KUAKINI GERIATRIC CARE, INC
Non profit - Corporation
187 Beds
Independent
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
0/100
#38 of 41 in HI
Last Inspection: January 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Kuakini Geriatric Care, Inc. has received a Trust Grade of F, indicating significant concerns about the facility's quality of care. It ranks #38 out of 41 nursing homes in Hawaii, placing it in the bottom half of state facilities, and #23 out of 26 in Honolulu County, meaning only a few local options are considered worse. The facility is trending towards improvement, having reduced its issues from 18 in 2024 to 7 in 2025. Staffing is a relative strength, with a rating of 4 out of 5 stars and a turnover rate of 21%, which is well below the state average. However, the facility has incurred $117,550 in fines, which is concerning as it is higher than 80% of other facilities in Hawaii. There have been critical incidents noted, including failures in food safety leading to risks of foodborne illness and serious medication management issues that could result in harm to residents. For example, medication for a resident was prescribed without the necessary diagnosis, risking negative side effects and falls. Additionally, nursing staff were found to be administering oxygen outside their scope of practice, which could endanger a resident with chronic respiratory issues. While there are strengths in staffing, the serious deficiencies in care highlight significant weaknesses that families should consider when researching this facility.
- Trust Score
- F
- In Hawaii
- #38/41
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ✓ Good
- 21% annual turnover. Excellent stability, 27 points below Hawaii's 48% average. Staff who stay learn residents' needs.
- Penalties ✓ Good
- $117,550 in fines. Lower than most Hawaii facilities. Relatively clean record.
- Skilled Nurses ✓ Good
- Each resident gets 90 minutes of Registered Nurse (RN) attention daily — more than 97% of Hawaii nursing homes. RNs are the most trained staff who catch health problems before they become serious.
- Violations ⚠ Watch
- 55 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 8%
Review needed
18 → 7 violations
★☆☆☆☆
1.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★☆☆
3.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 18 issues
2025: 7 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
Low Staff Turnover (21%) · Staff stability means consistent care
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover is low (21%)
27 points below Hawaii average of 48%
Facility shows strength in staffing levels, staff retention, fire safety.
The Bad
1-Star Overall Rating
Below Hawaii average (3.4)
Significant quality concerns identified by CMS
Federal Fines: $117,550
Well above median ($33,413)
Significant penalties indicating serious issues
The Ugly 55 deficiencies on record
2 life-threatening 1 actual harm
Jan 2025
7 deficiencies
1 IJ (1 facility-wide)
CRITICAL
(L)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Food Safety
(Tag F0812)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to assure kitchen staff using the dishwasher waited for the water tempera...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to assure kitchen staff using the dishwasher waited for the water temperature to raise to 180 degrees Fahrenheit (F) or more during the final rinse cycle before processing the dishes from the conveyor belt, placing them on the storage racks of clean dishes, failing to assure dishware and silverware were heat sanitized. This deficient practice puts all residents and staff, who eat their meals at the facility, at risk for foodborne illness.
The State Agency (SA) identified an Immediate Jeopardy (IJ) at §483.60 (F812) on 01/05/25 at 08:44 AM.
Findings Include:
On 01/05/25 at 08:43 AM an initial tour was conducted with Food Services Supervisor (FSS)1. During initial tour of the kitchen found the kitchen uses a dishwasher with high temperatures to sanitize their dishware and silverware. Review of facility log for the dishwasher stated Standards: Wash - 140-160 degrees F and Final Rinse - 180-190 degrees F. If temperature is above or below range, please inform the supervisor. Logs of temperatures written in for 01/01/25 - 01/04/25 were all within the standard temperatures.
Observed dishwasher at 08:44 AM with dishes loaded on the conveyor belt moving through the dishwasher and kitchen staff unloading the dishes onto a rack. During this time, the dishwasher temperature was checked by surveyor and the final rinse was at 172 degrees F. Inquired of the FSS1 what the final rinse temperature was at, and she stated 172.
Inquired with the Food Service Worker 1 who also confirmed the temperature was at 172 degrees F. Inquired with Food Service Worker (FSW) 2 what the final rinse has to be at for the dishes to be sanitized and she did not respond, FSW2 continued to unload the dishes that had gone through the dishwasher.
Inquired with FSS1 what the final rinse has to be at, and she told staff to stop what they were doing. She stated the final rinse has to be 180 degrees or more. Inquired with FSS1 if the dishwasher uses a chemical sanitizer to clean the dishes and she said it is done by heat. FSS1 showed surveyor where the dishwasher detergent was dispensed from that leads to the dishwasher and also showed the Temp Rinse All Temperature Drying Agent.
On 01/05/24 at 10:00 AM returned to the kitchen to meet with the Administrator to discuss findings about the dishwasher use. Reviewed dishwasher detergent with Administrator who confirmed the Micro-Pak detergent by microTECH concentrates is not a sanitizer and he also confirmed the Temp Rinse All Temperature Drying Agent is not a sanitizer.
On 01/05/25 at 10:35 AM, the facility Administrator was notified in writing of the IJ and provided with the IJ template. Administrator signed the template to attest receipt of the notice. The facility failed to follow the proper sanitizing practices for the dishes and silverware to prevent the outbreak of foodborne illnesses as evidenced by final rinse temperatures of the water in the High Temperature Dishwasher (using heat sanitization) that were below the temperatures recommended for safety by the U.S. Department of Health and Human Services, Public Health Services, Food and Drug Administration Food Code (https://www.fda.gov/media/110822/download). Widespread serious harm is likely to all residents using facility dishware and/or utensils due to risk of transmission of enteral pathogens related to improper sanitization.
On 01/05/25 at 01:04 PM requested kitchen use of dishwasher machine policy from Administrator which he provided.
Review of policy titled Procedure for washing dishes by the use of a machine, Effective date: 01/10/18 states Purpose: To properly wash and sanitize dishware and silverware for its aesthetic value and to prevent the spread of harmful germs to patients, residents and staff.
Scope: Food service workers
Policy: All dishes, dishware and silverware shall be washed after each use. Dish machine [sic.] wash temperature should be 140-160 degrees F and final rinse temperature should be 180 degrees F and above.
Procedure: .
5. In the event of any of the following conditions, the dishwashing procedures shall be stopped immediately. The food service worker shall inform the supervisor who shall call the Plant Operations department or the service representative. The supervisor shall direct the staff to use the dish machine [sic.] at Hale Pulama [NAME]
b. Final rinse temperature is below 180 degrees - call Plant Operations.
On 01/05/25 at 11:55 AM the facility presented an acceptable plan for removal of the immediate jeopardy.
On 01/06/25 at 04:00 PM, the SA finalized onsite verification that the IJ Removal Plan, provided by the facility and approved by the SA, had been implemented. Immediately the facility utilized one time use disposable plastic utensils and paper tableware (plates, cups and trays) till IJ was lifted. The facility was able to provide inservice training with their kitchen staff on proper use of the dishwasher which included coverage of final rinse temperature to be reached when cleaning dishes in the dishwasher prior to processing dishes and placing them on the clean rack. Kitchen staff were reminded to notify the kitchen supervisor if the wash and rinse temperatures are not met when using the dishwasher. Facility consulted with vendor for sanitizer that could be used with heat sanitizing dishwasher but this was not something the vendor offers. Vendor informed Kitchen Manager the sanitizer would break down with the heat.
Facility monitored residents for 72 hours for signs and symptoms of infection.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
Based on interviews and record review, the facility failed to ensure a resident's right to inform the resident's representative in advance, of the risk and benefits of proposed treatment one of five r...
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Based on interviews and record review, the facility failed to ensure a resident's right to inform the resident's representative in advance, of the risk and benefits of proposed treatment one of five residents (Resident (R)72) sampled for unnecessary medication(s). As a result of this deficient practice, residents receiving psychotropic medications are at risk for more than minimal harm.
Findings include:
Review of R72's Electronic Health Record (EHR) on 01/07/25 documented the resident's most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/16/24, Section C. Cognitive Functioning, Brief Interview for Mental Status (BIMS) score was 6, indicating the resident's cognition is severely impaired. Review of Section GG. Functional Patterns documented the resident is dependent on staff for all care. Review of R72's Physician's Orders documented orders for: Trazodone hydrochloride (HCl) Oral Tablet 50 milligrams (MG) Give 0.5 tablet by mouth two times a day for dementia behavior and agitation (Started on 12/27/24); Seroquel Oral Tablet 25 MG (Quetiapine Fumarate)
Give 25 mg by mouth two times a day hold if sleepy or respiratory rate is less than 11 (Started on 11/15/24); and Zoloft Oral Tablet 50 MG (Sertraline HCl) Give 1 tablet by mouth one time a day for anxiety (started on 11/08/24). Review of the EHR did not contain documentation of R72's representative's consent for the use of psychotropic medications. Review of the R72's profile in EHR documented Family Member (FM)5 is designated to make health decisions for R72.
On 01/07/25 at 01:48 PM, conducted a concurrent interview and review of R72's hard chart and the unit's psychotropic medication consent binder. Review of the binder did not contain documentation that FM5 consented to use of Trazodone, Seroquel, or Zoloft. RN3 confirmed there were no completed documentation in R72's EHR, hard chart, or the unit's Psychotropic Consent binder for R72. RN3 reported FM5 is off-island and consents are obtained through email and the unit supervisor or Director of Nursing (DON) is responsible for emailing FM5.
On 01/07/25 at 02:30 PM, conducted an interview with the DON. Informed the DON that there was no documentation related to FM5 giving written consent for R72 to receive Trazodone, Seroquel, or Zoloft or had been informed that the facility is currently administering these medications to the resident and there was no documentation FM5 was informed of the risk versus benefits for receiving these medications. DON reported the employee responsible for contacting FM5 is on leave and the facility is unable to provide documentation that FM5 was informed of, consented, and received education on the medications previously listed prior to administering the medication to the resident.
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, record review and interviews the facility failed to develop and implement a care plan (CP) for two of 23 ...
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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 develop and implement a care plan (CP) for two of 23 residents sampled. Resident (R) 89 for the use of oxygen and R38 for a urinary tract infection with extended spectrum beta lactamase (ESBL), a bacteria that is resistant to many antibiotics.
Findings Include:
1) On 01/05/25 at 11:56 AM interviewed R89 in her room. R89 was observed sitting up in her wheelchair and had a nasal cannula on that was attached to the wall oxygen. Confirmed with R89 that her oxygen (02) was at 2 liters (L) which she reported is on at all times. Resident stated she was diagnosed with chronic obstructive pulmonary disease (COPD) 20 years ago and only the last 2 years she has had symptoms of shortness of breath and needing to use oxygen.
Review of R89's Electronic Health Record (EHR) found physician order for Supplemental O2 2-4L/min by nasal cannula with humidifier continuous to keep sats > (greater than) 90% every shift for COPD. Review of R89's CP dated 10/04/24 revealed the continuous use of oxygen order at 2-4 L for resident's shortness of breath related to her COPD was not in the care plan.
On 01/08/25 at 11:37 AM a telephone interview was conducted with Nursing Assessment Specialist (NAS) 1. Inquired if R89's oxygen use should be included in the resident's baseline and ongoing care plan. NAS1 confirmed R89 had a doctor's order for oxygen and that oxygen use should be included in R89's care plan. Surveyor asked NAS1 to look at R89's CP for oxygen use for COPD and she confirmed the continuous oxygen use was not included on the resident's care plan.
On 01/08/25 at 12:04 PM interviewed the Director of Nursing (DON) regarding R89's CP. Informed DON R89's continuous use of oxygen was not on her CP. Inquired if this is something that should be on R89's CP and DON confirmed this should have been included.
2) During a review of R38's EHR, he was re-admitted to the facility on [DATE] and received antibiotics for a UTI intravenously three times a day for Sepsis due to acute pyelonephritis (inflammation of the kidney), ESBL/UTI until 01/03/25.
Review of R38's CP revealed the focus included . staff utilize enhanced barrier precautions (EBP) to care for resident related to history of ESBL which was Created and Date Initiated on: 10/04/24. The goal for this focus states Resident will be free from ESBL infection through review date of target date: 04/05/25.
Interventions included:
a. Cart set up outside of patient's room and stocked with appropriate personal protective equipment (PPE) and trash can inside the room for discarding used PPE items or soiled items.
b. Educate resident and residents' family/visitors on enhanced barrier precautions and when to utilized.
c. Place an enhanced barrier isolation sign on resident room door.
d. Staff will wear gown and gloves when performing high contact activities such as dressing, bathing, transferring, providing hygiene, changing linens, toileting, performing device care, or wound care.
On 01/07/25 at 12:57 PM interview was done with Certified Nurse Aide (CNA) 25 outside of R38's room. Inquired if CNA25 uses EBP with R38 when working with him since he had been positive for ESBL. CNA stated no that there is no sign. Surveyor observed at this time there was no signage outside of R38's room and no cart with PPEs.
On 01/08/25 at 10:49 AM interviewed DON and asked her about R38's CP for EBP use due to his history of ESBL. DON confirmed R38 has a CP for EBP due to his recent UTI with ESBL. She confirmed staff should be using PPEs and a sign should be up outside the room door and cart should have been outside of the room with PPEs.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to implement interventions to treat one of one Resident (R)79 in the ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to implement interventions to treat one of one Resident (R)79 in the sample for constipation. The deficient practice may affect the resident's quality of life due to increased pain and discomfort.
Findings include:
R79 was a [AGE] year-old resident admitted on [DATE] for long-term care. Diagnoses included but not limited to dehydration, muscle weakness and constipation.
On 01/06/25 at 10:25 AM, an interview was conducted with R79 in her room. R79 said she has constipation at times since she is less active now. Asked R79 if she takes any stool softeners, to which she replied, Yes. but does not recall how often.
Review of R79's Electronic Health Record (EHR) was conducted on 01/07/25. R79 had the following laxatives (medications that treat constipation) ordered: Senna 8.6 milligram (mg) tablet at bedtime, Lactulose 20 grams (gm) as needed if no bowel movement (BM) for two days, and Bisacodyl Suppository 10 mg if no BM for three days.
Review of R79's Bowel Elimination log in the EHR revealed that on the following days, she did not have a BM: 12/14/24 to 12/15/24 (two days); 12/18/24 to 12/20/24 (three days), 12/26/24 to 12/27/24 (two days); and 01/01/25 to 01/03/25 (three days).
Review of the Medication Administration Record (MAR) for December 2024 and January 2025 revealed that Lactulose was not administered for both months when R79 did not have BM for two days.
On 01/07/25 at 09:11 AM, concurrent interview and record review was conducted with Registered Nurse (RN)6 at the third-floor nurse's station. Asked RN6 if R79 ever complained of being constipated. RN6 said there were instances and looked at the Bowel Elimination log in the EHR. Asked if laxatives were administered as ordered when R79 did not have any BM. RN6 reviewed the MAR and acknowledged some doses were missed in December and January when R79 did not have BM for 2 days. RN6 said, She's supposed to get Lactulose after two days without BM. When asked if R79 refused the medication when offered, RN6 said there was no documentation in the MAR that R79 refused.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
Based on observations and interviews, the facility failed to provide appropriate care and services to prevent complications of enteral feeding (a way of delivering nutrition directly into the stomach ...
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Based on observations and interviews, the facility failed to provide appropriate care and services to prevent complications of enteral feeding (a way of delivering nutrition directly into the stomach or small intestine) for three of the 23 sampled residents (Resident (R)74, R50 and R59). The facility did not ensure the equipment used were properly cleaned and maintained. This deficient practice has the potential to put residents on enteral feeding at risk for preventable complications.
Findings include:
1) On 01/05/25 at 08:46 AM, initial screening of the residents was conducted. R74 was observed lying in bed with head elevated. A pole was next to her bed with a feeding pump attached. A plastic container filled with liquid enteral feeding formula was connected to the feeding pump. Observed the feeding pump, base of the pole and floor had some residue of dried formula.
On 01/06/24 at 09:01 AM, observed R74 lying in bed with head elevated. The drops of dried-up formula were still on the pump, base of the pole and floor. Returned to R74's room at 10:37 AM and drops of dried-up formula were still observed while the pump was running.
On 01/06/24 at 03:37 PM, a concurrent observation and interview was conducted with Patient Care Coordinator (PCC)3 in R74's room. Showed PCC3 the drops of dried formula that were still on the feeding pump, base of pole and floor. PCC3 acknowledged that it does not look sanitary and could attract insect and other pests that could carry pathogens (organisms that cause diseases). PCC3 then proceeded to wipe off the dried-up formula.
3) On 01/07/25 at 09:56 AM, conducted an observation of R59 lying in bed with a liquid filled bag of enteral formula which was connected to a feeding pump. The feeding set loop area of the pump was caked in a thickened layer of old feeding formula. A divided plastic tray positioned below the feeding pump had dried splatters of feeding formula.
On 01/08/25 at 10:15 AM, observed the feeding pump had been cleaned and inquired with RN3 about the clean feeding pumps. RN3 confirmed the feeding pumps on the fourth-floor unit had been cleaned due to the soiled surfaces.
2) On 01/07/25 at 09:30 AM observed Registered Nurse (RN) 44 prepare medications for R50 to be given via G-tube. RN44 stated she was going to start R50's gastrostomy tube (G-tube) feeding after giving his medications. While in resident's room observed a pole next to his bed with a feeding pump attached. A plastic container filled with liquid enteral feeding formula was connected to the feeding pump. Surveyor showed RN44 the area on the feeding pump and pole that was soiled. Inquired of RN44 who is responsible to take care of the feeding pump and clean it. RN44 stated night shift takes care of it. RN44 tried to wipe the feeding pump and commented that it was dried on and hard to get off.
On 01/08/25 at 09:04 AM an interview was done with the charge nurse, RN55. Inquired with the charge nurse who is responsible to process the feeding pumps and clean them. RN55 stated all the staff are to clean the machine when it gets dirty, the task is not assigned to anyone. Surveyor told the charge nurse that there is dried on formula on the poles the feeding pump hangs from and on the feeding pumps themselves.
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 observations, record review and interviews the facility failed to properly label oxygen tubing when it was initiated fo...
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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 properly label oxygen tubing when it was initiated for three of four Residents (R) 89, R19 and R216 sampled for respiratory care. The deficient practice placed the residents at risk of facility acquired respiratory infections.
Findings Include:
Cross Reference to F656 Develop/Implement Comprehensive Care Plan
1) On 01/05/25 at 11:56 AM an interview was conducted with R89 in her room. R89 was observed sitting in her wheelchair with a nasal cannula which was hooked up to the oxygen (O2) in the wall. Inquired of R89 if the oxygen was on and she confirmed it was on and at 2 Liters per minute (LPM) at all times for her shortness of breath due to her diagnosis of chronic obstructive pulmonary disease (COPD). Inquired of resident when does staff change the nasal cannula and she stated staff changes it out when she asks them to, when it gets dirty or wet inside the tubing. During the interview surveyor and R89 did not observe any sticker with the date the O2 tubing was implemented.
Review of R89's Electronic Health Record (EHR) found she was admitted to the facility on [DATE] and her diagnoses include, but are not limited to, chronic obstructive pulmonary disease with (acute) exacerbation (persistent respiratory disease with respiratory symptoms significantly worsening); acute respiratory failure with hypoxia (not enough oxygen in the blood); acute respiratory failure with hypercapnia (too much carbon dioxide in the blood); emphysema (air sacs of the lungs are damaged), unspecified; and pulmonary fibrosis (scarring and thickening of the tissue around and between the air sacs in the lungs), unspecified.
Review of R89's admission Minimum Data Set (MDS) with an assessment reference date of 11/05/24 found she had a Brief Interview for Mental Status (BIMS) with a score of 15 out of 15 identifying her as cognitively intact. Review of R89's physician orders found an order for Supplemental O2 (oxygen) 2-4L/min by nasal cannula with humidifier continuous to keep sats > (greater than) 90% every shift for COPD.
On 01/06/25 requested and received oxygen use policy from facility Administrator.
On 01/08/25 reviewed facility policy Respiratory Delivery Devices dated 01/24, Purpose: To set guidelines for the use of respiratory delivery devices in the facility which include nasal cannula, non-breather [sic.] mask, oxymizer pendant and bland aerosol administration. Scope: All qualified and trained Personal staff. Policy: Qualified and trained personal will utilize, treat, and monitor use of these respiratory delivery devices. Procedure: A. Nasal Cannula (1/4 - 6 LPM) . 3. Change nasal cannula weekly and PRN soiled.
On 01/08/25 at 08:47 AM interviewed Registered Nurse (RN)33 outside of R89's room and inquired who changes the nasal cannula tubing and when is it done. RN33 stated night shift usually changes the tubing and sterile saline for residents on O2. They usually change it on Fridays. At this time inquired of R89 about her nasal cannula and she stated staff did change out her tubing on Sunday 01/05/25 when she asked them about it, after our first interview before lunch. R89 stated the sticker came off and she was able to put it on her bedside table. Sticker was dated 01/05/25 and timed at 1400 (02:00 PM).
On 01/08/25 at 12:04 PM an interview was conducted with the Director of Nursing (DON). Inquired who changes the nasal cannula for those residents receiving O2. She confirmed the nasal cannula is switched out weekly by staff and as needed when it gets dirty. Inquired of DON if staff label the new tubing with dates and DON confirmed the nasal cannula tubing and bottle of sterile water should have had dates on them.
2) On 01/05/25 at 02:10 PM observation in R19's room. R19 was lying in his bed with Oxygen (O2) at 3 Liters per minute (LPM) via trachea collar and connected to an aerosol bottle with a blue tube. There was no label on the blue tubing with a date to indicate when it was changed.
Quarterly Minimum Data Set (MDS) with an assessment date of 07/19/24 was reviewed on 01/06/25. R19 is a [AGE] year-old male with a diagnosis that includes respiratory failure requiring Oxygen therapy and Tracheostomy care.
Treatment Administration Record (January 2025) reviewed on 01/06/25. Apply trachea collar daily.
On 01/08/25 at 11:30 AM, interviewed the Director of Nursing (DON) in her office with the Administrator. The surveyor asked the DON how often the respiratory tubing is changed and by whom. The DON discussed that the tubing is changed on night shift every Friday and that the tubing should be labeled to indicate that it was changed.
Facility Respiratory Delivery Devices policy 01/2024 was reviewed on 01/06/25. C. T-Piece/Trach Collar with Aerosol (21-100% Fio2, Set Flow 6-10 LPM) .6. Change nebulizer, tracheostomy collar, and tubing set up daily and as needed (PRN).
3) Observation on 01/05/25 at 02:45 PM in R216's room who is on droplet precautions. R216 was lying in bed with his eyes closed and observed to have a deep productive cough. He was wearing a nasal cannula (NC) for O2 delivery. Observation of the O2 meter on the wall behind the head of the bed was not registering (in the off position). Observed the O2 tubing was not labeled with a date when the O2 tubing was changed.
Observation and interview with Registered Nurse (RN) 25 in R216's room on 01/05/25 at 03:30 PM. The surveyor asked RN25 what the concentration of O2 is ordered for R216. RN 25 looked at the meter and said it's not on, but it's supposed to be at 2 L. RN25 turned the dial on the O2 meter until it reached 2 L. The surveyor asked RN25 when was the tubing was changed, by who and how often. She replied, its changed weekly by the Nursing staff, then looked closer at the tubing and said, there should be a label to note the date it was last changed, but there isn't one.
Physician orders dated 01/04/25 reviewed on 01/05/25. Noted droplet precautions for the respiratory syncytial virus (RSV) positive (+).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Cross reference to 656 Develop/ Implement Comprehensive Care Plan. Review of R38's electronic medical record found he returne...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Cross reference to 656 Develop/ Implement Comprehensive Care Plan. Review of R38's electronic medical record found he returned to the facility and was re-admitted on [DATE]. R38 had received antibiotics for a urinary tract infection (UTI) intravenously three times a day for Sepsis due to acute pyelonephritis and ESBL/UTI until 01/03/25 which was documented as completed on 01/03/25. Review of R38's Care Plan (CP) revealed staff are to utilize enhanced barrier precautions to care for resident related to history of ESBL. Interventions listed on R38's CP included Cart set up outside of patient's room and stocked with appropriate Personal protective Equipment (PPE) and trash can inside the room for discarding used PPE items or soiled items. Place an enhanced barrier isolation sign on resident room door.
On 01/07/25 at 12:58 PM an observation was made outside of R38's room along with a concurrent interview with Certified Nurse Aide (CNA) 25. Surveyor observed inside and outside of R38's room and saw there was no signage or PPE cart posted outside of resident's room and no discard bin inside R38's room for used PPEs. Inquired of CNA25 where the EBP sign and PPE cart was and CNA25 stated he is not on EBP, she confirmed there was no sign and cart of PPEs outside of R38's room.
On 01/08/25 at 10:49 AM interview with the Director of Nursing (DON) was conducted. Inquired about R38's CP which she confirmed has a CP for EBP due to his recent UTI with ESBL. She confirmed staff should be using PPEs and sign should be up outside the room door and cart should have been outside of the room with PPEs.
3) On 01/05/25 at 11:50 AM, observed Certified Nurse Aide (CNA)32 in R72's room delivering lunch. There was signage on the entrance to R72's room documenting the resident was on Droplet Precautions. However, CNA32 only wore a surgical mask. Inquired with CNA32 as to why R72 was on droplet precautions. CNA32 reported R72 was on droplet precaution due to testing positive for Respiratory Syncytial Virus (RSV).
On 01/08/25 at 10:30 AM, conducted an interview with the DON. Informed the DON of my observations and inquired what PPEs should staff wear while delivering a resident's meal who is on droplet precautions. DON confirmed staff should have been wearing a face-shield, gown, an approved mask, and gloves.
.
Based on observation, interview, and record review, the facility failed to implement the facility's infection prevention and control measures for three out of twenty-three resident sampled.
a. Resident (R)23 and (R)38 who were on isolation precautions did not have signage outside of their rooms at the door.
b. The facility failed to assure staff to use proper personal protective equipment (PPE) when delivering a meal to a Resident (R)72 who was on droplet precautions. This deficient practice placed everyone at risk for developing preventable infections and other adverse health complications.
Findings include:
1) R23 was a [AGE] year-old resident admitted to the facility for long-term care. Diagnosis included but not limited to Methicillin Resistant Staphylococcus Aureus, an infection that is resistant to many antibiotics, and had an order for contact isolation effective 08/03/24.
On 01/05/25 at 10:57 AM, observed no signage was posted outside R23's room stating that he was on transmission-based precautions (TBP) instructing everyone to follow contact precaution and check with the nurse before entering the room.
