Old Southwest Health and Rehabilitation

In the surveyor’s words

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

• Actual harm, isolatedF760Mar 29, 2024

  Based on resident interview, staff interviews, clinical record review, and facility document review the facility staff failed to ensure 1 resident (Resident #9) was free of significant medication errors. For Resident #9, the significant medication error resulted in a transfer to a higher level of care for an anaphylactic reaction on two separate occasions, two months apart. The findings were: 1. For Resident #9, the facility staff applied Biofreeze gel (which contained aloe) instead of the ordered Voltaren ointment on two separate occasions, the first time in December 2023 and again in February 2024. Aloe was listed as one of Resident #9's allergies in the clinical record upon admission. […]

• Actual harm, isolatedF867Mar 29, 2024

  Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure that their quality program implemented a corrective action plan following an initial medication error which resulted in a resident (Resident #9) requiring transfer and treatment at an acute care hospital. After the failure of the facility's quality program to adequately address the initial medication error, Resident #9 was subsequently provided the same incorrect medication which resulted in the resident again requiring transfer and treatment at an acute care hospital. […]

• Actual harm, isolatedF689Aug 16, 2023

  Based on staff interview, resident interview, and clinical record review, the facility staff failed to provide supervision to ensure resident safety for 1 of 6 residents, Resident #1. The findings included: For Resident #1 the facility staff failed to provide supervision which resulted in the resident being admitted to the hospital for treatment of heat stroke. On the date of this incident ([DATE]), the National Weather Service for the area reported a high temperature of 97 degrees, with a heat advisory in effect. […]

• Actual harm, isolatedF697Feb 11, 2022

  Based on staff interview, resident interview, clinical record review, facility document review, and during a medication pass and pour observation, the facility staff failed to provide adequate pain management for 1 of 16 residents, Resident #12, resulting in harm. Resident #12's pain medications [MEDICATION(S)] 10 mg and [MEDICATION(S)] 300 mg were not available for administration. The findings included: Resident #12's face sheet listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #12's most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 12/31/21 assigned the resident a BIMS (brief interview for mental status) score of 15 out of 15 in section C, cognitive patterns, indicating the resident was cognitively intact. […]

• Actual harm, isolatedF686Aug 5, 2021

  Based on staff interview, clinical record review, and during the course of a complaint investigation, the facility staff failed to ensure residents with pressure ulcers receive necessary treatment and services to promote healing and prevent infection for 1 of 30 residents in the survey sample, Resident #108. The findings included: For Resident #108, the facility staff failed to treat an unstageable pressure area to the sacrum and deep tissue injuries to the right malleolus, right heel, and left heel: 1) Greers [NAME] ordered but records do not consistently demonstrate that it was applied. […]