Our Lady of Perpetual Help

In the surveyor’s words

From the most serious findings on record at Our Lady of Perpetual Help, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF838Oct 14, 2021

  Based on observation, staff interview and the facility document review, the facility staff failed to document an ongoing facility wide risk assessment to include their current population of two (2) COVID-19 residents. The findings included: The facility had an outbreak of COVID-19 in the facility starting on 08/18/21. Resident cumulative COVID-19 cases totaled nine (9) with three (3) COVID-19 related deaths. Staff cumulative COVID-19 cases totaled ten (10), all staff recovered and no deaths. At the time of the survey, there were two (2) residents that were currently positive for COVID-19. The facility provided a document titled Infection Control Assessment and Response (ICAR) recommendation report dated 09/30/21 from the Virginia Beach Epidemiologist. […]

• No harm, potential for more than minimal, patternF657Oct 14, 2021

  Based on clinical record reviews, staff interviews, facility documentation, and review of the facility's policy; the facility staff failed to review and revise the person-centered care plan as each resident's condition changed for two of 19 residents (Resident #20 and #6) in the survey sample. The findings included: 1. The facility staff failed to review and revise Resident #20's person-centered care plan to include Hospice services and use oxygen (O2). Resident #20 was originally admitted to the facility 1/27/20 and readmitted [DATE] after an acute care hospital stay beginning 9/19/21. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, patternF684Oct 14, 2021

  Based on observations, clinical record review, staff interviews and facility document review the facility staff failed to apply bilateral hand rolls for 8 days for 1 of 19 residents in the survey sample with severe hand contractures, Resident #11. The findings included: Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #11's most recent Minimum Data Set (MDS) was a Quarterly with an Assessment Reference Date (ARD) of 8/25/21. The Brief Interview for Mental Status (BIMS) was not completed because the resident was coded as rarely or never understood. Resident #11 was coded as having long and short term memory problems and severely impaired for task of daily living. Under Section G Functional Status G0400. […]

• No harm, potential for more than minimal, patternF756Oct 14, 2021

  Based on clinical record review, staff interviews, and review of facility documents, the facility staff failed to ensure at least once a month a Licensed Pharmacist conduct a monthly Medication Regimen Review (MMR) for 5 of 19 residents (Resident #20, 13, 4, 6, and 2), in the survey sample. The findings included: 1. The facility staff failed to ensure Resident #20's drug regimen was reviewed at least once a month by a licensed pharmacist. Resident #20 was originally admitted to the facility 1/27/20 and readmitted [DATE] after an acute care hospital stay beginning 9/19/21. The current diagnoses included; [CONDITION(S)], COVID-19, diabetes and [CONDITION(S)]. […]

• No harm, potential for more than minimal, patternF758Oct 14, 2021

  Based on clinical record reviews, staff interviews and facility documentation, the facility staff failed to do a Gradual Dose Reduction (GDR) for 1 out of 19 residents, Resident #6 in the survey sample who was receiving a PRN (as needed) [CONDITION(S)] medication ([MEDICATION(S)]). The findings included: The facility staff failed to ensure an as needed [CONDITION(S)] medication ([MEDICATION(S)]) was limited to 14 days for Resident #6. The physician or Nurse Practitioner (NP) did not do an evaluation of Resident #6 to extend the [CONDITION(S)] medication pass 14 days without documenting the rational and duration in the resident's medical record. Resident #8 was admitted to the nursing facility on 01/25/21. Diagnosis for the resident included but not limited to Depression. […]