On 01/05/25 at 11:02 AM, an interview was conducted with Patient Care Coordinator (PCC)3 and confirmed that R23 is on TBP, and that signage should have been placed outside his door to alert everyone. When asked if facility is supposed to place the signage, PCC3 confirmed, Yes, that should be placed outside the resident's door.
On 01/07/25 at 10:21 AM, an interview was conducted with Director of Nursing (DON) in her office and confirmed that a sign should always be placed outside resident's room if they're on isolation precautions to alert staff, family, and visitors to prevent spread of infections.
Review of facility's policy on 01/07/25, Infection Control - Section 3.0 Body Substance Precautions stated, . a STOP sign is placed on the door to alert personnel and visitors to Check with the nurse before entering
Jul 2024
6 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
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on interviews and record reviews the facility failed to report allegations of abuse to the state agency within two hours of being reported to the Charge Nurse (CN), Nursing Supervisor (NS), or A...
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Based on interviews and record reviews the facility failed to report allegations of abuse to the state agency within two hours of being reported to the Charge Nurse (CN), Nursing Supervisor (NS), or Assistant Director of Nursing (ADON) and Director of Nursing (DON). During the review of two Residents (R) 26 and 33 allegations of abuse were reported to a NS, or ADON and DON. Initial reports submitted by the facility were sent to the state agency two days after the incidents were reported to the CN, NS, or ADON and DON. This deficient practice could affect all residents in the facility who have a reported or witnessed incident of abuse and the facility fails to notify the state agency within two hours.
Findings Include:
Cross Reference F600 Free From Abuse and Neglect
1) On 07/17/24 at 11:54 AM interviewed ADON for R26's incident that was reported on 03/20/24. ADON stated the resident (R26) did not specify a time the incident occurred and reported that it was her night shift nurse aide that was in question. Inquired when night shift is and ADON stated our night shift is from 11:30 PM to 08:00 AM. ADON stated according to the charge nurse, the incident likely happened between 03:00 AM to 04:30 AM. ADON confirmed he was present at R26's bedside with DON for the interview. R26 had reported night shift CNA had started to provide care for her (changing her brief) but had not told her what she was doing.
On 07/17/24 review of the Facility Reported Incident (FRI) for R26 found it was sent via email to the Office of Healthcare Assurance (OHCA) on 03/22/24 at 05:00 PM with the following boxes checked off staff to resident and mistreatment. On 03/20/24 at 11:15 AM R26 reported the allegation of abuse to the CNA who reported it to charge nurse and two days later the incident was initially reported to the state agency.
2) On 07/17/24 at 11:54 AM interviewed ADON. ADON confirmed he was working this day (07/05/24) but had gone home by the time this incident, witnessed staff abuse of R33, which occurred at 07:30 PM. There was a nursing supervisor working who received the phone call that a CNA had stomped on resident's foot. Supervisor reported this to the DON who then relayed this to the ADON. Inquired about R33 and ADON stated R33 is confused, has a diagnosis of Alzheimer's and is forgetful and was not interviewed after the incident. ADON explained R33 has a history of being agitated. R33 was reported as being restless and wandering to the other side of the floor. R33 was on a 1:1 (close monitoring by one staff with one resident) at the time the incident occurred with CNA4. Inquired about the interview with CNA4 and ADON explained CNA4 admitted to stepping on his (R33's) foot, that she explained it as a kiss a light touch. ADON stated we think it was intentional because she stated he (R33) was trying to hit her feet with his Front Wheel [NAME] (FWW).
On 07/18/24 review of the FRI for R33 was sent via email to the state agency on on 07/08/24 at 3:30 PM with the following boxes checked off staff to resident and mistreatment. Staff to resident abuse occurred on 07/05/24 at 07:30 PM. Almost three days later the facility initially reported the incident to the state agency.
07/19/24 at 01:30 PM interviewed DON who confirmed she interviewed residents who had reported allegations of abuse by staff. Inquired about reporting FRI's to the state agency and she stated she had been told the reports were submitted, she had not been informed they were submitted days later.
On 07/19/24 review of facility policy titled Dependent Adult Abuse/Neglect with an Effective Date 11/2019 under Procedure I. Reporting/ Response on page 6 and 7 of 10, E. Director of Nursing or designee (Patient Care Coordinator/ Shift Coordinator) responsibilities: 2. Notify State Officials in accordance with State law. a. Notify Department of Health, Office of Healthcare Assurance and Department of Human Services, Adult Protective Services and Honolulu Police Department per regulatory guidelines. b. Complete question #1 of the Notification of Event Memorandum,. and fax it to the Department of Health, Office of Healthcare Assurance (DOH, OHCA), (See Attachment G) within 24 hours or by the shorter time-frames noted in the KGC Reporting a Suspected Crime under the Federal Elder Justice Act Policy number 02-0401C5 if a KGC-ICF or SNF resident is the alleged victim.
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
Based on interview and record review the facility failed to provide sufficient nursing staff on 02/07/24 and 07/05/24 during their second shift (03:00 PM - 11:30 PM) on the skilled nursing unit. The d...
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Based on interview and record review the facility failed to provide sufficient nursing staff on 02/07/24 and 07/05/24 during their second shift (03:00 PM - 11:30 PM) on the skilled nursing unit. The deficient practice puts the residents at risk for harm such as abuse by staff and staff working outside of their scope of practice.
Findings Include:
Cross Reference F600 - Free From Abuse and Neglect and F726 Competent Nursing Staff
On 07/17/24 at 11:54 AM interviewed Associate Director of Nursing (ADON) who was able to provide copies of staffing on 02/07/24. Inquired if ADON was working on 02/07/24 and he confirmed he was. Inquired if he was informed of an RN delegating medication administration to a CNA to pass medication to Resident (R)40 and he stated the Director of Nursing (DON) notified him. Inquired if the facility teaches the nurses to delegate medication pass to the CNA's and he denied this. ADON confirmed he and DON met with the staff (RN3 and CNA5) to discuss their scope of practice and what was allowed and not allowed at the facility.
Continuation of interview with ADON confirmed he was working on 07/05/24 but had gone home by the time this incident (staff to resident abuse) occurred at 07:30 PM. ADON explained there was a nursing supervisor working who received the phone call that a CNA had stomped on resident's foot. Supervisor reported this to the DON who then relayed this to the ADON. Inquired about R33 and ADON stated R33 is confused, has a diagnosis of Alzheimer's and is forgetful and was not interviewed after the incident. ADON explained R33 has a history of being agitated. R33 was reported as being restless and wandering to the other side of the floor. R33 was on a 1:1 (close monitoring by one staff with one resident) at the time the incident occurred with CNA4. Inquired about the interview with CNA4 and ADON explained CNA4 admitted to stepping on his (R33's) foot, that she explained it as a kiss a light touch. ADON stated we think it was intentional because she stated he (R33) was trying to hit her feet with his Front Wheel [NAME] (FWW).
On 07/19/24 review of the facility's staffing matrix (per facility is Intended as a guideline for staffing levels. Specific resident care needs will always dictate actual staffing requirements.) and facility Census/Staffing forms found on 02/07/24 during the evening shift (03:00 PM - 11:30 PM), the Skilled Nursing Facility (SNF) floor had 37 residents and per the staffing matrix should have had 2 Registered Nurses (RNs), 2 Licensed Practical Nurses (LPNs) and 4 or 5 Certified Nurse Aides (CNAs). On 02/07/24 there were 2.5 RNS, no LPNs and 3.5 CNAs which means the floor was short 1.5 LPNs and short 0.5 - 1 CNAs for this shift. On 07/05/24 the SNF floor had 31 residents and per the staffing matrix for the evening shift (03:00 PM - 11:30 PM) should have had 1 RN, 2 LPNs and 4 or 5 CNAs. Review of the facility Census/Staffing form dated 07/05/24 found the facility had 2.5 RNs, no LPNs and 4 CNAs. The unit was short 0.5 LPN and up to 1 CNA.
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 F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
Based on interviews and record review the facility failed to assure a Registered Nurse (RN) and a Certified Nurse Aide (CNA) practiced within their professional scope of practice. This deficient pract...
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Based on interviews and record review the facility failed to assure a Registered Nurse (RN) and a Certified Nurse Aide (CNA) practiced within their professional scope of practice. This deficient practice could affect all residents and put them at risk for harm if licensed staff delegate tasks to unlicensed staff such as medication administration, which is outside their scope of practice.
Findings Include:
On 07/17/24 at 11:54 AM interviewed Associate Director of Nursing (ADON) who was able to provide copies of staffing on 02/07/24. Inquired if ADON was working on 02/07/24 and he confirmed he was. Inquired if he was informed of an RN delegating medication administration to a CNA to pass medication to Resident (R)40 and he stated the Director of Nursing (DON) notified him. Inquired if the facility teaches the nurses to delegate medication pass to the CNA's and he denied this. ADON confirmed he and DON met with the staff (RN3 and CNA5) to discuss their scope of practice and what was allowed and not allowed at the facility.
On 07/18/24 at 2:25 PM interviewed Certified Nurse Aide (CNA)5 who confirmed she worked on 02/07/24. Inquired if she was asked by Registered Nurse (RN)3 to give R40 her bedtime medication. CNA5 stated she was directly involved, she took care of the resident and stated she did her best to provide care and that R40 was very irritated. CNA5 stated R40 was demanding her bedtime medication and CNA5 stated she told R40 that RN3 was helping another resident and that she would tell RN3 that she is requesting her medication. CNA5 told RN3 that R40 wanted her medication and RN3 handed CNA5 the medication cup with the pills inside and told her to give R40 the medication. CNA5 stated she took the medication into R40 and R40 asked CNA5 why is she giving her the medication and not the nurse. R40 refused to take the medication. Inquired if CNA5 knew she was not supposed to do this because she is not a nurse and CNA5 confirmed she knew this.
On 07/18/24 at 03:50 PM interviewed RN3 and inquired if she had asked CNA5 to give R40 her medication and RN3 confirmed this. RN3 confirmed she is not supposed to do this, that it is outside her scope of practice. RN3 stated there was an incident the day before, on 02/06/24, with R40 and per RN3 R40 yelled at her. RN3 stated she did not feel comfortable going into R40's room. Inquired if RN3 asked the other nurse who was working with her to pass the bedtime medication to R40 and RN3 stated The other nurse was busy. Inquired if she asked the Nursing Supervisor (Shift Coordinator) for help and RN3 denied this, stated she was busy on the other floor testing residents. RN3 stated she gave CNA5 the medication cup and she (RN3) stayed at the resident's door as CNA5 offered the medication to R40. Inquired if R40 took the medication and RN3 stated she did not take her medication that night, she refused it.
On 07/19/24 review of facility policy titled Administering Medications states Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretations and Implementation 1. Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so.
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
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to assure staff accurately documented medication offered to and refused by resident (R)40. This deficient practice could affect all residents w...
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Based on interview and record review the facility failed to assure staff accurately documented medication offered to and refused by resident (R)40. This deficient practice could affect all residents who receive medication in the facility if their medication administration is not documented accurately.
Findings Include:
On 07/18/24 at 03:50 PM interviewed RN3 and inquired if she had asked CNA5 to give R40 her medication and RN3 confirmed this. RN3 stated there was an incident the day before, on 02/06/24, with R40 and per RN3 R40 yelled at her. RN3 stated she did not feel comfortable going into R40's room. Inquired if RN3 asked the other nurse who was working with her to pass the bedtime medication to R40 and RN3 stated The other nurse was busy. Inquired if she asked the Shift Coordinator for help and RN3 denied this. RN3 stated she gave CNA5 the medication cup and she (RN3) stayed at the resident's door as CNA5 offered the medication to R40. Inquired if R40 took the medication the CNA offered and RN3 stated R40 refused the medication.
Record review on 07/19/24 of R40's Medication Administration Record (MAR) found RN3 had documented at 2113 R40 had taken her Tylenol 625 mg by mouth and Melatonin 3 mg by mouth.
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
Notification of Changes
(Tag F0580)
Could have caused harm · This affected multiple residents
Based on interview and record review the facility failed to consult with the physician for three residents reviewed when Resident (R) 12 and R26 reported allegations of abuse by staff and R33 was witn...
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Based on interview and record review the facility failed to consult with the physician for three residents reviewed when Resident (R) 12 and R26 reported allegations of abuse by staff and R33 was witnessed by a staff being abused by another staff. This deficient practice could affect all residents at the facility and impede care the physician would order.
Findings Include:
Cross reference F600 - Free From Abuse and Neglect
1) On 07/17/24 at 11:54 AM interviewed ADON who confirmed he was present at R12's bedside with DON when they interviewed her. ADON reported resident stated CNA was rough handling her during her shower. ADON was not sure if it occurred more than once, not sure of the details. ADON reported R12 was afraid but not physically hurt, looked a little upset and concerned. ADON stated R12 was worried that CNA in question would retaliate against her. ADON stated the CNA no longer works at facility, stated she was a contract worker and they canceled the remaining contract.
On 07/17/24 during RR of R12's EHR did not find a progress note from the licensed staff stating R12's physician was notified of R12's family's reported allegation of abuse by staff.
On 07/19/24 at 12:25 PM interviewed R12's physician. Inquired if physician was notified of R12's family reported allegation of staff abuse and she stated she was on leave and would have to review her call log and would let the DON know.
On 08/07/24 the DON sent surveyor an email stating R12's physician had emailed her the following response: No, I was not informed of this issue/ family concern.
2) On 07/17/24 at 11:54 AM interviewed ADON for R26's incident that was reported on 03/20/24 and reported that it was her night shift nurse aide that was in question. ADON stated according to the charge nurse, the incident likely happened between 03:00 AM to 04:30 AM. ADON confirmed he was present at R26's bedside with DON for the interview. R26 had reported night shift CNA had started to provide care for her (changing her brief) but had not told her what she was doing.
On 07/17/24 during RR of R26's EHR did not find a progress note from the licensed staff stating R26's physician was notified of R26's reported allegation of abuse by staff.
On 07/19/24 at 11:10 AM interviewed R26's physician and inquired if he was notified of R26's allegation of abuse by staff. Physician stated he was not notified. Inquired what he would have done if he had been notified and he stated he would have asked the DON to investigate this incident and to check for physical or psychological harm.
3) On 07/18/24 at 02:55 PM interviewed nursing supervisor (NS)1. NS1 confirmed she was the nursing supervisor working on 07/05/24 at 07:30 PM when the incident occurred with R33. Inquired how she was informed and NS1 stated I just got a phone call on the supervisor's phone by the off going charge nurse (RN2) as she was leaving. I went upstairs from 3rd floor to 6th floor to talk to CNA3 to ask what happened, she told me that she was coming in to start her shift around 7-7:30 PM, she came to the nurses station, saw CNA4 with R33 who was offering him pudding, she (CNA3) went to the bathroom, came out of the bathroom and she (CNA3) saw CNA4 stomp on resident's foot and CNA3 stated she told CNA4 don't do that. Inquired what NS1 did and she stated she spoke with CNA4 who stated the resident was trying to use his walker to hit CNA4's feet and she stepped on his foot to stop him from doing this. Inquired if R33's doctor was notified of this incident and NS1 stated she did not know if the resident's doctor was notified.
On 07/18/24 during RR of R33's EHR did not find a progress note from the licensed staff stating R33's physician was notified of staff (CNA3) reported witnessed abuse by staff (CNA4). Review of completed report of Event Report submitted to Office of Health Care Assurance on 07/12/24 states R33's physician was not notified of this incident.
On 07/19/24 at 01:47 PM Interviewed R33's physician who confirmed she had not been notified of R33's witnessed staff abuse. Inquired what she would had done if she had been notified and she stated she would have asked staff to notify the DON, do an incident report and then she (physician) would have seen R33 the next day.
On 07/19/24 review of facility policy titled Dependent Adult Abuse/Neglect with an Effective Date 11/2019. found under Procedure page 6 and 7 of 10, I. Reporting/ Response C. Patient Care Coordinator/ Shift Coordinator (SC) responsibilities: . 2. In collaboration with the Charge Nurse, immediately initiate the action necessary to protect the client until the investigation is completed, including removing the suspected individual from direct contact with the affected client and from all direct care with clients. 4. Notify the client's physician and family respectively.
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
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected multiple residents
Based on interviews and record review, the facility failed to protect the resident's right to be free from physical abuse by staff. Three residents reviewed, Resident (R) 12 and R26 reported allegatio...
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Based on interviews and record review, the facility failed to protect the resident's right to be free from physical abuse by staff. Three residents reviewed, Resident (R) 12 and R26 reported allegations of abuse by staff and R33 was witnessed by a staff being abused by another staff. This deficient practice could affect all residents in the facility, placing the residents at risk of harm, if the facility fails to protect resident's right to be free from abuse by staff.
Findings Include:
Cross Reference F580 - Notify of Changes (injury/decline/room, Etc.)
1) On 07/17/24 at 10:47 AM interviewed Registered Nurse (RN) 1. Inquired if she was working with R12 on 03/20/24 and she said yes, stated on March 20th it was resident's Care Plan day meeting and during the meeting they discuss with the family any concerns and they (the family member) mentioned R12 had told them that a staff had pushed her head down while she was showering her, that the staff had pushed her head against the wall. Family member was not sure what day this occurred. R12 told the family member that she did not like the agency staff who was black. RN1 spoke with R12 right after the phone call with R12's family member. The resident stated during her shower, not sure what day it was, the staff pushed her head down while she was showering her. RN1 asked staff working on 03/20/24 during day shift (7 AM - 3 PM) if they received any report from R12 regarding complaint of a staff member being rough with her in the shower. Staff stated no and RN1 reported it to Assistant Director of Nursing (ADON) and Director of Nursing (DON).
On 07/17/24 at 11:54 AM interviewed Assistant Director of Nursing (ADON) confirmed he was present at R12's bedside with DON when they interviewed her. Resident stated CNA was rough handling her during her shower. Not sure if it occurred more than once. Not sure of the details. Resident was afraid but not physically hurt, looked a little upset and concerned. ADON stated R12 was worried that CNA in question would retaliate against her. ADON stated the CNA no longer works at facility, stated she was a contract worker and they canceled the remaining contract.
2) On 07/17/24 at 10:47 AM interviewed RN1. Inquired if she was working with R26 on 03/20/24 and she stated she was. RN 1 stated Certified Nurse Assistant (CNA) 1 reported that R26 had told her (CNA1) she has a concern about her care. CNA1 reported she asked resident what her concern was, R26 told CNA1 that she was sleeping and woke up and was like naked, the diaper was open and her gown was open. CNA1 told RN1 that R26 asked her why did the girl not tell me before doing it? RN1 reported to ADON (is the nursing supervisor during day shift if there is no supervisor) and DON.
On 07/17/24 at 11:14 AM interviewed CNA1. CNA1 stated R26 was not assigned to her but remembers that morning, On 03/20/24 between 6:30-7:30 AM she heard resident crying out to her from her room. R26 stated she needed help. R26 had told her she did not want the black woman and resident told CNA1 what happened to her. CNA1 stated R26 stated she was rudely awaked by staff (night shift CNA) undressing her when the blanket was off and the brief was open, uncovered. R26 stated night shift CNA told resident she was wet. CNA1 contacted the charge nurse for the day, RN1. Resident repeated the same story of what occurred during night shift to CNA1 and RN1. RN1 reported the incident and ADON and DON came to the floor to investigate.
On 07/17/24 at 11:54 AM interviewed ADON for R26's incident that was reported on 03/20/24. ADON stated the resident (R26) did not specify a time the incident occurred and reported that it was her night shift nurse aide that was in question. Inquired when night shift is and ADON stated our night shift is from 11:30 PM to 08:00 AM. ADON stated according to the charge nurse, the incident likely happened between 03:00 AM to 04:30 AM. ADON confirmed he was present at R26's bedside with DON for the interview. R26 had reported night shift CNA had started to provide care for her (changing her brief) but had not told her what she was doing.
3) On 07/17/24 at 11:54 AM interviewed ADON. ADON confirmed he was working this day (07/05/24) but had gone home by the time this incident occurred at 07:30 PM. There was a nursing supervisor working who received the phone call that a CNA had stomped on resident's foot. Supervisor reported this to the DON who then relayed this to the ADON. Inquired about R33 and ADON stated R33 is confused, has a diagnosis of Alzheimer's and is forgetful and was not interviewed after the incident. ADON explained R33 has a history of being agitated. R33 was reported as being restless and wandering to the other side of the floor. R33 was on a 1:1 (close monitoring by one staff with one resident) at the time the incident occurred with CNA4. Inquired about the interview with CNA4 and ADON explained CNA4 admitted to stepping on his (R33's) foot, that she explained it as a kiss a light touch. ADON stated we think it was intentional because she stated he (R33) was trying to hit her feet with his Front Wheel [NAME] (FWW). ADON stated the DON told him and the nursing supervisor that CNA4 could not work with R33. Inquired how the facility handles allegations of abuse by staff and he stated usually the staff would be reassigned to different resident or different location. After this incident CNA4 was not allowed to work on the 6th floor.
On 07/18/24 at 09:30 AM interviewed CNA3. Inquired of CNA3 what occurred on 07/05/24 at 07:30 PM. CNA3 stated she came in early to work, went to use the bathroom that is located behind the nurse's station on the 6th floor. CNA3 stated once she came out of the bathroom she looked up and saw CNA4 step on R33's foot. Inquired if she thought it was a mistake or by accident and she said no. CNA3 stated R33 was sitting down, appeared very restless. CNA3 stated I saw with my two eyes that CNA4 stomped his foot. CNA3 stood up and stomped her foot on the ground to demonstrate what CNA4 had done. CNA3 stated I went to her and told her don't do that, that's not nice. CNA3 explained CNA4 was wearing crocs and R33 was wearing only socks when this occurred. CNA3 went to the charge nurse and told her to talk with CNA4 to tell her not to do that. CNA3 stated she spoke with CNA4 and CNA4 tried to lie saying that she only tapped the resident's foot softly but CNA3 stated she did it harder than that. CNA3 stated the supervisor had asked staff to write up what happened on a yellow sheet.
On 07/18/24 at 11:07 AM interviewed RN2. RN2 stated she was working day shift (from 07:00 AM till 3:30 PM) when the incident occurred with R33 on 07/05/24 at 07:30 PM. RN2 stated she was working till 7 PM that day so that she could compete her admission. RN2 stated she was in the office when this occurred and did not witness the incident. RN2 stated she was told as I was leaving, I had clocked out. RN2 confirmed one of the CNAs (CNA3) who witnessed this incident told me about the incident, I think it was CNA3 who had come to work early. CNA3 told me that she actually saw CNA4 step on the resident's foot. I was clocked out and heading out and told the other nurses there to notify the supervisor and make sure there is an investigation. I also called the nursing supervisor to make sure too. Inquired who the nursing supervisor was and RN2 provided the name.
On 07/18/24 at 02:55 PM interviewed nursing supervisor (NS)1. NS1 confirmed she was the nursing supervisor working on 07/05/24 at 07:30 PM when the incident occurred with R33. Inquired how she was informed and NS1 stated I just got a phone call on the supervisor's phone by the off going charge nurse (RN2) and she was leaving, cannot remember the exact time, almost 8 PM and she (RN2) said something happened and that you have to check regarding a staff and a patient, no details but to check with CNA3. I went up stairs from 3rd floor to 6th floor to talk to CNA3 to ask what happened, she told me that she was coming to start her shift early around 7-7:30 PM, she came to the nurses station, saw CNA4 with R33 who she was offering him pudding, she (CNA3) went to the bathroom, came out of the bathroom, and stated she (CNA3) saw CNA4 stomp on resident's foot, and CNA3 stated she told CNA4 don't do that. Inquired what NS1 did and she stated she spoke with CNA4 who stated the resident was trying to use his walker to hit CNA4's feet and she stepped on his foot to stop him from doing this.
On 07/19/24 review of facility policy titled Dependent Adult Abuse/Neglect with an Effective Date 11/2019 under Procedure page 6 of 10, I. Reporting/ Response C. Patient Care Coordinator/ Shift Coordinator (SC) responsibilities: . 2. In collaboration with the Charge Nurse, immediately initiate the action necessary to protect the client until the investigation is completed, including removing the suspected individual from direct contact with the affected client and from all direct care with clients.
Feb 2024
3 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0726
(Tag F0726)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review (RR) and observation, the nursing staff failed to demonstrate the competence and skill sets t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review (RR) and observation, the nursing staff failed to demonstrate the competence and skill sets to provide safe nursing care in a manner to meet one resident's (R)2 physical needs. Specifically, the Certified Nurse Assistants (CNA) had been administering oxygen (O2), which is outside their scope of practice. In addition, the nursing staff administered oxygen to R2, who had Chronic Obstructive Pulmonary Disease (COPD) when her oxygen saturation level (sat) was outside the parameters ordered by the physician. Due to this deficient nursing practice, there was high likelihood that a Resident with COPD and oxygen administration parameters would be administered oxygen by licensed or unlicensed staff outside the order parameters and suffer harm. When identified by the facility, this deficiency was found to be corrected immediately the following day, and at the time of survey met the criteria for past noncompliance.
Findings include:
1) R2 was a [AGE] year old female with a history of end stage emphysema recently started on home oxygen and was hospitalized [DATE] to 11/09/2023 for chronic respiratory failure. At that time, she was diagnosed with a pulmonary embolism and started on an anticoagulant (blood thinner). R2 was transferred to Kuakini Geriatric Center (KGC) for short term rehabilitation with the goal to return home with family.
2) Reviewed R2's Physician (MD)1 notes, which included the following: Encounter date 11/09/2023: Respiratory insufficiency/Emphysema resp (respiratory) status improved, pt (R2) feels comfortable on 2L(liters) NC (nasal cannula) at rest.monitor O2 sats (saturation) & resp status during therapy. Encounter date 11/22/2023: .Emphysema resp status improved, pt feels comfortable on 2L NC at rest.monitor O2 sats & resp status during therapy, goal of supplemental O2 is to keep sats 88-93%
Reviewed R2's orders, which included:
11/13/2023 by MD1; Titrate /adjust O2 to keep O2 sats between 90-93%.
11/21/2023 by MD1, Titrate /adjust O2 to keep O2 sats between 90-93%.
