BRIARWOOD HEALTH CARE CENTER
For profit - Corporation
201 Beds
LIFE CARE CENTERS OF AMERICA
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
33/100
#56 of 208 in CO
Photo by Briarwood Health Care Center
Photo by Steve Replogle
Photo by Briarwood Health Care Center
1 / 10 photos
Last Inspection: October 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Briarwood Health Care Center has received a Trust Grade of F, which indicates significant concerns regarding its quality of care. It ranks #56 out of 208 facilities in Colorado, placing it in the top half of the state, and #6 out of 21 in Denver County, meaning there are only five local options better than this facility. The trend is currently improving, as the number of issues reported decreased from four in 2024 to one in 2025. Staffing is rated 4 out of 5 stars, with a turnover rate of 45%, which is slightly below the state average, indicating that staff tend to stay longer and get to know the residents. However, the facility has incurred $33,852 in fines, which is concerning as it suggests ongoing compliance issues. Specific incidents of concern include a critical failure to maintain an infection prevention program, which puts residents at risk of communicable diseases, and serious medication management errors that resulted in a resident missing critical doses of seizure medication, leading to hospitalization. Additionally, the facility did not provide adequate support for a resident's mobility needs, failing to assess and treat conditions that could have prevented further decline. While there are strengths in staffing and an overall good star rating for quality measures, these significant deficiencies highlight serious areas for improvement.
- Trust Score
- F
- In Colorado
- #56/208
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 45% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $33,852 in fines. Lower than most Colorado facilities. Relatively clean record.
- Skilled Nurses ✓ Good
- Each resident gets 43 minutes of Registered Nurse (RN) attention daily — more than average for Colorado. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 22 deficiencies on record. Higher than average. Multiple issues found across inspections.
33/100
Top 26%
Review needed
4 → 1 violations
★★★★☆
4.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★★
5.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 4 issues
2025: 1 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
Staff Turnover: 45%
Near Colorado avg (46%)
Higher turnover may affect care consistency
Federal Fines: $33,852
Above median ($33,413)
Moderate penalties - review what triggered them
Chain: LIFE CARE CENTERS OF AMERICA
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 22 deficiencies on record
1 life-threatening 4 actual harm
Jul 2025
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0760
(Tag F0760)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure one (#5) of 12 residents reviewed for medication management...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure one (#5) of 12 residents reviewed for medication management were free from significant medication errors out of 12 sample residents. Resident #5 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis (weakness and paralysis on one side of the body) following cerebrovascular disease (a condition that affects the blood vessels in the brain) and epilepsy (seizure disorder).On 6/7/25 the facility received a delivery from the pharmacy. Licensed practical nurse (LPN) #1 signed for the delivery and did not open the box to check the contents. LPN #1 placed the box in the medication room. When LPN #1 went to administer Resident #5's Dilantin medication (a medication used to prevent seizures) on 6/20/25 and 6/21/25, she was unable to locate the medication. This resulted in Resident #5 missing three consecutive doses of Dilantin. On 6/21/25 Resident #5 was transferred to the hospital for a possible seizure. The resident was monitored with a continuous electroencephalography (cEEG) (monitors brain activity), which showed focal status epilepticus (a prolonged seizure) as well as secondary generalized seizures. The resident was treated in the hospital with anticonvulsants intravenously (IV). Specifically, the facility failed to ensure Resident #5 was given her antiseizure medication as ordered. Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 7/15/25 to 7/16/25, resulting in the deficiency being cited as past noncompliance with a correction date of 6/27/25. I. Medication error on 6/20/25 and 6/21/25On 6/7/25 LPN #1 received and signed for a delivery from the pharmacy. She did not open the box and inventory the contents. She placed the delivered box in the medication room. On 6/20/25 at 6:55 p.m. LPN #1 documented she was unable to administer Dilantin 150 milligrams (mg) due to not having the medication. On 6/21/25 at 8:21 a.m. LPN #1 documented she was unable to administer Dilantin 100 mg due to not having the medication. On 6/21/25 at 4:58 p.m. LPN #1 documented she was unable to administer Dilantin 150 mg due to not having the medication. On 6/21/25, Resident #5 was sent to the hospital for a possible seizure and treatment. On 6/22/25 it was discovered that Resident #5's Dilantin medication was in the box that was delivered by the pharmacy on 6/7/25 and was not administered to the resident as ordered. II. Facility's performance improvement planThe performance improvement plan (PIP) the facility implemented in response to Resident #5's medication errors was provided by the nursing home administrator (NHA) on 7/15/25 at 12:18 p.m. The plan documented the problem identified was three doses of Dilantin were not given to Resident #5, resulting in the resident being sent to the hospital. The plan revealed the following:A. Root cause analysisLPN #1 failed to open the medication delivery box and the medication remained in the medication room, which was not noticed by any employees and the protocol for reporting unavailable medications to the physician was not followed. B. Identification of other residentsResident #5 was transferred to the hospital when she started showing signs of seizure activity. A medication administration record (MAR) audit of all residents who received anticonvulsant medication was implemented on 6/25/25 to ensure they were all receiving their anticonvulsant medications. The audit was still ongoing for monitoring. B. Systemic changesThe director of nursing (DON) completed a verbal corrective action form with LPN #1 and educated her on the process of receiving medication deliveries from the pharmacy and the process of when a resident was missing a medication. The education was given over the phone on 6/23/25 and the form was signed on the next shift that LPN #1 worked, which was 6/26/25. The staffing development coordinator (SDC) reeducated nursing staff on proper medication handling and documentation procedures and proper notification of the physician, the DON and the unit manager (UM) when medications were not available. Nursing staff were also given handouts on medication handling, when a medication was not available and significant medication errors. All nursing staff were educated by 6/27/25. C. MonitoringThe UM would conduct a weekly MAR audit on all residents receiving anticonvulsant medications to ensure no doses were missed. The UM would turn in the audit to the DON to double-check the audit. The audit was started on 6/25/25 and was ongoing. The UM or the DON would conduct a weekly audit on medications received to ensure that the medications are put away timely. The first audit was conducted on 6/20/25 and was ongoing. The UM or the DON would audit all medication rooms to ensure received medications were not left in the medication room. The DON conducted the first audit on 6/25/25 and was ongoing. The facility's determined date of compliance was 6/27/25. III. Professional referenceAccording to [NAME], P.A., [NAME], A.G et.al,, Fundamentals of Nursing, 10th ed., Elsevier, St. Louis, Missouri, pp. 606-607, Take appropriate actions to ensure the patient receives medication as prescribed. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation 7. The right indication. IV. Facility policy and procedureThe Medication Administration policy, revised 2/13/23, was provided by the regional director of clinical services on 7/16/25 at 10:08 a.m. It read in pertinent part, Staff who are responsible for medication administration will adhere to the 10 rights of medication administration: right drug, right resident, right dose, right route, right time and frequency, right documentation, right assessment, right to refuse, right evaluation/response, right education and information.The Reordering, Changing, and Discontinuing Medication Orders policy, revised 7/1/24, was provided by the regional director of clinical services on 7/16/25 at 10:16 a.m. It read in pertinent part, Facilities are encouraged to reorder medications electronically or by fax whenever possible. Facility staff should review the transmitted re-orders for status and potential issues and pharmacy response. The facility should retain a copy of the refill/order form communicated to the pharmacy to reconcile the medications delivered by the pharmacy against what was ordered.V. Resident #5A. Resident statusResident #5, age [AGE], was admitted on [DATE]. According to the July 2025 computerized physician orders (CPO), diagnoses included hemiplegia and hemiparesis following cerebrovascular disease and epilepsy.The 6/6/25 minimum data set (MDS) assessment indicated the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of six out of 15. The assessment documented that the resident was dependent on staff for the majority of her activities of daily living (ADL). The assessment documented that the resident was taking anticonvulsant medication and had a diagnosis of epilepsy. B. Resident #5's representative interview Resident #5's representative was interviewed on 7/15/25 at 1:38 p.m. The representative said Resident #5 was receiving her medications as ordered from what he knew. The resident's representative said he assumed Resident #5 was getting her medications, as when one of her medications became unbalanced, she had to be sent out to the hospital. The representative said Resident #5 was sent to the hospital two or three weeks prior. The representative said Resident #5 had been having seizures due to an imbalance in her medications, but the resident had been fine since she was readmitted to the facility. C. Record reviewThe June 2025 CPO revealed Resident #5 had physician's orders for the following daily scheduled medications: Dilantin Infatabs Tablet Chewable 50 milligrams (mg) for seizures). Give 100 mg by mouth one time a day every Tuesday, Wednesday, Thursday, Friday, Saturday and Sunday, ordered on 9/1/23. Dilantin Infatabs Tablet Chewable 50 mg. Give 150 mg by mouth every evening shift, ordered on 9/1/23.Review of the June 2025 MAR (from 6/1/25 to 6/31/25) documented that Resident #5 did not receive the 150 mg dose of Dilantin on the evening of 6/20/25 and 6/21/25 and the 100 mg dose of Dilantin on the day shift on 6/21/25. The administration notes for each of the missed doses entered by LPN #1 documented that the Dilantin Infatabs were on order for Resident #5. A progress note, dated 6/21/25 at 9:25 p.m. revealed Resident #5 was sent to the hospital for a possible seizure. The hospital after visit summary, dated 6/24/25, documented Resident #5 was diagnosed with focal status epilepticus (a constant, unending seizure) caused by missed doses of her anti-seizure medication. The summary documented she was treated with intravenous anti-seizure medications while at the hospital and then restarted on her home medications. It was recommended that she was to take all her anti-seizure medications consistently to prevent any further seizures. The hospital Discharge summary, dated [DATE], documented Resident #5 presented from the nursing home with abnormal twitching with unclear symptoms during the transport with emergency medical services (EMS) to the hospital. The discharge summary documented Resident #5's symptoms escalated during transport to more generalized shaking, flexion and stiffness of her extremities. She was treated by EMS with 12.5 mg of Versed (a sedative that can treat seizures). Upon arrival to the emergency department at the hospital, Resident #5 was lethargic and appeared to be postictal (period immediately following a seizure). The discharge summary documented that she was treated with a Keppra (anticonvulsant medication) loading dose and neurology recommended a fosphenytoin (anticonvulsant medication) load since her level was low due to her missed doses of Dilantin. She was also given phenobarbital (anti-seizure medication) intravenously. The summary documented the resident's Dilantin level was 8.3 mcg/ml (micrograms/milliliter) which was considered low, upon her admission to the hospital. On day two of her hospital stay her focal status epilepticus resolved and she was restarted on her home medications, but she was still being monitored at the hospital. On day four she was discharged back to the nursing home. The physician progress note, dated 6/26/25, documented Resident #5 had been at her baseline since her return from the hospital. The note documented the physician went over Resident #5's medications with the unit nurse that was onsite. VI. Staff interviewsThe pharmacist was interviewed on 7/15/25 at 12:37 p.m. The pharmacist said she was not notified of the three missed Dilantin doses for Resident #5. She said the therapeutic level for Dilantin was between 10 to 20 mcg/ml. She said the half-life (the time it takes the medication to decrease by half in the blood stream) of Dilantin varied depending on how the resident metabolized the medication. She said the half-life could go down to as low as seven hours, depending on how the resident metabolized and processed the medication. She said that she would expect the facility to administer the medications per the physician's orders. LPN #1 was interviewed on 7/15/25 at 1:47 p.m. LPN #1 said she was really busy on 6/7/25 when the box was delivered from the pharmacy. She said she had only read the label on the outside of the box. She said she did not open the box and look inside. She said she was unaware that there was medication inside of the box. She said because of her mistake, Resident #5 had a seizure and went to the hospital. She said she tried to order the medication from the pharmacy before it ran out. She said when a medication ran out, she would let the pharmacy know as well as the physician. She said she thought she had let Resident #5's physician know, but she could not remember if she did. She said that she should have documented that the medication was not given and if she had contacted the physician. She said there was a button in the electronic medical record (EMR) to reorder medications. She said the pharmacy would let the facility know if the reorder was too early, had been ordered already, or if there were any other issues with the medication order. She said there was a print out at the nurses' station which would let the staff know the status of the reorder. She said when the medication was not available she documented on the MAR the code number 10, which meant the medication was on order. Registered nurse (RN) #1 was interviewed on 7/16/25 at 10:10 a.m. RN #1 said he was recently trained on receiving medication orders from the pharmacy. He said he could not remember the date that he received the education. He said when receiving a bag from the pharmacy, the contents should always be inventoried and put away in its proper area. He said a pharmacy order should never be left in the medication room unopened. He said if a medication was missing he would let the pharmacy know, the DON and the physician. He said if it was a medication that was needed right away, he would get authorization from the DON to open the emergency kit (E-kit) and use the medication from there. The DON was interviewed on 7/16/25 at 11:34 a.m. The DON said when the nurses received an order from the pharmacy they should open the box to make sure the medication was correct and put the medication in the correct place. The DON said when a medication was not in the medication cart, the nursing staff should be checking to see if the medication had been reordered and let the pharmacy know. She said that if the missing medication was one that could be found in the E-kit, they could open the E-kit and use it. She said that Dilantin was not in the E-kit and the physician should have been notified. She said Resident #5's physician was not notified of the missed doses of medication but was notified when she was sent to the hospital. She said the nurses had to use their own discretion on when to notify the physician on missed doses of medication. The DON said LPN #1 might not have realized how important it was to let the physician know because Resident #5 was also on phenobarbital (another medication used to prevent seizures). She said the facility discovered the medication was in the medication room in a box on 6/22/25. She said when LPN #1 called the pharmacy, the pharmacy told her that the medication had been delivered and that was when they started searching the facility for the medication. She said they had missed the medication in the box on 6/20/25 when they did their medication room audit because they were looking for bags of medication, not boxes. She said that since 6/27/25, when all nursing staff had been educated, the facility had not had any missed doses of antiseizure medication.
Oct 2024
4 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and review of facility policy, the facility failed to ensure two residents (Resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and review of facility policy, the facility failed to ensure two residents (Resident (R)51 and R72) out two residents observed with catheter bags out of 20 sampled residents reviewed had dignity bags for their use of a foley catheter. This failure had the potential to cause embarrassment and loss of dignity to the two residents.
Findings include:
Review of the facility's policy, provided by the facility, titled Dignity with an issued date of 05/06/19 and reviewed on 09/25/23 revealed Each resident has the right to be treated with dignity and respect. The procedure was to promote resident independence and dignity while dining and refrain from practices demeaning to the resident, such as leaving urinary catheter bags uncovered.
1. Review of R51's Face Sheet located in the electronic medical record (EMR) under the admission Record revealed R51 was admitted to the facility on [DATE].
Review of R51's annual Minimum Data Set (MDS) located in the EMR under the MDS tab with an admission Reference Date (ARD) of 04/03/23 revealed a Brief Interview of Mental Status (BIMS) score of three out of 15 which indicated severely impaired cognition. The MDS indicated R51 had an indwelling suprapubic catheter.
During an observation on 10/01/24 at 10:19 AM revealed R51's foley catheter (indwelling urinary catheter) was attached to the bed frame on the side facing the door and there was a clear plastic bag over the catheter but you could still observe the bag and urine from the resident's doorway.
2. Review of R72's Face Sheet located in the EMR under the Admission tab revealed R72 was admitted to the facility on [DATE].
Review of R72's significant change MDS located in the EMR under the MDS tab with an ARD of 08/16/24 revealed a BIMS of zero out of 15 which indicated he was unable to complete the cognition assessment. The MDS revealed that R72 had an indwelling urinary catheter.
During an interview on 10/01/24 at 12:01 PM Certified Nursing Assistant (CNA)1 confirmed the catheter bags were not covered yesterday or earlier today for R51 and R72. CNA1 stated they had the blue dignity bags today and she had placed them on R51's and 72's catheter bag. CNA1 stated the catheter bag should be covered for resident dignity and privacy.
During an interview on 10/02/24 at 10:59 AM with Licensed Practical Nurse (LPN)1 revealed a catheter bag should be covered with a privacy bag to keep it private from others to maintain the dignity of a resident. LPN1 revealed there was a master key to the supply room, on the second floor, that staff had access to and could get a blue privacy bag anytime.
During an interview with the Director of Nursing (DON) on 10/02/24 at 11:25 AM revealed catheter bags should be in a privacy bag to ensure the residents dignity.
During an interview with the Administrator on 10/02/24 at 4:30 PM revealed the catheter bag should be covered with a dignity bag to ensure a resident maintained their dignity.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to ensure four residents (Reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to ensure four residents (Resident (R) 2, R6, R30, and R41) out of a total sample of 20 residents reviewed for respiratory services received appropriate care of their oxygen tubing. This created the potential for infection.
Findings include:
Review of the facility policy titled Oxygen Administration (Safety, Storage, and Maintenance), issued 12/03/18 and revised 02/27/24 and under the sub section titled Infection Control indicated .Change oxygen supplies weekly and when visibly soiled. Equipment should be labeled with patient name and dated when set-up or changed out .
1. Review of R2's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R2 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia and dependence on supplemental oxygen.
Review of R2's Physician Orders located under the Orders tab of the EMR revealed an order for oxygen at three liters per minute (lpm), continuously, per nasal cannula and an order to change the oxygen tubing every night shift, on every Sunday.
During an observation on 10/01/24 at 1:25 PM revealed R2's oxygen tubing had no date to indicate when the tubing change was last changed.
2. Review of R6's admission Record, located under the Profile tab of the EMR, revealed R6 was admitted to the facility on [DATE] with a diagnosis of obstructive sleep apnea.
Review of R6's Physician Orders located under the Orders tab revealed an order for the titration of oxygen to keep her pulse ox (measurement of the oxygen content of the blood) over 90%, the use of Bi-pap (breathing assistance via a mask and oxygen) at night, and an order to change the oxygen tubing every night shift on every Sunday.
During an observation on 10/01/24 at 2:00 PM revealed R6 had her oxygen on and there was no date on the tubing to indicate when it had last been changed.
3. Review of R30's admission Record, located under the EMR under the Profile tab, revealed R30 was admitted to the facility on [DATE].
Review of R30's Physician Orders revealed orders for oxygen at two liters continuously per nasal cannula and an order to change the oxygen tubing and nebulizer circuit every night shift on every Sunday as per the Physician order.
During an observation on 09/30/24 at 2:46 PM and on 10/02/24 at 11:00 AM revealed R30's oxygen tubing was not dated to indicate when the last time it was changed.
4. Review of R41's admission Record, located in the EMR under the Profile tab, revealed R41 was admitted to the facility on [DATE] with a diagnosis which included chronic obstructive pulmonary disease (COPD).
Review of R41's Physician Orders revealed an order for oxygen at three liters/minute continuously per nasal cannula and an order to change the oxygen tubing and nebulizer circuit every night shift every Sunday.
During an observation on 10/01/24 at 1:50 PM indicated R41's oxygen tubing was not dated to indicate the last time it had been changed.
During an interview with the Unit Manager on 10/02/24 at 1:00 PM, the Unit Manager confirmed that the oxygen tubing for R2, R6, R30, and R41 had not been changed on the night shift on Sunday per physician's orders.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of facility policy, the facility failed to ensure weights were documented for one ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of facility policy, the facility failed to ensure weights were documented for one (Resident (R) 31) of two residents reviewed for dialysis out of a sample of 20 residents. This had the potential for the resident to have unmet care needs.
Findings include:
Review of the facility policy titled Hemodialysis Offsite Policy effective 04/24/19 and last reviewed 09/06/24 indicated that under the Procedure section revealed, the facility should weigh the resident. Under the Day of Dialysis section indicated, the facility should observe the vascular access site prior to dialysis and initiate the Pre/Post Dialysis Communication Form to be sent to the dialysis with the resident. The Day of Dialysis section indicated on return to the facility, facility staff should obtain vital signs and complete the Pre/Post Dialysis Communication Form.
Review of R31's admission Record, located in the EMR under the Profile tab, revealed R 31 was admitted to the facility on [DATE] with a diagnosis including, end stage renal disease (ESRD).
Review of the Physician Order in R31's EMR revealed an order for R31 to have dialysis on Tuesdays, Thursdays, and Saturdays.
Review of Pre/post Dialysis Communication Form located in the EMR under the Documents tab dated between 06/01/24 and 09/28/24 indicated R31's pre and post weights, which were to be done by the facility staff according to the Pre/post Dialysis Communication Forms, were not completed as follows:
06/01/24-pre and post weights
06/04/24-pre and post weights
06/06/24-pre weight
06/08/24-pre and post weights
06/11/24-pre and post weights
06/20/24-pre and post weights
06/22/24-pre and post weights
06/25/24-pre and post weights
06/27/24-post weight
07/02/24-pre weight
07/08/24- pre and post weight
07/11/24-pre and post weight
07/13/24-pre and post weight
07/18/24-pre and post weight
08/01/24-pre and post weight
08/03/24-pre and post weight
08/08/24-post weight
08/10/24-pre and post weight
08/13/24-pre and post weight
08/15/24-pre and post weight
08/17/24-pre and post weight
08/20/24-pre and post weight
08/22/24-pre and post weight
08/24/24-pre and post weight
08/31/24-pre and post weight
09/03/24-pre and post weight
09/05/24-pre and post weight
09/07/24-pre weight
09/10/24-pre and post weight
09/12/24-pre and post weight
09/14/24-pre weight
09/17/24-pre and post weight
09/21/24-pre and post weight
09/24/24-pre and post weight
09/26/24-pre and post weight
09/28/24-pre and post weight
During an interview on 10/03/24 at 2:37 PM with the Minimum Data Set Coordinator (MDSC) and the Director of Nursing (DON) both confirmed the Pre/post Dialysis Communication Records, did not contain the pre and/or post weights as listed above for R31.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and review of facility policy, the facility failed to ensure one resident (Resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and review of facility policy, the facility failed to ensure one resident (Resident (R)51) observed out of 20 sampled residents had their call light within reach. This failure had the potential to cause R51 needs to not be met .
