TUALATIN, OR - Federal inspectors cited Marquis Tualatin Post Acute Rehab for failing to monitor a resident after a fall and providing inadequate catheter care that contributed to a serious infection requiring hospitalization.
Fall Monitoring Protocols Ignored
On December 3, 2023, a resident fell from their wheelchair after experiencing dizziness, sustaining a bruise to the left forehead. Despite facility protocols requiring 72-hour alert monitoring after falls to watch for latent injuries, staff failed to implement these safety measures.
The resident's care plan specifically required two-person mechanical lift transfers, non-slip socks when out of bed, and call light within reach. However, the fall occurred when the resident was left unattended in their wheelchair after breakfast.
Staff 12, the LPN who discovered the resident on the floor, completed an initial assessment and found the resident denied pain with normal range of motion. A neurological assessment was performed, and the resident was returned to bed. However, no documentation exists showing the required post-fall monitoring was initiated.
The family member stated the facility "did not monitor the resident appropriately prior to and after the resident fell out of her/his wheelchair."
Multiple staff members acknowledged the monitoring failure. Staff 4, the Registered Nurse Case Manager, confirmed that the resident "was not placed on alert charting from her/his fall on 12/3/24." The facility administrator also acknowledged this protocol violation during the inspection.
Post-fall monitoring serves a critical medical purpose. After any fall, residents face elevated risks for delayed complications including internal bleeding, brain injury, or fractures that may not immediately present symptoms. The 72-hour alert period allows staff to detect changes in mental status, mobility, or pain levels that could indicate serious injuries requiring immediate medical attention.
Mechanical Transfer Incident Goes Unreported
In a separate safety violation, two CNAs using a mechanical lift to transfer the same resident struck the resident's head during the transfer process. A family member witnessed the incident and reported that one CNA operating the lift was moving too quickly despite warnings from the other CNA to slow down.
Staff 10, an agency CNA involved in the transfer, stated: "The CNA operating the lift was not paying attention and moving quickly... I was guiding Resident 1's feet and hollered at the other CNA to slow down, but the CNA operating the lift did not listen, and the lift struck Resident 1 in the head."
Despite the head impact, neither CNA reported the incident to nursing staff for assessment. Staff 10 acknowledged "the incident should have been reported to rule out an injury." The nursing management was unaware of the incident until the inspection, representing a breakdown in communication protocols designed to ensure resident safety.
Mechanical lift transfers require precise coordination between staff members. Moving too quickly increases risks for equipment malfunction, improper positioning, or direct contact between lift components and residents. Any contact between equipment and residents requires immediate nursing assessment to rule out injury, particularly head impacts that could cause concussion or other neurological complications.
Catheter Care Deficiencies Lead to Infection
Inspectors also found serious deficiencies in catheter care for the same resident, who was admitted with benign prostatic hyperplasia and hematuria (blood in urine). The resident's care plan required daily catheter care with soap and water and monitoring for infection signs.
On December 5, 2023, the resident developed a fever reaching 102.2 degrees and was hospitalized due to suspected infection. Laboratory results showed elevated white blood cell counts, indicating a urinary tract infection.
The family member reported that hospital staff observed "blood and discharge coming from the genitalia" and "erosion at the catheter entry point which indicated possible improper positioning of the catheter."
Multiple staff members confirmed inadequate catheter care. Staff 9 expressed concerns that "residents did not receive appropriate catheter care in 11/2023 and 12/2023" and that "agency staff did not consistently provide appropriate ADL care." An agency CNA admitted to only emptying the catheter bag without providing cleaning or perineal care.
Staff 11 noted the catheter "was uncomfortable and caused tugging" and observed "redness and blood coming out of the tip of the resident's genitalia." Staff 7 stated catheter care "was not always provided adequately and depended on which CNAs were working."
Proper catheter care prevents serious complications including urinary tract infections, sepsis, and tissue damage. Daily cleaning with soap and water removes bacteria and debris that can migrate up the catheter into the bladder. Improper positioning or inadequate stabilization can cause trauma to urethral tissue, leading to bleeding and erosion.
Medical Consequences and Industry Standards
Urinary tract infections in catheterized patients can rapidly progress to urosepsis, a life-threatening condition where infection spreads to the kidneys and potentially the bloodstream. The resident's admission diagnosis of urosepsis indicates a previous serious infection, making proper ongoing catheter care even more critical.
The combination of fall monitoring failures and catheter care deficiencies created compounded risks. Falls can cause positioning changes that affect catheter placement, and the stress of undetected injuries can compromise immune function, increasing infection susceptibility.
Standard nursing home protocols require immediate post-fall assessments followed by enhanced monitoring periods. This typically includes neurological checks every four hours for 72 hours, documentation of any status changes, and physician notification of significant findings. The facility's failure to implement these protocols violated basic safety standards.
Staffing and Training Concerns
The inspection revealed systemic issues with staff training and consistency. Multiple staff members indicated that agency personnel lacked familiarity with residents and proper care protocols. The nursing management acknowledged expecting all CNAs to provide appropriate catheter care but failed to ensure this occurred.
The facility administrator and regional nurse consultant confirmed that staff should report any inability to provide required care to ensure residents receive appropriate services. However, the pattern of unreported incidents and inadequate care suggests these communication systems were not functioning effectively.
Regulatory Response and Oversight
The Centers for Medicare & Medicaid Services classified both violations as causing "minimal harm or potential for actual harm" affecting "few" residents. However, the inspection findings demonstrate how seemingly minor protocol violations can cascade into serious complications requiring emergency medical intervention.
Federal regulations require nursing homes to maintain accident-free environments and provide appropriate catheter care to prevent infections. Facilities must implement systems ensuring all care plan interventions are followed consistently, regardless of staffing changes or resident acuity levels.
The inspection occurred following a public complaint, highlighting the importance of family and community oversight in identifying care deficiencies. The facility must submit corrective action plans addressing the identified violations and demonstrate sustained compliance during follow-up monitoring.
These violations underscore the critical importance of consistent care protocols, proper staff training, and effective communication systems in preventing serious resident complications. The failure to implement basic safety measures like post-fall monitoring and daily catheter care represents fundamental breakdowns in nursing home quality standards.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Marquis Tualatin Post Acute Rehab from 2024-06-07 including all violations, facility responses, and corrective action plans.
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