3) Reviewed an event report regarding R2, which read: On 11/28/2023, R2's Family Member (FM) contacted the Social Worker (SW) and reported that MD1 recently put parameter's on pt's oxygen levels and there is a sign in pt's room stating those parameters.At some point that night (11/27/2023 to 11/28/2023), a nurse turned off pt's oxygen. Per FM, this morning right before breakfast was served, a nurse notified that the oxygen was still off and her (R2) oxygen levels dropped to the 70's. FM spoke to a nurse .today, and the nurse told FM that she will tell the other nurses to check the sign and check on her more frequently if the oxygen is turned off. FM told SW that he is still concerned as the sign was up, but yet the nurses left the oxygen off for an unknown period of time, letting pt's oxygen drop to the 70's., pt refused therapy with PT .today d/t (due to) being tired/fatigued. The report included: At that time MD1 provided rationale for that order and that chronic respiratory residents require a lower O2 flow in order to maintain optimal O2 levels, (risk of hypercapnia (too much carbon dioxide in blood that can lead to respiratory failure.)) The resolution comment included: Investigation is ongoing. It was determined that there was miscommunication between what was said about staff actions and what actually happened. Staff education included, Titration of O2 should only be completed by licensed personnel (RN) as oxygen is considered a medication; any changes in O2 regulation, should be followed by an assessment by of the resident reaction/tolerance to change. In addition to reading the pulse oximetry, the assessor should be noting the resident's symptoms e.g. pursed lip breathing, use of accessory muscles etc. The severity level on the event form was documented as D. Harm-Intervention Needed.
Reviewed the event report hand written attachments of the staff who had knowledge of the event, which included:
Lettergram (written communication tool) dated 11/29/2023 by RN1 read: On 11/27/2023 morning shift @ 9:00 AM, received a call from MD1 that she saw the SPO (oxygen saturation) entry in PCC (electronic medical record) always 99-100% with 2 Liter of oxygen, she told me that that it is in the PCC order to titrate 88%-93% Inform and supposed to be no need oxygen if above 93%. Inform [sic] my med nurse. She titrate and monitor the patient. I write and post information on the wall to titrate the O2 at 88% to 93% .
Lettergram dated 11/28/2023 written by CNA1 included: Found oxygen is low as 73-77% when I was taking my morning v/s (vital signs) and check the O2 regulator is off. So I reported it to the medicine Nurse.
Lettergram dated 11/30/2023, written by night RN2 include: CNA1 was taking V/S for day shift and overheard her saying O2 sat low 70% and she said she put O2 on and she (R2) was ok. I went to check + she had it (O2) @ 4L with sat at 97% so I lowered it to 1 liter with 93-94 % saturation.
Lettergram dated 11/29/2023,written by CNA2 included @ 5:45 AM did last round .asked her (R2) permission to changed [sic] and check her bottom.She said I can't breathe. I told her I'm gonna put the O2 to 2 lit (liters/L) while changing diaper immediately then after I did checked her O2 sat and was 92%, .
Reviewed Nursing Progress Notes which revealed there was no documentation by either the night shift staff or day shift staff (11/27/2023 to 11/28/2023) of R's O2 saturation level dropping to the 73-77%, or documentation of notification of the physician of the event. The legal medical record did not accurately reflect R2's condition and/or treatment, or meet the standard of nursing documentation. On 11/29/2023, R2 was transferred to the Emergency Department about 09:10 AM for respiratory failure.
Review of R2's Vitals Summary, revealed R2 was administered oxygen 22 times during the time period of 11/22/2023 to 11/28/2023, when it was outside the parameters ordered (keep oxygen saturation between 90-93%). 11/21/2023. The DON stated she was unable to provide the liters per minute that were administered on the printed report, so reviewed progress notes to obtain LPM and respiratory status if documented, and provided in hand written document. Review revealed the following entries: 11/22/2023 07:13 AM 96% (Oxygen via Nasal Cannula), LPM (L) not documented. 11/22/2023 09:11 AM 94% (Oxygen via Nasal Cannula), LPM not documented. 11/22/2023 05:42 PM 94% (Oxygen via Nasal Cannula), LPM not documented. 11/23/2023 06:39 AM 98% (Oxygen via Nasal Cannula), LPM not documented. 11/23/2023 09:10 AM 97% (Oxygen via Nasal Cannula), LPM not documented. 11/23/2023 02:42 PM 97% (Oxygen via Nasal Cannula), 0.5L- no SOB/Respiratory distress. 11/23/2023 08:24 PM 96% (Oxygen via Nasal Cannula), 0.5L no SOB/respiratory distress. 11/23/2023 04:52 PM 96% (Oxygen via Nasal Cannula), 0.5L- No SOB/Respiratory distress 11/24/2023 05:31 PM 98% (Oxygen via Nasal Cannula), LPM not documented. 11/24/2023 06:06 PM 98 % (Oxygen via Nasal Cannula), 0.5-1/0 LPM No SOB/Respiratory distress. 11/25/2023 03:06 AM 97% (Oxygen via Nasal Cannula), 2L No SOB/respiratory distress 11/25/2023 06:59 AM 97% (Oxygen via Nasal Cannula), LPM not documented. 11/25/2023 09:12 AM 97% (Oxygen via Nasal Cannula), LPM not documented. 11/25/2023 10:58 AM 100% (Oxygen via Nasal Cannula), 2L No SOB/respiratory distress 11/25/2023 04:52 PM 97% (Oxygen via Nasal Cannula), LPM not documented. 11/25/2023 09:32 PM 94%(Oxygen via Nasal Cannula), 0.5-1L No SOB/respiratory distress 11/26/2023 06:40 AM 97% (Oxygen via Nasal Cannula), 2L No SOB/respiratory distress 11/26/2023 01:24 PM 97%(Oxygen via Nasal Cannula), 1-2 L (Progress note: .increased resp rate 33 and SOB at 11:50 AM .O 1 sat 95% on 1 L increased oxygen to 2L/min 11/27/2023 09:51 AM 97% (Oxygen via Nasal Cannula), LPM not documented 11/27/2023 04:25 PM 94% (Oxygen via Nasal Cannula), LPM not documented. 11/28/2023 05:04 AM 95% (Oxygen via Nasal Cannula), 0.5L 11/28/2023 02:19 PM 94% (Oxygen via Nasal Cannula), LPM not documented.
3) During an interview with the DON on 02/29/2023 at 9:30 AM, she confirmed the CNA's had been administering oxygen. She went on to say she immediately addressed the practice when she found out. The Facility provided documentation of education provided to staff 11/30/2023 and 12/01/2023.
4) On 02/29/2023 at approximately 09:45 AM, observed the oxygen regulator that controls the liter flow in an empty Resident room. The room had wall oxygen with a flow meter regulator. Due to the low flow rate of .5L, it was very difficult to identify the specific location of marking on the regulator. Inquired if other residents had orders for .5L, and she said no, it was unusual for a flow rate that low.
5) Cross Reference F657: R2's CP was not revised in a timely manner to include the new order dated 11/21/2023, to titrate the oxygen to keep saturation between 90-93%. In addition, the focus notes created on 11/09/2023 was not changed and continued to read R2 was on continuous oxygen at 3 LPM/NC.
6) These deficiencies met the criteria for past noncompliance.
R2's oxygen administration resulted in a grievance from a family member, which resulted in an investigation, action plan and implementation of that plan. The facility was found to have corrected the deficiency and was found to be in compliance at the time of this survey. Actions taken included:
- All CNA's educated to scope of practice, and cannot adjust oxygen.
- All nursing staff educated to the importance of tight oxygen control and the need for oxygen administration parameters in the resident with COPD.
- All staff educated to the importance of accurate, timely updates to the CP.
- Reviewed the current oxygen regulator with all licensed staff to identify .5 L flow.
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
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
Based on interviews and document review, the facility failed to ensure the grievance policy included all the required elements. In addition, the facility was unable to provide documentation that Resid...
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Based on interviews and document review, the facility failed to ensure the grievance policy included all the required elements. In addition, the facility was unable to provide documentation that Residents were informed they have the right to file a grievance anonymously and the right to obtain a written decision regarding the grievance. There was lack of documentation of the pertinent findings or conclusions regarding the care concerns of two Residents (R), R1 and R2. As a result of these deficiencies, there was the potential residents do not know how to file an anonymous complaint and grievance findings may not be adequately communicated to the complainant, resulting in dissatisfaction.
Findings include:
1) Review of the facility policy titled Resolution of Patient/Resident grievances, complaints, and concerns, effective date 02/2023 revealed the following:
1. The policy did not include a reasonable timeframe the resident can expect a completed review of the grievance;
2. The policy did not identify the grievance official who was responsible for overseeing the grievance process, receiving and tracking grievances through their conclusions;
3. The policy did not include the written grievance decision requirements;
4. The policy did not specifically say a grievance/complaint could be made anonymously, orally or written.
5. The policy did not include the complainant could request a copy of the grievance findings and decision.
Reviewed the material provided to resident/representative at the time of admission, which included a document titled Resident/Family/Caregiver Complaint Procedure. The document did not include how to file an anonymous complaint. The admission packet also included a document titled A Matter of Rights. This document included information on the Grievance Procedures, but also did not include an anonymous complaint could be filed. The procedure in this document stated You have the right: . to voice concerns and complaints either orally or in writing, .
The facility has five different signs posted with resources for residents/representatives to contact if they would like to file a grievance. There was one titled Long Term Care Ombudsman, which included Your call will be kept confidential, but there was no directions of how to file an anonymous complaint with the facility.
2) On 02/27/2024, during an interview with the Director of Nursing (DON), she said she did not know who the grievance official was, but thought it may be Patient Relations.
On 02/28/2024 at 01:45 PM, during an interview with Patient Relations (PR), she said she was not sure who the grievance official was, but thought it was the Risk Manager. She explained the PR role and said she receives complaints from the facility staff and physicians and does some follow up. She went on to say she and the Risk Manager (RM) work together, and if a chart needs clinical review, she will send it to the RM, who gets information for her after the Nursing Manager investigates. PR said a complaint is more of a service recovery, and would not get a follow up letter as would be considered resolved, but a grievance should receive a written follow up.
On 02/28/2924 at 02:15 PM, during an interview with the Risk Manager (RM), she said they do not use the term Grievance Official, but the functions fall under Patient Relations. She explained they (PR) work together as a team, and would send anything that needed to be investigated to the Director of Nursing (DON) for follow up and resolution. At that time, reviewed the facility policy and the RM said the policy was fairly new, and some of the missing requirements were in the old policy, but had been deleted.
3) Reviewed facility documentation regarding grievance from R1's FM, which revealed the issue was unresolved to the complainant's (Family Member (FM))'s satisfaction and there was no written response with follow up regarding the investigation findings/summary, actions taken, or if the concern was substantiated.
Reviewed the Current Summary of R1's complaint entered on 11/11/2023. The description read I (Shift Coordinator) was notified by my Administrator that there was a concern coming from family member (FM) of resident (R1) in regards to care received from Certified Nurse's Assistant (CNA) this past NOC (night) shift. It was communicated to this writer that the party involved a male CNA. I was asked to speak with family and investigate the issue further. When calling the unit to talk privately to SNF (skilled nursing facility) Charge Nurse in regards to the situation, it was discovered that the FM had already voiced her complaint to her earlier. Charge nurse apologized to FM and explained she (R1) could be cared for by 2 person assist and offered her Posey sleeves to provide cushioning and skin protection to her bilateral arms. Separately, this writer went in to talk to FM and it appeared FM was trying to explain the incident, but said she was only relaying on what her mother verbalized to her what happened during this past night a .woman cared for her and was rough with her when she turned her. Patient said when she was turned and using a nudging motion of her right arm she mentioned that's when she hurt. Resident did not suffer any injuries from incident but there is a Mepilex dressing to right foreman, which according to nursing was applied for a skin tear treatment. Originally only had steri strip dressing, but FM requested something with more protection and so the treatment was changed. Unbeknownst to FM regarding new treatment, she believed that dressing may now be a new skin issue as well.
On 11/17/2023, the file was updated by PR, to include Patient (R)1 transferred to acute unit (hospital)/PCU. Met with FM to acknowledge her recent KGC (Geriatric Center) complaint, she commented that she was not there when the encounter with nurse happened, however mother told her what happened. FM also shared had a recent talk with the Interim Administrator (IA) and the [NAME] President (VP) to address . complaints. I reassured her that the KGC nursing administration will do a follow-up.
The Resolution and Outcomes of this complaint/grievance was marked as Satisfied. Outcome notes read DON and ADON (Assistant Director of Nursing) completed investigation and reported to the administrator. Refer to attached files. The attached files were handwritten notes made by the DON dated 11/06/2023.
During an interview with the DON, She said she was unsure who was responsible to send follow up letters after the investigation was completed. She said the investigation findings were that R1's pain and concern regarding rough treatment most likely occurred when staff were moving her when positioning in bed. The DON said she did not have a follow up conversation with FM as to the findings.
During an interview with PR, she said she had one contact with R1's FM after she was transferred to the hospital and wanted to establish a rapport with her because she was aware there had been concerns regarding the care, which included rough treatment when in KGC. She said she marked the event form satisfied because she could not personally address the issue and knew it had been escalated to the Interim Administrator and Senior [NAME] President. PR said she agreed this should have been handled as a grievance with documentation of closure. It was unclear to her who and what process would be used to do that.
During an interview with the Interim Administrator, she said she and the Senior [NAME] President (SVP), did have a conversation with R1's FM, but did not realize there was an unresolved concern related to KGC. She confirmed there was no letter or follow up from either of them on this grievance.
3) R2's family member (FM) called the Social Worker (SW) regarding an event that occurred on 11/28/2023. Review of the event included the following notes: Per PCC (Patient Care Coordinator), Shift Coordinator (SC) and DON were addressing the situation today with pt (R2's) FM. PCC states that she does not know the whole story and instructed SW to reach out to either SC or DON to address the situation.
On 11/28/23, FM had approached nursing staff; he had spoken with nursing supervisor. Administrator, DON, ADON and SNF PCC were informed. An investigation was performed, and staff were interviewed to determine the validity and the timeframe of the event
Resolution Comment: Investigation is ongoing.
During an interview with the DON, she said the issue was that the FM was concerned that even with a sign posted by R2's bed about oxygen administration, R2 went without oxygen for a period of time the night before. She went on to say the investigation was completed, and actions taken to prevent future occurrence, but she had not discussed her findings with FM, and to her knowledge, no written follow up had been done.
During an interview with the Risk Manager (RM), she said she was familiar with the event, and had been on leave at the time. She went on to say when she reviewed the investigation notes, she had unanswered questions and sent it back to the DON for further clarification. The RM considered this investigation still open. This grievance was not closed in a timely manner.
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 F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review (RR), the facility failed to revise Care Plans (CP) of two Residents (R)1 and R2, of a sam...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review (RR), the facility failed to revise Care Plans (CP) of two Residents (R)1 and R2, of a sample size of three in a timely manner. The facility did not 1) update R1's CP to include use of the abduction pillow or the skin condition on right forearm, and 2) did not update R2's CP in a timely manner to include parameters for oxygen administration when ordered. As a result of this deficiency, there was the potential the residents may not meet their highest potential of physical and mental well-being. This deficiency had been corrected prior to the survey, and met the criteria for past noncompliance.
Findings include:
1) R1 was a [AGE] year old female admitted to Skilled Nursing Facility on 10/28/2023 for rehabilitation services following right hip surgery after sustaining a right hip fracture from a fall at home. She was COVID + on admission. R1's medical history included but not limited to Diabetes mellitus, hypertension, congestive heart failure, Stage 3b chronic kidney disease and atrial fibrillation. She was hard of hearing, had very fragile skin, incontinent of bowel and bladder, and required two person assist for bed mobility and transfers. R1 required one person assist for other activities of daily living. She was on an anticoagulant and at risk for bleeding. R1 may have had a component of dementia, but family believed her cognition was intact and her deficits due to her hearing deficit. On admission to the facility she had a Stage 2 Pressure Ulcer to the sacral area, which was noted in her comprehensive CP.
Reviewed R1's Physician (MD)2 notes which included: 11/06/2023: Pain and swelling of right forearm unclear etiology. May be related to previous trauma. Appearance does to appear to be consistent with an infection, but the area remains painful.
11/07/2023: Right forearm pain, swelling, skin tears. Family member (FM) reports that the patient sustained some right forearm skin tears at some point. One of them received a Steri-Strip, but the other is still open to air.
11/14/2023: (discharge summary) The patient was noted to have swelling and bruising on her right forearm. The etiology of this is unclear; there have been reports that this was related to IV (intravenous) infiltration in the hospital, but alternatively it has been speculated that this could be an injury from her previous fall. Of note, there is also a dark, well circumscribed, raised area of unclear etiology that may be a large seborrheic keratosis (common noncancerous skin growth).She was subsequently evaluated by wound care and was started on Medihoney and a dressing.
Reviewed R1's CP, which revealed the following entries:
Created 10/28/2023: Potential for Impaired Skin Integrity as evidenced by Braden Scale for Predicting Pressure Ulcer Risk. Goal: Residents Skin will remain intact.
Created 11/06/2023: .All staff to maintain right hip precautions for resident when in bed: Use hip abductor pillow between legs to prevent legs from crossing over. Keep leg in abduction (away from the midline of your body). Support entire leg with pillows when turning in bed.
R1's CP was not revised to include the right forearm skin condition.
During an interview with the Director of Nursing (DON), she said she updated the care plan the same day or day after she spoke with R1's FM who expressed care concerns that included the staff did not consistently use the abduction pillow as recommended by Physical Therapy. At that time, the DON confirmed the staff had been inconsistent with placement of the pillow, and acknowledged the forearm issue should have been in the CP.
2) R2 was a [AGE] year old female with a history of end stage emphysema recently started on home oxygen (O2) and was hospitalized [DATE] to 11/09/2023 for chronic respiratory failure. At that time, she was diagnosed with a pulmonary embolism and started on an anticoagulant (blood thinner). She was transferred to Kuakini Geriatric Center for short term rehabilitation with the goal to return home with family.
Reviewed R2's Physician (MD)1 notes, which included the following: Encounter date 11/09/2023 Respiratory insufficiency/Emphysema resp (respiratory) status improved, pt (patient) feels comfortable on 2L (Liters/flow rate) CN (nasal cannula) at rest.monitor O2 sats (saturation) & resp status during therapy. Encounter date 11/22/2023 included: .Emphysema resp (respiratory) status improved, pt feels comfortable on 2L NC (nasal cannula) at rest.monitor O2 sats (saturation) & resp status during therapy, goal of supplemental O2 is to keep sats 88-93%
Reviewed R2's orders, which included:
11/13/2023 by MD1, Titrate/adjust O2 to kep O2 sats between 90-93%
11/21/2023 by MD1, Titrate/adjust O2 to keep O2 sats between 90-93%.
Review of R2's care plan (CP) initiated on admission [DATE] included the following information: Created on 11/09/2023. Focus: The resident has an ADL self-care deficit r/t (related to) Emphysema, COPD (Chronic Obstructive Pulmonary Disease) with nodule in the lungs.No SOB (shortness of breath) or respiratory distress. Resident on continuous oxygen at 3 LPM (liters per minute)/NC (nasal cannula), . Created on 11/28/2023. Focus: The resident has potential of pain r/t pneumonia, COPD. Intervention: O2 via nasal cannula PRN (as needed) SOB. May titrate as needed to maintain O2 Sat 92% or above as needed . Created on 11/28/2023. Focus: The resident has altered respiratory status/difficulty breathing r/t LOBAR PNEUMONIA, OBSTRUCTIVE PULMONARY DISEASE WITH (ACUTE EXACERBATION) EMPHYSEMA, pulmonary fibrosis, respiratory failure, other pulmonary embolism . She is at risk for SOB, respiratory distress . Intervention: Titrate/adjust O2 Keep O2 sats between 90-93%, humidifier for O2.
The CP was not revised in a timely manner to include the order to titrate the oxygen to keep saturation between 90-93%. In addition, the focus notes created on 11/09/2023 was not changed and continued to read that R2 was on continuous oxygen at 3 LPM/NC.
3) These deficiencies met the criteria for past noncompliance. The facility took action and corrected the deficiency prior to the survey. The facility plan of correction included:
R1's CP was revised appropriately and timely after a FM brought concerns to leadership. The changes included the abductor pillow for body alignment and specific requests for bathing and oral care.
R2's oxygen administration resulted in a grievance from a family member. As part of the action plan developed from that investigation, all nursing staff were educated on the reason and importance of oxygen parameters in Residents with COPD and ensuring they are reflected in the CP.
In addition, a recertification was conducted at the facility January 12, 2024, which identified a deficiency in ( F657) in Care Plan Timing and Revision. A desk revisit was conducted on February 27, 2024, which found the deficiency had been corrected on 02/16/2024 with ongoing monitoring. The facility Plan of Correction (POC) included 1. In-servicing the licensed staff, 2. MDS coordinator and interdisciplinary team of the requirements of accurate and timely review and revisions to the care plan. 3. The Patient Care Coordinator or Shift Coordinator were designated the responsible individual to update for any new medications. 4. The IDT will conduct quarterly review of all care plans and update as needed, and 5) The PCC or designee will conduct monthly audits of 25% of the residents for accuracy and report findings to the quarterly Quality Assurance Committee.
Jan 2024
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
Based on record review (RR) and staff interview the facility failed to inform Resident (R) 55 or their public guardian in advance, by the physician or other practitioner or professional, of the risks ...
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Based on record review (RR) and staff interview the facility failed to inform Resident (R) 55 or their public guardian in advance, by the physician or other practitioner or professional, of the risks and benefits of taking an antipsychotic and antidepressant medication, of treatment alternatives or treatment options and to choose the alternative or option she prefers.
Findings Include:
On 01/11/24 at 05:47 PM, RR of R55's Electronic Health Record (EHR) found her diagnoses include, but are not limited to, dementia in other diseases classified elsewhere, moderate, with psychotic disturbance; depression, unspecified psychosis not due to a substance or known physiological condition. R55 has doctors orders for the following medications: Seroquel oral tablet 50 milligrams (mg) (Quetiapine Fumarate) (antipsychotic) give 1 tablet by mouth two times a day for behavioral disturbances. Mirtazapine (antidepressant) oral tablet 15 mg give 1 tablet by mouth one time a day for appetite stimulant. During this record review found the resident has an appointed public guardian.
On 01/12/24 at 10:16 AM during RR of R55's EHR and hard medical record chart did not find a consent form for R55 to take an antipsychotic and an antidepressant medication. During this RR inquired with Unit Clerk (UC) 2's where these documents would be kept and she stated they would be kept under consent tab of the hard medical record chart if it was filled out. There were no signed consents by R55 or her public guardian in the EHR or in the hard medical record chart.
Met with Assistant Director of Nursing (ADON) and Director of Nursing (DON) on 01/12/24 at 09:29 AM and inquired if consents are being filled out to include the risks and benefits of taking medications for those residents who take medications such as an antipsychotic or antidepressants and stated this was not found in R55's records. Shared R55 is taking an antipsychotic and antidepressant medication and upon RR a signed consent was not found for either medication. ADON acknowledged this is not being done.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on record review (RR) and staff interview the facility failed to update Resident (R) 58's comprehensive care plan to include antidepressant as an intervention for the medication he is receiving ...
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Based on record review (RR) and staff interview the facility failed to update Resident (R) 58's comprehensive care plan to include antidepressant as an intervention for the medication he is receiving to treat his depression, correctly identify R58 is taking a blood thinner (Eliquis) to treat his pulmonary emboli (blood clot in the lung) and discontinue Mirtazapine as an intervention on his care plan for his poor intake when it was discontinued on 10/30/2023.
Findings Include:
During RR on 01/11/24 at 04:44 PM found R58 had doctor's orders for the following medications: Duloxetine HCL DR (antidepressant) 60 milligrams (mg) give one capsule by mouth one time a day related to depression, unspecified, Eliquis (blood thinner) 5 mg tablet give one tablet by mouth two times a day for PE (pulmonary emboli which is a blood clot in the lung). Also noted resident had a doctor's order discontinuing his Mirtazapine order on 10/30/23. Review of R58's CP found no mention of resident taking an antidepressant to help treat his depression and a care plan was found for Resident at risk for bleeding r/t Eliquis regimen. DX: Pulmonary Embolism . is currently not on anticoagulant. R58 is currently receiving Eliquis, this medication was not discontinued. Continued review of R58's CP found . uses psychotropic medications Mirtazapine 7.5 mg daily for anorexia. R58 no longer takes Mirtazapine, this was discontinued on 10/30/23.
On 01/12/24 at 09:29 AM met with Assistant Director of Nursing (ADON) and Director of Nursing (DON). Reviewed R58's medication orders and care plan and ADON and DON acknowledged these were errors in R58's CP.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to provide appropriate services to prevent urinary tract infections for one of the residents (Resident (R) 13) in the sample. The...
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Based on observation, interview and record review, the facility failed to provide appropriate services to prevent urinary tract infections for one of the residents (Resident (R) 13) in the sample. The deficient practice exposed the resident to contaminants that may cause preventable urinary tract infections. This has the potential to affect all residents with a urinary catheter.
Findings include:
On 01/09/24 at 08:22 AM, observed R13 lying on bed with head slightly elevated. R13 had a urinary catheter that was connected to a urine collection bag hung on the right side of the bed. The tubing connecting the urinary catheter and the collection bag was touching the floor. At 01:36 PM, R13 was sitting up in her bed with her television on. Observed both catheter tubing and collection bag touching the floor. Asked Registered Nurse (RN) 14 if the tubing and the bag are supposed to be touching the floor. RN14 said, No, I'll move them now so it will not be touching the floor.
Review of facility policies titled, Urinary Catheter Care and Guidelines for Care of Urinary Catheterization does not include instructions to keep the catheter tubing and collection bag from touching the floor.
Review of facility form. Daily Nursing Observation Report revealed that one of the items the nurses audit daily is, Foley Catheter tubings[sic] not touching the floor and clipped appropriately.
On 01/11/24 at 02:17 PM, an interview was conducted with the Director of Nursing (DON) in the conference room. When asked if the urinary catheter tubing or collection bag are supposed to be touching the floor, DON said, It's not acceptable for the tube or bag to be touching the floor.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
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 (RR), the facility failed to ensure nurse competency in medication administra...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review (RR), the facility failed to ensure nurse competency in medication administration and assessing for risk of falls. This deficient practice places the residents at increased risk for medication errors and avoidable falls.
Findings include:
1) Cross-reference to F761 Label/Store Drugs and Biologicals. The facility failed to ensure nurses check for medication expiration dates prior to administering them.
2) Resident (R) 9 is a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that include, but are not limited to, history of syncope (fainting) and collapse, difficulty in walking, muscle weakness, and dementia. On 01/09/24 at 09:09 AM, observed R9 from the hallway outside her room, sleeping in bed. A large bruise was visible to her left cheek/temple/forehead, with a 2x2 gauze above her left eyebrow.