Findings include:
Review of the facility's policy, provided by the facility, titled Keeping a Resident Room in Order, issued :08/09/2019 and reviewed 06/02/24 revealed The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and support for daily living safely, call lights must be within easy reach of the resident in bed and out of bed.
Review of R51's Face Sheet located in the electronic medical record (EMR) under the admission Record revealed R51 was admitted to the facility on [DATE] with diagnoses of cognitive communication deficit, muscle weakness, need for assistance with care, and schizophrenia.
Review of R51's annual Minimum Data Set (MDS) assessment located in the EMR under the MDS tab with an admission Reference Date (ARD) of 04/03/23 revealed a Brief Interview of Mental Status (BIMS) score of three out of 15 which indicated severely impaired cognition
Review of R51's comprehensive Care Plan with a target date of 10/20/24 located in the EMR under the Care Plan tab revealed a problem for ADL (activities of daily living) self-care deficit and one of the interventions was to encourage R51 to use the bell to call for assistance. Review of the problem for impulsiveness and impaired memory revealed an intervention was for the call light to be in reach.
During an observation on 09/30/24 at 1:20 PM revealed R51's in bed with his eyes closed and the call light was hanging on the drawers beside his bed and not in his reach.
During an observation on 10/02/24 at 3:17 PM revealed R51s was in bed with his eyes closed and his call light was on the floor behind the bed and not in the resident's reach.
During an interview on 10/02/24 at 3:17 PM with Licensed Practical Nurse (LPN)1 she confirmed the call light was on the floor and not within R51's reach. LPN1 revealed the call light should have a clip on it so it can be clipped to the blanket, and it did not have a clip. LPN1 stated R51 was able to utilize the call light.
During an interview on 10/02/24 at 4:30 PM with the Administrator revealed the call light should be in reach of the resident and not on the floor.
During an interview on 10/03/24 at 1:10 PM with the DON revealed call lights should be in reach of the residents for safety. The DON further revealed the call light should have a clip on it so it can be clipped to the bed so it would not fall on the floor. The DON stated the resident needed to be able to use the call light if he needed help.
May 2023
11 deficiencies
1 IJ
CRITICAL
(J)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Infection Control
(Tag F0880)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to establish and maintain an infection prevention and c...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.
Observations and interviews revealed the nursing staff lacked the knowledge, training, and equipment to manage the residents' routine and emergency blood glucose monitoring needs.
The facility's failure to monitor the blood glucose meters (glucometer) according to standard practice, coupled with the staff's lack of knowledge to ensure blood glucose meters were cleaned, sanitized and stored properly in between each resident's use created the situation for serious harm likely to occur at a level of immediate jeopardy if the blood glucose meters continued to be shared among residents due to potential transmission of blood-borne pathogens. One resident who shared the glucometer with another had a diagnosis of chronic viral hepatitis C (HCV, a viral infection that is spread by contact with contaminated blood).
In addition, nursing staff and student nurses failed to administer medication in a sanitary manner where hand hygiene was performed appropriately to prevent potential cross contamination during the procedure.
Findings include:
I. Immediate Jeopardy
A. Findings of Immediate Jeopardy
Blood glucose meters
The facility had six blood glucose meters, which were shared among 18 residents who required routine blood sugar checks. This included one resident who had a diagnosis of chronic viral hepatitis C.
Resident #38 had an active diagnosis of methicillin-resistant staphylococcus aureus infection (MRSA) and had been placed on enhanced barrier precautions. Resident #38 had an order for blood sugar checks before each meal and at bedtime.
Observation
During an observation on 5/4/23 beginning at 3:24 p.m. and ending at 3:50 p.m., the following was observed:
-At 3:24 p.m. registered nurse (RN) #2 used hand sanitizer and then collected the blood glucose monitor from the top drawer of the medication cart along with an alcohol swab and a lancet. RN #2 carried the supplies to Resident #79 and without donning gloves proceeded to clean the resident's finger with the alcohol swab and then used the lancet to puncture the resident's finger for the blood sample. The sample was collected into the test strip on the blood glucose monitor and the previously used alcohol swab was then used to stop the bleeding on the resident's finger.
RN #2 returned to the medication cart and disposed of the used lancet in the sharps container and placed the blood glucose monitor back in the top drawer of the medication cart without performing any cleaning or sanitation of the device and closed the drawer of the medication cart.
A few minutes later RN #2 used hand sanitizer and began collecting supplies for another blood glucose check. RN #2 opened the top drawer and removed the blood glucose monitor, an alcohol swab and a lancet. RN #2 closed the drawer and locked the cart. RN #2 did not clean or disinfect the glucometer and proceed to Resident #38's room.
RN #2 walked to the room of Resident #38 with the supplies, knocked on the door and entered the room. RN #2 asked for Resident #38's pain level; the resident expressed pain and a need for pain medications. RN #2 returned to the nurses' station to review the resident's medication orders for available pain medication orders. RN #2 consulted with RN #1(RN #1 was providing RN #2 supervision as RN #2 was a new employee and was still in orientation). After the consultation, RN #2 picked up a paper and a pen from the desk and walked over to the medication cart; RN #1 remained at the nurses station.
RN #2 logged into the computer on the medication cart and began documenting in the resident's record. RN #2 retrieved the keys to the medication cart from his pocket, unlocked the cart and returned the keys to his pocket. RN #2 did not use hand sanitizer again to clean his hands before collecting medications for Resident #38. RN #2 opened the drawer on the medication cart and removed a card of pills for Resident #38, pushed the medication out of the back of the medicine card and directly into his contaminated bare hand and then put the pills in the medicine cup.
Without any hand hygiene, RN #2 returned the pill card to the drawer in the medication cart and then closed the drawer and locked the cart. RN #2 walked back to the room of Resident #38, knocked on the door and entered the room. RN #2 gave the medication to Resident #38 and then removed the unsanitized blood glucose monitor, alcohol swab and lancet from his pocket where he had keys and other items stored. RN #2 had not performed hand hygiene as he began to perform the blood glucose check on Resident #38. The nurse began by cleaning the finger of Resident #38 and proceeded to puncture the resident's finger with the lancet and collect the blood sample onto the test strip into the device.
RN #2 returned to the medication cart and placed the blood glucose monitor on the top of the cart while he disposed of the lancet in the sharps container. RN #2 did not clean and sanitize the blood glucose monitor at any point and began to look on the computer for the third resident that needed to have their blood sugar checked. RN #2 gathered the unsanitized blood glucose device and supplies for testing the third resident's blood glucose level and without attempts to sanitize the device started to the third resident's room. RN #2 was stopped from proceeding to the third resident's room for an interview about infection control practices and procedures (see below).
Interviews
Registered nurse (RN) #2 was interviewed on 5/4/23 at approximately 3:47 p.m. RN #2 said he was in orientation with RN #1 being his mentor today. There were four residents who had orders for evening blood sugars checked. RN #2 said there were normally two glucometers on the medication cart but one of them was missing so only one was available for use. RN #2 said the blood glucose monitor was shared between the four residents in that unit. RN #2 said infection control and prevention for the medication pass included for the nurse to use hand sanitizer to clean their hands between administering medications and treatments to each resident. RN #2 said it was not appropriate to touch medications with bare hands. RN #2 said the blood glucose monitor was supposed to be cleaned in the resident's room with an alcohol pad before the blood glucose check.
RN #2 was not aware of the manufacturer's recommendations for cleaning and disinfecting the blood glucose devices provided for shared use with residents to test their blood glucose levels.
RN #1 was interviewed on 5/4/23 at 3:48 p.m. RN #1 said she was training RN #2 on the facility's clinical procedure. RN #1 said the blood glucometer device should be cleaned with the foaming hand sanitizer after each use, being careful not to get the device too wet. RN #1 was not aware of the manufacturer's recommendations for the blood glucometer.
The director of nurses (DON) was interviewed on 5/4/23 at approximately 4:05 p.m. The DON said the facility used shared glucometers and the nursing staff used Oxivir disinfectant to sanitize the glucometer devices in between each resident. The disinfectant contact time was one minute.
Further interviews with nurses from each unit on 5/4/23 revealed each nurse had a different method of cleaning the shared glucometers in between resident use.
RN #6 said the device was to be sanitized with Oxivir and ensure a contact time of one minute to kill pathogens.
Licensed practical nurse (LPN) #5 said the device was to be disinfected with [NAME] brand disinfecting wipes with a contact time of eight to 10 minutes.
RN #5 said the device was to be disinfected with an alcohol wipe and no contact time wait.
All glucometers were observed on 5/4/23 and they were all stored in the medication carts for each unit. They were not in individual storage spaces. Each blood glucose monitor was in a space shared with alcohol pads and lancets.
Facility policy and procedure
The Infection Prevention and Control Program (IPCP) and Plan, revised on 1/25/23, was provided by the nursing home administrator (NHA) on 53/23 at 11:15 a.m. The policy read in the pertinent part: The facility administration, infection preventionist, and medical director should ensure that current infection control standards of practice are based on recognized guidelines and facility assessment. These standards should be incorporated in the Infection Prevention and Control Program (IPCP).
Ensure staff follow the IPCP's standards, policies and procedures (hand hygiene and
appropriate use of PPE) while other needs are specific to particular roles, responsibilities,
and situations (injection safety and point of care testing);
Methods to reduce the risks associated with procedures, medical equipment, and medical devices . Appropriate storage, cleaning, disinfection, and/or disposal of supplies and equipment;
Applicable precautions, as appropriate, based on the following:
a. The potential for transmission
b. The mechanism of transmission.
c. The care, treatment, and services setting
The Cleaning and Disinfection of the Glucometer policy, revised 9/28/22, was provided by the DON on 5/4/23 at 5:45p.m. It read in pertinent part:
The meter should be cleaned and disinfected after use on each patient. The Assure
Prism multi Blood Glucose Monitoring System may only be used for testing multiple patients
when standard precautions and the manufacturer's disinfection procedures are followed.
The cleaning procedure is needed to clean dirt, blood and other bodily fluids off the exterior of the meter before performing the disinfection procedure.
The disinfecting procedure is needed to prevent the transmission of blood borne pathogens.
B. Facility notice of immediate jeopardy
On 5/4/23 at 7:18 p.m. the NHA was notified of the immediate jeopardy.
C. Facility plan to remove immediate jeopardy
On 5/4/23 at 8:12 p.m., the director of clinical services (DDCS) provided a plan to remove the immediate jeopardy.
The plan read:
Divisional and Regional team members for (facility name) are on-site and assisting the facility with the corrective action and management of this plan.
Super Sani-Cloth was obtained by the facility. The facility has placed an order for additional
supply and anticipates increased stock by end of day tomorrow, 5/5/23. Based on the manufacturer's guideline and facility policy and procedure, this germicidal disposable wipe is approved for use in cleaning the facility glucometers. This is the only approved disinfectant that the facility will utilize for cleaning of glucometers. If there is ever a problem with availability of the Super Sani-Cloth, the Director of Nursing (DON)/designee will determine the correct disinfect ant to be used until the Super Sani-Cloth is available and education will be provided to nurses.
A copy of the manual for the glucometer utilized in the facility was placed on each unit on 5/8/23 and nurses were informed. This manual includes cleaning and disinfecting instructions, along with approved disinfectants.
On 5/4/23, education regarding proper cleaning procedures of the glucometers and return demonstration competency was initiated immediately, including for the RN #1. 100 percent nurses currently in the facility received this education and return-demonstration competency check and this was documented. Education was provided by the DON/IP (infection preventionist)/designee(s). As of 5/8/23, all nurses except one prn nurse who has not worked in greater than three (3) weeks and one nurse who is out on leave. Education regarding proper cleaning procedures of the glucometers and return demonstration will be done with those nurses upon their return, prior to the start of their shift.
No finger stick blood glucose checks were performed until each glucometer was cleaned properly with the Super Sani -Cloth and each nurse received the education and return demonstration competency.
Nurses will receive education regarding proper cleaning procedures of the glucometers and return demonstration competency prior to the start of their shift until completed for 100 percent of nurses. This will include any agency nurses. Education was provided by the DON/IP/designee(s).
The facility Medical Director was notified of the concerns identified and of the plan of correction. A quality improvement (QAPI) meeting was held with the Medical Director via telephone on 5/4/23.
Identification of Others:
A list of residents that require finger stick blood glucose tests was created. Each glucometer in
use in the facility was identified.
Systemic Changes:
Finger stick Blood Glucose Glucometers are cleaned between each use with an Environmental Protection Agency (EPA) approved product for the correct amount of time based on manufacturer's guidelines:
-Treated surface must remain wet for recommended contact time.
-For all other contact times, refer to wipe manufacturers' instructions. Do not wrap the
meter in a wipe.
-Once contact time is complete, wipe the meter dry.
Nurses will receive education and return-demonstration competency upon hire and as needed. Education regarding proper cleaning procedures of the glucometers and return demonstration competency will be done for nurses upon hire during the skills orientation. The education and competency will remain in their education file. This education will be provided by the DON/ IP/designee(s). Nurses will not use the glucometer until the education and competency is completed and documented.
D. Removal of immediate jeopardy
The facility's plan to remove immediate jeopardy was accepted on 5/8/23 at 3:35 p.m. Record review and observations revealed the facility educated 14 nurses on the policy and proper procedure for performing cleaning and disinfection of a shared blood glucometer between use with multiple residents. On duty nurses (5/8/23) were able to provide verbal instruction on proper cleaning and disinfection with return demonstration of acceptable infection control practices when using a shared blood glucose device.
However, deficient practice remained at an E scope and severity, a pattern with the potential for more than minimal harm.
E. Additional interviews and observations
LPN #1 was interviewed on 5/8/23 at 11:25 a.m. regarding the training received on blood glucose monitor cleaning and disinfection. LPN #1 said the training was completed on 5/4/23 and that the blood glucose monitor should be cleaned with a sani-cloth wipe by scrubbing vertically three times on each side then scrubbing horizontally three times on each side and allowing it to dry for two minutes before performing the blood sugar check. LPN #1 said the device should be cleaned after each resident.
RN #3 was interviewed on 5/8/23 at 11:30 a.m. regarding the training received on blood glucose monitor cleaning and disinfection. RN #3 said the training was received and the device should be cleaned with the sani-cloth wipe by wiping three times horizontally and three times vertically on each side of the device. RN #3 said the device should be allowed to dry for two minutes before it is used on a resident. RN #3 said the device should be cleaned after each use.
RN #2 was observed on 5/8/23 at 3:11 p.m. while he prepared to perform a blood sugar check for Resident #19. RN #2 wiped each side of the blood glucose monitor vertically and horizontally three times with a sani-cloth wipe and allowed the device to dry for two minutes.
II. Failure to ensure blood glucose meters were cleaned, stored, and sanitized in a manner consistent with standards of practice
A. Professional reference
According to the Centers for Disease Control and Prevention (CDC) Injection Safety, Infection Prevention during Blood Glucose Monitoring and Insulin Administration, retrieved from https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html (5/11/23):
The CDC has become increasingly concerned about the risks for transmitting hepatitis B virus (HBV) and other infectious diseases during assisted blood glucose monitoring and insulin administration. CDC is alerting all persons who assist others with blood glucose monitoring and/or insulin administration of the following infection control requirements: Finger stick devices should never be used for more than one person.
Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared. Meters requiring preloading of the test strip may come in direct or close contact with the resident's finger stick wound. Subsequent residents can be exposed when the meter is used on them. Staff hands can become contaminated with blood that is transferred to the meter when they obtain the reading. Blood remaining on the meter can be transferred to subsequent residents through staff hands when they perform the next procedure.
According to the CDC Infection Prevention during Blood Glucose Monitoring and Insulin Administration, retrieved from https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html#anchor_1556215485 on 5/11/23,
Whenever possible, blood glucose meters should be assigned to an individual person and not be shared. If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions to prevent carry-over of blood and infectious agents.
B. Manufacturer instructions
According to Arkray USA Inc. Ark Care Technical Brief: Cleaning and Disinfecting the Assure Platinum Blood Glucose Monitoring System (BGMS) retrieved from:
https://www.arkrayusa.com/english/upload/docs/Assure%20Prism%20multi%20Cleaning%20%26%20Disinfecting%20Guide.pdfon 5/11/23.
To minimize the risk of transmitting bloodborne pathogens, the cleaning and disinfecting procedures should be performed as recommended in the instructions below.
-The Assure Prism multi BGMS is intended to be used for testing multiple patients in a professional healthcare setting when standard precautions and the manufacturer's cleaning and disinfecting procedures are followed.
-The meter should be cleaned and disinfected after use on each patient.
Cleaning and Disinfecting: The cleaning procedure is needed to clean dirt, blood and other bodily fluids off the exterior of the meter before performing the disinfecting procedure. The disinfecting procedure is needed to prevent the transmission of bloodborne pathogens. Only wipes with EPA registration numbers listed below have been validated for use in cleaning and disinfecting the meter. Any disinfectant product containing these EPA registration numbers may be used on this device.
Manufacturer recommendations for the glucometer cleaning indicated only the following wipes for use: Clorox healthcare bleach germicidal wipes, Dispatch hospital cleaner disinfectant towels with bleach, Super sani-cloth germicidal disposable wipes, and CaviWipes1.
Guidelines for cleaning and disinfecting the Assure Prism multi BGMS
-Each time the cleaning and disinfecting procedure is performed, two wipes are needed; one wipe to clean the meter and a second wipe to disinfect the meter.
-Always wear the appropriate protective gear, including disposable gloves.
-Open the disinfectant package and pull out one towelette.
-Squeeze any excess liquid out of the towelette.
-Wipe the entire surface of the meter using the towelette at least three times vertically and three times horizontally to clean blood and other body fluids from the meter.
-Dispose of the towelette.
-Repeat the above steps with a new towelette to disinfect the meter.
-Meter surfaces must remain wet according to contact times listed in the wipe manufacturer's instructions. Once complete, wipe the meter dry.
C. Facility cleaning product after immediate jeopardy
The facility used a product by PDI manufacturer, Super Sani-Cloth germicidal disposable wipes, to clean all blood glucose meter devices after the immediate jeopardy. The wipe required a two minute surface disinfectant time and was documented to be effective against non-enveloped viruses, bacteria, tuberculosis, fungi, multidrug resistant organisms and blood borne pathogens.
III. Hand hygiene failure when administering medications
A. Professional reference
According to the CDC Hand Hygiene in Healthcare Settings, last reviewed 1/30/2020, retrieved on from https://www.cdc.gov/handhygiene/providers/guideline.html on 5/11/23, Healthcare facilities should: Require healthcare personnel to perform hand hygiene in accordance with Centers for Disease Control and Prevention (CDC) recommendation.
Use an alcohol-based hand sanitizer immediately before touching a patient, before performing an aseptic task or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids or contaminated surfaces, and immediately after glove removal.
B. Facility policy and procedure
The Infection Prevention and Control Program (IPCP) and Plan, revised 1/25/23, was provided by the NHA on 5/3/23 at 11:15 a.m. The policy read in the pertinent part: Standard and transmission-based precautions to be followed to prevent the spread of infections. The hand hygiene procedures to be followed by staff involved in direct resident contact.
Interventions implemented may include the following: A facility-wide hand hygiene program that complies with CDC hand hygiene guidelines and Joint Commission National Patient Safety Goals, as warranted.
C. Observation
On 5/4/23 at 3:24 p.m. RN #1 gathered supplies for a blood glucose check. RN #1 did not wear gloves prior to performing the fingerstick for Resident #19.
At 3:31 p.m. RN #1 gathered supplies for a blood glucose check. RN #1 did not use hand sanitizer prior to collecting supplies and the RN had just finished performing a blood glucose check on a separate resident and touched the laptop and mouse prior. RN #1 did not put gloves on prior to performing the fingerstick for Resident #38 and the resident was on enhanced barrier precautions for MRSA.
On 5/8/23 at 12:40 p.m. licensed practical nurse (LPN) #1 assisted student nurses (SN #1 and SN #2) to prepare medications for Resident #19, neither student nurses performed hand hygiene prior to preparing or administering oral medications for Resident #19. The supervising LPN did not prompt the student nurses to perform any hand hygiene for the procedure.
At 2:17 p.m. LPN #1 was observed preparing medications for a resident without performing hand hygiene. Prior to gathering the medications, the LPN had been sitting at the nurses station typing on the computer and touching papers on the desk.
