Providence Pointe Healthcare

In the surveyor’s words

From the most serious findings on record at Providence Pointe Healthcare, in the surveyor’s own words.

• Immediate jeopardy, isolatedF656Jul 20, 2021

  Based on interview, record review, and review of the facility's policy it was determined the facility failed to implement a comprehensive person-centered care plan for one (1) of three (3) sampled residents (Resident #1). Review of a facility Fall Scene Investigation Reports, dated 02/15/2021 and 02/21/2021, revealed Resident #1 had falls from the bed and sustained fractures on 02/15/2021 and again on 02/21/2021. Interventions put in place after the resident's first fall, in which he/she fell while reaching for the call light on 02/15/2021 at 11:30 PM, was to keep the bed in low position and to clip the call light to the resident. […]

• Immediate jeopardy, isolatedF689Jul 20, 2021

  Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure one (1) of three (3) sampled residents (Resident #1) received adequate supervision and assistance devices to prevent accidents. The facility assessed Resident #1 to be at risk for falls. Resident #1 sustained fractures from a fall on 02/15/2021, while reaching for the call light. After the fall on 02/15/2021, the facility updated the resident's care plan to keep the residents call light within reach and to frequently check placement. However on 02/21/2021, at 3:50 PM, the resident was again reaching for his/her call light and fell from the bed. The resident was sent to the emergency room where he/she was diagnosed with a right nasal fracture. […]

• Actual harm, isolatedF580Jul 20, 2021

  Based on interview, record review and review of the facility's policy, it was determined the facility failed to inform the physician when a change in condition occurred for one (1) of three (3) sampled residents (Resident #2). Review of the resident's food and fluid records dated 03/17/2021 through 05/04/2021, revealed Resident #2 had decreased fluid intake and was not meeting his/her assessed fluid needs. However, the facility failed to recognize the resident's decreased intake and did not notify the resident's physician. On 05/04//2021, the facility transferred Resident #2 to the hospital for evaluation and treatment after staff noted a mental status change. […]

• Actual harm, isolatedF657Jul 20, 2021

  Based on interview, record review, and review of the facility's policy it was determined the facility failed to revise the comprehensive care plans for two (2) of three (3) sampled residents (Resident #1 and Resident #2 ). Review of the Comprehensive Care Plan in Point Click Care for Resident #1, initiated 02/04/2021, revealed the Fall Care Plan and the Pain and Activity of Daily Living care plans were not updated or revised to address the resident's pain after the 02/15/2021 fall with injury. In addition, staff interviews revealed they were unaware of the hospital discharge plan of care instruction that stated the resident was to remain bed bound due to spinal fractures. […]

• Actual harm, isolatedF692Jul 20, 2021

  Based on interview, record review, and facility policy review, it was determined the facility failed to ensure residents identified at nutritional risk were monitored and provided nutritional services to meet the needs of the resident to prevent severe weight loss for one (1) of three (3)sampled residents (Resident #2). Record review revealed from 03/16/2021 through 05/4/2021, Resident #2 did not meet his/her fluid or nutritional needs. Staff completed a hydration and nutrition risk assessment during this time frame; however, the facility failed to identify the resident was at risk for dehydration and was malnourished. Resident #2 was transferred to the hospital 05/04/2021. The resident's labs were assessed to be critical. […]