F-F600), was lowered from a S/S of J to a S/S of D while the facility develops a plan of correction to monitor the effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements.
Findings include:
Cross Reference
F-F609), was lowered from a S/S of J to a S/S of D while the facility develops a plan of correction to monitor the effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements.
Cross Reference
F-F610) was lowered from a S/S of J to a S/S of D while the facility develops a plan of correction to monitor the effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements.
Cross Reference
F-F656
Record review of the facility policy titled, MISSING RESIDENT/ELOPEMENTS with Revision Date 8/04 revealed the policy stated, The Unit charge Nurse is responsible for knowing the location of their residents . RESPONSIBILITY: The Charge Nurses and all other staff.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 29 255106 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255106 B. Wing 05/12/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Brandon Nursing and Rehabilitation Center 355 Crossgate Blvd Brandon, MS 39042
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689 Review of the Admission Record for Resident #5 revealed the facility admitted the resident on 5/23/23 and
the resident had diagnoses of bipolar disorder, anxiety disorder, schizophrenia, repeated falls and major Level of Harm - Immediate depressive disorder. jeopardy to resident health or safety Record review of the Annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) 4/10/25 for Resident #5 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14, which indicated Residents Affected - Few no cognitive impairment. No mood or behavioral issues were noted, including wandering or exit seeking behaviors, during the lookback period. The MDS documented she had no restraints or wander/elopement alarms in use and was able to walk with supervision only for one hundred fifty (150) feet and was at risk for falls.
Record review of the Progress Notes for Resident #5 dated 4/25/25 through 5/06/25 revealed that the resident began going to the facility front door with small bags packed with her clothes and reporting family was coming to get her on 4/25/25 after report that she sat up all night with increased confusion. According to Progress Note on 5/01/25 at 1:40 PM (13:40) by LPN #9, Resident #5 had exit seeking behaviors that included confusion about her brother being outside to get her, constant redirection away from the front entrance and walking with a bag of her belongings and the Nurse Practitioner was notified with new order noted for urinalysis and change to insulin orders with family notified. The Progress Notes dated 5/01/25 at 3:15 PM (15:15) by LPN #8 and at 3:30 PM by LPN #9 documented that the resident exited the facility unnoticed by staff and was observed by C.N.A. #9 sitting in his vehicle when the C.N.A. went on break at approximately 3:00 PM and escorted the resident back into the facility. There was no incident report noted. Progress Note dated 5/03/25 at 10:30 AM documented that Resident #5 was placed on one-on-one
observation related to elopement attempts.
Telephone interview on 5/08/25 at 1:08 PM Contact #1 for Resident #5 stated that she was notified by LPN #9 on 5/01/25 at approximately 1:30 PM that the resident had new orders for a urinalysis due to new behaviors that included wandering and making statements about leaving and again at 3:30 PM LPN #9 notified her that Resident #5 had exited the facility and was found sitting in a staff member's car in the facility parking lot.
