Royal Norwell Nursing & Rehabilitation Center LLC

In the surveyor’s words

From the most serious findings on record at Royal Norwell Nursing & Rehabilitation Center LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF658Sep 14, 2023

  Based on record review, document review, policy review, and interview, the facility failed to follow professional standards of practice in nursing for the care and monitoring of a peripherally inserted central catheter (PICC) and/or midline catheter. Specifically, the facility failed: 1. To obtain physician's orders and provide appropriate nursing interventions for 2 out of 2 PICC lines and 2 out of 2 midline catheter devices for one Resident (#20), out of a total sample of three residents with peripheral lines in place during the timeframe of 10/10/22 through 11/3/22. […]

• Immediate jeopardy, isolatedF694Sep 14, 2023

  Based on observation, record review, policy review, and interview, the facility failed to ensure the proper care and treatment of a peripherally inserted central catheter (PICC) and/or midline catheter device in accordance with the facility policy/protocols. Specifically, the facility failed: 1. For one Resident (#20), who had a history of chronic embolism and thrombosis (formation of a blood clot within blood vessels or arteries limiting the natural flow of blood), out of a total sample of three residents with peripheral lines in place, to ensure physician's orders were in place and implemented for the care and treatment of two out of two midline catheters and two out of two PICCs to include monitoring for signs and symptoms of intravenous (IV) related complications, catheter lumen… […]

• Actual harm, patternF726Sep 14, 2023

  Based on observation, record review, and interview, the facility failed to ensure licensed nursing staff had the appropriate competencies and skill set for providing the necessary care and treatment for residents with a peripherally inserted central catheter (PICC- long, thin tube inserted through a vein in your arm and passed through to the larger veins near your heart that delivers fluids and/or medications) and/or midline catheter (thin, soft tube that is placed into a vein at the level of the armpit that delivers fluids and/or medications directly into the vein) device per facility policy and acceptable standards of practice and to ensure nursing practice by nursing students and their supervising nurse were adhered to for the administration of medications. […]

• Actual harm, isolatedF656Jan 6, 2025

  Based on records reviewed and interviews for one of three sampled residents (Resident #3), whose care plan indicated he/she required a Hoyer lift (mechanical mobility aid that supports a person's total body weight to allow movement from one surface to another safely) for transfer and Geri-sleeves (stocking like sleeve to protect fragile skin) to both upper extremities to minimize skin injury, the facility failed to ensure staff consistently implemented and followed interventions from his/her care plan, when on 12/07/24, Resident #3, was manually lifted and transferred from his/her bed into a wheelchair by Certified Nurse Aide (CNA) #2 and CNA #3 instead of utilizing the Hoyer lift, he/she also did not have the geri-sleeve on his/her right upper extremity, and as a result he/she sustained a… […]

• Actual harm, isolatedF689Jan 6, 2025

  Based on records reviewed and interviews for two of three sampled residents (Resident #1 and #3), who both required a Hoyer Lift (mechanical mobility aid that supports a person's total body weight to allow movement from one surface to another safely) with the assistance of two staff members, the facility failed to ensure that necessary assistive devices were utilized properly and appropriately during transfers in order to maintain resident safety and prevent incidents/accidents resulting in injuries. […]