Warren Barr Oak Lawn

In the surveyor’s words

From the most serious findings on record at Warren Barr Oak Lawn, in the surveyor’s own words.

• Actual harm, isolatedF684Jul 24, 2024

  Based on observation, interview, and record review, the facility failed to recognize an acute change in condition for a resident. This failure applied to one (R5) of three residents reviewed for nursing care and resulted in a delay in care for R5 who was hospitalized for respiratory failure. Findings include: R5 is [AGE] years old and admitted to the facility on [DATE] and has diagnoses that include hydrocephalus, g-tube placement, communication deficit weakness and lack of coordination. Minimum data set (6/28/24) indicates R5 to have severe cognitive impairment and unable to make needs known to staff. The assessment data also includes that R5 is incontinent of bowel and bladder and totally dependent on staff for turning, repositioning and all other activities of daily living. […]

• Actual harm, isolatedF686Jul 24, 2024

  Based on interview and record review, the facility failed to implement turning and repositioning to prevent the development of new pressure injuries and complete treatment orders. This failure affected two residents (R4 and R5) who were at high risk of developing pressure ulcers and resulted in R4 and R5 developing deep tissue injuries to the sacrum. Findings include: R4 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that included Protein-calorie Malnutrition, Heart failure, and metabolic encephalopathy. According to Skin Evaluation Assessment of 3/13/24, R4 was assessed to have one pressure ulcer of the right heel. […]

• Actual harm, isolatedF726Dec 22, 2022

  Based on observation, interview, and record review, the facility failed to ensure that nursing staff had the required competencies when transcribing physician orders for newly admitted residents to ensure that care is being provided as ordered and to meet the needs of the residents; they also failed to ensure that standards of nursing practice were being followed during the administration of medication. This failure applied to three of three (R73, R103, and R504) residents reviewed for nursing services and resulted in (R73) receiving medication that was not ordered; (R103) not having a BiPap machine upon admission, that R103 was required to wear due to history of sleep apnea and respiratory failure; and (R504) did not receive medication that were needed for the prevention of blood clots… […]

• Actual harm, isolatedF760Dec 22, 2022

  Based on interview and record review, the facility failed to accurately transcribe hospital discharge orders to ensure that a newly admitted resident received all medications needed for treatment and failed to prevent a medication administration error. These failures affected two residents (R504 and R73) reviewed for medication administration and resulted in one resident (R73) receiving medication that was not ordered and resulted in (R504) not receiving medication for the prevention of blood clots upon admission to the facility and then being emergently transferred to the hospital and subsequently expiring. Findings include: R504 was an [AGE] year old male admitted to the facility [DATE] with diagnoses that included cerebral infarction and hypertension. […]

• Actual harm, isolatedF686Nov 17, 2022

  Based on interviews and records reviewed the facility failed to document a dependent resident's (R1) skin condition when initially observed or reported. This failure affected 1 or 3 residents reviewed for pressure ulcer prevention. This failure resulted in R1 developing an unstageable pressure ulcer to R1's sacrum. Findings include: R1 is [AGE] years old with diagnosis including but not limited to Metabolic Encephalopathy, Dysphagia, Urinary Tract Infections, Reduced Mobility, and Altered Mental Status. R1 admitted to the facility on [DATE] and discharged to home on 11/2/22. On 11/16/22 at 10:06 AM V7, Unit Manager Registered Nurse, stated R1 stayed in bed and was not active. V7 stated R1 was dependent on staff. […]