Queen Anne Healthcare

In the surveyor’s words

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

• Actual harm, isolatedF600Feb 9, 2024

  Based on interview and record review, the facility failed to prevent physical abuse to 1 of 3 residents (Resident 1), reviewed for abuse investigations. Resident 1, who had known behaviors of lack of boundary control and encroaching in other residents' space, was harmed when they initiated an aggressive incident with another resident, without staff present, Resident 1 was struck in the left eye resulting in a black eye. This failure placed other residents at risk for potential physical abuse, injuries, and a diminished quality of life. Findings included . Review of the admission Minimum Data Set (MDS - an assessment tool) dated 11/16/2023, showed Resident 1 was admitted to the facility on [DATE]. […]

• Actual harm, isolatedF689Feb 9, 2024

  Based on interview and record review, the facility failed to ensure supervision was provided to prevent an avoidable injury for 1 of 3 residents (Resident 1), reviewed for abuse investigations. Resident 1, who had known behaviors of striking, calling out, lack of boundary control and encroaching in other residents' space, experienced harm when another resident struck them in the left eye resulting in a black eye. This failure placed other residents at risk for potential physical injuries and a diminished quality of life. Findings included . Review of the admission Minimum Data Set (MDS - an assessment tool) dated 11/16/2023, showed Resident 1 was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, patternF656Oct 20, 2023

  Based on observation, interview, and record review, the facility failed to develop and implement comprehensive care plans for 5 of 21 residents (Residents 2, 4, 21, 60 & 16), reviewed for comprehensive care plans. The failure to develop and implement care plans to offer fluids, for use hearing aids and/or use of diuretics (medicines that help reduce edema [fluid buildup in the body]) placed the residents at risk for possible adverse effects and related complications. Findings included . […]

• No harm, potential for more than minimal, patternF657Oct 20, 2023

  Based on observation, interview, and record review, the facility failed to ensure resident care plans were reviewed, revised, and accurately reflected residents' care needs for 4 of 21 residents (Residents 31, 52, 66 & 58) whose care plans were reviewed. This failure placed the residents at risk for unmet needs, and a diminished quality of life. Findings included . Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised in December 2016, showed that assessments of residents were ongoing and care plans were revised as information about the residents and the residents' conditions change. […]

• No harm, potential for more than minimal, patternF695Oct 20, 2023

  Based on observation, interview, and record review, the facility failed to follow professional standards of practice to properly care and clean respiratory equipment for 4 of 6 residents (Residents 77, 66, 87 & 49), reviewed for respiratory care. The failure to properly label/store suction tubing/tip (a medical device used to remove mucus/saliva/blood obstructing a person's airway), masks for Continuous Positive Airway Pressure (CPAP- helps with breathing)/Bilevel Positive Airway Pressure (BIPAP-helps with breathing) placed the residents at risk for respiratory infections, and related complications. Findings included . USE OF SUCTION MACHINE Resident 77 admitted to the facility on [DATE] with a diagnosis that included dysphagia (difficulty swallowing). […]