Rockford, Illinois 2008 Nursing Home Report: River Bluff Nursing Home
River Bluff Nursing Home is a 304 bed nursing home facility located in Rockford, Illinois. This facility scored two out of five stars in the new rating system implemented by The Centers for Medicare and Medicaid, which indicates a below average facility. River Bluff Nursing Home has exceeded the state deficiency average of eight deficiencies twice in the past three years. The facility had ten deficiencies in 2007 and eight deficiencies in 2006.
All nursing home facilities must conduct an initial assessment of a resident's needs and the assess the resident periodically to update the resident's care plan to meet growing needs. In one instance, a resident at risk for potential weight loss did not have a nutritional assessment in place and was steadily losing weight. This same resident also was at risk for edema. She was observed by state officials sitting in her wheelchair with swollen feet and ankles. After state intervention, the facility was forced to complete a nutritional assessment for the resident and complete an audit to ensure all other residents had nutritional assessments in place. The Dietary Supervisor also was required to report the results of the monthly chart reviews to the Quality Assurance Committee.
Proper care of nursing home residents is vital to prevent pressure sores. All nursing home facilities must ensure that a resident entering the facility wihtout pressure sores does not develop pressure sores and any residents with pressure sores are to receive the necessary treatment to promote healing and prevent infection. River Bluff Nursing Home staff failed to identify a resident's risk factors that contributed to the skin breakdown. The staff failed to identify open areas on a resident's sacral area. After state intervention, a new report log system was developed for CNAs to write down their observations and not rely on spoken word. Nursing staff was re-educated on skin care, observation, and reporting.
All nursing home facilities are required to ensure that the nursing home environment remains free of accident hazards and that each resident receives adequate supervision and assistance to prevent accidents. River Bluff Nursing Home failed at least one resident at risk for aspiration in this regard. This resident was on a general pureed diet with honey-thickened liquids and had the potential for aspiration and needed to be monitored for coughing and choking during oral intake. This resident also had an MRSA infection that could be spread. The resident was to eat in small bites and was to have supervision at meals. This resident was on isolation due to the MRSA infection and the possible spread of the infection to the resident's finger. During the state investigation, this resident was found in his room in bed eating breakfast alone. No staff members were present to assist. No staff members were present to ensure his safety. After state intervention, the resident's care plan was altered so that all of his meals could be taken in the dining room, where he could have supervision. The facility was forced to review all care plans for residents at risk of aspiration.
Nursing home facilities must store, prepare, and distribute food under sanitary conditions. River Bluff Nursing Home failed to have the sanitizer level in its three compartment sink at the required level for two separate observations. After state intervention, all dietary personnel were re-inserviced on performing test strip monitoring and procedure to notify supervisory personnel of non-compliance.
If specialized services, such as speech therapy, occupational therapy, mental health rehabilitative services, etc., are required in the resident's comprehensive plan of care, the facility must provide those services. River Bluff Nursing Home failed to provide yearly psychiatric exams, psychiatric rehabilitation programs, and a discharge plan for a resident with a severe mental illness. After state intervention, the facility was forced to conduct initial assessments and re-assessments annually of residents with diagnoses of severe mental illness to ascertain if the resident has a continuing need for physical care.
It is vital for all nursing home staff to wash their hands after each direct contact for which handwashing is indicated by professional practice. In fact, federal regulation 42 C.F.R. 483.65(b)(3) states that facility staff must wash their hands after direct resident contact for whcih handwashing is indicated by accepted professional practice. Certainly handwashing is indicated after cleaning up a resident's bowel movement. River Bluff Nursing Home staff failed to wash their hands as appropriate during incontinence care. For example, one CNA was observed cleaning a resident after a bowel movement. After cleaning the resident, the CNA placed a clean sheet on the bed and on the resident, then raised the resident's bed using the buttons on the side rail. Only then did she remove the gloves she had worn during the incontinence care. She subsequently removed her gloves and left the room without washing her hands. After state intervention, facility staff was re-educated regarding proper glove changing and hand sanitation. Random observances of hand sanittion and glove changing were ordered done by the infection control nurse for six weeks.
The Terry Law Firm is experienced in handling cases of nursing home abuse and neglect. Please contact us at 1 (888) 317-2525 or visit us at www.nursinghomejustice.com.