During an interview with her family representative (FR) at the bedside on 01/09/24 at 01:29 PM, FR described how her mother had fallen out of her wheelchair the week before (on 01/03/24). FR explained that due to the fall, in addition to the pain and bruises, R9 had a laceration above her left eyebrow that required two stitches, and she broke her dental bridge [a replacement for missing teeth].
On 01/10/24 at 02:53 PM, during a review of R9's electronic health record (EHR), it was noted that the post-fall Fall Risk Evaluation (marked as completed) by Registered Nurse (RN) 7 on 01/03/24 at 04:53 PM was incomplete. Only the first section had been completed, yielding R9 a score of '6', indicating a low risk for falls. Further review of the EHR noted another Fall Risk Evaluation, this one a routine assessment performed quarterly, done by RN7 on 10/05/23 in the same fashion (incomplete with only the first section completed) yielding the same score of '6'. The previous Fall Risk Evaluation done by a different nurse on 07/29/23 had yielded a score of 13, with a score greater than 10 indicating a high risk for falls.
On 01/11/24 at 09:03 AM, an interview was done with RN7 near the third floor Nurses' Station. When reviewing her evaluation done on 01/03/24, RN7 confirmed that she had completed it with a score of 6, indicating a low risk of falls, despite R9 falling earlier that day and sustaining injuries. Upon closer inspection of her evaluation in the EHR and after further questioning by the State Agency (SA), RN7 realized that there were 2 additional sections on the evaluation that she did not complete. RN7 stated she did not know there was a second page, to the evaluation and did not see the NEXT button on the bottom of the first section. RN7 confirmed that she was not aware the evaluation contained further questions about gait, balance, and medications.
On 01/12/24 at 10:10 AM, an interview was done with the Director of Nursing (DON) in her office. The DON acknowledged that RN7 should have known there were more questions to the Fall Risk Evaluation and should have questioned how R9 could have such a low risk score given her history.
On 01/12/24 at 11:50 AM, an interview was done with the Nurse Educator in the Conference Room. The Nurse Educator provided documentation that the facility provides training on Fall Prevention annually which includes a review of the Fall Risk Evaluation, and confirmed that RN7 did not attend that specific training in 2023.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5) R74 is a [AGE] year-old male admitted to the facility on [DATE].
Observation was made on [DATE] at 07:25 AM in R74's room. A...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5) R74 is a [AGE] year-old male admitted to the facility on [DATE].
Observation was made on [DATE] at 07:25 AM in R74's room. A medication cup filled with crushed medications was sitting on R74's bedside table. During the time of the observation, R74 was in the process of eating his breakfast. At 07:35 AM, the medication cup remained on R74's bedside table without any staff supervision. R74 stated that the nurses would normally stay in the room until he took all his medications with his breakfast.
On [DATE] at 07:37 AM, RN6 was interviewed at the nurse's station on the sixth floor. RN6 was informed about the observation made of the medication filled cup on R74's bedside table. RN6 stated that R74 had requested to take his medications with breakfast and since he was still prepping his breakfast, she decided to leave the medication cup on his bedside table. RN6 stated that leaving the medication filled cup unattended was not a normal process. RN6 also added that she normally watches the residents take their medications before exiting their rooms.
On [DATE] at 02:13 PM, DON was interviewed in the conference room. DON was informed about the observation made of the medication filled cup on R74's bedside table. DON stated that R74's medications should not have been left on the bedside table. DON added that the RN6 should have administered all the medications prior to leaving R74's room.
The facility policy titled, Storage of Medication, dated 10/07 documented, Medications and biologicals are stored properly .to maintain their integrity and to support safe administration.
4) On [DATE] at 10:43 AM, sixth-floor medication cart was inspected with RN8. During the inspection, two plastic bags with insulin pens were observed in the top drawer. One of the insulin pens had a manufacturer's label that identified it as, Insulin Glargine Injector Solostar 100 Units. A sticker on the insulin pen noted the open date as [DATE] and a Discard Date of [DATE]. Further inspection revealed that the resident's name, dosage, and route were not noted anywhere on the insulin pen. Queried RN8 if the insulin pen was properly labeled. RN8 confirmed that although the information was on the plastic bag that the insulin pen was in, that same information needed to be on the insulin pen itself in case the plastic bag is misplaced.
On [DATE] at 02:15 PM, an interview was conducted with the Director of Nursing (DON) in the conference room. DON confirmed that the insulin pen should have a label that included the resident's name, dosage, route, and other parameters for administering the medication.
Based on observation, interview, and record review, the facility failed to ensure all medications used in the facility were labeled, administered, and stored in accordance with professional standards. Proper labeling, safe administration practices, and timely reconciliation of stored medications is necessary to decrease the risk for medication errors. The facility failed to dispose medications after the expiration stated by the manufacturer, an insulin pen stored in the medication cart was not labeled to include the resident's name, medication dosage and route of administration and properly store a resident's medication after declining to take the medication during administration time. This deficient practice has the potential to affect all residents in the facility who receive medications.
Findings include:
1) On [DATE] at 08:25 AM, observed medication administration with Registered Nurse (RN) 7. As she was preparing medications for Resident (R) 29, observed her prepare a Lisinopril 40mg [milligrams] tablet. Of the three medications RN7 prepared for R29, the State Agency (SA) noted that the Lisinopril was the only blister pack (medication storage package separating tablets and capsules into individual compartments) without a visible expiration date on the medication label or packaging. As RN7 prepared to leave the medication cart to administer the three medications, SA asked if she checks for expiration dates prior to administering medications. RN7 responded that she does. Asked RN7 to point out the expiration date on the Lisinopril. RN7 confirmed that the label and packaging did not have an expiration date. RN7 acknowledged that she did not notice that as she prepared the medications because she did not look.
2) On [DATE] at 08:47 AM, an inspection of the third floor team two medication cart was done with RN7 present. Observed a tube of mupirocin cream with the label rendered practically unreadable with age. What was visible on the label is an expiration date of 8/22 written in by the dispensing pharmacy. The manufacturer's imprinted expiration date on the bottom of the tube was [DATE]. The expired status of the cream was validated with RN7.
3) Observed an AeroChamber (assistive device used with aerosolized medication) ordered for R14 with an expiration date of 12/23 written on the label by the dispensing pharmacy. A review of her electronic health record (EHR) noted a current order for the device. The expired status of the device was validated with RN7.
CONCERN
(D)
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 store and label food in accordance with professional standards for food service safety. Residents (R) risk serious complications from foodborn...
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Based on observation and interview the facility failed to store and label food in accordance with professional standards for food service safety. Residents (R) risk serious complications from foodborne illness as a result of their compromised health status. Unsafe and/or unsanitary food handling practices represent a potential source of pathogen exposure for all residents at the facility.
Findings include:
On 01/09/24 at 08:31 AM, while conducting an initial tour of the kitchen with the Food Service Supervisor (FSS), the state agency (SA) observed a large metal container of approximately nineteen (19) cartons of completely thawed Egg Beaters Original in the walk-in refrigerator. Clearly displayed on the front of each carton are the manufacturer's instructions to KEEP FROZEN. No date was visible anywhere indicating when the products were pulled from the freezer to thaw. When asked about the thawing and labeling process for the product, the FSS stated that it takes 2-3 days to thaw the product from its frozen state, so they pull a case at a time from the freezer. The FSS was unaware if there were manufacturer's instructions regarding how long the product can be used after pulling it to thaw. The FSS continued to explain that their normal procedure is to date the cartons only when opened, then they would use the product for up to 7 days after that.
On 01/09/24 at 09:29 AM, an interview was done with the FSS and Food Service Manager (FSM) in the kitchen. The FSS reported that the case of Egg Beaters was pulled from the freezer on Saturday 01/06/24 and was good for 7 days after pulling, whether opened or not. The FSS continued that they would discard any unused portion on Saturday 01/13/24. When asked about its use, the FSS stated that the product was used mostly for breakfast (scrambled eggs, pureed eggs), sometimes used for lunch and dinner in the same way if special ordered, and also used in low cholesterol pancakes if ordered. The FSS further explained that they use approximately 1-2 cartons of the product per day so a case would be too much to use up in 7 days. The FSS confirmed that since they were unaware of this product handling, there had been no process to monitor how long the product had been thawed before use which meant they likely had been using some of the product past the manufacturer's instructions for safety.
A review of the manufacturer's product handling instructions found on the website https://www.eggbeaters.com/faq, revealed the following:
Frozen Egg Beaters packages can be stored in the freezer for up to one year after purchase. After you have defrosted a frozen package, it can be kept in the refrigerator for up to seven days, but do not refreeze.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5) R74 is a [AGE] year-old male admitted to the facility on [DATE]. A review of R74's EHR documented that R74 was transferred to...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5) R74 is a [AGE] year-old male admitted to the facility on [DATE]. A review of R74's EHR documented that R74 was transferred to ER on [DATE], for shortness of breath. R74 was then admitted from 12/03/23 to 12/12/23.
Further review of R74's EHR and hard medical record chart indicated a lack of documentation that LTCO was provided with a written notification that R74 was transferred on 12/03/23.
Interview was conducted on 01/11/24 at 12:51 PM with the sixth floor SW1. SW1 stated that she sends out notifications to the LTCO for residents with a planned discharge. For unplanned discharges, such as transfers to the hospital, SW1 does not send out notifications to the LTCO.
Interview was conducted on 01/11/24 at 01:41 PM with the DON and ADON. Both DON and ADON stated that the facility SWs usually send out the notification to the family and LTCO, but the process is very inconsistent. ADON was not able to provide supporting documents that the LTCO was notified of R74's transfer to the hospital.
3) R71 was admitted to the facility on [DATE]. On 01/10/24 at 09:44 AM, review of the EHR revealed that R71 was transferred to an acute care hospital on [DATE] for lethargy (lack of energy) and poor oral intake of food. Documentation of facility sending a written notification of discharge to the family representative and to the LTCO was not found in the EHR and in the paper chart kept in the nurses' station.
4) R89 was admitted to the facility on [DATE]. On 01/10/24 at 12:20 PM, review of EHR revealed that R89 was transferred to an acute care hospital on [DATE] for a bleeding sacral wound. Unable to find documentation of written notification sent to the resident representative and to the LTCO in the EHR and in the paper chart kept in the nurses' station.
On 01/11/24 at 09:54 AM, an interview was conducted with Registered Nurse (RN) 5 at the nurses' station. RN5 said the staff do not send written notification to the resident representative when a resident is transferred to the hospital, they just notify them by phone and document in the progress notes.
On 01/11/24 at 10:34 AM, an interview with the Social Worker (SW) 1 was conducted at the nurses' station. SW1 said they do not send written notification to the resident representative or to the LTC Ombudsman when a resident is transferred to the hospital.
On 11/11/24 at 01:41 PM, an interview with the DON was conducted in the conference room. DON confirmed that the nurses only notify the residents' family by phone if they are transferred to the hospital and document in the EHR, there were no written notifications sent out.
2) Review of R37's EHR documented R37 was transferred to the emergency room (ER) on 09/12/23 due to tachycardia, wheezing, and shortness of breath. R37's EHR and hard medical record chart did not include documentation of notifying or sending a copy of the written notification to the LTCO of the transfer/discharge.
On 01/11/24 at 01:41 PM, an interview with DON and Assistant Director of Nursing (ADON) was done. Requested for documentation that the LTCO was notified of R37's transfer to the ER. At 03:35 PM, ADON was not able to provide supporting documentation that the LTCO was notified.
Based on interview and record review, the facility failed to provide proper notification of transfer/discharge for five of 11 residents sampled for Hospitalization (Residents (R) 9, R37, R71, R89, and R74). Specifically, the facility failed to issue written notification of transfer/discharge to the residents or their representatives and/or failed to send notification of the transfer/discharge to the Office of the State LTC [long-term care] Ombudsman (LTCO). This deficient practice has the potential to affect all residents at the facility who are discharged or transferred.
Findings include:
1) Resident (R) 9 is a [AGE] year-old female originally admitted to the facility on [DATE]. During a review of her electronic health records (EHR) on 01/11/24 at 09:30 AM, it was noted that R9 was sent and admitted to an acute care hospital on [DATE]. There was no discharge notification or LTCO notification found in the EHR for this discharge.
On 01/11/24 at 09:40 AM, an interview was done with Unit Clerk (UC) 1 in the Conference Room. UC1 confirmed that there was no written notification of the discharge issued in June.
On 01/11/24 at 01:41 PM, during an interview with the Director of Nursing (DON) in the Conference Room, the DON acknowledged that written discharge notifications are not consistently done in the facility.
A review of the facility's A Matter of Rights, included in all admission Packets, noted the following under Our Policies & Procedures on admission, transfer, and discharge:
1. We will not transfer or discharge a resident without first providing written notice in a language and manner you understand . Our notice will be given at least thirty days before transfer or discharge.
2. We reserve the right to transfer or discharge a resident on shorter notice when . immediate transfer or discharge is required by the resident's urgent medical needs .
3. Notice of transfer or discharge shall contain . the reason for the transfer or discharge . the effective date . the location to which the resident is being transferred or discharged .
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6) R74 is a [AGE] year-old male admitted to the facility on [DATE]. A review of R74's EHR documented that R74 was transferred to...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6) R74 is a [AGE] year-old male admitted to the facility on [DATE]. A review of R74's EHR documented that R74 was transferred to the ER on [DATE] for shortness of breath. R74 was then admitted from 12/03/23 to 12/12/23.
A review of R74's EHR and hard medical record chart, indicated a lack of documentation that R74's representative was given a written notification of the facility's bed hold policy.
Interview was conducted on 01/11/24 at 01:41 PM with the DON and ADON. Both DON and ADON stated that the facility's process is to call the resident's representative during a transfer or discharge to the hospital. During the phone call, the resident's representative is provided with a verbal notification of the facility's bed hold policy. Furthermore, ADON stated that a written notification of the facility's bed hold policy is not provided to the resident's representative.
4) R71 was admitted to the facility on [DATE]. On 01/10/24 at 09:44 AM, review of the EHR revealed that R71 was transferred to an acute care hospital on [DATE] for lethargy (lack of energy) and poor oral intake of food. Documentation that the facility provided written notification to the family representative about the bed hold policy was not found in the EHR and in the paper chart kept in the nurses' station.
5) R89 was admitted to the facility on [DATE]. On 01/10/24 at 12:20 PM, review of EHR revealed that R89 was transferred to an acute care hospital on [DATE] for a bleeding sacral wound. Unable to find documentation that the facility provided written notification to the resident representative regarding the bed hold policy in the EHR and in the paper chart kept in the nurses' station.
On 01/11/24 at 09:54 AM, an interview was conducted with RN5 at the nurses' station. RN5 said she was not aware of the facility bed hold policy and that all notifications for resident representatives were done over the phone and documented in the EHR under progress notes.
On 01/11/24 at 01:41 PM, an interview was conducted with the DON and the ADON in the conference room. DON confirmed that the unit clerks call the resident representatives to notify them of the facility's bed hold policy and document it in the EHR. When asked if it was only for residents discharged home, the ADON said they notify everyone that leaves the facility regardless of reason after 24 hours. DON added that the notifications are not consistent.
2) Review of R69's EHR documented R69 was transferred to the emergency room (ER) and admitted to the Critical Care Unit with admitting diagnosis of Urinary Tract Infection (UTI) on 09/22/23. R69's EHR and hard medical record chart did not include documentation of written notification of the facility's bed hold policy upon R69's transfer.
On 01/11/24 at 11:00 AM, an interview with Registered Nurse (RN) 10 and Licensed Practical Nurse (LPN) 5 was done. RN10 and LPN5 reported they did not offer the bed hold policy to R69 because they knew R69 would eventually return to the facility.
On 01/11/24 at 01:41 PM, an interview with DON and Assistant Director of Nursing (ADON) was done. DON and ADON confirmed R69 did not receive written notification of the facility's bed hold policy upon transfer for hospitalization on 09/22/23. ADON reported the unit clerks are to notify residents and family members within 24 hours of the bed hold policy even if the facility knows the resident will eventually return to the facility.
3) Review of R37's EHR documented R37 was transferred to the ER on [DATE] due to tachycardia, wheezing, and shortness of breath. R37's EHR and hard medical record chart did not include documentation of written notification of the facility's bed hold policy upon R37's transfer.
On 01/11/24 at 01:41 PM, an interview with DON and ADON was done. DON and ADON confirmed R37 did not receive written notification of the facility's bed hold policy upon transfer for hospitalization on 09/12/23.
Based on interview and record review, the facility failed to ensure written notification of the facility's bed hold policy was provided to 10 of 11 residents sampled for Hospitalization (Residents (R) 9, R69, R37, R71, R89, R74, R66, R86, R58, and R55). This deficient practice has the potential to affect all residents at the facility who are discharged to an acute care hospital.
Findings include:
1) R9 is a [AGE] year-old female originally admitted to the facility on [DATE]. During a review of her electronic health records (EHR) on 01/11/24 at 09:30 AM, it was noted that R9 was sent and admitted to an acute care hospital on [DATE]. There was no written notification of the Bed Hold Policy found in the EHR for this discharge.
On 01/11/24 at 09:40 AM, an interview was done with Unit Clerk (UC)1 in the Conference Room. UC1 reported that she had informed R9's daughter of the Bed Hold Policy and offered it by phone, but the daughter had declined. When asked about documentation of the phone conversation, UC1 responded that it is not part of her normal process to document the verbal notification/offering.
On 01/11/24 at 01:41 PM, during an interview with the Director of Nursing (DON) in the Conference Room, the DON acknowledged that bed hold notifications are not consistently done in the facility.
A review of the facility's A Matter of Rights, included in all admission Packets, noted the following under Our Policies & Procedures on admission, transfer, and discharge: .
We will not transfer a resident to a hospital . without first providing written notification to that resident and a family member . specifying the applicable bed hold policy .
7) On 01/10/24 at 10:11 AM during RR of R55's EHR found the resident was discharged on 06/27/23 with return anticipated. R55 was transferred to the ER that day at 01:50 AM and admitted to a hospital with an admitting diagnosis of severe sepsis with complicated UTI. R55 returned to the facility on [DATE]. Continued review of R55's EHR and hard copy medical record did not find written documentation given to the resident or their representative of facility's bed hold policy.
8) On 01/10/24 at 10:58 AM during RR of R58's EHR found the resident was discharged on 07/13/23. R58 was sent to the ER for evaluation for COVID-19 positive. R58 returned to the facility on [DATE]. Resident's niece was made aware of discharge from facility and transfer to the ER via telephone. Continued review of R58's EHR and hard copy medical record did not find written documentation given to the resident or their representative of facility's bed hold policy.
9) 01/10/24 at 01:18 PM reviewed R86's EHR and found she had a fall on 09/22/23 and was transferred to the ER, had CT scans and X-Rays done before she returned to the facility that day. On 9/24/23, R86 reported pain in her right arm with edema noted by staff and she was unable to lift her arm. R86 was transferred to the ER and had CT scans and X-rays done. The CT scan showed R86 had a 13 mm area of intracranial hemorrhage posterior and inferior to the right thalamus which likely developed from the patient's fall. R86 was discharged from the facility and admitted to the hospital on [DATE] and returned to the facility on [DATE]. Continued review of R86's EHR and hard copy medical record did not find written documentation given to the resident or their representative of facility's bed hold policy.
10) 01/10/24 at 03:33 PM reviewed R66's EHR and found the resident was discharged on 06/06/23 with return anticipated. R66 was discharged from the facility and transferred to the ER that day for septic workup and dehydration. R66 was admitted to the hospital. R66 returned to the facility on [DATE]. Continuation of RR found R66 was transferred from the facility to the ER and admitted to the hospital on [DATE] due to tachycardia (fast heart rate) and sodium level was critically high at 161(normal blood sodium level is 135-145 mEq/L). R66 returned to the facility on [DATE]. During this RR found R66 was discharged on 07/09/23 and sent to the ER for emesis (vomiting) and large black tarry stools. The nurse practitioner had R66 sent to the ER due to suspected GI bleed. R66 returned to the facility on [DATE]. Continued review of R66's EHR and hard copy medical record did not find written documentation given to the resident or their representative of facility's bed hold policy.
On 01/12/24 at 08:37 AM met with DON and ADON. Inquired if the facility provides residents and or their representative written information on the facility's bed hold policy and the cost of the bed hold before the resident is transferred or discharged from the facility. DON and ADON stated they do not.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
Based on facility policy review and staff interview the facility failed to review it's infection and control program (IPCP) annually which included annually reviewing their facility policies including...
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Based on facility policy review and staff interview the facility failed to review it's infection and control program (IPCP) annually which included annually reviewing their facility policies including Infection Control and Prevention and Antibiotic Stewardship, Influenza Quarantine Protocol DON/Medical Director Guide, Influenza Prevention and Control Program, and Pneumococcal Vaccine Administration. The deficient practice could affect the residents and staff at the facility if appropriate guidelines are not included and followed in the facilities' IPCP and policies to guide the care of the residents and provide guidance for staff to follow when using personal protective equipment, assuring proper hand hygiene is being performed and resident care is being monitored to assure outbreaks are caught and controlled to prevent mass outbreaks such as influenza or COVID which could be detrimental to the residents and staffs health.
Findings Include:
On 01/11/24 at 03:05 PM met with facility Infection Preventionist (IP) and Director of Nursing (DON). DON stated she was attending this meeting because the IP was new to her position, started as the IP on 01/02/2023. The IP completed the TRAIN Nursing Home Infection Preventionist Training Course on 01/05/2024. Prior to this meeting requested the facility's Infection Control Plan and infection control and prevention policies from the administrator which he provided. Reviewed the dates on the policies and inquired with Administrator and DON if these policies provided were the most up-to-date policies and both confirmed they were. Noted the following dates on the provided policies: Infection Control Program approved by Infection Committee on 02/22/01 and Executive Committee of the Medical Staff on 03/20/01, Infection Control and Prevention and Antibiotic Stewardship with approval date of 08/19, Influenza Quarantine Protocol DON/Medical Director Guide with an approval date of 09/19, Influenza Prevention and Control Program with an approval date of 09/19, and Pneumococcal Vaccine Administration with an approval date of 09/12. Reviewed the binder provided by the facility, that was from 08/06/20 which included the Infection Prevention & Control Committee Annual Risk Assessment. Included in this binder there was also the Infection Control COVID-19 Planning/ Discussion Minutes dated 03/24/20. At this time the Administrator joined the meeting. The Administrator and DON confirmed the facility had not reviewed the polices in the past year.
Jan 2023
30 deficiencies
1 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
Drug Regimen Review
(Tag F0756)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, 1) the facility failed to ensure the attending physician reviewed and responded to the i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, 1) the facility failed to ensure the attending physician reviewed and responded to the identified irregularities on the pharmacist Medication Regimen Review (MRR) for one of five residents R91) sampled for medication review. The pharmacist identified an irregularity for a resident prescribed a psychotropic medication without a diagnosis and recommended a gradual dose reduction (GDR). This placed the resident at risk for harm including negative side effects of the psychotropic medication, experiencing a fall, mental status changes, or sustained negative psychosocial outcomes. The medical record did not show evidence that the attending physician had reviewed and responded to the pharmacist MRR recommendation. 2) The facility failed to ensure the facility developed policies and procedures that included time frames for the different steps in the monthly drug regimen review process. Pharmacist MRR recommendation for October 2022 identified to GDR a psychotropic medication for R91 that was not reviewed and responded to until January 2023. Due to inadequate medication management immediate action is required to avoid adverse consequences for residents on psychoactive medications in the facility.
Findings include:
Cross Reference to F657- Care Plan Revision, F689- Free from Accident Hazard, and F758- Free from Unnecessary Psychotropic Medication
1) On 01/09/23 at 3:11 PM, conducted a record review of R91's Electronic Medical Record (EMR) that documented R91 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia with behavioral disturbances, diabetes mellitus type 2, and hypertension. Review of R91's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/14/22 documented in section C. Cognitive function, R91 has a Brief Interview for Mental Status (BIMS) score of 5, indicating the resident has severe cognitive impairment. Review of the R91's physician orders documented an order for Mirtazapine 7.5 milligrams (mg) at bedtime for sleep disturbances that started on 07/18/22. R91 had a total of seven falls since admission. As a result of one of the falls R91 sustained a fractured left hip and fractured right humerus (upper arm bone) and required surgical interventions for both injuries.
Multiple observations (on 01/09/23 at 08:57 AM, 09:28 AM, 10:17 AM, 11:05 AM; 01/10/23 at 08:11 AM, 09:15 AM, 10:32; 01/11/23 at 09:30 AM and 10:45 AM; 01/12/23 at 09:15 AM, 10:15 AM, 1:45 PM) were made of R91 sleeping throughout the day. On 01/12/23 at 10:36 AM, conducted an interview with Unit Supervisor 5 (US)5 regarding observations sleeping in the mornings. US5 confirmed R91 is usually sleeping in the mornings.
On 01/11/23 at 11:20 AM, conducted a review of R91's hard chart on the unit with Registered Nurse (RN)88. Reviewed R91's hard chart for the pharmacy's MRR. This surveyor was unable to locate the pharmacy's MRR in the resident's hard chart. Inquired with RN88 and requested to review all the pharmacy's MRRs and the review and responses from the attending physician. RN88 could not locate the pharmacy MRR or documentation that the attending physician reviewed and responded to the MRR recommendations and confirmed there were no documents located in R91's medical chart (hard chart and EMR). Inquired what the process was for pharmacy MRR recommendation and the physician's review and responses to the recommendations.
RN88 stated the pharmacy MRR do not come to the unit individually, the units receive an email, the email is printed out, and staff follow-up with the physicians. RN88 showed this surveyor stapled printouts from the contracted pharmacy (PMA) titled Recommendation Summary for DON & Medical Director. RN88 explained that on the side column follow-through staff will write if the pharmacist MRR was followed up with the attending physician. RN88 stated some attending physician verbally inform unit staff or send a fax, but the fax does not go to the unit, the fax goes to the 6th floor. RN88 and Unit Clerk (UC1) confirmed that unit staff do not see the physician's responses if they fax it. Requested with UC1, RN88, Nursing Staff (NS)22, and US5 to provide any form of documentation that could identify that there was any documentation of the pharmacist MRR recommendations and that the attending physicians reviewed and responded to any recommendations. RN88 stated there was a binder at the nurse's station that contained all of the MRRs and physician responses. UC1, RN88, NS22 and US5 searched the unit and could not locate the binder or any past MRR recommendations or physician responses. UC1 stated the previous unit clerk had retired and they were not sure what happened to the binder. US5 confirmed there was no other system in place on the unit to recover those documents. Requested for US5 and RN88 to review all documentation in R91's medical chart for documentation that the attending physician reviewed and responded to the pharmacist's MRR recommendation for October 1-31, 2022. US5 and RN88 confirmed R91 medical chart did not contain any documentation that the attending physician reviewed and responded to any pharmacy MRR recommendations. US5 and RN88 also confirmed R91's medical chart did not contain physician progress notes (encounter notes) for October 2022, November 2022, and December 2022. This surveyor was informed by RN88 and US5 that the Consultant Director of Nursing (CDON) would have the pharmacy MRR recommendations and was unsure where the attending physician's responses to the recommendations were located.