On 5/9/23 at 9:52 a.m. LPN #1 was observed supervising SN #1 and SN #2 while they gathered medications for a resident. Neither of the student nurses performed hand hygiene prior to collecting the medications. The supervising LPN did not prompt the nurse to perform hand hygiene during the procedure.
D. Staff interviews
The student's clinical institution instructor was interviewed on 5/9/23 at 11:25 a.m. She said the student nurses were to perform hand hygiene prior to preparing medications.
The DON was interviewed on 5/9/23 at 6:05 p.m. The DON said the student nurses were to wash their hands or use hand sanitizer prior to preparing medications and delivering resident medications, then they should wash their hands or use hand sanitizer again.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0659
(Tag F0659)
Could have caused harm · This affected 1 resident
Based on record review and interviews the facility failed to ensure the nursing services were provided by individuals who had the skills, experience, knowledge and proper licensure to meet the residen...
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Based on record review and interviews the facility failed to ensure the nursing services were provided by individuals who had the skills, experience, knowledge and proper licensure to meet the residents' needs.
Specifically, the facility failed to monitor unlicensed student nurses during medication administration with a resident.
Findings include:
I. Facility policy
A request was made to the facility for a policy regarding the use of student nurses for resident care; no policy was provided during the survey.
A signed contract agreement between a named educational institute for student nurses and the facility was provided by the director of nursing (DON) on 5/8/23 at 2:12 p.m. It read in the pertinent part:
The facility agrees to: permit (affiliate's name) students to perform services for facility patients only when under the direct supervision of a registered, licensed or certified facility caregiver licensed in the discipline in which supervision is to be provided.
Retain ultimate responsibility for the provision of all services provided to patients or residents of the facility.
II. Observations
On 5/8/23 at 12:40 p.m. licensed practical nurse (LPN) #1 permitted and assisted student nurses (SN #1 and SN #2) to prepare medications for Resident #19. The student nurse prepared oral medication (including a narcotic medication) for Resident #19. After the medications were prepared LPN #1 told the student nurses to administer the medication to the resident and return to the nurses station and sat down at the desk while two student nurses delivered a controlled medication to Resident #19 in the resident room and out of sight of LPN #1. The student nurse who handled the resident medication and passed the medication to the resident did not confirm the resident's name prior to giving the resident the cup of medications.
III. Interviews
The director of nursing (DON) was interviewed on 5/9/23 at 6:05 p.m. The DON said student nurses should be supervised by a nurse until they have completed the task enough to be checked off on it.
The education institution's clinical instructor (CI) for the student nurses was interviewed on 5/9/23 at 11:25 a.m. The CI said student nurses were to perform the six rights of medication administration when preparing and giving a resident their prescribed medications; introduce themselves in the resident's room upon arrival to the resident's room, and confirm the resident's name prior to giving the resident the medication for consumption. The CI said it was required that the student nurses be supervised by a licensed nurse during every medication pass because the student nurses had not yet earned their license to practice nursing unsupervised.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure one (#10) of one resident reviewed for activit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure one (#10) of one resident reviewed for activities of daily living of 44 sample residents were provided appropriate treatment and services to maintain or improve their abilities.
Specifically, the facility failed to ensure strategies were in place to effectively communicate with Resident #10, who spoke a language other than English.
Findings include:
I. Facility policy and procedure
The Meaningful Communication with Persons with Limited English policy and procedure, revised 2022, was provided by the nursing home administrator (NHA) on 5/9/23 at 6:02 p.m. It documented in pertinent part,
Individuals who do not speak English as their primary language and who have a limited ability to read, write, speak, or understand English may be limited English proficient (LEP). The facility will take reasonable steps to ensure that LEP residents with have meaningful access and an equal opportunity to participate in our services, activities, programs and other benefits. The policy of the facility is to ensure meaningful communication (language assistance services, qualified sign language interpreters, or auxiliary aids if hearing is impaired) with LEP residents and their authorized representatives involving their medical conditions and treatment.
All interpreters, translators and other aids needed to comply with this policy shall be provided without cost to the LEP resident being served, and patients/clients and their families will be informed of the availability of such assistance will be provided free of charge.
Language assistance will be provided through use of staff interpreters, and through formal arrangements with interpretation or translation services, or technology and telephonic interpretation services.
Some LEP residents may prefer or request to use a family member or friend as an interpreter. However, family members or friends of the LEP resident will not be used as interpreters unless specifically requested by that individual and after the LEP resident has understood that an offer of an interpreter at no charge to the person has been made by the facility. Such an offer and the response will be documented in the resident's medical record. If the LEP resident chooses to use a family member or friend as an interpreter, issues of competency of interpretation, confidentiality, privacy, and conflict of interest will be considered. If the family member or friend is not competent or appropriate for any of these reasons, competent interpreter services will be provided to the LEP resident.
II. Resident #10
A. Resident status
Resident #10, age under 65, was admitted on [DATE]. According to the May 2023 computerized physician orders (CPO), the resident's diagnoses included osteomyelitis (inflammation of bone or bone marrow, usually due to infection), cerebral infarction (ischemic stroke) and type two diabetes.
According to the 3/16/23 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for a mental status score of 15 out of 15. She required extensive assistance of two people with bed mobility and extensive assistance of one person for transfers, dressing and toileting. She preferred Spanish and required an interpreter.
B. Resident interview
Resident #10 was interviewed on 5/8/23 at 12:59 p.m. Resident #10 said most of the time staff did not use interpreters or other tools to communicate with her. Resident #10 said she did not feel like the staff was communicating with her or understanding her concerns. Resident #10 said the facility used a hotline but not often. Resident #10 said she felt frustrated and the staff did not try to communicate with her effectively which upset her.
C. Observations
On 5/3/23 observations from 11:30 a.m. until 2:30 p.m. the resident's room did not have signs indicating communication needs or interventions staff could use. The staff were not observed using the communication hotline or any other communication tools.
On 5/8/23 observations from 11:30 a.m. until 2:00 p.m. the resident's room did not have signs indicating communication needs or interventions staff could use. The staff were not observed using the communication hotline or any other communication tools.
D. Record review
The communication care plan on 4/11/23, revealed the resident has a communication problem. Resident#10 primary language was Spanish and she understood very little English. Interventions include using the communication hotline 100% of the time.
III. Staff interviews
Certified nurse aide (CNA) #6 was interviewed on 5/9/23 at 9:08 a.m. CNA #6 said Resident #10 only spoke Spanish. CNA #6 said she thought there was a hotline number the staff could use to communicate with the residents that did not speak English; posted at the nursing station. CNA #6 said she would find another CNA that spoke Spanish if she needed to communicate with her.
Registered nurse (RN) #4 was interviewed on 5/9/23 at 11:45 a.m. RN #4 said the staff used the Spanish speaking CNAs and there was a hotline number staff could use to communicate with Resident #10.
The social worker (SW) was interviewed on 5/9/23 at 2:49 p.m. She said Resident #10 spoke Spanish and understood very little English. The SW said staff could use the language hotline or a Spanish speaking staff member. The SW said staff would know to use the hotline when they were oriented to the floor.
The director of nursing (DON) was interviewed on 5/9/23 at 6:16 p.m. She said individuals who had a primary language other than English, should be provided with a communication hotline for translation purposes. The DON said the staff did use pictures for some residents and Spanish speaking CNAs. The DON said some residents refused to use the communication hotline. The DON said Resident #10 did not refuse to use the hotline.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews, the facility failed to provide appropriate care and services to maint...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews, the facility failed to provide appropriate care and services to maintain the activities of daily living for one (#54) of five residents who required extensive assistance out of 44 sample residents.
Specifically, the facility failed to provide regular nail care for Resident #54.
Findings include:
I. Facility policy
The Nail Care policy, revised August 2022, was provided by the nursing home administrator (NHA) #1 on 5/9/23 at 5:00 p.m. The policy read in part:
The resident will receive assistance as needed to complete activities of daily living (ADLs). Any concerns with skin or nails identified during completion of nail care should be reported to the nurse who will document and report to the practitioner as needed. Ensure fingernails are clean and trimmed to avoid injury and infection. Report any abnormalities to the nurse.
II. Resident #54
A. Resident status
Resident #54, age [AGE], was admitted on [DATE]. According to the May 2023 computerized physician orders (CPO), the resident's diagnoses included chronic obstructive pulmonary disease, hemiplegia (one-sided paralysis) and encephalopathy (a disease in which the functioning of the brain is affected).
According to the 3/7/23 minimum data set (MDS) assessment, Resident #54 was unable to participate in a brief interview for mental status. The MDS assessment further revealed Resident #54 required extensive assistance with one-person physical assistance for ADLs of transfers, bed mobility, toileting, dressing, eating and personal hygiene.
B. Observations
Observation on 5/3/23 at 2:30 p.m. the resident's nails were half an inch long and yellow.
Observation on 5/4/23 at 1:36 p.m. the resident's nails were half an inch long and yellow.
On 5/9/23 at 1:00 p.m. registered nurse (RN) #4 went into Resident #54's room and acknowledged that Resident #54's fingernails were very long and needed to be cut. RN #4 asked the resident if his nails could be cut. Resident #54 held up his hand and said too long and said thank you. RN #4 said the resident's nails would be cut right away.
C. Record review
The care plan reviewed 4/6/23, documented that the resident has ADL self-care performance deficit and requires assistance with bathing and dressing. Encourage the resident to participate to the fullest extent possible with each interaction.
III. Staff interviews
Certified nurse aide (CNA) #6 was interviewed on 5/9/23 at 9:08 a.m. CNA #6 said Resident #54 was easy to work with if the resident knew the staff that was working with him. CNA #6 said CNAs did not perform nail care and an outside service provided the residents' nail care.
RN #4 was interviewed on 5/9/23 at 11:45 a.m. RN #4 said Resident #54 could be difficult to work with but he worked well with preferred staff. RN #4 said CNAs did resident nail care during their baths including bed baths.
The director of nursing (DON) was interviewed on 5/9/23 at 6:16 p.m. The DON said all nursing staff were responsible for nail care. The DON said the residnet's nails should be checked anytime staff interacted with the residents. The DON said if a resident refused nail care they should ask another staff to try. The DON said resident nails should be trimmed as needed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews, the facility failed to provide an ongoing program to support resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews, the facility failed to provide an ongoing program to support residents in their choice activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for one (#9) out of three residents reviewed for activity programming out of 44 sample residents.
Specifically, the facility failed to:
-Provide meaningful activities for Resident #9 while the resident was alone in her room; and,
-Update the resident activity's and social program care plan with individualized meaningful person centered interventions to meet Resident #9's recreational needs and preferences.
Findings include
I. Facility policy and procedure
The Activities Program policy, revised on 4/1/22, was received by the director of nursing (DON) on 5/10/23 at 11:50 a.m. It read in pertinent part, The facility should implement an ongoing resident centered activities program that incorporates the resident's interests, hobbies and cultural preferences which is integral to maintaining and/or improving a resident's physical, mental, and psychosocial well-being and independence. To create opportunities for each resident to have a meaningful life by supporting his/her domains of wellness (security, autonomy, growth, connectedness, identity, joy and meaning). It is important for residents to have a choice about which activities they participate in, whether they are part of the formal activities program or self-directed.
Additionally, a resident's needs and choices for how he or she spends time, both inside and outside the facility, should also be supported and accommodated, to the extent possible, including making transportation arrangements. Individual or independent programming ensures that all residents who are unable or unwilling to participate in group programs have consistent, goal-oriented and individualized recreation opportunities. All residents have a need for engagement in meaningful activities.
Residents who prefer not to participate in group programs and/or are independently involved in recreation pursuits will be identified through the assessment process. Individual interventions will be developed based on each resident's assessed needs and the family will be notified for any special requests. The individual program will be provided according to a consistent schedule identifying specific days of the week and the time frame in which the program will occur. Each resident's individual program will include interventions that meet the resident's assessed social, emotional, physical, spiritual and cognitive functioning needs. These approaches will reflect the resident's lifestyle and interests and will be incorporated into the interdisciplinary care plan.
II. Resident #9
A. Resident status
Resident #9, age [AGE], was admitted on [DATE]. According to the May 2023 computerized physician orders (CPO), the diagnoses included unspecified mood disorder, depression and altered mental status.
The 3/30/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of four out of 15. The resident required extensive assistance of two caregivers and a mechanical lift with transfers; extensive assistance of two caregivers with dressing; and, extensive assistance of one caregiver for toilet use and personal hygiene.
It was very important for Resident #9 to have books, newspapers, and magazines to read; listen to music and attend religious services.
B. Resident observations and interview
On 5/3/23 at 11:55 a.m. Resident #9 was observed in her room, sitting up in a wheelchair. No meaningful activities were observed in the area, television was off and remote was not within reach. There were no books, newspapers, magazines or activity packets observed in the area.
On 5/8/23 during a continuous observation beginning at 12:44 p.m. and ending at 5:24 p.m. Resident #9 was observed in her room, lying in bed, with no meaningful activities observed. The television was off for most of the observation and when staff did turn the television on the resident was not offered a choice of television programming. The television remote was not within reach of the resident throughout the entire observation.
-At 12:44 p.m. staff delivered the resident lunch and left the room, the resident was not offered the opportunity to eat lunch in the dining room in the company of her peers. Resident #9 was observed lying in bed eating lunch by herself.
-At 2:03 p.m. Resident #9 began moaning loudly, licensed practical nurse (LPN) #2 entered the room and inquired about pain. Resident #9 denied pain. LPN #2 turned on the television; there was no conversation regarding channel selection or to inquire if the resident wanted to do some other activity. After turning on the television, the nurse left the room. The television remote was observed to be out of the resident's reach if the resident wanted to change the station she was unable. Resident #9 was not engaged in the television program as she laid in bed with her eyes closed.
From 2:05 p.m. to 5:29 p.m. no staff offered Resident #9 any type of recreational activities programming.
-At 5:29 p.m. staff delivered the resident's dinner tray and left the room. Resident #9 was observed lying in bed eating dinner alone in the room. The resident was not offered the opportunity to eat dinner in the main dining room with her peers. The television remained on and the remote was not within the resident's reach.
Resident #9 was interviewed on 5/8/23 at 5:45 p.m. Resident #9 said she enjoyed watching news programs and doing word puzzles. Resident #9 said she would like to get out of her room more often but was stuck in bed a lot.
-The resident's activities care plan documented the resident was to be provided a computer tablet for social and sensory stimulation (see below); observations revealed the resident did not have a tablet in her room and no staff offered the resident a tablet for use. When interviewed the resident knew what a computer tablet was but was unaware if she had access to a computer tablet for her personal use.
On 5/9/23 during a continuous observation beginning at 9:16 a.m. and ending at 12:30 p.m. Resident #9 was observed lying in bed with a breakfast tray within reach; the resident's eyes were closed and the resident was not eating. There were no meaningful activities items within the resident's reach or observed anywhere in the resident's room, the television was off and the remote was not within reach of the resident. The resident remained in bed during the observation and no staff offered the resident any type or recreational activity.
C. Record review
The 10/29/22 activities evaluation revealed Resident #9 had a career as a nurse practitioner. Past and current activities enjoyed by Resident #9 included arts and crafts, Bingo, cards, current events/news, visits from family and friends, group discussions, television, music, reading, religious services, social gatherings and volunteering.
The comprehensive care plan with a review date 2/11/23, revealed Resident #9 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to physical limitations, with a goal for Resident #9 to maintain involvement in cognitive stimulation, social activities as desired.
Interventions included: Resident #9 preferred activities were watching television and using her tablet to be online; invite Resident #9 to scheduled activities; and when Resident #9 chooses not to participate in organized activities, the resident prefers to be on her tablet for social and sensory stimulation.
Progress note dated 5/2/23 revealed Resident #9 had been agreeable to being in a reclining chair more often; wanted to work on cognition using word puzzles and games, wanted to attend movies and other activities.
Activity participation record for Resident #9 was received by activities director (AD) on 5/9/23 at 7:00 p.m. It revealed Resident #9 participated in the following:
Current event/news on 5/3/23, 5/4/23, 5/8/23 and 5/9/23. Television was turned on by staff on 5/8/23 at 2:03 p.m. it was not a current event/news program and the television was observed to be off on all other days.
-There were no other sources of current event/news activities observed in the area of Resident #9.
Family/friend visits on 5/3/23 and 5/4/23. Resident #9 was observed to be out of bed and engaged in visit on these days.
Participated in group discussion on 5/3/23 and 5/4/23. Resident #9 was involved with family/friend visits.
Participated in music on 5/3/23 and 5/7/23 and refused participation in music and group discussion on 5/4/23 and 5/8/23. No activity involving music was observed or heard in vicinity of Resident #9.
-No alternative activities to music were observed to be available for Resident #9.
Participated in reading on 5/3/23, 5/4/23, 5/8/23, and was unavailable on 5/8/23.
-Staff was not observed reading to Resident #9, nor was there any reading materials observed in her area on these days. It was unknown if alternative activities were offered.
Engaged with television watching and independent leisure daily from 5/1/23 through 5/9/23. Television was observed being turned on by a staff member on 5/8/23 at 2:03 p.m. The television was off on 5/3/23, 5/4/23, and 5/9/23.
Refused to participate in religious activities on 5/7/23.
-It was unknown if alternative activities were offered on these days.
Resident #9 refused to participate in Bingo on 5/4/23, 5/9/23 and refused to participate in an educational program on 5/8/23.
-It was unknown if alternative activities were offered on these days.
III. Staff interviews
The activities director (AD) and activities assistant (AA) were interviewed on 5/9/23 at 6:00 p.m.
The AD said Resident #9 used to enjoy listening to jazz music but longer did. The AD said Resident #9 has not used her tablet since she moved rooms months ago. The AD said activity preferences were supposed to be documented in the resident's care plan. The AD said she was behind on updating care plans to reflect current activity preferences. The AD said the activity department put together activity packets for residents to have in their rooms.
The AA said Resident #9 enjoyed having company and visiting with people, but did not want to leave her room. The AA said Resident #9 liked to watch the news, children shows, old sitcoms or mystery television. The AA said she had not seen Resident #9 use her tablet for months. The AD said residents who prefer being in their rooms should still be offered activities. Resident #9 was not on a one-to-one program even though she preferred to stay in her room.
The AD was interviewed on 9/9/23 at 7:00 p.m. The AD said participation for current events included watching television. She said participation for group discussion occurred independently by residents forming a group to talk or were facilitated by staff. She said participation in independent leisure was an activity assistant providing one-to-one activity. She said participation in a reading activity included a resident reading on their own or using an activity packet. She said activity staff were the only staff members who charted in the resident's participation log.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** II. Ensure medical orders were followed
A. Facility policy
The Anti Embolism Stocking Application policy, reviewed 9/12/22, wa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** II. Ensure medical orders were followed
A. Facility policy
The Anti Embolism Stocking Application policy, reviewed 9/12/22, was provided by the director of nursing (DON) on 5/9/23 at 3:30 p.m. It read in the pertinent part: the facility will provide anti embolism stocking application in accordance with professional standards of practice, as outlined by [NAME] through the procedure linked below.
-The [NAME] link was not provided.
B. Resident status
Resident #28, age [AGE], was admitted to the facility on [DATE]. According to the May 2023 CPO, diagnoses included major depressive disorder, delirium due to unknown physiological condition, and difficulty walking.
The 3/22/23 MDS assessment revealed the resident had severely impaired cognition as evidenced by a BIMS score of three out of 15. The resident had inattention and disorganized thinking. The resident did not present with aggressive behaviors and did not reject care. The resident was able to walk with a walker without staff assistance.
The resident needed physical assistance from one person when dressing, performing personal hygiene, bathing, and toileting.
C. Resident observations
Resident #28 was observed on 5/4/23 at 1:46 p.m. and did not have TED hose on.
Resident #28 was observed at 3:52 p.m. and did not have TED hose on.
Resident #28 was observed on 5/8/23 at 11:22 a.m. and did not have TED hose on.
Resident #28 was observed at 1:52 p.m. and did not have TED hose on.
Resident #28 was observed on 5/9/23 at 9:46 a.m. and did not have TED hose on.
D. Record review
1. Treatment orders
A review of the resident's medication and treatment administration records (MAR and TAR) revealed the following treatment order related to TED hose to the resident's lower extremities:
-Apply bilateral TED hose daily. Remove TED hose every night at bedtime.
2. Care plan
The resident's comprehensive care plan initiated on 5/1/23 revealed the resident had a care focus for complaints of feet and leg pain and edema in lower extremities with a goal of the resident to express pain relief through the review date. Interventions included anticipating the resident's need for pain relief; respond immediately to any complaint of pain; evaluate the effectiveness of pain interventions; and provide pain medications as ordered.
-However, there was no documentation for the application of TED hose to be used daily.
E. Staff interviews
LPN #1 was interviewed on 5/9/23 at 9:44 a.m. LPN #1 stated she was responsible for applying the TED house for Resident #28. LPN #1 said she had already put the TED hose on Resident #28 this morning.
-However, the observation of Resident #28 at 9:54 a.m. showed she was not wearing TED hose.
The DON was interviewed on 5/9/23 at 6:05 p.m. The DON acknowledged doctor orders should be followed; either a nurse or a certified nurse aide (CNA) were able to apply TED hose to the residents who have orders for them.
