Aviata at Sand Key
For profit - Limited Liability company
120 Beds
AVIATA HEALTH GROUP
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
1/100
#612 of 690 in FL
Last Inspection: February 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Aviata at Sand Key has received a Trust Grade of F, indicating significant concerns about the quality of care provided. It ranks #612 out of 690 facilities in Florida, placing it in the bottom half of all nursing homes in the state, and #49 out of 64 in Pinellas County, meaning there are only a few local options that perform better. The facility's situation is worsening, with the number of issues increasing from 6 in 2023 to 19 in 2024. Staffing is a weakness, with a 2 out of 5 rating and reports of insufficient staffing on multiple occasions, which impacts care quality. Notably, there are serious incidents of neglect, including one where a resident exhibiting critical symptoms was not properly assessed or treated, leading to their death two days later. On a positive note, the staffing turnover rate is low at 0%, indicating stability among staff members. However, the facility has incurred $175,634 in fines, which is concerning and suggests ongoing compliance problems.
- Trust Score
- F
- In Florida
- #612/690
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- Turnover data not reported for this facility.
- Penalties ✓ Good
- $175,634 in fines. Lower than most Florida facilities. Relatively clean record.
- Skilled Nurses ○ Average
- Each resident gets 36 minutes of Registered Nurse (RN) attention daily — about average for Florida. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 37 deficiencies on record. Higher than average. Multiple issues found across inspections.
1/100
Bottom 12%
Review needed
6 → 19 violations
★☆☆☆☆
1.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★☆
4.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2023: 6 issues
2024: 19 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
1-Star Overall Rating
Below Florida average (3.2)
Significant quality concerns identified by CMS
Federal Fines: $175,634
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: AVIATA HEALTH GROUP
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 37 deficiencies on record
2 life-threatening
Sept 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure a safe and sanitary environment for residents as evidenced by ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure a safe and sanitary environment for residents as evidenced by discoloration on ceiling tiles in one of two resident day rooms; discoloration on ceiling tile in room [ROOM NUMBER] with evidence of water by the air conditioning wall unit; ceiling damage from rain in room [ROOM NUMBER]; discoloration on ceiling air vents above one of two nursing stations; and a fallen tree limb in one of one resident courtyard.
Findings included:
During the tour of the facility conducted on 09/05/2024 initiated at 9:30 a.m., the following physical plant observations were conducted. Photographic evidence obtained.
At 9:30 a.m., an observation on the 300 hall, the resident day room, revealed three of the ceiling panels next to the fan had brownish, black, pinkish discoloration present. The discoloration was approximately 10 inches by 10 inches in size each, with one of the marks having grayish growth like material on top of the pinkish black.
At 9:40 a.m., an observation on the 400 hall, resident room [ROOM NUMBER]. Three ceiling panels had brownish discoloration covering 25-50% of the panels located next to the window which had a room air conditioner (a/c) unit present. Under the a/c unit was a blanket on the floor.
At 9:50 a.m., an observation of the south wing (100 and 200 hall) showed the A/C return vent, approximate 18 inches by 18 inches in size in the ceiling outside of the south wing resident day room had an accumulation of dust debris hanging on the slats. Five air vents, approximate 12 inches by 12 inches in size, in the ceiling around the nurses' station and in the halls had noticeable black discolored material present. The ceiling panels and the seams had dust hanging down in the ceiling panels above the nursing station by the ceiling fan. A corner of the ceiling across from the nursing station had ceiling panels with brownish beige discoloration.
At 10:10 a.m., an observation was conducted of resident room [ROOM NUMBER]. The ceiling panels above the resident in bed A had been removed. The Maintenance Assistant was present and was interviewed. He stated when the wind blew, and it was raining, the water would come in through the vent in the roof. He was replacing the ceiling tiles above the bed due to water damage. An attempt to interview the resident in 121A was conducted at this time. He was not able to be interviewed. He would talk about other subjects that the questions posed. Observed his bed had a blanket over it to protect it. The ceiling tiles above his bed had been removed. The resident was sitting at bedside, dressed in seasonally appropriate clothing.
On 09/05/2024 at 11:40 a.m., an interview was conducted with the Maintenance Director. He stated the facility had been cited before for unclean air vents. It was corrected back in March 2024. When asked how often the vents were cleaned, he stated probably not since March. He stated the building had no insulation, there was condensation, the panels were discolored continuously. He stated a vendor for roof repairs had been out to the facility approximately one month ago. He stated, this company used one vendor for the repairs, and he had not heard any updates since the vendor had come out. He stated for room [ROOM NUMBER], the discoloration in the ceiling tiles was from the roof leaking. He stated the blanket on the floor was because the water would pool outside the building, and it would come in through the frame of the wall a/c (air conditioning) unit. He stated, that was not the only room with that issue. He stated he had gone around the building and raked the leaves away in order to facilitate better drainage. He stated, really, there should be rocks out there and the trees cut back. He stated, there were downed branches from Tropical Storm [NAME], August 4-5, 2024, there was a big one in the courtyard. He stated, I had three tree trimmers come out within the last two weeks. The Administrator just sent the bids up to corporate yesterday. He stated, for the roof repair there was a process. He provided the process, roof repair procedure. He said, from the e-mail date, the request was sent up on 08/15/2024, because they asked for a facility map.
An observation was conducted on 09/05/2024 at approximately 12:05 p.m. of the middle courtyard of the building with the Maintenance Director. An observation of the resident smoker's gazebo revealed the sidewalk, leading away from the gazebo to a fence with a gate, had a large portion of a tree laying across it. The tree limb was observed to be approximately 30 feet in length, the main branch approximately 12-14 inches diameter. The branches smothered the sidewalk. The Maintenance director stated at this time, the tree limb had come down during the tropical storm. He stated he had gotten two bids for the tree issue; the bids must go through corporate for approval. He stated one guy wanted to remove the trees because they look like they are dying; and he pointed to the tree that had lost the large section, which was hollow in the center.
The Maintenance Director subsequently provided two documents which he stated were proposals.
Review of one Proposal, invoice 1198 by (name of company, for $5400. Dated 10/03/24, which the Maintenance director stated, at approximately 12:15 p.m., the date was wrong, he thought the estimate was given approximately 1 month ago. Review of the proposal documented the labor description: Trim trees over roof throughout complex & remove 1 large limb laying on ground.
Review of the second Proposal, quote 08/13/2024, from (name of company), dated 08/13/2024, for $6,200.00, documented the labor description:
4 Laurel Oak Trees (courtyard) Remove all large limbs over units & remove large deadwood 360 degrees. Remove all hanging limbs. Strongly suggested for removal all four trees are in decline.
2 Laurel Oak Trees (right rear) elevate & reduce, remove all large deadwood over structure. 2-3 large limbs. Remove.
2 Laurel Oak trees (left rear) elevate & reduce, remove all large deadwood over structure. 4 large limbs remove.
1 dead queen Palm (front) remove.
All the Laurel Oaks on this property are approaching the end of their life cycle and are in decline.
No further documentation of a commitment to remove the tree downed in the courtyard was provided.
Subsequently, the Maintenance Director provided an e-mail document:
Review of the e-mail dated 08/15/2024, to [Email address of tree company], documented a facility map with tree pictures had been provided to the e-mail address.
No further documentation of a commitment to repair the roof was provided to the survey team.
On 09/05/2024 at 12:25 p.m. an interview was conducted with the Activities Director. When asked if he conducted activities out in the courtyard with the residents, he stated yes. He stated, mainly at this time it was supervised smoking. But we have done tea parties, corn hole games, or other games. Yes, the branch had been laying there since the tropical storm, it had been a while.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to respond to un-timely call bell light grievances voiced by Resident Council for three of three sampled months, June, July and August of 2024...
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Based on record review and interview, the facility failed to respond to un-timely call bell light grievances voiced by Resident Council for three of three sampled months, June, July and August of 2024.
Findings included:
A review of Resident Council Monthly meeting notes, dated 06/27/2024, documented, Old Business, Issues from last meeting: Call lights have not been answered in a timely manner.
The form continued, How are these issues being resolved?: Staff will rotate shifts to audit call light response times-Administrator and ADON (Assistant Director of Nursing) will do night shifts check-ins call lights.
The form continued, New business: Blank
A review of Resident Council Monthly meeting notes, dated 07/23/2024, documented, Old Business, Issues from last meeting: Residents have complained that their call lights are not being answered in a timely manner.
The form continued, How are these issues being resolved?: Staff will do audits.
The form continued, New business: Call lights are still bad .
A review of Resident Council Monthly Meeting notes, dated 08/27/2024, documented Old Business, Issues from the last meeting: Call light responses.
The form continued, How are these issues being resolved?: Administrator and staff are aware and conducted audits.
The form continued, New business: Response time to call lights are horrible-the lights are light (like a) Christmas tree-staff are missing-employees on phones-staff have excuses to not help-3 pm-staff sit and nit (sic).
On 09/05/2024 at 1:13 p.m., an interview was conducted with the Resident Council President. She confirmed the resident council meetings were held every month. When asked if the facility had responded to the concern voiced by Resident Counsel about the call bell lights, she stated no. She stated over the last three months, the response to the call lights had gotten worse. She said, because she was the president of the counsel, residents would come to her and complain about the call bell lights. She said, the staff were taking an hour and sometimes more to answer the light. The aid would come in, the resident would ask for something, and an hour later, the resident was still waiting. She said the worst was the 11 pm-7 am shift.
An interview was conducted on 09/05/2024 at 1:57 p.m. with the Director of Nursing (DON). She stated she had started her position at the end of July 2024. She stated for call lights, timeliness, or un-timeliness, I have not done audits. I do not know if others have done call bell light issues.
On 09/05/2024 at 2:36 p.m., the DON stated, back in June, the ADON (Assistant Director of Nursing) gave an in-service, there has been nothing since.
Feb 2024
17 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, interviews, and record reviews, the facility failed to ensure two residents (#20 and #78) out of two resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to ensure two residents (#20 and #78) out of two residents the at will right to access persons and services outside the facility.
Findings included:
On 1/30/23 at 02:50 p.m. Resident #20 was observed in his wheelchair in the lobby. On return to his room during an interview he said he enjoys going to [retail store] (close to the facility) to get snacks. Resident #20 said the Social Services Director (SSD) told him, Unsupervised leave of absence (LOA) was rescinded because the facility was told I [Resident #20] was observed behind a retail store smoking and drinking alcohol. Resident #20 said facility staff refused to identify who made the accusation.
Review of admission records for Resident #20's admission record revealed [last] admission date 11/2/22 with diagnoses including diabetes, renal disease, right below the knee amputation.
Review of Resident #20's order listing report revealed the following:
-May go LOA per Nurse Practitioner (NP) last order date 5/4/23.
-May go on LOA with staff supervision, last order date 10/05/23.
Review of Resident #20's Annual Minimum Data Set (MDS) assessment, dated 11/16/23, Section C - Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating cognitively intact.
Review of Resident #20's communication with Resident note, dated 10/18/23 at 12:58 p.m. by Social Services (SS) revealed; Note Text: Resident asking to have LOA reinstated. Informed him that the [doctor] has discontinued his LOA privileges due to suspicious behavior and he can only go out on an LOA with staff supervision. Informed him that if he needs anything such as snacks, lottery tickets, etc. he will need to call his brother and sister-in-law to provide it [for] him. Resident did voice understanding.
During an interview on 1/30/24 at 3:13 p.m. the Director of Nursing (DON) referred discussions regarding Resident #20's LOA to the SSD.
During an interview on 01/30/24 at 3:20 p.m. the Social Services Director (SSD) said Resident #20's LOA was rescinded because someone told the facility the resident doing unsavory things behind a retail store. The SSD said the facility's interdisciplinary team (IDT) makes decisions regarding LOA supervised or unsupervised status. The SSD said a second resident, Resident #78 unsupervised LOA status was rescinded by the facility.
Review of admission record revealed Resident #78 was admitted on [DATE] with diagnoses including chronic ulcer (sores) of the lower leg and atherosclerosis (buildup of substances in the arteries) of right leg.
Review of Resident #78's order listing report revealed the following:
-May go [out on] LOA independently, ordered on 05/18/23.
-May go out on leave of absence with supervision when arrangements recommend and found safe per care plan team, ordered 12/28/2023.
Review of Resident #78's quarterly MDS assessment, dated 11/16/23, Section C - Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating cognitively intact.
Review of Resident 78's
communication with Resident note, dated, 11/24/2023 at 3: 00 p.m. by SS revealed; Note Text: Resident spoke to writer to discuss LOA, informed her that the Doctor and Advanced Registered Nurse Practitioner (ARNP) have talked to her that she can only have an LOA with supervision.
During an interview and observation on 1/31/24 at 1:29 p.m. Resident #78 was dressed and sitting in a wheelchair. Resident #78 said the facility did not let the residents know that when on unsupervised LOA, the facility requires return before midnight. On two occasions, the resident returned to the facility after midnight and the facility rescinded unsupervised LOA orders.
Review of facility's policy and procedure subject, Resident Rights, effective on 11/30/2014 revealed:
Policy: Make residents and their legal representatives aware of residents' rights.
Procedure: Residents and /or their representatives, will be made aware of their rights upon admission to the nursing home.
Review of facility's policy and procedure subject, leave of absence, effective on 11/30/2014 and revised on 6/14/2021 revealed:
Process: A patient/ resident is allowed a leave of absence (LOA) from the center in accordance with safe medical practice and state and federal regulations. During admission process/ residents receive information regarding the Leave of Absence procedure.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure one (#81) out of four residents utilizing a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure one (#81) out of four residents utilizing a Geri-chair was assessed for its use, a physician order had been obtained for its use, and it did not restrict the residents movement.
Findings included:
On 1/29/24 at 6:48 a.m. Resident #81 was observed lying in a Geri-chair, asleep and dressed appropriately in the doorway of the resident's room.
On 1/29/24 at approximately 2:19 p.m., Resident #81 was observed lying in a Geri-chair next to the nursing station and the 400 hall medication cart. The chair back was laid back and resident was observed attempting to sit upright.
On 1/30/24 at 2:18 p.m. Resident #81 was observed sitting upright in a high-back wheelchair in the North unit Dining Room alone, while facing out toward the hallway.
On 1/31/24 at 8:50 a.m., Resident #81 was observed sitting in a highback wheelchair with the back layed back to approximately 30 degrees near the nursing station. Staff A, Licensed Practical Nurse/Unit Manager (LPN/UM) who was present during the observation stated the brown substance around the resident's mouth was probably breakfast and the reason the chair was laid back was for the resident to rest due to being awake all night and trying to walk.
On 2/1/24 at 7:18 a.m., Resident #81 was observed lying in a Geri-chair in the corner across from the North unit nursing station, next to the Dining Room door. The resident was wearing a hospital gown with one bare leg showing, both legs were bent at the knees, and the chair was laid down to approximate 45 degrees. Staff U, Registered Nurse (RN) who was present during the observation stated the resident was put in Geri-chair because the resident kept trying to get out of wheelchair and stand up, so for safety the resident was placed in the Geri-chair.
On 2/1/24 at 10:59 a.m., Resident #81 was observed in therapy sitting in a highback wheelchair with eyes closed and unattended.
Review of Resident #81's admission Record revealed the resident was admitted on [DATE] with diagnoses not limited to Parkinson's Disease without dyskinesia without mention of fluctuations, Neurocognitive disorder with Lewy Bodies, other abnormalities of gait and mobility, legal blindness as defined in the USA, and unspecified severity unspecified dementia with other behavioral disturbance.
Review of the comprehensive Minimum Data Set (MDS) dated [DATE], showed Resident #81 had functional limitation in range of motion in bilateral lower extremities, utilized both walker and wheelchair for mobility, required partial/moderate assist with bed mobility, and supervision/touching assistance with transferring between bed-to-chair.
Review of Resident #81's physician orders, active as of 2/1/24, showed the resident had an electronic monitoring device (observed on ankle of resident) due to exit-seeking and staff were to check functioning every night shift and placement every shift. The physician orders did not include an order for the use of a Geri-chair.
Review Resident #81's care plan included the following focuses and interventions:
- Has episodes of sleeplessness, Health. The interventions showed staff were to administer medication as ordered, offer food and drink, and to provide (a) quiet environment.
- At risk for elopement/exit seeking, Actively exit-seeking. The interventions showed staff were to use diversional activities when exit-seeking behavior is occurring (i.e.: offer food, activities, one-on-one company).
- At risk for decline in behaviors, can be resistive to care, going to bed, taking showers, has had periods of agitation and restlessness. Grabs onto residents walking by while trying to stand. Does have diagnosis (dx) of dementia, Lewy body disease, (and) resistant with wearing clothing. The interventions showed staff were to provide quiet environment, redirect (resident) as necessary, and explain all procedures to (resident) before starting and allow (pronoun) enough time to adjust to changes.
- At risk for falls and fall-related injury related to cognitive loss/decline, difficulty in walking, impaired mobility, Parkinson's, hard of hearing, legally blind-glaucoma, (and) Lewy body disease. The interventions showed staff were to encourage (resident) to be in common areas when out of bed (OOB).
- At risk for decreased ability to perform Activities of Daily Living (ADLs) in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting related to activity intolerance, chronic disease process, impaired mobility, Parkinson's, gait and mobility abnormality, (and) Lewy body disease. The interventions showed staff with to assist x1 with ambulation and may use high back wheelchair as tolerated.
Continued review of Resident #81's care plan did not include any interventions related to the use of a Geri-chair.
Review of Resident #81's progress notes showed the following:
- 12/21/23 at 7:57 p.m., Writer observed Residents family putting Resident in regular chair in TV/dining room by nurses station. Writer asked family to transfer resident back to w/c (wheelchair) to deter Resident getting out of chair and falling.
- 1/14/24 at 4:00 a.m., Has been up in wc most of the shift after attempting to get out of bed several times without assistance. Taking oral fluids when offered.
- 1/22/24 at 10:00 p.m., a Change in Condition evaluation was written in response to Resident #81 falling.
- 1/26/24 at 12:10 a.m., a Change in Condition evaluation was completed due to Resident #81 suffering a fall.
- 1/26/24 at 7:54 p.m., a note showed the resident had attempted to self transfer twice and staff reminded resident to wait for assistance (asst).
- 1/27/24 at 6:38 p.m., a note revealed the resident was very agitated. He tried to stand up numerous times. The note showed during one of the times the resident attempted to stand, grabbed another resident arm, and caused skin tears. The note revealed despite redirection (resident) continues to try to stand and grab other residents who walk by.
- 1/28/24 at 10:17 p.m., Resident continues to attempt to rise without assistance. Requires constant direct monitoring to decrease the likelihood of falls and possible injury.
- 1/29/24 at 3:12 a.m., Will sleep for approximately 15 to 20 minutes when laid down in bed, but awakens and attempts to rise unassisted. Seems to calm some when wheeled around facility in w/c, but becomes agitated soon after. Several attempts to redirect behavior unsuccessful.
During an interview on 1/31/24 at 1:32 p.m. Staff A, Licensed Practical Nurse/Unit Manager (LPN/UM) stated therapy assesses residents for the use of Geri-chairs.
An interview was conducted with Resident #81's family member on 1/31/24 at 2:20 p.m. The family member reported being notified of three of the believed four falls. The family member stated they feel it was not fair for long-term care facilities were unable to use methods (restraints) to keep people from falling and was happy with the highback wheelchair and reported when resident was sitting upright the family member will lean it (the wheelchair) back so the resident was less likely to lean out of chair.
An interview was conducted with the Director of Nursing (DON) on 1/31/24 at 3:09 p.m. The DON said Resident #81 was a frequent faller and Risk Management was only showing one fall however confirmed the resident has had 4 fall assessments since December. The DON reported the resident sees things that are not there, doesn't normally try to walk but will lean forward to reach for something not there, staff were to encourage resident to be in common areas when out of bed and keep frequently used items within reach. She reported the facility has not added any interventions related to the resident falling for the past 30 days. The DON stated a resident required a (physician) order and an assessment for the use of a Geri-chair and the resident has been in a Geri-chair since her arrival to the facility (30 days prior to 1/29/24). She said a Geri-chair was used for positioning needs and would be inappropriate for someone who attempts to get up to ambulate. The observations were discussed with the DON, she confirmed a Geri-chair lying back for the resident, I know then confirmed it looked like a restraint.
The DON continued the interview on 1/31/24 at 3:19 p.m. with the Director of Rehabilitation (DoR). The DoR reported Resident #81 could ambulate with moderate/maximum assist from 1-person with 1- person following behind the wheelchair depending on the day and the resident had not been assessed for the use of a Geri-chair, the resident went from a standard wheelchair to a reclining highback wheelchair.
Review of the policy titled Physical Restraints, revised 11/6/2020, showed Residents have the right to considerate and respectful care at all times and under all circumstances, with recognition of their personal dignity and safety in the least restrictive manner. As needed, the interdisciplinary team will evaluate the resident for the potential need for physical restraint. The restraint must be the least restrictive means available. If a resident is identified by the interdisciplinary team and/or a discipline as requiring further intervention due to safety concerns, alternative methods will be attempted before restraint application will be considered. Monitoring and release of restraints will be done according to any state specific regulation. This policy and procedure does not apply to protective/adaptive/mechanical services. These devices are used for postural support, to assist the resident to obtain/maintain normative body functioning, or to compensate for a specific physical deficit. For example, bed rail used to enable movement.
The policy revealed the following procedures related to the use of physical restraints:
- A restraint evaluation will be performed by nursing to assess physical, mental and other contributing factors which include indicate the need for a restraint/enabler.
- The interdisciplinary team may use restraint decision making tools as needed to assist in determining restraint versus enabler versus restraint/enabler.
- The resident/responsible party will sign consent for the use of a safety device after review of risk /benefits.
- The risk and benefits shall be explained to the resident or representative prior to initiating the restraint.
- The nurse will obtain the physicians order for the restraint. This order will include the medical reason for the restraint.
- Restraint use is documented in the resident care plan and in the nurses note.
- Documentation to include:
-- Events leading to the initiation of restraint;
-- Resident behavior;
-- Least restrictive measures attempted;
-- Medical rationale for application;
-- Date, time, type of restraint;
-- Resident response to restraint
Each resident will be reassessed and reviewed as per state regulation but at a minimum of quarterly and as needed to determine whether or not the resident is a candidate for restraint reduction, least restrictive measures are being utilized or total restraint elimination is warranted.
According to PhysicalTherapy.com, The definition of a physical restraint is any manual method, physical or mechanical device, material or equipment attached or adjacent to the resident ' s body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Review of the information, (located at https://www.physicaltherapy.com/ask-the-experts/definition-of-restraint-2423), revealed an example of a physical restraint would be a reclining geri-chair. An upright geri-chair with a lap tray, any standard wheelchair or any other seating that prevents the resident from rising from the seat due to physical functioning deficits; basically what we mean by that is if you have a person who can stand up, but if you change the angle at the hip such that it is a very acute angle, they are not able to stand up. You make your seating system or your wheelchair such that you really recline the patient and you wedge them in there, that could be considered a restraint, even though they do not have a lap belt, a lap tray, or anything else.
Review of the website, verywellhealth.com/the-dangers-of-restraints-for-people-with-dementia-, updated August 29, 2021, showed the definition of a restraint was anything that hinders movement or restricts freedom. Years ago, restraint use was much more common and included extremely restrictive restraints such as straight jackets and vests. While these restraints aren't used today in a nursing home, it's important to recognize that other equipment can act as a restraint even it the goal in its use is to keep someone safe. The listed examples of restraints included recliner chairs and explained While a recliner chair can be used for comfort and positioning, it also can be a restraint for some people if they can't get out of it independently. The information presented revealed Restraints as a Last Resort and In order for a nursing home to use restraint, the staff must have tried and been unsuccessful in using less restrictive alternatives first, and these attempts must be clearly documented. (Less restrictive measures include attempts to more safely and comfortably position the person in a chair, providing increased supervision, offering meaningful activities or attempting to improve functioning through physical or occupational therapy.)
Facilities must also have a time-limited order from a physician in order to use any type of restraint, and the person, his guardian or his power of attorney for health care must have been educated on the risks vs. the benefits of using restraint and have given permission to do so.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A review of the admission Record showed Resident #45 was originally admitted on [DATE] with diagnoses of schizoaffective diso...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A review of the admission Record showed Resident #45 was originally admitted on [DATE] with diagnoses of schizoaffective disorder, bipolar type, and major depressive disorder, recurrent, mild.
Review of Resident #45's PASRR Level I Assessment, dated 06/27/18 revealed no qualifying mental health diagnosis and that no PASARR Level II was required.
Review of Resident #45's medical record revealed new diagnoses of generalized anxiety disorder on 12/16/19, other bipolar disorder on 11/30/22, major depressive disorder, recurrent, moderate on 04/26/23, and the resident was not assessed for PASRR Level II
Section I Active Diagnoses of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #45 had the following psychiatric/mood disorders: anxiety disorder, depression, bipolar disorder, and schizophrenia.
On 01/31/24 at 2:25 p.m., the Social Services Director (SSD) reported she reviews PASRR's for accuracy with nursing upon admission. She also looks to see if there was anything checked in section II of the PASRR. If a PASRR was incorrect, she would do a corrected PASRR with the assistance of the Director of Nursing (DON). A Level II PASRR was submitted if the resident had a change in behavior or had to be [NAME] Acted during their stay if the hospital did not initiate one. The SSD confirmed a new PASRR should have been submitted due to the new diagnoses during Resident #45's stay.
4. A review of the admission Record showed Resident #14 was originally admitted on [DATE] with diagnoses of unspecified dementia, unspecified severity, with other behavioral disturbance, brief psychotic disorder, major depressive disorder, recurrent, mild, generalized anxiety disorder, and post-traumatic stress disorder, unspecified.
Review of Resident #14's PASRR Level I Assessment, dated 06/01/16 revealed no qualifying mental health diagnosis and that no PASRR Level II was required.
Review of Resident #14's medical record revealed new diagnoses of schizoaffective disorder on 10/28/21, vascular dementia, unspecified severity, with agitation on 10/21/22, and the resident was not assessed for PASRR Level II
Section I Active Diagnoses of the quarterly MDS dated [DATE] revealed Resident #14 had the following psychiatric/mood disorders: anxiety disorder, depression, schizophrenia, and post traumatic stress disorder.
On 01/31/24 at 2:34 p.m., the SSD confirmed a new PASRR should have been submitted due to the new diagnoses during Resident #14's stay.
The policies and procedures Preadmission Screening and Resident Review (PASRR) dated 11/08/21 provided by the facility revealed the following:
Policy:
The center will assure that all Serious Mentally Ill (SMI) and Intellectually Disable (ID) residents receive appropriate pre-admission screenings according to Federal/State guidelines. The purpose is to ensure that the residents with SMI or are ID receive the care and services they need in the most appropriate setting.
Procedure:
1.
It is the responsibility of the center to assess and ensure that the appropriate preadmission screenings, either Level I or Level II, are conducted and results obtained prior admission and placed in the appropriate section of the resident's medical record.
4.
If it is learned after admission that a PASRR Level II screening is indicated, it will be the responsibility of the Social Services to coordinate and/or inform the appropriate agency to conduct the screening and obtain the results.
7.
Social Services will be responsible for coordinating significant change updates of these screenings, conducted by the appropriate agency. These results, along with the results from the previous years will be kept in the appropriate sections of the resident's records.
Based on record review, and staff interviews, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) for four (#74, #81, #14, and #45) of thirty-eight initially sampled residents were revised for accuracy to include diagnoses recognized at the time of admission and/or later identified.
Findings included:
1. Review of Resident #74's admission Record revealed the resident was admitted on [DATE]. The record showed diagnoses present on admission included primary insomnia and generalized anxiety. The record revealed secondary diagnoses with an onset date of 4/12/23 of unspecified post-traumatic stress disorder (PTSD), uncomplicated cocaine, and opioid abuse, a diagnosis of moderate recurrent major depressive disorder with an onset date of 4/26/23, and a diagnosis of dysthymic disorder with an onset date of 9/21/23.
Review of Resident #74's Level 1 PASRR, completed at an acute care facility on 11/2/22, showed the resident had diagnoses of substance abuse, anxiety disorder, and depressive disorder. The screening showed the resident had recent partial hospitalization or inpatient psychiatric treatment and had experienced an episode of significant disruption to the normal living situation. The level 1 screening did not include the resident's diagnosis of PTSD.
Review of Resident #74's Level II determination summary, completed on 11/4/22, showed the resident had a medical history of moderate depressive episode, suicide attempt, opioid abuse with intoxication with a history of psychiatric hospitalizations/Baker Acts. The Level II included the Level I diagnoses of anxiety disorder, depressive disorder, and substance abuse. The review did not reveal the resident's diagnosis of PTSD was included in the determination.
Review of Section I: Active Diagnoses, of Resident #74's annual Minimum Data Set (MDS), dated [DATE] revealed diagnoses of anxiety disorder, depression (other than bipolar), and Post-Traumatic Stress Disorder (PTSD).
An interview was conducted with the Social Services Director (SSD) on 1/31/24 at 2:41 p.m. The SSD reviewed Resident #74's medical diagnoses and Level 1 PASRR. She stated the PASRR came from the hospital. The SSD confirmed the diagnosis of PTSD which should have been added to the Level 1 under other in the Mental Illness (MI) section and resubmitted.
2. Review of Resident #81's admission Record revealed the resident had been admitted on [DATE]. The record showed the resident had admission diagnoses of neurocognitive disorder with Lewy Bodies, unspecified severity dementia in other disease classified elsewhere with other behavioral disturbance, recurrent moderate major depressive disorder, and brief psychotic disorder.
Review of Resident #81's PASRR, dated 12/12/23, revealed completion by Staff O, Registered Nurse (RN) at the facility. The mental illness section of the evaluation revealed a diagnosis of visual hallucinations and section II showed the resident had primary diagnoses of dementia and a related neurocognitive disorder. The screening revealed A Level II PASRR evaluation must be completed if the individual has a primary or secondary diagnosis of dementia or related neurocognitive disorder, and a suspicion or diagnosis of a Serious Mental Illness, Intellectual Disability, or both. The evaluation showed Resident #81 did not have a diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated and a Level II evaluation was not required.
Review of Resident #81's Minimum Data Set (MDS), dated [DATE], showed the resident was currently not considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. The MDS assessment of section I revealed diagnoses of dementia and psychotic disorder.
An interview was conducted with the Social Service Director (SSD) on 1/31/24 at 2:39 p.m. The SSD reviewed Resident #81's PASRR, stating the resident came from home and the facility went off what had been presented at that time. She reviewed the medical diagnoses and PASRR, confirming the PASRR should have been resubmitted with the additional diagnoses of major depressive disorder and psychotic disorder. The SSD stated depending on the resubmission with the diagnoses a Level II could be possibly be required.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to develop and implement a care plan related to a urina...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to develop and implement a care plan related to a urinary catheter for one resident (# 62) out of three residents sampled.
Findings included:
On 01//30//24 at 9:00 AM., Resident was observed laying in bed with his call light within reach.
On 02/01/2024 at 10:00 AM., Resident was observed laying in bed with his call light within reach. Resident was observed with a urine catheter, with sluggish sediment inside the tubing.
Review of a Resident Information Record dated 02/01/2024 showed Resident # 62 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses to included but not limited to Sepsis, Unspecified Organism, Urinary Tact Infection Site Not Specified, Retention of Urine, Difficulty Walking Major Depressive Disorder.
Review of a Minimum Data Set (MDS) dated [DATE] showed Resident # 62 had a Brief Interview Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. Further review of the MDS showed Section H for bladder and bowel that Resident # 62 was coded for having an indwelling catheter.
Review of an order summary report dated 02/01/2024 showed an active order for a urine catheter to straight bag drainage (16fr [french] 10 cc [cubic centimeters]) for diagnosis of: Urinary retention due to (d/t) obstructive uropathy.
Further review of the clinical record showed no evidence a care plan was developed for Resident # 62's urine catheter.
On 02/01/2024 at 10:00 AM., an interview was conducted with Staff R, Certified Nursing Assistant (CNA). She said she is familiar with Resident # 62 and his care needs. She assistant him with most of his activities of daily living (ADL's) and she assists him with emptying his urine catheter bag. She said she had not been provided with catheter care training at the facility. She said honestly, I learned how to do catheter care by looking at YouTube videos. She said if there was a problem with Resident # 62's catheter she would report it to the nurse. She said she seen the sluggish sediment in his catheter, but she did not report it to the nurse because she did not think anything was wrong with him.
On 02/01/2024 at 10:30 AM., an interview was conducted with Staff L, Registered Nurse (RN). She said she was the nurse responsible for Resident # 62 today and she was familiar with all his care needs. He has had a catheter for a long time for urinary retention, stating I take care of his catheter, but I haven't looked at it today. When I reviewed the resident care plan, I did not see a care plan for his catheter. Continuing, she stated I did not go over any interventions with the cna's because the nurses are the ones responsible for cleaning and changing out the resident's catheter if there are any problems. I was not aware of the resident having any sluggish sediment in his tubing.
On 02/01/2024 at 10:45 AM., an interview was conducted with Staff R, Minimum Data Set /License Practical Nurse (MDS/ LPN). She said she is responsible for developing the residents' care plans in the facility. After reviewing Resident # 62's care plan she confirmed she did not develop a care plan for his catheter.
On 02/01/2024 at 10: 50 AM., an interview was conducted with the Director of Nursing (DON) inside Resident # 62's room. She said her expectation is that staff should notify their nurse if they see a resident with sluggish sediment in their catheter tubing. The tubing should be either changed out or flushed out. She confirmed if a resident has Catheter they should also have a care plan in place with intervention for her staff to follow.
Review of facility policy titled, Plans of Care, Revision Date 09/25/2017 showed:
Policy: An individualized person - centered plan of care will be established by the interdisciplinary team (IDT) with the resident and /or resident representative (s) to the extent practicable and updated in accordance with state and federal regulatory requirement. Plan of care is to be maintained as part of the final medical record.
Procedure:
Develop a com plan of care for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs that are identified in the comprehensive assessment.
Review updated and/ or revise the comprehensive plan of care based on changing goals, preferences and needs of the resident and in response to current interventions after the completion of each OBRA MDS assessment (except discharge assessments), and as needed. The interdisciplinary team shall ensure the plan of care addresses any resident needs and that the plan is oriented toward attaining or maintaining the highest practicable physical, mental, and psychosocial well-being.
