Pocopson Home

In the surveyor’s words

From the most serious findings on record at Pocopson Home, in the surveyor’s own words.

• Actual harm, isolatedF604Feb 14, 2024

  Based on review of facility policies, resident clinical records, and facility investigative reports, as well as staff interviews, it was determined that the facility failed to ensure residents were free from physical restraints not required to treat the medical symptoms for one of one residents reviewed, resulting in harm to Resident R1 who was physically restrained using a pair of pajama pants tied tightly around resident's waist, causing a reddened area on the resident's skin. […]

• Actual harm, isolatedF656Feb 14, 2024

  Based on clinical record review and interviews with staff, it was determined that the facility failed to develop a comprehensive care plan related to restlessness, scoot chair use, restraints, or bed rails for Resident R1 which resulted in harm to Resident R1 by being tied to a scoot chair and sustaining reddened area on abdomen. Findings include: Review of Resident R1's quarterly Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs) for Resident R1, dated December 19, 2023, revealed the resident was severely cognitively impaired, unable to make his/her needs known, required extensive assistance for care activities, incontinent of bowel/bladder, and exhibited inattentive behaviors during the assessment period. […]

• No harm, potential for more than minimal, isolatedF880Mar 22, 2024

  Based upon review of facility policy and procedure and observation, it was determined the facility failed to ensure adequate infection control measures occurred during medication pass observation on one of two nursing units observed (1 West). Findings include: Review of facility policy and procedure titled Medication Administration, revised June 2022, revealed nurses will wash his or her hands and apply gloves previous to administering any eye medication. Observation of medication administration on the 1 [NAME] nursing unit on March 20, 2024, at 8:56 a.m. revealed Licensed Employee E3 removing medications from pill packs and placing the individual pills in the employee's hand before placing the medication in the medication cup. […]

• No harm, potential for more than minimal, isolatedF609Feb 14, 2024

  Based on clinical record review, facility documentation, and staff interviews it was determined that the facility failed to report allegations of abuse including physical restraint of Resident R1 for one of one residents reviewed. Findings include: Review of the facility policy titled, Restraint/Device/Siderail, dated [DATE], revealed it is the policy of Pocopson Homes that all residents are free from physical or chemical restraints imposed for the purposes of discipline or convenience, and not required to treat the resident's medical condition. Restraints will be applied only after a physician's order has been obtained and the family has been notified. Consent must also be signed by the responsible party of the resident. […]

• No harm, potential for more than minimal, isolatedF610Feb 14, 2024

  Based on policy, facility documentation, and clinical record review, it was determined that the facility failed to thoroughly investigate an allegation of physical restraint in a timely manner for one of one resident reviewed (Resident R1). Findings include: Review of the facility policy titled, Restraint/Device/Siderail, dated [DATE], revealed it is the policy of Pocopson Homes that all residents are free from physical or chemical restraints imposed for the purposes of discipline or convenience, and not required to treat the resident's medical condition. Restraints will be applied only after a physician's order has been obtained and the family has been notified. Consent must also be signed by the responsible party of the resident. […]