LONGVIEW, WA - Federal inspectors found significant deficiencies in medical records management, infection control protocols, and equipment safety at Frontier Rehab & Extended Care during a February inspection, raising concerns about resident safety and quality of care.
Critical Medical Records Violations Put Vulnerable Residents at Risk
Inspectors discovered that Frontier Rehab & Extended Care failed to maintain complete and accurate medical records for residents with serious mental health conditions, potentially compromising their access to specialized care and services.
The facility's documentation failures centered on PASARR evaluations - mandatory federal assessments that determine whether residents with mental illness or intellectual disabilities require specialized services. These evaluations are crucial for ensuring appropriate placement and care coordination for vulnerable populations.
Two residents with documented mental health diagnoses faced incomplete evaluations. Resident 43, who was admitted with Depression and Post Traumatic Stress Disorder, had a PASARR Level I assessment from 2020 that identified mood disorder indicators but failed to reflect current service needs. When questioned by inspectors, the Social Services Assistant acknowledged, "We need to do a new PASARR," and was unable to locate any updated documentation in the resident's electronic health records.
Similarly, Resident 70, diagnosed with Major Depressive Disorder and Psychotic Disorder with Delusions, required a Level II PASARR evaluation for serious mental illness according to their 2023 assessment, but no such evaluation existed in their medical records. This Level II evaluation is specifically mandated for residents with serious mental illness to ensure they receive appropriate psychiatric services and treatment.
The absence of proper PASARR documentation creates significant barriers to accessing specialized mental health services, psychiatric care, and appropriate treatment planning. These assessments directly influence funding for specialized services and determine whether residents should receive care in alternative settings better equipped to handle their specific needs.
Infection Control Breakdown Threatens Disease Prevention
Federal inspectors observed a licensed practical nurse violating basic infection control protocols while providing direct patient care, potentially exposing vulnerable residents to infectious diseases and compromising facility-wide safety measures.
During the inspection, a licensed practical nurse was observed providing care to a resident under Contact Precautions without wearing required personal protective equipment. The nurse was handling the resident's arm with only gloves while attempting to locate a vein, despite clear CDC guidelines posted outside the room requiring staff to wear gowns before entering and discard them before exiting.
Contact Precautions represent a critical infection control measure designed to prevent the transmission of infectious organisms through direct contact with residents or contaminated surfaces. These protocols are particularly vital in nursing home settings where residents often have compromised immune systems and multiple chronic conditions that increase their vulnerability to infections.
The observed violation indicates a potential breakdown in staff training and compliance monitoring. When questioned, the nurse acknowledged she was "supposed to wear PPE anytime they provided care to Resident 46," demonstrating awareness of the requirement but failure to follow established protocols.
Proper infection control measures are essential for preventing healthcare-associated infections, which can lead to serious complications, extended hospitalizations, and increased mortality rates among elderly residents. The facility's administrator confirmed expectations that "staff abide by the posted precaution signs," highlighting a gap between policy and practice.
Equipment Failures Create Dangerous Transfer Situations
Perhaps most concerning were the equipment safety violations involving mechanical lifts used to transfer residents, where multiple battery failures left vulnerable individuals suspended in the air during routine care activities.
A resident reported being left suspended in mechanical lifts "numerous times" when batteries died during transfers, forcing staff to leave the room or call for assistance while the resident remained helplessly elevated between bed and chair. This dangerous situation was witnessed firsthand by inspectors, who observed a resident suspended mid-transfer for two minutes when the lift battery failed unexpectedly.
The mechanical lift violations revealed multiple systemic failures in equipment maintenance and safety protocols. Inspectors discovered lifts with wheels clogged by hair and lint, creating jerky, unstable movements during transfers that could result in falls or injuries. The Housekeeping Supervisor admitted there was "no schedule for cleaning the wheels on the mechanical lifts" and acknowledged the equipment "does need to be cleaned" only after inspection.
The Maintenance Supervisor described battery failures as an "ongoing issue," attributing problems to user error while acknowledging he performed maintenance checks randomly "when he thought of it" without maintaining proper logs. This informal approach to critical safety equipment maintenance violates fundamental healthcare facility standards and puts residents at unnecessary risk.
Mechanical lift failures pose serious safety threats to residents who depend on these devices for mobility and transfers. Falls during transfers can result in fractures, head injuries, and other trauma that can be life-threatening for elderly residents with fragile bones and underlying health conditions.
Medical Context and Industry Standards
These violations represent significant departures from established healthcare standards and regulatory requirements designed to protect nursing home residents. Medical records accuracy is fundamental to providing appropriate care, as incomplete documentation can lead to missed diagnoses, improper medication management, and inadequate treatment planning.
PASARR evaluations serve as critical gatekeeping mechanisms to ensure residents with mental illness receive specialized psychiatric services and appropriate placement. The federal requirement exists because nursing homes without specialized psychiatric capabilities may not adequately address complex mental health needs, potentially leading to behavioral crises, inappropriate medication use, and reduced quality of life.
Infection control protocols in healthcare settings follow evidence-based guidelines developed by the CDC and other leading medical organizations. Contact Precautions specifically prevent transmission of multidrug-resistant organisms and other pathogens that pose serious threats to vulnerable populations. Failure to follow these protocols can result in facility-wide outbreaks that may necessitate quarantine measures and lead to serious resident illness or death.
Equipment maintenance standards in healthcare facilities require systematic approaches to ensure patient safety devices function reliably. Mechanical lifts are considered essential safety equipment, and their failure during use creates immediate risk of serious injury. Industry standards mandate regular maintenance schedules, battery testing protocols, and staff training to prevent equipment-related incidents.
Additional Issues Identified
The inspection also documented concerns about medication administration accuracy and staff communication protocols. These additional findings reflect broader systemic challenges in maintaining comprehensive safety and quality standards throughout the facility's operations.
The combination of documentation failures, infection control lapses, and equipment safety issues suggests underlying problems with staff training, supervision, and quality assurance systems that require immediate administrative attention and corrective action.
Federal regulations require nursing homes to address identified deficiencies through comprehensive corrective action plans that demonstrate how violations will be prevented in the future and ensure resident safety and quality of care standards are maintained consistently.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Frontier Rehab & Extended Care from 2025-02-07 including all violations, facility responses, and corrective action plans.
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