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
Based on observations, record review, and interviews, the facility failed to ensure splints were applied and oxygen flow rate was accurate and completed per physicians' orders for one (Resident #47) o...
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Based on observations, record review, and interviews, the facility failed to ensure splints were applied and oxygen flow rate was accurate and completed per physicians' orders for one (Resident #47) of one sampled resident.
Findings included:
Multiple observations were conducted of Resident #47, from 1/29/2024 at 6:50 AM to 2/1/2024 at 10:00 AM. Resident #47 was observed in his bed, with the head of his bed slightly raised without any splints, braces, abduction pillow, or palm guards. Resident #47 was observed during this time frame with a washcloth rolled up in the palm of his right hand. Resident #47's right and left hands were closed, fingers bent and touching the palms. The oxygen concentrator flow rate was set to 4.5 liters/minute (L/M). (Photographic Evidence Obtained).
Review of the medical record for Resident #47 was conducted. The admission Record revealed diagnoses that included persistent vegetative state, Traumatic Brain Injury with loss of consciousness of unspecified duration, person injured in a motor-vehicle accident, tracheostomy, gastrostomy, and other co-morbidities. The Minimum Data Set (MDS) assessment, dated 12/21/2023, revealed a Brief Interview for Mental Status (BIMS) score of 0/15 which meant the resident was severely cognitively impaired. The MDS revealed Resident #47 required total assistance with all activities of daily living (ADL) performance and had functional limitations in range of motion on both sides for upper extremity (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle foot). The Order Summary Report with active orders as of 11/01/2023 reflected the following orders: Abduction pillow to be utilized at all times may remove for care and assessment of skin condition; resident to wear bilateral palm guards on in AM and Off in PM *Check skin for breakdown pre/post application*. Place rolled clean washcloth in hands over night and compressed, humidified Oxygen at 2 L/Min via trach collar. The Treatment Administration Record revealed documentation that the bilateral palm guards and abduction pillow were in place during the time from of 1/29/2024 to 2/1/2024. The Medication Administration Record revealed staff administered the Oxygen at 2 L/Min for the time frame of 1/29/2024 to 2/1/2024.
An interview was conducted on 1/30/2024 at 3:15 PM with Staff F, Certified Nursing Assistant (CNA) assigned to resident #47. Staff F, CNA stated Resident #47 does not have any splints or other devices, we only put pillows under the heels, that is all. Staff F, CNA continued to state if the Resident were to have splints, they would be in the resident room. Staff F, CNA could not locate any splints or abduction pillows in the resident room.
An interview was conducted on 1/30/2024 at 3:30 PM with Staff A, Licensed Practical Nurse (LPN) assigned to resident #47. Staff A, LPN stated the Resident should have a foam cushion between his legs to keep his knees apart and hand splints on. Staff A, LPN confirmed, Resident #47 has a washcloth in the palm of the right hand. Staff A, LPN confirmed no splints or abduction pillow was in the resident room. Staff A, LPN confirmed no splints or pillows in place and the treatment administration record had been marked as if they were available. Staff A, LPN confirmed the oxygen flow rate was set at 4.5 to 5 L/M. Staff A, LPN stated the physician orders for the oxygen flow rate was 2 L/M.
An interview was conducted on 1/31/2024 at 10:45 AM with Staff B, CNA assigned to resident #47. Staff B, CNA stated caring for Resident #47 on a regular basis and is not aware of any splints or other devices. Staff B, CNA continued to state if the Resident were to have splints, they would be in resident room. Staff B, CNA could not locate any splints or abduction pillows in the resident room.
An interview was conducted with the Director of Rehabilitation (DOR) on 1/31/2024 at 11:00 AM. The DOR stated familiarity with Resident #47 and therapy has recommended splints for the resident's contractures. The DOR continued to state the past medical records are not available at this time due to the company ownership change. The DOR stated the resident was currently placed on Occupational Therapy caseload for evaluation of range of motion, started 1/30/2024.
An interview was conducted with the Director of Nursing (DON) on 1/31/2024 at 1:22 PM. The DON confirmed the Oxygen flow setting was set to 4.5 to 5 L/M. The DON continued to state the expectation is to follow all physician orders.
Review of the facility policy and procedures on the subject of : Contractures, Prevention with a revision date of 8/22/2017 showed: Policy: To prevent contracture of extremities for those residents who no longer have full use of their extremities. All contracture prevention devices should be removed at least daily for hygiene and observation of skin conditions. Each resident must be evaluated for need of contracture prevention procedures on admission, readmission and as needed. Procedure: . Positioning: Some residents may have braces or splints to prevent or help release contractures - be sure to follow the physician's order regarding the schedule of when to put these on and when to remove them.
Review of the facility policy and procedures on the subject of: Oxygen Therapy with a revision date of 8/28/2017 showed. Policy: Oxygen therapy is the administration of a FiO2 [fraction of inspired oxygen] greater than 21% by means of various administration devices to: Equipment: the selection of an appropriate oxygen delivery device is based on the FiO2 necessary to reduce or correct the hypoxemia, provide resident comfort and is practical to use for that individual. The type must be sized properly to avoid skin irritation and nasal obstruction. Procedure: *Physician's order for oxygen therapy shall include: *Administration modality *FiO2 or liter flow .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to document a fall, assess the resident, and notify t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to document a fall, assess the resident, and notify the physician of an injury for one (#74) out of four residents sampled for accidents.
Findings included:
During an initial observation and interview with Resident #74 on 1/29/24 at 9:34 a.m., the resident reported falling last night (1/28/24). The resident stated the Certified Nursing Assistant (CNA) and the nurse were aware of the fall. Resident #74 revealed a right forearm abrasion approximately 6 inches long that was reported as occurring during the fall the night before.
Review of Resident #74's progress notes did not show the resident had a fall on the night of 1/28 or prior to the interview conducted on 1/29/24.
During an interview with the Director of Nursing (DON) on 1/29/24, she stated she was unaware Resident #74 had fallen.
Review of a late entry progress note, effective 1/29/24 at 1:27 p.m., showed Resident #74 had reported to the DON of a fall in the resident room while walking to the bathroom and scraping arm on the footboard of bed causing an abrasion to arm.
An interview was conducted on 1/31/24 at 1:07 p.m., with Staff O, Registered Nurse (RN). The staff member reported the first thing to do when a resident fell was to ask them if they had pain, what happened, get vital signs, and if having pain call the physician, then stated the physician should be called regardless, call family if not own emergency contact, and start neurological checks. Staff O stated a fall assessment should be completed in the electronic record, a change in condition (form), a post-fall evaluation, and a fall risk scale. The staff member reported Resident #74 had scraped the right arm last week either Tuesday or Wednesday.
During an interview on 1/31/24 at 1:20 p.m., Staff A, Licensed Practical Nurse /Unit Manager (LPN/UM) reported not knowing about Resident #74's fall. A review of the risk manager report revealed a fall had occurred on 1/29/23 at 12:22 a.m. but could not tell when the date or time the report had been completed. The staff member reported the fall should be documented in the clinical record and the physician should have been notified.
On 1/31/24 at 3:01 p.m., the DON stated the nurse on Sunday night should have documented Resident #74's fall and assessment. She said the expectation was a risk management/incident report be completed as well as a fall risk assessment, pain assessment, skin assessment, post-fall assessment, and a change in condition (assessment). The DON reported the risk management information transfers into a progress note, the physician should have been notified of the fall and treatment orders received as needed.
The policy - Fall Management, revised 7/29/19, showed Residents are evaluated for fall risk. A fall refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as the result of an overwhelming external force (e.g. resident pushes another resident). The policy revealed Post-fall Strategies included:
1. Resident will be evaluated and post-fall care provided.
2. Initiate neurological tracts as per policy or directed by physician order.
3. Notify the physician in resident representative.
4. Re-evaluate fall risk utilizing the post fall evaluation.
5. Update care plan and nurse aid [NAME] with interventions.
6. Initiate post fall documentation every shift for 72 hours.
7. Interdisciplinary team to review fall documentation and complete root cause analysis.
8. Update plan of care with new interventions as appropriate.
9. Review resident weekly times (x) four.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0699
(Tag F0699)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of the admission Record showed Resident #14 was originally admitted on [DATE] with diagnoses of Alzheimer's disease,...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of the admission Record showed Resident #14 was originally admitted on [DATE] with diagnoses of Alzheimer's disease, unspecified, schizoaffective disorder, unspecified, vascular dementia, unspecified severity, with agitation, unspecified dementia, unspecified severity, with other behavioral disturbance, brief psychotic disorder, major depressive disorder, recurrent, mild, other specified persistent mood disorders, generalized anxiety disorder, post-traumatic stress disorder (PTSD), and personal history of other mental and behavioral disorders.
Section C Cognitive Patters of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #14 Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicating moderately impaired.
Section E Behavior of the MDS showed Resident #14 had behavioral symptoms not directed towards others (e.g., physical symptoms 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).
Section I Active Diagnoses of the quarterly MDS dated [DATE] revealed Resident #14 had the following psychiatric/mood disorders: anxiety disorder, depression, schizophrenia, and post-traumatic stress disorder.
A review of the Progress Notes revealed the following notes:
-1/6/2024 at 15:11- Resident had been agitated today. He was refusing to allow the nurse aide to give him a shower. Refused bed bath offered. Agitated at staff for changing soiled brief.
-12/4/2023 at 11:11- Met with resident in room to ask about events over this weekend. Resident in bed with old western on TV, smiling, and appearing calm. He said, Oh, I just went over on the floor, I do that sometimes, I'm ok. When asked if he went to the floor on purpose, he responded, Yeah, when I get upset with them over something that is what I do. Encouraged resident in future to speak to staff and/or management as soon as he starts to feel upset so that we can help him and decrease risks for injuries.
The Trauma Informed Care Evaluation dated 10/26/23 showed the only question marked yes was: 1. Have you ever served in a war zone, or have you ever served in a noncombatant job that exposed you to war related casualties? The evaluation revealed Resident #14 could not identify triggers that may cause re-traumatization and no triggers were listed on the evaluation.
The Social Services assessment dated [DATE] revealed Resident #14 had a history of being verbally aggressive with staff, being physically aggressive, yelling at staff, and saying inappropriate things to staff at times.
The care plans included a focus area related to behavior problems such as verbally aggressive, yelling out, calling staff inappropriate names, and throwing things. He had diagnoses of PTSD, depression, and anxiety. He was physically aggressive, will place himself on the floor, agitation, ran into med cart injured toes, pulls trim off handrails, and peels paint off walls/doors initiated on 08/09/23. Interventions included administer medications as ordered, approach/speak in a calm manner, assist him with developing appropriate methods of coping and interacting, encourage him to express his feelings appropriately, explain all procedures to him before starting and allow him enough time to adjust to changes, explain/reinforce why behavior is inappropriate and/or unacceptable, if reasonable, discuss his behavior, psychiatry services as needed, redirect him as necessary, and social services will visitor to monitor behaviors as needed.
The care plans included a focus area related to being at risk for distressed/fluctuating mood symptoms related to PTSD and depression initiated on 08/09/23. Interventions included administer medications as ordered, attend PTSD groups at the VA, behavioral health consult as needed, encourage/assist him to maintain as much independence and control as possible, if he needs time to talk, encourage him to express feelings, provide empathy, reassurance and supportive listening, monitor/document and report increased anger, labile mood or agitation, monitor/document and report mood patterns to doctor as needed, and social services visits to provide support and monitor mood as needed.
There was no care plan in place related to triggers for Resident #14's diagnosis of PTSD.
On 01/31/24 at 12:34 p.m., Staff W, Licensed Practical Nurse (LPN), stated Resident #14 had PTSD bad. It can be really bad, stated Staff W, LPN. Continuing, Staff W stated He gets antsy towards the end of the day. He will throw himself out of the wheelchair and throw himself out the bed when he gets mad. He was in the war so he's had it for a while. She reported she was not sure what triggered him, stating He goes out for peer group meeting at a local hospital for PTSD. Once in the while he will lose it. He throws medications and throws things out the door while in his room.
On 01/31/24 at 1:04 p.m., Staff H, Certified Nursing Assistant (CNA), stated his mood depends on the day. She was his assigned CNA and stated she took care of him often. She stated He throws himself out the bed. He was very demanding, but not aggressive. He goes to meetings at a local hospital every Thursday but every time he goes to the meetings, he comes back very upset. Staff H, CNA, stated she was not sure if he had PTSD, and she was not sure about what triggered him. She reported staff took his wheelchair from him once because he threw himself out of it. Staff H, CNA, stated she did not remember being educated on whether Resident #14 had PTSD and his triggers.
On 01/31/24 at 2:39 p.m., the Social Services Director (SSD) stated Resident #14 gets upset, yells at staff, he's verbally aggressive, gets angry, and will say he wants to get out of the facility. She said they would call his wife if they couldn't calm him down. Continuing, The behaviors usually happen around an important date in his life like the day his mother died, the day his twin died, and the 4th of July was always a trigger which we all know because that's when he came back from Vietnam. When the wife calls, she speaks to the staff and that's how they are aware of the dates that may trigger him. His wife had not been coming in often due to her own health issues, but she normally calls. His wife would call and say if it was an anniversary of a death. There was no specific thing that triggered Resident #14 stated the SSD. The State Surveyor asked, What happens if she forgets to call or if she calls later that evening to tell staff about the important date in his life? She stated his wife would normally call ahead of time to keep an eye on him on certain dates. He goes out weekly every Thursday to a local hospital for PTSD group meetings and was followed by psychiatry at that hospital. A few weeks ago, she worked with him, and it was determined that he was just hungry as the reason he was acting out. He would throw a remote and coffee at staff, but it was not an everyday thing. The SSD stated she did not know his triggers. I don't know if any of us know, stated the SSD. The SSD stated they do a trauma assessment to see if there can be retraumatization. Resident #14 did not report any triggers when she completed the assessment with him. If a patient say, there are triggers then they would identify that on the care plan. She answered the questions on the assessment according to the answers he provided. The State Surveyor asked, Would the important dates or anniversaries of deaths provided by his wife be triggers? The SSD stated yes. She stated she would try to get exact dates from his wife to get them put on the care plan. She stated staff should look at care plans for triggers related to PTSD. She confirmed that triggers for PTSD were not listed on the care plan.
The polices and procedures Trauma Informed Care effective 10/24/22 revealed the following:
Policy:
Residents will be evaluated to identify a history of trauma, triggers, and cultural preferences. Resident-centered interventions are initiated based on the resident triggers and preferences to decrease the risk of re-traumatization.
Procedure:
1.
Residents are evaluated for trauma, triggers and cultural preference on admission/ readmission, quarterly and annually.
2.
Develop resident-center interventions based on trauma triggers and resident cultural preferences.
3.
Develop a care plan and add interventions to the nurse aide [NAME].
4.
Review and update care plan and interventions quarterly and as needed.
Based on observations, record reviews, and interviews, the facility failed to recognize, document, and educate staff regarding triggers for two (#74 and #14) out of two residents sampled for Post-Traumatic Stress Disorder (PTSD).
Findings included:
1. On 1/29/24 at 9:34 a.m., Resident #74 was observed lying in bed with no lights, and the door and blinds closed. The resident reported falling during the night and the aide had been rude to her. The resident showed writer an approximate 6 inch abrasion to the right forearm. The resident said she does see psychiatry and has had suicidal ideations in the past.
Review of Resident #74's admission Record showed the resident was admitted on [DATE] and the diagnoses of unspecified Post-Traumatic Stress Disorder (PTSD) was added on 4/12/23.
Review of Resident #74's Level II Preadmission Screening and Resident Review, dated 11/4/22, showed the resident had a medical history included suicide attempt and opioid abuse with intoxication. The screening revealed the resident had prior psychiatry admissions, history of substance abuse, was noted to be homeless, and hospitalized after being found unresponsive. The review did not show the resident had been diagnosed with PTSD at the time of its completion.
Review of Resident #74's Minimum Data Set (MDS), dated [DATE], revealed the resident had a diagnosis of PTSD, anxiety, and depression. The assessment showed the resident's Brief Interview of Mental Status (BIMS) score of 12 out of 15, indicating a moderate impairment of cognition.
Review of Resident #74's Trauma Informed Care Evaluation, dated 7/26/23, showed the resident had answered yes to the following questions:
- Any serious car accident, or a serious accident at work or somewhere else?
--- If the event happened, did you think your life was in danger or you might be seriously injured?
--- If the event happened, were you seriously injured?
- Have you ever been in a major natural or technological disaster, such as a fire, tornado, hurricane, flood, earthquake, or chemical spill?
--- If the event happened did you think your life was in danger or you might be seriously injured?
--- If the event happened, were you seriously injured?
- Have you ever had a life threatening illness such as cancer, a heart attack, leukemia, AIDS, multiple sclerosis, etcetera?
- Before age [AGE] were you ever physically punished or beaten by parent, caretaker, or teacher so that: you were very frightened; Or you thought you might be injured; or you received bruises, cuts, welts, lumps, or other injuries?
--- If the event happened did you think your life was in danger or you might be seriously injured?
- Has anyone ever made or pressured you into some type of unwanted sexual contact?
- Has a close family member or friend died violently, force example in a serious car crash, mugging attack, suicide or homicide?
The evaluation did not include any triggers that may cause the resident retraumatization or comments.
Review of Resident #74's Trauma Informed Care Evaluation, dated 10/26/23, showed the resident had answered yes to the following questions:
- Any serious car accident, or a serious accident at work or somewhere else?
--- If the event happened, did you think your life was in danger or you might be seriously injured?
--- If the event happened, were you seriously injured?
- Have you ever been in a major natural or technological disaster, such as a fire, tornado, hurricane, flood, earthquake, or chemical spill?
--- If the event happened did you think your life was in danger or you might be seriously injured?
--- If the event happened, were you seriously injured?
- Have you ever had a life threatening illness such as cancer, a heart attack, leukemia, AIDS, multiple sclerosis, etcetera?
- Before age [AGE] were you ever physically punished or beaten by parent, caretaker, or teacher so that: you were very frightened; Or you thought you might be injured; or you received bruises, cuts, welts, lumps, or other injuries?
--- If the event happened did you think your life was in danger or you might be seriously injured?
- Has anyone ever made or pressured you into some type of unwanted sexual contact?
- Has a close family member or friend died violently, force example in a serious car crash, mugging attack, suicide or homicide?
The evaluation did not include any triggers that may cause the resident retraumatization or comments.
Review of Resident #74's Trauma Informed Care Evaluation, dated 1/26/24, showed the resident had answered yes to the following questions:
- Any serious car accident, or a serious accident at work or somewhere else?
--- If the event happened, did you think your life was in danger or you might be seriously injured?
--- If the event happened, were you seriously injured?
- Have you ever been in a major natural or technological disaster, such as a fire, tornado, hurricane, flood, earthquake, or chemical spill?
--- If the event happened did you think your life was in danger or you might be seriously injured?
--- If the event happened, were you seriously injured?
- Have you ever had a life threatening illness such as cancer, a heart attack, leukemia, AIDS, multiple sclerosis, etcetera?
- Before age [AGE] were you ever physically punished or beaten by parent, caretaker, or teacher so that: you were very frightened; Or you thought you might be injured; or you received bruises, cuts, welts, lumps, or other injuries?
--- If the event happened did you think your life was in danger or you might be seriously injured?
- Has anyone ever made or pressured you into some type of unwanted sexual contact?
- Has a close family member or friend died violently, force example in a serious car crash, mugging attack, suicide or homicide?
The evaluation did not include any triggers that may cause the resident retraumatization or comments.
Review of Resident #74's care plan listed special instructions Only female caregivers for all tasks. Must be two staff member present at all times due to history of false allegations. The care plan did not reveal foci or interventions related to resident's history or diagnosis of PTSD and did not show the resident had any triggers related PTSD.
During an interview on 1/31/24 at 1:07 p.m, Staff O, Registered Nurse (RN) stated Resident #74 had reported a diagnosis of PTSD and had listed on it the resident's list of diagnosis. The staff member stated the resident's triggers were not getting medications timely, wanting showers when the resident wanted showers, and stated I don't know what really is the trigger, maybe it's males going in the room.
During an interview on 1/31/24 at 1:20 p.m. Staff A, Licensed Practical Nurse/Unit Manager (LPN/UM), reviewed Resident #74's diagnoses and confirmed the diagnosis of PTSD. The staff member reported the resident would be smooth and mellow and every so often would walk out (into the hallway) naked. Staff A stated the resident's triggers were getting pain medication, tries to get everything (medications) at one time, no male aides, and suppose to have 2-persons for care.
During an interview on 1/31/24 at 2:49 p.m., the Social Service Director (SSD) stated there were no (PTSD) triggers for Resident #74. The staff member reported the resident had quite a few behaviors, episodes of yelling out related to pain medications, making accusations regarding medications, come out of the room naked looking for medications, and has made allegations against staff regarding care, the reason for no males was the resident had made accusations against male caregivers. The SSD stated the resident had a care plan for mood and behaviors and confirmed PTSD should have been added.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
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 provide and obtain medication per physician orders f...
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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 provide and obtain medication per physician orders for one resident (Resident #35) of the sampled six residents.
Findings included:
On 01/30/24 at 9:30 a.m., Resident #35 was observed lying in bed. She was alert and responded appropriately to questions. Resident #35 stated she felt a little sick in her stomach.
A review of the admission Record for Resident #35 showed she was originally admitted to the facility on [DATE] with diagnoses to include pancytopenia, myelodysplastic syndrome, and anemia.
Section C Cognitive Patterns of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #35 had a Brief Interview for Mental Status (BIMS) score of 08 out of 15 indicating cognitively impaired.
A review of the Order Summary Report with an order date range of 12/01/23-02/29/24 revealed the following orders:
-01/17/24- Send resident to emergency room for blood transfusion for hemoglobin and hematocrit 6.5;
-12/26/23- Send resident to hospital for blood transfusion for hemoglobin 6.3 and hematocrit 20.4;
-12/28/23- Epoetin Alfa Injection Solution 20000 unit/ml (milliliter)- Inject 3 ml intramuscularly every day shift every Tuesday, Thursday, and Saturday for hemoglobin less than 10 hold if hemoglobin was greater than 10;
-01/18/24- Procrit Injection Solution 20000 unit/ml- Inject 3 ml intramuscularly every day shift every Tuesday, Thursday, and Saturday for low hemoglobin and hematocrit;
-02/01/24- Procrit Injection Solution 20000 unit/ml- Inject 3 ml intramuscularly one time a day every Tuesday, Thursday, and Saturday for low hemoglobin and hematocrit;
-01/24/24-01/24/24- Procrit Injection Solution 20000 unit/ml- Inject 3 ml intramuscularly one time only for anemia until 01/24/24;
-01/31/24- Retacrit 20000 unit/ml Solution- Inject 3 ml intramuscularly one time a day every Tuesday, Thursday, and Saturday for low hemoglobin and hematocrit;
-01/24/24-01/25/24- Retacrit 20000 unit/ml Solution- Inject 3 ml intramuscularly one time only for anemia for 1 day;
-01/12/24- Retacrit 20000 unit/ml Solution- Inject 3 ml subcutaneously one time a day every Monday, Wednesday, and Friday related to anemia in other chronic diseases classified elsewhere. Hold if hemoglobin is greater than 10. May use Procrit as alternative;
-01/30/24-01/30/24- Retacrit Injection Solution 40000 unit/ml- Inject 1.5 ml intramuscularly for low hemoglobin;
-02/01/24- Retacrit Injection Solution 40000 unit/ml- Inject 1.5 ml subcutaneously one time a day every Tuesday, Thursday, and Saturday for hemoglobin less than 10 hold if hemoglobin was greater than 10;
-01/31/24-02/01/24- Retacrit Injection Solution 40000 unit/ml- Inject 1.5 ml subcutaneously one time only for hemoglobin less than 10 hold if hemoglobin was greater than 10 for one day.
A review of the Medication Administration Record (MAR) for 01/01/24 to 01/31/23 revealed the following:
-Epoetin Alfa Injection Solution 20000 unit/ml with a start date of 12/28/23 and a discontinued date of 01/11/24 was not administered on 01/09 and 01/11. The box was blank on 01/09 and the number 9 was in the box on 01/11. According to the Chart Codes/ Follow Up Codes, 9 means other/see progress notes.
-Procrit Injection Solution 20000 unit/ml with a start date of 01/18/24 and a discontinued date of 01/30/24 was not administered on 01/18, 01/20, 01/23, 01/25, 01/27, and 01/30. The number 9 was in the box on 01/18, 01/20, 01/23, 01/25, and 01/27. According to the Chart Codes/ Follow Up Codes, 9 means other/see progress notes. The box was blank on 01/30.
-Retacrit 20000 unit/ml Solution with a start date of 01/12/24 and a discontinued date of 01/16/24 was not administered on 01/15. The box was blank.
-Retacrit 20000 unit/ml Solution with a start date of 01/24/24 was not administered on 01/24. The number 9 was in the box. According to the Chart Codes/ Follow Up Codes, 9 means other/see progress notes.
A review of the Progress Notes revealed the following:
-01/31/24 at 03:31 (Staff X, Licensed Practical Nurse (LPN)- Writer called pharmacy to follow up on Retacrit injection. Per pharmacy technician, the medication will arrive on the morning run of today 01/30/24.
-01/30/24 at 17:27 (Director of Nursing (DON)- This writer was notified of Procrit not being available today. This writer spoke with APRN and got Procrit order reinstated and spoke with pharmacy and requested for medication to
be sent to facility.
-01/30/24 at 16:56 (Provider)- I am seeing the patient today to follow up upon recommended hospice consultation, as well as abnormal labs. Patient labs on 1/29 revealed hemoglobin level of 6.7. Nursing has alerted me that patient had not been receiving Procrit this week due to insurance issues. I have requested that pharmacy be contacted in order to supply therapeutic substitute of Retacrit/Epotein alpha. Procrit was not currently available per nursing. Advised to seek therapeutic replacement per pharmacy recommendation. Patient was currently asymptomatic. Send patient for emergency room (ER) evaluation/red blood cells (RBC) transfusion if patient begins exhibits symptomatic anemia, lethargy, syncope and notify provider.
-01/30/24 at 12:58 (Provider)- I am seeing the patient today to follow up upon recommended hospice consultation, as well as abnormal labs. Patient labs on 1/29 revealed hemoglobin level of 6.7. Nursing had alerted me that patient had not been receiving Procrit this week due to insurance issues. I have requested that pharmacy be contacted in order to supply therapeutic substitute of Retacrit/Epotein alpha. Patient was not symptomatic. Procrit was not currently available per nursing. Advised to seek therapeutic replacement per pharmacy recommendation. Patient was currently asymptomatic. Send patient for ER evaluation/RBC transfusion if patient begins exhibits symptomatic anemia, lethargy, syncope and notify provider.
-01/30/24 at 11:22am (Staff W, LPN)- Spoke with Advanced Registered Nurse Practitioners (ARNP) in regards about patient's labs and Procrit. Pharmacy waiting on insurance approval. ARNP stated power of attorney (POA) was notified of patient's condition but waiting for other POA's decision on hospice.
-01/27/24 at 14:01 (Staff W, LPN)- Writer called pharmacy in regard to patient's Procrit. pharmacy states they need authorization to send med out.
-01/27/24 at 13:55 (Staff W, LPN)- Procrit: waiting on pharmacy.
-01/25/24 at 18:49 (Staff W, LPN)- Procrit: waiting on pharmacy.
-01/24/24 at 12:27 (Staff S, LPN)- Retacrit: not available.
-01/23/24 at 18:18 (Staff Y, ARNP [advanced registered nurse practitioner])- I am seeing the patient today for hospital follow up visit. Patient was scheduled for routine visit to her hematologist on 01/18/24. Unfortunately, the patient suffered syncopal episode due to symptomatic anemia and was sent to emergency room. Hemoglobin level of 7.1 required 1 unit RBC transfusion. The patient was stabilized and discharged with recommendation to repeat labs in 1 week and send results to the doctor and call hematologist office directly if hemoglobin was less than 7. Due to patient's transfusion dependence, comorbidities, and steady decline I recommend hospice services consultation. Continue Procrit. I have ordered repeat labs per hospital discharge recommendation. The resident was transfusion dependent. Attempted outpatient transfusion set up last week. Unfortunately, the outpatient center will not accept patient due to her Hoyer transfer status. The patient was bed bound. I have recommended hospice services at this time.
-01/23/24 at 13:39 (Staff Z, LPN)- Procrit: drug will be delivered on late run. Will administer as soon as possible.
-01/20/24 at 14:22 (Staff AA, LPN)- Procrit: pending approval through insurance.
-01/18/24 at 20:37 (Staff Z, LPN)- Resident went to appointment with oncologist per wheelchair transport and escort this morning at 0900. The doctor called to report resident became diaphoretic, clammy, and hypotensive. She was sent to the ER for further evaluation. She was admitted with diagnoses of syncope and symptomatic anemia.
-01/18/24 at 11:06 (Staff Z, LPN)- Procrit: to Hematologist appointment.
-01/17/24 at 15:52 (Staff W, LPN)- Change in condition. Recommendations: stat hemoglobin and hematocrit. Send to ER for transfusion.
-01/16/24 at 16:22 (Staff Y, ARNP)- I am seeing the patient today due to nursing report that patient's routine labs for scheduled Retacrit injection resulted with 6.9 reading yesterday 1/15/24. The patient did not receive her Retacrit injection yesterday per eMAR for unknown reason. Unit manager aware. Patient was asymptomatic, stable at her baseline. The patient was without GI bleeding, hematemesis, hematochezia. She had a history of MDS with chronic anemia. She is followed by hematology. Facility staff tell me they are having trouble hearing back from hematology office in order to schedule an appointment or regarding any medication regimen adjustments recommended at this time. I have ordered STAT repeat of hemoglobin and hematocrit. Patient administered her Retacrit injection today per documentation and unit manager. I have ordered outpatient blood transfusion of one unit to be scheduled. Continue Retacrit at three times a week 60,000 units with weekly labs. Discussed orders to call office to facilitate appointment/alert of patient's recent hospitalization for any further recommendations regarding medication regimen/dosing. Low blood hemoglobin. Patient asymptomatic. Transfusion dependent per previous hematology notes. Outpatient transfusion ordered. Retacrit administered today. 5. Recommended medication
Schedule not followed (Patient's other noncompliance with medication regimen for other reason). By facility staff without notification to provider. Retacrit to be injected unless contraindicated with ordered parameters of Hgb level >10. Providers must be notified if medication was not administered. Discussed with facility staff/unit manager. She has informed me the pharmacy was requesting to switch Retacrit to Epogen for insurance purposes. This is approved. Outpatient transfusion 1 unit RBC. Retacrit to be administered - Must notify provider if medication is not given. Follow up with Hematology. I have again reiterated need to facilitate further management of disease process with specialist. Repeat labs.
-01/11/24 at 14:36 (Staff BB, LPN)- Epoetin Alfa Injection: order updated.
Review of the care plan related to anemia initiated on 10/01/21 revealed interventions to include administering medications as ordered.
During an interview on 01/30/24 at 4:12 p.m., Staff W, LPN, stated Resident #35 had been dealing with anemia for months. They sent her out to the hospital for blood transfusions and other medications. They are waiting for approval from an insurance company to see if they will pay for the Procrit. She called the pharmacy the other day and they won't send the medication because they are waiting to see if the insurance would cover it. Right now, the medication was on hold. Staff W, LPN, stated she can't keep marking the medication on hold on the MAR [medication administration record].
During an interview on 01/30/24 at 4:55 p.m., the Director of Nursing (DON) stated the resident had an order for Procrit, but it was discontinued by the doctor today. It was discontinued today at 9:51 this morning. She stated she was not sure why the medication was discontinued. Maybe because her hemoglobin was 6.5 and now it was 6.7. The DON stated, it looks like they gave it on January 2nd, 4th, and 5th. Resident #35 had an order in place but had not gotten the medication since the 6th. The DON said the doctor should be made aware if a medication was not available for whatever reason and it should be documented in the progress notes. The DON confirmed the resident had Medicare as her insurance and she stated the facility was responsible for paying for the medications if a resident had Medicare as their insurance. The DON stated she was not sure who kept denying the medication. The DON confirmed the progress notes that stated awaiting pharmacy. The resident did not have any other medications in place for a diagnosis of anemia. The DON stated the expectation was for the facility to pay for the medication and she gets the medication as ordered.
During an interview on 01/30/24 at 5:43 p.m., the DON stated she called the ARNP and got the orders reinstated and she was going to report the issue as a medication error.
During an interview on 01/31/24 at 10:50 a.m., Staff Y, ARNP, stated she was notified via phone by Staff W, LPN, of Resident #35 not receiving the Procrit yesterday. The pharmacy notified them of an insurance issue with the Procrit, so she okayed them to change the order to Retocrit. Resident #35 was ordered Procrit because she had a diagnosis of myelodysplastic syndrome, and she was considered transfusion dependent. Staff Y, ARNP, stated Resident #35 was unable to go out for outpatient transfusions due to mobility. Not receiving the Procrit could have certainly prevented or prolonged hospitalizations.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observations, policy review and interview, the facility failed to provide a clean, clutter free, comfortable, and homelike environment in three (100 Hall, 200 Hall, 400 Hall) of four halls, a...
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Based on observations, policy review and interview, the facility failed to provide a clean, clutter free, comfortable, and homelike environment in three (100 Hall, 200 Hall, 400 Hall) of four halls, and in one (#47) of one resident rooms.
Findings included:
1. On 2/1/2024 the following observations were made:
-In the clean utility rooms (North and South) multiple pieces of trash on the floor, flowerpot, walls without baseboards, baseboards with gunk, dirty floor tiles, air vents with hanging dust particles and dust on adjacent ceiling. (Photographic Evidence Obtained)
-In the North and South shower rooms, the external toilet surface was dirty. The shower chair was noted with feces on the seat stored next to clean patient items. (Photographic Evidence Obtained). Staff M, Certified Nursing Assistant, who was present during the observation agreed there was feces on the shower chair seat and said, I will clean it now.