Based on record review, observations, and interviews, the facility failed to ensure two out of two residents (#2 and #28) of 44 sample residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan.
Specifically, the facility failed to:
-Provide positioning assistance and monitoring of air mattress for proper inflation for comfort and skin integrity for Resident #2; and,
-Ensure medical orders were followed for thrombo-embolic deterrent (TED) hose for Resident #28.
Findings include:
I. Proper application of an air mattress and repositioning
A. Facility policy and procedure
The Alignment and Pressure-reducing Device Application policy, with a revision date of 10/11/21, was received by the director of nursing (DON) on 5/10/23 at 12:00 p.m. it read in pertinent part,
The facility will provide alignment and pressure-reducing device application in accordance with professional standards of practice, as outlined by [NAME] through the procedure linked below (link was not made available). The services provided or arranged by the facility, as outlined by the comprehensive care plan, must meet the professional standards or care.
B. Manufacturers manual
The Direct Supply Panacea Air Advance Alternating Pressure Air Mattress manufacturer manual was retrieved from: https://store.directsupply.com/Product/Family/panacea-air-advance-alternating-pressure-air-mattress-37346 on 5/10/23. It read in pertinent part, Indications for use: The Panacea Air Advance Mattress is a flotation therapy mattress that provides pressure management to assist in the prevention and treatment of up to stage IV pressure injuries. The alternating-pressure and low air loss mode provided with the Panacea Air Advance Mattress is indicated for use as a preventive tool against further complications associated with critically ill residents or immobility.
Control unit: firmness button adjusts the pressure within the mattress; Static button allows for the alternating-pressure functionality to be turned off; alternating pressure provides 10-, 15-, 20-, 25-minute loading and unloading cycles designed to maintain low interface pressures throughout the mattress to redistribute peak interface pressures during the cycle.
This device is only a tool to assist with pressure reduction as part of an overall care plan. Failure to comply with all instructions, warnings and precautions or using the product for a purpose other than the recommended use could result in bodily injury or death. This product is not designed to replace good caregiving practices including, but not limited to: direct patient and resident supervision; adequate care plans and training for staff personnel for entrapment and fall prevention; inspection and testing before use.
This product is only one element of care in the prevention and treatment of pressure ulcers by medical professionals and skilled caregivers to assist in the treatment and prevention of up to stage IV decubitus ulcers for residents under their care. This product is not designed to and cannot replace good caregiving practices and treatment including, but not limited to: appropriate nutrition and hydration, frequent positioning, routine skin assessment, wound treatment, infection control, and other generally accepted standards of care and prevention.
Adequate training for and precautions by staff personnel for bed entrapment; selection of an appropriate bed system to use with the product and proper maintenance and use of the product; testing of the product before each use.
C. Resident status
Resident #2, age [AGE], was admitted on [DATE]. According to the May 2023 computerized physician orders (CPO), the diagnoses included multiple sclerosis, morbid obesity and major depressive disorder.
The 3/20/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. The resident required extensive assistance of two caregivers with bed mobility, transfers, dressing, and toilet use, and extensive assistance of one caregiver for eating. The resident was at risk for skin breakdown.
D. Resident interview
Resident #2 was interviewed on 5/3/23 at 3:11 p.m. She said she was unable to reposition herself because of multiple sclerosis (MS); and was dependent on staff for repositioning. The resident said she preferred to be in bed most of the day, but was often uncomfortable due to lack of regular positioning assistance; and the air mattress she laid on provided no extra comfort. Resident #2 said staff did not offer repositioning on any regular schedule and she had to call staff when she wanted to be repositioned; and she wanted to be repositioned more often than what was provided.
E. Resident observations
On 5/3/23 during continuous observation beginning at 11:30 a.m. and ending at 3:11 p.m. Resident #2 was observed lying in bed on an air mattress, positioned on her back, head of the bed was raised approximately 30 degrees. The resident was not provided any type of pillows or props to support off loading pressure points as she laid on her back. The resident's air mattress settings were observed to have an alternating cycle time of 20 minutes, but the mode was set to static (lacking in movement). Static mode deactivated the alternating-pressure function. There was no auditory evidence of air transfer to inflate or deflate the mattress (sound of pump, mattress rising or falling). The firmness indicator was one bar below maximum firmness.
At 4:57 p.m. Resident #2 was observed lying in bed, in the same positioning as in the earlier observation (see above). The air mattress setting remained the same.
On 5/4/23 p.m. at 2:30 p.m. Resident #2 was observed at scheduled group activity in a wheelchair. At 3:26 p.m. Resident #2 was assisted back to her room. At 5:38 p.m. Resident #2 remained in her wheelchair. Positioning remained the same from 3:26 p.m. to 5:38 p.m.
-Observations of the resident's air mattress revealed the brand identification tag read direct supply Panacea air advanced mattress. The inflation device located at the foot of Resident #2's bed had a visible control panel that was set the same for all observations on 5/3/23, 5/4/23, 5/8/23 and 5/9/23. The settings indicated the air mattress was set on an alternating pressure cycle time for 20 minutes, the firmness was set one bar below max inflation; however the control panel static setting was set to on. Per the manufactures manual (see above) using the static mode deactivated the alternating-pressure function.
-Facility staff were not able to explain during interviews (see below) acceptable settings for the resident's air mattress or how they would know if the mattress was functioning properly to maintain proper position for comfort and relief of pressure point to protect Resident #2 from developing pressure injuries related to poor positioning. The resident record failed to document that the mattress was assessed for proper fit and met condition to properly address the resident positioning needs see resident records above.
F. Record review
The comprehensive care plan, last review 2/23/23, revealed Resident #2 had a care focus for mobility related to a diagnosis of multiple sclerosis. The goals of the care included Resident #2 would remain free of complications or discomfort. The interventions failed to include person centered approaches to help the resident achieve comfort and avoid skin related complications.
-The use of the air mattress was care planned for risk of skin breakdown. Interventions included the mattress having alternating pressure. Staff were not provided with instructions to ensure the mattress was implemented per manufactures recommendations.
-The resident records failed to provide an assessment for the use of the air mattress or guidance on appropriate control setting based on the residents individualized needs.
The 4/29/23 Braden scale for predicting pressure sore risk and risk factors revealed Resident #2 was moderately at risk. It revealed Resident #2 had a slightly limited ability to respond meaningfully to pressure-related discomfort and could not always communicate discomfort or the need to be turned; and was unable to make frequent or significant changes independently because of limited mobility, requiring her to need moderate to maximum assistance with moving.
G. Staff interviews
Licensed practical nurse (LPN) #2 was interviewed on 5/9/23 at 11:00 a.m. LPN #2 said residents with limited mobility should be repositioned and changed every two hours. LPN #2 said Resident #2 activated her call light when she wanted to be repositioned. LPN#2 said repositioning was not documented because staff verbally communicated to one another when a resident was last assisted with positioning. LPN #2 said Resident #2 was on an air mattress but she did not know what setting the air mattress should be on.
Certified nurse aide (CNA) #5 was interviewed on 5/9/23 at 11:00 a.m. CNA #5 said residents who were dependent on staff for care were repositioned and checked for cleanliness every two hours was a standard of care. CNA #5 said she did not wake up Resident #2 for repositioning if she was asleep, and waited until Resident #2 asked to be changed or repositioned. CNA #5 said Resident #2 used an air mattress, but she did not know how to tell if it was inflated properly. The CNAs relied on the Resident #2 to tell them if she was uncomfortable and then staff would provide positioning assistance.
The minimal data set coordinator (MDSC) was interviewed on 5/9/23 at 4:30 p.m. The MDSC said Resident #2 admitted to the facility with the air mattress she was using. The MDSC said the family brought in the resident's air mattress requesting it to be used for Resident #2. The settings were already in place so they did not assess or readjust the mattress settings. The MDSC said residents with limited mobility should be repositioned and changed every two hours; a resident's repositioning needs would not be care planned because it was considered a standard of care. The MDSC said pressure ulcers were avoidable if a resident admitted without an existing pressure injury.
LPN #3 was interviewed on 5/9/23 at 6:00 p.m. LPN #3 said Resident #2 activated her call light when she wanted to be repositioned, therefore the resident was not on a repositioned schedule. LPN #2 said staff were in her room every 15 minutes checking bed inflation and repositioned Resident #2. LPN #3 confirmed the resident was on an air mattress with an electronic pump device, however the nurse did not know what settings the air mattress should be on.
LPN #3 said if the mattress was inflated and not flat it was assumed to be functioning properly.
The director of nursing (DON) was interviewed on 5/9/23 at 6:15 p.m. The DON said residents that were dependent on staff for care were repositioned and checked for incontinence every two hours. Repositioning and incontinence care were not care planned because it was a standard of care.
The DON said nursing staff or the wound care doctors would initiate the order of an air mattress and its settings. However, Resident #2 did not need an order for the use or specific setting for the air mattress she was using because Resident #2 moved into the facility with the air mattress. The DON said Resident #2 was using an alternating air mattress which when set on alternating pressure would reduce the frequency of staff needing to reposition Resident #2. The DON said the mattress inflation could be tested for appropriate inflation by staff placing a hand between the resident and the mattress, if staff felt the bed frame there needed to be more air in the mattress.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure one (#61) of two residents with limited mobi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure one (#61) of two residents with limited mobility reviewed for range of motion (ROM) and splinting application receives consistent treatment and services to increase range of motion and/or to prevent further decrease in range of motion, out of 44 sample residents.
Specifically, the facility failed to ensure Resident #61 received:
-Consistent regular restorative services as prescribed in the computerized physician's orders (CPO) and restorative nursing referral (see record review below);
-A plan for contracture management services for hand and wrist contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) to maintain the current level of function/mobility and prevent worsening of contractures; and,
-Provide consistent daily care to the resident's contracted hand to prevent potential skin breakdown, including hand hygiene and application of prescribed hand splint.
Findings include:
I. Facility policy
The Restorative Nursing Services policy, revised September 2022, provided by the nursing home administrator (NHA) on 5/9/23 at 6:15 p.m., read in pertinent part: Restorative nursing care refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning.
Restorative nursing function and procedures included range of motion, splint or brace,
assistance, bed mobility, transfers.
-Providing resident/caregiver teaching regarding the restorative care plan.
-The trained CNA (certified nurse aide) will document provided techniques per the restorative care plan in the medical record.
-The licensed nurse will conduct an evaluation on a routine basis, to include progress towards
goal and response to the program. Any changes will be documented in the medical record.
-Restorative care plan and care directives will be reviewed/revised as indicated.
II. Resident #61
A. Resident status
Resident #61, under the age of 65, was admitted on [DATE] and readmitted on [DATE]. According to the May 2023 CPO, diagnoses included quadriplegia (paralysis of all four limbs), contracture of right ankle, left ankle, right hand, left hand, left and right elbow, muscle weakness and edema.
The 3/30/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required extensive assistance from staff with bed mobility, dressing, personal hygiene, and toileting. There was no rejection of care documented.
According to the MDS assessment, the resident was receiving restorative nursing services three to four times per week.
B. Resident observations and interview
On 5/4/23 at 9:37 a.m., Resident #61 was observed lying in bed with both arms on a pillow. The resident's hands appeared contracted as evidenced by both hands being bent forward at the wrist at an approximate 90-degree angle with the fingers curled inwards causing the resident's long fingernails to rest on each palm. The resident did not have any type of hand splint or cloth palm protector on either contracted hand.
The resident was able to hold a conversation. The resident said he was not in pain and did not know where his splints were but knew he was supposed to be wearing hand splints. The resident then said even if he was in pain or needed something he was not going to call for assistance because he did not want to be a bother to the staff.
At 2:22 p.m., Resident #61 was observed laying in his reclinable wheelchair with pillows placed under both hands. The resident did not have on his prescribed hand splints or any type of protective/adaptive device to support his contracted wrists or fingers and maintain skin integrity.
Resident #61 said he had been provided splints and padded boots by the restorative aide however he did not know where they were. Resident #61 said he only received a range of motion exercises and the assistance to apply his hand splint when the restorative aide was available, which was not very often.
On 5/8/23 at 9:05 a.m., Resident #61 was observed lying in bed without his hand splint applied.
At 4:00 p.m., Resident #61 was observed without his hand splint applied.
On 5/9/23 at 10:45 a.m., Resident #61 was observed in his bed without his hand splint or any adaptive device to help prevent further deterioration of his contractures and maintain skin integrity.
C. Record review
The May 2023 CPO documented the following orders:
-Elevate both arms on pillow(s). every shift for edema and comfort, order date 2/7/23;
-Restorative program: Dining and contracture management, order date 4/11/23; and,
-Splint wearing to the right and left hand- blue and white splints daytime for six hours. Splint to prevent contractures and skin breakdown, order date 2/7/23.
The comprehensive care plan documented Resident #61 had an ADL (activities of daily living) self-care performance deficit and was at risk for impaired skin integrity. Interventions included assistance with ADLs as needed; elevate bilateral arms on pillows to decrease edema, while in bed and while in recliner or wheelchair; provide velcro boots to be on for four hours and off for four hours each day; keep hands and body parts from excessive moisture; and keep fingernails short.
The restorative care focus indicated Resident #61 had limited physical mobility with contractures to the upper extremities; with the goal that the resident would have a maximum pain level of 3 out of 10 (with 10 being the worst pain on the scale) with PROM (passive range of motion)to both upper extremities.
-The care focus failed to document interventions to achieve the resident's goal.
The visual bedside [NAME] accessible to the certified nurse aides (CNA) for the resident daily care needs documented the resident needed assistance with:
-Dressing assistance to apply hand splints to be worn during the day;
-Keeping nails short; and,
-Keeping hands and body parts from excessive moisture.
-There was no documentation in the resident's medical record to explain why the resident was not provided consistent restorative services and no record of the resident refusing any services.
-The restorative nursing notes did not document how many restorative sessions were provided per week and did not provide any documentation that Resident #61 was unable to tolerate restorative services including ROM, hand splints or the velcro boots.
-The treatment administration record (TAR) had no documentation indicating nursing staff were offering the resident of ROM or splint assistance.
III. Staff interviews
The restorative nurse aide (RNA) was interviewed on 5/9/23 at 11:03 a.m. The RNA said Resident #61 was on the restorative nursing program and was to receive ROM and splint application between two to three sessions per week. The RNA said each session provided was documented in the restorative nursing progress notes. The RNA said the floor staff had been trained to offer ROM and splint applications in between the sessions provided by the restorative aides. The splints were to be provided for six hours each day.
The RNA said the muscle tone in Resident #61's hands was very strong and if the restorative nursing program was not followed as ordered it could result in worsening of the contractures and with skin integrity issues because the more contracted the resident's hands became the harder it would be to open the resident hand to perform ROM and hand hygiene.
Licensed practical nurse (LPN) #4 was interviewed on 5/9/23 at 11:20 a.m. LPN #4 said the splint application for Resident #61 was provided by only a physical therapist (PT) or restorative nursing aide (RNA). The LPN said the splint application was necessary to prevent further decline in ROM.
The director of restorative care (DRC) was interviewed on 5/9/23 at 1:45 p.m. The DRC said the floor CNAs had been trained to offer splint application and ROM for Resident #61. The DRC said the restorative program for splint and ROM was implemented two to three times per week by the restorative aide and daily for the nursing staff. The DRC said ROM and splint application were necessary to prevent further decline in ROM and to maintain skin integrity.
The director of nursing (DON) was interviewed on 5/9/23 at 5:45 p.m. The DON said Resident #61 was dependent on staff for ADLs. The DON said Resident #61 was admitted with contractures to both the left and right hands and used a hand splint during the day and padded boots when in bed. The DON said Resident #61 was on a restorative program but the details of the order needed to be reviewed. The DON said it was important for consistent application of the splint as it prevented further decline in ROM and provided skin integrity for the resident. The DON said the splint application helped to reduce the stiffness of the resident's hands and muscles which enabled staff to perform hand hygiene for the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0712
(Tag F0712)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure timely physician visits for one (#55) of five residents rev...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure timely physician visits for one (#55) of five residents reviewed out of 44 sample residents.
Specifically, the facility failed to ensure Resident #55 was seen by the physician once every 30 days for the first 90 days following admission to the facility.
Findings include:
I. Facility policy
The Physician Services policy, reviewed 2/2/23, was provided by the clinical nurse consultant (CNC) on 5/18/23 at 11:35 a.m. It read in pertinent part: Each resident admitted to the facility is under the continuing supervision of a physician who evaluates as needed and as required by state, federal, and Joint Commission guidelines.
Every resident is visited and assessed at least once every 30 days for the first 90 days following admission, and no less than once every 60 days thereafter for the duration of their stay in the facility. Visits may be conducted by the physician or his or her alternate as often as medically necessary.
II. Resident #55
A. Resident status
Resident #55, under the age [AGE], was admitted on [DATE] and readmitted on [DATE] after a two-day visit with family for the holiday. According to the May 2023 computerized physician orders (CPO), diagnoses included multiple sclerosis, anxiety and depression.
The 3/24/23 minimum data set (MDS) revealed the resident was cognitively intact with a brief interview for mental status (BIMS) with a score of 15 out of 15. The resident required extensive assistance of one person for transfers and toilet use; and limited assistance of one staff to complete bed mobility, walking, and personal hygiene.
B. Record review
Review of Resident #55's medical record on 5/8/23 revealed:
On 11/11/22, the resident's physician spent greater than 60 minutes total on E&M (evaluation and management a non-face to face evaluation and management services) away from FTF (face to face), reviewing hospital notes, medications, vitals, labs, social history, discussing with the RN (registered nurse) therapies and established plan of care.
-There was no documentation of any in person medical exam/visit until 2/27/23 over two months after admission (see below).
On 2/27/23, Resident #55 was seen in person by a physician's assistant due to diagnosed COVID-19 on 2/25/23, and the presence of ongoing COVID-19 symptoms. The visit was initial documentation as a health and physical visit but was later changed to designation of a follow-up visit.
On 2/28/23, Resident #55 was seen in person by a physician in follow-up of hypokalemia, muscle spasms and mood.
On 3/1/23, Resident #55 was seen in person by a physician in follow-up for hypokalemia, muscle spasms and mood.
On 4/6/23, Resident #55 was seen in person by a physician in follow-up for multiple sclerosis, physical therapy, mobility and mood.
On 5/1/23, Resident #55 was seen in person by a physician's assistant in follow-up after experiencing a fall.
-The resident was admitted on [DATE], and was not seen by a physician until 2/28/23 which was greater than 90 days before the first medical visit by a physician.
-A request was made to the facility for additional medical provider visits for the resident but no other documentation was provided.
III. Interviews
The director of nursing (DON) was interviewed on 5/9/23 at 6:05 p.m. The DON said when residents admitted to the facility they were supposed to see a medical provider every 30 days for the first 90 days. The first visit should occur within 72 hours of admission.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0744
(Tag F0744)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure a resident diagnosed with dementia, received...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure a resident diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for one (#28) resident reviewed for dementia care out of 44 sample residents.
Specifically, the facility failed to address Resident #28's wandering behavior, who had a diagnosis of dementia.
Findings include
I. Facility policy and procedure
The Dementia policy, dated 8/29/22, was provided by the director of nursing (DON) on 5/10/23 at 11:50 a.m. It read in pertinent part, The facility will provide dementia treatment and services which may include, but are not limited to the following: ensuring adequate medical care, diagnosis, and supports based on diagnosis; ensuring that the necessary care and services are person-centered and reflect the resident's goals, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety; and utilizing individualized, non-pharmacological approaches to care (for example: purposeful and meaningful activities). Meaningful activities are those that address the resident's customary routines, interests, preferences, and choices to enhance the resident's well-being. Procedure: Identify, address, and/or obtain necessary services for the dementia care needs of residents; develop and implement person-centered care plans that include and support the dementia care needs, identified in the comprehensive assessment; develop individualized interventions related to the resident's symptomology and rate of progression (for example: providing verbal, behavioral, or environmental prompts to assist a resident with dementia in the completion of specific tasks); modify the environment to accommodate resident care needs.
II. Resident #28
A. Resident status
Resident #28, age [AGE], was admitted on [DATE]. According to the May 2023 computerized physician orders (CPO), the diagnoses included dementia without behavioral disturbances.
The 5/4/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of zero out of 15. She required supervision of one person with transfers, toilet use, personal hygiene, and was independent with dressing. She was independent with ambulation (walking) without an assistive device or staff assistance.
She was identified to have behavioral symptoms not directed at others such as: hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds. These behaviors were identified to significantly interfere with the resident's participation in activities or social interactions, and significantly disrupt care or living environment.
B. Observations
During a continuous observation on 5/3/23 beginning at 11:34 a.m. and ending at 12:06 p.m. Resident #28 was observed walking, unattended, throughout the unit. Resident #28 was observed stopping in the doorway of the dining room, an occupied and unoccupied resident room. At the occupied resident room, she was overheard asking where she could find a bathroom. No care staff were present.
At 2:48 p.m. Resident #28 was observed walking into room [ROOM NUMBER] with bare feet, holding a pair of shoes. No care staff were present.
