SGMC Health Villa

In the surveyor’s words

From the most serious findings on record at SGMC Health Villa, in the surveyor’s own words.

• Actual harm, isolatedF657Aug 13, 2021

  Based on record review and staff interviews the facility failed to review and revise the Comprehensive Care Plan for four of 24 residents (R#210, #49, #2 and #28) whose care plans were reviewed. Failure to revise the Care Plan for each resident resulted in the nursing staff being unaware of the current status of each resident, which resulted in a fall with a major injury for R#210. Actual harm was identified to have occurred on 6/29/2021 when R#1 fell , while being transferred with a mechanical lift, and sustained an intertrochanteric fracture of the right hip that required surgery. […]

• Actual harm, isolatedF689Aug 13, 2021

  Based on observations, record reviews, and resident and staff interviews the facility failed to use a two-person transfer for one of four residents (R#210) transferred with a Hoyer lift. Actual harm was identified to have occurred on 6/29/2021 when R#1 fell , while being transferred with a mechanical lift, and sustained an intertrochanteric fracture of the right hip that required surgery. The findings include: Review of the facility Job Aid titled, Mechanical Lift dated 11/1/2019 revealed Purpose: To provide direction on the proper and safe use of mechanical lifts at SGMC Lakeland villa. Mechanical lifts include but are not limited to Hoyer, car extractor, and stander. At least two nursing staff members are needed to transfer an individual when using any lift. […]

• Actual harm, isolatedF726Aug 13, 2021

  Based on observations, record reviews, and interviews, the facility failed to provide staff with the necessary education and skill set to perform resident transfers; the facility staff improperly transferred one of four residents (R#210). This resulted in actual harm that required surgery. The findings include: Review of the facility policy titled Villa Safe Lifting dated 11/13/2019 revealed, 2. Evaluation of nursing staff use of lifting equipment is accomplished through in-service post-test, return demonstration, as well as on-the-job performance reports. R#210 was admitted to the facility on [DATE]. A review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF882Oct 19, 2021

  Based on staff interviews and review of the facility policy titled, Infection Prevention and Control Program the facility failed to have a qualified Infection Preventionist who had completed the required specialized training in infection prevention and control. This failure placed all residents at risk for the potential transmission of infections and communicable diseases. The facility census was 59 residents. Findings include: Review of the facility policy, Infection Prevention and Control Program dated 7/30/2018 with a revised date of 11/1/2019 documented, Facility maintains an Infection Prevention and Control Program (IPCP) to provide a safe, sanitary, and comfortable environment and to prevent the development and transmission of communicable disease as well as infection. Procedure 6. […]

• No harm, potential for more than minimal, widespreadF756Aug 13, 2021

  Based on interviews, record review, and review of policy titled, Villa Drug Regiment the facility failed to ensure the pharmacist provided documentation to the attending Physician, the facility's Medical Director and the Director of Nursing (DON) regarding any irregularity (including excessive dose, duplicate therapy, excessive duration, without adequate monitoring, without adequate indications for its use, the presence of adverse consequences or any combinations of the previous reasons) identified during the pharmacist's review of the drug regimen and medical chart for each resident for five of five residents reviewed (Resident (R) #2, R#28, R#43, R#48 and R#49). […]