During the survey between 1/29/24 to 2/1/24 the following was observed in multiple resident rooms:
-peeling paint, scuffed and dirty walls, buckling baseboards, holes in the walls, furniture with groves, bedside table and dresser drawers that cannot close, missing dresser drawers, and dirty floors. (Photographic Evidence Obtained)
Review of facility's policy titled, Infection Control, undated, version 1.3 revealed the following
- Policy statement: This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.
- Policy Interpretation and Implementation
1.This facility's infection control policies and apply equally to all personnel, consultants, contractors, residents, visitors, volunteer workers and the public alike, regardless, of race, color, national origin, religion, age, sex, handicap, marital or veteran status or payor source.
2.The objectives of our infection control policies and practices are to:
-Maintain a safe sanitary, and comfortable environment for personnel, residents, visitors, and the general public.
-Provide guidelines for the safes cleaning and reprocessing of reusable resident-care equipment.
Review of facility's policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, undated, version 2.0 revealed the following:
-Policy statement: resident- care equipment including reusable items and durable medical equipment will be clean and disinfected according to current Centers for Disease Control (CDC) recommendations for disinfection and the Occupational Safety and Health Administration (OSHA) bloodborne pathogen standard.
-Policy Interpretation and Implementation
5. Reusable items are cleaned and disinfected or sterilized between residents (e.g. stethoscopes, durable medical equipment)
9. DME is cleaned and disinfected before reuse by another resident.
2. On 1/29/2024 at 7:15 AM, 1/30/2024 at 9:05 AM and 3:15 PM, and on 1/31/2024 at 10:30 AM, Resident #47's room floor had large spills of a brownish liquid on the floor between the A bed and B bed. The substance had a stickiness when touched with a gloved hand. (Photographic Evidence Obtained).
During an interview on 1/31/2024 at 1:30 PM, the Director of Housekeeping confirmed there was a substance on the floor of Resident #47's room. The Director of Housekeeping stated the substance should have been mopped and cleaned up.
Review of facility policy and procedure titled Healthcare Cleaning Policy, Policy Section: Environmental Services. Policy: To clean a facility to a measure of cleanliness routinely maintained in care areas of the health care setting as they are periodically monitored and audited with feedback and education.
Procedure: 1. Floors and baseboards are free of stains, visible dust, spills and streaks. 2. Walls, ceilings and doors are free of visible dust, gross soil, streaks, spider webs and handprints. 3. All horizontal surfaces are free of visible dust or streaks (includes furniture, window ledges, overhead lights, phones, picture frames, carpets, etc.) 4. Bathroom fixtures including toilets, sinks, tubs and showers are free of streaks, soil, stains and soap scum. 5. Mirrors and windows are free of dust and streaks. 6. Dispensers are free of dust, soiling and residue and replaced/replenished when empty. 7. Appliances are free of dust, soiling and stains. 8. Waste is disposed of appropriately daily by housekeeping team as well as at shift change by nursing department. 9. Items that are broken, torn, cracked or malfunctioning are replaced. 10. High touch surfaces and client/patient/resident care areas are cleaned and disinfected with a hospital-grade disinfectant. 11. Non-critical medical equipment is cleaned and disinfected between clients/patients/residents.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
Based on observations, record reviews, and interviews, the facility failed to ensure that the medication error rate was less than 5.00%. Thirty-five medication administration opportunities were observ...
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Based on observations, record reviews, and interviews, the facility failed to ensure that the medication error rate was less than 5.00%. Thirty-five medication administration opportunities were observed and ten errors were identified for three (#86, #29, and #63) of six residents observed. These errors constituted a 28.57% medication error rate.
Findings included:
On 1/30/24 at 4:18 p.m., an observation of medication administration with Staff A, Licensed Practical Nurse (LPN), was conducted with Resident #86. The staff member dispensed the following medications:
- Lubiprostone 8 microgram (mcg) capsule
- medroyprogesterone acetate 2.5 milligram (mg) - 2 tablets
- Metformin Extended Release 850 mg tablet
The staff member confirmed dispensing 2 tablets of medroyprogesterone and with a plastic spoon removed one of the tablets, taking it to the medication room where it was destroyed. Staff A stated I wouldn't normally.
Review of Resident #86's Medication Administration Record (MAR) revealed the following medication was scheduled to be administered at the time of the observation:
- medroxyprogesterone acetate 2.5 mg tablet - Give 1 tablet by mouth in the evening.
During an interview on 1/31/24 at 3:27 p.m., the Director of Nursing (DON) said the expectation was for nurses to triple check, look at card (medication), the order, match the two.
On 1/31/24 at 8:07 a.m., an observation of medication administration with Staff S, Licensed Practical Nurse (LPN), was conducted with Resident #29. The staff member dispensed the following medications:
- Docusate sodium 100 mg tablet over-the-counter (otc)
- Eliquis 5 mg tablet
- Gabapentin 300 mg capsule
- Metoprolol Tartrate 50 mg tablet
- Amlodipine 10 mg tablet - 0.5 tab
- Vitamin C 500 mg otc tablet
Review of Resident #29's Medication Administration Record (MAR) showed the following medications were scheduled to be administered at time of the observation:
- Aldactone 25 mg tablet (documented as administered),, scheduled at 9:00 a.m.
- Sennosides 8.6 mg - 2 tablets (documented as administered), scheduled at 9:00 a.m.
- Hiprex (Methenamine Hippurate) 1 gram (gm) (documented as administered), scheduled at 9:00 a.m.
- Miralax 17 gm (documented as administered), scheduled at 9:00 a.m.
- Ascorbic Acid 500 mg - 2 tablets, scheduled at 9:00 a.m.
- Oxybutynin ER 5 mg (documented as administered), scheduled at 9:00 a.m.
- Paroxetine 30 mg (documented as administered), scheduled at 9:00 a.m.
On 1/31/24 at 8:38 a.m., an observation of medication administration with Staff T, Registered Nurse (RN), was conducted with Resident #63. The staff member dispensed the following medications:
- Vitamin D 25 mcg over-the-counter (otc) tablet
- Calcium + Vitamin D 500 mg otc tablet
- Ferric X 150 mg otc capsule
- Aripiprazole 15 mg tablet
- Triamterene - HCTZ 37.5-25 mg tablet
- Oxybutynin 100 mg ER tablet
- Prazosin 1 mg capsule
- Metformin 1000 mg tablet
- Duloxetine 60 mg capsule
- Losartan potassium 25 mg tablet
- Gemfibrozil 600 mg tablet
- Eye drops (Tetrahydrozoline) 0.05% otc
Staff F confirmed dispensing 11 oral tablets. The staff member administered one drop of Tetrahydrozoline into right eye then one drop into the left eye.
Review of Resident #63's Medication Administration Record (MAR) revealed the following errors were observed:
- Cholecalciferol - Give 1000 mg by mouth one time a day.
- Artificial Tears Ophthalmic 1% solution (carboxymethlcullulose sodium)
During an interview on 1/31/24 at 3:40 p.m. the DON stated the eye drops administered were not what was ordered, and voiced no comment regarding the milligram dosage of Vitamin D.
Review of the policy - Administration Procedures For All Medications (April 2018) revealed To administer medications in a safe and effective manner. The procedure instructed staff to Review 5 Rights (3) times, which included:
- Prior to removing the medication package/container from the cart/drawer staff were to check MAR for order, check for vital signs and other tests, and prepare resident for medication administration.
- Prior to removing the medication from the container staff were to check the label against the order on the MAR and note any supplemental labeling (fractional tablet, multiple tablets, volume of liquid, shake well, give with another medication).
- After the dose has been prepared and before returning the medication to storage.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 1/29/2024 at 6:35 AM and 1/30/2024 at 9:11 AM, two skin prep packets were observed on the top of the nightstand next to th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 1/29/2024 at 6:35 AM and 1/30/2024 at 9:11 AM, two skin prep packets were observed on the top of the nightstand next to the bed of room [ROOM NUMBER] A. (Photographic Evidence Obtained).
On 1/29/2024 at 6:50 AM and 1/30/2024 at 11:47 AM, Psyllium fiber supplement, Dulcolax laxative, and multiple packets of skin prep were observed on the top of the dresser of room [ROOM NUMBER]. (Photographic Evidence Obtained).
On 1/29/2024 at 7:10 AM and 1/30/2024 at 9:15 AM, Dermal wound cleanser was observed in a basin on the top of the nightstand next to the bed of 303 B. (Photographic Evidence Obtained).
On 1/29/2024 at 7:15 AM and 1/30/2024 at 9:05 AM, Hydrogen Peroxide bottle was sitting on the over the bed table, next to bed 304 B and dermal wound cleanser was in the bathroom, on top of the back of the toilet tank. (Photographic Evidence Obtained).
On 1/29/2024 at 9:22 AM and 1/30/2024 at 9:40 AM, Dermal wound cleanser was observed on the nightstand next to the bed of 308 B. (Photographic Evidence Obtained).
An interview was conducted with Staff T, RN on 1/31/2024 at 10:30 AM. Staff T, RN stated skin prep and dermal wound cleanser are considered medicine and require an order from a physician. Staff T, RN is not aware of any of the residents having self-administration orders.
An interview was conducted with Staff A, LPN who confirmed Hydrogen Peroxide should not be left at the bedside of the resident.
During an interview) on 1/31/2024 at 1:22 PM the Director of Nursing (DON) stated medications should not be left out in the open.
Review of the facility policy and procedures titled: Medication Storage In The Facility, ID1: Storage of Medications, by Polaris Pharmacy dated April 2018. Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures: . B. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aids) permitted to access medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. D. Orally administered medications are kept separate from externally used medications and treatments such as suppositories, ointments, creams, vaginal products, etc. Eye medications are stored separately per facility policy. F. Medications labeled for individual residents are stored separately from floor stock medications when not in the medication cart. I. Medication storage areas are kept clean, well-lit, and free of clutter and extreme temperatures and humidity. J. Medication storage conditions are monitored on a monthly basis by the consultant pharmacist or pharmacy designee and corrective action taken if problems are identified. K. Refrigerated medications are kept in closed and labeled containers, with internal and external medications separated and separate from fruit juices, applesauce, and other foods used in administering medications. Other foods such as employee lunches and activity department refreshments are not stored in this refrigerator. L. All medications are maintained within temperature ranges noted in the United States Pharmacopoeia (USP) and by the Centers for Disease Control (CDC). 1) Room Temperatures 59°F to 77°F (15°C to 25°C). 2) Controlled Room Temperature (the temperature maintained thermostatically) 68°F to 77°F (20°C to 25°C) 3) Refrigerated 36°F to 46°F (2 to 8°C) with a thermometer to allow temperature monitoring. 4) Frozen in the freezer at 14°F to 20°F (-10°C to -7°C). Temperature: A. Medications and biologicals are stored at their appropriate temperatures and humidity according to the United States Pharmacopoeia (USP) guidelines for temperature ranges. C. Medications requiring refrigeration are kept in a refrigerator at temperatures between 36°F (2°C) and 46° F (8°C) with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place are refrigerated unless otherwise directed on the label. Controlled substances that require refrigeration are stored within a locked box within the refrigerator. This box must be attached to the inside of the refrigerator. D. Medications that should be frozen should be stored in the freezer at 14°F (-10°C) to -20°F(-7°C). E. The facility should maintain a temperature log in the storage area to record temperatures at least once day. F. The facility should check the refrigerator or freezer in which vaccines are stored at least two times a day, per CDC guidelines.
2. On 01/29/24 at 8:18 a.m., a medication cart was observed unlocked (photographic evidence obtained), with no staff in direct sight of the cart on the 100 hall. The nurse who was assigned to the cart was observed going into room [ROOM NUMBER] with medications and the cart was outside of room [ROOM NUMBER]. Two staff members walked by the cart and did not lock the cart. At 8:23 am., Staff C, Registered Nurse (RN), confirmed the cart was left unlocked.
Based on observations, record reviews, and interviews, the facility failed to store medications appropriately and safely as evidenced by improper temperature in one (north) of two medication room refrigerators, failed to ensure medications were stored when administering medications on one (100) out of four hallways, and failed to ensure medications were not left at the resident's bedside unattended in five (104a, 302, 303b, 304b, and 308b) of five resident rooms.
Findings included:
1. On 1/31/24 at 7:56 a.m., an observation was conducted with Staff S, Licensed Practical Nurse (LPN) of medication administration. The staff member dispensed medications which were refused by the resident. Staff S walked to the medication room on the north unit to destroy the medications and the observation of the med room revealed the refrigerator door was open. The thermometer hanging inside the refrigerator read 68 degrees Fahrenheit. The staff member stated it was warm, and she had not noticed the door being open but did confirm the temperature could not have risen from the posted temperature taken by night shift of 36 degrees to the 68 in the seconds this writer brought the refrigerator to her attention. The refrigerator door was unable to shut, the staff member left it as is and left the room returning to the medication cart. The observation revealed several insulin pens and 2 pre-filled immunization-type syringes were left in 2 gray basins inside the warm refrigerator. The observation revealed staff members had recorded a refrigerator temperature of 36 Fahrenheit at 5:30 a.m.
During the task of medication administration, on 1/31/24 at 8:07 a.m., Staff S was observed dispensing medication at the cart parked at the side of Resident #29's room. The resident was sitting in the doorway. The staff member left 3 pharmacy blister cards containing medications and 2 bottles of over-the-counter medications on the opposite end of the cart, while administering the medications to the resident. The staff member confirmed the medications were left on the cart, unsecured.
An interview was conducted on 1/31/24 at 8:30 a.m. with Staff A, Licensed Practical Nurse/Unit Manager. The staff member observed the refrigerator in the medication room on the North unit. The door of the refrigerator continued to be open. The staff member became upset stating all the insulins, 9 pens, were not any good, would have to be reordered. Staff A examined the refrigerator and removed a slim yellow plastic bin from the door and reported it was the reason the door had not been able to shut. The Regional Nurse Consultant (RNC) arrived and stated the insulin would need to be reordered. and asked Staff A to ensure nurses had not removed any medications from the refrigerator.
The policy - Storage of Medications, effective April 2018, revealed:
Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. The procedure showed Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) permitted to access medications. Medication rooms, carts, and medications supplies are locked when not attended by persons with authorized access. All medications are maintained within the temperature ranges noted in the United States Pharmacopoeia and by the Centers for Disease Control:
1.Room temperature 59 to 77° Fahrenheit (F)
2. Controlled room temperature (the temperature maintained thermostatically) 68 to 77 F.
3. Refrigerated 36 to 46°F with a thermometer to allow temperature monitoring.
4. Frozen in the fridge freezer at 14 to 20°F.
Review of the manufacturer information, unused Novolog should be stored in a refrigerator between 36 to 46 degrees F. (Information located at https://www.novo-pi.com/novolog.pdf)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observations and interviews, the facility failed to ensure one (north) of two nourishment refrigerator/freezer was maintained to prevent the potential for foodborne illness and to ensure that...
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Based on observations and interviews, the facility failed to ensure one (north) of two nourishment refrigerator/freezer was maintained to prevent the potential for foodborne illness and to ensure that food items were dated and labeled.
Findings Included:
On 01/31/ 2024 at 9:00 AM an observation was made in North and South Nourishment Rooms with the dietary manager and Nursing Home Administrator. The North nourishment room was observed dirty with food items stored in the refrigerator and freezer not dated or labeled.
On 01/31/2024 at 9: 20 AM an interview was conducted with the Certified Dietary Manager. He said the nourishment room refrigerator and freezer were maintained by the dietary staff daily. The refrigerators and freezers in the nourishment rooms should be kept clean. If food items are stored in the nourishment rooms staff must ensure those items are labeled and dated before they store food in the refrigerator or freezers. Staff are not allowed to store their own food in the refrigerator because it's only for the residents. If food is stored in the refrigerator of freezers the policy is that it must be discarded within three days. He stated In the North side nourishment room food should have never been stored in the refrigerator and freezer without being labeled or dated. I will give an in service to the nursing and dietary staff regarding food storage.
On 1/31/2024 at 9:35 AM an interview was conducted with the Nursing Home Administrator. She said food should be labeled and dated before staff store any food items in the nourishment rooms refrigerator or freezers. We will have to provide further education for our staff regarding the usage of the nourishment rooms and food storage.
Review of the facility policy titled Food and Supply Storage Effective date 11/30/2014,
Policy: Food and supplies will be stored under sanitary and secure conditions and according to approved State and Federal standards, to retain the quality of products.
The facility did not provide a completed food storage policy to reflect the facility storage guidelines as referred to in their food and supply storage policy.
(Photographic evidence obtained)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0848
(Tag F0848)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to ensure the arbitration agreements presented to two residents of of three residents reviewed provided for the selection of a venue convenien...
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Based on record review and interview, the facility failed to ensure the arbitration agreements presented to two residents of of three residents reviewed provided for the selection of a venue convenient to both parties and selection a neutral arbitrator agreed upon by both parties.
Findings included:
Review of the admission Agreement with a revised date of 8/19, page 13 and 14. Page 13, showed a heading of OPTIONAL ARBITRATION AGREEMENT. the fifth paragraph on page 13 shows: The parties agree that only one (1) arbitrator is required to resolve any Dispute(s) and the arbitrator shall be selected from a panel to be provided by the Facility. The panel shall consist of at least three (3) individuals who are qualified by the state to serve as an arbitrator, who have experience and knowledge of the health care industry or have served as mediators in health care malpractice claims, and who can certify they are neutral and impartial. If the parties agree to a single arbiter, the arbitrator's compensation and administrative fees related to the arbitration shall initially be paid by Facility. If the Facility prevails, then the arbitrator may order that the Resident/Representative reimburse it for any or part of any compensation or administrative fees paid. In the event the parties are unable to agree on a single (1) arbitrator, then a panel of three (3) is to be used (each party will select one (1) arbitrator and then the two (2) selected arbitrators shall select the third (neutral). If the parties cannot agree to a single arbitrator, then each party shall bear the cost of their selected arbitrators compensation and administrative fees and will pay half of the neutral's costs and fees. The panel may order the non-prevailing party to reimburse the prevailing party for any or part of any compensation or administrative fees paid.
An interview was conducted with the admission Director (AD) on 1/31/2024 at 8:59 AM. The AD confirmed responsibility of admission Agreement, which includes the Arbitration Agreement. The AD stated that the wording of a panel to be provided by the Facility does not indicate a neutral arbitrator agreed upon by both parties. Appears the Facility chooses the panel for the Resident/Representative to choose from.
An interview was conducted with the Nursing Home Administrator (NHA) on 1/31/2024 at 9:30 AM. The NHA reviewed the Arbitration Agreement and stated, a panel to be provided by the Facility. The NHA stated this does not sound like a neutral arbitrator agreed upon by both parties.
An interview was conducted with the Nursing Home Administrator (NHA) on 1/31/2024 at 11:15 AM. The NHA returned and stated the legal department had been consulted and that a a panel to be provided by the Facility, not one chosen by the parties.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
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, interviews, and policy review, the facility failed to ensure infection control practices were followed re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and policy review, the facility failed to ensure infection control practices were followed related to 1.) cleanliness and prevention of biogrowth on two (north and south) ice machines; 2.) use of Personal Protective Equipment (PPE) as required by door signage for two (#342, #20) of two residents; 3.) hand hygiene on three of four halls (100, 200 and 400) halls; and 4.) cleanliness of resident equipment/supplies in resident rooms for residents #47 and #66
Findings included:
On 1/13/24 at 8:20 a.m. during observation of the North and South Clean utility rooms. The Ice machines (bins) had what appeared to be yellow mineral deposits and grayish black bio growth. (Photographic Evidence Obtained).
On 1/31/24 at 8:45 a.m. the Nursing Home Administrator (NHA) was accompanied to observe the ice machines. The NHA said she was not sure if the housekeeping or maintenance staff was responsible for cleaning the ice machines. The NHA took photographs of the ice machine. Copies of the ice machines cleaning logs and maintenance service invoices were requested.
On 1/31/24 at 08:50 a.m. the Environmental Services Director (EVS) said it was the maintenance department's responsibility to clean the ice machines.
On 1/31/24 at 9:30 a.m. the NHA said the ice machine bins in the North and South clean utility rooms have been placed out of commission. She said she will provide ice machine cleaning logs and service invoices.
On 2/1/24 the NHA provided a [brand name], Instruction Manual, issued 4/18/2016, revised 10/14/2022, cleaning and sanitizing instructions revealed -The ice dispenser must be cleaned and sanitized at least once a year. More frequent cleaning and sanitizing may be required in some water conditions.
Throughout the remainder of the survey the facility failed to provide copies of the ice machines cleaning logs or maintenance invoices.
On 1/31/24 at 10:34 a.m. during interview and observation of the facility's laundry area was conducted with the Environmental Services Director. In the clean side of the laundry area, mechanical lift slings were hanging from wall hooks and resting directly on the floor.
On 1/31/24 at 1:09 p.m. during an interview Staff H, Certified Nursing Assistant (CNA), said it is easy to know when residents require PPE because isolation precautions signs are posted on the room doors. A tour of 100 and 200 halls was conducted with Staff H. Two separate isolation rooms were observed (100 and 200 halls) with residents in Special Droplet/ Contact Precautions signs. The sign on 100 hall contained x beside the precaution's instructions while the same sign on 200 halls did not. Staff H, CNA, said she did not know what the sign with the x meant. (Photographic Evidence Obtained)
A review of Resident 342's admission record revealed admission to the facility on 1/24/24. Resident 342 diagnoses include cellulitis (inflammation), and methicillin resistant staphylococcus aureus (MRSA) infection.
A review of Resident # 342's Medical Certification for Medicaid Long-term Care Services and Patient Transfer form (3008), signed 1/22/24 revealed MRSA infection in the wound.
A review of physician order for Resident # 342 written on 1/25/24 revealed evaluate for possible scabies.
A review of physician order for Resident # 342 dated 1/29/ 24 at 10:39 a.m. revealed an order for Contact precautions- MRSA in wound.
A review of Resident #342's admission orders revealed both ankle wounds should be cleansed, and dressing applied every night shift.
On 1/29/24 at 7:30 a.m. Staff N, CNA, was observed entering and exiting Resident #342's room without wearing PPE. An interview was conducted and Staff N, CNA, said I do not have any residents on isolation.
During an interview on 01/29/24 at 7:32 a.m. Resident # 342 said she was admitted to the facility on [DATE]. She was told at the hospital she had scabies and needs a pill to treat the condition. Resident #342 said her wound dressings had not been changed since Friday night 1/26/24. A scattered rash was observed on Resident #342's right forearm.
During an interview one 01/29/24 10:37 a.m. the Director of Nursing (DON) said Resident #342 was on Contact isolation for MRSA in wound. The DON was notified of staff observations entering and interacting with the resident without the use of PPE. The DON confirmed if it was noted on admission Resident #342 was in contact isolation for MRSA in wound, the admission staff should have initiated the appropriate isolation precautions.
Review of the admission records for Resident #20's admission record revealed Resident #20 was admitted on [DATE] with diagnoses including diabetes, renal disease, right below the knee amputation.
Review of Resident #20's order listing report revealed the following:
-Enhanced contact precautions for C. Auris. Must wear gown and gloves when providing intimate care dated 9/7/23. Isolation-Contact: Enhanced Barrier dated 11/21/23.
Observation of Resident #20's room door revealed a sign titled Contact Precautions posted Resident #20's room door revealed the following instructions:
-Perform hand hygiene
-Wear gown before entering and remove upon exiting
-Wear gloves before entering and remove upon exiting
On 1/29/24 at 9:30 a.m. observation and interview conducted with Resident #20 who in reference to the isolation sign stated Don't know what it means, people come in and out don't know what the sign is for. Resident #20 said he has lived at the facility a little over a year.
Review of Resident # 45's admission record revealed admission to the facility on [DATE] with diagnoses to include chronic respiratory failure, dependence on supplemental oxygen, and diabetes. Review of Resident #45's Order Listing Report revealed on 1/23/24 Isolation droplet precautions due to COVID-19.
An observation on 01/29/24 at 7:23 a.m. revealed Resident # 45's room door had signage special droplet/ contact precautions sign posted. The sign revealed the following.
-Everyone must clean hands when entering and leaving the room
-Wear facemask at all ties (N-95 or higher-level respirator for aerosol generating procedures)
-Wear eye protection
-Gown and glove at door
-Keep door closed
-Use patiently dedicated or disposable equipment. Clean and disinfect shared equipment.
On 01/29/24 at 8:29 a.m. an unidentified facility staff member was observed entering resident #45's room. The Staff member did not wear eye protection; a second staff member was observed entering the room to provide assistance and did not wear eye protection.
01/31/24 at 9:32 a.m. during observation of the south shower room shower chairs, mechanical lifts and wheelchairs are all commingled with no indication if the equipment is clean or dirty. An interview was conducted with Staff B, Certified Nursing Assistance (CNA) at the time of the observation who said I always clean the shower chair before I use it, it is common Sense.
Review of facility's policy titled, Infection Control, undated, version 1.3 revealed.
- Policy statement This facility's infection control policies and practices are intended Review of facility's policy titled, Cleaning and Disinfection of Resident-Care, undated, version 2.0 revealed. Items and equipment.
to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.
- Policy Interpretation and Implementation
1. This facility's infection control policies and apply equally to all personnel, consultants, contractors, residents, visitors, volunteer workers and the public alike, regardless, of race, color, national origin, religion, age, sex, handicap, marital or veteran status or payor source.
2. The objectives of our infection control policies and practices are to:
a. Prevent, detect, investigate and control infections in the facility.
b. Maintain a safe sanitary, and comfortable environment for personnel, residents, visitors, and the general public.
c .Establish guidelines for implementing isolation precautions, including stand and transmission-based precautions;
d. Establish guidelines for the availability and accessibility of supplies and equipment necessary for standard and transmission-based precautions.
e. Maintain records of incidents and corrective actions related to infections and
f. Provide guidelines for the safes cleaning and reprocessing of reusable resident-care equipment.
3.The Quality Assurance and Performance Improvement Committee (QAPI), through the Infection Control Committee, shall establish, review, and revise infection control policies and practices, and help department heads and managers ensure that they are implemented and followed.
4. All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities.
5.The administration and governing board, through the QAPI and infection control committees, has adopted infection control policies and practices. Inquiries concerning our infection control policies and facility practices should be referred to the infection preventionist or director of nursing services.
Review of facility's policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, undated, version 2.0 revealed.
-Policy statement: resident- care equipment including reusable items and durable medical equipment will be clean and disinfected according to current Centers for Disease Control (CDC) recommendations for disinfection and the Occupational Safety and Health Administration (OSHA) bloodborne pathogen standard.
-Policy Interpretation and Implementation
5. Reusable items are cleaned and disinfected or sterilized between residents (e.g. stethoscopes, durable medical equipment)
5 a. Single resident use items are cleaned/ disinfected between uses by a single resident and disposed of afterwards (e.g. bedpans and urinals)
6. Reusable resident care equipment is decontaminated and/ or sterilized between residents according to manufacturer's instructions.
7. Only equipment that is designated reusable is used by more than one resident.
9. DME is cleaned and disinfected before reuse by another resident.
Review of facility's policy titled, Isolation - Categories of Transmission Based Precautions (TBP), undated, version 2.1 revealed. Items and equipment.
-Policy Statement: transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents.\
-Policy Interpretation and Implementation
1. Standard precautions are used when caring for residents at all times regardless of their suspected or confirmed infection status.
2. Transmission based precautions are additional measures that protect staff, visitors and other residents from becoming infected. These measures are determined by the specific pathogen and how it spreads from person to person. The three types of transmission-based precautions our contact, droplet and airborne.
3. The Centers for Disease Control and Prevention (CDC) maintains a list of diseases, modes of transmission and recommended precautions.
4. The facility makes every effort to use the least restrictive approach to manage an individual's potentially communicable infections. Transmission based precautions are used only when the spread of infection cannot be reasonably prevented by a less restrictive method.
5. When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and type of precaution.
a. The signage informs the staff of the type of CDC precautions, instructions for use of PPE, and/ or instructions to see a nurse before entering the room.
b. Signs and notifications comply with the resident's right to confidentiality or privacy.
6. When transmission-based precautions are in effect, non-critical resident care equipment items such as a stethoscope, sphygmomanometer, or digital thermometer will be dedicated to a single resident (or cohort of residents) when possible.
Contact Precautions
1. Contact precautions may be implemented for residents known or suspected to be infected with microorganism that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the resident's environment.
2. The decision on whether contact precautions are necessary will be evaluated on a case-by-case basis.
3. The individual on contact precautions will be placed in a private room if possible. If a private room is not available, the infection preventionist will assess various risks associated with other resident placement options (e.g. cohorting, placing with a row risk roommate).
4. Staff and visitors will wear gloves (clean, or non-sterile) when entering the room.
a. While caring for a resident, staff will change gloves after having contact with infective material (for example, fecal material and wound drainage)
b. Gloves will be removed, and hand hygiene performed before leaving the room.
c. Staff will avoid touching potentially contaminated environmental surfaces or items in the resident's room after gloves are removed.
5. Staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after a gown is removed.
6. When transporting individuals with skin lesions, excretions, secretions, or drainage that is difficult to contain, contact precautions will be taken join resident transport to minimize the risk of transmission.
Droplet Precautions
1. Droplet precautions may be implemented for an individual documented or suspected to be infected with transmitted by droplets (large particle droplets [ larger than 5 microns in size] that can be generated by the individual coughing, sneezing, talking, or by the performance of procedures such as suctioning).
2. Residence on droplet precautions will be placed in a private room if possible.
a. When a private room is not available, residents may share a room with a resident infected with the same microorganism or with limited risk factors.
b. When a private room is not available and cohorting is not achievable, a curtain will be used and a distance of at least three feet in space will be maintained between the infected resident and his or her roommate.
c. Special air handling and ventilation are unnecessary and the door to the room may remain open.
3. Mask must be worn when entering the room.
4. Gloves, gowns and goggles should be worn if there is risk of spraying respiratory secretions.
2. On 1/29/2024 at 8:20 AM, Staff D, Certified Nursing Assistant (CNA) was observed with procedure mask on. Staff D, CNA started to assist with the morning breakfast tray service to the residents of the 100 hallway. Staff D, CNA removed a breakfast tray from the meal cart outside the door of room [ROOM NUMBER]. room [ROOM NUMBER] had a droplet isolation sign posted on the door and a Personal Protective Equipment (PPE) supply cart outside the door. Staff D, CNA opened the meal cart, removed a tray, and proceeded into room [ROOM NUMBER], bed A. Placed the tray down and set up the meal, exited the room. No hand hygiene was observed. Walked to the coffee cart, which was located behind the nurse's station. Prepared a cup of coffee. Carried the cup back to room [ROOM NUMBER]. Entered and gave the coffee to the resident in bed A. Exited the room at 8:23 AM. No hand hygiene was observed. At 8:25 AM Staff D, CNA touched her procedure mask with her ungloved hands and requested Staff H, CNA assist her. Staff D, CNA walked directly back into room [ROOM NUMBER]. Staff H, CNA called to Staff D, CNA to come back and put on your PPE. Staff H, CNA, and Staff D, CNA donned gown and gloves. Staff D, CNA had a procedure mask on and Staff H, CNA had a KN95. Staff H, CNA went to two PPE carts looking for eye protection. Gave up and entered the room without eye protection. At 8:28 AM both CNAs were observed doffing the gowns and gloves inside the resident door, placed the gowns in the trash receptacle. Both removed gloves. Staff H, CNA donned a new pair of gloves and gathered up the overflowing trash bag. Proceeded to exit the room. While walking to exit the room, Staff H, CNA removed one glove and placed this glove in the hand of her other gloved hand, which was holding the trash bag. Exited the room. Proceeded to the soiled utility room. No hand hygiene was observed. Staff D, CNA doffed PPE inside resident room [ROOM NUMBER]. Exited room, walked to the nurses' station, attempted to open the bathroom door, was unsuccessful. Proceeded to the recreation/dining room, located in front of the nurses' station and washed her hands with soap and water.
An interview was conducted with Staff H, CNA on 1/29/2024 at 2:05 PM. Staff H, CNA stated room [ROOM NUMBER]B has Covid and is on droplet isolation. Staff H, CNA noted a droplet sign on the door indicates the PPE needed to enter, gown, gloves, N95 or equivalent, and eye protection. Staff H, CNA stated proper PPE must be worn any time entering the room. Staff H, CNA confirmed no shield was available for eye protection and earlier in the morning no eye protection was available and had to enter the room without. Staff H, CNA confirmed no hand hygiene was completed at the time they exited the room.
An interview was conducted with Staff D, CNA on 1/29/2024 at 2:35 PM. Staff D, CNA stated she only needed to wear PPE in room [ROOM NUMBER] when caring for bed B. Staff D, CNA was not able to differentiate between what PPE to wear in a contact isolation room and droplet. Staff D, CNA stated only if I am providing care do you need to wear PPE and this is when hand hygiene would be performed. Staff D, CNA confirmed no hand hygiene occurred earlier in the day.
An interview was conducted with the Licensed Practical Nurse, Unit Manager (LPN, UM) on 1/29/2024 at 3:05 PM. The LPN, UM stated the staff know what PPE to wear by reading sign on the outside of the resident room door. The staff should utilize whatever PPE is on the sign. Proper hand hygiene should always be utilized regardless of isolation. Hand hygiene should be done when entering/exiting a room, don/doff PPE etc.
On 1/29/2024 at 7:20 AM and 1/30/2024 at 2:30 PM, Resident #66's bathroom was observed with a bowl and eating utensil, sitting in the resident's sink, the dish was full of cloudy water. On the top of the toilet tank was a stack of dishes and utensils. (Photographic Evidence Obtained).
An interview was conducted with Resident #66 on 1/29/2024 at 7:20 AM. Resident #66 stated the CNAs wash them for me if they have time. I utilize the dishes to make some of the food I have here in my room. The CNAs assist me with preparing and serving when I ask. He stated the CNAs must've forgotten to wash them. After they wash the dishes in my sink, they place them on the back of the toilet.
On 1/29/2024 at 7:15 AM and 1/30/2024 at 10:30 AM, Resident #47's oxygen concentrator was observed with small particles of debris, crusted brownish particles and a light brownish liquid sticky in appearance dripping, all over the front of the machine.