On 01/12/22 at 10:05 AM, this surveyor revisited the unit and inquired with RN88 and UC1 if staff was able to locate the binder of MRR recommendations with physician responses or the physician progress notes (encounter notes) for October, November, and December 2022. RN88 and UC1 confirmed staff did not have the binder or the physician progress notes. RN88 lost the stapled printout of the pharmacy MRR recommendations (for December 2022) that she/he was using the day before and had no way to identify which MRR recommendations were reviewed, if changes were made, or what the changes were.
On 01/11/23 at 11:15 AM, conducted an interview with the Consultant Pharmacist (CP1) regarding the MRR recommendations and the timeframe for attending physician to respond to MRR recommendation(s). CP1 stated that he/she conducts monthly audits and send recommendations to the facility. The attending physician should review and document in the resident's chart whether they will implement the recommendation, and if not then they should provide a rationale if they choose not to implement the recommendation. CP1 stated monthly percentages are provided to the facility regarding their rate of compliance for attending physicians responding to monthly MRR recommendations (percentage of compliance in listed below (Executive Summary of Consultant Pharmacist's Medication Regime Review)). CP1 also stated the attending physicians do not provide documented responses directly to the pharmacist and there is no streamline system to ensure the recommendations are reviewed and responded to. Inquired with CP1 if R91 had a diagnosis or clinical indication for the use of Mirtazapine to the resident. CP1 confirmed R91 did not have a diagnosis of depression or other diagnosis that would clinically indicate the use of a psychotropic medication for the resident. Inquired whether R91's attending physician reviewed or responded to the GDR for Mirtazapine. CP1 confirmed there was no documentation that the attending physician reviewed or responded to the MRR recommendation.
On 01/11/23 at 11:50 AM, conducted an interview with the CDON regarding the pharmacy MRR. CDON stated the pharmacy MRR recommendations are emailed to the units and a printout is provided to the units, faxed to the physicians, and should be stored in a binder on the unit for the attending physicians to review. Informed CDON that the 5th floor staff confirmed the unit could not locate or provide the binder to this surveyor, there were no pharmacy MRR recommendations or the responses from the attending physician to any recommendations from the pharmacy located in R91's medical record. Request a copy of the pharmacy MRR recommendations starting from October 2022.
On 01/11/23 at 12:05 PM, received and reviewed the Executive Summary of Consultant Pharmacist's Medication Regime Review forms for July 2022 to December 2022 (report prepared by the Consultant Pharmacist (CP1) documented the facility's follow-up of the last visit's recommendation out of 100% was:
July- 19.5%.
August- 60.8%
September- 32.1%
October- 29.8%
November- 80.2%
December- 66.0%
On 01/11/23 at 12:29 PM, received the Recommendation Summary for DON & Medical Director form (for October and November 2022) from CDON and reviewed the documents. A recommendation was made in October and November 2022 for R91 was, This resident continues to receive Mirtazapine 7.5 mg QHS (bedtime) for sleep disturbance and Melatonin 9 mg QHS for sleep disturbance. Please evaluate the current doses and consider a dose reduction. Kindly consider a trail gradual dose reduction of the Mirtazapine to 3.75 mg QHS (no response was documented on the forms).
On 01/12/23 at 2:05 PM, conducted a telephone interview with R91's attending physician. Inquired with AP2 if he/she had reviewed and responded to CP1's MRR recommendation from 2022 to decrease R91's dose of Mirtazapine. The attending physician did not have access to resident records and could not answer questions specifically related to R91.
On 01/12/23 at 02:15 PM, this surveyor went into the CDON's office and requested with the CDON, Senior [NAME] President (SVP), and Chief Nursing Officer (CNO) to provide any documentation that the pharmacist MRR recommendations are part of R91's medical chart and documentation that R91's Attending Physician (AP)2 reviewed and responded to the pharmacist MRR recommendation to GDR Mirtazapine from 7.5 mg to 3.75 mg.
On 01/12/23 at 4:12 PM, CDON came down into the surveyor's conference room and stated he/she spoke to the AP2 and confirmed AP2 did not review or respond to CP1's MRR recommendation to GDR R91's Mirtazapine prior to this day (01/12/23) but has decided not to change the order.
On 01/13/23 at 08:30 AM, CDON came into the conference room and stated the facility audited the MRR recommendations and there was no documentation that AP2 reviewed or responded to the October 2022 GDR recommendation. The facility had reviewed all MRRs recommendation for October and November 2022 for completion and identified other residents that the attending physician did not review or respond to. CDON stated the facility does not know what happened on a system level that the MRR recommendations were not reviewed or responded to in a timely manner.
The facility was notified of the Immediate Jeopardy (IJ) on 01/13/23 at 09:21 AM. The facility provided an acceptable plan for removal of the immediacy IJ on 01/13/22 at 10:33 AM to the survey team. The corrective measure included: 1) Review of all Pharmacy Recommendations completed. All Pharmacy Consultant recommendations responses received 100 % and the signed Pharmacy Consultant for were filed in the Medical Record. 2) The facility will review all Pharmacy Consultant recommendations. All letters to the MD (medical doctors) will be faxed to the physician for review and recommendations. Physician will fax the letters back to the facility and units with their recommendations. Facility staff and Patient Care Coordinators or designee will track all the recommendations on a daily basis and will call the Geriatrician if no response is received within a week. All Pharmacy Consultant letters will be filed in the resident's medical record. 3) The facility Patient Care Coordinators will maintain a log for all Pharmacy Consultant reviews to ensure compliance. Audits will be completed on a monthly basis to ensure 100% compliance and submit to QAA committee. The IJ immediacy was abated on 01/13/23 at 10:50 AM.
2) Review of the facility's policy and procedure, Medication Regimen Review and Reporting Section 8.1 dated 10/07 documented Findings and recommendations are communicated to those with authority and/or responsibility to implement the recommendations and responded to in an appropriate and timely fashion. And 8 .Recommendations shall be acted upon within a reasonable timeframe. The policy and procedure do not specifically address what is an appropriate and timely fashion timeframe for attending physician to review and respond to recommendations.
On 01/12/23 at 11:15 AM, conducted an interview with the Consultant Pharmacist (CP1) regarding the MRR recommendations and the response of the attending physician regarding the recommendation(s). CP1 stated that he/she conducts monthly audits and send recommendations to the facility. Inquired with CP1 if the facility implements a timeframe for the attending physicians to review and respond to the pharmacist MRR recommendations to maintain the resident's highest practicable level of physical, mental, and psychosocial well-being and to prevent or minimize adverse consequences related to medication therapy. CP1 stated that although there is a timeframe implemented for the pharmacist, there is no timeframe implemented for the attending physician to review and respond. Inquired with CP1 if there was documentation in R91's medical chart (hard chart and EMR) that documents the attending physician reviewed and responded to October 2022 and November 2022 MRR recommendation to decrease Mirtazapine 7.5 mg to 3.75 mg. CP1 confirmed there was no response from the attending physician regarding the recommendation to decrease the Mirtazapine dose made in October 2022.
On 01/13/23 at 08:30 AM, CDON came into the conference room and stated the facility audited the MRR recommendations and there was no documentation that AP2 reviewed or responded to the October 2022 GDR recommendation. The facility had reviewed all MRRs recommendation for October and November 2022 for completion and identified other residents that the attending physician did not review or respond to. CDON stated the facility does not know what happened on a system level that the MRR recommendations were not reviewed or responded to in a timely manner.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on observations and interviews, the facility failed to provide a functioning call system for one Resident (R)260, in a sample of 32 residents. The facility failed to ensure that the visual alert...
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Based on observations and interviews, the facility failed to provide a functioning call system for one Resident (R)260, in a sample of 32 residents. The facility failed to ensure that the visual alerts outside of R260's room and at the nursing station lit when she initiated her call device. This deficient practice has the potential to affect all residents who can utilize their call devices for help due to the lack of processes to identify a broken call system, other than the direct patient care employees, and a lack of follow up on repairs done by their Biomedical department,
Findings include:
On 01/09/23 at 12:45 PM, an interview was made with R260 and family member (FM)5. During the interview, R260 repeatedly stated she wanted a urinary tube to help drain her bladder because she had difficulty voiding and had urinary urgency. FM5 stated that R260 was newly admitted into the facility, and they were waiting for test results to find out what was the cause of R260's voiding difficulty and urinary urgency.
On 01/09/23 at 12:55 PM, after the interview with FM5, an observation was made of R260 triggering her call device to obtain assistance with going to the restroom to void. The visual alert outside of R260's room did not illuminate, but an audible alarm could be heard. The visual alert at the nursing station was also not lit. After a few minutes, FM5 came out of R260's room to obtain assistance for her stating, My mom really needs to use the restroom!
On 01/11/23 at 09:25 AM, Unit Clerk (UC)7 was interviewed. UC7 stated that the visual alert outside of R260's room and at the nursing station was broken last year and the Biomedical staff fixed it. UC7 stated that when the call system is broken, the staff report it to her, she calls and sends a request to the Biomedical department (BD) to fix it. UC7 called BD and filled out a form for BD to fix R260's call light visual alerts.
On 01/11/23 at 09:30 AM, queried the Maintenance Supervisor (MS) about the broken call device system and he stated that the BD fixes it when it is reported by the nursing staff. The Maintenance department does not do call device system checks during their environmental rounds.
On 01/11/23 at 2:27 PM, in a query with UC7, their Biomedical staff was unable to fix the call light system for R260's room, so R260 was moved to another room.
On 01/11/23 at 3:41 PM, asked Biomedical staff to provide a log of repair requisitions to fix R260's call light system and he stated that they do not keep a log of repair requests.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff member, the facility failed to assure one of two residents (R)44 sampled exercis...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff member, the facility failed to assure one of two residents (R)44 sampled exercised their right to formulate an advanced health care directive (AHCD). This deficient practice has the potential to cause harm to residents when they are provided medical care that is not in accordance with their wishes.
Findings include:
R44 was admitted to the facility on [DATE].
On 01/10/23 at 08:08 AM reviewed R44's Electronic Health Record (EHR) and health record at the nurse's station for documentation of an AHCD. AHCD was not found. Review of R44's Declaration of Authority to Act as Surrogate for Patient form documented R44's adult child as an Appointed (Non-Designated) Surrogate signed on 03/13/17. Documentation of persons who took part in the selection were not documented. Under additional facts and circumstances to establish claimed authority was not documented. The form defined non-designated surrogate as a selected person .to make health care decisions for a patient has been determined to lack capacity to provide informed consent to or refusal of medical treatment.
On 01/10/23 at 2:19 PM interview with Social Worker (SW) was done. Inquired if R44 has an AHCD, SW reported R44 does not have an AHCD. SW reported R44's husband was the guardian but had passed away. Inquired with SW regarding R44's appointed non-designated surrogate and if the facility has documentation from the physician that R44 lacks capacity to provide informed consent to or refusal of medical treatment, SW stated she will check. Documentation was not received.
Review of R44's legally appointed conservatorship and guardianship form documents R44's husband as the legal guardian with no limitation of power. The legal form is dated on 07/21/17 after the Declaration of Authority to Act as Surrogate for Patient form was signed, 03/13/17.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
Based on record review and interviews the facility failed to follow the facility's grievance policy to ensure prompt resolution of all grievances for two sampled residents (R)58 and R85.
Findings inc...
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Based on record review and interviews the facility failed to follow the facility's grievance policy to ensure prompt resolution of all grievances for two sampled residents (R)58 and R85.
Findings include:
Review of the facility's policy and procedure (P&P) 5021 RESOLUTION OF PATIENT/RESIDENT/VISITOR GRIEVANCES, COMPLAINTS AND CONCERNS effective 12/2021 defines complaint as a verbal expression of dissatisfaction .regarding care or services which can be resolved at the point which it occurs by the staff present. Most complaints will have simple solutions that can be promptly addressed and are considered resolved when patient/patient's representative is satisfied with the action taken on their behalf. The facility's policy defines grievance as a .formal verbal or written expression of dissatisfaction with some aspect of care or service that has not been resolved to the patient/patient's representative's satisfaction at the point of service. The P&P further documents The complaint, findings and resolution of the complaint shall be communicated by the immediate supervisor or to Risk management and Administration and electronically entered into the RL program . and if the complaint cannot be resolved the facility is to treat the complaint as a grievance. Upon conclusion of the review/investigation .written response with explanation of the resolution to the grievance must be provided to patient/patient's representative in a timely manner - 7 days for the provision of the response .
1) On 01/09/23 at 11:55 AM interview with R58 was done. R58 stated he had a lot of complaints and grievances and felt some of them were not resolved unless he .goes higher up . R58 reported he has not gotten a written response with explanation of the resolution to his grievances. R58 stated he complained about staff not cleaning his bottom well and felt he developed sores and his sores got worse because staff were not .doing a good job . R58 stated he felt this complaint has been resolved but only after he made .a lot of noise.
On 01/10/23 at 01:15 PM requested from Social Worker (SW) for the facility's grievance log for the last three years.
Review of the facility's grievance log from 02/10/2020 to 11/27/22 received, did not document R58's complaint of staff not cleaning his bottom well or .doing a good job . and his concern of developing sores and/or his sores getting worse.
Review of a nursing note on 09/19/22 documented R58 .requested to check his buttocks. Noted his both inner buttocks reddened but no open area. Blaming CNA [Certified Nursing Aide] not cleaning him good and not reporting. This complaint was not documented in the grievance log along with findings and resolution.
On 01/12/23 at 09:03 AM interview with Social Worker (SW) was done. SW reported during one-on-one meetings R58 does not bring up concerns or complaints but during the care plan meeting he does. SW reported R58 complained about sores on his bottom and staff not cleaning him well and staff are not doing a good job. SW explained that R58 has strong preferences in which staff he works well with, and the facility has been doing their best to accommodate to his preference. SW confirmed his complaint was not documented in the facility's grievance log along with the findings and resolution.
On 01/12/23 at 09:50 AM interview and concurrent record review with Patient Care Coordinator (PCC)1 was done. Inquired if R58 complained about his bottom not cleaned well or staff not doing a good job, PCC1 stated R58 had been complaining that his bottom is getting worse because staff are not cleaning it well. PCC1 explained R58 usually complains about staff not cleaning him well or doing a good job when it is agency staff providing the care or a CNA he does not like. PCC1 stated R58 complains of staff often and his complaints may be documented in the progress notes. Inquired if complaints are kept in the facility's grievance log, PCC1 confirmed they should be documented in the facility's RL program. Concurrent review of the facility's grievance log, PCC1 confirmed R58's frequent complaints of staff not doing a good job and not cleaning his bottom well, contributing to the sores on his bottom, is not documented in the log, along with the findings and resolution.
On 01/12/23 at 02:18 PM requested with Consultant Director of Nursing (CDON) documentation of the facility's written responses with explanation of the resolution to R58's grievances. Documentation was not provided.
2) On 01/09/23 at 11:23 AM interview with R85 was done with three family members (FM) in the room and visiting. R85 reported he complained to staff that his suction machine is not suctioning strong enough, but they are not addressing his complaint. R85 reported staff will brush him off and tell him that it is not weak but never investigating it or check it and they never offered to replace it. FM2 stated he visited R85 before Christmas, a few weeks ago, R85 complained about his suctioning machine then and FM2 requested the facility fix the cable in R85's room because it was snowy.
Review of the facility's grievance log from 02/10/2020 to 11/27/22 received, did not document R85's complaints of his suction machine not suctioning strong enough or FM2's complaint of static on R85's television. There were no complaints/grievances documented for December 2022 and January 2023.
On 01/12/23 at 08:05 AM interview with CNA75 was done. CNA75 stated when a resident has a complaint, they are to report it to the Registered Nurse (RN) or Licensed Practical Nurse (LPN). Inquired if R85 complained about his suction machine not suctioning strong enough, CNA75 reported he always complains about his suction machine.
On 01/12/23 at 09:43 AM concurrent record review and interview with PCC1 was done. PCC1 stated R85's complaints about his suction machine should be documented in the RL program, the facility grievance log and if it is not resolved it would get escalated to a higher level, such as administration, Risk Manager and/or to the Director of Nursing (DON). Concurrent review of the facility's grievance log, PCC1 confirmed R85's frequent complaints of his suction machine was not documented in the log, along with the findings and resolution.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) R83 is an [AGE] year-old female admitted to the facility on [DATE] for long-term care. R83's admitting diagnoses include Alzh...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) R83 is an [AGE] year-old female admitted to the facility on [DATE] for long-term care. R83's admitting diagnoses include Alzheimer's Disease, high blood pressure, a urinary tract infection, anemia (a condition in which the blood does not have enough healthy red blood cells, and hyponatremia (a condition that occurs when the level of sodium in the blood is too low).
On 01/10/23 at 09:35 AM, a review was done of R83's EHR. While reviewing R83's admission MDS assessment with an assessment reference date (ARD) of 10/17/22, it was noted that the assessment was completed on 10/25/22.
On 01/12/23 at 09:28 AM, an interview was done with MDSC1 in her office. During a concurrent review of R83's admission assessment, MDSC1 confirmed that it had been completed a day late.
Based on record review and interview, the facility failed to complete a comprehensive assessment of functional capacity within fourteen (14) days of admission, for two of 27 residents (R)103 and R83 in the sample. As a result of this deficient practice, the facility failed to identify R103's cognitive status which is important in defining care and staff did not have the information necessary to adequately care for R83 so that she could meet her highest potential of physical and psychosocial well-being. This deficient practice has the potential to affect all newly admitted residents to the facility.
Findings include:
1) Reviewed the electronic health record (EHR) of R103 who was admitted on [DATE], and the initial Minimum Data Set (MDS) was completed on 12/21/22. While reviewing the initial MDS, noted that section C of the MDS, which covers cognitive patterns, was not completed. Question 0100 asked, Should Brief Interview for Mental Status (C0200-C0500) be conducted?, the answer was yes. There were no answers for questions 0200 to 0500. Reviewed under Assessment Notes, a progress note documented on 12/15/22 at 6:09 PM, under Mental Status, stated that R103 was alert & oriented X3 [person, time, and place] communicated verbally, speech is clear, is able to understand and be understood when speaking.
On 01/11/23 at 12:02 PM, conducted a phone interview with MDS Coordinator (MDSC)1. Asked if section C of the initial MDS should have been completed, she said yes.
On 01/12/23 at 08:18 AM, concurrent observation and interview were done with MDSC1 in her office. Reviewed R103's EHR to see if the Brief Interview for Mental Status (BIMS) was documented in another section. MDSC1 was not able to find the BIMS in the EHR. She then said that it was not completed and that it was missed.
Reviewed policy, Interdisciplinary Care Management Process, policy number 02-03-01, effective date 09/21/20. It stated, .1. Assessment of Residents: a. An initial assessment is completed by the nursing staff on newly admitted residents within 24 hours of admission .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff members, the facility did not assure resident assessments were electronically tr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff members, the facility did not assure resident assessments were electronically transmitted within 14 days after completion. There was no record of successful transmittals to reflect the discharge for 3 (Residents 96, 88, and 64) of 3 residents identified.
Findings include:
The Long-Term Care (LTC) software identified three residents that did not have assessments transmitted for over 120 days. Residents (R) 96, R88, and R64.
On 01/11/23 at 3:01 PM, record review with concurrent interview was done with the Minimum Data Set Coordinator (MDSC)1. The MDSC1 reported she started doing the assessments in October 2022.
The review found:
-R96 was admitted to the facility on [DATE] and discharged on 07/30/22.
-R88 was admitted to the facility and readmitted on [DATE]. MDSC1 reported a quarterly assessment was done on 07/16/22. R88 later went out of the facility on 08/07/22 with return on 08/10/22. R88 was discharged on 08/14/22 to acute hospital, therefore, an admission assessment was not done.
-R64 was admitted to the facility on [DATE] and discharged on 07/30/22.
MDSC1 reported these assessments were completed in the facility's former electronic health record (EHR) software and was unable access the former EHR. MDSC1 was agreeable to request Patient Care Coordinator (PCC)1 run the report as he would be able to get into the former EHR.
On the afternoon of 01/11/23, PCC1 provided copies of the printed assessments for the residents. Clarified, requesting a copy of the transmittal confirmation sheet. PCC1 was agreeable to request consultation and assistance as he was unable to access the former EHR.
On 01/12/23, PCC1 provided copies of CMS Submission Report - MDS 3.0 Submitted Final Validation. Review noted the accepted transmittal for R96 was an entry assessment, NEW RECORD with a target date of 07/15/22. There was no documentation a discharge assessment was completed and transmitted.
Further review noted acceptable transmittals for R88. There was an acceptable transmittal for entry with target date of 07/15/22. Another submission for a quarterly assessment with a target date of 07/16/22 was transmitted. The following warning note identified the quarterly assessment was completed late. PCC1 was unable to produce transmittal receipt for the discharge assessment reflecting R88's discharge on [DATE].
There was no documentation of an acceptable transmittal reflecting R64's discharge assessment.
PCC also provided a copy of Accepted Batch Results. Noted the discharge assessments for R96 and R64 were In Progress.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to accurately complete a comprehensive assessment of fun...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to accurately complete a comprehensive assessment of functional capacity for two residents (R) in the sample. As a result of this deficient practice, resident-specific care areas were not triggered for further evaluation and staff did not have the information necessary to adequately care for the residents (R55 and R83) so that they could meet their highest potential of physical and psychosocial well-being. This deficient practice has the potential to affect all residents at the facility.
Findings include:
1) Resident (R)55 is a [AGE] year-old female admitted to the facility on [DATE] for skilled care following a physical decline and weakness related to chemotherapy treatment. R55's admitting diagnoses include liver cancer, diabetes, chronic kidney disease, and history of breast and colon cancer. On 12/29/22 R55 was admitted to Hospice for end-of-life care.
On 01/11/23 at 1:40 PM, a review of R55's electronic health record (EHR) noted that R55 did not have a comprehensive care plan (CP) for pain management. Review of her minimum data set (MDS) assessments with assessment reference dates (ARD) of 10/30/22 and 12/30/22 noted that for question J0200. Should Pain Assessment Interview be Conducted, both assessments indicated a 1 for yes. However, every question in the Pain Assessment Interview following J0200 was left blank.
On 01/12/23 at 08:57 AM, an interview was done with MDS Coordinator (MDSC)1 in her office. During a concurrent review of R55's assessments, MDSC1 confirmed that although both assessments indicated that the pain interview should be conducted with R55, there was no documentation that it had been done, or why it wasn't done. A subsequent review of nurse progress notes with MDSC1 validated that R55 was verbal and responsive at the time of both assessments. MDSC1 agreed that given her admitting diagnoses, it would be reasonable to expect that R55 might have been experiencing pain, and had the Pain Assessment Interview been completed, it likely would have triggered pain as a care area that required a CP.
2) Resident (R)83 is an [AGE] year-old female admitted to the facility on [DATE] for long-term care. R83's admitting diagnoses include Alzheimer's Disease, high blood pressure, a urinary tract infection, anemia (a condition in which the blood does not have enough healthy red blood cells, and hyponatremia (a condition that occurs when the level of sodium in the blood is too low).
On 01/09/23 at 09:29 AM, observations were done at the bedside of R83. R83 was observed sleeping in her bed and appeared to have no teeth.
On 01/10/23 at 09:44 AM, during a review of R83's EHR, it was noted that her MDS admission assessment with an ARD of 10/17/22 documented no problems or irregularities with her Oral/Dental Status (such as having no natural teeth).
On 01/11/23 at 09:51 AM, an interview was done with Licensed Practical Nurse (LPN)1 at the third-floor Nurses' Station (NS). LPN1 confirmed that R83 has none of her own teeth left and has no dentures.
On 01/12/23 at 09:28 AM, an interview was done with MDSC1 in her office. During a concurrent review of R83's admission assessment, MDSC1 confirmed that R83's admission assessment documented no problems with her Oral/Dental Status. When asked, MDSC1 verified that she was unaware that R83 had no teeth. MDSC1 validated that if the Oral/Dental Status question had been answered correctly, it would have triggered the dental care area/care plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
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 identify residents' medical needs and failed to pr...
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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 identify residents' medical needs and failed to provide caregivers important interventions on the initial care plan to give personalized and effective care to treat these medical needs for two residents (R), R259 and R260, in a sample of two. This deficient practice has the potential for ineffective and unindividualized care to be given to all newly admitted residents.
Findings include:
1) Cross Reference to F684 Quality of Care. The facility failed to provide the needed medical care for R259, who has kidney failure, and was not receiving hemodialysis (a life-saving treatment involving a machine to clean the individual's blood of toxins). R259's specialized medical needs were not timely identified by the facility.
On 01/10/23 at 08:18 AM, observed R259 sitting up in bed with her bedside table that contained her breakfast tray pushed to the side. R259 was sleepy, but responded to verbal stimulation. R259 requested to have oxygen applied and initiated her call device for assistance.
On 01/10/23 at 10:22 AM, R259 laid in bed with her eyes closed, wearing tubing in her nose (nasal cannula) delivering oxygen from the wall connection while she received medication intravenously (IV) through an IV access in her right arm.
On 01/10/23 at 2:05 PM, interviewed R259's family member (FM)12. FM12 stated that R259 had a left upper arm arteriovenous fistula (AVF, permanent access surgically created with the individual's vein and artery) to prepare for impending hemodialysis (a life-saving treatment utilizing a machine to clean the individual's blood of toxins).
On 01/11/23 at 08:59 AM, R259 laid in bed awake wearing the nasal cannula to deliver oxygen. R259 did not answer when asked if she felt short of breath.
Reviewed R259's electronic health record (EHR). R259 was admitted to the facility on [DATE] with a diagnosis of sepsis (infection in the blood) and kidney failure. Under Progress Notes reviewed an admission Summary with effective date and time of 12/30/22 at 4:33 PM. R259 had a left arm arteriovenous fistula (AVF), but was not currently receiving hemodialysis. Under Orders, there were orders for oxygen to be administered as needed for shortness of breath, to do weekly PICC line dressing changes, and for an antibiotic (medication to treat infection) to be administered for R259's sepsis. There were no orders for the care of R259's left arm AVF. Reviewed R259's care plan. There were no Focus, Goal, and Interventions to address the care of her left arm AVF and associated medical treatment for her kidney failure, PICC (peripherally inserted central catheter) line care with current treatment of an infection with an antibiotic, and for R259's need of oxygen.