Interview on 5/08/25 at 2:25 PM LPN #9 stated that she was familiar with Resident #5 and her care and the resident had exit seeking behaviors which included packing her belongings in bags and going to the front door of the facility and talking about leaving for several days at least since 4/24/25. She stated that she had documented her observations in the Progress Notes but had not updated the resident's care plan and there had been no orders for application of wander management device or other supervision resulting from the behavior until after the resident's elopement on 5/01/25 at approximately 3:00 PM. LPN #9 confirmed she was assigned to the care of Resident #5 on 5/01/25 during the day shift. She stated that at approximately 3:15 PM C.N.A. #9 arrived at the nurses station with Resident #5 who was wearing a short-sleeved shirt, long pants and a pair of shoes. She said C.N.A. #9 reported he had gone to his car and found Resident #5 seated in his front passenger's seat. LPN #9 said she had not known the resident had exited the facility and no one had reported the resident missing. LPN #9 confirmed that the Social Services Director was notified of
the incident as well as Contact #1 and the primary healthcare provider for Resident #5 who issued new orders for wander guard. She confirmed that she did not complete an incident report and had no request to participate in any investigation into the incident. LPN #9 said that she was not aware of any head count of residents, and she had not participated in any elopement drills since the 5/01/25 incident. She confirmed that
the Elopement Binder was missing from the Nurses Station. She confirmed upon review that there was not a Release During Pass form for Resident #5 in the Out on Pass binder at the Unit #1 Nurses' station.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 29 255106 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255106 B. Wing 05/12/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Brandon Nursing and Rehabilitation Center 355 Crossgate Blvd Brandon, MS 39042
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689 On 5/08/25 at 3:00 PM observation and record review revealed the absence of an Elopement Binder at the Unit 1 nurses' station. Resident #5's Release During Pass form was not found in the Out on Pass form was Level of Harm - Immediate not found in the Unit 1 binder. SA located the form in the binder at the Unit 4 nurses' station with jeopardy to resident health or documentation of the last time Resident #5 being signed out on 12/20/24 at 11:16 AM. safety
Interview with CNA #9 on 5/08/25 at 3:10 PM revealed that on 5/01/25 at approximately 3:15 PM he had Residents Affected - Few gone out to his car, which was parked in the first parking spot to the right upon exit from the front door. CNA #9 stated, I looked at my car and saw someone sitting in the passenger seat and thought it wasn't my car, then I realized it was my car, and I opened the drivers' door and asked, 'Mam, you in my car?' and she opened the door and said she thought it was her brother's car. I went around and helped her out and took her inside. CNA #9 reported that the weather was clear, dry and moderate temperature. He said he was not aware of any head count of residents, and he had not participated in any elopement drills since the 5/01/25 incident.
Interview with LPN #7 on 5/08/25 at 3:50 PM (the assigned Unit Manager for Resident #5 on 5/01/25 on Unit 1) stated that the procedure for a resident to leave for out on pass was that the person picking the resident up and taking responsibility for the resident had to report to the resident's nurses station and sign them out with date, time, address and telephone number, name and signature prior to exiting the building with the resident. LPN #7 said she worked at least five days a week and had never known the family or any person to sign Resident #5 out on pass. LPN #7 confirmed that Resident #5 had not had any order or application of any wander alarm device and that she had not updated the resident's care plan due to change in behavior/development of wandering/exit seeking behaviors, and that she had not been involved in a head count of residents following the elopement of Resident #5 on 5/01/25 or any investigation into how the resident exited the facility or any elopement drills since. She confirmed that the DON had assessed the resident upon return to the unit and obtained orders for and applied a Wander Guard wander management device to the resident's left ankle and initiated one-on-one supervision for seventy-two hours.
Interview with the Executive Director on 5/09/25 at 11:00 AM revealed that the facility had investigated the 5/01/25 elopement of Resident #5 on 5/08/25. The Executive Director stated that the facility did not report the incident to the State Agency because it was determined that it was not an elopement because the resident told staff that her brother was coming to pick her up. The Executive Director confirmed that the facility procedure was for any person taking a resident out on pass was required to go to the nurses' station and sign the resident out in a binder with the date and time. He said he had not been aware that Resident #5 had new wandering/exit-seeking behaviors. He stated that the facility did not have operational security cameras.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 29 255106 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255106 B. Wing 05/12/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Brandon Nursing and Rehabilitation Center 355 Crossgate Blvd Brandon, MS 39042
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689 Interview with the Social Services Director (SSD) on 5/12/25 at 11:26 AM revealed she was made aware through visual observation and interaction with Resident #5 on 5/01/25 that the resident was anxious, made Level of Harm - Immediate multiple, repeated trips to the front hall of the facility on 5/01/25 throughout the day and packing her jeopardy to resident health or belongings, but had not identified exit seeking behavior. She revealed she could clearly see that the resident safety had increased anxiety. She stated that Resident #5's behavioral changes were discussed on 4/25/25 during
a Behavioral Meeting with the resident's primary healthcare provider notified of behavioral changes that at Residents Affected - Few the time were not identified as elopement risk. She stated that on 5/01/25 she updated the Elopement Binders which were supposed to be located at each of the facility's four (4) nurses' stations and added Resident #5 but had not updated the resident's care plan with 'Focus' for elopement risk. She confirmed that there was 18 Residents identified as having wandering behaviors and at risk for elopement. She stated that a Trauma Screen was conducted for Resident #5 on 5/10/25.