An interview was conducted with Director of Nursing (DON) on 1/31/2024 at 1:20 PM. The DON confirmed the dish in the sink appeared dirty and the dishes on the back of the toilet. The DON continued to state the dishes should not be stored in the bathroom. The dishes should be taken to the kitchen for proper sanitation. The DON continued to state the oxygen concentrator for Resident #47 was soiled and needed to be cleaned.
A review of the facilities policy and practices titled, Infection Control, revealed: Policy: this facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. Policy interpretation and implementation: 1. This facility's infection control policies and practices apply equally to all personnel, consultants, contractors, residents, visitors, volunteer workers, and the general public alike, regardless of race, color, creed, national origin, religion, age, sex, handicap, marital or veteran status, or payer source. 2.d. Establish guidelines for the availability and accessibility of supplies and equipment necessary for standard and transmission based precautions; . f. Provide guidelines for the safe cleaning and reprocessing of reusable resident care equipment. 4. All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected multiple residents
Based on interviews and record reviews, the facility failed to ensure the resident's medical record included documentation indicating the resident or resident's representative was provided education r...
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Based on interviews and record reviews, the facility failed to ensure the resident's medical record included documentation indicating the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza and pneumococcal immunizations; and the resident either received the immunization or did not receive the immunization due to medical contraindications or refusal for five (#12, #77, #15, #55 and #20) out of five resident immunization records reviewed.
Findings Included:
A review of the facility's admission forms, provided to all new admissions did not include influenza and pneumococcal immunization education and vaccine consents.
A review of the immunization and miscellaneous sections of the resident's Electronic Health Record (EHR) where vaccine administration and related education are documented was conducted. Residents #12, #77, #15, #55 and #20 EHR was silent for documentation indicating the resident or the resident's representative was provided education regarding the benefits and potential side effects of influenza and pneumococcal immunizations; and the resident either received the immunization or did not receive the immunizations due to medical contraindications or refusal. A review of residents #77, #15, #55 and #20 did not reveal documentation the influenza vaccine was offered and/or administered between 10/1/23 and 2/1/24 per facility policy.
On 1/30/24 at 2:25 p.m. during an interview the Director of Nursing (DON) said, vaccine administration is documented in the Medication Administration Record (MAR) of the EHR. Evidence regarding vaccine education was the Vaccine Information Sheet (VIS) is scanned to the Electronic Health Record (EHR). Immunization administration documentation can also be found in the immunization section of the EHR.
A review of EHR did not reveal influenza and pneumonia vaccines were offered to residents #77, #15, #55, #30 and immunization education was provided. The DON said she would provide immunization records residents # 12, #77, #15, #55 and #20. (Photographic Evidence Obtained)
On 1/31/24 at 10:15 a.m. during an interview the DON said this is what I found and provided several sheets of paper. The DON said documentation regarding resident influenza and pneumonia immunization status is missing and the facility will have to start over verifying resident's immunization status and providing vaccine education.
Review of facility's policy titled, Pneumococcal Vaccine, version 2.1.
-Policy Statement: All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/ pneumococcal infections.
Policy and interpretation and implementation
1. Prior or upon admission, residents will be as for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated.
2. Before receiving the pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Provision of such education shall be documented in the resident's medical record.
Review of facility's policy and procedure subject, Influenza Vaccine- Resident, revised on 8/17/2020, showed.
-Policy residents will be offered the influenza vaccine annually (between October 1st and March 31st unless otherwise directed by the CDC) to encourage and promote the benefits associated with vaccinations against immunization, in accordance with the local health department and Centers for Disease control guidelines.
1. Provide resident and resident /. representative education on potential side effects and risk and benefits of the vaccine
-Provide a copy of the Vaccine Information Sheet (VIS) from the Centers for Disease Control (CDC)
2. Obtain informed consent from them. resident / resident representative if indicated.
3. Obtain a physician's order.
4. Administer the vaccine and document on the Medication Administration Record
5. File the informed consent in the medical record.
6. Document in the medical record included.
-Education including potential side effects of the vaccine.
-Resident received the vaccine.
-The resident did not receive the vaccine due to medical contraindication, has received the vaccine outside of the center, or refused.
Review of facility's policy and procedure subject, admission Assessment, effective 11/30/2014 and revised on 8/22/2017.
-Procedure: at the time of admission or readmission, the nurse shall initiate the admission data collection form or its electronic equivalent. Pertinent information shall be collected by physical review, interview with the resident and a family and review of the resident's available medical records. The data collection form or its electronic equivalent will be completed within 24 hours.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
Could have caused harm · This affected multiple residents
Based on interviews and record review, the facility failed to ensure screening and eligibility to offer the COVID -19 vaccine and vaccine education regarding the benefits and potential side effects wa...
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Based on interviews and record review, the facility failed to ensure screening and eligibility to offer the COVID -19 vaccine and vaccine education regarding the benefits and potential side effects was documented according with national recommendations for five (# 12, #77, #15, #55 and #20) out of five resident immunization records reviewed.
Findings Included:
A review of the facility's admission forms, provided to all new admissions did not reveal COVID-19 immunization education, refusal or consents related to vaccines.
On 1/30/24 at 2:25 p.m. during an interview the Director of Nursing (DON), said vaccine administration is documented in the Medication Administration Record (MAR). When vaccine education is provided the Vaccine Information Sheet (VIS) is scanned to the resident's Electronic Health Record (EHR). Documentation can also be found in the immunization section of the EHR. A request was made for the facility's immunization policies.
On 1/31/24 at 10:15 a.m. an interview was conducted with the DON said this is what I found. Documentation of screening, and eligibility to offer the COVID -19 vaccine, and education regarding the benefits and potential side effects of the vaccine was not provided for Residents # 12, #77, #15, #55 and #2. The DON failed to provide a Covid-19 immunization policy throughout the survey.
Review of facility's policy and procedure subject, admission Assessment, effective 11/30/2014 and revised on 8/22/2017.
-Procedure: at the time of admission or readmission, the nurse shall initiate the admission data collection form or its electronic equivalent. Pertinent information shall be collected by physical review, interview with the resident and a family and review of the resident's available medical records. The data collection form or its electronic equivalent will be completed within 24 hours.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected most or all residents
Based on observations, interviews, and record review, the facility failed to ensure sufficient staffing in order to provide care and services to residents on four (100, 200, 300 and 400) of four halls...
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Based on observations, interviews, and record review, the facility failed to ensure sufficient staffing in order to provide care and services to residents on four (100, 200, 300 and 400) of four halls observed
Findings Include:
1. On 1/29/2024 at 7:00 AM an observation occurred of Staff O, Registered Nurse (RN) stating to another employee, I refuse to take over two medications carts that are across the building, that is too much.
On 1/29/2024 at 7:30 AM an observation of Staff O, RN was in the Nurse Manager office stating, only taking the cart accepted on the 300 hallway and to accept the cart for 100 hallway is too much for one nurse.
On 1/29/2024 at 7:45 AM an observation of Staff O, RN speaking to Staff C, RN. Staff O, RN explained that Staff O, RN would not be taking over the care of the residents on the 100 cart.
An interview was conducted with Staff C, RN on 1/29/2024 at 10:45 AM. Staff C, RN stated I am the only nurse on this unit, the other nurse scheduled did not show up. I am currently responsible for 47 residents.
An interview was conducted with the Staffing Coordinator (SC) on 1/29/2024 at 11:10 AM. The SC stated we usually staff 4 nurses on day (7a-3p) shift, although we are trying to split the assignment down to 3 nurses. Today, we had a nurse, no call no show and another nurse who called off. We are not utilizing any agency for staff, management decided we could work with 3 nurses today. We have a total of 90 residents on the 4 hallways. Continuing, she said I am not aware [Staff O, RN] refused to assist with the 100 hall residents, I will have to go find out.
An interview was conducted with the SC on 1/29/2024 at 11:45 AM. The SC stated the Licensed Practical Nurse (LPN) Unit Manager (UM) would be taking over the cart on the 100 hallway.
An interview was conducted with Resident #66 on 1/29/2024 at 7:20 AM. Resident #66 stated it takes forever for the staff to answer the call light, stating It does not matter time of day or day of week, takes a long time. This makes me nervous, if I were to really need help.
An interview was conducted with Resident #47's responsible party on 1/29/2024 at 1:29 PM. Resident #47's responsible party stated, I see some care areas lacking. The responsible party continued to state, I have to wipe him up when I come and massage his hands the staff don't seem to have time for any extras.
An interview was conducted with Staff J, Certified Nursing Assistant (CNA) on 1/30/2024 at 4:20 PM. Staff J, CNA stated, I don't have time to finish all my work. The entire assignment of residents need total care (they are all dependent for all activities of daily living). When I mention this to the Director of Nursing (DON), I am told to just find someone to help you. I try to find someone to assist me although everyone is busy. No one has time to assist anyone else, plus I would need someone all day since the entire assignment is total care and requires two people for most everything. I can get the basics completed with the residents, change them, meals, etc. but any extra Passive Range of Motion, some documentation just doesn't happen.
An interview was conducted with the SC on 1/31/2024 at 12:50 PM. The SC stated the facility only staff by the census. She continued saying We do not take any acuity into the equation. We usually try to schedule 5 CNAs for the first shift (11p-7a), 9 CNAs for second (7a-3p) and third (3p-11p) shift. Nurses work 12-hour shifts, and we schedule the nurses by numbers required, as well. Sometimes, 4 but we are trying to go to 3 for all shifts.
An interview was conducted with Staff E, CNA on 1/31/2024 at 1:10 PM. Staff E, CNA stated staffing is terrible. I can barely finish my work, cannot usually finish my documentation or any little extra for my residents. I refuse to work two of the assignments as I don't know how the CNAs accomplish what they need to for the residents.
An interview was conducted with Staff B, CNA on 1/31/2024 at 1:15 PM. Staff B, CNA stated the assignments are ridiculous, especially the front hall of 300. All the residents are total care, require 2-person assistance. The facility just staff by the number. I can get the very basic completed, ensure they are clean and dry, repositioned etc. but extras are not possible. Documentation is just barely completed.
An interview was conducted with the DON and the Nursing Home Administrator (NHA) on 2/1/2024 at 8:55 AM. The DON stated the facility staffed by the minimum requirements. The floor nurses complete the assignments for the CNAs prior to the beginning of the shift. This usually happens by the number of residents they care for. The DON stated The CNAs don't like it if the numbers are not the same. I educate them to assist each other out if an assignment is more challenging than another. Continuing, the DON stated For example, if one CNA has 4 showers on that shift and another CNA only has one shower assigned. The CNA with only one should assist the CNA with 4. The NHA stated we discussed earlier in the week at looking how the resident's acuity is taken into account for the assignments.
2. An interview was conducted with 1/29/24 at 8:35 a.m. with Staff N, Certified Nursing Assistant (CNA), who stated sometimes the unit (400) will go down to 2-3 aides if the facility pulls a floor aide to go on transport. She stated she is able to get work done if there were 4 (aides) sometimes 3 depending on the residents.
An interview was conducted with Staff P (CNA) on 2/1/24 at 11:19 a.m. The staff member reported not being able to get everything done, and when the unit went down to 3 aides, assignment was going to be 15, 15, and 14 residents for the remaining aides. Staff P stated it can't be about the family and residents. A review of the schedule board showed 4 aides were assigned to the unit at the time. Staff P, Staff L (CNA) and Staff T (RN) reported one aide had left at 11:00 a.m.
Oct 2023
2 deficiencies
2 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, hospital record review, facility documentation and policy review, the facility failed to pro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, hospital record review, facility documentation and policy review, the facility failed to protect the resident's right to be free from neglect for one Resident (#1) of three residents reviewed for change in condition.
On [DATE] during a 12 hour shift when Resident #1 exhibited shortness of breath and not feeling well, was unable to perform her normal daily activities, unusual behaviors and was begging to go to the hospital the nurses on duty neglected to respond with in a way that could have helped the resident. There were no PRN (as needed) medications provided to the resident except pain medication, no documented assessments or vital signs (VS), no call to the resident's provider, and no call to the resident's family. One hour into the following shift the resident was found unresponsive by an aide and CPR (Cardiopulmonary Resuscitation) started. EMS (Emergency Medical Services) transported the resident to a hospital where she was admitted to intensive care and died 2 days later.
This failure created a situation that resulted in a worsened condition, serious injury and or death to Resident #1 and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to a D.
Findings included:
An interview was conducted on [DATE] at 11:20 a.m. with Staff A, Personal Care Attendant. (Personal Care Attendant or PCA means a person who meets the training requirement in this rule and Section 400.141(1)(w), F.S., and provides care to and assists residents with tasks related to the activities of daily living. According to Florida Administrative Code 59A-4.1081 Personal Care Attendant Training Program Requirements). Staff A, PCA said the day Resident #1 went to the hospital, [DATE], she looked really bloated and hadn't been able to go to the bathroom. Staff A, PCA said the resident was really out of it. He said Resident #1 didn't go out of her room, didn't eat all day and she took her clothes on and off. He said he had never seen the resident act that way before. He said Resident #1 said she wasn't feeling good and was begging to go to the hospital. Staff A, PCA said he told Staff B, Licensed Practical Nurse (LPN) what the resident said and Staff B, LPN told him [Resident #1] tends to exaggerate. Staff A, PCA said when the LPN made that comment he reminded her the resident wanted to go to the hospital. He said another time he went to Staff B, LPN and told her the resident was bloated and not feeling good, Staff B, LPN said she would give Resident #1 a suppository. He said he went to Staff B, LPN three to four times during his shift and told her the resident wasn't feeling good and wanted to go to the hospital.
Review of admission records showed Resident #1 was admitted on [DATE] with diagnoses including Acute and Chronic respiratory failure with hypoxia, COPD (chronic obstructive pulmonary disease), atrial fibrillation, speech and language deficits following cerebral infarction (CI,) hemiplegia and hemiparesis following CI, focal symptomatic epilepsy and epileptic syndromes.
Review of Resident #1's admission Minimum Data Set (MDS), dated [DATE], Section C, Cognition, showed the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. Section E, Behaviors, did not indicate the resident had any behaviors. Section G, Functional Status, showed the resident needed one-person physical assist with bed mobility, transfers, and toileting.
Review of Resident #1's Order Summary Report, printed on [DATE] showed the following orders:
Full Code. (Meaning all resuscitation efforts should be made to keep the resident alive) Date [DATE]
Record pain level every shift using numerical scale or pain scale for cognitively impaired. Every shift. Date [DATE].
Atorvastatin Calcium Oral Tablet 20 milligram (mg). Give 20 Mg by mouth at bedtime for cholesterol. Date. [DATE].
Allopurinol Oral Tablet 100 mg. Give 100 mg by mouth two times a day for gout. Date [DATE].
Clonazepam Oral Tablet 0.5 mg. Give 1.5 tablets by mouth two times a day for anxiety. Date [DATE].
Cholecalciferol Oral Tablet. Give 25 microgram (mcg) by mouth one time a day for supplement. Date [DATE].
Debrox Otic Solution. Instill 5 drops in both ears at bedtime for ears. Date [DATE].
Diltiazem HCL (hydrocholoride) ER (extended release) Oral Tablet. Give 120 mg by mouth in the morning for hbp (high blood pressure). Date [DATE].
Advair Diskus Inhalation Aerosol Power Breath Activated 500-50 mcg/act (actuation.) 1 puff orally two times a day for SOB (shortness of breath). Date [DATE].
Ferrous Sulfate Tablet 325 mg. Give 1 tablet by mouth two times a day for low hgb (hemoglobin). Date [DATE].
Guaifenesin Oral Tablet. Give 600 mg by mouth two times a day for mucus. Date [DATE].
Furosemide Oral Tablet 20 mg. Give 20 mg by mouth one time a day for edema. Date [DATE].
Latanoprost Ophthalmic Solution 0.005%. Instill 1 drop in both eyes at bedtime for glaucoma. Date [DATE].
Magnesium Oxide Oral Tablet 400 mg. Give 400 mg by mouth one time a day for antacid. Date [DATE].
Nicotine Patch 24 hour 14 mg/24 hour. Apply to arm topically in the morning for Nicotine for 14 days for less than 10 cigarettes a daily. Date [DATE].
Olanzapine Oral Tablet 5 mg. Give 5 mg by mouth in the morning for bipolar. Date [DATE].
Omeprazole Oral Capsule Delayed Release 30 mg. Give 20 mg by mouth in the morning for GERD (Gastroesophageal reflux disease). Date [DATE].
Potassium Chloride ER (extended release) Tablet 20 milliequivalents (meq). Give two tablets by mouth one time a day for hypoxia. Date [DATE].
Pregabalin Oral Capsule 75 mg. Give 75 mg by mouth at bedtime for muscle pain. Date [DATE].
Levetiracetam oral tablet 1000 mg. Give 1000 mg by mouth two times a day for seizure. Date [DATE].
Albuterol Sulfate HFA 108 mcg/act Aerosol, solution 2 puff inhale orally every 6 hours as needed for SOB. Date [DATE].
Ipratropium-Albuterol solution 0.5-2.5 mg/3 ml [milliliter] inhale orally via nebulizer every 6 hours as needed for SOB. Date [DATE].
Norco Oral tablet 5-325 mg. Give 1 tablet by mouth every 4 hours as needed for Moderate to severe pain 5-10. Date [DATE].
Ondansetron HCL Tablet 4 mg. Give 1 tablet by mouth every 6 hours as needed for nausea and vomiting. Date [DATE].
Complete nursing assessment or observation of respiratory system daily. Notify MD or ARNP of any changes. Every night for 10 days. Date [DATE].
Isolation Droplet Precautions due to COVID-19 and/or possible exposure. Every shift for 10 days. Date [DATE].
Review of Resident #1's Treatment Administration Record (TAR) dated [DATE] - [DATE] revealed: Oxygen at 2 liters/ min [minute] via Nasal Cannula, Humidification: [specify] No. every shift, Start date [DATE] 1500, D/C [discontinue] date [DATE] 0829. The oxygen was signed off as provided for 2 shifts on [DATE] and one shift for [DATE].
Review of Resident #1's Order Summary Report, printed on [DATE], and Resident #1's Medication Administration Record (MAR) and TAR dated [DATE] - [DATE] revealed no active order for oxygen administration.
Review of Resident #1's MAR showed the resident was administered Cholecalciferol, Diltiazem HCL, Furosemide, Magnesium oxide, a nicotine patch, Olanzapine, Omeprazole, Potassium Chloride, Advair Diskus, Allopurinol, Clonazepam, Ferrous Sulfate, Guaifenesin, Levetiracetam on the morning of [DATE]. These were all scheduled medications.
Review of Resident #1's medical records showed a care plan in place for Risk for respiratory complications related to dx [diagnosis] of COPD, Acute and Chronic hypoxia, respiratory failure, tobacco dependance, Asthma, CHF [Congestive heart failure], initiated [DATE]. The Interventions included: Administer oxygen as ordered (Refer to MAR for current order), Check and report O2 Sat (oxygen saturation) levels via pulse oximetry as ordered and report prn, Encourage to express feelings of fear and anxiety and provide verbal and non-verbal support, Medicate as ordered and monitor for effectiveness and observe for signs and symptoms of side effects, Report to MD (Medical doctor) as indicated, Observe for increased wheezing and or lower activity tolerance and report to MD as indicated.
Review of an article titled Pulse Oximetry, accessed on [DATE], showed the following: Oxygen saturation is a crucial measure of how well the lungs are working A resting oxygen saturation level between 95% and 100% is regarded as normal for a healthy person.Note that for people with known lung disorders such as COPD, resting oxygen saturation levels below the normal range are usually considered acceptable. (https://www.yalemedicine.org/conditions/pulse-oximetry)
Review of Resident #1's medical records showed a care plan in place for Risk for cardiovascular complications related to: A-fib, H/O [history of] Arrhythmias, HTN [hypertension,] Pacemaker, CHF, HLD [Hyperlipidemia], initiated [DATE]. The interventions included administer medication as ordered, administer oxygen as ordered, diet as ordered and meal consumption monitored, monitor for SOB, chest pains, bradycardia, hypotension, dizziness, tachycardia, HTN, increased edema, weight gain-report abnormalities to nurse, and monitor for vitals.
Review of a progress note dated [DATE] at 6:12 a.m. showed the following: LATE ENTRY Resident c/o (complained of) SOB. Full assessment of resident showed decreased O2 SATs 88%. Call placed to MD. Orders to send out to (hospital name) for observation.
Review of progress notes showed the following: [DATE] at 7:12 a.m. Change in Condition: Shortness of Breath. The VS documented in the progress note were dated [DATE] 6:29 a.m.: Blood pressure (BP) 127/72
Pulse (P) 80, Respiratory rate (RR) 18, Temperature (T) 98.0, Pulse Oximetry (O2 Sat) 93% Method: Oxygen via Nasal Cannula. Primary care provider responded to send resident out to the hospital.
Review of Resident #1's Medical Certification for Medicaid Long-Term Care [NAME] and Patient Transfer From (AHCA Form 5000-3008,) dated [DATE], showed the resident returned to the facility from the hospital. At the time of transfer Resident #1 was on 2 Liters of continuous oxygen, could ambulate independently with assistance, could feed herself, was continent of bowel and bladder, was alert and oriented, followed instructions, and was capable of making healthcare decisions.
Review of a progress note dated [DATE] at 4:00 a.m. showed the following: Awake in bed complaining she was incontinent of urine and she could not breathe to go to the bathroom. SATS 90% with O2 @2L/m via nasal cannula. Inhale provided without good effect. Nebulizer treatment provided with good relief and O2 SAT up to 96% with O2 @2L/m via nasal cannula. Requested and provided pain medication for back pain. Peri care provided. Had another episode of urinary incontinence and peri care provided with new brief. Will continue to monitor.
Review of a progress note dated [DATE] at 6:30 a.m. showed the following: Resting quietly in bed at present. SATs 96% with O2 @3L/M via nasal cannula. Requested to be given smoke patches to help her stop smoking as she was very upset with her SOB. Will pass on to oncoming nurse to obtain orders for same.
Review of a Progress Note written by an APRN (Advanced Practice Registered Nurse) dated [DATE] revealed the following: History of Present Illness: This is a complicated patient who was recently discharged from the hospital under the care of multiple subspecialists. Medically the patient requires continued close monitoring and follow up in the skilled nursing arena on a proactive basis to have an impact on reduction of rehospitalization/morbidity/and mortality. The patient's respiratory status is slowly improving at this time. We will continue to monitor closely due to the patient's multiple comorbidities and high risk for decompensation. In the review of systems the resident was negative for reduced appetite, negative for dyspnea (feeling short of breath) on exertion.
Review of a progress note dated [DATE] at 6:59 p.m. showed the following: Pt (patient) reported to NP(Nurse practitioner name) she was having severe pain in her abdomen. NP (name) gave orders to write to order a KUB (kidney, ureter, and bladder x-ray).
Review of a Radiology Results Report, dated [DATE], showed the KUB conclusion was: Unremarkable abdomen exam. Consider more sensitive imaging evaluation with CT (computerized Tomography Scan, sometimes called a CAT scan) as clinically directed. This result was reviewed by Staff G, LPN/UM on [DATE] at 9:40 a.m.
Review of a progress note dated [DATE] at 11:21 a.m. showed the following: During care plan meeting resident verbalized that she would like to stay at facility for long term care as she feels this is the level of care she needs. Explained that she will need to speak to the BOM (Business office manager) regarding the Medicaid process and she did state she has spoken to her about this as well as the owner of the previous home she was in.
A Nutrition/Dietary Note, dated [DATE] at 11:50 a.m. showed the following: Resident came in dining room today and spoke to this clinician regarding her teeth. Resident c/o tooth pain d/t (due to) cracked/broken upper teeth. Resident states that she thinks that all of her upper teeth need to be pulled. Resident states that she has lower dentures but that they may to be readjusted. Resident on regular textures and agreed to downgrade to mech (mechanical) soft at this time for easier chewing. Resident had concerns regarding her hearing and needing glasses. Notified unit manager as social services was not available. Will continue to monitor and f/u (follow-up) prn.
The resident had an active order for Ipratropium-Albuterol Solution 0.5-2.5 mg/3ml. 3 ml inhale orally via nebulizer every 6 hours as needed for shortness of breath. Start date: [DATE]. The MAR shows this medication was last administered on [DATE] and was not administered on [DATE].
The MAR showed Resident #1 was administered PRN Norco 5-325 mg at 8:18 a.m. on [DATE] with a pain level documented as 0 out of 10 and again at 3:02 p.m. with a pain level documented as 0 out of 10. The resident received Norco 2 to 3 times daily from [DATE] to [DATE].
Resident #1 had an order to complete nursing assessment or observation of respiratory system daily. Notify MD or ARNP of any changes. Every night shift for 10 days. Start date [DATE]. This was signed off on the Treatment Administration Record (TAR) as being completed 10/5 and [DATE]. There was no documentation related to the assessments in the medical record.
Review of Resident #1's electronic medical record weights and vitals summary pages and progress notes showed the VS documented for her stay of [DATE] to [DATE] and [DATE] to [DATE] were the following:
[DATE]
admitted , no VS documented
[DATE] 6:29 a.m.
BP 127/72, P 80, RR 18, T 98.0, O2 Sat 93% Method: Oxygen via Nasal Cannula.
[DATE] 6:12 a.m.
O2 Sat 88%, no other VS documented
[DATE]
Resident in the hospital
[DATE]
Resident in the hospital
[DATE]
readmitted , no VS documented
[DATE]
no VS documented
[DATE]
no VS documented
[DATE]
no VS documented
[DATE]
no VS documented
[DATE]
no VS documented
[DATE] 4:00 a.m.
O2 Sat 90% with oxygen at 2L/m, no other VS documented
[DATE] 4:00 a.m.
O2 Sat 96% with oxygen at 2L/m after breathing treatment
[DATE] 6:30 a.m.
O2 Sat 96% with oxygen at 2L/m, no other VS documented
[DATE]
no VS documented
[DATE]
no VS documented
[DATE]
no VS documented
[DATE]
no VS documented
[DATE]
no VS documented
[DATE]
no VS documented
[DATE]
no VS documented
[DATE]
no VS documented
[DATE]
no VS documented
[DATE]
no VS documented
[DATE]
no VS documented
[DATE]
no VS documented
[DATE]
no VS documented
[DATE]
no VS documented
[DATE]
no VS documented
[DATE]
no VS documented
[DATE]
no VS documented
[DATE]
no VS documented
[DATE]
no VS documented
[DATE] 8:00 p.m.
BP 0/0, P 0, RR 0, T 98°, O2 Sat 90%
[DATE] 8:30 p.m.
BP 90/60
[DATE] 8:39 p.m. BP 0/0
An interview was conducted on [DATE] at 11:15 a.m. with Staff G, LPN/UM. Staff G, LPN/UM said the documentation of blood pressure (of 90/60) on [DATE] at 8:30 p.m. and O2 Saturation (at 90%) on [DATE] at 8:00 p.m. were an error. Staff G, LPN/UM said Staff D, RN had called her that evening to let her know she had problems with documenting VS at the time.
During an interview on [DATE] at 9:35 a.m. Staff F, RN said the VS were documented in the weights and vitals tab of the electronic medical record.
During an interview on [DATE] at 10:05 a.m. Staff C, RN said VS were documented on the MAR/TAR if it asks for them and if vital signs are being taken because of a concern they are documented directly under the VS tab or sometimes in the progress notes (in the electronic record).
During an interview on [DATE] at 11:51 a.m. Staff B, LPN/UM said VS are documented in the electronic record in the progress notes and she does not know the Policy and Procedure for monitoring VS. She said there was usually an O2 sat order along with the oxygen order. She agreed there was no evidence in the medical record of the resident being stable because assessments and VS were not documented. She said that she did not notify the physician about the resident wanting to go to the hospital and she said I know, I didn't document .
An interview was conducted on [DATE] at 11:15 a.m. with Staff G, LPN/UM. Staff G, LPN said regarding vitals for Resident #1 being documented throughout her stay at the facility she said, that would have been nice, especially her. Staff G, LPN said for a resident with a distended abdomen she would listen for bowel sounds, call the doctor, and see if they wanted to order an x-ray or anything else. Staff G, LPN/UM reviewed Resident #1's KUB results from [DATE] and confirmed there had been no follow-up.
An interview was conducted on [DATE] at 1:05 p.m. with Resident #1's primary care physician. He said he would not have expected Resident #1's oxygen orders to have stopped. He said he would expect a patient that came to the facility with a history of respiratory failure to have oxygen saturation monitoring and I would be surprised if they were not. He said for the chest x-ray results on [DATE], the results would not have been overly concerning assuming the resident did not have a fever, but the facility should have notified the provider of all abnormal labs.
An interview was conducted on [DATE] at 2:18 p.m. with Staff H, RN. Staff H, RN said Resident #1 was pleasant, alert, and oriented. He said she would sometimes take her oxygen off when she was in the hall and staff would tell her to put it back on due to her having shortness of breath. He said she was out of her room [ROOM NUMBER]% of the time. Staff H, RN said the resident didn't ever complain, say she wanted to go to the hospital and didn't have any behaviors besides occasionally refusing something.
An interview was conducted on [DATE] at 2:22 p.m. with Staff J, CNA. Staff J, CNA said Resident #1 mostly took care of herself. Staff J, CNA said the resident would ask for ice or help with little things. She said the resident did get short of breath getting out of bed or doing simple tasks. Staff J, CNA said the resident never gave anybody a hard time and didn't complain unless it was something small. She said Resident #1 would normally eat and if she didn't like the meal, she would ask for snacks or order something to be delivered. Staff J, CNA said the resident never complained of stomach pain or said she wanted to go to the hospital. She said the resident would often have conversations with other residents.
An interview was conducted on [DATE] at 2:48 p.m. with Staff I, CNA. Staff I, CNA said Resident #1 was a sweet lady and a good eater. Staff I, CNA said she doesn't remember the resident complaining or having any behaviors.
An interview was conducted on [DATE] at 10:34 a.m. with Staff B, LPN. Staff B, LPN said the day Resident #1 went to the hospital ([DATE]) she had cared for the resident on the day shift, from 7:00 a.m. to 7:00 p.m. Staff B, LPN said Resident #1 was not feeling well that day. She confirmed Staff A, PCA came to her three to four times during her shift and told her the resident wasn't feeling good and wanted to go to the hospital. Staff B, LPN said while she was at lunch, Staff A, PCA came and said he didn't feel like Resident #1 was acting right. Staff C, RN went down and was getting a set of VS when Staff B, LPN said she joined him. Staff B, LPN said Resident #1 was saying she was having a hard time breathing. She said the resident was scooted down in the bed and Staff B, LPN told the resident she could breathe better if staff pulled her up in bed and got her lungs straight. Staff B, LPN said she thinks that was around 3:00-4:00p.m. She said when Staff A, PCA told her what the resident said, she did an assessment of what the resident needed and she basically just wanted her pain medication. Staff B, LPN said she gave Resident #1 a pain pill when she went down there and she was much more pleasant.
A follow-up interview was conducted on [DATE] at 11:51 a.m. with Staff B, LPN. Staff B, LPN said for Resident #1 she noticed her abdomen was distended earlier in the day on [DATE]. She said when she went back around 3:00 p.m. the resident had just had a bowel movement. She said she thinks the resident's abdomen was down some compared to what it was. Staff B, LPN said she thinks the bowel movement could have possibly been the cause of her distended abdomen. Staff B, LPN confirmed the resident was complaining of breathing issues on [DATE]. She said she did not administer the resident's PRN breathing treatment because her oxygen saturation was ok. She said we just sat her up in bed. Staff B, LPN said at that time no she did not ask the resident if she wanted her breathing treatment. Staff B, LPN confirmed she did not document any assessments or VS she did during the day of [DATE]. Staff B, LPN said on [DATE] she did not consider the resident was having a change in condition. She said the resident had taken her oxygen off before and was short of breath. She said that day the resident was slumped in bed, so we straightened her up and put her oxygen back on. Staff B, LPN was asked if a resident is alert and oriented and requested to go to the hospital does she have the right to go. Staff B, LPN responded, yes ma'am! She said, I wasn't trying to rebuke her rights, I checked on her and like I said, she was stable. Staff B, LPN confirmed she did not notify the physician about the resident's condition or request to go to the hospital. She said at the time I assessed her. I didn't feel at the time she needed to go to the hospital.
An interview was conducted on [DATE] at 11:43 a.m. with Staff C, Registered Nurse (RN.) Staff C, RN said on [DATE] from 7:00 a.m. to 7:00 p.m. he worked on the unit with Staff B, LPN. Staff C, RN said Staff A, PCA said Resident #1 was feeling bad and needed assistance. He said he and Staff B, LPN went to the room and Resident #1 said she wasn't feeling ok and wanted to go to the hospital. Staff C, RN said the resident's stomach was distended and he believes her oxygen saturation was normal for her. He said Staff B, LPN was the nurse assigned to the resident and the one that would have assessed her.
A follow-up interview was conducted on [DATE] at 10:05 a.m. with Staff C, RN. He said the PCA came to him because Staff B, LPN was on her lunch break. He said as he walked to the resident's room, Staff B, LPN came in. He said vitals were done and the resident's abdomen was distended. Staff C, RN said the resident was saying she was in a lot of pain and wanted to go to the hospital. Since Staff B, LPN was the assigned nurse, she took over and he went back to his residents.
An interview was conducted on [DATE] at 4:03 p.m. with Staff D, RN. Staff D, RN said she worked [DATE] from 7:00 p.m. to 7:00 a.m. and was assigned to Resident #1. She said she got report at 7:00 p.m. from Staff B, LPN and does not recall anything being said about Resident #1 not feeling well, having a distended abdomen, or wanting to go to the hospital. She said she was only told about the room being on precautions due to Resident #1's roommate having COVID. Staff D, RN said she had not seen Resident #1 yet that shift until the Certified Nursing Assistant (CNA) came down the hall around 8:00 p.m. and said the resident needed help. Staff D, RN said she went to assess the resident and the resident did not have a pulse and was not breathing. She said she started CPR on the resident and attached the AED (Automated External Defibrillator) and allowed it to analyze. Staff D, RN said she continued compressions until EMS arrived.
