St Luke's Rehabilitation and Nursing Center

In the surveyor’s words

From the most serious findings on record at St Luke's Rehabilitation and Nursing Center, in the surveyor’s own words.

• Actual harm, isolatedF686Jan 12, 2023

  Based on observation and a review of clinical records and select incident reports and staff interviews it was determined that the facility failed to timely and consistently monitor the application of a therapeutic device to preserve the resident's skin integrity, which resulted in the development of an avoidable pressure sore by one resident out of three reviewed (Resident 35). Findings: A review of the clinical record revealed that Resident 35 was admitted to the facility on [DATE], with diagnoses to include dementia, anxiety, atrial fibrillation (an irregular and often very rapid heart rhythm -arrhythmia, that can lead to blood clots in the heart), chronic kidney disease, hypertension, and fracture of T11-T12 (midback) vertebra. […]

• No harm, potential for more than minimal, patternF691Dec 1, 2023

  Based on clinical record review, facility policy review, and resident and staff interviews, it was determined that the facility failed to provide colostomy (an operation that creates an opening for the colon, or large intestine, through the abdomen) care and services consistent with professional standards of practice for one of one resident reviewed with a colostomy (Resident 27). Findings include: Review of the facility Ostomy Care Policy last reviewed February 21, 2023, indicated that it is the policy of the facility to ensure that residents who require colostomy services receive care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. […]

• No harm, potential for more than minimal, patternF692Dec 1, 2023

  Based on a review of clinical records and staff interview it was determined that the facility failed to consistently monitor a resident's fluid intake for maintenance of the physician prescribed fluid restriction and to ensure adequate hydration for one resident out of 12 sampled (Resident 4). Findings included: A review of the clinical record revealed that Resident 4 had diagnoses, which included acute and chronic respiratory failure and congestive heart failure. A physician order dated September 6, 2023, was noted for a Fluid Restriction 1800 ml per day distributed per shift: day - 360 cc, evening-360 cc, night-180 cc to equal 900 ccs. […]

• No harm, potential for more than minimal, patternF697Dec 1, 2023

  Based on a review of clinical records and select facility policy and staff interview, it was determined that the facility failed to provide person-centered pain management consistent with professional standards of practice for one resident out of 12 sampled (Resident 4). The findings include: A review of the facility's current Pain Management policy, last reviewed by the facility on October, 2023, revealed that the facility must ensure that pain management is provided to residents who require such services, consistanet with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. […]

• No harm, potential for more than minimal, patternF758Feb 24, 2022

  Based on a review of clinical records, facility provided documents, and select facility policy and staff interview, it was determined that the facility failed to attempt gradual dose reduction (GDR) of psychoactive drugs prescribed for three out of five sampled residents (Residents 12, 20, and 11). Findings include: A review of the facility's policy entitled Use of [CONDITION(S)] Drugs last reviewed by the facility on February 8, 2022, indicated that residents are not given [CONDITION(S)] drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record and the medication is beneficial to the resident as demonstrated by monitoring and documentation of the resident's response to the medication(s). […]