Interview with the facility Receptionist on 5/09/25 at 1:36 PM revealed she manned the desk at the front entrance and had a button she pressed which released the lock on the front door to allow entrance/exit. She stated that all the other doors required, and the front door could also be opened with numeric code entered into wall-mounted keypad on the inside or outside of the doors. She stated that she was familiar with Resident #5 because the resident had developed the behavior of packing her belongings in bags and coming to the front door prior to the 5/01/25 elopement. She said that Resident #5 had come to the front entrance at least three (3) separate times on 5/01/25 talking about going out, she said that she had to call the nurses station and a C.NA came and got the resident at least twice and escorted her back to her unit. The Receptionist stated that around 3:00 PM she had taken a break and asked someone to fill in for her but that
she could not recall whom. She stated that she returned to her desk and shortly thereafter (could not recall time) and CNA #9 came in with Resident #5 and said he had found her sitting in his car in the parking lot.
She stated that she notified the Executive Director approximately five to ten minutes later. She stated that
the Executive Director checked the entrance door for proper locking on 5/01/25 following the return of Resident #5 and the locks were working correctly.
On 5/09/25 at 3:00 PM observation revealed the first parking space on the right approximately fifty-five feet from the front entrance. Observation revealed one ambulance and six other vehicles traveling through the parking lot. The sidewalk which led from the facility's front porch/portico area, along the front of the parking spaces led to a busy four lane boulevard with a speed limit of thirty-five miles per hour and no cross walks;
observation revealed one hundred twenty-five (125) vehicles traveling on the boulevard between 3:00 PM and 3:05 PM.
Record review of the local weather history according to WWW.Wunderground, Copyright The Weather Channel, for the facility for 3:00 PM on 5/01/25 revealed the temperature was eighty-one degrees Fahrenheit, with zero precipitation, eight mile per hour winds and partly cloudy.
Interview with the former DON on 5/12/25 at 4:26 PM by telephone revealed that she confirmed that she became aware that Resident #5 had exited the facility unnoticed and unsupervised on 5/01/25 at approximately 3:15 PM when C.N.A. #9 escorted the resident back into the facility. She said there was no head count done to confirm the safety of other residents, and said she was not aware of any missing resident protocol. She confirmed that the care plan for Resident #5 had not been updated for wandering or exit seeking behaviors prior to the elopement.
Removal Plan - IJ
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 29 255106 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255106 B. Wing 05/12/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Brandon Nursing and Rehabilitation Center 355 Crossgate Blvd Brandon, MS 39042
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689 The facility was informed by state agency on 05/09/2025 at 5:30 PM of 5 immediate jeopardies.
Level of Harm - Immediate The state agency provided the facility with IJ template for
F-F689. jeopardy to resident health or safety On 05/01/2025, Resident #1 exited the facility unaccompanied and unnoticed and sitting in a staff member's car with no supervision until the resident was found by staff approximately 15 minutes later. The facility failed Residents Affected - Few to implement a care plan with interventions when Resident #1 exhibited behavioral changes that included wandering and exit seeking and a history of altered mental status. The facility also failed to report the allegation of neglect within the required time frame and complete a thorough investigation.
On May 1. 2025 at approximately 2:45-3 :00 PM, a CNA walked to his car on his break and noticed a resident sitting in his passenger seat. The CNA immediately told the resident that she has to come back inside. Calmly and without hesitation, the resident stated ''okay. The CNA walked the resident back inside
the building, notified the front desk, and walked the resident to the sitting area on the unit The CNA also let Resident (Proper Name Resident #5) nurse know what happened. The front desk notified the Administrator and the DNS. The Resident was assisted to her room by the evening shift Charge Nurse. A skin assessment was completed by the DNS with no negative findings. Vital signs were obtained. Nurse Practitioner and Sister of Resident# 1 was notified. New orders received by the Nurse Practitioner to included to apply wanderguard signaling device and consult psych services. Resident was also seen by the Physician on 05/01/25 and new orders were received for UA with C&S and Novolog sliding scale change. Resident was also seen by the Psych NP on 05/02/25 and placed 1: 1.