An interview was conducted on [DATE] at 4:32 p.m. with Staff E, CNA. Staff E, CNA said she took over care for Resident #1 at 7:00 p.m. on [DATE]. She said in report she was told Resident #1 had been different that day and not her usual self. She said it was not like the resident to soil her bed, but when she went to check on her the resident had her brief off and had urinated all over the bed. Staff E, CNA said she thought Resident #1 was asleep. She said she grabbed supplies and asked another CNA to assist her. She said when she went to the resident to wake her up and roll her to her side, she noticed the resident was limp. She said the other CNA ran and got the nurse, the nurse came right away and started CPR.
An interview was conducted on [DATE] at 11:46 a.m. with the facility's Medical Director. The Medical Director said he doesn't know the specifics of Resident #1, but it sounded like she had a pretty sudden change in condition. He said usually with COPD you see a slow decline in oxygen saturation. The Medical Director said if a patient with that history said she isn't feeling well and needs to go to the hospital, the nurse should call the provider. He said if a resident had a change in condition the process should be for the nurse to first assess the resident, hopefully properly and completely, then contact the provider for orders. He said that could be medication or going to the hospital. The Medical Director said, no matter how self-inflicted things may be a change in condition warrants an assessment.
An interview was conducted on [DATE] at 1:20 p.m. with the interim DON and Registered Nurse Consultant (RNC). The RNC said if Resident #1 came from the hospital with oxygen orders, they should have been put in the computer. The interim DON said staff should have been monitoring Resident #1's O2 saturation and documenting. He said they have identified the facility is lacking in the area of documentation and have started education. Regarding the stat x-ray for Resident #1 on [DATE], the RNC said she could not attest to what happened or why there was no documented response. She said, Regardless, the nurse who received the results should have notified the physician and documented. The RNC stated regarding Resident #1 complaining she did not feel well on [DATE], she spoke with the nurse (Staff B) who said once the resident had a bowel movement, she was okay and did not have further complaints. She stated the nurse reported the resident had a bowel movement sometime after 3 p.m. She said, I would expect if a resident was requesting to go to the hospital, that their right to seek medical care was honored. The RNC stated she would have expected the nurse (Staff B) to document vitals and all assessments completed on Resident #1 when she verbalized not feeling well.
Review of hospital records showed the patient presented in cardiac arrest. Allegedly had been in cardiac arrest for 30 minutes prior to arrival. She was immediately intubated in the prehospital airway was swapped out for an endotracheal tube. After initial dose of epinephrine in the emergency department she did have return of spontaneous circulation. Pulses were palpable. The record added the prognosis is extremely guarded considering she was allegedly in cardiac arrest for approximately 30 to 45 minutes prior to the return of spontaneous circulation. Of note, EMS reported her bloog [sic] glucose was 26 on arrival. They administered d10 and her glucose went up to 126 prior to arrival. A normal blood glucose level is between 70-100 milligrams(mg)/deciliter(dL.)
The Emergency Department history of present illness showed Patient is a [AGE] year old Female presenting in cardiac arrest. Patient allegedly was found around 8 PM this evening approximately an hour prior to arrival unresponsive and allegedly in cardiac arrest. Unknown when she was last normal per the rehab
facility. EMS reports that she was in PEA (Pulseless Electrical Activity) cardiac arrest through the entire transport. She underwent multiple rounds of ACLS (Advanced Cardiac Life Support) guidelines and epinephrine prior to arrival. However other than this the history is extremely limited from what was provided to me via EMS from the rehab facility.
Hospital records showed the resident was admitted to the ICU (Intensive Care Unit) and died on [DATE] at 10:35 a.m.
The hospital record Death Summary showed Resident #1's individual problem list as follows: Cardiac arrest, Patient found down at facility for unknown amount of time. Underwent CPR for more than 30 minutes prior to return of circulation. Patient placed on Arctic sun protocol [A non-invasive temperature management system used to induce hypothermia in comatose patients that ha[TRUNCATED]
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0726
(Tag F0726)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, hospital record review, facility documentation and policy review, the facility failed to ens...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, hospital record review, facility documentation and policy review, the facility failed to ensure nursing staff were competent to recognize and respond to a change in condition for one resident (#1) out of three residents reviewed for change in condition.
On [DATE] Resident #1 complained of shortness of breath and not feeling well, was unable to perform her normal daily activities, exhibited unusual behaviors and was begging to go to the hospital. The aide assigned to the resident notified the nurses on duty of the resident's condition and complaints multiple times during a 12-hour shift. There were no documented assessments, vital signs (VS) or notifications to a physician or family member. There were no PRN (as needed) medications provided to the resident except pain medication. One hour into the following shift the resident was found unresponsive by an aide and CPR (Cardiopulmonary Resuscitation) was begun by facility staff. EMS (Emergency Medical Services) transported the resident to a hospital where she was admitted to intensive care and died 2 days later.
This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #1 and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to a D.
Findings included:
An interview was conducted on [DATE] at 11:20 a.m. with Staff A, Personal Care Attendant. (Personal Care Attendant or PCA means a person who meets the training requirement in this rule and Section 400.141(1)(w), F.S., and provides care to and assists residents with tasks related to the activities of daily living. According to Florida Administrative Code 59A-4.1081 Personal Care Attendant Training Program Requirements). Staff A, PCA said the day Resident #1 went to the hospital, [DATE], she looked really bloated and hadn't been able to go to the bathroom. Staff A, PCA said the resident was really out of it. He said Resident #1 didn't go out of her room, didn't eat all day and she took her clothes on and off. He said he had never seen the resident act that way before. He said Resident #1 said she wasn't feeling good and was begging to go to the hospital. Staff A, PCA said he told Staff B, Licensed Practical Nurse (LPN) what the resident said and Staff B, LPN told him [Resident #1] tends to exaggerate. Staff A, PCA said when the LPN made that comment he reminded her the resident wanted to go to the hospital. He said another time he went to Staff B, LPN and told her the resident was bloated and not feeling good, Staff B, LPN said she would give Resident #1 a suppository. He said he went to Staff B, LPN three to four times during his shift and told her the resident wasn't feeling good and wanted to go to the hospital.
An interview was conducted on [DATE] at 10:34 a.m. with Staff B, LPN. Staff B, LPN said the day Resident #1 went to the hospital ([DATE]) she had cared for the resident on the day shift, from 7:00 a.m. to 7:00 p.m. Staff B, LPN said Resident #1 was not feeling well that day. She confirmed Staff A, PCA came to her three to four times during her shift and told her the resident wasn't feeling good and wanted to go to the hospital. Staff B, LPN said while she was at lunch, Staff A, PCA came and said he didn't feel like Resident #1 was acting right. Staff C, RN went down and was getting a set of VS when Staff B, LPN said she joined him. Staff B, LPN said Resident #1 was saying she was having a hard time breathing. She said the resident was scooted down in the bed and Staff B, LPN told the resident she could breathe better if staff pulled her up in bed and got her lungs straight. Staff B, LPN said she thinks that was around 3:00-4:00p.m. She said when Staff A, PCA told her what the resident said, she did an assessment of what the resident needed and she basically just wanted her pain medication. Staff B, LPN said she gave Resident #1 a pain pill when she went down there and she was much more pleasant.
A follow-up interview was conducted on [DATE] at 11:51 a.m. with Staff B, LPN. Staff B, LPN said for Resident #1 she noticed her abdomen was distended earlier in the day on [DATE]. She said when she went back around 3:00 p.m. the resident had just had a bowel movement. She said she thinks the resident's abdomen was down some compared to what it was. Staff B, LPN said she thinks the bowel movement could have possibly been the cause of her distended abdomen. Staff B, LPN confirmed the resident was complaining of breathing issues on [DATE]. She said she did not administer the resident's PRN breathing treatment because her oxygen saturation was ok. She said we just sat her up in bed. Staff B, LPN said at that time no she did not ask the resident if she wanted her breathing treatment. Staff B, LPN confirmed she did not document any assessments or VS she did during the day of [DATE]. Staff B, LPN said on [DATE] she did not consider the resident was having a change in condition. She said the resident had taken her oxygen off before and was short of breath. She said that day the resident was slumped in bed, so we straightened her up and put her oxygen back on. Staff B, LPN was asked if a resident is alert and oriented and requested to go to the hospital does she have the right to go. Staff B, LPN responded, yes ma'am! She said, I wasn't trying to rebuke her rights, I checked on her and like I said, she was stable. Staff B, LPN confirmed she did not notify the physician about the resident's condition or request to go to the hospital. She said at the time I assessed her. I didn't feel at the time she needed to go to the hospital.
An interview was conducted on [DATE] at 11:43 a.m. with Staff C, Registered Nurse (RN.) Staff C, RN said on [DATE] from 7:00 a.m. to 7:00 p.m. he worked on the unit with Staff B, LPN. Staff C, RN said Staff A, PCA said Resident #1 was feeling bad and needed assistance. He said he and Staff B, LPN went to the room and Resident #1 said she wasn't feeling ok and wanted to go to the hospital. Staff C, RN said the resident's stomach was distended and he believes her oxygen saturation was normal for her. He said Staff B, LPN was the nurse assigned to the resident and the one that would have assessed her.
A follow-up interview was conducted on [DATE] at 10:05 a.m. with Staff C, RN. He said the PCA came to him because Staff B, LPN was on her lunch break. He said as he walked to the resident's room, Staff B, LPN came in. He said vitals were done and the resident's abdomen was distended. Staff C, RN said the resident was saying she was in a lot of pain and wanted to go to the hospital. Since Staff B, LPN was the assigned nurse, she took over and he went back to his residents.
An interview was conducted on [DATE] at 4:03 p.m. with Staff D, RN. Staff D, RN said she worked [DATE] from 7:00 p.m. to 7:00 a.m. and was assigned to Resident #1. She said she got report at 7:00 p.m. from Staff B, LPN and does not recall anything being said about Resident #1 not feeling well, having a distended abdomen, or wanting to go to the hospital. She said she was only told about the room being on precautions due to Resident #1's roommate having COVID. Staff D, RN said she had not seen Resident #1 yet that shift until the Certified Nursing Assistant (CNA) came down the hall around 8:00 p.m. and said the resident needed help. Staff D, RN said she went to assess the resident and the resident did not have a pulse and was not breathing. She said she started CPR on the resident and attached the AED (Automated External Defibrillator) and allowed it to analyze. Staff D, RN said she continued compressions until EMS arrived.
An interview was conducted on [DATE] at 4:32 p.m. with Staff E, CNA. Staff E, CNA said she took over care for Resident #1 at 7:00 p.m. on [DATE]. She said in report she was told Resident #1 had been different that day and not her usual self. She said it was not like the resident to soil her bed, but when she went to check on her the resident had her brief off and had urinated all over the bed. Staff E, CNA said she thought Resident #1 was asleep. She said she grabbed supplies and asked another CNA to assist her. She said when she went to the resident to wake her up and roll her to her side, she noticed the resident was limp. She said the other CNA ran and got the nurse, the nurse came right away and started CPR.
Review of admission records showed Resident #1 was admitted on [DATE] with diagnoses including Acute and Chronic respiratory failure with hypoxia, COPD (chronic obstructive pulmonary disease), atrial fibrillation, speech and language deficits following cerebral infarction (CI,) hemiplegia and hemiparesis following CI, focal symptomatic epilepsy and epileptic syndromes.
Review of Resident #1's admission Minimum Data Set (MDS), dated [DATE], Section C, Cognition, showed the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. Section E, Behaviors, did not indicate the resident had any behaviors. Section G, Functional Status, showed the resident needed one-person physical assist with bed mobility, transfers, and toileting.
Review of Resident #1's Order Summary Report, printed on and dated [DATE] showed the following orders:
Full Code. (Meaning all resuscitation efforts should be made to keep the resident alive) Date [DATE]
Record pain level every shift using numerical scale or pain scale for cognitively impaired. Every shift. Date [DATE].
Atorvastatin Calcium Oral Tablet 20 milligram (mg). Give 20 Mg by mouth at bedtime for cholesterol. Date. [DATE].
Allopurinol Oral Tablet 100 mg. Give 100 mg by mouth two times a day for gout. Date [DATE].
Clonazepam Oral Tablet 0.5 mg. Give 1.5 tablets by mouth two times a day for anxiety. Date [DATE].
Cholecalciferol Oral Tablet. Give 25 microgram (mcg) by mouth one time a day for supplement. Date [DATE].
Debrox Otic Solution. Instill 5 drops in both ears at bedtime for ears. Date [DATE].
Diltiazem HCL (hydrocholoride) ER (extended release) Oral Tablet. Give 120 mg by mouth in the morning for hbp (high blood pressure). Date [DATE].
Advair Diskus Inhalation Aerosol Power Breath Activated 500-50 mcg/act (actuation.) 1 puff orally two times a day for SOB (shortness of breath). Date [DATE].
Ferrous Sulfate Tablet 325 mg. Give 1 tablet by mouth two times a day for low hgb (hemoglobin). Date [DATE].
Guaifenesin Oral Tablet. Give 600 mg by mouth two times a day for mucus. Date [DATE].
Furosemide Oral Tablet 20 mg. Give 20 mg by mouth one time a day for edema. Date [DATE].
Latanoprost Ophthalmic Solution 0.005%. Instill 1 drop in both eyes at bedtime for glaucoma. Date [DATE].
Magnesium Oxide Oral Tablet 400 mg. Give 400 mg by mouth one time a day for antacid. Date [DATE].
Nicotine Patch 24 hour 14 mg/24 hour. Apply to arm topically in the morning for Nicotine for 14 days for less than 10 cigarettes a daily. Date [DATE].
Olanzapine Oral Tablet 5 mg. Give 5 mg by mouth in the morning for bipolar. Date [DATE].
Omeprazole Oral Capsule Delayed Release 30 mg. Give 20 mg by mouth in the morning for GERD (Gastroesophageal reflux disease). Date [DATE].
Potassium Chloride ER (extended release) Tablet 20 milliequivalents (meq). Give two tablets by mouth one time a day for hypoxia. Date [DATE].
Pregabalin Oral Capsule 75 mg. Give 75 mg by mouth at bedtime for muscle pain. Date [DATE].
Levetiracetam oral tablet 1000 mg. Give 1000 mg by mouth two times a day for seizure. Date [DATE].
Albuterol Sulfate HFA 108 mcg/act Aerosol, solution 2 puff inhale orally every 6 hours as needed for SOB. Date [DATE].
Ipratropium-Albuterol solution 0.5-2.5 mg/3 ml [milliliter] inhale orally via nebulizer every 6 hours as needed for SOB. Date [DATE].
Norco Oral tablet 5-325 mg. Give 1 tablet by mouth every 4 hours as needed for Moderate to severe pain 5-10. Date [DATE].
Ondansetron HCL Tablet 4 mg. Give 1 tablet by mouth every 6 hours as needed for nausea and vomiting. Date [DATE].
Complete nursing assessment or observation of respiratory system daily. Notify MD or ARNP of any changes. Every night for 10 days. Date [DATE].
Isolation Droplet Precautions due to COVID-19 and/or possible exposure. Every shift for 10 days. Date [DATE].
Review of Resident #1's Treatment Administration Record (TAR) dated [DATE] - [DATE] revealed: Oxygen at 2 liters/ min [minute] via Nasal Cannula, Humidification: [specify] No. every shift, Start date [DATE] 1500, D/C [discontinue] date [DATE] 0829. The oxygen was signed off as provided for 2 shifts on [DATE] and one shift for [DATE].
Review of Resident #1's Order Summary Report, printed on and dated [DATE], and Resident #1's Medication Administration Record (MAR) and TAR dated [DATE] - [DATE] revealed no active order for oxygen administration.
Review of Resident #1's MAR showed the resident was administered Cholecalciferol, Diltiazem HCL, Furosemide, Magnesium oxide, a nicotine patch, Olanzapine, Omeprazole, Potassium Chloride, Advair Diskus, Allopurinol, Clonazepam, Ferrous Sulfate, Guaifenesin, Levetiracetam on the morning of [DATE]. These were all scheduled medications.
Review of Resident #1's medical records showed a care plan in place for Risk for respiratory complications related to dx [diagnosis] of COPD, Acute and Chronic hypoxia, respiratory failure, tobacco dependance, Asthma, CHF [Congestive heart failure], initiated [DATE]. The Interventions included: Administer oxygen as ordered (Refer to MAR for current order), Check and report O2 Sat (oxygen saturation) levels via pulse oximetry as ordered and report prn, Encourage to express feelings of fear and anxiety and provide verbal and non-verbal support, Medicate as ordered and monitor for effectiveness and observe for signs and symptoms of side effects, Report to MD (Medical doctor) as indicated, Observe for increased wheezing and or lower activity tolerance and report to MD as indicated.
Review of an article titled Pulse Oximetry, accessed on [DATE], showed the following: Oxygen saturation is a crucial measure of how well the lungs are working A resting oxygen saturation level between 95% and 100% is regarded as normal for a healthy person.Note that for people with known lung disorders such as COPD, resting oxygen saturation levels below the normal range are usually considered acceptable. (https://www.yalemedicine.org/conditions/pulse-oximetry)
Review of Resident #1's medical records showed a care plan in place for Risk for cardiovascular complications related to: A-fib, H/O [history of] Arrhythmias, HTN [hypertension,] Pacemaker, CHF, HLD [Hyperlipidemia], initiated [DATE]. The interventions included administer medication as ordered, administer oxygen as ordered, diet as ordered and meal consumption monitored, monitor for SOB, chest pains, bradycardia, hypotension, dizziness, tachycardia, HTN, increased edema, weight gain-report abnormalities to nurse, and monitor for vitals.
Review of a progress note dated [DATE] at 6:12 a.m. showed the following: LATE ENTRY Resident c/o (complained of) SOB. Full assessment of resident showed decreased O2 SATs 88%. Call placed to MD. Orders to send out to (hospital name) for observation.
Review of progress notes showed the following: [DATE] at 7:12 a.m. Change in Condition: Shortness of Breath. The VS documented in the progress note were dated [DATE] 6:29 a.m.: Blood pressure (BP) 127/72
Pulse (P) 80, Respiratory rate (RR) 18, Temperature (T) 98.0, Pulse Oximetry (O2 Sat) 93% Method: Oxygen via Nasal Cannula. Primary care provider responded to send resident out to the hospital.
Review of Resident #1's Medical Certification for Medicaid Long-Term Care [NAME] and Patient Transfer From (AHCA Form 5000-3008,) dated [DATE], showed the resident returned to the facility from the hospital. At the time of transfer Resident #1 was on 2 Liters of continuous oxygen, could ambulate independently with assistance, could feed herself, was continent of bowel and bladder, was alert and oriented, followed instructions, and was capable of making healthcare decisions.
Review of a progress note dated [DATE] at 4:00 a.m. showed the following: Awake in bed complaining she was incontinent of urine and she could not breathe to go to the bathroom. SATS 90% with O2 @2L/m via nasal cannula. Inhale provided without good effect. Nebulizer treatment provided with good relief and O2 SAT up to 96% with O2 @2L/m via nasal cannula. Requested and provided pain medication for back pain. Peri care provided. Had another episode of urinary incontinence and peri care provided with new brief. Will continue to monitor.
Review of a progress note dated [DATE] at 6:30 a.m. showed the following: Resting quietly in bed at present. SATs 96% with O2 @3L/M via nasal cannula. Requested to be given smoke patches to help her stop smoking as she was very upset with her SOB. Will pass on to oncoming nurse to obtain orders for same.
Review of a Progress Note written by an APRN (Advanced Practice Registered Nurse) dated [DATE] revealed the following: History of Present Illness: This is a complicated patient who was recently discharged from the hospital under the care of multiple subspecialists. Medically the patient requires continued close monitoring and follow up in the skilled nursing arena on a proactive basis to have an impact on reduction of rehospitalization/morbidity/and mortality. The patient's respiratory status is slowly improving at this time. We will continue to monitor closely due to the patient's multiple comorbidities and high risk for decompensation. In the review of systems the resident was negative for reduced appetite, negative for dyspnea (feeling short of breath) on exertion.
Review of a progress note dated [DATE] at 6:59 p.m. showed the following: Pt (patient) reported to NP([Nurse practitioner name) she was having severe pain in her abdomen. NP (name) gave orders to write to order a KUB (kidney, ureter, and bladder x-ray).
Review of a Radiology Results Report, dated [DATE], showed the KUB conclusion was: Unremarkable abdomen exam. Consider more sensitive imaging evaluation with CT (Computerized Tomography Scan, sometimes called a CAT scan) as clinically directed. This result was reviewed by Staff G, LPN/UM on [DATE] at 9:40 a.m.
Review of a progress note dated [DATE] at 11:21 a.m. showed the following: During care plan meeting resident verbalized that she would like to stay at facility for long term care as she feels this is the level of care she needs. Explained that she will need to speak to the BOM (Business office manager) regarding the Medicaid process and she did state she has spoken to her about this as well as the owner of the previous home she was in.
A Nutrition/Dietary Note, dated [DATE] at 11:50 a.m. showed the following: Resident came in dining room today and spoke to this clinician regarding her teeth. Resident c/o tooth pain d/t (due to) cracked/broken upper teeth. Resident states that she thinks that all of her upper teeth need to be pulled. Resident states that she has lower dentures but that they may to be readjusted. Resident on regular textures and agreed to downgrade to mech (mechanical) soft at this time for easier chewing. Resident also had concerns regarding her hearing and needing glasses. Notified unit manager as social services was not available. Will continue to monitor and f/u (follow-up) prn.
Resident #1 had an order for a stat chest x-ray PA/Lateral one time only for hypoxia on [DATE]. The results, reported on [DATE] at 6:36 p.m. showed the following:
Findings: The heart is modestly enlarged. Mediastinum is normal. There is a right lower lobe atelectasis. Pulmonary vascularity is normal. There is a pacemaker in position.
Conclusion: Right lower lobe atelectasis and modest cardiomegaly, no infiltrate or congestion.
There was no progress note, VS, or assessment to show why the Stat Chest x-ray was ordered. The results, however, do not show they were reviewed until [DATE] by Staff G, LPN/Unit Manager (UM,) after the resident left the facility. There is no note indicating a provider had been notified of the results.
The resident had an active order for Ipratropium-Albuterol Solution 0.5-2.5 mg/3ml. 3 ml inhale orally via nebulizer every 6 hours as needed for shortness of breath. Start date: [DATE]. The MAR shows this medication was last administered on [DATE] and was not administered on [DATE].
The MAR showed Resident #1 was administered PRN Norco 5-325 mg at 8:18 a.m. on [DATE] with a pain level documented as 0 out of 10 and again at 3:02 p.m. with a pain level documented as 0 out of 10. The resident received Norco 2 to 3 times daily from [DATE] to [DATE].
Resident #1 had an order to complete nursing assessment or observation of respiratory system daily. Notify MD or ARNP of any changes. Every night shift for 10 days. Start date [DATE]. This was signed off on the Treatment Administration Record (TAR) as being completed 10/5 and [DATE]. There was no documentation related to the assessments in the medical record.
Review of Resident #1's electronic medical record weights and vitals summary pages and progress notes showed the VS documented for her stay of [DATE] to [DATE] and [DATE] to [DATE] were the following:
[DATE]
admitted , no VS documented
[DATE] 6:29 a.m.
BP 127/72, P 80, RR 18, T 98.0, O2 Sat 93% Method: Oxygen via Nasal Cannula.
[DATE] 6:12 a.m.
O2 Sat 88%, no other VS documented
[DATE]
Resident in the hospital
[DATE]
Resident in the hospital
[DATE]
readmitted , no VS documented
[DATE]
no VS documented
[DATE]
no VS documented
[DATE]
no VS documented
[DATE]
no VS documented
[DATE]
no VS documented
[DATE] 4:00 a.m.
O2 Sat 90% with oxygen at 2L/m, no other VS documented
[DATE] 4:00 a.m.
O2 Sat 96% with oxygen at 2L/m after breathing treatment
[DATE] 6:30 a.m.
O2 Sat 96% with oxygen at 2L/m, no other VS documented
[DATE]
no VS documented
[DATE]
no VS documented
[DATE]
no VS documented
[DATE]
no VS documented
[DATE]
no VS documented
[DATE]
no VS documented
[DATE]
no VS documented
[DATE]
no VS documented
[DATE]
no VS documented
[DATE]
no VS documented
[DATE]
no VS documented
[DATE]
no VS documented
[DATE]
no VS documented
[DATE]
no VS documented
[DATE]
no VS documented
[DATE]
no VS documented
[DATE]
no VS documented
[DATE]
no VS documented
[DATE]
no VS documented
[DATE] 8:00 p.m.
BP 0/0, P 0, RR 0, T 98°, O2 Sat 90%
[DATE] 8:30 p.m.
BP 90/60
[DATE] 8:39 p.m. BP 0/0
An interview was conducted on [DATE] at 11:15 a.m. with Staff G, LPN/UM. Staff G, LPN/UM said the documentation of blood pressure (of 90/60) on [DATE] at 8:30 p.m. and O2 Saturation (at 90%) on [DATE] at 8:00 p.m. were an error. Staff G, LPN/UM said Staff D, RN had called her that evening to let her know she had problems with documenting VS at the time.
During an interview on [DATE] at 9:35 a.m. Staff F, RN said the VS were documented in the weights and vitals tab of the electronic medical record.
During an interview on [DATE] at 10:05 a.m. Staff C, RN said VS were documented on the MAR/TAR if it asks for them and if vital signs are being taken because of a concern they are documented directly under the VS tab or sometimes in the progress notes (in the electronic record).
During an interview on [DATE] at 11:51 a.m. Staff B, LPN/UM said VS are documented in the electronic record in the progress notes and she does not know the Policy and Procedure for monitoring VS. She said there was usually an O2 sat order along with the oxygen order. She agreed there was no evidence in the medical record of the resident being stable because assessments and VS were not documented. She said that she did not notify the physician about the resident wanting to go to the hospital and she said I know, I didn't document .
An interview was conducted on [DATE] at 11:15 a.m. with Staff G, LPN/UM. Staff G, LPN said lab and x-ray results go into a portal and have to be reviewed. The nurses, Director of Nursing (DON,) UM, and Advanced Practice Registered Nurse (APRN) had access to view. The reviewed by on the report is the first person to review the results. Staff G, LPN said nurses can view the results without clicking reviewed. She confirmed the results for the stat chest x-ray for Resident #1 on [DATE] were not reviewed until [DATE]. Staff G, LPN also confirmed there is no documentation showing a provider was notified of the results. Regarding vitals for Resident #1 being documented throughout her stay at the facility she said, that would have been nice, especially her. Staff G, LPN said for a resident with a distended abdomen she would listen for bowel sounds, call the doctor, and see if they wanted to order an x-ray or anything else. Staff G, LPN/UM reviewed Resident #1's KUB results from [DATE] and confirmed there had been no follow-up.
An interview was conducted on [DATE] at 1:05 p.m. with Resident #1's primary care physician. He said he would not have expected Resident #1's oxygen orders to have stopped. He said he would expect a patient that came to the facility with a history of respiratory failure to have oxygen saturation monitoring and I would be surprised if they were not. He said for the chest x-ray results on [DATE], the results would not have been overly concerning assuming the resident did not have a fever, but the facility should have notified the provider of all abnormal labs.
An interview was conducted on [DATE] at 1:57 p.m. with the Social Services Director (SSD.) The SSD said Resident #1 was alert and was trying to decide if she was going to stay long term care or move back home with her husband. The SSD said Resident #1 was a smoker and understood the issues with smoking. She said the week prior to going to the hospital, the resident said she was going to try to stop smoking. The SSD said Resident #1 was active with therapy, would eat normally and was out of her room often interacting with people. She said the resident got close with the group of smokers. The SSD said Resident #1 wasn't difficult to work with and if the resident had concerns, she would go to social services.
An interview was conducted on [DATE] at 2:05 p.m. with the Activities Director. The Activities Director said Resident #1 was alert, oriented, and aware. She said the resident was boisterous and would get into discussions with other residents. The Activities Director said Resident #1 would come out to smoke and got along with most of the people out there. She said Resident #1 had started a smoking patch and wanted to stop smoking. The Activities Director said she never heard Resident #1 complain about being sick or wanting to go to the hospital.
An interview was conducted on [DATE] at 2:18 p.m. with Staff H, RN. Staff H, RN said Resident #1 was pleasant, alert, and oriented. He said she would sometimes take her oxygen off when she was in the hall and staff would tell her to put it back on due to her having shortness of breath. He said she was out of her room [ROOM NUMBER]% of the time. Staff H, RN said the resident didn't ever complain, say she wanted to go to the hospital and didn't have any behaviors besides occasionally refusing something.
An interview was conducted on [DATE] at 2:22 p.m. with Staff J, CNA. Staff J, CNA said Resident #1 mostly took care of herself. Staff J, CNA said the resident would ask for ice or help with little things. She said the resident did get short of breath getting out of bed or doing simple tasks. Staff J, CNA said the resident never gave anybody a hard time and didn't complain unless it was something small. She said Resident #1 would normally eat and if she didn't like the meal, she would ask for snacks or order something to be delivered. Staff J, CNA said the resident never complained of stomach pain or said she wanted to go to the hospital. She said the resident would often have conversations with other residents.
An interview was conducted on [DATE] at 2:48 p.m. with Staff I, CNA. Staff I, CNA said Resident #1 was a sweet lady and a good eater. Staff I, CNA said she doesn't remember the resident complaining or having any behaviors.
An interview was conducted on [DATE] at 11:46 a.m. with the facility's Medical Director. The Medical Director said he doesn't know the specifics of Resident #1, but it sounded like she had a pretty sudden change in condition. He said usually with COPD you see a slow decline in oxygen saturation. The Medical Director said if a patient with that history said she isn't feeling well and needs to go to the hospital, the nurse should call the provider. He said if a resident had a change in condition the process should be for the nurse to first assess the resident, hopefully properly and completely, then contact the provider for orders. He said that could be medication or going to the hospital. The Medical Director said, no matter how self-inflicted things may be a change in condition warrants an assessment.
An interview was conducted on [DATE] at 1:20 p.m. with the interim DON and Registered Nurse Consultant (RNC.) The RNC said if Resident #1 came from the hospital with oxygen orders, they should have been put in the computer. The interim DON said staff should have been monitoring Resident #1's O2 saturation and documenting. He said they have identified the facility is lacking in the area of documentation and have started education. Regarding the stat x-ray for Resident #1 on [DATE], the RNC said she could not attest to what happened or why there was no documented response. She
Jun 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and medical record review, the facility failed to ensure that the medication error rate was l...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and medical record review, the facility failed to ensure that the medication error rate was less than 5.00%. Twenty-five medication administration opportunities were observed, and seven errors were identified for three (#7, #8, and #9) of four residents observed. These errors constituted a 28% medication error rate.
Findings Included:
1. On [DATE] at 8:35 a.m. Staff B, Licensed Practical Nurse (LPN) was observed as she prepared the following medications for Resident # 7.
-Ascorbic acid 500 mg (milligrams) tablet
-Clopidogrel bisulfate 75 mg tablet
-Haldol 10 mg tablet
-Apixaban 5 mg tablet
-Lisinopril 5 mg tablet
-Amlodipine besylate 2.5 mg tablet
-Divalproex sodium DR 500 mg tablet
-Metformin HCL 500 mg tablet
-Cholecalciferol 1000 units tablet
-Lactulose 30 ml (milliliters) solution
-Incruse Elipta 62.5 mcg (micrograms)/act inhaler 1 puff package open on date [DATE].
-Fluticasone- Salmeterol 500-50 mcg 1 puff
Staff B confirmed a total of ten medications and two separate inhalers.
At 8:30 a.m. Staff B entered the bedroom that revealed Resident #7 was not present. Staff B asked a staff member that indicated she was in the dining room.
At 8:40 a.m. Resident #7 returned to her bedroom and confirmed she had eaten breakfast. Staff B provided the oral medications followed by one puff of Incruse Elipta inhaler. After twenty-five seconds the second inhaler Fluticasone- Salmeterol was administered.
Medication reconciliation revealed the following Physician orders:
-Metformin HCL 500 mg tablet. Give one tablet by mouth before meals for diabetes mellitus (DM) dated [DATE]; the medication was administered after breakfast.
-Fluticasone -salmeterol 500/50 mcg/act Aerosol Powder, breathe activated. Give 1 puff by mouth two times a day related to acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia (RINSE MOUTH AFTER USE) dated [DATE]. Resident #7 was not directed to rinse mouth after use.
-Polysaccharide Iron complex oral tablet 150 mg (polysaccharide iron complex). Give 1 table by mouth one times a day for anemia dated [DATE]. The medication was omitted.
2. On [DATE] at 8:50 a.m. Staff B LPN was observed as she prepared and administered the following medications to Resident #8.
-Eliquis 2.5 mg tablet
-Metoprolol 25 mg tablet
-Sertraline 50 mg tablet
-Potassium Chloride ER 10 [NAME] (milliequivalents) tablet
-Bumex 1 mg tablet
Staff B confirmed a total of five medications were due at that time.
Medical reconciliation revealed the following Physician orders:
-NU-IRON 150 mg cap give 1 capsule orally in the morning for anemia dated [DATE]. The medication was omitted.
3.On [DATE] at 11:45 a.m. Staff B LPN was observed as she prepared Resident #9 insulin pen -Lispro for administration. Staff B turned the dose knob on the pen to 2 units, pointed the pen side ways and expelled the insulin. She stated, I primed the pen. Staff B then attached the needle to the pen and turned the dose knob to 20 units. The cartridge on the pen was observed with an air bubble. Staff B then entered the Resident #9 bedroom when she was asked to stop.
The Director of Nursing (DON) was in the hallway at the time when Staff B stated, I primed the pen. The DON was present and confirmed he heard staff B state she had primed the pen. The DON was informed during the observation the pen was primed without a needle in place.
Review of the Manufacture's Instructions for Use: HUMALOG KwikPen® insulin lispro injection revealed:
-Priming your Pen
-Prime before each injection.
-Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly.
-If you do not prime before each injection, you may get too much or too little insulin.
-Step 6:
-To prime your Pen, turn the Dose Knob to select 2 units.
-Step 7:
-Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top.
-Step 8:
-Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly.
-You should see insulin at the tip of the Needle.
Accessed on [DATE] at https://uspl.lilly.com/lispro/lispro.html#ug1.
On [DATE] at 2:15 p.m. Staff B removed the Elpt inhaler from the medication cart and confirmed she administered it to Resident #7.
