PruittHealth-Union Pointe

In the surveyor’s words

From the most serious findings on record at PruittHealth-Union Pointe, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jul 1, 2024

  Based on record review, observations, and staff and Nurse Practitioner interviews the facility failed to protect Resident #1's and Resident #2's right to be free from sexual abuse. On 6/16/24 staff (Nurse Aide #1, Nurse Aide #2, and Nurse #1) observed Resident #1 (female) in Resident #2's (male) room. Resident #2 was lying on his back on the bed naked from the waist down and Resident #1 was on top of him with her brief and pants down at her ankles. Resident #2 had one hand on his erect penis and was trying to insert his penis in Resident #1, and he was touching her private parts with his other hand. […]

• Immediate jeopardy, isolatedF607Jul 1, 2024

  Based on record review, observations, and staff interviews the facility failed to implement their abuse policy by failing to immediately implement protective measures when Nurse Aide #1 and Nurse Aide #2 observed two residents with severe cognitive impairment (Resident #1 and Resident #2) engaged in sexual activity that they did not have the capacity to consent to and the staff did not immediately separate the residents to provide protection from further abuse. The residents remained engaged in the sexual act until Nurse #1 arrived at the room and instructed Nurse Aide #1 and Nurse Aide #2 to separate the residents. […]

• Actual harm, patternF550Feb 16, 2024

  Based on record reviews, resident, family member, and staff interviews, the facility failed to protect residents' dignity when residents were left soiled in feces and saturated in urine for 4 of 17 residents reviewed for dignity issues (Resident #192, Resident #34, Resident #48, and Resident #69), and failed to provide a dignity cover over a urinary catheter drainage bag for 1 of 4 residents reviewed for urinary catheters (Resident #390). Resident #192, Resident #34, Resident #48, and Resident #69 reported they felt upset, angry, mad, and like they did not matter at all when they were not provided incontinence care. […]

• Actual harm, patternF725Feb 16, 2024

  Based on observations, record reviews, and staff, resident, Nurse Practitioner, and Medical Director interviews, the facility failed to provide sufficient nursing staff which resulted in residents being treated in an undignified manner when left incontinent of urine or stool (Resident #192, #34, #48, and #69) and when a urinary catheter bag was left uncovered (Resident #390). These residents reported feeling upset, angry, mad and unimportant. The facility failed to provide sufficient nursing staff to assist with activities of daily living (ADL) care for dependent residents (Resident #192, #34, #69, #48, and #339). The facility failed to supervise a resident who was at high-risk for falls which resulted in acute cervical 6, cervical 7 and 1 thoracic fractures due to a fall (Resident #16). […]

• Actual harm, isolatedF689Feb 16, 2024

  Based on staff, Nurse Practitioner, (NP) #1 and Medical Director (MD) interviews, observations and record review, the facility failed to supervise Resident #16 who was cognitively impaired and impulsive. The resident was eating in a dining room without any staff present in the room and with the back of her wheelchair positioned in front of a stone hearth. While passing trays on the 300 hall, NA #8 observed Resident #16 aggressively bounce her wheelchair and suddenly flip her wheelchair backwards hitting her head on the stone fireplace. This accident resulted in acute cervical 6, cervical 7 and thoracic 1 fractures. The fall on 12/23/23 resulted in pain at a level of 6 out of 10 and the use of a hard cervical collar. This was for 1 of 6 residents reviewed for accidents (Resident #16). […]