The HSC Pediatric Skilled Nursing Facility

In the surveyor’s words

From the most serious findings on record at The HSC Pediatric Skilled Nursing Facility, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF837Jan 6, 2023

  Based staff interview, the Governing body failed to appoint an administrator who is licensed by the District of [NAME] to be responsible for the management of the facility. The census on the day of survey was 12 residents and the facility capacity is 16 residents. The findings include: On January 06, 2023, at approximately 9:50 AM, an onsite visit of the facility was conducted. Upon entrance to the facility, a request was made to speak with the Administrator of the facility. At approximately, 9:48 AM, Employee # 1 entered the lobby and shared that there was no administrator in place. That they (the facility administration) are currently in the process of bringing someone in (to serve as the administrator). […]

• No harm, potential for more than minimal, patternF584Feb 9, 2023

  Based on observations and interview, facility staff failed to provide housekeeping services necessary to maintain a safe, clean, comfortable environment as evidenced by privacy curtains that were hanging loose, detached from the curtain tracks in five (5) of eight (8) resident's rooms, and wall clocks in eight (8) of eight (8) resident's rooms that did not display the correct time. The findings included: 1. Privacy curtains in residents' rooms #1077, #1078, #1079, # 1080, and #1082 were hanging loose, detached from curtain hooks and ceiling tracks. 2. Wall clocks in eight (8) of eight (8) resident's rooms did not display actual time. Employee #1 acknowledged the findings during a face-to-face interview on February 8, 2023, at approximately 10:00 AM.

• No harm, potential for more than minimal, patternF607Feb 9, 2023

  Based on record review and staff interviews for three (3) of 13 sampled residents, facility staff failed to implement its written policies and procedures to investigate any potential allegations of neglect as evidenced by the facility's staff failure to investigate two incidents involving residents with a dislodged g (gastrostomy)-tube and one incident involving a resident's decannulation of the tracheostomy tube. (Residents' #1, #8 and #4). The findings included: Review of the facility's policy titled Abuse Investigation and Reporting with a reviewed date of 01/2020, instructs .If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the Administrator will investigate or assign the investigation to an appropriate individual . […]

• No harm, potential for more than minimal, patternF610Feb 9, 2023

  Based on record review and staff interviews for three (3) of 13 sampled residents, facility staff failed to conduct thorough investigations as evidenced by there being no evidence that the facility investigated an incident involving one (1) resident's decannulation of the tracheostomy, and for two resident's incidents in which their G (Gastrostomy)-tube dislodged. (Resident's #1, #8, and #4. The findings included: Review of the facility's policy titled Abuse Investigation and Reporting with a reviewed date of 01/2020, instructs .If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of an unknown source is reported, the Administrator will investigate or assign the investigation to an appropriate individual .The individual conducting the investigation will… […]

• No harm, potential for more than minimal, patternF756Feb 9, 2023

  Based on record review and staff interview, for three (3) of 13 sampled residents, facility staff failed to show documentation that the attending physician reviewed, accepted, acted upon or rejected any identified recommendations made by the pharmacists in the resident's medical record. Residents #9, #7 and #8. The findings included: 1. Resident #9 was admitted to the facility on [DATE] with diagnoses that included: Recurrent Urinary Tract Infection (UTI), Bilateral Hydronephrosis, Seizure, and Chronic Respiratory Failure. Review of Resident #9's monthly Medication Regimen Reviews (MRR) from June 2022 to December 2022 showed the following: Antibiotic usage: yes; Nitrofurantoin PPX (prophylactic) UTI (urinary tract infection) . […]