At 3:25 p.m. Resident #28 was observed touching items located on a cart outside of room [ROOM NUMBER]. Items included plastic see through bad with white bandage. The cart was unattended, with no care staff present. Resident #28 then walked into room [ROOM NUMBER] and closed the door. room [ROOM NUMBER] was an unoccupied resident room. Resident #28 exited room [ROOM NUMBER] with a fake decorative plant and a package of disposable briefs. Resident #28 placed items on the couch in the common area and re-entered room [ROOM NUMBER]. No staff members were present.
At 3:47 p.m. a staff member located Resident #28 in room [ROOM NUMBER] and escorted her to the common area. No meaningful activity was provided.
-Resident #28 now resided in a different unit in the building.
On 5/8/23 at 11:27 a.m. Resident #28 was observed at nurses station opening draws, looking through items on the desk and attempting to open cabinets. Certified nurse aide (CNA) #4 informed Resident #28 that she was not allowed to be in that area. No meaningful activity was provided.
At 12:22 p.m. Resident #28 was observed at the medication cart touching a laptop computer mounted to the top of the cart. CNA #4 approached Resident #28 and offered to get a soda and walked away. Resident #28 then walked into a resident room that was not her own and asked a staff member about her daughter. Staff member redirected the resident back to the hallway and informed the resident he did not know where her daughter was. No meaningful activity was provided.
At 12:30 p.m. the medication cart was observed to be unlocked and unattended by staff, staff returned to the medication cart at 12:40 p.m. and locked it.
At 12:28 p.m. CNA #4 returned with a soda and approached Resident #28. Resident #28 declined soda and was adamant CNA #4 find her daughter. CNA #4 was unable to provide this information and walked away from Resident #28. Resident #28 was observed grabbing the arm of an empty wheelchair and shaking it back and forth, she then entered the room of another resident and took a wheelchair from the room. The owner of the wheelchair activated call light. No meaningful activity or staff engagement were observed.
During a continuous observation beginning at 1:00 p.m. and ending at 2:10 p.m. Resident #28 was observed attempting to remove a fire extinguisher from the wall, while another resident was telling her to leave it alone. CNA #4 attempted to redirect Resident #28 with having her sit to eat lunch, Resident #28 declined the suggestion and entered another resident's room. Resident #28 was instructed by a resident to leave the room. There was no staff intervention observed, no meaningful activities offered.
-At 1:37 p.m. Resident #28 was observed in the common area attempting to turn off the television. Residents who were engaged in television watching instructed Resident #28 to stop touching the television. No staff intervention was observed. Resident #28 was observed unplugging a laptop cord from the wall and was approached by activities assistant (AA) #1 and offered books. Resident #28 declined the offer of books, AA #1 walked away from Resident #28, no other staff intervened. Resident #28 was observed pulling on television cords. Resident #28 was approached by another resident and was instructed not to touch the television. Staff intervened and offered for Resident #28 to sit and eat lunch. Resident #28 declined and entered another resident's room at 1:58 p.m. and declined to exit until 2:10 p.m. No meaningful interaction or activities were provided throughout observation.
-The medication cart was left unlocked and unattended from 1:00 p.m. to 1:20 p.m.
C. Record review
The 5/2/23 elopement risk evaluation revealed Resident #28 had a diagnosis of dementia and was able to ambulate independently.
The 5/3/23 activities evaluation revealed Resident #28 had a career as a school teacher and enjoyed music, dancing, parties and being outdoors.
The 5/4/23 progress note revealed Resident #28 had a tendency to wander that led to difficulty with being cared for at home with family. The facility staff had reported Resident #28 was frequently observed wandering into other residents' rooms at the facility.
The care plan dated, 5/2/23, revealed Resident #28 was dependent on staff for meeting emotional, intellectual, physical and social needs because of impaired mental processing. Interventions included providing activities that were compatible with physical and mental capabilities; compatible with known interests and preferences; and, compatible with individual needs and abilities.
-The resident did not have a care plan to address her dementia and behaviors of wandering.
III. Interviews
The former roommate (Resident #2) of Resident #28 was interviewed on 5/3/23 at 3:11 p.m. She said Resident #28 entered her side of the room. She said because of her multiple sclerosis she could speak loudly enough to ask her to leave or move independent from the area. She said Resident #28 had approached her and covered her feet with blankets. She said she was not comfortable with Resident #28 as a roommate.
Licensed practical nurse (LPN) #2 was interviewed 5/8/23 at 11:00 a.m. She said she was not provided dementia training. She said Resident #28 was new to the facility and had difficulty locating her room consistently. She said staff redirected Resident #28 as best they could.
Certified nurse aide (CNA) #5 was interviewed on 5/8/23 at 11:00 a.m. She said she has not received dementia training at the current facility. She said Resident #28 spent most of the day walking within the unit and went into other rooms often. She said it was difficult to keep Resident #28 occupied with an activity (puzzles, books, coloring) because she preferred to walk around the unit.
The director of nursing (DON) was interviewed on 5/9/23 at 5:00 p.m. She said prior to Resident #28 moving in the family had said she frequently wandered in the home. She said Resident #28 needed time to acclimate to her new environment at the facility. She said facility staff would continue to monitor Resident #28 and implement interventions to support her.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observations and interviews the facility failed to ensure three out of four medication refrigerators stored narcotic, non-narcotic medications and biologicals in accordance with accepted prof...
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Based on observations and interviews the facility failed to ensure three out of four medication refrigerators stored narcotic, non-narcotic medications and biologicals in accordance with accepted professional standards and that only licensed staff had access to resident-prescribed medications.
Specifically, the facility failed to:
-Ensure controlled medications were in a locked storage area that was permanently secured to the refrigerator;
-Ensure the medication cart was locked when the nurse was not at the cart; and,
-Ensure food was not stored with medications.
Findings include:
I. Facility policy and procedure
The Storage and Expiration Dating of Medications policy and procedure, last revised on 7/21/22, was provided by the director of nursing (DON). It read in the pertinent part, Facility should ensure that only authorized facility staff, as defined by the facility, should have possession of the keys, access cards, electronic codes, or combinations which open medication storage areas. Authorized staff may include nursing supervisors, charge nurses, licensed nurses, and other personnel authorized to administer medications in compliance with applicable Law.
Facility should store Schedule II - V Controlled substances, in a separate compartment within the locked medication carts and should have a different key or access device.
-Store all drugs and biologicals in locked compartments, including the storage of Schedule II-V medications in separately locked, permanently affixed compartments,
-Facility should ensure that Schedule II -V controlled substances are only accessible to licensed nursing, Pharmacy, and medical personnel designated by Facility.
Facility should ensure that resident medication and biological storage areas are locked and do not contain non-medication/biological items.
Facility should ensure that food is not to be stored in the refrigerator, freezer, or general storage areas where medications and biologicals are stored.
III. Observations
On 5/8/23 from 12:30 p.m. to 1:20 p.m. during a continuous observation the medication cart on four [NAME] was unlocked and licensed practical nurse (LPN) #1 was not within direct line of sight or with the cart for at least eight minutes while she was sitting at the nurse's station working on the computer behind a half wall. Two nursing students were refilling the water pitcher for the medication cart at this time. The student nurses did not lock the cart.
From 12:31 p.m. to 1:20 p.m. Resident #284, a resident with severe cognitive deficits and diagnosed with dementia with behavioral disturbance, was wandering on the unit during the times the mediation was observed to be unlocked. Resident #284 was going into other resident rooms, opening doors, opening drawers and was touching the items on the unlocked medication cart. This resident had an observed history of continuous wandering; touching items belonging to others; and unplugging electronic devices. The resident was not easily redirected by staff when staff attempted to redirect the resident from the room of other residents; upsetting other residents; or when touching items that did not belong to this resident. (Cross referenced to F744 failure to a resident diagnosed with dementia, received the appropriate treatment and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being).
At 12:38 p.m. LPN #1 returned to the medication cart, the cart was unlocked; LPN #1 began preparing medications with the two nursing students. The nurse and the student nurses left the cart to administer the medications and left the cart unlocked.
At 12:40 p.m. LPN #1 returned to the medication cart and locked the medication cart.
At 1:11 p.m. LPN #1 returned to the medication cart to prepare resident medications and walked away from the medication cart leaving the cart unlocked. LPN #1 continued to leave the medication cart unlocked while she followed a resident down the hall attempting to get the resident to take her medications.
At 1:20 p.m. LPN #1 returned to the medication cart and locked the medication cart.
At 4:04 p.m. the four East medication room medication refrigerator was observed with LPN #6. The refrigerator contained a locked box to hold controlled medications needing refrigeration. The narcotic locked box was not permanently affixed to the refrigerator. Additionally, there were containers of yogurt stored in the medication refrigerator on the same shelf as the controlled substance medication locked box. The nurse confirmed the locked controlled substance locked box inside of the refrigerator contained controlled substance medications.
At 4:20 p.m. the two East medication room medication refrigerator was observed with LPN #2. The controlled medication box was not permanently affixed to the refrigerator. The nurse confirmed the locked controlled substance locked box inside of the refrigerator contained controlled substance medications.
At 6:50 p.m. the four [NAME] medication room medication refrigerator was observed with RN #2. The controlled medication box was not permanently affixed to the refrigerator. The nurse confirmed the locked controlled substance locked box inside of the refrigerator contained controlled substance medications.
IV. Staff interviews
LPN #6 was interviewed on 5/8/23 at 4:05 p.m. LPN #6 said the medication refrigerator should not have food stored in it and she removed the yogurt to take elsewhere.
The director of nursing (DON) was interviewed on 5/9/23 at 6:05 p.m. The DON acknowledged medication carts should be locked at all times when the nurses stepped away from the medication cart. The DON said the narcotic boxes in the refrigerators were in a locked box in a locked room and was not aware that the boxes needed to be permanently affixed to the refrigerator itself.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected most or all residents
Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate...
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Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life and resident safety.
Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to infection control and shared glucometers, quality of care and activities to meet resident needs.
Findings include:
I. Facility policy
The QAPI (Quality Assurance and Performance Improvement) Program Design and Scope policy, last reviewed on 10/24/22, was received from the nursing home administrator (NHA) on 5/9/23 at 6:45 p.m. The policy read in pertinent part: The facility will have a QAPI program that is ongoing, comprehensive and capable of addressing the full range of care and services it provides. At a minimum, the QAPI program will:
-Address all systems of care and management practices;
-Include clinical care, quality of life and resident choice;
-Utilize the best available evidence to define measure indicators of quality and facility
goals that reflect processes of care and facility operations that have been shown to be predictive
of desired outcomes for residents; and
-Reflect the complexities, unique care and services that the facility provides.
II. Review of the facility's regulatory record revealed it failed to operate a QAPI program in a manner to prevent repeat deficiencies and initiate a plan to correct
F880 Infection control
During a recertification survey on 7/25/19 F880 (infection control) was cited at a F scope and severity.
During a recertification survey on 1/14/21 F880 (infection control) was cited at an E scope and severity.
During a recertification survey on 3/15/22 F880 (infection control) was cited at an E scope and severity.
During a recertification survey on 5/9/23 F880 (infection control) was cited at an increased scope and severity for failure to maintain proper infection control procedures at a J (immediate jeopardy) level.
F684 Quality of care
During a recertification survey on 7/25/19 F684 (quality of care) was cited at a D scope and severity.
During a recertification survey on 1/14/21 F684 (quality of care) was cited at a Gscope and severity.
During a recertification survey on 3/15/22 F684 (quality of care) was cited at an E scope and severity.
During a recertification survey on 5/9/23 F684 (quality of care) was cited at a D scope and severity.
F679 Activities to meet the interests, needs of a resident(s)
During a recertification survey on 3/15/22 F679 (activities of interests) was cited at a D scope and severity.
During a recertification survey on 5/9/23 F679 (activities of interests) was cited at a D scope and severity.
III. Interview
The NHA was interviewed on 5/9/23 at 6:14 p.m. The NHA said the QAPI committee met monthly with the interdisciplinary team (IDT) and the medical director in attendance. The QAPI had identified several areas of opportunity including improvements to the activities program and an area identified and an action plan had been developed to enhance programming for residents diagnosed with multiple sclerosis.
The NHA said IDT/program managers presented trending concerns which could include infection control and resident care matters for QAPI review and from there the QAPI committee determined the need for performance improvement plans.
The division director of clinical services (DDCS) was interviewed on 5/8/23 at 10:20 a.m. The DDCS said the regional and division directors were assisting the facility (QAPI committee) with an improvement plan related to infection control.
Mar 2022
6 deficiencies
3 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0688
(Tag F0688)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure one (#58) of four residents reviewed for rang...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure one (#58) of four residents reviewed for range of motion (ROM) and mobility out of 26 sample residents received appropriate treatment and services to prevent further decrease in ROM and mobility.
Resident #58 admitted to the facility for long term care on 11/8/21 with diagnoses of muscle weakness, abnormality of gait and mobility, dysphagia (difficulty swallowing) and lack of coordination. The resident required staff assistance with activities of daily living (ADLs) and was admitted to the facility with a contracture in his right hand (as indicated by staff interviews and minimum data assessment 11/12/21). The facility failed to assess, provide services to maintain or improve his ADLs to include his swallowing function. The facility failed to assess the level of the resident's contracture and whether his hand/s had worsened during his stay at the facility. Recommendations from the restorative certified occupational therapy assistant were recommended on 2/13/22 and 2/17/22, which was three months into the resident's stay at the facility but were not initiated until after he had a decline.
Due to the facility's failures, the resident had an avoidable decline with his ADLs to include transferring, toileting, personal hygiene and dressing. In addition, per record review and staff interviews, his contractures worsened since his admission to the facility.
Furthermore, the facility failed to follow physician orders and assess the resident's swallow status in order to determine the most suitable diet and provide exercises or compensatory strategies to maintain his swallowing function; the resident had significant weight loss. Cross-reference F692 for maintaining acceptable parameters of his nutritional status.
Findings include:
I. Facility policies and procedures
A. The Managing Referrals policy and procedure, revised 12/19/16, was provided by the director of nursing (DON) on 3/15/22 at 12:04 p.m. It read, in pertinent part, Referrals made for therapy are handled in an efficient and professional manner. If (facility) is not a participating provider in the patient's insurance plan, the therapy may assist the patient in locating a provider in the area.
B. The Restorative Nursing policy and procedure, revised 8/7/21, was provided by the DON on 3/15/22 at 12:04 p.m. It read, in pertinent part, The facility is responsible for providing maintenance and restorative programs as indicated by the resident's comprehensive assessment to achieve and maintain the highest practicable outcome. To promote the resident's optimum function, a restorative program may be developed by proactively identifying, care planning, and monitoring of a resident's assessments and indicators. Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities of daily living do not diminish. Generally, restorative nursing programs can be initiated when a patient is discharged from a formalized physical, occupational, or speech rehabilitation therapy.
II. Resident status
Resident #58, age [AGE], was admitted on [DATE]. According to the March 2022 computerized physician orders (CPO), diagnoses included muscle weakness, abnormalities of gait and mobility, dysphagia (difficulty swallowing), and lack of coordination.
III. Decline in Resident #58 activities of daily living
A. 11/12/21 minimum data set (MDS) assessment
The 11/12/21 admission MDS assessment documented the resident had severe cognitive impairment with a score of four out of 15 according to the brief interview for mental status (BIMS). The resident had no behaviors or rejection of care.
The resident had functional limitations in range of motion for upper extremities on one side and lower extremities on one side. It indicated he had no swallowing trouble. Therapy and restorative programs were not coded. It indicated the resident had an active discharge plan to return to the community.
The assessment indicated the resident was extensive assistance of two staff for bed mobility, extensive assistance of two staff with transfers, extensive assistance of one staff for locomotion on the unit, extensive assistance of one staff for dressing, extensive assistance of one staff for eating, extensive assistance of one staff for toileting, and supervision of one staff for personal hygiene.
The assessment indicated that direct care staff believed the resident was capable of increased independence in at least some ADLs.
B. 2/5/22 MDS assessment
The 2/5/22 MDS assessment indicated the resident was not cognitively intact and unable to complete a brief interview for mental status. It indicated the resident's cognitive skills for daily decision making were severely impaired. It indicated no behaviors related to rejection of care.
The resident had functional limitations in range of motion for upper extremities on one side and lower extremities on one side. It indicated he had no swallowing trouble. No therapy or restorative programs were indicated on the assessment. It indicated the resident had an active discharge plan to return to the community.
The assessment indicate the resident was extensive assistance of two staff for bed mobility, total dependence of two staff for transfers, extensive assistance of one staff for locomotion on the unit, total dependence on two staff for dressing, extensive assistance of one staff for eating, total dependence of one staff for toileting and extensive of one staff for personal hygiene.
-From the initial 11/12/21, the resident had a decline in transferring from extensive assistance of two staff to total dependence of two staff; in dressing he was extensive assistance of one staff to total dependence of two staff; toileting he was extensive with one staff to total dependence of one staff; and with personal hygiene he was supervision of one staff to extensive with one staff.
IV. Resident representative interview
The resident representative was interviewed on 3/14/22 at 8:33 a.m. The resident representative said the resident was sent out to the hospital on the previous day due to fever and vomiting. He said he saw the resident and thought his contractures looked worse. He said the resident had a carrot to help with range of motion for his hands but he had not seen the resident use it and was unsure where it was. He said he was unsure if the resident had therapy services but said it was recommended by a nurse at one point. He said his family wanted to bring the resident home but since the resident's contractures had worsened, he did not think this was possible.
V. Additional record review
The activities of daily living (ADL) care plan, initiated 11/11/21, indicated ADL assistance and therapy services were needed to maintain or attain the highest level of function. Interventions included assistance with ADL as needed and therapy services as ordered.
-The care plan did not indicate services related to contracture management.
The director of therapy (DOT) provided physician orders on 3/14/22 at 4:11 p.m. The orders were for evaluation and treatment for speech therapy. The orders were dated 11/17/21. The orders were faxed to the home health care provider on 11/18/21.
The DOT provided an email exchange with the home health care provider on 3/14/22 at 4:11 p.m. The document indicated the outside therapy service provider attempted a physical therapy evaluation on or around 2/2/22 and the resident declined services.
-This was the only documentation provided regarding the resident being provided therapy services. In addition, staff interviews indicated the resident did not refuse care and in addition the restorative certified occupational therapist was able to provide services on 2/13/22 and 2/17/22 (see below).
The restorative progress notes were reviewed. The notes were documented by the restorative certified occupational therapist assistant (COTA):
A restorative progress note from 2/13/22 indicated therapist monitored contractures. It indicated attempts had been made to provide therapy services. The note indicated the resident had a palm guard and may be able to work up to using a carrot.
A restorative progress note from 2/17/22 indicated the therapist measured upper and lower extremity contractures to establish a restorative nursing program for two times a week. The note indicated initial measurements and education provided to the resident on passive range of motion. It indicated the resident used a palm guard.
-The initial measurements were taken on 2/17/22 of his left and right wrist indicating that they were both contracted, when the resident was admitted to the facility on [DATE] with only one contracted hand (see staff interviews).
-No other restorative progress notes were provided to indicate that he was receiving restorative treatment two times a week as indicated on the 2/17/22 progress note. In addition, the restorative COTA was unavailable for interview during the survey.
Review of March 2022 CPO revealed the following:
-Physical therapy evaluation and treatment as indicated one time only for contracture management for upper and lower extremities ordered on 3/7/22.
-Occupational therapy evaluation and treatment as indicated one time only for contracture management for upper and lower extremities ordered 3/7/22.
The director of therapy (DT) provided the speech therapy evaluation and plan of treatment on 3/15/22 at 2:00 p.m. The evaluation indicated the resident had mild oropharyngeal dysphagia (swallowing problems occurring in the mouth and throat). Recommendations included to continue with puree texture and thin liquids. Carryover of swallowing techniques included alternating liquids and solids, modification of size of bite, using tongue to clear oral cavity, upright position for all meals, and monitoring signs and symptoms of aspiration including coughing and throat clearing, changes in respiratory symptoms, and fever.
-The speech therapy evaluation was completed on 3/15/22 despite the initial referral for evaluation on 11/17/21(cross-reference F692).
VI. Staff interviews
Licensed practical nurse (LPN) #3 was interviewed on 3/10/22 at 2:49 p.m. She said when a resident required therapy services, orders were inputted into the resident's electronic health record. She said Resident #58 had recently had orders placed for therapy services.
The DOT was interviewed on 3/14/22 at 4:11 p.m. He said Resident #58 was not on the therapy caseload because there were issues with the resident's insurance. He said Resident #58 was admitted to the facility with orders for physical and occupational therapy for contracture management in November 2021. He said he sent this referral to the home health care provider to be handled. He said the therapy team at the facility could not provide services due to insurance constrictions. He said he had documentation that Resident #58 declined physical therapy services from the home health care provider in February 2022. He said Resident #58's contractures had worsened during this time and he needed restorative services. He said the restorative staff was able to see the resident in February 2022 and made a plan, though typically residents were seen by therapy prior to a restorative plan. He said Resident #58 also had orders for speech therapy but the home health care provider said they did not have a speech therapist.
The DON was interviewed on 3/17/22 at 10:17 a.m. She said Resident #58 was coughing during meals and a swallowing evaluation with a speech-language pathologist was recommended. She said she was unsure of the dates. She said the DOT would be responsible for the follow up and would have more information.