The Director of Nursing was present when Staff B confirmed the package contained an open on date [DATE]. The package manufacture's instructions read to discard after 42 days, that indicated the discard date on [DATE]. The DON confirmed the medication was expired and should not have been administered.
During the interview, Staff B indicated she was unaware on how much time to wait in-between inhalers. The DON stated, the normal time to wait between inhalers is to two to three minutes. Staff B confirmed after the second inhaler was administered (Fluticasone) she failed to instruct Resident #7 to rinse her mouth after use.
On [DATE] at 10:35 a.m. a phone interview was conducted with the facility's Pharmacist. The Pharmacist stated the normal time to wait in between two different inhalers is a minute. We follow manufactures recommendations. She confirmed if the inhaler has directions to rinse mouth after use it needs to be followed. The Pharmacist stated, we follow manufacture's recommendation. She confirmed if the manufacture indicates to discard an inhaler after 42 days it should be discarded and reordered. The Pharmacist indicated manufacture's directions need to be followed when priming an insulin pen. She confirmed if the pen is not primed as directed the resident will not receive the correct insulin dose. The Pharmacist confirmed all Physician ordered medications should be administered and not omitted.
Review of policy titled Medication Administration revised date [DATE]. Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.
Policy Explanation and Compliance Guidelines:
11. Compare medication source (bubble pack, vial, ect.) with MAR to verify resident name, medication name, form, dose, route, and time. b. Administer with 60 minutes prior to or after scheduled time unless otherwise ordered by physician. C. If other than PO route, administer in accordance with facility policy for the relevant route of administration (i.e., injection, eye ear, rectal, ect.) 12. Identify expiration date. If expired, notify nurse manager. 14. Administer medications as ordered in accordance with manufacture specifications. Example guidelines for Medication Administration (unless otherwise ordered by physician), this list is not all-inclusive. Medication requiring a wait time period between inhalations or drops: Metered dose inhalers-follow manufactures product information for administration instructions.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to ensure and maintain water pitchers in a clean manner for two (100 cart and 200 cart ) out of four pitchers used on medication carts as eviden...
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Based on observation and interview, the facility failed to ensure and maintain water pitchers in a clean manner for two (100 cart and 200 cart ) out of four pitchers used on medication carts as evidenced by a build up of pink and dark tan colored residual biogrowth.
Findings Included:
1.On 06/26/223 at 8:50 a.m. the 100-medication cart contained a clear colored water pitcher dated 6/21. The water pitcher cover was observed with a dark tan colored residual surrounding the inside edge. Staff B, Licensed Practical Nurse stated, I just washed it this morning. She confirmed she had used the same water pitcher when she administered the morning medications to the residents. She removed the cover off the pitcher and with a tissue wiped the inside of it. The tissue reflected a moderate amount of pink to brown colored residual. Staff B stated I'm going to take it the kitchen.
2. On 06/26/2023 at 9:01 a.m. the 300-medication cart was observed with a clear colored water pitcher. The pitcher did not contain a date. Staff D, Registered Nurse Minimum Data Sheet Coordinator confirmed the water pitcher should contain a date that would indicate it was clean that day.
3. On 9:15 a.m. the 200-med cart water pitcher was dated 6/26 Staff C, Licensed Practical Nurse was present and stated, I cleaned it this morning when I got here. She confirmed she had used the same water pitcher during the morning medication administration. Staff C removed the cover from the pitcher and wiped the inside. The wipe contained a pink to tan colored debris (photographic evidence was obtained).
On 06/26/2023 at 9:44 a.m. an interview was conducted with the Staff E, Registered Nurse Assistant Director of Nursing (ADON) who stated, all the water pictures are being cleaned. He said he would look to see if a process was in place.
On 06/27/2023 at 11:45 a.m. an interview was conducted with the Director of Nurse (DON) who indicated he was not unaware of a process for cleaning water pitchers. The DON said the nurses in the evening send the pitchers to the kitchen for cleaning and them pick them up. He indicated he was unaware nurses wash the water pitchers. The DON stated yes, like we have a bottle of [company name] detergent in each medication room, we don't. The nurses should not be washing them.
At 2:00 p.m. on 06/27/2023 an interview was conducted with the Staff F Kitchen Manager who stated there is no process in place, for the cleaning of the water pitchers. Staff F reviewed the photographic evidence and stated that could be from not being washed for a few days or a week. He confirmed the residual had resembled what is found in the ice maker if not routinely cleaned. The DON was present and stated, the water pitchers should be sent to the kitchen in the evening to get washed. He confirmed his agency staff members would not know this unless something was posted. He confirmed he did not have anything posted and it was his expectation the pitches were washed daily by the kitchen staff.
At 2:15 p.m. on 06/27/2023 Staff K stated I looked and cannot find any type of process about cleaning the water pitchers.
May 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
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 sufficient nursing staff to meet the needs o...
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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 sufficient nursing staff to meet the needs of eight (#3, #4, #5, #6, #7, #8 and #9) out of 12 sampled residents related to answering call lights timely.
Findings included:
1. On 5/17/23 at 10:30 a.m., an interview was conducted with Resident #3 in his/her room as resident reported the day shift (7 a.m. to 3 p.m.) is great, second shift (3 p.m. to 11 p.m.) it may take 15 minutes to over 2 hours for them to answer the light. They are always short staffed, or staff don't care and don't answer. I put my call light on because I need help, go to the bathroom or I'm in pain, they never come. I have given up on telling people, doesn't do any good.
2. On 5/17/23 at 10:47 a.m., an interview was conducted with Resident #4 in his/her room as resident reported, Call lights are awful on the second and third (11 p.m. to 7 a.m.) shift. I must go out and yell in the hallway to get someone. Sometimes, I even have to go all the way to the nurses' station, where staff are usually sitting at the desk. So frustrating, like we are doing this on purpose and get irritated for no reason. We need assistance, what if I was having another heart attack or something, most people think they should come quickly, within 5 minutes.
Review of Resident #4's medical record revealed that he was admitted to the facility on [DATE] with multiple diagnoses to include end stage renal disease, dependence one renal dialysis, below the knee amputation, convulsions, seizures, chronic kidney disease, epilepsy, and type 2 diabetes mellitus with complications to name a few. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating cognition was fully intact. Section G for functional status indicated that the resident required limited assistance for transferring with a one person assist and limited assistance for toilet use. Review of the care plan dated 11/26/22 and revised on 3/8/23 for Resident #4 revealed an Activities of Daily Living (ADL) self-care deficit related to chronic disease process, impaired mobility and right below the knee amputation. He may need more care following dialysis. Review of the CNA (certified nursing assistant) [NAME] for Resident #4 shows to ensure call light is encouraged for use and assist. Notify nurse asap if seizure occurs.
3. On 5/17/23 at 10:51 a.m., an interview was conducted with Resident #5 in his/her room as resident reported, they never answer my call light in the evening - I'll be crying in pain, and no one comes.
Review of Resident #5's medical record revealed that he/she was admitted to the facility on [DATE] with multiple diagnoses to include thrombocytopenia, chronic respiratory failure with hypoxia, severe protein calorie malnutrition, chronic obstructive pulmonary disease, rheumatoid arthritis, idiopathic neuropathy, major depressive disorder, epilepsy, history of falling, muscle weakness, and lack of coordination. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 13/15, indicating cognition was intact. Section G for functional status indicated that the resident required limited assistance for transferring with a one person assist as well as for toilet use. Section G also indicated that the resident was not steady. Review of the care plan dated 12/21/22 with revision on 1/8/23 revealed an Activities of Daily Living (ADL) self-care deficit related to chronic disease process. Resident # 5 was care planned for toileting as limited assistance, one staff. Review of the Certified Nursing Assistant (CNA) [NAME] indicates for the CNA to ensure call light is within use and encourage use for assist with standing/transferring and ambulation, notify nurse as soon as possible (asap) if seizure activity occurs.
4. On 5/17/23 at 10:55 a.m., an interview was conducted with Resident #9 in his/her room, resident reported, They never come, well sometimes they do but mostly it takes an hour. Usually, by then you need something different, as it has been so long.
Review of Resident #9's medical record revealed that she/he was admitted to the facility on [DATE] with multiple diagnoses to include hemiplegia and hemiparesis following cerebral infarction (stroke) affecting right dominant side, major depressive disorder, need for assistance with personal care, difficulty in walking, muscle weakness, acute kidney failure and compartment syndrome to name a few. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15/15, indicating cognition was fully intact. Review of the care plan dated 11/4/22 for Resident #9 revealed an Activities of Daily Living (ADL) self-care deficit related to recent hospitalization. Resident #9 was care planned for bathing, grooming, toileting, and ADL needs met with assistance from staff. Review of Resident #9 [NAME] shows to encourage resident to use soft touch call light for assist with standing/transferring and ambulation dated 4/17/23.
5. On 5/17/23 at 11:00 a.m., an interview was conducted with Resident #6 in his/her room, resident reported, they don't assist me; I call, and they don't come. Well, they sometimes come but not often.
Review of Resident #6's medical record revealed that she/he was admitted to the facility on [DATE] with multiple diagnoses to include acute cystitis without hematuria, sepsis, sacrum fracture, bipolar disorder, personality disorder, post-traumatic stress disorder, history of falling, Major Depressive disorder, Rheumatoid Arthritis, anxiety disorder, sedative, hypnotic or anxiolytic dependence, cardiac murmur, and suicidal ideations. The Minimum Data Set (MDS) assessment has not been completed, as resident just admitted .
6. On 5/17/23 at 4:35 p.m., an interview was conducted with Resident #8 in his/her room as resident reported, it can take no less than 45 minutes but usually at least an hour in the evening for the staff to answer my call light. My urinal was not left in my reach, and I had to ball my sheet up and urinate into the balled-up sheet. I still had to wait for them to clean me up and I was cold, wet no sheet. How demeaning. I have told them; it doesn't seem to help. Resident needed to utilize the bathroom room during the interview, resident pushed his call light at 4:38 p.m. C.N.A. entered the room at 4:52 p.m. to assist. When the surveyor exited the room, several nurses were behind the nurses' station.
7. Upon exiting Resident # 8's room at 4:52 p.m. the call light to Resident #7's room was sounding. Surveyor waited at the nurses' station to observe the call light response. Two nurses were at the nurses' station, documenting, and 2 different C.N.A.s walked past the room on separate occasions, without answering. A different C.N.A. entered the room at 5:05 p.m., the light was turned off.
Review of Resident #8's medical record revealed that he was admitted to the facility on [DATE] with multiple diagnoses to include hemiplegia and hemiparesis following cerebral infarction (stroke) affecting left non dominant side, spondylosis without myelopathy or radiculopathy of lumbar region, spinal stenosis, muscle weakness, chronic kidney disease stage 3, difficulty in walking and lack of coordination to name a few. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15/15, indicating cognition was fully intact. Section G for functional status indicated that the resident required extensive assistance for transferring with a two person assist and extensive assistance for toilet use. Section G also indicated that the resident was not steady, only able to stabilize with staff assistance moving on and off the toilet. Review of the care plan dated 5/2/23 for Resident #8 revealed an Activities of Daily Living (ADL) self-care deficit related to his CVA. Resident #8 was care planned for toileting as extensive assistance, one staff. Review of the CNA [NAME] shows resident needs extensive assistance for all ADLs and to ensure call is encouraged to use with standing/transferring and ambulation.
8. On 5/17/23 at 5:10 p.m. an interview with Resident #7, in his/her room as resident reported, I had to wet myself, how embarrassing, it's awful I'm a grown man/women. I could transfer myself if they would add a grab bar in front of toilet, there is only one next to the toilet on my left side. I had a stroke and cannot utilize my left arm. I have told the social worker, although nothing happens. You stop telling after a while.
Review of Resident #7's medical record revealed that he was admitted to the facility on [DATE]. The Minimum Data Set (MDS) assessment has not been completed as resident was just admitted . The record did reveal the resident had a Brief Interview for Mental Status (BIMS) score of 15/15, indicating cognition was fully intact.
Review of the Resident Council Minutes from March 27, 2023 showed that CNAs do not come, 30 minutes or not come at all. Surveyors were given a Signature page with Resident Council Meeting dated 4/11/23 with the Ombudsman's business card stapled to the paper. No minutes were provided.
Review of a staff listing with signatures dated 4/15/23, with Call Light Response Times handwritten on top of the page, no other documents were received, as requested.
Review of the grievance log for February 2023 to May 17, 2023, showed one grievance on 5/9/23 to be related to call lights. The grievance on 5/9/23 showed, resident stated that it takes a very long time to answer call light and to be changed, has waited a few hours. Also feels some staff will talk to him/her disrespectfully and the tone in which they speak to him/her. On 5/12/23 the grievance follow-up shows: All staff meeting on 5/11/23 addressed residents' rights and customer service, tone in how staff speak to residents and how it can be misinterpreted. Also addressed in servicing call lights timely and addressing needs.
Review of a staffing list with signatures, showed a handwritten date in the upper right corner of 5/11/23, documented at the top of the page, handwritten Town Hall Meeting. No other documents were received, as requested.
Review of the facility policy on Call Lights: Accessibility and Timely Response, date reviewed/revised: 7/19/2022, shows: Policy: The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. The next section titled, Policy Explanation and Compliance Guidelines: number 10 shows: All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified.
Reviewed the call light audits forms that were provided showed:
-3/29/23 - Room-101A - time call light on: 24 minutes 22 sec; room [ROOM NUMBER]A time of response to light, 20 minute 15 seconds. room [ROOM NUMBER] response time 7 minutes; room [ROOM NUMBER] response time 1 minute; room [ROOM NUMBER] response time 11 minutes; room [ROOM NUMBER] response time 14 minutes.
-3/30/23 - room [ROOM NUMBER] response time 4 minutes, room [ROOM NUMBER] response time 4 minutes; room [ROOM NUMBER] response time 4 minutes.
-3/30/23 - room [ROOM NUMBER] response time 4 minutes 23 seconds.
-3/31/23 - room [ROOM NUMBER] response time 5 minutes; room [ROOM NUMBER] response time 7 minutes; room [ROOM NUMBER] response time 3 minutes.
-4/1/23 - room [ROOM NUMBER] response time 3 minutes; room [ROOM NUMBER] response time 7 minutes; room [ROOM NUMBER] response time 15 minutes; room [ROOM NUMBER] response time 6 minutes; room [ROOM NUMBER] response time 10 minutes; room [ROOM NUMBER] response time 17 minutes.
4/2/23 - room [ROOM NUMBER] response time 12 minutes; room [ROOM NUMBER] response time 2 minutes; room [ROOM NUMBER] response time 6 minutes; room [ROOM NUMBER] response time 10 minutes; room [ROOM NUMBER] response time 4 minutes; room [ROOM NUMBER] response time 5 minutes.
-4/3/23 - room [ROOM NUMBER] response time 5 minutes; room [ROOM NUMBER] response time 8 minutes; room [ROOM NUMBER] response time 11 minutes; room [ROOM NUMBER] response time 6 minutes; room [ROOM NUMBER] response time 12 minutes; room [ROOM NUMBER] response time 3 minutes.
-4/4/23 - room [ROOM NUMBER] response time 2 minutes; room [ROOM NUMBER] response time 25 minutes.
-4/5/23 - room [ROOM NUMBER] response time 2 minutes.
-4/6/23 - room [ROOM NUMBER] response time 13 minutes; room [ROOM NUMBER] response time 9 minutes; room [ROOM NUMBER] response time 1 minute; room [ROOM NUMBER] response time 9 minutes; room [ROOM NUMBER] response time 5 minutes; room [ROOM NUMBER] response time 3 minutes.
-4/7/23 - room [ROOM NUMBER] response time 6 minutes.
-4/11/23 - room [ROOM NUMBER] response time 10 minutes; room [ROOM NUMBER] response time 8 minutes; room [ROOM NUMBER] response time 2 minutes; room [ROOM NUMBER] response time 16 minutes.
-4/14/23 - room [ROOM NUMBER] response time 12 minutes; room [ROOM NUMBER] response time 12 minutes.
-4/18/23 - room [ROOM NUMBER] response time 2 minutes; room [ROOM NUMBER] response time 12 minutes; room [ROOM NUMBER] response time 13 minutes.
-4/20/23 - room [ROOM NUMBER] response time 3 minutes; room [ROOM NUMBER] response time 5 minutes.
-4/22/23 - room [ROOM NUMBER] response time 7 minutes; room [ROOM NUMBER] response time 26 minutes; room [ROOM NUMBER] response time 12 minutes; room [ROOM NUMBER] response time 3 minutes; room [ROOM NUMBER] response time 3 minutes; room [ROOM NUMBER] response time 3 minutes.
-4/23/23 - room [ROOM NUMBER] response time 5 minutes; room [ROOM NUMBER] response time 7 minutes; room [ROOM NUMBER] response time 2 minutes; room [ROOM NUMBER] response time 5 minutes; room [ROOM NUMBER] response time 8 minutes; room [ROOM NUMBER] response time 6 minutes.
-4/25/23 - room [ROOM NUMBER] response time 6 minutes; room [ROOM NUMBER] response time 11 minutes.
-4/26/23 - room [ROOM NUMBER] response time unreadable; room [ROOM NUMBER] response time 13 minutes; room [ROOM NUMBER] response time 15 minutes; room [ROOM NUMBER] response time 6 minutes.
-4/27/23 - room [ROOM NUMBER] response time 12 minutes; room [ROOM NUMBER] response time 10 minutes.
-5/3/23 - room [ROOM NUMBER] response time 20 minutes; room [ROOM NUMBER] response time 20 minutes.
-5/4/23 - room [ROOM NUMBER] response time 8 minutes; Room not listed response time 20 minutes.
On 5/17/23 at 6:09 p.m., an interview with the Director of Nursing (DON) who stated that he was made aware of some call light issues earlier this year. He decided to initiate call light audits and educate the staff on response time face to face. The DON stated he let the staff know his expectations are to answer call lights within 10 to 15 minutes and the bathroom (emergency) light in 3 to 5 minutes. The DON stated he did not really review the audits and the audits did stop on 5/4/23. The audits were also only completed on the day shift. The DON stated this did not go through the Quality Assurance and Performance Improvement committee for follow up on the call light trend.
Feb 2023
1 deficiency
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0885
(Tag F0885)
Could have caused harm · This affected most or all residents
Based on record review and interview, the facility failed to inform resident representatives and family members by 5 p.m. of the next calendar day for three or more residents or staff with a new-onset...
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Based on record review and interview, the facility failed to inform resident representatives and family members by 5 p.m. of the next calendar day for three or more residents or staff with a new-onset of respiratory symptoms occurring within 72 hours of each other. after twenty-seven (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, and #27) of twenty-seven residents acquired the COVID-19 virus.
Findings include:
Review of the facility-provided list, Positive Residents in the last 4 weeks, 1/16/23 and the last notification letter, dated 1/17/23, that was sent to family members and resident representatives, identified the following residents had tested positive for COVID-19 after the notification letter was sent:
- Resident #1 and Resident #2 tested positive on 1/19/23;
- 15 residents (#3 through #17) tested positive on 1/20/23;
- 5 residents (#18 through #22) tested positive on 1/25/23;
- 4 residents (#23 through ##26) tested positive on 1/29/23;
- 1 resident (#27) tested positive on 1/31/23.
During an interview, the Director of Nursing (DON) and Nursing Home Administrator (NHA) stated at 2:28 p.m. on 2/15/23, family members and representatives were notified by flyers posted at the front door if the numbers had gone up or down. The NHA confirmed the last notification was on 1/17/23. The NHA stated, at 3:06 p.m. on 2/15/23, that she was doing a posting (at the front door) daily, and notifying weekly. She stated she was going off the visitation policy regarding the weekly notifications.
Review of the policy - COVID-19 Visitation, revised October 19, 2022, indicated that, The facility will communicate this visitation policy through multiple channels. Examples include facility website, signage, calls, letters, social media posts, emails, and recorded messages for receiving calls. The policy did not identify the frequency of communication.
The policy - Coronavirus Prevention and Response, reviewed/revised on 10/12/22, identified that This facility will respond promptly upon suspicion of illness associated with a SARS-CoV-2 infection in efforts to identify, treat, and prevent the spread of the virus. The policy did not identify the allotted timeframe required for the facility's to notify family members and/or representatives of a new COVID-19 infection.
Dec 2021
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and medical record review, the facility failed to ensure a care plan intervention was impleme...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and medical record review, the facility failed to ensure a care plan intervention was implemented for one (Resident #9) of thirty-four residents in the sample group.
Findings Included:
An initial observation was conducted on 12/07/2021 at 9:47 a.m. of Resident #9 lying in bed, not wearing the physician-ordered splint to her right hand.
A later observation was made on 12/08/2021 at 12:47 p.m. During the observation, Resident #9's hand splint was not applied to her right hand for a contracture.
An observation was made later in the day on 12/08/2021 at 3:35 p.m. During the observation, an interview was conducted with Resident #9's mother who was at bedside. Resident #9's mother revealed the resident wore a right-hand splint for her right-hand contracture. The resident's mother also confirmed that Resident #9 did not have the splint on at the time. She walked over to the resident's dresser top drawer and opened it up. An observation was made of a blue hand splint in the drawer; photographic evidence was obtained. The resident's mother stated, I have not seen it on her [Resident #9], and I visit regularly.
A record review for Resident #9 indicated she was admitted on [DATE] with multiple diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. A review of the active physician orders dated 11/11/2021 read, Apply right hand splint on in AM [morning] and off in PM [evening]. Wear Resting hand splint for eight hours during daytime. Review of the Care Plan for Resident #9 revealed a focus area for extensive ADL (Activities of Daily Living) assistance, with a goal of maintaining the highest level of ADL ability to perform ADLs with the least level of support from facility staff, dated 01/19/2021 and revised 11/09/2021. Under interventions it read, Apply right hand splint on in am and off in pm as resident tolerates.
An interview was conducted on 12/08/2021 at 5:00 p.m. with the Director of Rehabilitation. She indicated the Certified Nursing Assistant's (CNA's) apply the restorative devices and are trained by therapy staff on the application of devices such as hand splints.
During an interview with the Director of Nursing (DON) on 12/09/2021 at 12:55 p.m., he confirmed the CNA's applied all splints which were located on their [NAME] Report during shift change, and as part of their assignment under Restorative Area, which read, Apply the splint device to the right hand on in am and off in pm. The DON stated, It should have been on, I was the one who care-planned the resident for the right-hand splint device.
During a subsequent interview conducted with the DON on 12/10/2021 at 9:44 a.m., he stated, When there is an order for residents to have a splint, the splint should be applied as the order states and is followed by my staff.
A facility provided policy titled, Comprehensive Care Plans, revision date December 2021, Pages 01 and 02, reads under Policy , consistent with resident rights, that include measurable It is the policy of this facility to develop, implement and follow a comprehensive person centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychological needs that are identified in the resident's comprehensive assessment.
Policy Explanation and Compliance Guidelines:
8. The Facility will follow the comprehensive care plan interventions.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observations and interviews, the facility failed to ensure air conditioning (A/C) units were maintained in a sanitary manner on one (Hall 100) of four halls observed.
Findings included:
Duri...
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Based on observations and interviews, the facility failed to ensure air conditioning (A/C) units were maintained in a sanitary manner on one (Hall 100) of four halls observed.
Findings included:
During a facility tour on 12/07/21 between 10:13 a.m. and 12:38 p.m., the air conditioning (A/C) units and filters were observed with dirt, debris, and bio-growth in the 100 hall in resident rooms 101, 102, 105, 106, 107, 108, 109, 111 and 112. The filters were noted fully clogged with visible dark ashy-looking material, bio-growth, a white fuzzy appearance of growth on the unit's surfaces, and covered with dirt, dust, and debris. Photographic evidence was obtained.
On 12/08/21 at 11:15 a.m., a second facility tour was conducted in hall 100. The A/C units were observed in the same condition as the observation made on 12/07/21, with concerns related to dirt, dust, debris, and bio-growth in rooms 101, 104, 105, 106, 107, 108,109, 111 and 112.
On 12/09/21 at 9:49 a.m., a third facility tour was conducted in hall 100. The A/C units were observed in the same condition as the observations made on 12/07/21 and 12/08/21 with concerns related to dirt, dust, debris, and bio-growth in rooms 101, 104, 105, 106, 107, 108,109, 111 and 112.
On 12/09/21 at 10:20 a.m., an interview was conducted with Staff D, Housekeeping Aide. Staff D stated he cleaned residents' rooms daily but did not clean Air Conditioning units, saying he wiped off the outside surface of the A/C units occasionally. Staff D stated the Maintenance department was responsible for the cleaning and maintenance of A/C units in the resident's rooms.
An interview was conducted with Staff E, Maintenance Director on 12/09/21 at 11:19 a.m. Staff E stated Housekeeping cleaned the A/C units when they did terminal cleaning of resident rooms. Staff E stated the maintenance department did monthly or 30-45-day cleaning of A/C filters. Staff E stated the housekeeping department was responsible for the outside of the unit. While viewing the photographic evidence, Staff E stated, It's been more than a month since we checked them. Some get dirty more than others. Staff E said the expectation would be to clean the inside and outside of the A/C units. He stated, They should not be that bad. Bio-growth should have been dealt with by Housekeeping and maintenance both. We might have missed those units.
An interview was conducted on 12/09/21 at 3:10 p.m. with the Nursing Home Administrator (NHA), during which he stated, This is a problem. They should not look like that. They should be cleaned. I would not want to be in that room.
A follow up interview was conducted with Staff E and the Director of Operations on 12/10/21 11:45 a.m. Staff E confirmed observations and said, I walked through hall 100 and noticed that some of the units were bad, they may have been missed occasionally. Staff E said he did not have records showing A/C maintenance was being conducted.
Review of an undated facility policy titled HVAC system revealed that it was the facility's policy to maintain (heating ventilation and air conditioning) HVAC system in a manner that protects resident health and safety from fire and extreme temperatures.
The policy states:
#7. HVAC units' preventative maintenance (PM) shall be done by maintenance personnel in accordance with the manufacturer's specifications.
#9. HVAC filters shall be changed monthly and a date of install clearly printed on new filter.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A review of an admission record information sheet showed Resident #33 admitted to the facility on [DATE] with diagnoses to inclu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A review of an admission record information sheet showed Resident #33 admitted to the facility on [DATE] with diagnoses to include complete traumatic amputation, cellulitis left of lower limb, type 2 diabetes, unspecified dementia without behavioral disturbance, and blindness one eye unspecified. Review of the admission MDS dated [DATE] showed that Resident #33 had a brief interview for mental status (BIMS) score of 14, indicating intact cognition. Review of a smoking evaluation for Resident #33 conducted on 11/01/21 showed Resident #33 was a smoker who smoked about 5-9 times per day and was deemed a safe smoker. A Care Plan initiated on 11/02/21 showed Resident #33 was a safe smoker, and able to smoke off property. The goal indicated Resident #33 would smoke safely at a designated area off property through the next review.
During the facility's entrance conference on 12/07/21 at 9:27 a.m., the NHA reported the facility was a non-smoking facility. The NHA stated that there were two residents who could sign out and go out of the facility to smoke.
On 12/07/21 at 2:26 p.m., Resident #33 was observed smoking on the facility grounds in front of the building. Resident #33 was observed dropping his ashes on the ground as he smoked his cigarette. An ash tray or cigarette butt receptacle was not observed, and the area did not have a designated smoking sign.
On 12/08/21 at 11:19 a.m., an interview was conducted with Resident #33. The resident stated he smoked by the gazebo, per policy, and pointed to a policy on the bed side table. Resident #33 said, They reviewed this with me, made me sign it yesterday. When asked what he signed, Resident #33 stated it was to make sure cigarette butts go into the receptacle. Resident #33 stated that no one had spoken to him about smoking before yesterday (12/07/21). Resident #33 said he had been a resident of the facility since the end of October, and he did not follow a smoking schedule and could smoke anytime. Resident #33 stated that his smokes and lighter were kept at the nurse's station.
On 12/08/21 at 5:35 p.m., Resident #33 was observed smoking at the same spot in front of the facility. The resident stated, there used to be a gazebo, but not anymore. The resident was noted without an ash tray or receptacle for cigarette butts and was observed dropping his ashes on the ground as he smoked. The resident stated, I sometimes put them [cigarette butts] in my wheelchair bag and throw them in a trash can inside.
An interview was conducted with the NHA on 12/09/21 at 12:30 p.m. The NHA stated, We used to be a smoking facility before Covid. When Covid came and no one could go out, we became a non- smoking facility unofficially. We did not notify the ombudsman or families. The NHA said they had two smokers who were independent and were allowed to sign out and go out front to smoke. The NHA confirmed this was not a designated smoking area, stating, we don't want them on the streets. We want them in the front area where we can all view them. The NHA said if there was inclement weather, the residents could go to the Gazebo in the courtyard. She confirmed the Gazebo area was the designated smoking area that had all the necessary smoking supplies. The NHA stated, The two are independent smokers. I ask them not to go to the road, as long they are on the premises and are safe, they are okay. They can use the trash can in the middle of the front yard, the top of the trash can is metal. She said she would like the facility to be non-smoking, but it was their [resident's] right to smoke. A facility-provided smoking policy was reviewed with the NHA during the interview. The policy, dated with an October 2021 revision date, revealed smoking was prohibited except in the smoking area. The NHA confirmed the designated smoking area was the Gazebo and said she would not consider the front yard as a designated smoking area. The NHA stated, The two residents know not to smoke in the front but prefer and choose where they want to be. Regarding the cigarette butts, the NHA stated, I think they save them and bring them to the red container. I don't know. It has not been an issue.
On 12/10/21 at 11:34 a.m., a follow -up interview was conducted with the NHA. The NHA said they reviewed the smoking policy and confirmed the facility would now follow their own procedures.
A review of the policy provided by the facility Resident Smoking revised October 2021 indicated the following:
-Policy:
This facility provides a safe environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and non-smoking residents.
-Policy Explanation and Compliance Guidelines:
1. Smoking is prohibited in all areas except the designated smoking area. A Designated Smoking Area sign will be prominently posted.
2. Safety measures for the designated smoking area will include, but not limited to:
a. Protection from weather conditions (i.e., covered).
b. Provision of ashtrays made of noncombustible material and safe design.
c. Accessible metal containers with self-closing covers into which ashtrays can be emptied.
d. Accessible fire extinguisher.
e. Prohibition of oxygen use in the smoking area.
F. A Smoking blanket will be available in the designated area.
g. Smoking aprons will be available in the designated area.
5. All residents and family members will be notified of this policy during the admission process, and as needed.
8. All residents will be supervised while smoking.
11. If a resident or family member does not abide by the smoking policy or care plan (e.g., smoking materials are provided directly to the resident, smoking in non-smoking areas, does not wear protective gear), the plan of care may be revised to include additional measures such as room searches, prohibited smoking, or even discharge.
Based on observations, record reviews, and interviews, the facility failed to ensure two (Resident #19 and #33) of two sampled residents were free from potential accident hazards related to unsafe smoking in undesignated smoking areas.
Findings included:
On 12/08/21 at 8:40 a.m., the Nursing Home Administrator (NHA) reported the facility had two residents who smoked. Both residents smoked independently and were allowed to sign out for a leave of absence (LOA) to smoke on the facility grounds. She reported they had a designated smoking area underneath the covered patio area.
On 12/08/21 at 8:15 a.m., Resident #19 was observed wheeling her wheelchair out of the main entrance of the facility with an unlit cigarette in her mouth. She wheeled out to the sidewalk near a trash can underneath the tree in the front of the main entrance (photographic evidence obtained). Resident #19 pulled a lighter from her pocket, lit the cigarette, and began smoking. The resident was observed dumping the ashes on the ground. There was no signage which indicated the area was the designated smoking area.
On 12/08/21 at 9:30 a.m. in an interview, Resident #19 reported she had lived in the facility for about six months, and she liked to go outside to feed squirrels and to smoke underneath the tree in the front of the main entrance.
On 12/09/21 at 8:39 a.m., Resident #19 was observed sitting in her wheelchair underneath the tree near the main entrance. The resident pulled a cigarette out, lit it, and started smoking. At 8:45 a.m., Resident #19 was observed dropping ashes on the ground as she opened the lid on the top of the trash can to put the cigarette out. At 8:51 a.m., she wheeled herself back into the facility.
A review of the admission Record revealed that Resident #19 was initially admitted into the facility on [DATE] with a diagnosis that included but was not limited to nicotine dependence. Section C Cognitive Patterns of the Minimum Data Set (MDS) dated [DATE] indicated that Resident #19 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating she was cognitively intact. A review of the OC Smoking Evaluation with an effective date of 11/17/21 revealed that Resident #19 currently smoked. The form also indicated the resident was able to acknowledge understanding of the smoking policy. The policy was signed by Resident #19 on 12/07/21. The care plan related to smoking initiated on 11/16/21 revealed the resident may smoke independently per the smoking assessment. The goal reflected Resident #19 would smoke safely through the next review period. Interventions included but were not limited to inform and remind the resident of location of smoking area/times.
Sept 2020
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation of the resident, interview with facility staff, and review of the medical record and facility policy the fa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation of the resident, interview with facility staff, and review of the medical record and facility policy the facility did not ensure that one resident (Resident #25) of 30 sampled residents, received a Level II PASRR evaluation prior to admission to the facility, as required since the resident had been identified on the Pre-admission Screening and Resident Review (PASRR) as not being eligible for admission to a nursing home because of serious mental illness.
Findings included:
Resident #25 had multiple admissions to the facility based on a review of the electronic medical record and the Minimum Data Set (MDS) Assessments. The resident was initially admitted to the facility on [DATE] with diagnoses that included Adult Failure to Thrive, Schizophrenia, and Metabolic Encephalopathy.
A transfer to the hospital, documented in the MDS assessments, was dated 8/13/2020 with a return to the facility on [DATE]. The resident was again transferred to the hospital on [DATE] and returned on 08/31/2020. The resident was again transferred to the hospital on [DATE] and returned on 09/11/2020. The resident was transferred to the hospital on [DATE] and returned on 09/16/2020.
