Split Rock Rehabilitation and Health Care Center

Based on observations, record review, and staff interviews, the facility did not ensure the resident's right to retain and use personal clothing items. This was evident for 1 of 30 sampled residents. (Resident # 9).
This resulted in no actual harm with potential for more than minimal harm.
The finding is:
1) Resident #9 is a 93 year old with the diagnoses of Anemia, Chronic Renal Failure, and Dementia. The resident was admitted to the facility on 7/31/2009.
The Minimum Data Set (MDS) 3.0 dated 3/26/11 documented the resident's cognition as severely impaired.
The Care Plan for "Dressing" dated 7/15/2010 and updated on 3/24/2011 documented that the "Resident is totally dependent on staff for dressing." The interventions are "Assure residents clothing is clean, neat and well fitting when dressing. Maintain clean and clutter free environment to dress in. Gentle handling during care."
On 6/3/11 at 10:30am, the resident was observed wearing a hospital gown in bed. On 6/6/11 at 3 PM, the resident was observed in her room sitting in a geri chair, the resident was wearing a house dress with no bra.
An observation of the resident's closet was conducted with the CNA on 6/6/11 at 3PM, who dressed the resident. The surveyor and the CNA went thru resident's closet and drawers. There was only one house dress in the resident's closet. There were no other clothing in resident's closet or drawers. There were no undergarments (such as a bra) and socks, in the resident's closet or drawers.
An interview was conducted with the CNA right after the observation. The CNA stated that the resident may have clothing in the laundry. The CNA stated she did not know when the resident's clothes were picked up by the laundry or when the clothing would be returned from the laundry. The CNA stated she did not know what clothing items were sent to the laundry.
A review of resident's property sheet revealed that the last clothing list was done 2 years ago on August 22, 2009. The property sheet documented that the resident has 4 dresses, 2 pairs of socks, 1 sweater.
An interview was conducted with the nurse manager on 6/6/11 at around 3 PM. The nurse manager stated that the laundry is usually picked up on Wednesday and that she does not know when the laundry is returned to the resident.
An interview with the Director of Social Services was conducted on 6/6/11 at 4:30 PM and stated that the staff in therapeutic recreation are responsible for making the arrangement for the clothing store to come to the facility so residents can purchase their clothing. She further stated that the CNAs do the shopping for the residents.
415.15(h)(1)

Based on observation and interview it was determined that the facility did not ensure that precautionary signs, readable from a distance of 5 ft (1.5 m), are conspicuously displayed wherever supplemental oxygen is in use. This was observed on resident units on the third and fourth floors where oxygen concentrators were in use.

This resulted in no actual harm with potential for greater than minimal harm that is not immediate jeopardy.

The Findings are:

On June 03, 2011, during the Annual Life Safety evaluation of the facility it was observed that between the hours of 9:00 am, and 12:00 pm, various resident rooms 411,303,309,311,323,310,318,338,316 were not provided with no smoking signage in accordance with NFPA 99.

All of the stated rooms were observed with oxygen concentrators. The importance of providing no smoking signage is warranted by the fact that the facility has smokers and a smoking room is provided on the first floor.

In an interview with the Housekeeping Director at approximately 11:30 am, he stated that signage were already provided at these rooms.

711.2 (a)(1)
NFPA 99, 8.6.4.2.

Based on observation and interview it was determined that the facility did not ensure to indicate the exit discharges or the way to reach an exit discharge in accordance with Section 7-10. This was observed in the day rooms on the fourth and third floors.

This resulted in no acutual harm with the potential for more than minimal harm that is not immediate jeopardy.

The Findings are:

On June 03, 2011 between the hours of 9:00 am and 3:00 pm, during the Annual Life Safety evaluation it was noted that exit signs were not provided in the dayrooms on the fourth and third floors.Two doors were observed that lead to the corridor from this area, and none were observed with exit signage.The egress path was not clear if a smoke or fire develops in this area.

In an interview with the Housekeeping Director and Director of Engineering at approximately 12:00 PM, they stated that new exit signs will be immediately placed above the doors.

711.2 (a)(1)