The Brownstone at Park Crossing

The facility failed to ensure that three sampled staff members were validated by a licensed health professional as competent to use a Hoyer lift. While staff had completed validations for other assistive devices, there was no documentation of competency for the Hoyer lift despite its use for resident transfers.

The facility failed to ensure that staff members were validated by a licensed health professional as competent to use a Hoyer lift. A review of personnel records for three sampled staff members showed no documentation of skills validation for the use of this assistive device, despite residents requiring its use for transfers.

The facility failed to ensure the resident received and followed up on necessary health care needs regarding a TLSO brace for a compression fracture. Specifically, the facility did not ensure the resident wore the prescribed brace while out of bed and failed to notify the Orthopedic PA of the resident's refusal to comply with the treatment order.

The facility failed to ensure proper contact with the resident's physician or prescribing practitioner for the verification or clarification of orders for treatments. This was evidenced by the lack of communication regarding the resident's non-compliance with the prescribed spinal brace.

The facility failed to ensure necessary follow-up for a resident's health needs by not notifying the resident's Orthopedic Physician's Assistant regarding the resident's refusal to wear a required TLSO brace. Although the resident was ordered to wear the brace when out of bed, staff failed to coordinate with the physician's office despite the resident's ongoing noncompliance.

The facility failed to ensure physician notification and follow-up for a resident's noninvasive ventilator (NIV) needs. Specifically, there were no physician orders for the maintenance, cleaning, or replacement of the NIV tubing and filters, and staff were not properly trained on the management of the device.

The facility failed to properly document physician orders and the implementation of treatments for 2 of 3 sampled residents. This included failures regarding orders for monitoring COVID-19 symptoms and wound care.

The facility failed to ensure physician notification and appropriate orders for a resident requiring a noninvasive ventilator (NIV). While orders existed for specific NIV settings, there were no physician orders for the maintenance, application, removal, or management of the device.

The facility failed to ensure all staff were properly tested for tuberculosis upon hire and maintained proper documentation. Specifically, one medication aide worked for several months after a positive TB skin test was recorded without a follow-up chest X-ray to confirm they were negative. Additionally, another staff member's record lacked documentation of a TB skin test being placed upon their hire at the facility.

The facility failed to ensure that all staff were tested for tuberculosis disease in compliance with required control measures. Specifically, a review of personnel records revealed that a medication aide had a positive TB skin test and worked at the facility without proper documentation confirming they were negative for TB disease.