When the resident returned to the facility on [DATE], the hospital Social Worker completed a Pre-admission Screening and Resident Review (PASRR) evaluation which identified the resident as having the following Mental Illnesses: Bipolar Disorder, Depressive Disorder, Schizophrenia, and Other: Psychosis. The resident was identified as currently receiving services for MI (Mental Illness). Section II of the Evaluation identified the resident as having had Psychiatric treatment more intensive than outpatient care. The individual was identified as exhibiting actions or behaviors that may make them a danger to themselves or others. The resident had not been diagnosed as having a primary diagnosis of Dementia or a related neurocognitive disorder, including Alzheimer's Disease. This admission was not a Provisional Admission.
Section IV of the PASRR determined that the Individual may not be admitted to a Nursing Facility due to the resident's Serious Mental Illness.
The form was signed by the Hospital's MSW (Masters prepared Social Worker) on 08/30/2020, with the resident signing on 08/31/2020. According to page one of the evaluation, the Social Worker was requesting admission for the resident to this facility.
On 09/17/20 in an interview that began at 1:13 p.m., the facility's social worker (SW) reported that she looks over new admissions' PASRR evaluations prior to their admission to the facility. The SW confirmed, Resident #25's PASRR dated 08/31/20 indicated the resident was not cleared for admission to a nursing home and a PASRR Level II should have been obtained prior to the transfer from the hospital. The SW confirmed that the MSW at the hospital should have stopped the transfer. The SW pointed to the facility's name listed on page 1 of the PASRR indicating the hospital was requesting admission to the facility. She reported that if there was a PASRR Level II in progress, it should be received prior to the resident's transfer to the facility. The SW confirmed that she had not attempted to obtain a Level II PASRR for Resident #25.
Continued interview with the SW revealed that there was a facility policy related to the PASRR evaluations. The facility policy, Pre-admission Screening for Mental Disorder and/or Intellectual Disability Patients, included facility will assure that all patients with Mental Disorders and/or Intellectual Disability receive appropriate pre-admission screenings according to federal and/or state regulations. Under the section entitled Practice Standards, guidance was given: Social Services will coordinate and/or inform the appropriate agency to conduct the evaluation and obtain results if: 1.1 it is learned after admission that the PASRR was not completed or is incorrect; 1.2 There is a significant change in status that results in new evidence of possible mental disorder, intellectual disability or a related condition.
In a separate interview on 09/18/2020 beginning at 11:00 a.m., the Director of Nurses agreed that the facility should not have taken the resident back, according to the PASRR.
In a phone interview on 09/18/2020 beginning at 12:33 p.m., the Medical Director reported that they had attempted to help Resident #25 by re-admitting him, but the resident seemed impossible to offer care to due to his behaviors. The Medical Director reported that he didn't think Resident #25 was appropriate for a nursing home due to his noncompliance. The Medical Director reported that the facility had no control over the admission process, as the Corporate Admissions Office directs admissions.
On 09/17/20 at approximately 9:20 a.m., the resident was observed awake, eyes open, lying on his side in bed with his covers pulled up under his neck. He stared at the surveyor when greeted. The resident was asked several questions such as how he felt, how he slept and how his breakfast was. The resident did not answer but continued to stare at the surveyor, until the aide answered the question about the resident's breakfast. Later that morning, before lunch, the resident was observed sitting up in bed, with his sheet pulled over his head. Again, he did not respond when the surveyor spoke with him.
The nurses' notes for the admission beginning 08/31/2020 revealed:
On 09/01/2020 at 7:10 a.m., the nurse's note indicated the resident had had a change in condition and included symptoms: resident called 911 from office phone 09/01/2020 at night. At 10:30 a.m. on 09/01/2020 the nurse's note read resident noncompliant all shift. Resident propelling throughout facility freely. Declining to stay in room or wear mask. Resident states, If you try to stop me I'll say you hit me. Resident in dietitian's office, sitting in her chair, twice. resident stated, I'm comfortable here. Resident proceeded to call 911. On 09/01/2020 the resident refused his nystatin and levothyroxine, per the nurse's note.
On 09/02/2020 at 6:33 a.m., the nurse's note read, resident kept coming out of his room claiming he was going to find a phone to call 911 because we won't do anything for him here and that when the police come he will tell them that he is being abused so they will take him to the hospital. redirected multiple times back to his room and he was yelling vulgar words and stating he would punch anyone that came near him. I called his aunt at 9:30 p.m. and put the phone on speaker phone. she was able to calm him down a little and told him that she does not want him going back to the hospital anymore because of COVID. Around 3 a.m., he walked out of his room and went into another resident's room and took her wheelchair. Asked resident why he went into the room and he stated he wanted to use that bathroom but since we stopped him he just went in wheelchair instead. He finally calmed down at 4:30 a.m. and went to bed. On 09/02/2020 the resident refused benztropine mesylate (ordered for extrapyramidal symptoms), haloperidol (for schizophrenia), mirtazapine (for depression) , and keppra (for seizures).
On 09/02/2020 at 22:35 (10:35 p.m.) the nurse's note read: 8 pm was in another resident's room when she heard some female residents screaming get out, get out of here, when writer ran to room found this resident in room [ROOM NUMBER] at the foot of (resident's bed). he had closed the door and was hanging onto her bed. refused to let go. and walk back to room. swearing at staff to 'f off.' it took three staff members to get him out. sat on his bed. explained to patient that he can not go into a female's room or any other rooms. finally laid down. approximately 10 p resident was found standing in his doorway ready to come out. again two staff members had to help him back to bed. told patient not to get out of bed again. 10:45 p remains in his room. writer returned to room [ROOM NUMBER] to apologize for his actions. resident very upset, wanted her door closed. door closed, no further problems.
On 09/03/2020 at 3:24 a.m., the nurse's note read, resident entering various resident's rooms attempting to take their wheelchairs. resident educated multiple times to wear a mask, stay in room. resident states F*ck that and F*ck you. I can go where I want. Touch me and I'll tell them you assaulted me. Writer and Aide assisted resident back to his room without difficulties. resident currently in bed. call light functioning and within easy reach. fluids at bedside. On 09/03/2020 the resident refused barrier cream to sacrum, levothyroxine, benztropine mesylate, haloperidol, keppra and mirtazapine.
From 09/04/20 until 09/07/2020, according to the nurse's notes, the resident did not have a documented behavior, but had refused medications.
On 09/08/2020 at 4:11 a.m. the nurse documented that the resident had called 911 and they were awaiting their arrival. The resident was readmitted on [DATE].
On 09/12/2020 at 1:39 a.m., the nurse's note documented, resident is having behavior issues at this time, observed sitting on his pillow and scooting down the hallways looking for a phone, trying to go to other rooms to find a phone, very non-compliant, staff attempted to re-direct with no effect, he is cursing and yelling at staff. he is refusing to go back to his room. Later on 09/12/2020, at 18:00 (6 p.m.) the nurse's documented that the resident would not allow the aide to take his vitals.
On 09/12/2020 at 23:35 (11:35 p.m.) the nurse documented, resident found in another female resident's room sitting on the bed. patient refused to get up. reminded patient that nurse would be calling 911. patient then said shut up B****. after ten minutes he returned to his room with assist. the hospice nurse was here to see patient. he wouldn't acknowledge her, kept his blanket over his head. 11 p.m. , patient remains in bed. patient also refused all his meds this shift.
On 09/13/2020 at 23:45 (11:45 p.m.) the nurse documented, 5p, resident sitting on pillow in his doorway with no mask, writer educated resident about wearing his mask and having the door shut. writer educated resident about using call light system which is affixed to his bed. resident said, ' F*** you, B****'. resident remained on floor on a pillow. Later, resident observed sitting on a chair in hallway with no mask on. resident declined to leave chair. shortly afterwards staff heard screaming. said resident was in a female's room. female resident was propelling up the hallway crying, stating there was a man in her room. and now wants to leave facility and go home. DON (Director of Nurses) now on scene. instructed writer to call 911. 911 here, informed DON he needed a MD to sign off on [NAME] Act. Doctor arrived to speak to police and initiate paperwork. resident taken to local hospital. POA notified.
A review of the Certificate of Professional Initiating Involuntary Examination form completed by the resident's physician and facility Medical Director on 09/13/2020, revealed the resident was exhibiting behaviors that included, refusing essential meds and care; intruding and threatening the safety of other residents. The physician documented that the resident was a threat to himself and others.
On 09/15/2020 the resident was back in the facility and at 22:42 (10:42 p.m.), per the nurse's note, the resident was observed walking down the hall, writer and aide tried to get him back to his room. He was screaming, F*** you, get out of my way or I will hit you. Swung his arms multiple times at staff. He then went into another resident room and sat down on his bed. Multiple aides tried to help him but he continued to try to hit the staff. Officer was called and stated that he needed to go to the hospital so officer called EMT (Emergency Medical Transport).
On 09/16/2020 at 16:01 p.m. (4 p.m.), the social services staff documented, called to the unit to assist with resident as he was being argumentative, swearing at staff, trying to walk down the hall to find a phone to call 911 so he can go to the hospital. nursing and this writer were able to talk to him to get him to sit in a chair. he threatened to hit staff numerous times but did allow the DON to clean and treat his face as he was complaining of pain in that area. He did allow the nurse to give him pain medication as well. Offered to give him a snack and he did accept two cookies. Did tell him that I spoke to his Aunt and we are all working to find him placement closer to the family. He did say he wanted to go now. Explained to him that as soon as placement can be found he will be able to be transferred. Resident did become agitated , swearing and threatening staff numerous times through out conversation.
Later on 09/16/2020 , at 22:40 (10:40 p.m. ) the nurse documented, resident has been out of control this whole shift, refusing meds and dinner. resident has a one to one tonight. while aide on break at 9:45 p.m., resident was able to walk into another resident's room, closed the door behind him. writer and other nurse entered room and found patient on the phone. resident took bottle of lotion and threw it at writer's head, just missing her face. 911 here and an officer. they spoke with the resident and informed him they weren't taking him to the hospital, so patient stated he was gonna kill himself. after a few minutes they spoke to his aunt who started yelling at the resident. 911 left and resident assisted back to his room by his aide.
On 09/17/2020 at 4:12 p.m., the nurse documented that the resident was able to use the phone in another resident's room. The EMTs arrived but did not take him to the hospital as the POA (power of attorney) had been called and she requested he not be taken to the hospital.
The resident had been followed monthly by a Medication Management team to ensure that the resident's medications related to his psychiatric history were appropriate. A note was reviewed that was written on 09/17/2020, after the resident had returned from the hospitalization for the involuntary admission. The APRN (Advanced Practice Registered Nurse) assessed the resident as continuing to have behaviors that were present before the psychiatric inpatient stay. patient expresses delusions of persecution and harm as well as occasional hallucinations that were not observed this visit. Patient can become agitated and physical with staff, he has not been compliant with pharmacological recommendations that would manage psychotic features. Goal of inpatient psychiatric stay was to establish MI (mental illness) schedule of antipsychotic dosing to prevent exacerbation of delusions and consequential medication refusals. patient appears to have been discharged with no changes to psychotropics following psychiatric admission.
One of the APRN's recommendations was consider alternative placement tailored to psychiatric needs.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 9/15/20 at 11:50 a.m., Resident #22 was observed lying on his back in bed with the head of bed elevated and a bed side tra...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 9/15/20 at 11:50 a.m., Resident #22 was observed lying on his back in bed with the head of bed elevated and a bed side tray table in front of him. Resident # 22 stated that at times he has to wait for his call light to be answered and will start yelling for someone. He stated he likes to have his bed bath around 7:00 PM and was told that would be mentioned to the certified nursing assistants (CNA's). He reported that there have been times when the CNA's will tell him they do not have time to give him a bath. The resident stated that he feels staff avoid caring for him because of his weight.
A review of the resident's record revealed diagnoses to include chronic diastolic heart failure, morbid obesity and quadriplegia. Review of Resident #22's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident required extensive assistance with all care tasks, such as personal hygiene, dressing, and toileting.
Review of the care plan completed on 7/14/20 revealed a focus care area documenting that Resident #22 required assistance for activities of daily living (ADL) care in bathing, grooming, personal hygiene, dressing, bed mobility, transfer, locomotion, and toileting related to: Chronic disease condition including chronic respiratory failure, resulting in activity intolerance, Limited mobility. The interventions included: Provide Resident #22 with assistance for bathing, dressing, grooming and toileting/catheter care.
Review of the CNA's documentation form for July, August, and September 2020: ADL RECORD revealed the form was divided by care areas to include bed mobility, transfers, eating, toilet use, walk, locomotion, dressing, personal hygiene and bathing. Each of these tasks were then divided by day and shift (11 PM - 7 AM, 7 AM - 3 PM and 3 PM - 11 PM) Each day and care area had a box where the CNA's were to mark each task with the level of assistance the resident required and at the bottom there was a coordinating box for day and shift where the CNA was to initial.
From 7/1/20-7/31/20 there were:
31 days of no CNA documented care on the 11 PM - 7 AM shift for all care areas.
29 days of no CNA documented care on 7 PM - 3 PM shift for all care areas.
29 days of no CNA documented care on the 3 PM - 11 PM shift for all care areas.
From 8/1/20-8/9/20 there were:
8 days of no CNA documented care on 11 PM - 7 AM shift for all care areas.
8 days of no CNA documented care on 7 AM - 3 PM shift for all care areas.
8 days of no CNA documented care on the 3 PM - 11 PM shift for all care areas.
From 8/14/20-8/31/20 there were:
10 days of no CNA documented care on 11 PM - 7 AM shift for all care areas.
6 days of no CNA documented care on 7 AM - 3 PM shift for all care areas.
14 days of no CNA documented care on the 3 PM -11 PM shift for all care areas.
From 9/1/20-9/16/20
11 days of no CNA documented care on the 11 PM -7 AM shift for all care areas.
11 days on no CNA documented care on the 7 AM - 3 PM shift for all care areas.
10 days of no CNA documented care on the 3 PM - 11 PM shift for all care areas.
On 9/17/20 at 10:40 AM, Staff C, CNA, assisted with explaining the CNA ADL RECORD form for Resident #22. Staff C reported that the form was supposed to be completed at the end of each shift.
On 9/18/20 at 11:20 AM, the DON stated he expected the CNA's to complete the ADL RECORD form and nurses were to complete their documentation for each of their assigned residents by the end of each shift before they leave. The unit manager was to bring the forms/documentation to morning meetings for review. If the form was not completed the assigned staff member would be contacted and asked to come in and complete their documentation.
3. On 9/15/20 at 10:30 AM, Resident #80 was observed up in her wheelchair visiting with another resident. Resident # 80 was observed with slight redness and swollen bilateral lower extremities.
During an observation of Resident #80 on 9/16/20 at 11:20 AM, she was up in her wheelchair seated in her room next to her bed. Resident #80 pointed out the folded clothes and towels on the foot of her bed and stated she was waiting for the CNA. Interview with Resident #80 revealed that she did not wear stockings and never has since she was a little girl. She stated she did not like them, she was in her 80's, and she wasn't going to change now. Resident #80 was not wearing any stockings or TED hoses at the time of interview and observation.
Clinical record review revealed Resident #80 had diagnoses of heart failure, atrial fibrillation, and type 2 diabetes. A review of the Resident #80's quarterly MDS dated [DATE] revealed Resident # 80 required extensive assistance of one staff person with all ADL's.
A review of the resident's current physician orders revealed:
Knee high TED hose on in AM off in PM, Order date: 1/22/20
Review of Resident #80's care plan completed on 9/3/20 revealed a focus area of: Resident #80 exhibits fluid volume excess as evidence by edema. The intervention included to administer medication as ordered and monitor for side effects, report as indicated to physician, and notify physician if edema continues or increases. A second focus area of: Resident # 80 requires assistance with ADL's was documented. The intervention stated: Assist in wearing TED hose as ordered-encourage as she refuses often.
On 9/16/20 at 10:15 AM review of Resident #80's electronic treatment administration record (eTAR) revealed that from 7/1/20 through 7/31/20 there were 10 blanks for the 7-3 shift regarding physicians order to assist resident with putting on knee high TED hose in the AM. From 8/1/20 through 8/31/20 there were 3 blanks on the 7-3 shift regarding assisting the resident with putting on the TED hose and one blank for the 11-7 shift in regard to taking off the TED hose. There were also, 10 refusal's documented on the 7-3 shift. From 9/1/20 through 9/16/20 there was one blank on 7-3 regarding assisting the resident to put on TED hose.
On 9/16/20 at 10:00 AM a review of Resident #80's progress notes revealed no refusals were documented from 9/1/20 through 9/16/20 and 10 refusals of putting on the knee-high TED hose from 8/1/20 through 8/31/20, and 1 refusal from 7/1/20 through 7/31/20. No progress notes were noted on contacting the physician or resident's representative related to the resident's refusals.
Interview with Staff G on 9/16/20 at 11:50 AM revealed she did not work with Resident # 80 often but was familiar with her. She stated Resident #80 does not like to wear TED hose. Staff G stated if she was working with the resident and she attempted to assist with putting on the TED hose and the resident refused, she would attempt again later and notify the nurse of the resident's refusal.
On 9/16/20 at 12:00 PM, Staff B revealed that if a resident refused to participate in a physician order it would be documented. If the resident refused 3 days in a row the physician was to be notified to decide if he would like to discontinue or change the order. When a nurse notified the physician, it was protocol for the nurse to make a note in the chart.
On 09/17/20 at 09:58 AM, the Assistant Director of Nursing (ADON) stated that nursing was to monitor the resident's edema to determine if treatment was effective. If the resident was refusing TED hose, the family was contacted, and staff would approach the resident again later in the day. Once the family and physician were notified and orders have been given, the care plan needs to be modified to reflect the physician's orders. If Resident # 80 had been refusing the TED hose for a period of time the physician should be contacted and an alternative treatment approach should have been ordered. The ADON stated the resident had an order for diuretics and the TED hose but that should have been discontinued.
During an observation on 9/17/20 at 10:10 AM, Resident #80 was seated in her wheelchair visiting with another resident. She did not have on TED hose at this time.
During an interview with the DON on 09/17/20 at 10:50 AM, he stated if a resident refused he expected the CNA to report to the nurse, the nurse should re-attempt, and if they are unable to encourage the resident, the family should be contacted. If the resident had multiple days of refusing an order, the physician should be contacted and informed about the refusals and orders should be adjusted accordingly.
A review of the policy and procedure titled Person-Centered Care Plan, effective date: 11/28/16, revision date: 7/1/19 revealed:
POLICY: The center must develop and implement a baseline person-centered care plan within 48 hours for each patient that includes the instructions needed to provide effective and person-centered care that meet professional standards of quality of care.
PURPOSE:
To promote positive communication between patient, resident representative, and team to obtain the patient's and resident representative's input into the plan of care, ensure effective communication and optimize clinical outcomes.
PRACTICE STANDARDS:
7.
Care plans will be:
7.2
Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, and as needed to reflect the response to care and changing needs and goals.
Based on observation, record review, and interview the facility failed to implement and develop a resident centered care plan for three (#20, #22, #80) of thirty sampled residents related to continuous oxygen use for Resident #20, activities of daily living (ADL) for Resident #22, and the use of Thrombo-Embolic Deterrent (TED) hoses for Resident #80.
Findings included:
1. On 9/15/20 at 10:15 a.m., Resident #20 was observed in her room watching television, and wearing an O2 (oxygen) Nasal Cannula (NC) connected to an oxygen concentrator. The oxygen concentrator was set to 2.5 Liters (L).
An observation was conducted on 9/16/20 at 11:40 a.m. of Resident #20 self-propelling in a wheelchair to her room, wearing a Nasal Cannula facemask. The oxygen tubing was connected to an oxygen tank located behind the wheelchair. The dial on the oxygen tank was set to 1.5 (L).
On 9/17/20 at 12:09 p.m., Resident #20 was observed in her room watching television and was receiving 2.5 liters of oxygen via NC. The resident stated, I always wear it, it is continuous, and I am supposed to be on 2.5 L of oxygen always.
A record review for Resident #20 indicated she was admitted on [DATE] with multiple diagnoses that included Chronic Obstructive Pulmonary Disease (COPD), Systolic (Congestive) Heart Failure, and Shortness of Breath (SOB). A review of physician orders revealed that there was no order for continuous use of oxygen.
A review of the quarterly Minimum Data Set (MDS) dated [DATE], identified in Section C, that Resident #20's Brief Interview for Mental Status (BIMS) score was 10, indicating moderate cognitive impairment.
On 9/18/20 at 11:25 a.m., an interview was conducted with the Care Plan Coordinator. She confirmed Resident #20's most recent care plan dated 7/7/20, did not have continuous oxygen on it. She further revealed that with diagnoses of COPD and SOB, it was important to address the monitoring of side effects and interventions for wearing continuous oxygen for the resident.
An interview was conducted with the Director of Nursing (DON) on 09/17/20 at 4:30 p.m. He was informed of the concerns related to Resident #20's continuous oxygen usage. The DON confirmed that the resident's most recent care plan did not have a focus care area, goals, and interventions related to continuous oxygen use and that the care plan should be updated. The DON further revealed that the resident never had a physician order to wear continuous oxygen since she was admitted on [DATE], and he could not find an order in the Electronic Medical Record (EMR) that was discontinued or dropped out of the system.
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, clinical record review, and interview, the facility failed to ensure storage of respiratory equipment, of ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, and interview, the facility failed to ensure storage of respiratory equipment, of a facemask, in accordance with professional standards of practice for three residents (#4, #20 and #44) of 17 residents receiving respiratory treatments for four of four days observed.
Findings included:
1. On 9/15/20 at 10:05 a.m., an observation was conducted of Resident #4's room; the resident was in the bathroom and it was observed that the respiratory (nebulizer) facemask was hanging on the side of the bedside nightstand, and not properly stored in the plastic treatment bag. (Photographic Evidence Obtained.)
During observation and interview of Resident #4's on 9/16/20 at 9:00 a.m., the respiratory (nebulizer) facemask was observed to be hanging on the side of the bedside table. The resident was observed to be looking at the facemask and was asked if she had previously had a nebulizer treatment that morning. Resident #4 revealed that it was her fault that the facemask was not stored properly in the plastic treatment bag. She further indicated she did not want to get the nurses in trouble.
An observation was conducted of Resident #4 on 09/18/20 at 8:15 a.m., lying in bed and watching television. During the observation it was noted that the nebulizer facemask was again hanging off the bedside nightstand but had liquid in the nebulizer cup below the nebulizer facemask piece. The resident was asked if she had been given her nebulizer treatment today, and she stated, Oh no, I was just going to put it on my face and do it. Resident #4 was further asked if the nurse had poured the nebulizer medication in the cup piece and left the room. The resident indicated that she did and left the room because she knows how to administer it herself.
An immediate interview was conducted at 8:22 a.m., with the Director of Nursing (DON), who was informed of the observation and confirmed that Resident #4 did not have a physician order to administer her own medications.
An interview was conducted with Staff F, Unit Manager, (UM) on 09/18/20 at 10:26 a.m., who earlier in the morning was seen administering medications on Resident #4's hallway. Staff F was informed of the prior observation made of Resident #4's nebulizer facemask, with nebulizer medication inside the cup. Staff F stated, I did not give the resident the nebulizer medication. It was from a previous shift, and I do confirm that the nurse needs to be in the room while administering the nebulizer treatment. The resident needs a self-medication order to administer her own nebulizer.
Clinical record review of Resident #4's care plan revealed that she was re-admitted on [DATE] with multiple diagnoses that included chronic obstructive pulmonary disease (COPD), systolic (congestive) heart failure, and shortness of breath. A further record review of physician orders for Resident #4 revealed:
Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML (milligram/milliliter) 1 vial inhale orally every 6 hours for COPD (6:00 a.m.,12:00 p.m., and 6:00 p.m.)
2. During a random observation on 09/15/20 at 10: 39 a.m., Resident #20 was observed to be sitting in a wheelchair dressed and groomed. Respiratory equipment of a nebulizer facemask was observed, from the hallway, to be on the bedside nightstand and not stored appropriately in a plastic bag.
A repeat observation of Resident #20's room was conducted on 09/15/20 at 11:41 a.m. The facemask was noted to be on the bedside nightstand not stored appropriately in a plastic bag , but this time next to a roll of toilet paper. (Photographic Evidence Obtained.)
During a subsequent observation of Resident #20's room on 09/17/20 at
8:35 a.m., the nebulizer facemask was observed to be on the bedside nightstand again improperly stored. The resident was asked about the nebulizer treatment, and where it is usually stored. She stated Yes when it's completed it goes on the bedside nightstand, I put it there when it's done. Resident #20 further indicated that her nebulizer treatment was administered early in the morning and when it was completed it stays on the bedside nightstand until staff put it away in the plastic bag next to the nebulizer respiratory machine.
On 9/18/20 at 8:00 a.m. an observation was conducted of Resident #20's room. During the observation, the nebulizer facemask was not stored in the plastic bag near the respiratory nebulizer machine. Staff F, Unit Manager (UM) for the North Hall, was outside the resident's room and confirmed the presence of the nebulizer mask on the nightstand bedside table.
Clinical record review for Resident #20 indicated she was admitted on [DATE] with multiple diagnoses that included chronic obstructive pulmonary disease (COPD), systolic (congestive) heart failure, and shortness of breath. Record review of a physician order dated on 4/02/20 for Resident # 20 revealed Albuterol Sulfate Nebulization Solution (2.5 Mg/3 ML [milligrams/milliters]) 0 0.083, 3ML inhale orally via nebulizer one time a day (06:30 a.m.) for Diagnosis of Shortness of Breath (SOB).
3. On 09/15/20 at 10:47 a.m. an observation was conducted of Resident #44 lying in bed sleeping. During the observation the resident's respiratory facemask was seen to be on top of the continuous positive airway pressure (CPAP) machine, near a role of toilet paper, and not stored appropriately in the plastic bag. Subsequent observation was conducted at 12:00 p.m., of the CPAP facemask still on top of the CPAP machine located on the bedside nightstand, and not stored appropriately. (Photographic Evidence Obtained.)
Clinical record review for Resident #44 indicated that he was re-admitted on [DATE] with multiple diagnoses that included systolic (Congestive) heart failure, cerebral infarction due to thrombosis of unspecified cerebral artery, non-ST Elevation (NSTEMI) Myocardial Infarction, and sleep apnea.
A record review of Resident #44's recent care-plan dated 8/12/20, indicated the resident was care-planned for risk of respiratory issues related to sleep-apnea- requiring CPAP therapy at bedtime.
On 9/17/20 at 4:30 p.m. an interview was conducted with the Director of Nursing (DON). The DON was informed of the observations made of the respiratory (nebulizer) facemask being left out on Resident #20's bedside nightstand. The DON was also shown two photographs of the nebulizer facemask near a toothbrush, magazines and next to a towel on the bedside nightstand. The DON stated, I will immediately have staff change out her nebulizer facemask and tubing for it, and I will make sure the staff put it in the bag when they do the nebulizer treatments.
A second interview was conducted with the DON on 9/18/20 at 12:05 p.m. The DON was informed of the earlier 08:00 a.m. observation, and that Staff F confirmed its presence of being left out on the resident's bedside nightstand. The DON further revealed that Resident #20 does not have an order to self-administer medications, and that the nurse should have stayed in the room at 06:00 a.m., until the nebulizer treatment was complete and stored the respiratory (nebulizer) facemask appropriately.
A review of facility policy titled, Nebulizer: Small Volume with a revision date of 11/01/19, read as follows: 20.1 Place in treatment bag labeled with patient name and date.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0740
(Tag F0740)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation of the resident, review of the resident's medical record, and interview with facility staff, the facility d...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation of the resident, review of the resident's medical record, and interview with facility staff, the facility did not ensure that one resident (#25) of 30 sampled residents, received mental health services appropriate for his assessed needs.
Findings included:
Resident #25 had multiple admissions to the facility based on a review of the electronic medical record and the Minimum Data Set (MDS) Assessments. The resident was initially admitted to the facility on [DATE] with diagnoses that included Adult Failure to Thrive, Schizophrenia, and Metabolic Encephalopathy.
A transfer to the hospital, documented in the MDS assessments, was dated 8/13/2020 with a return to the facility on [DATE]. The resident was transferred to the hospital on [DATE] and returned on 08/31/2020. The resident was transferred to the hospital on [DATE] and returned on 09/11/2020. The resident was transferred to the hospital on [DATE] and returned on 09/16/2020.
When the resident returned to the facility on [DATE], admission paperwork included the Pre-admission Screening and Resident Review (PASRR) evaluation which identified the resident as having the following Mental Illnesses: BiPolar Disorder, Depressive Disorder, Schizophrenia, and Other: Psychosis. The resident was identified as currently receiving services for MI (Mental Illness). Section II of the Evaluation identified the resident as having had Psychiatric treatment more intensive than outpatient care. The individual was identified as exhibiting actions or behaviors that may make them a danger to themselves or others. The resident had not been diagnosed as having a primary diagnosis of Dementia or a related neurocognitive disorder, including Alzheimer's Disease. This admission was not a Provisional Admission.
Section IV of the PASRR determined that the Individual may not be admitted to a Nursing Facility. due to the resident's Serious Mental Illness.
The form was signed by the Hospital's MSW (Masters prepared Social Worker) on 08/30/2020, with the resident signing on 08/31/2020. According to page one of the evaluation, the Social Worker was requesting admission for the resident to this facility.
A review of the Minimum Data Set Quarterly Assessment completed on 07/10/20 identified the resident as having moderately impaired cognition (Brief Interview for Mental Status score of 12). The resident answered yes to several Mood - related questions, indicating almost daily he had trouble sleeping, felt tired with little energy, had a poor appetite, felt badly about himself, and was fidgety and restless. According to the assessment the resident had behavioral symptoms, needed extensive assist by one staff member for Activities of Daily Living, and was always incontinent of bowel and bladder. The resident was 67 tall and weighed 108 lbs, which was 73% of his ideal body weight for his height. The MDS listed diagnoses that included seizure disorder and schizophrenia. At the time of the MDS assessment, he was not taking any antipsychotic medications, but he was taking an antidepressant and a hypnotic.
His care plan (initiated on 11/11/2019 with revision on 09/16/2020), included focus areas of being resistive to care, refusing to talk, refusing to take medication, hitting out and yelling at staff, calling 911, and urinating in the courtyard, which were identified as all being related to mood/psychiatric disorders. Interventions were to include allowing time for the resident to express his feelings; Staff were to provide empathy, encouragement and reassurance; the need for psych/behavioral health needs was to be evaluated; When the resident became resistive, care or activities were to be postponed to allow time for the resident to regain composure; Staff were to provide a calm quiet, well - lit environment and to explain all care including the procedure and the reason; and Social services was to provide support .
The care plan (initiated on 07/12/20) also focused on the resident's risk for distressed or fluctuating mood symptoms related to verbalizing various mood issues and the diagnosis of schizophrenia and metabolic encephalopathy. Interventions were for psych intervention as needed; observing for signs or symptoms of worsening sadness or depression; existing psychiatric disorders or new psychiatric disorders; and the resident was to be encouraged to seek staff support for his distressed mood, to focus on the positive.
The care plan (initiated on 12/03/2019) also focused on the resident's PASRR II level of determination secondary to his diagnoses of schizophrenia, adjustment disorder with depressed mood. The intervention included arranging for a PASRR re-evaluation if there was a significant change in status that may result in new evidence of a possible mental disorder.
Review of the resident's medical record revealed a PASRR completed on 10/23/2019 which indicated the need for a Level II evaluation. The Level II evaluation, dated 12/03/2019, indicated the resident's nursing facility placement was recommended to continue and that he didn't require specialized services for serious mental illness. A new PASRR was completed on 08/30/2020 which determined that the resident had a Serious Mental Illness and that he shouldn't be admitted to a nursing facility. A level II evaluation was required prior to being admitted to a nursing facility. The resident was admitted to the nursing facility on 08/31/2020.
The resident was followed monthly by a medical management Advanced Practice Registered Nurse (APRN) . Review of the note dated 08/25/2020, just after and also prior to a hospitalization, included the assessment, patient was seen for evaluation since return from inpatient stay. Patient continues to have paranoid delusions and has been calling 911. Patient was in his room with his blanket over his head, he becomes agitated with questioning and is minimally engaged. He asks why are you here? Patient appears to be paranoid as before when patient was off of haldol. Patient might benefit from an increase in haldol to manage psychotic features during acute phase.
The APRN assessed the resident on 09/17/2020, after he had returned from the hospital admission due to an Involuntary admission (Baker Act) and documented : patient continues to have behaviors that were present before psychiatric inpatient stay. patient expresses delusions of persecution and harm as well as occasional hallucinations that were not observed this visit. The APRN recommended consider alternative placement tailored to psychiatric needs if family honors patients refusals.
In a phone interview on 09/18/2020 beginning at 12:33 p.m., the Medical Director reported that they had attempted to help the resident, by re-admitting him, but the resident seemed impossible to offer care to due to his behaviors. The Medical Director reported that he didn't think Resident # 25 was appropriate for a nursing home due to his noncompliance. The Medical Director reported that the facility had no control over the admission process, as the Corporate Admissions Office directs admissions.
On 09/17/20 at approximately 9:20 a.m., the resident was observed awake, eyes open, lying on his side in bed with his covers pulled up under his neck. He stared at this Surveyor when greeted. He was given an explanation of this surveyor's purpose for visiting him, he was asked several questions such as how he felt, how he slept and how his breakfast was. The resident did not answer, but continued to stare at this Surveyor, until the aide answered the question about the resident's breakfast. Later that morning, before lunch, the resident was observed sitting up in bed, with his sheet pulled over his head. Again, he did not respond when this Surveyor spoke with him.
The nurses' notes for the admission beginning 08/31/2020 were reviewed.
On 09/01/2020 at 7:10 a.m., the note indicated a change in condition and included symptoms: resident called 911 from office phone 09/01/2020 at night. At 10:30 a.m. on 09/01/2020 the nurse's note read resident noncompliant all shift. Resident propelling throughout facility freely. Declining to stay in room or wear mask. Resident states, If you try to stop me I'll say you hit me. Resident in dietitian's office, sitting in her chair, twice. resident stated, I'm comfortable here. Resident proceeded to call 911. On 09/01/2020 the resident refused his nystatin and levothyroxine.