The DOT was interviewed again on 3/15/22 at 10:40 a.m. He said restorative staff took measurements of the contractures in February 2022 but there were no contracture measurements at admission. He said he believed Resident #58 had declined since admission and needed a lot more assistance with ADLs. He said Resident #58 had not been seen by the speech-language pathologist for swallowing difficulties and would be seen that day.
LPN #3 was interviewed again on 3/15/22 at 11:44 a.m. She said Resident #58 required a lot of assistance. She said she had worked at the facility for two months and during that time he had contractures. She said she could not speak to whether the contractures had worsened.
Certified nurse aide (CNA) #2 was interviewed on 3/15/22 at 12:10 p.m. She said Resident #58 had always required a lot of assistance. She said initially his right hand was more contractured, but now both hands were contracted. She said he sometimes coughed during meals and when she helped assist him with eating. She said he did not refuse care.
The MDS coordinator (MDSC) was interviewed on 3/15/22 at 1:43 p.m. She said if contractures were observed at the initial MDS assessment, she would notify the therapy department so they could monitor. She said at the initial assessment, Resident #58 required extensive assistance with ADL involving bed mobility, transfers, locomotion on unit, dressing, and eating and required set up assistance for personal hygiene. She said at his quarterly assessment on 2/5/22, Resident #58 required extensive and total assistance for ADL involving bed mobility, transfers, locomotion on unit, dressing, and eating and extensive assistance with personal hygiene which indicated a decline with personal hygiene.
-However, the resident had more decline than just in personal hygiene, the resident had decline in transferring, dressing and toileting (refer to MDS assessment 2/5/22).
She said Resident #58 was motivated to get strong because he wanted to go home and live with family. She said the family no longer believed Resident #58 would be able to discharge home due to the level of care needed.
The DON was interviewed on 3/15/22 at 2:40 p.m. She said Resident #58 was recently seen by restorative services. She said she did not know if the residents' contractures had worsened since admission and that therapy typically measures contractures. She said if a resident had contractures there should be a contracture care plan. She said she was unsure if Resident #58 had a care plan related to his contractures. She said it had been challenging to work with the resident's insurance in order to get rehabilitation services.
-However, the facility was aware of what limitations, medical diagnoses and the insurance the resident had in order to provide him with assistance with his care when he was admitted to the facility for long term care. The facility failed to provide the care and services needed to maintain his current functioning in order to avoid decline with his ADLs, swallowing function and contractures.
VII. Facility follow-up
The nursing home administrator (NHA) provided additional documentation on 3/16/22 at 12:48 p.m. The documentation indicated Resident #58 came from a rehabilitation facility without orders for physical or occupational therapy at admission. It indicated an attempt for a physical therapy evaluation was completed around 2/2/22 and Resident #58 declined the evaluation. It also noted the restorative COTA had worked with the resident on range of motion. Included in this documentation was the email exchange with the home health care provider that indicated Resident #58 declined physical therapy services and copies of progress notes from the restorative COTA. The documentation also indicated the restorative COTA provided education to staff on contracture management for Resident #58.
-However, there was no formal documentation of the education to the staff on contracture management. In addition, there was no additional documentation submitted regarding restorative or therapy that was not included (refer to additional record review).
The primary care physician was interviewed on 3/23/22 at 2:20 p.m. He said he was aware Resident #58 had contractures on both right and left hands. He said the resident's contractures had worsened since admission but he did not know the severity. He said he did not know if the resident was receiving any services for his contractures.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure the environment was free of accidents and hazards and failed...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure the environment was free of accidents and hazards and failed to provide adequate supervision and assistance to prevent an accident for one (#25) of four out of 26 sample residents.
Resident #25 had a known history of elopement and wandering behaviors. Resident #25 often verbalized she was looking for something in attempts to leave the unit. The facility failed to implement measures to ensure her safety with her wandering, attempting to leave the unit and history of elopement. Resident #25 was assisted on 2/23/22 by a male resident to the elevator at around 9:45 p.m. where he reported to staff he sent the resident down on the elevator. The facility staff began looking for her on the unit and other units. About an hour and 15 minutes later, Resident #25 was found in the boiler room in the basement of the facility. When Resident #25 was found at 11:00 p.m. she had complaints of right arm pain, a large hematoma was located on her elbow and her right shoulder was noted to droop. Resident #25 was sent to the hospital for evaluation and treatment.
Due to the facility's failures, Resident #25 had wandered off her unit and was found in the facility's boiler room, where she had an unwitnessed fall and sustained a fracture to the right humeral head (shoulder) requiring hospital care.
Findings include:
Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 3/9/22 to 3/15/22, resulting in the deficiency being cited as past noncompliance with a correction date of 2/24/22.
I. Facility policies and procedures
A. The Missing Residents/Actual Elopement Event policy and procedure, revised 4/22/21, was provided by the director of nursing (DON) on 3/15/22 at 12:04 p.m. It read in pertinent part, Residents will be assessed for unsafe wandering and elopement indicators upon admission, readmission, change in condition, quarterly and with any unsafe wandering or elopement event. During the admission and readmission process, a care plan will be initiated by the admitting nurse on any residents assessed with unsafe wandering or elopement behaviors.
B. The Fall Management policy and procedure, revised 8/2/21, was provided by the DON on 3/15/22 at 12:04 p.m. It read in pertinent part, The facility will assess the resident upon admission/readmission, quarterly, with change in condition, and with any fall event for any fall risks and will identify appropriate interventions to minimize the risk of injury related to falls. Implement interventions, including adequate supervision, consistent with the resident's needs, goals, care plan, and current professional standards of practice in order to eliminate or reduce the risk of an accident. Monitor the effectiveness of the interventions and modify the interventions as necessary, in accordance with current professional standards of practice.
II. Resident status
Resident #25, age [AGE], was admitted on [DATE] and readmitted from the hospital on 2/24/22. According to the March 2022 computerized physician orders, diagnoses included dementia, delirium, wandering, and arthritis.
The 1/7/22 minimum data set (MDS) assessment indicated the resident had a severe cognitive impairment with a brief interview for mental status score of seven of 15. The resident required one person assistance for locomotion on and off the unit. It indicated both walker and wheelchair were used for mobility. It indicated the resident did not have behaviors including wandering. It indicated the resident had not had any falls since the last MDS assessment on 11/1/21.
III. Resident observations and interview
Resident #25 was interviewed on 3/9/22 at 10:20 a.m. Resident #25 was sitting on her bed watching television. A sling was visible on her right arm. She said she broke her arm recently when she had a fall. She pointed out the window when asked where she fell. She said she was in constant pain because of the fall but the nurses helped her manage the pain.
On 3/9/22 at 12:30 p.m. Resident #25 was observed walking out of room using her four wheeled walker with a sling on her right arm. Licensed practical nurse (LPN) #3 redirected the resident back to her room and to use her wheelchair when out of her room.
On 3/15/22 at 11:49 p.m. Resident #25 was observed sitting in her wheelchair in the dining area. Resident #25 was watching television.
IV. Record review
The elopement care plan, revised on 10/20/2020, was reviewed on 3/10/22. It indicated Resident #25 would search for her dog or parents and displayed exit seeking behavior. Interventions included addition of the resident to the elopement board at reception, completing elopement risk assessments, frequent monitoring by staff, and use of visual barriers.
The 1/2/22 fall risk assessment indicated the resident did not have a fall within the past 90 days. It indicated the resident ambulated with problems, with device and maintained position as required. Her score was marked at 16 with ten being a score in which fall interventions should be in place.
The fall care plan, revised on 1/7/21, indicated Resident #25 had a history of falls with risk factors including: unsteady gait, wandering, and wakefulness during night. Interventions included assist Resident #25 to bed, anticipate needs, and orient to room.
The 2/2/22 elopement risk assessment indicated Resident #25 ambulated independently, had a history of elopement, wandered, and became agitated when diverted from exits. It indicated the resident was not at risk for elopement.
-However, based on the resident's risk factors of ambulating independently, history of elopement, wandered, and became agitated when diverted from exits, she should have been at risk for elopement since she was care planned for it since 10/20/2020 (see elopement care plan above).
Progress notes were reviewed for behaviors and falls from the past six months and revealed the following:
-On 12/23/21 a progress note indicated Resident #25 was confused in the hallway and asked staff to call family. It was noted the resident had not slept in 48 hours and the physician was notified. The resident was redirected to bed.
-On 1/13/22 a progress note indicated Resident #25 was verbally aggressive towards staff and repeatedly asked about her family. Staff members redirected. It noted Resident #25 had a history of wandering and often attempted to leave the floor by getting on the elevator.
-On 1/14/22 a progress note indicated Resident #25 was verbally aggressive towards staff. It noted she repeatedly attempted to get on the elevator and staff redirected her.
Progress notes from 2/24/22 were reviewed. The progress notes indicated that on 2/23/22, Resident #25 was assisted onto the elevator by a male resident and went down to the basement around 9:45 p.m. She was found at 11:00 p.m. in the boiler room, located in the basement, with complaints of right arm pain. A large hematoma was located on her elbow and her right shoulder was noted to droop. She was sent to the emergency room for evaluation and the physician and family were notified. The progress notes indicated the resident returned from the hospital on 2/24/22 and was lethargic, confused, and had a sling on her right arm.
The Abuse/Adverse event investigation was provided by the DON on 3/14/22 at 11:30 a.m.
It indicated the event, fall with injury, occured on 2/23/22 at 9:45 p.m. The incident was described by staff in the report. It noted Resident #25 was assisted onto the elevator by another resident and went to the basement. The other resident told staff that he sent the resident down on the elevator. The staff then began to search the unit for Resident #25 and later moved to other units. A licensed practical nurse (LPN) went to the basement and located Resident #25 in the boiler room. She was holding her right arm. Resident #25 was sent to the hospital. The investigation included notes for training that occured after the incident related to missing persons and audits for checks of the locks on doors in the basement initiated after the event. The report indicated stop signs were ordered to be placed on elevators (see facility observations below).
Included in the Abuse/Adverse event investigation were audits of the basement doors for 2/23/22-3/1/22. The audits indicated all locks in the basement were in working order and locked during these dates during both morning and evening. Documentation also included all staff in service regarding missing persons. The training covered the urgency of finding missing residents with 12 follow-up questions related to the process for monitoring, reporting, and finding missing residents. The notes indicated this training was initiated on 2/24/22.
The hospital notes from 2/24/22 were provided by the DON on 3/15/22 at 4:33 p.m. The notes indicated a fracture to the right humeral head (shoulder) and no abnormalities were observed in the head and the spine. She was given a sling for her right arm and discharged with follow-up to orthopedics as well as an order for hydrocodone-acetaminophen 3-325 milligrams every eight hours for pain related to right arm.
The 2/24/22 elopement risk indicated the resident was recently readmitted from the hospital, ambulated independently, had a history of elopement, wandered, and became agitated when diverted from exits. It indicated the resident was a risk for elopement. Interventions in the assessment included the same interventions marked in the elopement care plan (see below).
The 2/24/22 fall risk assessment, completed at readmission, indicated a fall within the last 90 days. It indicated the resident ambulated without problems with devices and maintained position as required. Her score was marked as 13 with ten being a score in which fall interventions should be in place.
-However, the resident had an unwitnessed fall on 2/23/22 where she sustained a fracture so she was at an increased fall risk. On 1/2/22 she was marked with a score of 16 and now after her fall she was scored lower with a score of 13.
The social services director (SSD) provided behavior tracking forms on 3/15/22 at 2:45 p.m. The form indicated target behaviors of cussing at staff, exit seeking, yelling, and excess wakefulness. The form was dated for 10/31/2020 to 11/28/2020. A request for more recent documentation was made. The SSD provided additional documentation on 3/15/22 at 3:05 p.m. This included a behavior tracking form for March 2022. Target behaviors were listed as verbal aggression, wandering, and crying.
-The tracking form did not denote any behaviors for the month.
V. Facility observations and interviews
Velcro stop signs were observed on the outside of the elevators on the unit where Resident #25 resided on 3/9/22 at 11:42 a.m. The sign was stretched across the elevator door frame. At 12:20 p.m., a staff member exiting the elevator asked LPN #3 why there was a stop sign. LPN #3 said it was for a male resident and Resident #25.
For the remainder of the survey, until 3/15/22, the signs were not placed across the elevator door frame but hanging off to the side. The DON indicated the stop signs were implemented at night (see interview below).
The basement was observed on 3/11/21 at 3:56 p.m. All doors were labeled and locked except for the employee break room.
VI. Staff interviews
The DON was interviewed on 3/14/22 at 4:53 p.m. She said staff that have been at the facility for years know Resident #25 well. She said Resident #25 had a history of wandering and looking for a white truck, her dogs, or her husband. The DON said when Resident #25 was looking for these things, staff would give Resident #25 a cold soda and snack and keep watch of her.
The DON said on 2/23/22, Resident #25 was up and had stated she was looking for something. The DON said the certified nurse aide (CNA) that was working that night was unfamiliar with Resident #25 and did not know Resident #25's statement was indicative of elopement or wandering behavior. She said one CNA left the floor to take out the trash which left one other CNA and a nurse on the floor. The DON said around 9:50 p.m. the CNA was approached by a male resident who said he had sent Resident #25 down on the elevator because she was lost. The DON said the male resident had dementia so staff was unsure how accurate his statement was. The staff on the unit began to look for Resident #25 on the unit first and later began to search other floors since the male resident stated he helped Resident #25 onto the elevator. The DON said she was notified via phone at 10:40 p.m. and she asked the staff to report it as a missing person. The DON said the staff searched on all floors and outside. She said a licenced practical nurse (LPN) found Resident #25 in the boiler room with her walker. She said she was found about 10-20 minutes after she was called. She said Resident #25's hair turban and glasses were on the floor which indicated she may have fallen. She said Resident #25 was sent to the hospital because staff suspected she broke her arm.
The DON said immediately after the event they began to educate staff on missing persons and all doors in the basement were checked. She said several doors in the basement were found to have broken locks and they were replaced by 2/24/22. The DON said she ordered stop signs to be placed on the elevator doors and they arrived on 3/10/22. She said they were to be used at night. She said she was unsure what could be done to ensure the male resident did not assist other residents off the floor in the elevator.
Licensed practical nurse (LPN) #3 was interviewed on 3/15/22 at 11:44 a.m. She said Resident #25 would wander in the hallway and ask where her room or family was. She said she would redirect the resident. She said there was no set protocol on what to do besides redirect the resident. She said Resident #25 ambulated in her wheelchair since the fall because her balance was not as strong. She said she had not eloped since the accident. She said there is a behavior book on the unit to track behaviors. She said she did not use the book and instead marked behaviors in the resident's electronic health record.
Certified nurse aide (CNA) #2 was interviewed on 3/15/22 at 12:10 p.m. She said Resident #25 would wander on the unit but usually did not want to leave the floor. She said she had received training on how to redirect the resident. She said the resident did not have triggers that would indicate elopement. She said the resident had not eloped since her accident because she would mostly be in her wheelchair.
The DON was interviewed again on 3/15/22 at 2:40 p.m. She said would expect the care plan to be updated following an event such as a fall or elopement. She said she was unsure if Resident #25's care plan was updated and would follow up. She said when Resident #25 was first admitted she had numerous behaviors and was hard to redirect. She said the behaviors had been stable. She said her behaviors included wandering, verbal aggression, and weepiness. She said wandering was not necessarily a behavior but it needed to be monitored. She said the plan for Resident #25 was for her to move to a secured unit following her surgery. She said Resident #25 was not wandering in the unit and was using a wheelchair to ambulate. She said the facility did not have a wanderguard system.
The DON was interviewed again on 3/15/22 at 3:22 p.m. She said Resident #25's care plan was not updated following the event.
The DON said the staff focused on external factors that led to the event such as audits of the locks in the basement and training on missing persons. She said Resident #25 will transition to a locked unit after her surgery.
VII. Facility follow-up
The DON provided additional information on 3/15/22 at 4:33 p.m. It included orders from the nurse practitioner from 3/14/22. It noted the orthopedic consultation was reviewed and indicated a severely displaced right humeral fracture with a plan to proceed with surgery in one week. It included orders for preoperative lab work to be completed.
The nursing home administrator (NHA) provided the quality assurance and performance improvement plan for the 2/23/22 event on 3/16/22 at 3:57 p.m. after facility exit on 3/15/22.
It indicated corrective actions taken post event (2/23/22-2/24/22) included:
-Resident #25 was assessed by a registered nurse (RN) and sent to hospital;
-Interviewed all staff on duty regarding the event;
-Reviewed camera footage for timeline of events;
-Contacted resident's nurse practitioner to discuss secure placement and orthopedic follow up;
-Contacted the elevator company to inquire about having a code to go to basement level;
-Audit of basement doors completed and locks replaced;
-Stop signs ordered for elevator doors; and,
-Training provided to staff regarding missing persons.
The plan indicated the facility will monitor the changes (start date of 2/24/22 and completion date of 3/31/22) by:
-Audit tool for basement doors to ensure the doors are locked daily;
-Elopement drills four times a year; and,
-Audits of at risk binder at the front desk to be completed monthly for six months.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0692
(Tag F0692)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed ensure one (#58) of five out of 26 sample residents re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed ensure one (#58) of five out of 26 sample residents received the care and services necessary to meet their nutrition needs and to maintain their highest level of physical well-being.
Resident #58 admitted to the facility for long term care on 11/8/21 with diagnosis of malnutrition and dysphagia (swallowing trouble). The resident had a BMI of 16.6 (underweight being 18.5 or less) when he was admitted to the facility, which indicated he was underweight. The resident had a loose fitting bottom denture causing chewing difficulty. According to the registered dietitian, she was aware the resident had weight loss prior to being admitted to the facility. The resident was at nutritional risk due to previous weight loss, malnutrition and with swallowing trouble. According to the resident's primary care physician, the resident had sustained weight loss but had increased intake when he ate with his family or had the food the family brought in for him, in addition had ordered speech therapy and a modified barium swallow study for his swallowing problems. A nutritional supplement was ordered for the resident but was not evaluated when the resident had sustained significant weight loss. Remeron was ordered on 1/28/22 to promote the resident's appetite, however, the resident started losing weight 2/27/22. The resident had an order for weekly weights that were not consistently obtained. The interdisciplinary team failed to comprehensively address the resident's weight loss, ongoing nutritional risk and swallowing function in order to maintain the parameters of his nutritional status.
Observations revealed the food the resident representative brought in was in the refrigerator for the resident to eat, however it was not offered to him consistently. The resident representative had been bringing in food and snacks for the resident since early January 2022.
Due to the facility's failures, the resident sustained a 9.5 pound weight loss, which was 10.1% since his admission to the facility in November 2021 with a current BMI of 14.9 (underweight).
Furthermore, the resident was not offered speech therapy to address his swallowing problems to offer the least restrictive diet, exercise and compensatory strategies for his swallowing function. The resident was sent to the hospital on 3/13/22 for pneumonia and urinary tract infection. Cross-reference F688 due to the resident's decline in mobility, swallowing function and worsening contractures.
Findings include:
I. Facility policies and procedures
A. The Modified Texture Diets and Hydration policy, revised 10/18/21, was provided by the director of nursing (DON) on 3/15/22 at 12:04 p.m. It read, in pertinent part, As the resident's swallowing/chewing ability changes, the diet can be progressed or regressed based on an assessment of the resident by a Speech/Language Pathologist (SLP). In case the SLP is not available, Nursing may downgrade a diet until the SLP has an opportunity to assess.
B. The Hydration and Nutrition policy, revised 7/14/21, was provided by the DON on 3/15/22 at 12:04 p.m. It read, in pertinent part, An ongoing assessment of the ability to consume and assimilate food and fluid is conducted by nursing personnel and all concerns are reported to the nurse, to include: positioning needs, environmental and social consideration, ability of resident to feed self, ability of resident to chew, drink and swallow, amount of food lost in spillage, nutritional balance or imbalance of intake, weight loss or gain, signs of dehydration. Consultation with dietary and therapy personnel is performed on admission and as needed.
II. Resident status
Resident #58, age [AGE], was admitted on [DATE]. According to the March 2022 computerized physician orders (CPO), diagnoses included dysphagia (difficulty swallowing), malnutrition, and kidney failure.
The 2/5/22 minimum data set (MDS) assessment indicated the resident was not cognitively intact and unable to complete a brief interview for mental status. It indicated the resident's cognitive skills for daily decision making were severely impaired. It indicated the resident required extensive assistance for activities of daily living, including one person assistance for eating. It indicated the resident did not have difficulty swallowing and did not lose 5% of weight over the past month or 10% over the past six months. The MDS indicated the resident was on a mechanically altered diet. It indicated the resident did not have broken, loose, or partial dentures as well as no discomfort or pain with chewing food. He did not have any behaviors or rejection of care.
III. Resident interview
Resident #58 was interviewed on 3/9/22 at 2:48 p.m. He was tired and spoke in short sentences and answered yes/no questions. He said he had recent weight loss and that it sometimes hurt to swallow. He also said the food was usually good and he sometimes received snacks. He said his family brought food for him.