An interview with Resident (Proper Name Resident #5) on 05/01/25 who stated that she was going outside to wait on her brother, noticed a car that looked like her brother's and got in on the passenger side to wait until
he signed her out. She stated that she exited the facility with other people and that her brother normally comes to take her out.
Corrective Actions:
The [NAME] President in-serviced the Social Services Department on 05/10/25 on ensuring that care plans and interventions are implemented for Residents with behavioral changes that verbalizing to leave the facility, exit seeking, wandering and packing belongs should be immediately assessed and elopement precautions implemented.
On 05/10/25 The Executive Director notified the Mississippi Department of Health of the incident regarding Resident # 1 exiting the facility unaccompanied and unnoticed by staff.
On 05/10/25 an audit was completed for all 18 Residents who were determined to be at risk for elopement risk to ensure accuracy of the care plan and appropriate interventions by the Director of Nurses.
On 05/10/25 a sign was placed on all exit doors reminding staff and visitors to be cautious when entering and exiting the facility in an effort to prevent Residents from leaving the facility without staff knowledge.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 29 255106 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255106 B. Wing 05/12/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Brandon Nursing and Rehabilitation Center 355 Crossgate Blvd Brandon, MS 39042
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689 The Executive Director and Director of Nurses reinterviewed Resident# 1 on 05/10/25. Resident# 1 confirmed that she exited the facility from the front door by following other people out. Resident #1 could not Level of Harm - Immediate recall how many people she followed or give a decription. jeopardy to resident health or safety Letters were mailed to family members on 05/10/25 by Social Services as a reminder to use precautions when entering and the facility in an effort to prevent Residents from exiting the facility unaccompanied or Residents Affected - Few unnoticed by staff. The letter also requested that family members notify the staff of the facility if a Resident verbalizes thoughts of the leaving the facility.
The Receptionist who vacated the front desk on 05/01/25 was in-serviced on 05/10/25 by the Executive Director to ensure that coverage is requested by another staff member prior to leaving the front desk. In addition to all routine staff who [NAME] the receptionist area was in-serviced on 05/10/25 by the Executive Director.
100% audit of elopement binders were conducted on 05/10/25 by the Social Service Department to ensure
the binders information was reflective of all Residents who are deemed as elopement risk.
An Emergency Quality Assurance Committee was held on 05/10/25 with the following staff in attendance: [NAME] President, Executive Director, Regional Director of Clincial Services, Director of Nurses (2) Assistant Executive Directors, Social Service Director, (2) Social [NAME] vice Assistants and Medical Director. The IP nurse was present by phone.
The facility completed all actions to remove the Immediate Jeopardies on 5/10/25 and alleges the IJ was removed on 5/11/25.
On 5/12/25, SA validations were made onsite during the complaint investigation through interviews and
record reviews that all corrective actions had been taken by the facility to remove the IJ and the IJ was removed on 5/11/25, prior to exit.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 29 255106 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255106 B. Wing 05/12/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Brandon Nursing and Rehabilitation Center 355 Crossgate Blvd Brandon, MS 39042
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0691 Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47873
Residents Affected - Few Based on interviews, record review and facility policy review, the facility failed to provide appropriate care and services for Resident #6's nephrostomy tube. Specifically, the facility did not perform or document any nephrostomy tube dressing changes or flushes since admission, creating a potential for infection due to improper device care. This deficient practice affected Resident #6, one (1) of two (2) nephrostomy appliances in the building.
Findings include:
Record review of facility policy Weekly Skin Audit Policy: A Skin audit will be documented on residents weekly. Any identified skin conditions will be documented and treatment initiated. Responsibility director of nursing, licensed nurses, medical records. Procedure: 1. Every resident will have a head-to-toe skin evaluation performed and documented on a weekly basis, the evaluation will be documented electronically or
on a weekly scan audit form. 5. Treatment will be initiated per the physician's orders.