On 01/11/23 at 10:53 AM, conducted an observation of R259 and subsequent interview with RN10. R259 was not present in her bed. An immediate query with RN10 revealed that R259 left her room to have a chest xray done. RN10 confirmed that R259 had a right arm PICC line and a left upper arm AVF that was supposed to be assessed for functioning by the nursing staff every shift and documented in a progress note. RN10 further stated that interventions outlining the care of R259's PICC line and AVF should be on her care plan.
On 01/12/23 at 09:40 AM, interviewed the Patient Care Coordiation (PCC) who confirmed that R259's use of oxygen needed to treat her shortness of breath should be identified on R259's care plan.
2) On 01/09/23 at 12:45 PM, an interview was done with R260 and family member (FM)5. During the interview, R260 repeatedly stated that she wanted a urinary tube to help drain her bladder because she had difficulty voiding and had urinary urgency. FM5 stated that R260 was newly admitted into the facility, and they were waiting for test results to find out what was the cause of R260's difficulty voiding and urinary urgency. FM5 further stated that R260's difficulty voiding, and urinary urgency causes her to become anxious.
01/09/23 at 12:55 PM, after the interview with FM5, an observation was made when R260 triggered her call device to obtain assistance with going to the restroom to void. After a few minutes, FM5 came out of R260's room to obtain assistance for her stating, My mom really needs to use the restroom!
On 01/10/23 at 08:40 AM, interviewed Registered Nurse (RN)10. RN10 stated that R260 is continent and incontinent of urine and bladder scans were done to check for residual of urine. R260 did not have any residual of urine after voiding.
Reviewed R260's electronic health record (EHR). R260's care plan for Current Functional Performance stated R260's toilet use required one-personal physical assist. R260's difficulty voiding, urinary urgency, and the use of bladder scans to be performed by the nursing staff as needed were not addressed on her care plan.
On 01/12/23 at 09:40 AM, interviewed PCC8. PCC8 stated that R260's urinary problem with personalized caregiver interventions should be addressed on her care plan.
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 F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Cross Reference to F690. The facility failed to ensure a resident (Resident (R) 85) with an indwelling catheter was removed a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Cross Reference to F690. The facility failed to ensure a resident (Resident (R) 85) with an indwelling catheter was removed as soon as possible after a successful void trial. The facility failed to ensure R85 received appropriate interventions to restore as much urinary function as possible without use of a catheter and education on implications and risks associated with the use of a catheter without an indication for continued use.
R85 was admitted to the facility on [DATE] with diagnoses that include but not limited to gastrointestinal hemorrhage and benign prostatic hyperplasia with lower urinary tract symptoms. R85 has an indwelling Foley catheter since 09/17/21 with history of refusing a voiding trial. R85's quarterly MDS with ARD of 10/16/22 documented R85's BIMS score 10, indicating the resident has moderate cognitive impairment.
On 01/11/23 at 011:40 AM during a review of R85's EMR and hard chart (located on the unit), reviewed a physician progress note dated 06/30/22 documenting R85 passed a voiding trial on 06/30/22 and the physician discussed the risks and benefits, as well as treatment options. The physician recommended transurethral resection of the prostate (TURP); a surgery used to treat urinary problems that are caused by an enlarged prostate but R85 wished .to keep an indwelling foley catheter rather than void in a diaper.
On 01/11/23 at 12:41 PM interview with RN38 and concurrent record review was done. Concurrent review of R85's care plan under Knowledge Deficit and/or The resident has Indwelling Foley Catheter, RN38 confirmed the care plan was not revised to include R85 had a successful voiding trial on 06/30/22, refused removal of the indwelling Foley catheter and recommended treatment option from the physician, and education of the risks associated with continued use of the Foley catheter prior to replacing/changing the Foley catheter or when complications/concerns arise from the Foley catheter. RN38 stated nursing staff should have discussed the risks with R85 when he may not need the Foley catheter based on R85's last void trial when his catheter was replaced/changed and when R85 had concerns or complications from this catheter.
Further review of R85's care plan did not include interventions to restore as much urinary function as possible without the use of catheter.
Based on observations, interviews, and record reviews, the facility failed to ensure the comprehensive person-centered care plan was reviewed and/or revised by the interdisciplinary team after each assessment and as needed for two of 27 residents (Resident (R)91 and R85) sampled.
Findings include:
1) Cross Reference to F689- Free from Accident Hazard, F756- Drug Regime Review, and F758- Free from Unnecessary Psychotropic Medication
Facility Reported Incident (FRI) #HI00009469 (#9469) in the Aspen Complaints/Incidents Tracking System (ACTS) was investigated. The completed report submitted by the facility documented R91 was admitted to the facility on [DATE]. On 04/22/22 at approximately 3:45 PM, R91 was observed by staff in bed, quiet, no restlessness and declined an offer to go to the bathroom. At 4:35 PM, staff went back to check on the resident and found her sitting in bed. R91 informed staff that she fell when she went to the bathroom. R91 informed staff that she needed to use the bathroom again, stood up and kept walking. As soon as R91 was assisted back to bed, nursing staff assessed the resident and she had swelling on the right elbow with pain and left hip pain on range of movement (ROM). R91 was transferred and admitted to an acute hospital where she had surgery. R91 sustained a right humerus (upper arm bone) fracture and left hip pain. R91 was admitted to the acute hospital and required surgical interventions for both fractures.
On 01/11/23 at 03:38 PM, conducted a record review of R91's Electronic Medical Record (EMR) and hard chart (located on the unit). R91 admitted to the facility on [DATE] with diagnoses that include Alzheimer's disease, dementia, diabetes mellitus, and hypertension. R91's quarterly Minimum Data Set (MDS) with an Assessment Reference Data (ARD) of 11/04/22 documented in Section C. Cognitive Patterns the resident had a Brief Interview for Mental Status (BIMS) score was 5 indicating the resident has severe cognitive impairment.
Review of R91's fall care plan (CP) located in R91's hard chart documented the resident had falls on 04/04/22 at 06:30 AM (witnessed), 05/04/22 (assisted), 5/06/22, (unwitnessed), 5/10/22 at 8:00 PM (unwitnessed), 06/15/22 (unwitnessed), 06/22/22 (witnessed), and 12/04/22 (unwitnessed). Interventions included Check bed alarm and personal alarm every shift (resident knows how to disable alarm); Reorient how to use call light every shift (resident doesn't know how to use call light); and Timed toileting every 2 hours. R91's CP in the EMR documented a duplicated intervention to Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt responses to all request for assistance.
On 01/12/23 at 10:20 AM, conducted a concurrent interview and observation of R91 with Unit Supervisor 5 (US5). R91 was lying in bed and awake. Staff came into the room and handed R91 the call light. R91 did not know what the call light was or how to use it. US5 explained to R91 that she could push the call light like a button and staff would come and help her. R91 was unable to understand what US5 had just explained to her and started to pull on the call light cord (which was attached to the wall). R91 appeared confused and kept pulling at the call light until RN88 removed it from her hands. After conducting the observation at 10:36 AM, this surveyor conducted a concurrent interview and record review of R91's hard chart records/EMR with US5. After reviewing R91's charts, US5 confirmed R91's fall CP intervention for the use of a call light was not person centered due to the extent of R91 impaired cognition the resident is not capable of understanding the how to physically use the call light and is unable to use the call light with intent. US5 also confirmed that due to extent of R91's cognitive impairment, using the call light could potentially be an accident hazard to R91.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and interview, the facility failed to provide the necessary care and services to maintain the activities o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and interview, the facility failed to provide the necessary care and services to maintain the activities of daily living, including grooming and personal hygiene for one resident (Resident 45) in the sample. As a result of this deficient practice, Resident (R)45 was hindered from attaining his highest practicable well-being and was placed at risk for a decreased quality of life. This deficient practice has the potential to affect all the residents at the facility.
Findings include:
Resident (R)45 is an [AGE] year-old male admitted to the facility on [DATE] for long-term care. Admitting diagnoses include high blood pressure, diabetes, depression, and left-sided weakness following a stroke.
On 01/09/23 at 09:39 AM, observations were done at R45's bedside. R45 was alert with his hair uncombed and in disarray and he was wearing a facility gown that had a large yellow spill stain that had dried, covering his chest area and extending down to his abdomen. When asked what happened to his gown, R45 responded, I don't know.
On 01/09/23 at 11:14 AM and again at 12:15 PM, R45 was observed still in his bed with his hair in disarray and his gown heavily and noticeably soiled. Observed a rounding sheet outside his room that was initialed off by staff members at 08:00 AM and 10:00 AM.
On 01/09/23 at 12:17 PM, an interview was done with Registered Nurse (RN)38 at the third-floor Nurses' Station (NS). RN38 stated that resident gowns/clothes are changed, and morning hygiene was done for each resident every day.
On 01/09/23 at 02:52 PM, a review of R45's electronic health record (EHR) was done. Review of his last minimum data set (MDS) assessment with an assessment reference date (ARD) of 11/12/22 noted that R45 required extensive assistance for dressing/changing his clothes, and limited assistance with personal hygiene such as combing his hair.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Cross Reference to F655 Baseline Care Plan.
On 01/09/23 at 10:27 AM, made an initial observation of R259 who laid in bed wit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Cross Reference to F655 Baseline Care Plan.
On 01/09/23 at 10:27 AM, made an initial observation of R259 who laid in bed with her eyes closed. R259 did not arouse to verbal stimulation and her skin color was gray.
On 01/09/23 at 1:13 PM, observed R259 lying in the same position in bed with her eyes closed and still did not arouse to verbal stimulation.
On 01/10/23 at 08:18 AM, observed R259 sitting up in bed with her bedside table that contained her breakfast tray pushed to the side. R259 was sleepy but responded to verbal stimulation. R259 requested to have oxygen applied and initiated her call device for assistance.
On 01/10/23 at 10:22 AM, observed R259 lying in bed with her eyes closed, wearing tubing in her nose (nasal cannula) delivering oxygen from the wall connection while she received medication intravenously (IV) through an IV access in her right arm.
On 01/10/23 at 2:05 PM, interviewed R259's family member (FM)12. FM12 stated that R259 had a left upper arm arteriovenous fistula (AVF, permanent access surgically created with the individual's vein and artery) to prepare for impending hemodialysis (a life-saving treatment utilizing a machine to clean the individual's blood of toxins).
On 01/10/23 at 2:27 PM, observed Medical Doctor (MD)3 speaking with Registered Nurse (RN)29. MD3 stated that he ordered a chest Xray for R259 to check for CHF (congestive heart failure, medical complication of kidney failure).
On 01/11/23 at 08:59 AM, R259 was awake lying in bed wearing a nasal cannula to deliver oxygen. R259 did not answer when asked if she felt short of breath.
On 01/11/23 at 10:53 AM, an observation of R259 and subsequent interview with Registered Nurse (RN)10 were done. R259 was not present in her bed. An immediate query with RN10 revealed that R259 left her room to have a chest xray done. RN10 confirmed that R259 had a left upper arm AVF that was supposed to be checked by the nursing staff every shift to ensure it was functioning and documented in a nursing note. RN10 stated that the blood pressure checks for R259 are taken on her leg because of the PICC (peripherally inserted central catheter) line on her right arm and AVF on her left arm. RN10 further stated that the care of R259's left upper arm AVF and kidney failure should be addressed on her care plan.
Reviewed R259's electronic health record (EHR). R259 was admitted to the facility on [DATE] with a diagnosis of sepsis (infection in the blood) and kidney failure. Under Progress Notes an admission Summary with effective date and time of 12/30/22 at 4:33 PM revealed that R259 had a left arm AVF, was not currently receiving hemodialysis, but needed continued care with a nephrologist (medical doctor specializing in kidney diseases). Skilled Nursing Prog Note template for nursing documentation in the progress notes were reviewed. Out of the 15 progress notes documented from 01/01/23 at 05:25 AM to 01/10/23 at 4:32 PM, only three notes documented the assessment of R259's left arm AVF to verify that it was functional. Under Orders, there were no orders to care for R259's left arm AVF. Care plan was reviewed. There were no Focus, Goal, and Interventions to address the needed care of R259's left arm AVF and associated medical care of her kidney failure and its medical complications.
Based on observations, record reviews and interviews, the facility did not ensure bowel regimen was provided in accordance with the physician's order for Resident (R)40 and the facility failed to appropriately provide the needed medical care for R259, who has kidney failure. R259 has kidney failure and was not yet receiving hemodialysis (a life-saving treatment involving a machine to clean the individual's blood of toxins). This deficient practice has the potential to affect all residents and residents who have kidney failure but are not yet receiving their life-saving treatment.
Findings include:
1) Resident (R)40 was admitted to the facility on [DATE]. Diagnoses include Wernicke's encephalopathy; depression; psychotic disorder; and Post Traumatic Stress Disorder.
Resident interview on 01/09/23 at 10:33 AM, R40 reported she sometimes experiences constipation. Inquired whether the facility provides any treatment. R40 responded a suppository is administered which is effective.
Record review done on 01/12/23 at 07:40 AM found physician orders for bowel elimination protocol, senna 8.6 milligram (mg) in morning for constipation; bisacodyl suppository 10 mg, insert one rectally as needed for constipation if no bowel movement in three days; and tap water enema if no results from suppository. A review of her bowel elimination records documented R40 did not have bowel movement on the following days: 12/30, 12/31 and 1/1/23 and 01/07/23, 01/08/23, and 01/09/23. A review of the Medication Administration Record (MAR) found no documentation suppository was administered on the third day of no bowel movement.
On 01/12/23 at 12:08 PM concurrent record review and interview was conducted with the Unit Supervisor (US)5 in the nursing office. US5 confirmed R40 did not have bowel movement 12/30/22 to 01/01/23 and 01/07/23 to 01/09/23. US5 reviewed the physician's orders for bowel regimen. US5 confirmed a suppository is administered on the third day of no bowel movement. US5 reviewed the MAR and confirmed the suppository was not administered as ordered by the physician. US5 stated the suppository should have been administered on 01/01/23 and 01/09/23.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record reviews, the facility failed to provide treatment to prevent or improve pressure ulcers/injury for one Resident (R)259, in a sample of six residents. R259...
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Based on observations, interviews, and record reviews, the facility failed to provide treatment to prevent or improve pressure ulcers/injury for one Resident (R)259, in a sample of six residents. R259 was at risk to develop pressure ulcers, and due to the lack of timely repositioning, she developing a worsened skin wound. This deficient practice has the potential to affect the health of residents in the facility who are dependent on the staff for positioning.
Findings include:
On 01/09/23 at 10:27 AM, an initial observation was made of R259 who laid in bed with her eyes closed, lying on her right side. R259 did not arouse to verbal stimulation.
On 01/09/23 at 1:13 PM, observed R259 lying in the same position in bed with her eyes closed and she still did not arouse to verbal stimulation.
On 01/10/23 at 2:05 PM, interviewed R259's family member (FM)12. FM12 stated that the staff do not turn R259 while lying in bed every two hours.
On 01/12/23 at 10:00 AM, a concurrent observation and interview were done with Registered Nurse (RN)10 during R259's pressure ulcer dressing change on her buttocks. RN10 stated that the coccyx wound has healed, but that the wound on her right buttock has worsened.
Reviewed R259's electronic health record (EHR). admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 01/06/23 revealed under Section GG Functional Abilities and Goals that R259's admission performance for rolling from lying on her back to the left and ride side and returning to lying on her back as 02 or needing Substantial/maximal assistance. Initial N Adv - Braden Scale for Predicting Pressure Ulcer Risk done on 12/30/22 at 12:47 PM scored R259 as a Moderate Risk for developing pressure ulcers. Follow up N Adv - Braden Scale for Predicting Pressure Ulcer Risk done on 01/09/22 at 11:55 AM scored R259 as At Risk for developing pressure ulcers. Reviewed R259's BED MOBILITY: SELF-PERFORMANCE task flowsheet for the dates 12/30/22 through 01/10/23 and noted that R259 was with limited or extensive assistance, or total dependence for turning and was done two to four times per day.
On 01/12/23 at 09:40 AM, a concurrent observation and interview were done with Patient Care Coordinator (PCC)8. Reviewed the BED MOBILITY: SELF-PERFORMANCE task flowsheet for R259 in R259's EHR for dates 12/30/22 to 01/10/23. PCC8 confirmed that the staff did not turn R259 every two hours as required by the facility's policy and procedure for pressure ulcer/injury management.
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
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure the resident's environment remains free of ac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure the resident's environment remains free of accident hazards for one resident (Resident (R)91) sampled.
Findings include:
Cross Reference to F657- Care Plan Revision, F756- Drug Regime Review, and F758- Free from Unnecessary Psychotropic Medication
On 01/09/23 at 08:45 AM, conducted an initial observation of R91 in the resident's assigned room. R91 was resting on an air mattress and the resident's feet was positioned higher than her head. A wedged cushion was placed under the left side of the air mattress and aligned with the area of the resident's legs. As a result of the wedge cushion under the mattress, R91's feet (heels in contact with the bed) pointed toward the right side of the bed. On the left side of the mattress, wedge cushions were placed under the sheet starting from the bedrail down to the foot of the bed. As a result of placing the wedge cushions under the sheet, the resident's sheet did not properly fit the mattress and the mattress was exposed. The placement of the wedge cushions under the sheet formed a barrier wall along the side of the bed and was not placed under R91 to assist with repositioning. The right side of the bed was parallel to a wall and there was a foot gap between R91's bed and the wall.
On 01/10/23 at 08:11 AM, conducted an observation of R91 in the resident's assigned room. This surveyor observed several wedge cushions, placed on top of the sheet, along the left side of the bed starting from the bedrail to the foot of the bed. The cushions were placed on top of each other and formed a barrier wall along the left side of the bed.
On 01/09/22 at 3:11 PM, conducted a review of R91's Electronic Medical Record (EMR). R91 was admitted to the facility on [DATE] with diagnosis of Alzheimer's disease, dementia with behavioral disturbances, diabetes mellitus type 2, and hypertension. Review of the facility event reports documented R91 had seven falls, four of those falls were unwitnessed, and five of the falls occurred due to R91 attempting to get out of the bed.
04/04/22- Witnessed fall at 06:30 AM, R91 stood up from her bed quickly, lost her balance quickly and hit her head on the floor. The resident was confused and unable to use call light for assistance, gets out of bed unassisted. Resident had on cloth slippers with socks that did not have grip.
04/22/22- Unwitnessed fall, staff entered R91's room and reported to staff that she fell down. Staff reported R91 had swelling and bruising to her right elbow and was unable to move her right arm. R91 was sent to an acute hospital. Per the hospital report, R91 complained of left hip pain in the emergency room and it was discovered she had fractured her left hip also. Both injuries required surgical interventions.
05/04/22-Unwitnessed fall, staff heard bed alarm and found the resident on the floor next to her bed, holding onto the right grab bar. R91's right arm sling had been removed and was found in the bed.
05/10/22- Witnessed fall, Bed alarm alerted staff R91 was attempting to get out of bed. R91 was uncooperative with staff, staff was unable to hold resident's balance and assisted the resident to the floor.
06/04/22- Unwitnessed fall at 1:30 PM. R91 was found lying on her back on the floor mat next to the bed. Two staff assisted the resident back into her bed.
06/22/22- Unwitnessed fall, resident was found lying on the floor mat next to the bed.
12/04/22- Unwitnessed fall at 11:05 AM. R91 found on the floor mat next to her bed.
Review of MD progress note on 05/11/22 documenting R91 had 2 falls since returning to the facility. Resident is unable to recall that she is weaker after hospitalization, short term memory requires a lot of cues for safety during therapy and activities of daily living (ADLs).
On 01/12/23 at 10:36 AM, conducted an interview and concurrent record review for R91 with Unit Supervisor 5 (US5). US5 stated R91 has poor safety management, impaired sleep cycle, frequent urgency to urinate (prior to sustaining the fractures), and it has been difficult to keep the resident safe due to her impaired cognition she continuously attempts to get up on her own. This surveyor shared visual documentation of observations made on 01/09/23 at 08:45 AM and on 01/10/23 at 08:11 AM of R91 that depicted the placement and use of the wedge cushions. US5 confirmed the wedge cushion placed under the air mattress is unsafe for the resident and is a potential accident hazard, R91 could slide off the mattress and become wedged in the foot gap between the bed and the wall and she would not be able to stop herself from sliding off the mattress. Placement of the wedges under the sheet caused the sheet to not properly fit the bed and could become dislodged and potentially be an accident hazard due to the resident's poor cognition. US5 also confirmed that the wedge cushions were not used to reposition the resident, but as a barrier to exiting the bed and was a potential for an accident hazard.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews the facility failed to ensure a resident (Resident (R) 85) with an indwelli...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews the facility failed to ensure a resident (Resident (R) 85) with an indwelling catheter was removed as soon as possible after a successful void trial. The facility failed to ensure R85 received appropriate interventions to restore as much urinary function as possible without use of a catheter and education on implications and risks associated with the use of a catheter without an indication for continued use. As a result, all residents are at risk of unnecessary use of indwelling catheters.
Findings include:
Cross Reference to F657. The facility failed to revise R85's care plan to address education to be provided on risks associated with the use of a catheter without an indication for continued use and include interventions to restore as much urinary function as possible without the use of catheter.
R85 was admitted to the facility on [DATE] with diagnoses that include but not limited to gastrointestinal hemorrhage and benign prostatic hyperplasia with lower urinary tract symptoms. R85 has an indwelling Foley catheter since 09/17/21 with history of refusing a voiding trial. R85's quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 10/16/22 documented R85's Brief Interview for Mental Status (BIMS) score 10, indicating the resident has moderate cognitive impairment.
On 01/09/23 at 11:32 AM interview with R85 was done. R85 stated he has an unusual situation, his urinary catheter tube leaks. R85 explained every time he urinates some of his urine leaks out of the tube and it is a problem for him because it makes his bottom moist and is worried if he has or develops sores on his bottom. R85 stated he is experiencing pain in his penis after urinating. R85 reported he informed nursing staff of catheter tube leaking and the pain he is experiencing but .it seems like they cannot do anything about it .
During review of R85's Electronic Health Record (EHR) reviewed a social services note on 10/13/2022 documenting R85's concern with his catheter. The note further documented the catheter was changed .but is leaking a little. Resident [R85] reported that Dr. [doctor] felt that he should remove the catheter. SW [Social Worker] inquired what resident felt about it. Resident reported that he prefers having the catheter and asked what SW thought he should do. SW explained that the doctor can make their recommendation, but in the end it is up to him to decide, but having it off would allow him to move around more. Resident noted that it was a lot think about and that he would think about it.
Review of R85's hard chart (located on the unit), reviewed the physician's progress note with an encounter date of 10/27/22 documenting Dysuria [painful urination] and hematuria [blood in urine] - Patient [R85] notes that he has been having burning sensations when urinating for the past couple of months but has noticed that it has worsened recently. Nursing staff has also noted hematuria for the past 3 days.
Review of the Urology physician progress note with an encounter date of 06/30/22 documented R85 passed a voiding trial on 06/30/22 and the physician discussed the risks and benefits, as well as, treatment options. The physician recommended transurethral resection of the prostate (TURP), a surgery used to treat urinary problems that are caused by an enlarged prostate but R85 wished .to keep an indwelling foley catheter rather than void in a diaper.
On 01/11/23 at 12:41 PM concurrent record review and interview with Registered Nurse (RN) 38 was done. RN38 stated the physician recommended R85 to discontinue use of the catheter but R85 wanted to continue to use it without clinical indication of use. Inquired what are some of the risks associated with continue use of an indwelling catheter, RN38 stated a high risk of Urinary Tract Infections (UTI) and other infections. Concurrent review of R38's EHR, progress notes and [NAME] card documents R85's indwelling Foley catheter was changed on 08/03/22, 09/01/22, 10/12/22, 10/20/22, 11/21/22, and 12/25/22, RN38 confirmed the facility did not document education and discussion of the risks associated with use of the catheter. Inquired if nursing staff should use the opportunity to educate and discuss the risks when R85 is expressing concern and or has complications with his catheter, RN38 confirmed nursing staff should have and confirmed it was not documented that they did.
On 01/12/23 at 08:56 AM interview with Social Worker (SW) was done. SW explained when a resident tells her nursing related concerns, she informs the unit manager. Inquired if R85 expressed concern regarding his indwelling catheter, SW reported R85 mentioned it was leaking and the physician recommended him to discontinue use of the catheter. SW reported R85 asked for her opinion, but SW redirected R85 to talk to his physician. SW stated she only informed nursing staff that the catheter was leaking and did not inform nursing staff of the other concerns R85 had related to his catheter.
Review of the facility's GUIDELINES FOR CARE OF URINARY CATHETERIZATION documents UTIs .continue to be the most common site of nosocomial infections and catheterizations continue to be the most frequent predisposing factor to infections. To reduce infections, the following guideline is recommended . Catheterization should be done only when necessary and the catheter is kept in place only for as long as necessary. It should not be done for the convenience of patient care personnel.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident (R)83 is an [AGE] year-old female admitted to the facility on [DATE] for long-term care. R83's admitting diagnoses i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident (R)83 is an [AGE] year-old female admitted to the facility on [DATE] for long-term care. R83's admitting diagnoses include Alzheimer's Disease, high blood pressure, a urinary tract infection, anemia (a condition in which the blood does not have enough healthy red blood cells, and hyponatremia (a condition that occurs when the level of sodium in the blood is too low). Both anemia and hyponatremia can be caused and/or worsened by poor nutritional intake.
Observations of R83 made throughout the day on 01/09/23 and 01/10/23 noted that R83 spent most of the day sleeping in bed and even while awake and actively being fed her pureed diet, frequently fell asleep.
On 01/10/23 at 09:35 AM, a review was done of R83's electronic health record (EHR). A review of her weights noted an 8.6 pound (lb.) weight loss since 12/13/22, reflecting a 7.9% loss in the last month, and a 16.6 lb. weight loss since 11/3/22, reflecting a 14.63% loss in the last two (2) months.
Further review of her EHR noted the following Nutrition/Dietary Note by the
Registered Dietician (RD) on 11/09/22:
. 6# [pound] weight loss/1mo [in one month] 5% significant . Resident is totally dependent on staff for all ADL's [activities of daily living] including meals . Plan1.Discontinue [sic] . [a high-calorie, high-protein liquid dietary supplement] (not taking) Add . pudding [a branded dietary supplement in pudding form] BID [twice a day]. [NAME] [sic] progress PRN [as needed].