IV. Resident representative interview
The resident representative was interviewed on 3/10/22 at 9:07 a.m. The resident representative said Resident #58 had lost weight while he had been at the facility. He said he brought in homemade food weekly, since January 2022, because Resident #58 said he did not like the food. The resident representative said he also brought in snacks for Resident #58 though he was unsure if the staff provided these snacks to the resident. He said Resident #58 only wore his top dentures because the bottom ones did not fit and that it could make the resident's chewing difficult.
The resident representative was interviewed again on 3/14/22 at 8:33 a.m. The resident representative said he was concerned because he was notified on 3/12/22 that Resident #58 had a fever and was vomiting and staff thought he had aspirated (had food or liquid go into lungs). He said Resident #58 was sent to the hospital on 3/13/22 in order to be assessed and have a chest x-ray and labs completed. He said the staff at the hospital said Resident #58 was dehydrated, malnourished, and had pneumonia. The resident representative said Resident #58 informed him that he did not always receive feeding assistance from staff. The resident representative said he was unsure if Resident #58 had a swallow assessment since he was admitted but knew he was initially on a ground diet texture and was downgraded to puree. He said Resident #58 returned to the facility on 3/13/22 and was not admitted to the hospital. He said brought homemade food to be provided to Resident #58 on 3/13/22.
V. Observations
Resident #58 was observed in the unit dining room on 3/10/22 at 12:21 p.m. Certified nurse aide (CNA) #5 was beside the resident and provided feeding assistance. At 12:56 p.m. Resident #58 ate 50% of his meal which consisted of puree meat, vegetable, and mashed potatoes and drank 12 ounces of coffee. The meal ticket was not sent up with the tray and CNA #5 was unable to report what specifically was on the tray. The meal did not consist of any additional items that were provided by the resident's representative.
Tray line was observed on 3/14/22 at 11:32 a.m. Resident #58's meal was plated at 12:13 p.m. The meal consisted of puree chicken, broccoli, and rice. The meal was plated from the steam table. The meal did not consist of any additional items that were provided by the resident's representative.
Resident #58 was observed in his room on 3/14/22 at 12:35 p.m. CNA #4 entered the room with the lunch meal and provided feeding assistance. CNA #4 finished providing assistance at 1:08 p.m. CNA #4 said he ate about 50% of his meal and drank 24 ounces of water. She said she was unsure what the puree meal was. She said Resident #58 required total assistance for meals and needed assistance with drinking because he had contractures.
On 3/14/22 at 2:16 p.m. the homemade meals from Resident #58's representative were observed in the walk-in refrigerator located in the main kitchen. Ten containers of puree meals were observed. Dietary aide (DA) #1 said the resident's representative provided food the resident liked and it was prepared and sent to the unit in conjunction with the regular meal for both lunch and dinner. She said it was the cooks' responsibility to send it and she was unsure why it was not sent on that day.
VI. Record review
The March 2022 weights revealed the following:
-93.6 lbs. on 11/9/21
-94.4 lbs. on 11/23/21
-90.6 lbs. on 12/7/21
-81.9 lbs. on 1/11/22
-80.5 lbs. on 1/16/22, 13.1 lbs. weight loss, 14.0% over two months
-85.0 lbs. on 1/24/22
-86.3 lbs. on 2/13/22
-83.2 lbs. on 2/27/22
-83.2 lbs. on 3/2/22
-84.1 lbs. on 3/10/22, 9.5 lbs weight loss, 10.1% since admission over four months.
-The resident had an order for weekly weight ordered 2/3/22, however the facility failed to consistently monitor his weight weekly.
The initial nutritional assessment was completed on 11/15/21. It indicated Resident #58 was on a ground meat texture diet with thin liquids. It indicated the resident received medical nutritional support with Med Pass supplemental shakes of 120 milliliters three times a day. It indicated the resident's weight was 93.6 lbs (pounds) and he was 63 inches tall, his BMI was 16.6 (underweight) and ideal body weight was indicated at 103-127 lbs. It indicated meal intakes were 51-75%.
The quarterly nutrition assessment was completed on 2/7/22. It indicated Resident #58 was on puree diet texture with thin liquids. It indicated Resident #58's most recent weight was 85 lbs. It did not indicate if a significant weight change had occurred as nothing was marked on the assessment. It noted Resident #58's intake had improved since admission to 75% and greater and his family brought in food for him.
-There were no additional nutrition assessments by the RD when the resident sustained weight loss since his admission [DATE].
The nutrition care plan, revised 1/18/22, was reviewed. It indicated Resident #58 had ongoing weight loss since admission and intake less than estimated needs. Interventions included: assistance with eating and drinking, preferences for Mexican food, potatoes, and soup as well as food brought in from family, puree diet, monitor weight per facility protocol and supplements as ordered.
Progress notes from 11/8/21-3/15/22 were reviewed and revealed the following:
On 11/12/21 a progress note was completed that indicated Resident #58 did not wear dentures and had difficulty chewing food. No coughing or swallowing difficulties were observed.
On 12/29/21 a progress noted was completed that indicated Resident #58 only ate a few spoonfuls of both breakfast and lunch. It noted the resident did not verbalize if he wanted an alternative meal. It indicated the physician was notified of recent weight loss and physician mentioned a feeding tube may be indicated.
On 1/7/22 a progress note was completed that indicated Resident #58 had poor intake and appetite at date. It noted he consumed three to four spoonfuls of breakfast and lunch and required prompting to open mouth and take medications during shift. It indicated intake of fluids was fair.
On 1/11/22 a progress note was completed that indicated Resident #58's family brought in three meals and were left in the unit refrigerator.
On 1/11/22 a progress note was completed that indicated Resident #58 reported difficulty swallowing both liquids and solids. It noted a CNA confirmed resident coughed on occasion with both liquids and solids and the nurse reported no difficulty with swallowing medications. The note indicated the physician was notified of weight loss and a swallowing evaluation was requested.
On 1/12/22 a progress note was completed that indicated the resident's representative was notified of decreased intake. The note indicated the family reported they would continue to bring in food for the resident.
On 1/15/22 a progress note was completed that indicated the resident's representative reported they were only interested in a feeding tube if it becomes necessary.
On 1/16/22 a progress note was completed that indicated the resident's representative provided eight containers of pureed meals and were left in the walk-in refrigerator to be provided with lunch and dinner.
On 1/17/22 a progress note was completed that indicated a weight warning of -5.0% change over the past 30 days. It indicated the results of a calorie count were available with average meal intake of 227 kilocalories and 7.3 grams of protein. It indicated the physician was notified of these results and the family was aware of current weight. It indicated the resident was at risk of continued weight loss and his current intake was not meeting estimated needs at this time.
-However, no interventions were put in place when the resident had additional weight loss. The family were supplying meals as early as 1/11/22.
On 1/18/22 a progress note was completed that indicated a CNA reported 100% intake of a lunch meal and the resident consumed all of the Med Pass as ordered. It indicated there was an order for a modified barium swallow study (exam to observe swallow to determine what food texture and liquid thickness was most appropriate).
On 1/28/22 a progress note was completed that indicated an increase in weight up 3% from previous with an improved appetite. It indicated the family continued to bring in food for the resident and he continued to take Remeron for appetite and Med Pass supplements three times a day.
-The Remeron was ordered 12 days after the resident had a 13.1 lbs weight loss since admission to the facility.
On 2/18/22 a progress note was completed that indicated an increase in weight up 5% over the past 30 days. It indicated the resident continued to eat well at meals and family continued to bring in meals.
On 3/10/22 a progress note was completed that indicated a decrease in weight. It indicated weight fluctuated between 80-86 lbs. over the past two months. It indicated his intake was 50-100% of meals. It noted the resident received 120 milliliter of Med Pass supplement three times a day and staff assisted with meals, snacks, and supplements.
-However, there were no additional nutritional interventions, the remeron medication and nutritional supplements were not evaluated when the resident started losing weight 2/27/22.
On 3/13/22 a progress note was completed that indicated the resident had an elevated temperature and emesis and was sent to the emergency room for evaluation.
On 3/13/22 a progress note was completed that Resident #58 returned from the hospital with a diagnosis of community acquired pneumonia and a urinary tract infection. The resident was prescribed Amoxicillin 500 milligrams every eight hours and Doxycycline hyclate 100 milligrams two times a day.
On 3/14/22 a progress note was completed that indicated the resident returned from the hospital after being treated for aspiration pneumonia.
The meal intakes were reviewed for 2/15/22-3/15/22. The intakes indicated the resident was typically consuming 50-100% of meals.
-However, resident observations above indicate the food and snacks that the family representative provided were not included at meal time, with his intake estimated at 50% on 3/10/22 and 3/14/22.
The director of therapy (DOT) provided physician orders on 3/14/22 at 4:11 p.m. The orders were for evaluation and treatment for speech therapy. The orders were dated 11/17/21. The orders were faxed to the home health care provider on 11/18/21.
Review of March 2022 CPO revealed the following:
-House supplement, frozen, three times daily for malnutrition ordered 11/8/21 and discontinued 1/18/22;
-A physician order for modified video barium swallow study for dysphagia ordered 1/11/22;
-Regular diet, puree texture, and thin liquids ordered 1/18/22;
-2 Cal Med Pass three times a day for malnutrition ordered 1/18/22;
-Remeron tablet of 7.5 milligrams one time a day for poor appetite ordered 1/28/22; and,
-Weekly weights every Wednesday for weight loss ordered 2/3/22.
The DON provided the hospital notes on 3/15/22 at 12:04 p.m. The notes indicated the resident was seen at the hospital on 3/13/22 with concerns related to cough, shortness of breath, and fever. The notes indicated the resident was on supplemental oxygen upon arrival though it noted the resident did not wear supplemental oxygen at baseline. The notes indicated the resident was on two liters of oxygen and was at 85% oxygen saturation. The staff increased to four liters and the resident reached normal oxygenation. The notes indicated pneumonia was observed on x-ray and the resident was able to be titrated back to room air. Specifically, the notes from the chest x-ray indicated patchy airspace disease in the right midlung. He was started on antibiotics including Amoxicillin and Doxycycline.
The director of therapy (DT) provided the speech therapy evaluation and plan of treatment on 3/15/22 at 2:00 p.m. The evaluation indicated the resident had mild oropharyngeal dysphagia (swallowing problems occurring in the mouth and throat). Recommendations included to continue with puree texture and thin liquids. Carryover of swallowing techniques included alternating liquids and solids, modification of size of bite, using tongue to clear oral cavity, upright position for all meals, and monitoring signs and symptoms of aspiration including coughing and throat clearing, changes in respiratory symptoms, and fever.
-The speech therapy evaluation was completed on 3/15/22 despite the initial referral for evaluation on 11/17/21. In addition, the MBSS test for his swallowing trouble was ordered on 1/18/22. The MBSS test was not completed by the survey exit on 3/15/22.
VII. Staff Interviews
Licenced practical nurse (LPN) #3 was interviewed on 3/14/22 at 9:14 a.m. She said Resident #58 had a fever and emesis on the previous day and there were concerns for aspiration. She said he was sent to the hospital for evaluation and it was determined he had pneumonia and an urinary tract infection.
The registered dietitian (RD) was interviewed on 3/15/22 at 9:23 a.m. She said Resident #58 had experienced weight loss since admission and from conversations with the resident's family, he was losing weight prior to admission. The RD said an intervention she added was Med Pass supplements three times a day on 1/18/22.
-However, per the nutrition assessment 11/15/21, the resident was supposed to be receiving Med Pass three times per day to meet his estimated nutrition needs and this was not a new intervention when the resident sustained additional weight loss.
She said Resident #58's family also brought in food for him which was to be served in addition to his lunch and dinner. She said she did not know why he was not served the extra food on 3/14/22 and confirmed it was in the walk-in refrigerator. She said he was not served the additional food on 3/10/22 because staff had served all the extra meals the family had brought in at that time.
-However, during the 3/14/22 observation the resident had 10 containers in the refrigerator to provide to the resident and the staff did not provide him with the additional meals from the representative on 3/14/22 (see observation above).
She said she did not believe Resident #58 had difficulty with swallowing. She said Resident #58 was admitted to the facility on a ground texture and was now on a puree texture. She said she did not know who downgraded his diet but it was changed on 1/18/22. She said if there was a swallow evaluation the DON may have notes. She said nursing staff may downgrade a diet and the speech-language pathologist would follow up later. She said his current diet was regular with puree texture and thin liquids.
-However, the progress notes indicated the resident had difficulty swallowing with his meals and speech therapy and swallowing tests were ordered.
She said she felt comfortable with the interventions the team had put into place related to weight loss and would speak to staff to ensure the meals the family brought in were served in addition to facility meals. She said she met with the DON once a week to discuss residents with weight changes. She did not indicate if she met with the interdisciplinary team.
The DON was interviewed on 3/15/22 at 10:17 a.m. She said information related to a referral for a swallow evaluation was given to the director of therapy. She said Resident #58 had been observed coughing during meals and a nurse downgraded his texture to puree. She said nursing staff would downgrade a diet and have the speech-language pathologist follow up, as this was typical. She said the modified barium swallow study (MBSS) was ordered because a feeding tube had been mentioned by the physician at one point due to weight loss. She said it did not fall on nursing staff to schedule the swallow evaluation.
The DOT was interviewed on 3/15/22 at 10:40 a.m. He said he handled scheduling therapy evaluations as well as outside therapy-related evaluations such as a MBSS. He said the RD came to him and asked for Resident #58 to have a MBSS and the order was put in on 1/11/22. He said the physician did not sign the order until 1/30/22 and he was not notified the physician signed. He said since he was not notified, he did not follow up. He said Resident #58 had orders for a speech therapy evaluation dated 11/17/21 and he sent it out to the therapist that worked with the resident's payor source. He said he was told that the therapy company did not have a speech-language pathologist, so the evaluation was not completed. He said the facility's speech-language pathologist was going to see Resident #58 later that day.
The DON was interviewed again on 3/15/22 at 2:40 p.m. She said she could not determine if the resident had aspiration pneumonia since the hospital notes indicate pneumonia.
VIII. Facility follow-up
The primary care physician was interviewed on 3/23/22 at 2:20 p.m. He said he had placed orders for speech therapy and a modified barium swallow study for Resident #58, though he was unsure of exact dates when orders were placed. He said the resident had not been eating well since he was admitted to the facility. He said the resident's intake increased when he ate with his family or ate food the family brought in.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to provide an ongoing program to support residents in t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to provide an ongoing program to support residents in their choice activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction for one (#38) of three out of 26 sample residents.
Specifically, the facility failed to invite and offer activities of choice to Residents #38.
Findings include:
I. Facility policy
The Therapeutic Activities Program policy and procedures, revised 11/2/21, was provided by the director of nursing (DON) on 3/15/22 at 11:00 a.m. It read in pertinent part, the facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community.
II. Activity schedule
3/9/22-Morning greet and current events-9:30 a.m., Music and stretch-10:30 a.m., Care conferences-1:00 p.m., Bingo-2:00 p.m., Sudoku group-4:15 p.m and Sensory games-6:00 p.m.
3/10/22-Morning greet and current events-9:30 a.m., Music and stretch-10:30 a.m., Care conferences-1:00 p.m., World travel group and scrabble-2:00 p.m., Room visits-3:30 p.m.
3/14/22-Morning greet and current events-9:30 a.m., Music and stretch-10:30 a.m., Care conferences-1:00 p.m., Bingo-2:00 p.m., Sudoku group-4:15 p.m., and History and Trivia-6:00 p.m.
3/15/22-Morning greet and current events-9:30 a.m., Music and stretch-10:30 a.m., Care conferences-1:00 p.m., World travel group and scrabble-2:00 p.m, Room visits-3:30 p.m.
III. Resident status
Resident #38, age [AGE], was admitted on [DATE]. According to the March 2022 computerized physician orders (CPO), diagnosis included history of falling and difficulty in walking.
The 1/21/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of zero out of 15. He was usually understood and sometimes understood by others. He was independent with bed mobility and transfer and required extensive assistance with dressing and toilet use. Activities preferences section documented it was very important for the resident to have animals such as pets, keep up with the news and go outside for fresh air.
IV. Observations
On 3/9/22 at 10:36 a.m. the resident was lying in bed. He was staring at the wall. The television (TV) was on but he was not watching it.
On 3/10/22 from 10:00 a.m. to 11:30 a.m., the resident was lying in bed. He was looking toward the wall and pulling on the call light cord. Certified nurse aide (CNA) #1 walked into the resident ' s room and asked him if he needed anything. She offered him a glass of coke that was on his bedside table. She left the room. There was no stimulation in the room.
On 3/14/22 at 10:33 a.m., the resident was lying in bed. He was looking up at the ceiling. The TV was not turned on. He said he was bored and he was pulling on the call light cord.
V. Record review
The comprehensive care plan, dated on 11/6/2020, identified that the resident has an interest in participating in group activities conducted on the unit. The Resident has expressed feeling distressed, sad, disconnected and lonely as a result of not having the ability to interact with peers and engage in group activities. Intervention: Staff to coordinate and plan group activities follow safety protocols put into place to prevent the spread of COVID-19. Resident have agreed to abide by the protocol for participating in group activities.
The March 2022 activity participation log was reviewed. It documented participation codes: A-active participation, P-passive participation, R-Refused and U-Unable.
The participation log document on 3/9/22, the resident participated in activities such as: Walking-A, Television-A and Leisure-A.
There were no times and duration documented on the log.
However, during observations, the resident was lying in bed and not watching TV.
VI. Staff interviews
The certified nurse aide (CNA) #1 was interviewed on 3/14/22 at 1:15 p.m. She said she was not sure of what activities the resident liked to do. She said, usually there was an activity assistant on the floor doing activity, but she has not seen her around on the unit. She said she was responsible for assisting the resident with his activities of daily living (ADLs) such as bathing, hygiene, grooming and toileting).
The activity director (AD), was interviewed on 3/15/22 at 10:30 a.m. She said she had been out of the facility on family leave. She said she has an activity assistant and she expected her to invite and encourage residents to come to activities. She said Resident #38 liked to be in group activity, she said even if he does not participate, he likes to watch the activity. She said the activity assistants assigned on the unit should have invited and encouraged the Resident #38 to participate in activities. She said she would provide education to the activity staff.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure one (#36) of three residents, received medication man...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure one (#36) of three residents, received medication management treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan for 26 sample residents reviewed.
Specifically, the facility failed to follow current physician orders to hold Metoprolol (blood pressure medication) when Resident #36 ' s blood pressure and heart rate were outside of parameter ranges to give the medication.
Findings include:
I. Facility policy
The Administration of Medications policy and procedure, last revised 7/14/21, was provided by the director of nursing (DON) on 3/15/22 at 12:04 p.m. It read in pertinent part, All medications are administered safely and appropriately per physician order to address residents ' diagnoses and signs and symptoms .A physician order that includes dosage, route, frequency, duration, and other required considerations including the purpose, diagnosis or indication for use is required for administration of medication.
II. Resident #36
A. Resident status
Resident # 36, age [AGE], was admitted on [DATE], with re-entry 9/22/21. According to the March 2022 computerized physician orders (CPO), diagnoses included heart failure, type 2 diabetes mellitus, cardiac arrhythmia (electrical impulses in the heart do not work properly), atrial fibrillation (irregular heart rate), and pulmonary hypertension (a type of high blood pressure).
The 1/19/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required extensive assistance with two persons for bed mobility, and transfers. Extensive assistance with one person for locomotion on/off unit, and dressing. Supervision with set up help only for eating.
B. Resident interview
Resident #36 was interviewed on 3/15/22 at 10:35 a.m. She said she did not feel light headed or dizzy laying in bed however felt that way with transfers from the bed to the wheelchair each day. She said felt light headedness and dizziness with every transfer that occurred at about 12:30 p.m. when she got up each day.
C. Record review
The March 2022 computerized physician orders were reviewed and revealed order for,
Metoprolol tartrate tablet 25 milligrams (MG). Give 0.5 tablet by mouth two times a day for atrial fibrillation. Hold if the heart rate is less than 60 or systolic blood pressure is less than 120. Order date 9/22/21 at 1:40 p.m.
-The time that the medication was administered was not recorded on the MAR except to say morning, and bedtime (HS).
The January 2022 vitals record revealed a systolic (the first number) blood pressure:
Of 103/60 millimeters of mercury (mmHg) on 1/1/22;
Of 108/60 mmHg on 1/2/22;
Of 97/52 mmHg on 1/3/22;
Of 98/49 and 97/51 mmHg on 1/4/22;
Of 106/56, 108/58, 108/50 and 100/46 mmHg on 1/5/22;
Of 108/56, and 97/54 mmHG on 1/6/22;
Of 100/50, and 90/45 mmHG on 1/7/22;
Of 100/56 mmHg on 1/8/22;
Of 92/58 mmHg on 1/9/22;
Of 109/58 mmHg on 1/10/22;
Of 100/69 mmHg on 1/11/22;
Of 100/52, 92/44, and 96/63 mmHg on 1/12/22;
Of 104/60, 90/59, and 99/68 mmHg on 1/13/22;
Of 110/60 mmHg on 1/17/22;
Of 100/71 mmHg on 1/18/22;
Of 99/64 mmHg on 1/19/22;
Of 112/58, 112/64, and 105/46 mmHg on 1/20/22;
Of 112/52, and 99/50 mmHg on 1/21/22;
Of 102/58 mmHg on 1/23/22;
Of 106/54, 98/53, and 112/60 mmHg on 1/24/22;
Of 96/54, and 105/60 mmHg on 1/25/22;
Of 94/47, and 91/62 mmHg on 1/26/22;
Of 95/47, and 98/57 mmHg on 1/27/22;
Of 91/60, and 100/56 mmHg on 1/29/22;
Of 98/54 mmHg on 1/30/22; and
Of 108/67, and 98/58 mmHg on 1/31/22.