Record review of the Mississippi Attorney General Nurse Review revealed a complaint received on 08/05/2024. The complainant, from (Proper Name of Local Hospital), reported that Resident # 6 was transferred from (Proper Name/Address of Facility). The allegation stated that upon presentation to the emergency room , the attending physician noted that the resident's urostomy dressing had not been changed
in 14 days. No specific date of the incident was provided in the complaint. Based upon review of the documents submitted, the allegations of criminal abuse or neglect could not be substantiated. However, the
review indicated concerns regarding the quality of care Resident # 6 received. It was recommended that the matter be reported to the Mississippi State Department of Health for further investigation. Record review of Resident #6 admission record revealed was admitted to the facility on [DATE REDACTED] with multiple diagnoses, including a urinary obstruction that required a nephrostomy tube (a tube inserted into the kidney to drain urine). The hospital discharge records and admission notes indicated the presence of a nephrostomy tube. No physician orders for specific nephrostomy tube care (such as flushing the tube or changing the dressing) were noted upon admission, and no initial care plan addressing the nephrostomy tube was developed at that time.
Record review of Resident #6's clinical record from admission through the survey date (May 2025) revealed no documentation of any nephrostomy tube dressing changes or flushes. There were no nursing notes or treatment records indicating that the nephrostomy site dressing had been changed or that the tube had been flushed to maintain patency.
On 5/08/25 at approximately 11:30 AM, an interview was conducted with an RN (Registered Nurse) responsible for Resident #6's unit. The RN stated that she had not changed the nephrostomy tube dressing or flushed the tube since the resident's admission. She explained that I didn't have any specific orders or schedule for the nephrostomy tube care, and she assumed that perhaps the wound care nurse or urology provider was managing it. The RN confirmed that no documentation existed in the resident's chart for any dressing change or flush and acknowledged it should have been done; we normally would at least change
the dressing weekly. She expressed concern that not performing these care routines could lead to infection or tube blockage.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 29 255106 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255106 B. Wing 05/12/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Brandon Nursing and Rehabilitation Center 355 Crossgate Blvd Brandon, MS 39042
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0691 On 5/08/25 at 2:15 PM, Licensed Practical Nurse (LPN) #5 was interviewed. LPN #5 had frequently cared for Resident #6. She stated that she was not aware of any care plan instructions or physician orders regarding Level of Harm - Minimal harm or the nephrostomy tube. She confirmed that during her shifts she only monitored the site visually and would potential for actual harm address it if it looked red or leaking, but otherwise did not perform routine maintenance. LPN #5 agreed that routine care (like dressing changes and flushes) should be in place to prevent complications and Residents Affected - Few acknowledged that no such guidance or documentation was present for Resident #6.
On 5/09/25 at 10:00 AM, an interview was conducted with the Director of Nursing (DON) regarding Resident #6's nephrostomy care. The DON stated that it is the facility's expectation and standard practice that any resident with an invasive device (such as a nephrostomy tube) has appropriate physician orders and nursing care routines. This includes regular dressing changes (at least weekly or more often if soiled) and periodic flushing of the tube as per physician orders or protocol, with each instance documented in the treatment record. Upon reviewing Resident #6's chart, the DON confirmed the lack of orders and documentation for nephrostomy care. She acknowledged that we should have been flushing that tube and changing the dressing on a schedule and documenting it every time. The DON described this as a failure in care and stated that staff should have contacted the physician or urology specialist upon admission to obtain orders for care if none were given. She agreed that not providing these services posed an infection control risk to
the resident.
On 5/09/25 at 11:00 AM, the facility's Medical Director was interviewed about Resident #6's nephrostomy tube management. He stated that a nephrostomy tube requires routine care and monitoring to prevent complications. The Medical Director expected the nursing staff to notify him or the consulting urologist if specific orders were needed for maintaining the tube. He expressed concern upon learning that no flushing or dressing changes had been done. The Medical Director said, According to standard care practices, a nephrostomy tube dressing should be changed regularly (e.g., at least weekly or when soiled) and the tube flushed as ordered to prevent blockage and infection. The absence of documentation suggested that these care tasks were not being performed or not recorded. He confirmed that the facility failed to follow professional standards of practice in this case, as nursing staff should proactively ensure all devices are cared for even if initial orders are missed.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 29 255106