No orders were placed for more frequent weight checks or closer monitoring, and a review of her comprehensive care plan (CP) noted no care plan initiated for significant weight loss.
Continued review of R83's EHR noted the following Nutrition/Dietary Note by the RD on 12/07/22:
. SNF [skilled nursing] due to IVAbx [intravenous antibiotic] PNA [pneumonia] & significant wt decline . Poor po [oral] intake ongoing . 8# wt loss/1mo 6.6% significant . Plan: Continue current nutrition intervention.
No orders were placed for more frequent weight checks or closer monitoring, and a review of her CP noted no care plan initiated for significant weight loss.
On 01/11/23 at 12:59 PM, an interview was done with the RD in her office. State Agency (SA) reviewed her Dietary Notes with her and asked her to describe the normal practice after documenting significant weight loss in a resident two months in a row. The RD stated she would usually have a conversation with the resident's family and ask them to bring in some favorite food or talk to the nurses on the unit to ask if adding another dietary supplement would be helpful. The RD also stated that she usually would flag the resident in her personal notes for a follow-up. After reviewing both her personal notes and the EHR documentation, the RD confirmed that she could not find evidence that she had spoken to R83's family or nurses, nor had she followed up on R83's weight loss since December. The RD stated she would do so by the end of the day.
Based on observation, record review and interview with staff members, the facility failed to assure two Residents (R)72 and R83 of two residents sampled, maintained acceptable parameters of nutritional status as evidenced by significant weight loss. As a result of these deficient practices, the facility placed this resident at risk for avoidable declines and injuries. This deficient practice has the potential to affect all residents at the facility.
Findings include:
1) R72 was admitted to the facility on [DATE] from an acute hospital. Diagnoses includes but not limited to dementia with behavioral disturbance, myocardial infarction, chronic kidney disease, and Type 1 diabetes mellitus.
On 01/10/23 at 10:20 AM, record review noted on 11/29/22, R72 weighed 125.4 lbs. and on 12/23/22, the resident weighed 116 pounds indicative of a 7.5% weight loss. A comparison of subsequent weights noted on 11/29/2022, the R72 weighed 125.4 lbs. and on 12/25/2022, the resident weighed 119 pounds which is indicative of a 5.10 % weight loss.
The physician orders include: Novolog solution 100 unit/ML, inject 8 unit subcutaneously with meals for diabetes mellitus, hold if residents eats <50% of her meal; Insulin glargine solution, 100 unit/mL, inject 18 subcutaneously one time a day for diabetes mellitus, hold if blood sugar <100; and Glucerna shake (order date 12/12/22) one time a day.
A review of the Dietary Profile - Initial dated 12/22/22 documents a diet order of no concentrated sweets, dysphagia minced, no fluid restrictions, and good appetite. R72 noted to be eating well mostly >85%.
A review of R72's weights include: 11/29/22 = 125.4, 12/21/22 = 125, 12/21/22 = 125, 12/23/22 = 116.0, and 12/25/22 = 119. There was no progress note to address the resident's weight loss from 12/21/22 to 12/23/22 and/or 12/25/22.
On 01/11/23 at 12:25 PM an interview was conducted with the Registered Dietitian (RD) in her office. The weights were reviewed, and RD acknowledged R72 had a weight loss. RD reported on 11/29/22, R72 was eating well, weights were stabilized, and at that time the plan was not to increase food or supplements due to diabetes mellitus (blood sugars were high). RD recalled R72's insulin required adjusting by the physician and continued Glucerna as the resident was already drinking this supplement. RD reported when residents have a significant weight loss, nursing will notify her or order a consult. RD further reported conversation with the resident's family found R72's usual body weight is 115 to 120 pounds. RD further reported it may be possible that the hospital scale was not accurate, or R72 had edema due to use of IV fluids. RD did not assess R72's weight loss, causal factors and need for interventions, as she was not aware of the 5.10% to 7.5% weight loss.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview with staff member, the facility did not ensure enteral formula for two Residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview with staff member, the facility did not ensure enteral formula for two Residents (R)5 and R81, of two residents sampled, receiving enteral nutrition (also known as tube feeding, a way of delivering nutrition directly to the stomach or small intestine) did not exceed the expiration date.
Findings include:
1) On 01/09/23 at 09:21 AM, conducted an observation of Resident (R)5 lying in bed and a bottle of Jevity tube feeding (TF) formula hanging with 400 milliliters (ml) left. The label on the Jevity bottle documented that bottle of TF formula was started on 01/08/23 at 05:00 AM, administration instructions for the formula was a bolus of 180 ml/hr (hour), and a beyond use date of 01/09 at 05:00 AM. At 10:25 AM, the same bottle was actively infusing and the infusion pump display documented 272 ml of formula had been administered to the resident.
On 01/10/23 at 09:15 AM, conducted an interview with Nursing Staff (NS)22 regarding R5's TF formula. This surveyor shared the observation made of R5's TF formula being infused beyond the 24 hour period. NS22 confirmed the TF formula that was started on 01/08/23 at 05:00 AM should not have been used past 01/09/23 at 05:00 AM and the formula is considered spoiled and not safe to administer to the resident 24 hours after it is spiked (tubing inserted for feeding).
2) Resident (R)81 was admitted to the facility on [DATE] with diagnoses of gram-negative sepsis, pyonephrosis, paraplegia, encounter for attention to gastrostomy, and pressure ulcer of sacral region, Stage 2.
On 01/09/23 at 08:40 AM, R81 was observed in bed with tube feeding infusing. The formula was labeled, Glucerna 1.2. with a date of 01/08/23 and no documentation of the time. Also observed an unopened container of Glucerna on the table that was labeled with current date of 01/09/23.
On 01/09/23 at 08:56 AM concurrent observation was done with Unit Supervisor (US)5. US5 reported R81 is on continuous feeding, so the formula was probably changed out at midnight. US5 further reported the formula is good for 24 hours after opening as it is a milk product. US5 acknowledged without the documentation of time formula was opened, it questionable whether the formula had exceeded 24 hours. Subsequently, the US5 replaced the formula that was dated 01/08/23.
On 01/11/23 at 10:38 AM, the Consultant Director of Nursing (CDON) provided a copy of the facility's policy and procedure. The policy was titled Tube Feeding, Nasogastric (NG) or Gastrostomy (GT) with a policy date of 06/03/17. The procedure includes affixing a label to the formula administration containers. The label should reflect elements of the order, formula type, enteral access deliver site/access, administration method, individuals responsible for preparing and hanging the formula, and time and date formula is prepared and hung.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
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 prevent and manage pain adequately for one resident Re...
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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 prevent and manage pain adequately for one resident Resident (R)55, in the sample. Specifically, the facility failed to recognize and act upon indicators of unmanaged pain, failed to evaluate, or assess what (R)55's pain management goals were, and failed to develop a resident-centered care plan for pain management. As a result of this deficient practice, R55 was prevented from attaining or maintaining her highest practicable level of well-being.
Findings include:
Cross-reference to F641 Accuracy of Assessments. The facility failed to accurately complete a comprehensive assessment that included an assessment of pain. As a result of this deficient practice, resident-specific care areas were not triggered for further evaluation and staff did not have the information necessary to adequately manage R55's pain.
R55 is a [AGE] year-old female admitted to the facility on [DATE] for skilled care following a physical decline and weakness related to chemotherapy treatment. R55's admitting diagnoses include liver cancer, diabetes, chronic kidney disease, and a history of breast and colon cancer. On 12/29/22 R55 was admitted to Hospice for end-of-life care.
On 01/09/23 at 2:50 PM, observations were done outside of R55's room next to the third-floor Nurses' Station (NS). R55 could be heard persistently moaning loudly from inside her room. From 2:50 PM to 3:00 PM, R55's son walked out of her room four times looking for her nurse, asking for pain medication, and asking for R55 to be re-positioned for comfort. R55's son repeatedly stated, I just want her to be comfortable. Although staff was around the NS at the time, and could hear R55 moaning in pain, no staff was observed entering her room or attempting to intervene until after her son requested assistance several times.
On 01/09/23 at 3:14 PM, an interview was done with R55's son near the third-floor elevator. Surveyor thanked him for his time and apologized for taking time away from his mother. R55's son responded, this may sound insensitive, but it's nice to be away for a bit, it's a mental break for me because it is so difficult to watch her be in pain. R55's son reported that for the last four days R55 has seemed to be in more pain. He believes that the morphine does help but seems to be wearing off faster lately. When asked if he felt her pain was being managed adequately, R55's son replied no.
On 01/10/23 at 1:59 PM, an interview and a concurrent review of R55's medication administration record (MAR) was done with Registered Nurse (RN)38 at the third-floor NS. RN38 confirmed that R55 had orders for morphine ranging from 0.25 milliliters (mls) to 1 ml every hour, depending on her pain level. The dosages ordered were as follows:
Give 0.25 ml by mouth every 1 hours [sic] as needed for MILD PAIN/SOB [shortness of breath] . 0.5 ml by mouth every 1 hours [sic] as needed for MODERATE PAIN/SOB . 1 ml by mouth every 1 hours [sic] as needed for SEVERE PAIN/SOB .
During a review of the MAR, it was noted that R55 did not receive any morphine on 01/07/23 or 01/08/23 but on 01/09/23, she received 0.25 mls at 10:56 AM and 0.5 mls at 1:27 PM. After R55's son repeatedly came out of her room to request more pain medication, she received another 0.5 mls at 3:02 PM. RN38 stated that R55's nurse had intended to give her 0.25 mls, but RN38 instructed her to give 0.5 mls. RN38 agreed that R55's moaning was unusual and probably an indicator of poor pain management, which is why she instructed R55's nurse to give her more than 0.25mLs, the dose ordered as needed for mild pain/shortness of breath.
On 01/11/23 at 1:40 PM, a review of R55's electronic health record (EHR) noted that R55 did not have a comprehensive care plan (CP) for pain management.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected 1 resident
Based on interviews with residents, a family member, and a staff member the facility did not ensure enough nursing staff is provided to respond to each resident's basic needs.
Findings include:
1) Cr...
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Based on interviews with residents, a family member, and a staff member the facility did not ensure enough nursing staff is provided to respond to each resident's basic needs.
Findings include:
1) Cross reference to F584. The facility did not assure residents on the third and fifth floor were provided with clean and safe shower equipment.
Cross reference to F880. The facility failed to thoroughly clean and sanitize shower equipment after use for the third and fifth floors.
On 01/09/23 at 2:51 PM interview with Resident (R)9's family member (FM)1 was done. FM1 reported the Certified Nursing Aides (CNA) are short-staffed. FM1 stated F9 needs less care than she did before because she is in hospice but when she needed more care, FM1 would physically sanitize and wash the facility's shower chair because they were filthy with mildew and mold. FM1 reported the CNAs are busy and short-staffed that they don't have time to clean and maintain the shower chairs after resident use. FM1 stated she used to come to the facility four times a week to assist feed F9 and provide other care R9 may need while visiting R9 at the facility. FM1 expressed .I can't be there every day making sure she is cleaned up .
2) On 01/09/23 at 11:59 AM interview with R58 was done. R58 reported the night shift is short-staffed and had to wait frequently in the last month and hour for staff to respond and receive care. R58 stated one time during night shift he had to wait four hours for nursing staff to help change his diaper.
3) Confidential interview with staff member, it was reported there are times when the facility is short-staffed on the weekends and night shift. At times there are only two aides to care for 42 residents.
4) On 01/09/23 at 10:27 AM, confidential interview with a resident, learned that the facility is short-staffed on weekends, nights, and holidays. The resident reported having to wait a long time for help. The resident was unable to state how long he/she has to wait for assistance.
5) On 01/09/23 at 10:57 AM, confidential interview with a resident was done. The resident was hesitant, stating he/she did not want to get in trouble and cause the facility to lose funding for staff. The resident reported the facility is often short staff and having to wait longer for peri-care.
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
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure a resident who use psychotropic drugs are not given these d...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure a resident who use psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record, receives gradual dose reductions (GDR) unless clinically contraindicated and documented in the clinical record for one of five (Resident (R)91) residents sampled.
Findings include:
Cross Reference to F657- Care Plan Revision, F689- Free from Accident Hazard, and F756- Drug Regimen Review
On 01/09/23 at 3:11 PM, conducted a record review of R91's Electronic Medical Record (EMR) that documented R91 was admitted to the facility on [DATE] with diagnosis that included Alzheimer's disease, dementia with behavioral disturbances, diabetes mellitus type 2, and hypertension. Review of the R91's physician orders documented an order for Mirtazapine 7.5 milligrams (mg) at bedtime for sleep disturbances (ordered on 07/18/22). Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/14/22, quarterly MDS with an ARD of 08/07/22, and quarterly MDS with an ARD of 11/04/22, Section I. Active diagnosis does not include any psychiatric/mood disorder diagnosis. Review of R91's medical chart (hard chart and Electronic Medical Record (EMR)) did not contain an active diagnosed condition(s) (insomnia or depression) for which Mirtazapine 7.5 mg is prescribed. Review of R91's physician orders did not contain documentation that a GDR was attempted or if a GDR was contraindicated with a rationale.
On 01/11/23 at 12:29 PM, received and reviewed the Recommendation Summary for DON & Medical Director form (for October and November 2022) from Contracted Director of Nursing (CDON) documents. A recommendation was made in October and November 2022 for R91, This resident continues to receive Mirtazapine 7.5 mg QHS (bedtime) for sleep disturbance and Melatonin 9 mg QHS for sleep disturbance. Please evaluate the current doses and consider a dose reduction. Kindly consider a trail gradual dose reduction of the Mirtazapine to 3.75 mg QHS. This surveyor and staff could not find a response to the pharmacist medication regimen review (MRR) documented in R91's medical record.
On 01/12/23 at 4:12 PM, CDON came down into the surveyor's conference room and stated he/she spoke to R91's Attending Physician (AP)2 and confirmed AP2 did not review or respond to CP1's MRR recommendation to GDR R91's Mirtazapine prior to this day (01/12/23) but has decided not to change the order. CDON also confirmed that there was no documentation supporting an attempt to GDR the order for Mirtazapine.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
Based on interview and record review (RR), the facility failed to ensure documentation that all residents who were eligible for the pneumococcal vaccine were offered or received it. Coupled with advan...
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Based on interview and record review (RR), the facility failed to ensure documentation that all residents who were eligible for the pneumococcal vaccine were offered or received it. Coupled with advanced age and chronic conditions, this deficient practice made one out of the five residents sampled potentially vulnerable to the bacteria that causes pneumonia. This deficient practice has the potential to affect all residents at the facility.
Findings include:
On 01/10/23 at 10:25 AM, a review of Resident (R)95's electronic health record (EHR) was done. Documentation of his pneumococcal vaccination status could not be found in his immunization record or progress notes.
On 01/11/23 at 3:10 PM, during a review of immunization records provided by the facility, it was noted that Resident (R)95 had no documentation on whether he had been offered or received his pneumococcal vaccination.
On 01/12/22 at 3:00 PM, an interview was done with the Consultant Director of Nursing (CDON) in the first-floor Conference Room. The CDON stated that after looking further into it, she had found that R95 had received his first pneumococcal vaccine in the past [prior to admission] and had refused the facility's offer of the second vaccination. Requested that the CDON provide the documentation that the vaccination had been offered and refused.
On 01/13/23 at 08:30 AM, during an interview with the CDON in the Conference Room, the CDON provided a copy of a Pneumococcal Vaccine Consent & Release form with R95's name on it. The form had no space to indicate refusal. On the signature line giving consent, pt's [sic] refused to have vaccine had been hand-written in. The form was dated 10/18/22 and had not been signed by the resident or by the staff member completing the form. The CDON confirmed that there was no progress note in the EHR regarding the offer and refusal.
On 01/13/23 at 09:30 AM, the facility's Pneumococcal Vaccine policy, dated 09/2012, was reviewed and the following was noted:
Procedure:
1. Each resident's immunization status will be determined upon admission . Immunization status will be documented in the resident's medical record .
4. Consent: .
b. The resident . may refuse vaccination. Vaccination refusal and the reason for refusal . will be documented on the Vaccine Administration Record.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) On 01/09/23 at 2:54 PM interview with Resident (R) 9's family member (FM)1 was done. The FM1 requested the surveyors to check...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) On 01/09/23 at 2:54 PM interview with Resident (R) 9's family member (FM)1 was done. The FM1 requested the surveyors to check the shower chairs for mold and mildew, specifically the bottom of the seats. FM1 reported she used to scrub the shower chair R9 sits on because the facility did not clean and sanitize the chairs after use.
On 01/10/23 at 10:06 AM observation of the central bath/shower room across room [ROOM NUMBER] found a total of three shower chairs. During observation of two white shower chairs, observed black substance on connecting parts of the frame and black substance covering the bottom of the seats of the chairs. One of the two chairs observed had black spots on the top of the seat. Further observation of the third shower chair was not done. Observation in the shower room across room [ROOM NUMBER], observed two of five shower chairs found. During observation of a blue shower chair with metal framing and a label date of August 2017 and a white chair located in the shower area, observed black substance on the bottom of the seat.
On 01/10/23 at 10:20 AM concurrent observation and interview with Certified Nursing Assistance (CNA) 35 was done in the shower room across room [ROOM NUMBER]. Concurrent observation of a white shower chair with black substance on the connecting parts and black dots on the top of the seat of the shower chair. CNA35 flipped the shower chair around and observed black substance covering the bottom of the seat. CNA35 reported the chair was dirty and the black substance looks like mold.
On 01/10/23 at 10:29 AM concurrent observation and interview with Environmental Services Supervisor (ESS) was done in the shower room across room [ROOM NUMBER] of the same white shower chair. ESS reported the black substance on the shower chair could be mold.
3) On 01/09/23 at 08:48 AM, a concurrent interview and observations were done with Resident (R)16 in his room. Observed R16 lay in his bed which was placed up against the wall on his right side. When asked, R16 stated he spent each day in his room, and did not leave for activities or meals. Observed R16's bed low to the ground with a bedside safety mat on the floor next to the left side of his bed. The safety mat appeared dirty/dusty, and bits of food were visible on the floor. On the wall to R16's right, observed a large (approximately two feet wide by one foot tall) area of dry, dark brown smears to the immediate right of his head. When asked if anyone periodically came in to clean his room, R16 stated no. At 08:58 AM, observed Registered Nurse (RN)38 enter R16's room to respond to his call light. While RN38 was in the room, inquired with her what the brown stain on the wall was. RN38 responded that sometimes he [R16] throws things at the wall. Asked RN38 if the stain appeared to her as if it was fresh. RN38 responded no. Asked RN38 what she thought could have caused a stain on the wall that color. RN38 stated sometimes the resident smears his BM [bowel movement/feces] on the wall. Asked RN38 if she thought it could be feces. RN38 responded maybe.
On 01/09/23 at 11:34 AM, an interview was done with Housekeeper (HK)1 outside of room [ROOM NUMBER]. HK1 stated that the facility pulled her and her trainee off of the second floor to cover the third floor today because the housekeepers are really short. HK1 reported that the housekeeper usually assigned to the third floor had been on leave for over a year, so the other housekeepers take turns floating down to the third floor at least once a week, in addition to cleaning their own sections. HK1 admitted that the rooms themselves do not get cleaned regularly on the third floor because there just isn't enough housekeepers. HK1 stated that when the housekeepers float to the third floor, they concentrate on at least emptying the trash in all the rooms.
4) On 01/09/23 at 09:23 AM, while touring the third floor, observations were made of multiple rooms with part or all of their large room numbers missing. room [ROOM NUMBER] was missing the '3'. room [ROOM NUMBER] was missing the '27'. room [ROOM NUMBER] was missing the '3'. room [ROOM NUMBER] was missing the '1'.
Based on observation, and interview, the facility failed to provide the services necessary to maintain a clean, sanitary, and homelike environment for multiple residents (R) in the sample, as evidenced by a dirty room for R16, multiple rooms on the third floor with part or all of the room numbers missing, and dirty shower equipment in use on the fifth and third floor. As a result of this deficient practice, the residents were placed at risk for a decreased quality of life. This deficient practice has the potential to affect all residents at the facility.
Findings include:
1) On 01/10/23 at 10:00 AM observation of the shower room across room [ROOM NUMBER] found a shower chair with metal framing encrusted with white and black substance. The metal frame under the seat and by the footrest appeared rusted. The commode bucket was observed with a few brown substances adhered to the side of the bowl. The nylon straps attached to the chair were wet. Observation in the shower room across room [ROOM NUMBER] found a shower gurney with two brown spots on the netting at the foot of the gurney.
On 01/10/23 concurrent observation and interview was done with the Unit Supervisor (US) 5 in the shower room across room [ROOM NUMBER]. The US5 lifted the blue seat and reported the substance on the frame is probably soap scum and mildew. US5 confirmed the metal framing and footrest were rusted. US5 left and returned with a blue plastic bag and covered the shower chair. She stated she wonders why the staff would use that shower chair when there was another shower chair that was in better condition. US5 stated the plan is to dispose of this chair.
In the shower room across room [ROOM NUMBER], US5 confirmed the brown spots on the shower gurney. US5 tried to wipe the spots; however, the substance did not come off. US5 surmised the spots were possibly mildew. The US5 also observed a white bath chair with reclined back with the plastic frame cracked around the wheel cap. Also observed a shower chair with white spots on the blue seat. The US5 attempted to wipe off the substance; however, was not successful. The US5 stated the white substance is probably a cream.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
2) Cross-reference to F697 Pain Management. The facility failed to develop a comprehensive care plan for pain management for Resident (R)55. As a result of this deficient practice, R55's pain was not ...
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2) Cross-reference to F697 Pain Management. The facility failed to develop a comprehensive care plan for pain management for Resident (R)55. As a result of this deficient practice, R55's pain was not adequately managed.
3) Cross-reference to F692 Nutrition/Hydration Status Maintenance. The facility failed to initiate a care plan to address significant weight loss identified and documented two months in a row for Resident (R)83. As a result of this deficient practice, R83 was placed at risk of continued unplanned and significant weight loss.
Based on observations, record review, and interview with staff members, the facility did not ensure that the development and implementation of comprehensive person-centered care plans were done for three of 27 residents (Residents (R) 86, R55, R83) in the sample. Specifically, a resident identified with significant weight loss for two consecutive months had no care plan to address it. A resident with liver cancer who was admitted to Hospice for end-of-life care had no care plan to manage her pain. Activity care plans were not developed to include person-centered interventions that would engage the resident in meaningful activities. As a result of this deficient practice, these residents were placed at risk for a decline in their quality of life, and were prevented from attaining their highest practicable physical, mental, and psychosocial well-being. This deficient practice has the potential to affect all the residents at the facility.
Findings include:
1) Multiple observations (01/09/23 at 08:58 AM, 09:45 AM, 11:45 AM, 12:35 PM, 3:06 PM; 01/10/23 at 09:05 AM, 12:03 PM, 12:54 PM; 01/11/23 at 09:00 AM, 10:13 AM, and 3:05 PM) of R86 in bed without music, television, or engaged in any planned activity other than the care provided by staff. On 01/10/22 at 09/05 AM, during an interview R86 stated he/she does not attend group activities outside of the room, does not listen to music regularly, and answered yes when this surveyor asked if he/she was bored just lying in the room.
On 01/10/23 at 1:14 PM, conducted a review of R86's Electronic Medical Record (EMR). R86 has diagnoses that include end stage renal disease with dependance on renal dialysis, diabetes mellitus, and acquired absences of the right and left leg below the knee. An annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/21/22 documented R86 had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. Review of Section G. Functional Ability documented R86 is totally dependent (full staff performance every time) for bed mobility (how the resident moves to and from lying position, turns side to side), transfer (how the resident moves between surfaces), locomotion on/off the unit, dressing, eating, toilet use, and personal hygiene (combing hair, brushing teeth, wash/dry hands etc). Review of R86's care plan (CP) documented an activity care plan was not developed for the resident.
On 01/10/23 at 1:20 PM, conducted a review of R86's hard chart on the unit. A therapeutic recreation progress note (completed on 03/30/22) documented the recommendations for activities identified R86's Need for social support. Staff will do check in 1:1 visits 2-3 times a week for socialization.
On 01/10/23 at 1:25 PM, conducted a concurrent record review (R86's EMR and hard chart) and interview with Nursing Staff (NS)4. NS4 confirmed an activity CP was not developed for R86 and it should have been developed. NS4 could not identify the activities R86 is involved in the activity and if the activities provided is consistent with R86's interest with measurable objectives and timeframes to meet R86's need for social support.
On 01/10/23 at 3:10 PM, conducted a concurrent interview and concurrent record review with Recreational Activity staff (RA)1 and RA2 regarding R86's activities. RA1 and RA2 reviewed R86's CP and confirmed and the activity CP was not developed for the resident despite RA1 providing 1:1 activity for the resident.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the staff was competent in performing qua...
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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 staff was competent in performing quality control (QC) testing for the blood glucose meter. The QC solutions that were used for QC testing expired (as indicated by the manufacturer's expiration date) before the date the vials were opened. QC testing of the glucose meter verifies that precision of residents' glucose test results. As a result of this deficient practice, the facility placed all residents that need glucose testing at risk for potential harm as their medical care is dependent on precise glucose test results.
Finding includes:
On [DATE] at 09:40 AM, observed a box of QC solution with two vials inside that had a manufacturer's expiration date of [DATE] in the medication cart. Lot numbers for the vials were: 015921A for the normal level and 100720A for the high level. Handwritten on the box was the open date of [DATE] with a 90-day expiration date of [DATE]. No other box of control solutions were found in the cart. Expiration dates and lot numbers were confirmed with Registered Nurse (RN)10, and she confirmed that they should not be in the medication cart.
On [DATE] at 10:36 AM, reviewed Glucose Quality Control Form for [DATE] and [DATE]. Forms showed that lot number 051921A for normal level and lot number 100720A for high level with an open date of [DATE] and expiration date of [DATE] were being used for QC testing. On the form below the open and expiration dates field it stated: *Expiration date is 90 days from the date of opening OR the original expiration date, whichever is earlier.
Review of the facility's policy and procedure for Blood Glucose Monitoring Using the Assure Platinum, policy number 01-01-16 with an effective date of [DATE] stated for frequency of changing test or QC material, The vials of test strips and the vial of quality control are good for 90 days after opening. Once 90 days have been reached, or the original expiration date, you must discard the test strips and quality control material and use new ones. Failure to do so can result in inaccurate readings from the Assure Platinum meter.
