O'Connor Hospital D/P SNF

In the surveyor’s words

From the most serious findings on record at O'Connor Hospital D/P SNF, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF700May 20, 2024

  Based on observation, interview, and record review, the facility failed to ensure proper use of side rails (or bed rails, adjustable rigid bars attached to the side of a bed [examples include safety rails, grab bars, and assist bars]) for 23 of 23 residents (Residents 1, 14, 21, 15, 10, 13, 11, 2, 7, 3, 22, 8, 19, 5, 9, 4, 6, 12, 16, 17, 18, 20, and 23), when 1. For Residents 4 and 23, the Siderail Assessment indicated side rails were not required, though the residents were observed to have side rails. 2. […]

• No harm, potential for more than minimal, patternF695May 20, 2024

  Based on observation, interview and record review, the facility failed to ensure that proper care and treatment services for the use of oxygen (O2, colourless, odourless, tasteless gas essential to living organisms; it is not flammable but causes other materials that burn to ignite more easily and to burn far more rapidly, that a fire involving oxygen can appear explosive-like) were provided for 19 of 19 sampled residents (Residents 2, 3, 11, 6, 15, 21, 10, 22, 12, 18, 13, 20, 1, 19, 23, 16, 5, 8, and 9) as there were no Oxygen In Use signs at these 19 residents' doors. […]

• No harm, potential for more than minimal, patternF755Mar 23, 2023

  Based on observation, interview, and record review, the facility failed to provide proper pharmaceutical services when: 1. Medications were unavailable and were not administered as ordered for six of 12 residents (Residents 2, 3, 9, 12, 20, and 22); and, 2. The disposition of two of five discontinued narcotic medications (controlled substance medications, drugs with high potential for abuse or addiction) were not documented. These failures resulted in six residents not receiving medications as ordered by the physicians and had the potential to result in misuse of narcotic medications. Findings: 1a. […]

• No harm, potential for more than minimal, patternF865Mar 23, 2023

  Based on interview and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) program implemented their policy. 1. A performance indicator, medication error, did not capture medication omissions. 2. A performance indicator, Medication Management, did not monitor gradual dose reduction (GDR) of psychoactive medications and implementation of the consultant pharmacist (CP)'s recommendations from Medication Regimen Review (MRR, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication). […]

• No harm, potential for more than minimal, patternF880Mar 23, 2023

  Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. A licensed nurse did not change gloves and perform hand hygiene between tasks; 2. Staff used gloves to cover respiratory tubing; and 3. Multiple face masks were hanging by the bed. These failures had the potential for development and transmission of communicable diseases and infections in the facility. Findings: 1. During a medication pass observation, on 3/21/23 at 8:53 a.m., RN F prepared medications for Resident 14. RN F donned gloves in Resident 14's room. RN F dropped an item on the ground and picked it up. RN F did not remove his gloves and perform hand hygiene. […]