27. In addition, a resident who had fallen was moved before an assessment was completed by qualified personnel; the facility had hot water. […]

• Actual harm, isolatedF692Dec 6, 2023

  Based on interview, observation and record review, the facility did not ensure that 5 of 47 sample residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range. Specifically, current weights were not being obtained to allow staff to appropriately assess the residents' nutritional status. In addition, interventions were not being implemented in a timely manner, residents were not being provided with the appropriate supplements, and were not assisted with meals . The findings for resident 53 were determined to have occurred at a harm level. Resident identifiers: 30, 31, 51, 53 and 121. Findings include: HARM 1. […]

• Actual harm, isolatedF867Dec 6, 2023

  Based on interview and record review, the facility did not ensure that the Quality Assessment and Assurance (QAA) committee developed and implemented plans of action to correct identified quality deficiencies. Specifically, the facility was found to be in non-compliance for the same deficiencies identified in the last annual recertification survey. Resident identifiers: 22, 25, 27, 30, 31, 36, 44, 47, 51, 53, 58, 64 and 121. Findings included: 1. An annual recertification survey was completed on 2/28/22. During that survey F559, F609, F656, F661, F677, F684, F692, F755, F757, F812, F867, F880, F908, F880, F883, F908. F910, F912 and F915 were cited. 2. A recertification survey was completed on 12/6/23. […]

• Actual harm, isolatedF677Feb 28, 2022

  Based on observation, interview, and record review, it was determined the facility did not ensure a resident who was unable to carry out activities of daily living (ADL) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, for 1 out of 32 sampled residents, a resident was not provided with the necessary services related to incontinence care, which resulted in the resident acquiring Moisture Associated Skin Damage (MASD). Resident identifier: 167. Findings included: Resident 167 was admitted to the facility on [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/22/22 at 12:43 PM, resident 167's family member was interviewed. […]