On [DATE] at 11:30 AM, interviewed the Nurse Educator (NE). NE confirmed that the staff completed the glucose meter training, which includes how to perform QC testing, from April to [DATE].
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to promptly provide or obtain from their dental consultant, routine dental services to meet the resident's needs. This deficient...
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Based on observation, interview, and record review, the facility failed to promptly provide or obtain from their dental consultant, routine dental services to meet the resident's needs. This deficient practice has the potential to affect all residents currently residing in the facility.
Findings include:
On 01/09/23 at 09:29 AM, observations were done at the bedside of Resident (R)83. R83 was observed sleeping in her bed and appeared to have no teeth.
On 01/10/23 at 09:44 AM, during a review of R83's electronic health record (EHR), it was unclear when her last routine dental exam/assessment had been done. No dental consults or exams were documented although there was a physician order from 10/11/22 that stated, dental consult on admission and annually.
On 01/10/23 at 02:20 PM, an interview was done at the third-floor Nurses' Station (NS) with Unit Clerk (UC)3, Registered Nurse (RN)38, and Licensed Practical Nurse (LPN)1 present. All confirmed that the facility contracted Dentist had not come in to do routine dental exams since the COVID-19 pandemic began in 2020. UC3 reported that he has responded to calls for acute dental visits, but those are few and far between.
On 01/11/23 at 09:51 AM, after finding conflicting information documented in R83's EHR regarding her dental status, an interview was done with LPN1 at the third-floor NS. LPN1 confirmed that R83 has none of her own teeth left and has no dentures, which impacts her intake and creates a challenge for preventing unplanned weight loss.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Administration
(Tag F0835)
Could have caused harm · This affected multiple residents
Based on record review and interview with staff members, the administration failed to provide support effectively and efficiently to the facility and staff members to ensure residents attain or mainta...
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Based on record review and interview with staff members, the administration failed to provide support effectively and efficiently to the facility and staff members to ensure residents attain or maintain their highest practicable physical, mental, and psychosocial well-being. The facility failed to ensure all areas of the facility's Plan of Correction (POC) were corrected and/or worked toward compliance by the corrective action date the facility chose, 02/28/23.
Findings include:
(Cross-reference to F791 Dental Services)
1) Review of the facility's POC documented for the deficient practice in Dental Services Dental services to be provided by the dental consultant was scheduled for all . residents. The Unit Clerks will schedule annual dental appointments for all . residents and submit the schedule to the Patient Care Coordinator by the 31st of January on an annual basis. The ADON/DON or designee will review and ensure that all . residents are scheduled for dental consults annually.
On 03/22/23 at 03:05 PM, conducted concurrent interview and record review (RR) with Director of Nursing (DON) and Assistant Director of Nursing (ADON). RR showed that dental services were scheduled for 01/28/23 for 3rd floor residents. Review of Resident (R) 83 and R209's medical records showed no documentation that a dentist saw or treated them. Further RR indicated the 3rd floor residents were not seen on the scheduled date, 01/28/23, nor rescheduled. The DON and ADON confirmed they had no current plan to correct this deficiency as they were unaware that 3rd floor residents were not seen or rescheduled.
2) Review of the facility's POC documented for the deficient practice in Sufficient Nursing Staff .R58 was assigned hourly rounding by .[facility] .staff.
On 03/22/23 at 10:06 AM interview and concurrent record review with Certified Nurse Aide (CNA) 13 was done. CNA13 reported nursing staff are to round every two hours for R58. Concurrent review of the rounding logs kept at the entrance, in front, of R58's room documents rounds every hours. Two rounding logs were reviewed for the dates 03/21/23 and 03/22/23, CNA13 confirmed only one time on each form was initialed and documented that rounding occurred. CNA13 reported there is another form inside R58's room that documents turning and positioning that may reflect how often rounding is done.
On 03/22/23 at 10:08 AM interview with Licensed Practical Nurse (LPN) 3 was done. LPN reported nursing staff are to round every two hours for R58. Inquired if R58 had hourly rounding in the last few months, LPN3 confirmed R58 never had hourly rounding.
On 03/22/23 at 10:09 AM interview and concurrent record review with CNA19 was done in R58's room. CNA19 stated nursing staff are to round every two hours, including turning and positioning for R58, but he sometimes refuses. CNA19 pointed to the turning and positioning log taped inside R58's room wall.
On 03/22/23 at 01:34 AM interview with ADON and DON was done. ADON stated nursing staff are to round hourly as documented in the POC and confirmed nursing staff are rounding every two hours instead of every hour and ADON did not ensure they POC was executed.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on interviews the facility failed to designate a registered nurse to serve as the director of nursing (DON) on a full time basis.
Findings Include:
During the entrance conference on 01/09/23 at...
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Based on interviews the facility failed to designate a registered nurse to serve as the director of nursing (DON) on a full time basis.
Findings Include:
During the entrance conference on 01/09/23 at 08:12 AM, Patient Care Coordinator (PCC)1 stated the facility currently does not have a DON effective 01/01/23 but the previous DON, Consultant Director of Nursing (CDON), was hired as a consultant.
On 01/11/23 at 3:26 PM interview with CDON was done. CDON stated she was supposed to work two days per week, a total of 16 hours a week, as a consultant DON.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observations, interviews, and record review, the facility failed to store food that was identifiable and/or had an expiration date and failed to provide a clean area to prepare food. This def...
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Based on observations, interviews, and record review, the facility failed to store food that was identifiable and/or had an expiration date and failed to provide a clean area to prepare food. This deficient practice has the potential to infect residents, visitors, and staff, who have meals served to them by the facility's kitchen, with a food-borne illness.
Findings include:
1) On 01/09/23 at 08:29 AM, an initial concurrent observation of the facility's kitchen and interview with the Kitchen Manager (KM) were done. The walk-in freezer contained a large metal pan covered with plastic wrap that had unidentifiable slabs of food. No label indicating the food contents or date was found on the plastic wrap. Kitchen staff (KS)15 was queried as to the food contents in the metal pan and KS15 stated that it was baked salmon from a few days ago. KM confirmed that the food contents in the large metal pan should have the name of the food contents and the date of expiry written on the plastic wrap covering the metal pan.
2) On 01/09/23 at 08:40 AM, continued concurrent observation and interview of the facility's kitchen with the KM. The food preparation area had a large, white covered container filled with a dry, white, powdery substance and a smaller, white covered container filled with dry, white, powdery material. No identifying labels of the contents were found on both containers. KM stated that the two containers are filled with food thickener and that the labels were inadvertently washed off when the buckets were cleaned. KM confirmed that there should be a label on the bins to identify its contents.
3) On 01/09/23 at 08:45 AM, continued concurrent observation and interview of the facility's kitchen with the KM. In the food preparation area, observed a small, black portable electric fan with dust, and a larger, white electric fan attached to the wall was dirty. KM confirmed that the fans were dusty and stated that the maintenance department is responsible for checking the fans every month and cleaning the electric fans as needed.
4) On 01/09/23 at 08:50 AM, continued concurrent observation and interview of the facility's kitchen with the KM. The food preparation area refrigerator contained a half gallon of milk that was not dated. An immediate query with kitchen staff (KS)20 was made. KS20 stated that she just opened the milk but forgot to write the date on the container before placing it into the refrigerator. KM stated that date was supposed to be written on the container once the container is opened and before it is placed into the refrigerator.
5) On 01/11/23 at 10:27 AM, conducted a follow up concurrent observation of the kitchen and interview with the KM. In the food preparation area, kitchen staff was cutting raw fish, with fish contained in a large container next to him. The small, black portable electric fan was pointed in the direction of the staff cutting the fish and the fan was noted to still be dusty. The larger, white electric fan attached to the wall was still also dirty. KM confirmed that the fans were still dirty. KM stated that she instructed KS20 to clean the small, black portable fan after the initial observation of it being dirty, but it was not done.
6) Reviewed the facility's policy on SAFE LABELING AND DISCARD GUIDELINES, POLICY NO: 11-J-10 dated 02/02/19. It stated, 1. All foods will be stored in its original packaging/container. Once removed or opened, item will be securely covered and labeled to identify item . and 2 .Once food is thawed, prepped, cooked or original container is opened, it will be dated with appropriate discard date.
On 01/12/23 at 12:00 PM, asked KM for a facility policy or procedure (P/P) on the cleaning or maintenance of electric fans in the kitchen and KM stated that she does not have that P/P for the kitchen, but will check the maintenance department for a P/P. No P/P for cleaning or maintenance of electric fans in the kitchen was received by the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0838
(Tag F0838)
Could have caused harm · This affected most or all residents
Based upon record review and interview with staff member, the facility failed to assure the facility assessment accurately reflected the resident and staffing ratios needed in the facility to ensure t...
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Based upon record review and interview with staff member, the facility failed to assure the facility assessment accurately reflected the resident and staffing ratios needed in the facility to ensure that the staffing resources met the needs of the resident population. The deficient practice affects all residents in the facility to maintain and attain the highest practicable physical, mental, and/or psychosocial well-being.
Findings include:
A review of the Facility Assessment Tool provided by the facility and approved by the Director of Nursing (DON) and Medical Director on 11/03/22. The assessment did not include nursing resources to meet the acuity of the facility's resident population.
The assessment documents the facility is licensed for 187 beds with an average daily census of 160 to 168 residents.
A review of the payroll base journal, noted the facility with low weekend staffing for Fiscal Year 2022, first quarter (October to December) and fourth quarter (July to September).
On 01/12/23 at 09:33 AM an interview was conducted with the Consultant Director of Nursing (CDON). CDON reported the staffing levels are dependent on the acuity of resident care. The aide to resident ratio for the day shift is one to seven for skilled nursing and one to nine/ten for intermediate care. However, if there is a need for one-to-one services, another staff member would be added. The staff to resident ratio for evening reportedly is the same as the day; however, may go up to one to 12 residents. The night shift is two to three aides for 40 residents (1:20 or 1:13 staff to resident ratio) with the goal for three aides for the night shift.
Inquired what may have attributed to the low weekend staffing. CDON reported that the payroll base journal does not include agency staff. CDON stated the facility has used four to five agency certified nurse aides and one licensed nurse. CDON further reported when there are call outs, staff members are mandated to stay another shift.
The CDON confirmed the staffing ratios were not included in the facility assessment. CDON reported the facility has another document for staffing and agreed to request PCC provide the document.
On 01/13/23, PCC provided a copy of the staffing matrix. The matrix is divided by skilled nursing services (provided on the 6th floor) and intermediate care services on the other floors. This matrix is not included in the facility assessment to reflect the acuity and needs of the residents admitted to this facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) On 01/09/23 at 0:54 PM interview with Resident (R) 9's family member (FM)1 was done. The FM1 requested the surveyors to check...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) On 01/09/23 at 0:54 PM interview with Resident (R) 9's family member (FM)1 was done. The FM1 requested the surveyors to check the shower chairs for mold and mildew, specifically the bottom of the seats. FM1 reported she used to scrub the shower chair R9 sits on because the facility did not clean and sanitize the chairs after use. FM1 stated, I think someone should be sanitizing the shower chairs and turn it upside down and scrub it.
On 01/10/23 at 10:06 AM observation of the central bath/shower room across room [ROOM NUMBER] found a total of three shower chairs. During observation of two white shower chairs, observed black substance on connecting parts of the frame and black substance covering the bottom of the seats of the chairs. One of the two chairs observed had black spots on the top of the seat. Further observation of the third shower chair was not done. Observation in the shower room across room [ROOM NUMBER], observed two of five shower chairs found. During observation of a blue shower chair with metal framing and a label date of August 2017 and a white chair located in the shower area, observed black substance on the bottom of the seat.
On 01/10/23 at 10:20 AM concurrent observation and interview with Certified Nursing Assistance (CNA) 35 was done. CNA35 explained after a resident showers, nursing staff take out the soiled linen used and spray the shower chairs with water after use. Inquired how the shower chairs are disinfected and sanitized after use, CNA35 stated the environmental services staff clean the shower and shower chairs in the afternoon. As CNA35 explained another nursing staff walks by after giving a resident a shower and the nursing staff stated environmental services cleans the shower chairs at around 1:00 PM. During a concurrent observation in the shower room across 311 of a white shower chair, observed black substance on the connecting parts and black dots on the top of the seat of the shower chair. CNA35 flipped the shower chair around and observed black substance covering the bottom of the seat. CNA35 reported the chair was dirty and the black substance looked like mold.
On 01/10/23 at 10:29 AM concurrent observation and interview with Environmental Services Supervisor (ESS) was done. ESS stated environmental services staff clean the shower rooms but they do not clean, disinfect, or sanitize the shower chairs. ESS reported the nursing staff are responsible for cleaning, disinfecting, and sanitizing the shower chairs between use. ESS explained nursing staff should be using grout cleaner and an antivirus cleaner and the Environmental Services Department provides the chemicals for use. During concurrent observation of the shower room across room [ROOM NUMBER] of the same white shower chair, ESS reported the black substance on the shower chair could be mold.
Review of the facility's policy and procedure on restroom cleaning reference #8027 revised on 02/2019, documents Shower Chairs/Stretchers are cleaned by nursing staff after each use.
On 01/12/23 at 08:05 AM interview with CNA75 was done. CNA75 confirmed nursing staff was not disinfecting and sanitizing shower chairs after use but were only spraying the shower chairs with water after use. CNA75 they were recently instructed to spray the shower chairs with hot water first and use disposable disinfectant/germicidal wipes between resident use.
3) On 01/09/23 at 10:57 PM during observation and interview with Resident (85), Registered Nurse (RN) 16 came into R85's room and requested if she could change R85's tube feeding formula. Observed RN16 wearing gloves and a face mask while changing the tube feeding formula, replace the tubing, and flush the gastrostomy tube (g-tube). RN16 was not wearing a gown. After providing tube feeding care, R85 was observed to use the suction machine himself and RN16 was then observed to change her gloves and assist R85 in oral suctioning. RN16 was not wearing a face shield and gown.
On 01/12/23 at 12:58 PM interview with Consultant Director of Nursing (CDON) was done. CDON stated when nursing staff are providing g-tube care such as flushing the g-tube they should be wearing a face mask, gown, and gloves. CDON further stated for nursing staff providing oral suctioning care because it is aerosol, staff should be wearing a face shield, face mask, gown, and gloves.
Based on observation, interview, and record review, the facility failed to ensure protective and preventive measures for COVID-19 and other communicable infections. Facility staff did not follow protocols for standard and transmission-based precautions (TBP); did not wear the proper personal protective equipment (PPE); did not thoroughly clean and sanitize shower equipment after use; did not ensure an indwelling catheter tubing was correctly stored, and did not clean hands between glove use. These deficient practices have the potential to affect all residents, healthcare personnel, and visitors at the facility.
Findings include:
1) On 01/09/23 at 09:05 AM, observed room [ROOM NUMBER] with a Droplet Plus sign. The sign described the PPE required for entering the room as: Gown, Gloves, Goggles [or face shield] & N95 mask [respirator] (if available) . At 09:10 AM, observed Certified Nurse Aide (CNA)8 enter the room without changing out her procedure mask for an N-95 respirator. At 09:19 AM, asked CNA8 about the N-95 respirator as she exited the room, CNA8 apologized and stated that she had forgotten to change her mask, but was aware that she should have done so. Confirmed with CNA8 that there were N-95 respirators in her size available in the top drawer of the PPE cart outside the room. At 11:07 AM, observed a Hospice staff member enter the same room, also without stopping to change out her mask for an N-95 respirator.
On 01/09/23 at 11:10 AM, observed a Droplet Precautions sign at the entrance of room [ROOM NUMBER], which listed the PPE required for entrance as: Mask. A concurrent review of the physician orders for Resident (R)95 in the room noted a 01/08/23 order for COVID 19 PCR [test] and flu pcr [sic] with reflex and droplet + precautions.
On 01/10/23 at 07:59 AM, an interview was done with Licensed Practical Nurse (LPN)1 at the third-floor Nurses' Station (NS). LPN1 reviewed the physician orders for R95 and confirmed that whoever had taken off the order had mistakenly put a Droplet Precautions sign on the door when it should have been a Droplet Plus sign. LPN1 then made the correction and placed a Droplet Plus sign outside the door of room [ROOM NUMBER].
On 01/11/23 at 11:15 AM, with the Droplet Plus sign still posted outside the door, observed CNA9 enter room [ROOM NUMBER] wearing a gown, gloves, and a procedure mask, but no N-95 respirator, goggles, or face shield. Two face shields were observed hanging outside the door above the PPE cart. An interview was done with LPN1 at this time, who validated that CNA9 did not have on the proper PPE. Observed LPN1 enter room [ROOM NUMBER] and correct CNA9. At 11:42 AM, observed CNA9 enter room [ROOM NUMBER] (also with a Droplet Plus sign outside the door) without switching out her procedure mask for an N-95 respirator. At 11:47 AM, an interview was done with CNA9 outside of room [ROOM NUMBER]. When asked what PPE were required for Droplet Plus precautions, CNA9 could not say, stating she was not sure. Walked CNA9 over to the Droplet Plus sign and asked her the same question. CNA9 hesitantly stated gown, gloves, face shield. When asked specifically about an N-95 respirator, CNA9 stated yes, I should have worn one, and confirmed that she was aware where to find them, that she had been fit-tested for one, and that the PPE cart outside the room had her specific respirator available. CNA9 also confirmed that she had entered both room [ROOM NUMBER] and 322 without wearing one.
6) On 01/09/23 at 10:27 AM, an initial observation was made of R259. R259's urinary catheter system tubing was touching the floor beneath her bed. R259 laid in bed with her eyes closed and did not arouse to verbal stimulation
On 01/09/23 at 1:13 PM, R259 was lying in bed with her eyes closed and did not arouse to verbal stimulation. R259's urinary catheter system tubing was noted to be touching the floor beneath her bed.
On 01/10/23 at 10:22 AM, R259 laid in bed with her eyes closed wearing tubing in her nose (nasal cannula) delivering oxygen from the wall connection while she received medication intravenously (IV). R259's urinary catheter system tubing touched the floor beneath her bed.
On 01/11/23 at 08:59 AM, R259 was lying in bed wearing with the nasal cannula to deliver oxygen and responded to verbal salutation. Her urinary catheter system tubing touched the floor beneath her bed.
On 01/11/23 at 2:37 PM, a concurrent observation and interview were done with Registered Nurse (RN)10 of R259's about urinary catheter system. R259's urinary catheter tubing was touching the floor beneath her bed and RN10 stated that it shouldn't be touching the ground due to possible contamination. RN10 raised R259's bed so that the urinary catheter tubing would not touch the floor.
On 01/12/23 at 10:33 AM, conducted an interview with the Nurse Educator (NE). NE stated that during the initial orientation and with annual competency checks, the CNAs are educated on the care of urinary catheter systems. CNAs are taught to make sure that the catheter tubing does not touch the floor as an infection control measure to prevent urinary tract infections.
7) On 01/12/23 at 10:00 AM, observed Registered Nurse (RN)10 perform R259's dressing change of her pressure injury on her buttocks. RN10 changed her gloves several times between dirty and clean tasks, but did not hand sanitize after removing her dirty gloves and donning on clean gloves.
Reviewed KGC Infection Control Plan, policy number 01-06-01, date 12/11/19. It stated, .5. Monitoring and improving hand hygiene compliance a. Policy number 01-06-11 on hand hygiene describes indications, techniques, and products for hand hygiene. Personnel are educated regarding hand hygiene requirements. It is based on the CDC [Centers for Disease Control and Prevention] guideline.
Reviewed CDC's Hand Hygiene Guidance from the web address: https://www.cdc.gov/handhygiene/providers/guideline.html and it stated, .Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications .Immediately after glove removal.
4) On 01/10/23 at 10:00 AM observation and interview were done with the Unit Supervisor (US)5. In the shower room across room [ROOM NUMBER] there was a shower chair with white substance on the blue seat. US5 was asked what the white substance on the seat is. US5 replied if it is powder, it would have been rinsed off with water. US5 stated it is probably cream. Inquired who sanitizes the shower chairs, US5 responded the Certified Nurse Aides (CNAs) would use sani wipes between use then housekeeping would clean the shower chairs at the end of the day.
Further queried if is cream on the seat, shouldn't the seat be cleaned and sanitized to remove the residue from application to the previous resident . US5 responded cream remnants should be cleaned off. In the shower room across room [ROOM NUMBER], observed another shower chair with white substance/cream on the blue seat.
5) On 01/09/23 at 08:40 AM on initial tour of the unit, entered Resident (R)71's room to make observation and screen the resident. At 11:25 AM observed staff member remove R71's tray from the cart. The staff member went down the hall to deliver the lunch tray. The staff member returned to the cart, observed there was a paper tray atop the plastic tray. The paper tray was removed from the plastic tray. R71's lunch was served on a paper tray. The staff member was asked why the resident's lunch was on a paper tray, the staff member deferred to the US. US5 was asked why the resident's food was on a paper tray. US5 responded she did not think the kitchen staff are aware R71 is no longer on infection control precautions and would inform the kitchen.
On 01/09/23 at 2:24 PM observed signage was posted by R71's door. The sign was titled Modified Precautions and there was a white plastic container with drawers placed under the sign. The sign documented: Step 1: Clean your hands before putting on personal protective equipment (PPE) and after removing PPE. If PPE not warranted, perform hand hygiene before and after resident information; Step 2: PPE needed: Gown and gloves ONLY with activities that have a higher transmission risk (wound care, toileting, bathing, changing clothes or linen, extensive physical contact). If in the event, PPE is available in the room to put on before high transmission risk interaction. Remove PPE before leaving the room.; Step 3: Use patient-dedicated or single-use disposable equipment or clean and disinfect shared equipment with disinfectant wipes.
Interviewed Registered Nurse (RN)8. He reported R71 is on modified precautions due to colonization of ESBL.
On 01/12/23 at 09:30 AM an interview was conducted with CDON. Inquired why R71 is on Modified Precautions. CDON reported R71 was on the red zone so disposable utensils should have been long discontinued. CDON clarified R71 is on modified precaution as her urine is not clear, she is colonized, has an MDRO. CDON stated the signage and cart were probably mistakenly removed during cleaning as staff thought R71 was no longer on precautions.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0886
(Tag F0886)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to thoroughly conduct COVID-19 testing following the identification of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to thoroughly conduct COVID-19 testing following the identification of a direct-care staff member and a resident diagnosed with COVID-19 in the facility. As a result of this deficient practice, the facility placed the residents at an increased risk of COVID-19 transmission. This deficient practice has the potential to affect all residents in the facility, as well as all healthcare personnel, and visitors at the facility.
Findings include:
On 01/12/23 at 10:06 AM, an interview was done with the Consultant Director of Nursing (CDON), who also served as the only certified Infection Preventionist for the facility, in room [ROOM NUMBER]. Regarding COVID-19, the CDON reported that the facility had last experienced an outbreak in December of 2022 with outbreak testing beginning on 12/16/22. When asked to describe the facility's process for outbreak testing, the CDON stated that the facility practice was to do broad-based or mass testing (as opposed to contact tracing). While reviewing the documentation of COVID-19 tests conducted during the outbreak, observed that not all residents of the facility were tested despite ongoing transmission and the use of float pool and agency staff throughout the outbreak. The CDON confirmed that only the residents who were symptomatic or resided on the fifth floor (where the outbreak was identified), were included in the broad-based testing. When asked why all residents wouldn't be included in the broad-based testing, especially since the facility had staff that floated and/or rotated between floors, the CDON responded, We're not going to test the whole building when they're asymptomatic, and we only have a handful of staff that float.
On 01/12/23 at 02:30 PM, the facility COVID-19 Policy and Procedure, last updated 09/28/2022, was reviewed. The following was noted regarding Outbreak Testing:
Test all staff and residents in response to an outbreak (defined as any single new COVID-19 infection in staff or any nursing home onset COVID-19 infection in a resident).
A concurrent review of a staff list provided by the facility noted sixteen staff members identified as part of the float pool.
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
- • 21% annual turnover. Excellent stability, 27 points below Hawaii's 48% average. Staff who stay learn residents' needs.
Concerns
- • Multiple safety concerns identified: 2 life-threatening violation(s), Special Focus Facility, 1 harm violation(s), $117,550 in fines, Payment denial on record. Review inspection reports carefully.
- • 55 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $117,550 in fines. Extremely high, among the most fined facilities in Hawaii. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility is on CMS's Special Focus list for poor performance. Consider alternatives strongly.
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About This Facility
What is Kuakini Geriatric Care, Inc's CMS Rating?
CMS assigns KUAKINI GERIATRIC CARE, INC an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Hawaii, 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 Kuakini Geriatric Care, Inc Staffed?
CMS rates KUAKINI GERIATRIC CARE, INC's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 21%, compared to the Hawaii average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Kuakini Geriatric Care, Inc?
State health inspectors documented 55 deficiencies at KUAKINI GERIATRIC CARE, INC during 2023 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, and 52 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 Kuakini Geriatric Care, Inc?
KUAKINI GERIATRIC CARE, INC is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 187 certified beds and approximately 115 residents (about 61% occupancy), it is a mid-sized facility located in HONOLULU, Hawaii.
How Does Kuakini Geriatric Care, Inc Compare to Other Hawaii Nursing Homes?
Compared to the 100 nursing homes in Hawaii, KUAKINI GERIATRIC CARE, INC's overall rating (1 stars) is below the state average of 3.4, staff turnover (21%) is significantly lower than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Kuakini Geriatric Care, Inc?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.
Is Kuakini Geriatric Care, Inc Safe?
Based on CMS inspection data, KUAKINI GERIATRIC CARE, INC 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 is currently on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes nationwide). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Hawaii. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Kuakini Geriatric Care, Inc Stick Around?
Staff at KUAKINI GERIATRIC CARE, INC tend to stick around. With a turnover rate of 21%, the facility is 24 percentage points below the Hawaii average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly. Registered Nurse turnover is also low at 26%, meaning experienced RNs are available to handle complex medical needs.
Was Kuakini Geriatric Care, Inc Ever Fined?
KUAKINI GERIATRIC CARE, INC has been fined $117,550 across 3 penalty actions. This is 3.4x the Hawaii average of $34,254. 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 Kuakini Geriatric Care, Inc on Any Federal Watch List?
KUAKINI GERIATRIC CARE, INC is currently an SFF Candidate, meaning CMS has identified it as potentially qualifying for the Special Focus Facility watch list. SFF Candidates have a history of serious deficiencies but haven't yet reached the threshold for full SFF designation. The facility is being monitored more closely — if problems continue, it may be added to the official watch list. Families should ask what the facility is doing to address the issues that led to this status.