St Peters Post Acute

In the surveyor’s words

From the most serious findings on record at St Peters Post Acute, in the surveyor’s own words.

• Actual harm, isolatedF658Aug 21, 2024

  Based on observation, record review and interview, the facility failed to ensure one resident (Resident #3) received an antibiotic and a probiotic to treat a urinary tract infection (UTI) as ordered by the physician. The assistant director of nursing (ADON) received a verbal order from the resident's physician on 8/2/24 for Florastor (probiotic) that was never entered on the resident's medication administration record to administer and on 8/7/24 she received another verbal order to discontinue Macrobid (antibiotic) and start Cipro (antibiotic). She discontinued one antibiotic but did not enter the order in the resident's electronic medication administration record for the new antibiotic. This resulted in the resident being hospitalized for his/her continued untreated symptoms from the UTI. […]

• Actual harm, isolatedF684Jul 24, 2024

  Refer to 50SJ12. Based on interview and record review, the facility failed to ensure one resident (Resident #1), in a review of four sampled residents, received care and treatment in accordance with professional standards of practice when staff failed to obtain an x-ray in a timely manner after the resident sustained a fall and was in pain. The resident fell at 2:15 A.M. and the responsible party (RP) chose not to send the resident to the hospital and requested a mobile x-ray. Staff obtained a physician order for a STAT mobile x-ray at 3:00 A.M. on 6/30/24. The x-ray provider did not arrive until 10:30 A.M. on 6/30/24 to complete the x-ray and sent the x-ray results to the facility at 10:50 A.M. […]

• Actual harm, isolatedF692Jul 24, 2024

  Refer to 50SJ12. Based on observation, interview, and record review, the facility failed to identify weight loss, notify the physician and dietician of further weight loss, implement interventions, or evaluate effectiveness of the interventions for three residents (Resident #2, #3, and #4) out of four sampled residents who had significant weight loss. Resident #2 had a 5.9% weight loss in five months; Resident #3 had a 9.3 % weight loss in 3 months and Resident #4 had a 17% weight loss in seven months. The facility failed to notify the physician or the registered dietician of the weight loss. The facility failed to implement and communicate the interventions that the Registered Dietician had put in place for Resident #4 to help prevent further weight loss. The facility census was 117.

• Actual harm, isolatedF684Jun 14, 2024

  Based on interview and record review, the facility failed to ensure one resident (Resident #1), in a review of four sampled residents, received care and treatment in accordance with professional standards of practice when staff failed to obtain an x-ray in a timely manner after the resident sustained a fall and was in pain. The resident fell at 2:15 A.M. and the responsible party (RP) chose not to send the resident to the hospital and requested a mobile x-ray. Staff obtained a physician order for a STAT mobile x-ray at 3:00 A.M. on 6/30/24. The x-ray provider did not arrive until 10:30 A.M. on 6/30/24 to complete the x-ray and sent the x-ray results to the facility at 10:50 A.M. […]

• Actual harm, isolatedF684Jun 14, 2024

  Based on interview and record review, the facility failed to ensure one resident (Resident #1), in a review of four sampled residents, received care and treatment in accordance with professional standards of practice when staff failed to obtain an x-ray in a timely manner after the resident sustained a fall and was in pain. The resident fell at 2:15 A.M. and the responsible party (RP) chose not to send the resident to the hospital and requested a mobile x-ray. Staff obtained a physician order for a STAT mobile x-ray at 3:00 A.M. on 6/30/24. The x-ray provider did not arrive until 10:30 A.M. on 6/30/24 to complete the x-ray and sent the x-ray results to the facility at 10:50 A.M. […]