-The January 2022 medication administration record (MAR) revealed metoprolol tartrate was administered in these instances when the systolic blood pressure was out of the parameters of the physician order (hold when less than 120).
The January 2022 vitals record revealed a heart rate:
Of 56, and 51 beats per minute (bpm) on 1/1/22;
Of 52, 58, and 58 bpm on 1/2/22;
Of 57 bpm on 1/3/22;
Of 57, and 52 bpm on 1/4/22;
Of 58, 50, 50, and 57 bpm on 1/5/22;
Of 58, and 55 bpm on 1/6/22;
Of 58 bpm on 1/7/22;
Of 55 bpm on 1/9/22;
Of 58, and 56 bpm on 1/10/22;
Of 53, 58 bpm on 1/16/22;
Of 57 bpm on 1/17/22;
Of 52 bpm on 1/21/22;
Of 58, and 58 bpm on 1/23/22;
Of 54, 51 bpm on 1/26/22;
Of 56, and 55 bpm on 1/29/22; and
Of 56 bpm on 1/30/22.
-The January 2022 medication administration record (MAR) revealed metoprolol tartrate was administered in these instances when the heart rate was out of the parameters of the physician order (hold when less than 60).
The February 2022 vitals record revealed a systolic (the first number) blood pressure:
Of 102/62, 100/55, 105/89 mmHG on 2/1/22;
Of 102/60 mmHg on 2/3/22;
Of 101/64 mmHg on 2/5/22;
Of 96/54 mmHg on 2/6/22;
Of 112/58 mmHg on 2/7/22;
Of 109/60, and 79/45 mmHg on 2/8/22;
Of 107/55 mmHg on 2/9/22;
Of 116/54 mmHg on 2/10/22;
Of 93/56 mmHg on 2/11/22;
Of 108/54 mmHg on 2/13/22;
Of 96/51 mmHg on 2/14/22;
Of 102/90 mmHg on 2/15/22;
Of 91/50, 96/54 mmHg on 2/16/22;
Of 118/54 mmHg on 2/17/22;
Of 111/89 mmHg on 2/18/22;
Of 102/58, 103/54, and 116/52 mmHg on 2/20/22;
Of 114/55 mmHg on 2/21/22;
Of 92/58 mmHg on 2/22/22;
Of 96/54 mmHg on 2/23/22;
Of 95/54 mmHg on 2/24/22; and
Of 97/54 mm Hg on 2/28/22.
-The February 2022 medication administration record (MAR) revealed metoprolol tartrate was administered in these instances when the systolic blood pressure was out of the parameters of the physician order (hold when less than 120).
The February 2022 vitals record revealed a heart rate:
Of 58, 49 bpm on 2/1/22;
Of 49 bpm on 2/4/22;
Of 50 bpm on 2/6/22;
Of 55 bpm on 2/11/22;
Of 50 bpm on 2/13/22;
Of 52 bpm on 2/14/22;
Of 51 bpm on 2/16/22;
Of 46 bpm on 2/18/22;
Of 58 bpm on 2/19/22;
Of 50 bpm on 2/21/22;
Of 54 bpm on 2/22/22;
Of 54, 49, and 51 bpm on 2/23/22;
Of 56, 53, and 50 bpm on 2/24/22;
Of 50 bpm on 2/27/22; and
Of 55 bpm on 2/28/22.
-The February 2022 medication administration record (MAR) revealed metoprolol tartrate was administered in these instances when the heart rate was out of the parameters of the physician order (hold when less than 60).
The March 2022 vitals record revealed a systolic (the first number) blood pressure:
Of 108/58, and 99/50 mmHg on 3/1/22;
Of 110/62, and 99/60 mmHg on 3/2/22;
Of 90/48 mmHg on 3/3/22;
Of 110/60 mmHg on 3/5/22;
Of 110/59, and 106/58 mmHg on 3/6/22;
Of 94/51 mmHg on 3/7/22;
Of 104/50 mmHg on 3/9/22;
Of 100/52 mmHg on 3/10/22; and
Of 100/58, 92/63, and 99/55 mmHg on 3/12/22.
-The March 2022 medication administration record (MAR) revealed metoprolol tartrate was administered in these instances when the systolic blood pressure was out of the parameters of the physician order (hold when less than 120).
The March 2022 vitals record revealed a heart rate:
Of 52 bpm on 3/1/22;
Of 58 bpm on 3/2/22;
Of 50 bpm on 3/3/22;
Of 50 bpm on 3/6/22;
Of 52, and 48 bpm on 3/7/22;
Of 54, and 55 bpm on 3/8/22;
Of 54 bpm on 3/9/22;
Of 50 bpm on 3/10/22; and
Of 54 and 52 bpm on 3/12/22.
-The March 2022 medication administration record (MAR) revealed metoprolol tartrate was administered in these instances when the heart rate was out of the parameters of the physician order (hold when less than 60).
D. Staff Interview
Licensed practical nurse (LPN) #2 was interviewed on 3/15/22 at 10:43 a.m. She said the process for administering a medication such as Metoprolol tartrate was to first check the blood pressure and heart rate. LPN #2 said the results are then recorded in the vital sections or sometimes recorded in the MAR. LPN #2 said it was important to only administer the medication if the vitals are in the parameters set by the physician orders because otherwise it could stop the heart, or the resident could get dizzy, faint, or die. LPN #2 viewed Resident #36 ' s MAR and vitals on 3/12/22 and said according to the low blood pressure and low heart rate the nurse should have held the medication but both the morning and bedtime doses were administered. LPN #2 said doing so could cause arrhythmias and not help Resident #36 ' s atrial fibrillation.
LPN #1 was interviewed on 3/15/22 at 10:54 a.m. She said the process for administering a medication such as Metoprolol tartrate was to look at the orders first and then check the blood pressure and heart rate parameters and to hold the medication if out of the parameter ranges. LPN #1 said if medication were administered when out of parameter range the blood pressure would drop even more, causing the resident to feel tired, weak, dizzy, or light headed. LPN #1 said if the heart rate was already low and the medication was given the resident could pass out or have bradycardia (slow heart rate). LPN #1 viewed Resident #36 ' s MAR and vitals on 3/12/22 and said the blood pressure and heart rate were low and the medication should have been held.
The DON was interviewed on 3/15/22 at 11:20 a.m. She said the process for administering a medication such as Metoprolol tartrate was to check the doctors orders and parameters and hold if needed in order to stay within the parameters. The DON said it was important in order to keep the resident from bottoming out with symptoms of increased lethargy and dizziness when sitting up. The DON said the nurse should be checking the blood pressure and heart rate prior to administration. The DON viewed Resident #36 ' s MAR and vitals on 3/12/22 and acknowledged that the morning and bedtime doses had been administered although the blood pressure and heart rate vitals were out of range of the physician orders. The DON said the medication should have been held.
III. Facility follow-up
Documentation was provided by the DON on 3/15/22 at 1:10 p.m. It was a physician order for Resident #36, dated 3/15/22 at 12:46 p.m. to discontinue, Metoprolol tartrate tablet 25 MG. Give 0.5 tablet by mouth two times a day for atrial fibrillation. Hold if heart rate less than 60 or systolic blood pressure less than 120. The discontinue reason read, blood pressure out of parameters for medication.
-This was completed after the concern was brought to the facility's attention.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure infection control practices were established ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure infection control practices were established and maintained to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of communicable diseases and infections.
Specifically, the facility failed to:
-Ensure the residents were practicing proper hand hygiene before meals and staff wore personal protective equipment (PPE);
-Ensure resident's personal items were marked; and,
-Ensure the housekeeping staff cleaned resident rooms appropriately.
Findings include:
I. Professional reference
A. Professional reference
The Centers for Disease Control (CDC) Hand Hygiene, updated 1/8/21, accessed on 3/24/22 from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/hand-hygiene.html, revealed in part, Hand hygiene is an important part of the U.S. response to the international emergence of COVID-19. Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in healthcare settings. CDC recommendations reflect this important role.
The exact contribution of hand hygiene to the reduction of direct and indirect spread of coronaviruses between people is currently unknown. However, hand washing mechanically removes pathogens, and laboratory data demonstrate that ABHR formulations in the range of alcohol concentrations recommended by CDC, inactivate SARS-CoV-2.
ABHR effectively reduces the number of pathogens that may be present on the hands of healthcare providers after brief interactions with patients or the care environment.
The CDC recommends using ABHR with greater than 60% ethanol or 70% isopropanol in healthcare settings. Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Hand rubs are generally less irritating to hands and are effective in the absence of a sink.
According to the CDC, https://www.cdc.gov/coronavirus/2019-ncov/community/disinfecting-building-facility.html last revised 11/15/21, accessed 3/24/22, read:
Clean high-touch surfaces at least once a day or as often as determined is necessary. Examples of high-touch surfaces include pens, counters, shopping carts, tables, doorknobs, light switches, handles, stair rails, elevator buttons, desks, keyboards, phones, toilets, faucets, and sinks Use a disinfectant product from the EPA List Nexternal icon that is effective against COVID-19. Check that the EPA Registration numberexternal icon on the product matches the registration number.
II. Facility policy and procedures
The Infection Control policy, revised 9/2/2020, was received from the director of nursing (DON) on 3/10/22 at 11:18 a.m. It read in pertinent part:
This organization-wide infection control policy addresses detection, prevention, and control of infection for residents and personnel. The goal of the infection prevention program is to reduce the risk of acquisition, transmission, and healthcare associated infections. It also identifies and corrects problems associated with infection prevention and control practices.
The infection prevention and control plan will be implemented by the infection preventionist (IP).
The plan should include completion of the Infection Prevention and Control risk assessment tool.
This should be reviewed and updated at least annually and with significant changes in the facility related to infectious agents.
The Hand Hygiene policy, revised 12/4/2020, was received from the DON on 3/10/22 at 2:00 p.m. It read in pertinent part:
Hand hygiene is generally the most important procedure for preventing nosocomial infections. The purpose of appropriate hand hygiene is to decrease the risk of transmitting infection.The facility should provide education to the staff on hand hygiene not limited to when to perform hand hygiene with soap and water or alcohol based hand rubs (ABHR). This includes:
1.When coming on duty or leaving for the day.
2.Before and after using the bathroom.
3.Before and after resident contact.
4.Before applying gloves.
5.After removing gloves.
6.Prior to eating or drinking
7.Before putting on and after removing personal protective equipment (PPE).
II. Failure of staff to offer and encourage resident hand hygiene and staff wearing PPE appropriately during meal time
A. Main dining room
3/9/22
-At 11:47 a.m. continuous lunch observations in the main dining room from 11:47 a.m. to 12:27 p.m. revealed the staff did not offer hand hygiene to the residents before the meal.
3/10/22
-At 11:42 a.m. continuous lunch observation in the main dining room from 11:42 a.m. to 12:21 p.m. revealed the residents were not offered hand hygiene before the meal.
B. Four east unit
3/10/22
-At 12:02 p.m. licensed practical nurse (LPN) #2 delivered lunch trays to the residents. There were no sanitizer towels on the trays. The residents were not offered any hand hygiene prior to consuming their meal.
-At 12:07 p.m. LPN#2 served the meal tray to room [ROOM NUMBER]. She did not offer hand hygiene to the two residents in the room.
-At 12:09 p.m. certified nurse aide (CNA#2) served meal trays to room [ROOM NUMBER] and #402. She did not offer hand hygiene to the residents.
-At 12:15 p.m the wound care nurse (WCN) completed wound/skin care on an unidentified resident's feet at the dining room table while the tablemate sat there eating. Her mask was down from her face and her face shield was lifted up on her head.She was wearing gloves and did not take them off during observation.
-At 12:21 p.m. CNA #2 delivered a food tray to Resident #58 at his table. She did not offer hand hygiene to the resident. CNA #2 began to assist Resident #58 with eating his meal. The resident began to cough and the CNA patted the resident on his back.She touched the resident's wheelchair and his fork with bare hands.The resident stopped coughing and the CNA began assisting the resident with his meal again without sanitizing her hands. She then touched the resident's cornbread on his plate with her bare hands and broke it into pieces for the resident.
C. 200 west unit
3/9/22
-At 12:29 p.m., continuous observation of 200 west unit revealed that the residents did not receive sanitizing hand wipes nor were offered hand hygiene from 12:29 p.m. to 1:05 p.m.
D. Staff interview
The infection preventionist (IP) and director of nursing (DON) were interviewed on 3/14/22 at 2:30 p.m. The DON said that any staff serving food to the residents should be offering hand hygiene before meals. The IP said he would provide additional training for the staff and strongly encourage the importance of hand hygiene for the staff and residents.
Certified nurse aide (CNA) #2 was interviewed on 3/14/22 at 3:00 p.m. She said the staff should offer hand hygiene to the residents before their meals. She said she forgot to perform hand hygiene at the meal. She said most of the residents would comply with hand hygiene if offered.
III. Unmarked personal items
A. Facility policy
The Inventory of Personal Effects, last updated 5/7/21, was received from the nursing home administrator on 3/24/22 read in pertinent parts, Mark and list items brought to the facility for personal use of the resident .
B. Observations
On 3/10/22 at 1:45 p.m. walk through three of the four units in facility: All of the following rooms observed were double occupancy rooms.
1. Fourth floor west wing
-room [ROOM NUMBER] had two toothbrushes in a cup on the sink. They were not marked. The towels on the rack were not marked. There was a nylon pull cord in the bathroom.
-room [ROOM NUMBER] had dirty adaptive equipment silverware in the sink. It was not marked by who it belonged to. There was a nylon pull cord in the bathroom.
-room [ROOM NUMBER] had towels and hair brushes on the sink that were not identified by who owned them.There was a nylon pull cord in the bathroom.
-room [ROOM NUMBER] had towels which were not marked to who they belonged to.The bathroom had a nylon pull cord.
room [ROOM NUMBER] had bathroom towels which were not labeled. The pull cord in the bathroom was made of nylon.
room [ROOM NUMBER] had two hair brushes and two toothbrushes lying on the sink.They were not marked. There were two towels on the rack and they were not marked. There was a nylon pull cord in the bathroom.
2. Fourth floor east wing
room [ROOM NUMBER] had towels that were not marked. There was a nylon cord in bathroom
room [ROOM NUMBER] had towels that were not marked. There was a urinal cylinder on the back of the toilet. It was not marked or covered. There was a nylon cord in the bathroom.
room [ROOM NUMBER] had towels on the rack that were not marked. There was a nylon pull cord in the bathroom.
Room # 424 had two hair brushes on the sink. They were not marked. The residents did not have towels on the rack. There was a nylon pull cord in the bathroom
3. Second floor east
room [ROOM NUMBER] had towels that were not marked. There was a nylon pull cord in the bathroom.
room [ROOM NUMBER] had two hair brushes on the sink. They were not marked. The room had towels that were not marked. There was a nylon pull cord in the bathroom.
room [ROOM NUMBER] had towels on the rack that were not marked. There was a nylon pull cord in the bathroom.
room [ROOM NUMBER] had towels on the rack were not marked. There was a nylon pull cord in the bathroom.
room [ROOM NUMBER] had two combs on the sink that were not marked. There was a nylon pull cord in the bathroom.
D. Staff interview
The dietary manager (DM) was interviewed on 3/17/22 at 1:00 p.m. The DM said the silverware should always be sent to the kitchen so it could be washed in the dishmachine and not left in the resident's room. She said she would provide training to the certified nurse aides that the silverware needed to be brought to the kitchen.
The infection preventionist (IP) and director of nursing (DON) were interviewed on 3/14/22 at 2:30 p.m. He said he would talk with maintenance staff to ensure that new plastic pull cords would be installed in all of the residents' bathrooms.
The nursing home administrator was interviewed on 3/15/22 at 1:25 p.m. She said she was not aware that the nylon pull cords in the residents' bathrooms were an infection control issue. She said she would talk to the maintenance director (MD) to replace the nylon cords with plastic ones right away.
IV. Housekeeping
A. Observations
3/14/22
-At 9:45 a.m. room [ROOM NUMBER] housekeeper (HK #1) sprayed the disinfectant spray in the room on the counters, residents tables and dressers and the toilet and bars in the bathroom.
-At 9:48 a.m. HK #1 retrieved a clean cloth from the cart and wiped down the surfaces in the room. He first wiped down the sink which was by the door to the room.
-At 9:49 a.m. HK #1 used the same cloth and moved toward the back of the room. He wiped down the counters and resident's dressers as he went.
-At 9:51 a.m. HK #1 used the same cloth to wipe the window ledges and then moved on to bedside tables. He did not change his gloves or perform hand hygiene.
- 9:56 a.m. HK #1 used the same cloth to wipe down the areas in the bathroom.
-At 9:58 a.m. HK #1 put a dirty cloth in a bag on the cart. He did not change his gloves or perform hand hygiene.
-At 10:00 a.m. HK #1 retrieved a water bottle from the cart and took a drink. He did not remove his gloves.
-At 10:02 a.m. HK #1 took the mop from the bucket on the cart and squeezed out the excess water.
-At 10:03 a.m. HK #1 proceeded to mop the floor in the room starting at the front of the room and moving to the back.
-At 10:05 a.m. HK #1 came to the cart and got the broom and dustpan and went to the room.
-At 10:06 a.m. HK #1 put the broom and dustpan back on the cart. He did not change his gloves or perform hand hygiene.
-At 10:08 a.m. HK #1 finished mopping the room and proceeded to mop the floor in the bathroom. He did not change the mop head before he did this.
-At 10:10a.m. HK #1 came to the cart and put the dirty mop head in a bag on the cart. He did not remove his gloves or perform hand hygiene.
-At 10:12 a.m. HK #1 took the mop bucket from the cart and went into a washroom to rinse out the bucket. He did not lock the cleaning cart.
- At 10:25 a.m. HK #1 returned to the cart with more mop water. He did not remove his gloves or perform hand hygiene before going to the next room.
B. Interviews
The environmental services director (ESD) was interviewed on 3/14/22 at 10:40 a.m. She said the residents' rooms were to be cleaned from the back of the room to the front of the room. She said a clean cloth was to be used for each resident's area in the room. She said a different cloth should be used for wiping down the area in the bathroom. She included that the housekeepers should be changing gloves in between tasks where their gloves become contaminated and perform hand hygiene. She said the resident's room should be mopped from the back of the room to the front of the room and a different mop head should be used for the bathroom. She said HK #1 had been with the company for over a year and he should know the proper room cleaning procedures. She said the housekeepers had a checklist to mark for each room that was cleaned. She said she would provide additional training to the housekeeping staff.
-However, the training was not provided before the end of the survey on 3/15/22.
HSK#1 was interviewed on 3/14/22 at 10:58 a.m. HSK#1 said he had been at the facility for over a year. He said he received training upon hire. He said he had received updates on infection control but could not give exact dates. He said the dwell time on the disinfectant spray was one minute.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), 4 harm violation(s), $33,852 in fines. Review inspection reports carefully.
- • 22 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $33,852 in fines. Higher than 94% of Colorado facilities, suggesting repeated compliance issues.
- • Grade F (33/100). Below average facility with significant concerns.
Bottom line: Trust Score of 33/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Briarwood Health's CMS Rating?
CMS assigns BRIARWOOD HEALTH CARE CENTER an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Colorado, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Briarwood Health Staffed?
CMS rates BRIARWOOD HEALTH CARE CENTER's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 45%, compared to the Colorado average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Briarwood Health?
State health inspectors documented 22 deficiencies at BRIARWOOD HEALTH CARE CENTER during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 4 that caused actual resident harm, and 17 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Briarwood Health?
BRIARWOOD HEALTH CARE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by LIFE CARE CENTERS OF AMERICA, a chain that manages multiple nursing homes. With 201 certified beds and approximately 80 residents (about 40% occupancy), it is a large facility located in DENVER, Colorado.
How Does Briarwood Health Compare to Other Colorado Nursing Homes?
Compared to the 100 nursing homes in Colorado, BRIARWOOD HEALTH CARE CENTER's overall rating (4 stars) is above the state average of 3.1, staff turnover (45%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Briarwood Health?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.
Is Briarwood Health Safe?
Based on CMS inspection data, BRIARWOOD HEALTH CARE CENTER has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in Colorado. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Briarwood Health Stick Around?
BRIARWOOD HEALTH CARE CENTER has a staff turnover rate of 45%, which is about average for Colorado nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Briarwood Health Ever Fined?
BRIARWOOD HEALTH CARE CENTER has been fined $33,852 across 1 penalty action. The Colorado average is $33,417. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Briarwood Health on Any Federal Watch List?
BRIARWOOD HEALTH CARE CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.