On 09/02/2020 at 6:33 a.m., the nurse's note read, resident kept coming out of his room claiming he was going to find a phone to call 911 because we won't do anything for him here and that when the police come he will tell them that he is being abused so they will take him to the hospital. redirected multiple times back to his room and he was yelling vulgar words and stating he would punch anyone that came near him. I called his aunt at 9:30 p.m. and put the phone on speaker phone. she was able to calm him down a little and told him that she does not want him going back to the hospital anymore because of COVID. Around 3 a.m., he walked out of his room and went into another resident's room and took her wheelchair. Asked resident why he went into the room and he stated he wanted to use that bathroom but since we stopped him he just went in wheelchair instead. He finally calmed down at 4:30 a.m. and went to bed. On 09/02/2020 the resident refused his benztropine mesylate (ordered for his Extrapyramidal symptoms) his haloperidol (for schizophrenia), his mirtazapine (for depression), and his keppra (for seizures).
On 09/02/2020 at 22:35 (10:35 p.m.) the nurse's note read: 8 pm was in another resident's room when she heard some female residents screaming get out, get out of here, when writer ran to room found this resident in room [ROOM NUMBER] at the foot of (resident's bed). he had closed the door and was hanging onto her bed. refused to let go. and walk back to room. swearing at staff to f off. it took three staff members to get him out. sat on his bed. explained to patient that he can not go into a female's room or any other rooms. finally laid down. approximately 10 p resident was found standing in his doorway ready to come out. again two staff members had to help him back to bed. told patient not to get out of bed again. 10:45 p remains in his room. writer returned to room [ROOM NUMBER] to apologize for his actions. resident very upset, wanted her door closed. door closed, no further problems.
On 09/03/2020 at 3:24 a.m., the nurse's note read, resident entering various resident's room attempting to take their wheelchairs. resident educated multiple times to wear a mask, stay in room. resident states F*ck that and F*ck you. I can go where I want. Touch me and I'll tell them you assaulted me. Writer and Aide assisted resident back to his room without difficulties. resident currently in bed. call light functioning and within easy reach. fluids at bedside. On 09/03/2020 the resident refused barrier cream to his sacrum, his levothyroxine, his benztropine mesylate, his haloperidol, his keppra and his mirtazapine.
From 09/04/20 until 09/07/2020 the resident did not have a documented behavior, but had refused medications.
On 09/08/2020 at 4:11 a.m. the nurse documented that the resident had call 911 and they were awaiting their arrival. The resident was readmitted on [DATE].
On 09/12/2020 at 1:39 a.m., the nurse's note documented, resident is having behavior issues at this time, observed sitting on his pillow and scooting down the hallways looking for a phone, trying to go to other rooms to find a phone, very non-compliant, staff attempted to re-direct with no effect, he is cursing and yelling at staff. he is refusing to go back to his room. Later on 09/12/2020, at 18:00 (6 p.m.) the nurse's documented that the resident would not allow the aide to take his vitals.
On 09/12/2020 at 23:35 (11:35 p.m.) the nurse documented resident found in another female resident's room sitting on the bed. patient refused to get up. reminded patient that nurse would be calling 911. patient then said shut up B****. after ten minutes he returned to his room with assist. the hospice nurse was here to see patient. he wouldn't acknowledge her, kept his blanket over his head. 11 p.m. , patient remains in bed. patient also refused all his meds this shift.
On 09/13/2020 at 23:45 (11:45 p.m.) the nurse documented, 5p, resident sitting on pillow in his doorway with no mask, writer educated resident about wearing his mask and having the door shut. writer educated resident about using call light system which is affixed to his bed. resident said, ' F*** you, B****' resident remained on floor on a pillow. Later, resident observed sitting on a chair in hallway with no mask on. resident declined to leave chair. shortly afterwards staff heard screaming. said resident was in a female's room. female resident was propelling up the hallway crying , stating there was a man in her room. and now wants to leave facility and go home. DON (Director of Nurses) now on scene. instructed writer to call 911. 911 here, informed DON he needed a MD to sign off on [NAME] Act. Doctor arrived to speak to police and initiate paperwork. resident taken to local hospital. POA notified.
On 09/15/2020 the resident was back in the facility and at 22:42 (10:42 p.m.) the nurse documented, the resident was observed walking down the hall, writer and aide tried to get him back to his room. He was screaming, F*** you, get out of my way or I will hit you. Swung his arms multiple times at staff. He then went into another resident room and sat down on his bed. Multiple aides tried to help him but he continued to try to hit the staff. Officer was called and stated that he needed to go to the hospital so officer called EMT (Emergency Medical Transport).
On 09/16/2020 at 16:01 p.m. (4 p.m.) the social services staff documented, called to the unit to assist with resident as he was being argumentative, swearing at staff, trying to walk down
the hall to find a phone to call 911 so he can go to the hospital. nursing and this writer were able to talk to him to get him to sit in a chair. he threatened to hit staff numerous times but did allow the DON to clean and treat his face as he was complaining of pain in that area. He did allow the nurse to give him pain medication as well. Offered to give him a snack and he did accept two cookies. Did tell him that I spoke to his Aunt and we are all working to find him placement closer to the family. He did say he wanted to go now. Explained to him that as soon as placement can be found he will be able to be transferred. Resident did become agitated , swearing and threatening staff numerous times through out conversation.
Later on 09/16/2020 , at 22:40 (10:40 p.m. ) the nurse documented, resident has been out of control this whole shift, refusing meds and dinner. resident has a one to one tonight. while aide on break at 9:45 p.m., resident was able to walk into another resident's room, closed the door behind him. writer and other nurse entered room and found patient on the phone. resident took bottle of lotion and threw it at writer's head, just missing her face. 911 here and an officer. they spoke with the resident and informed him they weren't taking him to the hospital, so patient stated he was gonna kill himself. after a few minutes they spoke to his aunt who started yelling at the resident. 911 left and resident assisted back to his room by his aide.
On 09/17/2020 at 4:12 p.m. the nurse documented that the resident was able to use the phone in another resident's room. The EMTs arrived but did not take him to the hospital as the POA (power of attorney) had been called and she requested he not be taken to the hospital.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review revealed Resident # 17 was admitted to the facility on [DATE] with diagnoses to include Generalized anxiety dis...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review revealed Resident # 17 was admitted to the facility on [DATE] with diagnoses to include Generalized anxiety disorder and Major depressive disorder. Review of care plan completed on 7/6/20 revealed a focus area that Resident #17 is at risk for distressed/fluctuating mood symptoms.
Review of Resident #17's current physician orders revealed that she had current orders of:
Guaifenesin-DM Liquid 100-10 MG/5ML (Dextromethorphan-Guaifenesin), Give 10 ml by mouth every 6 hours as needed for cough, Order Date: 3/3/20
Questran Packet (Cholestyramine) Give 1 tablet by mouth every 8 hours as needed for loose stool, Order Date: 10/2/19
Review of the consultant pharmacist recommendations revealed the following:
On 8/11/20 (repeated recommendation from 6/10/20. Please respond promptly to assure facility compliance with federal regulations.)
Resident #17 PRN Order(s) below have not been used within the previous 60 days:
1.
prn Guaifenesin DM
2.
prn Questran)
Please consider discontinuing due to lack of use.
On 9/9/20 (repeated recommendation from 6/10/20. Please respond promptly to assure facility compliance with federal regulations.)
(Resident #17 PRN Order(s) below have not been used within the previous 60 days:
1.
prn Guaifenesin DM
2.
prn Questran)
Please consider discontinuing due to lack of use.
Review of Resident # 17's current physician orders and MAR, the PRN medications were still ordered. There is no documentation in the record that would indicate that the physician was made aware of the consultant pharmacist recommendations and there is no documentation that would indicate that the recommendations were acted upon.
Continued review of Resident # 17's record revealed a MAR for the months of July 2020, August 2020, and September 2020. Closer review of the July, August and September 2020 MARs revealed a total of 33 blanks as follows:
ALPRAZolam Tablet 0.25 Mg, Give 1 tablet by mouth three times a day for anxiety, order date: 6/16/19,
15 blanks from July 1st to present
Blood Glucose Test Strip (Glucose Blood), Inject 1 strip subcutaneously two times a day for Diabetes mellitus notify Doctor if BG >400 or <60, order date: 5/28/20
7 blanks from July 1st to present
Carvedilol Tablet 3.125MG, Give 1 tablet by mouth two times a day for hr **HOLD for B/P less than 100/60 or pulse less than 60** order date: 6/12/20
6 blanks from July 1st to present
Fiber Tablet, Give 1 tablet by mouth two times a day for ibs, order date: 12/27/19
2 blanks from July 1st to present
Gabapentin Capsule 100MG, Give 1 capsule by mouth three times a day for neuropathy, order date: 5/29/19
11 blanks from July 1st to present
GlipiZIDE Tablet 5 MG, Give 1.5 tablet by mouth two times a day for diabetes Total 7.5mg, order date: 9/14/20
2 blanks from July 1st to present
Is resident free from side effects of psychotherapeutic medications? (if no, document side effects in PN), every shift for depression, anxiety, order date 2/11/19
3 blanks from July 1st to present
metFORMIN HCI Tablet, Give 1000MG by mouth two times a day for Diabetes, order date: 9/14/20
1 blank from July 1st to present
Omeprazole Tablet Delayed release 20 MG, Give 20 mg by mouth one time a day for GERD 12/24/19
3 blanks from July 1st to present
Synthroid Tablet 75 MCG, Give 1 tablet by mouth one time a day hypothyroidism, order date: 10/21/19
2 blanks from July 1st to present
Review of the records revealed that there was no documentation that would indicate that the Consultant Pharmacist was reviewing the MARs and making recommendations to the facility related to ensuring that medications are given as ordered and appropriately documented as given.
2. A review of the Consultation Report on 9/18/20 at 1:00PM for Resident # 22 revealed recommendations were submitted from the pharmacist on 8/17/20, 9/9/20 and 9/9/20 on various medication changes and monitoring, however no follow through from physician was noted.
3. Review of Resident #22's current physician order revealed that his orders included:
Digoxin Tablet 125MCG, Give .5 Tablet by mouth one time a day for heart failure, order date:8/14/20
Omeprazole Tablet Delayed Release 20MG, Give 1 tablet by mouth two times a day for acid indigestion, order date: 8/14/20
Metoprolol Tartrate Table 25MG, Give 1 tablet by mouth two times a day for htn, 8/14/20.
Review of the consultation pharmacist recommendations revealed the following:
On 8/17/20 Please clarify the following items on the medication administration record (MAR)/ prescriber order sheet (POS):
1.
Digoxin order needs a pulse prompt.
2.
Metoprolol order has parameters and needs a pulse and blood pressure prompt on the eMAR
3.
Please change the times Omeprazole to 630 am and 430 pm.
On 9/9/20 Please clarify the following items on the medication administration record (MAR)/prescriber order sheets (POS):
1.
Digoxin order needs a pulse prompt.
2.
Metoprolol order has parameters and needs a pulse and blood pressure prompt on the eMAR
3.
Please change the times Omeprazole to 630 am and 430 pm.
Review of Resident # 22's current physician orders and MAR revealed the resident was still maintained on the same dosage with no changes to the medications parameters documentation and change in time of administration. There is no documentation in the record that would indicate that the physician was made aware of the consultant pharmacist recommendations and there was no documentation that would indicate that the recommendations were acted upon.
Continued review of Resident # 22's record revealed a MAR for the months of July 2020, August 2020, and September 2020 with a total of 33 blanks as follows:
Ascorbic Acid Tablet 500MG, Give 1 tablet by mouth two times a day for supplement, order date: 8/14/20
7 blanks from July 1st to present
Budesonide Suspension 0.5 MG/2ML, 1 vial via trach two times a day for sob, order date: 8/14/20
8 blanks from July 1st to present
Cetirizine HCI Tablet 10MG, Give 1 tablet by mouth one time a day for Allergy symptoms, order date: 8/14/20
3 blanks from July 1st through August 10th
Insulin Regular Human Solution 100UNIT/ML, Inject as per sliding scale, order date: 8/14/20
9 blanks from July 1st to present
Omeprazole Tablet Delayed Release 20MG, Give 1 tablet by mouth two times a day for acid indigestion, order date: 8/14/20
7 blanks from July 1st to present
Simvastatin Tablet 10MG, Give 1 tablet by mouth one time a day for cholesterol control, order date 8/14/20
11 blanks from July 1st to present
3. During an interview with the DON on 9/18/20 at 11:04 AM it was learned that the DON was receiving medication reviews from the pharmacist through e-mails. The DON stated he has not had much time to follow through because he has been busy with staffing and working the nursing cart at times.
A phone interview on 9/18/29 at 11:35 AM with the Consultant Pharmacist revealed that he started working at this facility in February 2020 and has only entered the facility one time due to COVID-19 restrictions. He reported that he has been completing his reviews via remote access to the facilities electronic records and that he e-mails his recommendations to the DON and puts them on an electronic e-mailing system. He stated he has not been receiving follow up to his recommendations. He has been communicating with the administrator and the DON. He stated that when he completes his reviews and if they are not acted upon he will repeat his recommendation the following month if he feels it is still appropriate. He reported that he would like a response to his recommendations with-in two weeks after his recommendation, but his expectation is that the facility acts on his recommendations at least before the next review date. He stated that he is unsure as to why the facility was not responding to his recommendations. He reported that he sends the physician a copy of the recommendations. The Consultant Pharmacist reported that he has not contacted the medical director regarding the lack of follow-up to the consultant pharmacy recommendations when he does not hear back from the administrator or DON. The Consultant Pharmacist reported that if he sees any blanks on the eMAR that are significant he will make recommendations to address that as well.
Phone interview on 9/18/20 at 12:36 PM the Medical Director revealed that he had not been contacted directly about the medication reviews conducted by the Consultant Pharmacist. He reported that his expectation is that if the Consultant Pharmacist saw blanks in the eMAR that the pharmacist would make a recommendation to follow up. He reported that his expectation is that medications used to monitor resident behavior be monitored each shift by the staff and that if this is not done that recommendations from the Consultant Pharmacist are expected.
Based on record review and interview the facility failed to ensure a drug regimen review was conducted and communicated to report and correct irregularities for 3 out of 5 (Resident #30, Resident # 22, Resident # 17) residents sampled for unnecessary medications regarding lack of recommendations related to missing data on the Medication Administration Record (MAR), lack of monitoring of medications used to control resident behavior and failure to ensure that the consultant pharmacist recommendations were reviewed and acted on.
Findings include:
1. Review of Resident #30's current physician orders and his MAR for the months of July 2020, August 2020 and September 2020 revealed that the resident had order for medications that included the following:
-Accu check twice per day REPORT GLUCOSE BELOW 60 AND ABOVE 400, with a start date of 12/27/18.
-Baclofen 10 mg three times a day for Muscle Spasms, with a start date of 6/4/20.
-Dextromethorphan-Qulnldine Capsules 20-10 mg two times a day for PBA, with a start date of 9/7/18
-Duloxetine HCI Capsules DR Particles 30 mg 2 times a day for depression, with a start date of 9/7/18.
-Gabapentin 600 mg two tablets at bedtime for neuropathy, with a start date of 9/13/19.
-Levemir FlexPen Solution, Inject 80 units SQ two times a day for DM, with a start date of 5/16/20.
-Novolin R Solution Inject 5 units SQ before meals for DM, with a start date of 5/15/20.
-Oxycontin ER 12 hour abuse-deterrent 20 mg, one tablet two times a day for non-acute pain, with a start date of 7/31/20.
Closer observations of the MAR revealed the following blanks on the MAR:
-Accu check twice per day -2 blanks for the month of July.
-Baclofen 10 mg three times a day-1 blank for the month of July.
-Dextromethorphan-Qulnldine Capsules 20-10 mg two times a day- 1 blank for the month of July; 2 blanks for the month of august; and 1 blank for the month of September.
-Duloxetine HCI Capsules DR Particles 30 mg 2 times a day-1 blank for the month of July; 2 blanks for the month of August; and 1 blank for the month of September.
-Gabapentin 600 mg two tablets at bedtime -1 blank for the month of July; 2 blanks for the month of August; and 1 blank for the month of September.
-Levemir FlexPen Solution, Inject 80 units SQ two times a day-2 blanks for the month of July.
-Novolin R Solution Inject 5 units SQ before meals-3 blanks for the month of July.
-Oxycontin ER 12 hour abuse-deterrent 20 mg, one tablet two times a day-2 blanks for the month of August.
For a total of 22 blanks on the MAR for resident #30 from 7/1/20 to present (9/18/20).
Interview on 9/17/20 at 11:40 AM with the DON revealed that the he was not aware if the consultant Pharmacist had reviewed the MARs for blanks. He reported that the Consultant Pharmacist reviews and recommendations are non-existent, that there are just piles of papers and that he has not been able to find any of them other that August 2020 since he took over the DON position.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.During an interview with the DON on 9/18/20 at 11:04 AM the DON stated the pharmacist is sending medication recommendations in...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.During an interview with the DON on 9/18/20 at 11:04 AM the DON stated the pharmacist is sending medication recommendations in e-mail to DON. The DON stated he had been busy working on staffing and covering nursing carts. He also stated a GDR review is an IDT (Interdisciplinary Team) with the psychologist and they should be discussing behaviors and looking at dosage and see if can be reduced. He continued to state that the GDR meetings are not occurring; however, the psychologist is coming in and reviewing dosage, then it is being discussed in morning meeting.
On 9/18/29 at 11:35 AM the Pharmacist stated he started working at this facility in February and has only entered the one time due to COVID. He has been completing his reviews on the electronic medical record and he e-mails his recommendations to the DON. He reported that he does have meetings every month with the psychologist and they discuss GDR, but these meetings are not a team meeting. He reported that he is unaware of previous attempts of GDR.
During an interview on 9/18/20 at 12:36 PM the Physician stated he has not been contacted directly about the medication reviews by the pharmacist. He states the psychotropic medications review should be completed by the psychologist and they should consider nursing recommendations with behaviors to make the GDR recommendations accordingly. He reported that the psychologist will make the original recommendations for medication changes and the physician will follow up on any changes.
4. A record review for Resident #44 indicated he was re-admitted on [DATE] with multiple diagnoses that included Psychotic Disorder with Delusions due to known physiological condition. A review of physician orders indicated Risperdal Solution 0.25 ml via G-tube one time a day for delusions.
A continued record review revealed no documentation of behavioral monitoring since the resident was admitted to the facility on [DATE]. Clinical record review of psychiatric progress notes indicated the resident has been taking Risperdal Solution, and managed by facility Psychiatrist and Advanced Practice registered nurse (APRN). The APRN writes on most recent progress notes Gradual Dose Reduction (GDR) remains clinically inadvisable at this time.
A continued record review revealed target behavior documentation for behavior monitoring was not being conducted, based on observation of Electronic Medical Record (EMAR) for 7/1/2020 to 7/31/2020, 8/1/2020 to 8/31/2020, and 9/1/2020 to 9/16/2020.
A review of care plan dated 08/12/2020 showed under interventions to complete behavior monitoring flow sheet, monitor for changes in mental status and functional level and report to the MD as indicated. Monitor for continued need for medication as related to behavior and mood. Monitor for side effects and consult physician and/or pharmacist as needed.
The review of the quarterly Minimum Data Set (MDS) dated [DATE], identified in Section C, that resident #44's Brief Interview For mental Status (BIMS) score was 06, (indicating severe cognitive impairment); and Section N indicated the resident was receiving antipsychotic therapy on a routine basis.
On 09/18/20 08:03 a.m., an observation was conducted of Resident #44, lying in bed, sleeping, with the television volume on.
During an interview with the Director of Nursing (DON) on 09/18/2020 at 11:04 a.m., he was informed that Resident # 44 had not had behavior monitoring conducted for the past three (3) months on the EMAR for the medication Risperdal. The DON confirmed that target behavior monitoring was not being conducted and revealed that his staff are not able to monitor Resident #44 appropriately if they do not know what they are specifically supposed to be looking for when assessing behavior monitoring.
On 09/18/2020 at 12:08 AM a telephone interview was conducted with the pharmacy consultant for the facility. He was notified that the facility was not conducting anti-psychotic behavior and side effects monitoring for the medication Risperdal. He revealed that the facility must be monitoring psychotic medications with specific target behaviors and documenting them appropriately.
A facility provided policy titled 3.8 Psychotropic Medication Use, revision date 11/28/16 Page 1-3 reads:
Procedure
1.1.3 Staff should become familiar with the cultural, medical, and psychological information about the resident to identify potential environmental and other triggers to prevent or reduce behavioral symptoms and/or distress, types and the consequences of behaviors exhibited by the resident and interventions that may be indicated for a specific behavior type.
7. All medications used to treat behaviors must have a clinical indication and be used in the lowest possible dose to achieve the desired therapeutic effect. All medications used to treat behaviors should be monitored for:
7.1 Efficacy
7.2 Risks
7.3 Benefits, and
7.4 Harm or adverse consequences
12. Facility staff should monitor the resident's behavior pursuant to Facility policy using a behavioral monitoring chart or behavioral assessment record for residents receiving psychotropic medication for organic mental syndrome with agitated or psychotic behavior(s). Facility staff should monitor triggers, episodes, and symptoms. Facility staff should document the number and/or intensity of symptoms and the resident's response to staff intervention.
Based on record review and interview the facility failed to assure 2 out of 5 (#30, #44) sampled residents were free from unnecessary medications related to Gradual Dose Reductions (GDR), lack of monitoring medications used to control behavior.
Findings included:
1. Review of the Resident #30's medical record revealed his diagnoses included Schizoeffective disorder dated 9/27/18, and Major Depression dated 10/1/16.
Review of the resident's current physician orders revealed that he had the current medications to address behaviors:
-Depakote sprinkles cap DR 125 mg 2 caps bid (twice daily) for major depressive
-Quetiapine Fumarate 25 mg qd (daily) for schizophrenia
-Duloxetine HCI cap DR particles 30 mg bid for depression
An interview on 09/17/20 at 11:40 AM with the Director of Nurses (DON) revealed that he was not sure if he could locate Gradual Dose Reduction (GDR) information and said that the consultant pharmacist reviews and recommendations were non-existent.
Interview on 9/17/20 at 1:35 PM with Staff B LPN/Unit Manager revealed that Resident #30 used to exhibit behaviors such as trying to hit staff and being non-compliant with taking his medication and receiving care. She reported that since the resident's change in condition he had a decline and had not exhibited any behaviors in months.
Interview on 9/17/20 at 1:36 PM with Staff A, RN revealed that over the past several months Resident #30 has had a steady decline, is currently on hospice and does not exhibit behaviors anymore.
Review of the medication management assessment dated [DATE] revealed that the resident has current diagnoses that included Major Depression disorder, single episode, anxiety disorder, Unspecified Dementia with behavioral disturbances, with a past psychiatric history that included non-compliance, behaviors, strange behaviors, schizophrenia, and depression. The document revealed that the resident had current use of Seroquel 25 mg daily, Cymbalta 30 mg bid and Depakote 259 mg bid. The document indicated that Self abusive thoughts; suicidal thoughts; aggressive thoughts and homicidal thoughts were absent, No known of past attempts to harm self or others, and estimation of risk for violence was absent and that patient was currently not a danger to self or others. The assessment and recommendation section of this document indicated that The patient was seen for routine 7 week follow up, Patient has displayed no new behaviors or concerns. Stable at this time. Continued review of this document revealed that Seroquel was the only medication reviewed for GDR and that the determination was that GDR Contraindicated; Chronic mental Illness w/Relapse Risk, and a GDR Rationale #1 Patient past reduction failed; #2: patient use has persisted beyond 6 months without reduction trial.
Review of the behavior monitoring found on the MAR for July, August, and September 2020 revealed that the resident did not exhibit any behaviors during these months.
Review of the resident record revealed that there was no other documentation in the record that would indicate that Resident #30 had received a Gradual Dose Reduction in the past year.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interviews, and record review the facility failed to appropriately secure medications in three of four medication carts.
Findings included:
A review of the facility's Policy & P...
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Based on observation, interviews, and record review the facility failed to appropriately secure medications in three of four medication carts.
Findings included:
A review of the facility's Policy & Procedures Page 01-02, dated 12/1/07 and revised 10/31/16, titled 5.3 Storage and Expiration of Medications, Biologicals, Syringes and Needles, read as follows:
Applicability:
Policy 5.3 sets for the procedures relating to the storage and expiration dates of medications, biologicals, syringes and needles.
3. General Storage Procedures:
3.3 Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors.
10. Facility should ensure that all medications and biologicals for each resident are stored in containers in which they were originally received.
On 09/17/20 at 12:40 p.m., an observation of medication cart #2, located on the South Hall included seven (7) loose tablets, and seven (7) loose half and quarter pieces of loose tablets. (Photographic Evidence Obtained.) Staff B, Licensed Practical Nurse, (LPN) confirmed the presence of the unsecured tablets.
On 9/17/20 at 1:00 p.m., an observation was conducted on medication cart #1, located on the South Hall, which included ten (10) loose tablets and three (3) loose pieces of tablets. ((Photographic Evidence Obtained.) Staff D, (LPN) confirmed the presence of the unsecured tablets.
On 9/17/20 at 1:15 p.m., an observation was conducted on North Hall medication Cart #1, which included many loose tablets that filled a clear medication cup up to the one-half marker or one (1) tablespoon (TBS). Staff E, (LPN) confirmed the presence of the unsecured tablets.
An interview was conducted with the Director of Nursing (DON) on 09/18/20 at 1:30 p.m. During the interview the DON who was informed of the observation made of unsecured tablets in three (3) of four (4) medication carts. The DON stated, The
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected 1 resident
Based on observations, review of maintenance requests and proposals for work, an interview with the Director of Dietary, the Director of Maintenance and the Administrator, the facility failed to maint...
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Based on observations, review of maintenance requests and proposals for work, an interview with the Director of Dietary, the Director of Maintenance and the Administrator, the facility failed to maintain equipment and the facility premises in safe operating condition as evidence by the facility: 1. failed to ensure that four ceiling tiles surrounding air vents in two of four resident halls were clean and free of dark stains and black spots; 2. failed to replace floor tiles and a loose wall board in the kitchen; and 3. failed to replace a freezer door that was identified as not fitting the door frame due to a build-up of ice.
Findings included:
1. On 09/16/2020 at 8:49 a.m., three ceiling tiles surrounding outflow air vents on the 400 hall were noted to be stained with a brown color and the metal flanges on the ceiling vents were noted to be soiled with a black spotty substance. The three ceiling tiles (Photographic Evidence Obtained, photo # 5, 6, 7), were adjacent to rooms #402, #406, and #408.
The fourth ceiling tile was observed outside of the storage room on the 300 hall. In an interview with the Director of Maintenance, on 09/18/2020 beginning at 2:45 p.m., the ceiling tiles were observed. The Director of Maintenance, while observing the ceiling tiles and outflow vents, reported that the brown staining on the ceiling tiles was only a buildup of dust that had been smeared into the surface of the tile. The Director of Maintenance reported that the black spots observed on the ceiling vent flanges were only dust, and they would disappear if the flanges were dusted.
When it was suggested that the brown stains on the ceiling tiles resembled water stains, the Director of Maintenance disagreed, commenting that there had been no problem with water in the ceiling that would have stained the ceiling tiles.
In an interview with the Administrator on 09/18/2020 beginning at 2:20 p.m., the Administrator confirmed that she had been made aware of the discolored ceiling tiles and the black spots on the vent flanges, but she had not observed them for herself. She reported that they would need to remove the tiles and see what was happening above.
2. On 09/15/2020 beginning at 9:30 a.m., an initial tour was made of the facility's main kitchen. Floor tiles in the dish machine room were noted to be cracked with some missing tile pieces allowing water to collect in the depressions. (Photographic evidence obtained - see photos 3 and 4.)
In the dish machine room, at the exit door to the service hall, where meal tray carts entered the dish machine room, the last tile in the baseboard was noted to be standing away from the door frame. This tile was attached to the wall board, and when the tile was moved, the tile and wall board moved. The loose tile and the unsecured wall board provided an entry point for vermin.
The request for maintenance of the broken floor tiles in the dish machine room was reviewed and noted to have been requested on 7/17/20 . The work needed was described as broken tiles are located in dish room area and by freezer door. The priority was marked as High.
3. On 09/15/2020 at 9:40 a.m., the door to the walk-in freezer was noted to be ill-fitting in the door frame. When the door was pulled opened, a wire rack just inside of the freezer and to the left, was noted to be storing boxed product which was frosted with ice. The door threshold of the freezer was noted to have a buildup of ice pushing up the metal threshold plate. The Dietary Manager reported at that time, that the freezer door needed to be replaced and this had been a problem as the ice buildup kept the door from shutting fully.
On 09/18/20 at 10:30 a.m., the freezer door was noted to have a chunk of ice (approximately 4 inches high) at the juncture of the bottom of the door and floor. (Photographic evidence obtained - Photo # 1, 2). When the freezer door was pulled open, ice was noted to have built up under the threshold, pushing the threshold up. (See photo 2).
Again, the Dietary Manager reported that the freezer door was a problem and there had been discussion about having to replace the entire walk-in freezer/refrigerator unit. He reported that the freezer door had been replaced in the past , but that didn't ensure the door fit well curtailing the ice buildup.
The Director of Maintenance provided documents related to the replacement of the walk-in freezer. They were noted to date back to 10/30/2018 with the description of service: requested service for the walk- in freezer that is not properly working. There is ice buildup and the heating/cycle is off. Work completed onsite. Technician arrived on site and found the frames degraded. Recommend replacement of the unit.
On 12/17/18 a second maintenance request was reviewed and noted with the description: requests service for the buildup of ice on their walk-in freezer. They think that air is entering from the door. Work completed onsite. Technician determined the walk-in freezer box needs to be replaced. This request included that a quote for the work was needed.
A quote provided to the facility, dated 02/22/2019, was reviewed. The quote included the facility's address as the site where the work would be performed, but the project scope, replacement of existing walk in cooler/freezer combo unit with new walk in cooler/freezer unit, named a different facility. The quote was not signed by the facility. The quote included a photo of the freezer, which mirrored photo #2, obtained by the surveyor, which showed ice under the freezer floor at the threshold.
The request for replacement of the walk-in units for the 2021 capital budget included the description, The walk-in walls are deteriorated and are causing major condensation issues in the freezer. The box itself has had the freezer door replaced in the past. The State wrote this up on their last visit. Some of the refrigeration components have already been replaced. Proposals for the replacement of this box were obtained last year as the walls of the box itself are splitting at the seams from being frozen and melting.
The request for maintenance of the broken floor tiles in the dish machine room was reviewed and noted to have been requested on 7/17/20 . The work needed was described as broken tiles are located in dish room area and by freezer door. The priority was marked as High.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview and record review the facility failed to ensure that the environment was maintained in a safe man...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview and record review the facility failed to ensure that the environment was maintained in a safe manner in three of eight resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER]) located on one of four resident halls (200 hall) related to a wrapped call light string and holes in the walls.
Findings included:
Observations during the initial tour of the facility on 9/15/20 at 10:30 a.m. revealed the following:
-room [ROOM NUMBER]- A hole was noted in the wall, located near the bathroom door, where an electrical outlet should be.
-room [ROOM NUMBER]- A large gaping hole was noted in the wall behind the bed located closest to the window.
-room [ROOM NUMBER]- The call light string was noted to be wrapped around the grab bar located in the bathroom.
(Photographic Evidence Obtained)
Observations on 9/17/20 at 2:30 p.m. of the resident rooms 203, 204, 206 with the Director of Maintenance present confirmed that there was a large hole behind the resident's bed in room [ROOM NUMBER], confirmed that an electrical outlet was hanging leaving an open hole in the wall in room [ROOM NUMBER], and confirmed that the call light string was wrapped around the grab bar in the bathroom of room [ROOM NUMBER]. Interview with the Director of Maintenance at this time revealed that staff are to report all maintenance concerns to him and then it would be reflected on the Building Management Software system. He reported that he has a helper and that they both would be responsible to fix these concerns.
A request was made to provide from the Building Management Software system any type of documentation that would indicate that this concern was presented to the maintenance department and to provide the facility policy on maintenance. This documentation was not provided.
Review of the facility policy titled, Accommodation of Needs, with an effective date of 6/15/05 revealed: 1. The Center must provide:
1.1 A safe, clean, comfortable, and homelike environment, allowing the resident to use his/her personal belongings to the extent possible.
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: 2 life-threatening violation(s), $175,634 in fines. Review inspection reports carefully.
- • 37 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $175,634 in fines. Extremely high, among the most fined facilities in Florida. Major compliance failures.
- • Grade F (1/100). Below average facility with significant concerns.
Bottom line: Trust Score of 1/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Aviata At Sand Key's CMS Rating?
CMS assigns Aviata at Sand Key an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Florida, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Aviata At Sand Key Staffed?
CMS rates Aviata at Sand Key's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes.
What Have Inspectors Found at Aviata At Sand Key?
State health inspectors documented 37 deficiencies at Aviata at Sand Key during 2020 to 2024. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 35 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 Aviata At Sand Key?
Aviata at Sand Key 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 AVIATA HEALTH GROUP, a chain that manages multiple nursing homes. With 120 certified beds and approximately 111 residents (about 92% occupancy), it is a mid-sized facility located in CLEARWATER, Florida.
How Does Aviata At Sand Key Compare to Other Florida Nursing Homes?
Compared to the 100 nursing homes in Florida, Aviata at Sand Key's overall rating (1 stars) is below the state average of 3.2 and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Aviata At Sand Key?
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 you walk me through typical staffing levels on day, evening, and night shifts?" "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?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the below-average staffing rating.
Is Aviata At Sand Key Safe?
Based on CMS inspection data, Aviata at Sand Key has documented safety concerns. Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Florida. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Aviata At Sand Key Stick Around?
Aviata at Sand Key has not reported staff turnover data to CMS. Staff turnover matters because consistent caregivers learn residents' individual needs, medications, and preferences. When staff frequently change, this institutional knowledge is lost. Families should ask the facility directly about their staff retention rates and average employee tenure.
Was Aviata At Sand Key Ever Fined?
Aviata at Sand Key has been fined $175,634 across 3 penalty actions. This is 5.0x the Florida average of $34,835. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Aviata At Sand Key on Any Federal Watch List?
Aviata at Sand Key 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.