Ararat Nursing: Staff Training Failures Lead to Safety Violations
MISSION HILLS, CA - Federal inspectors discovered serious staff training deficiencies at Ararat Nursing Facility that resulted in improper medical care and potential injuries to residents requiring specialized joint mobility treatments.
Critical Training Gaps in Joint Mobility Assessments
The August 2024 inspection revealed that registered nurses were performing Joint Mobility Assessments without proper competency evaluations. The Director of Nursing acknowledged that nursing staff lacked the specialized knowledge required for these assessments, stating "there was no way to ensure the JMAs for all residents were accurate since the RNs did not have the competence to perform the JMA."
Joint mobility assessments require specific expertise to evaluate range of motion limitations and determine appropriate therapeutic interventions. These assessments guide critical decisions about resident care plans, including the use of splints and range of motion exercises designed to prevent contractures - permanent muscle shortening that causes joint stiffness and pain.
The facility's policy required that range of motion services be "delivered by staff trained in the procedures," yet inspectors found widespread training deficiencies among both nursing and aide staff.
Dangerous Splint Application Errors
Inspectors witnessed concerning practices during resident care observations. A restorative nursing aide applied splints incorrectly to a resident with Alzheimer's disease, including placing an elbow splint upside down and using a knee extension splint that didn't properly fit the resident's joint positioning.
Medical professionals at the facility determined that the improperly fitted knee splint "could put pressure on the skin and bones" and potentially result in pressure sores and joint dislocation. When the splint was removed, inspectors observed redness on the resident's kneecap where the strap had been positioned.
Range of motion therapy and splint application are critical interventions for residents with limited mobility. When performed incorrectly, these procedures can cause pain, skin breakdown, and worsen existing joint limitations rather than providing therapeutic benefit.
Progressive Joint Deterioration Due to Inadequate Care
The inspection documented significant decline in one resident's condition over nearly two years. Between October 2022 and August 2024, the resident experienced substantial worsening of joint contractures despite receiving regular restorative nursing services.
Physical therapy evaluations showed the resident's right knee extension deteriorated from 20 degrees to 73 degrees of limitation, while both hips developed new flexion contractures that hadn't existed previously. Occupational therapy assessments revealed declining shoulder mobility and new hand limitations.
Medical staff explained that contractures "develop over time" and that proper range of motion exercises, positioning, and splint application are essential for prevention. These contractures can cause pain, limit function, increase skin breakdown risk, and create potential for injury during routine care activities.
Widespread Competency Evaluation Failures
The facility employed 13 restorative nursing assistants responsible for providing specialized range of motion services, yet seven lacked any competency evaluations for their assigned duties. The six who had evaluations were assessed by a staff development director who "was not competent in the provision of RNA services."
Employee files for registered nurses showed similar deficiencies. While some nurses had general competency evaluations, none included assessments for joint mobility evaluation or splint assessment - specialized skills required for their assigned responsibilities in the restorative nursing program.
The Director of Nursing acknowledged that "13 of 13 RNAs did not have appropriate competency skills evaluations to determine whether the RNAs accurately performed their duties." This systemic failure meant the facility couldn't ensure staff were providing safe, effective care to residents with complex mobility needs.
Medication Safety and Control Violations
Beyond the mobility care failures, inspectors identified significant medication safety issues. Staff failed to obtain physician orders for medications found at residents' bedsides, including saline nasal spray and vision supplements.
More concerning were controlled substance accountability problems. Inspectors found missing doses of controlled medications for two residents with inadequate documentation and verification procedures. The facility's controlled drug records lacked required signatures from supervisory nursing staff, creating opportunities for medication diversion.
These medication control failures posed risks to residents who depend on controlled substances for pain management and other medical conditions. Inadequate oversight could result in delayed treatments or unauthorized access to potentially dangerous medications.
Medical Standards and Best Practices
Healthcare facilities must maintain rigorous competency standards for staff performing specialized medical procedures. Joint mobility assessments require understanding of normal range of motion parameters, recognition of abnormal findings, and knowledge of therapeutic interventions.
Proper splint application demands specific training in anatomical positioning, skin assessment, and monitoring for complications. Staff must understand how to adjust devices based on individual resident needs and recognize signs of improper fit that could cause injury.
Medication management requires strict adherence to verification protocols, particularly for controlled substances. Multiple staff signatures and detailed documentation create accountability systems that protect both residents and facilities from medication errors and diversion.
Potential Health Consequences
The documented training failures created multiple risks for facility residents. Improper joint mobility assessments could miss important changes in resident condition, leading to delayed interventions and progressive deterioration.
Incorrect splint application can cause pressure injuries, joint damage, and increased pain rather than therapeutic benefit. The observed skin redness and poor splint fit demonstrated these risks had already materialized for at least one resident.
Medication control failures posed risks of delayed treatments, unauthorized medication access, and potential adverse reactions from unsupervised medication use.
Regulatory Response and Facility Obligations
Federal regulations require nursing facilities to ensure staff competency through regular evaluations and training programs. The facility's own policies acknowledged these requirements but failed to implement them consistently.
The inspection classified these violations as causing "actual harm" to residents, reflecting the documented deterioration in resident condition and observed safety risks. This level of citation requires immediate corrective action and ongoing monitoring.
Healthcare facilities must maintain current competency evaluations for all staff performing specialized procedures, implement proper medication control systems, and ensure therapeutic interventions are provided safely and effectively. Resident safety depends on systematic adherence to these fundamental standards.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ararat Nursing Facility from 2024-08-09 including all violations, facility responses, and corrective action plans.
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