Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, and record review, the facility failed to ensure routine and 24-hour emergency dental care was provided or obtained from an outside resource to meet the needs for one of one resident (Resident (R) 55) reviewed for dental care out of 30 sampled residents resulting in significant weight loss. The facility failed to provide prompt dental services to a resident with identified dental pain by ensuring dental services were properly and timely arranged and completed to ensure continuity of care was provided to the resident. Findings include: Review of R55's Face Sheet located in the resident's electronic medical record (EMR) Face Sheet tab revealed the resident was admitted to the facility on [DATE] with diagnoses that included left and right hip contracture, right knee contracture, congestive heart failure, and adjustment disorder with anxiety. Review of R55's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/24/24 located in the resident's EMR under the MDS tab indicated the facility assessed R4 to have a Brief Interview for Mental Status (BIMS) score was eight out of 15, indicating R55 was moderately cognitively impaired. The MDS also indicated R55 was on a regular textured diet and had no dental concerns. Review of R55's Care Plan, last revised 12/05/23, indicated the resident had the potential for acute pain related to a history of fractures. The interventions included to administer analgesia .as ordered, to monitor and document for probable cause of each pain episode, to monitor/record/report to nurse any signs or symptoms of non-verbal pain, loss of appetite, refusal to eat and weight loss, and to notify the physician if interventions were unsuccessful or if current complaint was a significant change from the resident's past experience of pain. The care plan failed to identify changes in dental pain. Review of R55's Care Plan, dated 02/22/24, without revision in the EMR under the Care Plan tab, indicated the resident had an unplanned/unexpected weight loss related to poor food intake. The interventions included alerting the dietitian if consumption was between 0-25% for more than 48 hours, monitoring and evaluating any weight loss. The care plan failed to identify a decline due to dental concerns. Review of R55's Nursing Progress Notes, dated 07/24/24, revealed the resident complained of tooth pain, upon assessment the resident was noted with decay at left molar/tooth chipped. The Nurse Practitioner was made aware, and a new order was made for Anbesol as needed and 360 dental consult. The family was notified. Review of R55's Physician's Order and Signature Sheet, dated 07/29/24, documented a dental consult-left lower tooth pain/decayed tooth. Anbesol every 2 hours as needed for tooth pain. Review of R55's Nursing Progress Notes, dated 07/30/24, [He/She] was medicated this afternoon for complaint of dental and LE [lower extremity] pain with prn [as needed] Norco with good effect. An additional note stated Anbesol was applied for tooth pain. Review of R55's Nursing Progress Notes, dated 07/30/24, revealed to follow-up with 360 dental related to dental pain and decay one time only on 07/31/24 .360 not here today. Review of R55's Physician Progress Note, dated 08/01/24, revealed Patient seen for follow-up today. Patient complaining of toothache. Has not been eating very well because of dental pain. Dental pain likely secondary to tooth infection. Will treat with a course of Augmentin. Review of R55's Nursing Progress Notes, dated 08/01/24, revealed the resident complained of left lower gum pain related to left lower molar and that resident was scheduled to see 360 dental group on 08/14/24. The resident was medicated with as needed Norco for pain and also topical analgesic for left molar gum pain. The resident stated he/she could not eat her lunch related to dental pain. He/She was given a soft sandwich and ordered a mechanical soft diet. Review of R55's Nursing Progress Notes, dated 08/02/24, revealed the resident had complained of .lower molar pain, to see a new order for Augmentin (antibiotic) and resident had a pending dental consult. Review of R55's Nursing Progress Notes, dated 08/03/24, revealed .left lower dental pain. He/She declined her lunch. He/She is due to see the 360 dental on August 14th. Review of R55's Dietitian Progress Notes, dated 08/07/24, revealed Resident has mouth pain due to dental issues. Her meal intake is 0-50% currently. He/She has not wanted to eat since the pain started. He/She is on an antibiotic for the tooth. HIs/Her diet was also downgraded to Soft with Ground Meat due to the dental pain. Will upgrade diet as soon as dental issue has been resolved. Review of R55's Nursing Progress Notes, dated 08/11/24, revealed the resident completed prescribed antibiotics on 08/10/24. Review of R55's Summary Report, dated 08/14/24, also documented that the 360 dental group had Not Seen Resident was not seen due to time constraint. Review of R55's Nursing Progress Notes, dated 08/20/24, revealed the resident was scheduled to be seen by 360 dental group on 08/14/24 but was not seen due to time constraints. Review of R55's Dietitian Progress Notes, dated 08/22/24, revealed [His/Her] diet is Soft with Ground Meat due to dental pain currently. Resident wants to continue with this diet. HE/She had also taken Augmentin for the dental discomfort . Annual Dietary Evaluation: Height 62 inches. Weight 138.2 # (pounds). July weight was 145 # (pounds). Resident has had a 5% weight loss in one month. Review of R55's Plan of Care Note, completed by the MDS Coordinator (MDS) on 08/23/24, revealed Then when this nurse performed an oral assessment she pointed to her bottom left tooth in the back and stated it hurts. He/She rated her worst pain as a 10 and stated it rarely affects her sleep or activities. Review of R55's Nursing Progress Notes, dated 08/27/24, revealed, pain to bilateral knees and tooth .medicated for c/o [complaint of] tooth pain .tooth pain to lower gumline. Review of R55's Nursing Progress Notes, dated 08/28/24, revealed .lower tooth pain .c/o pain and discomfort to left lower tooth. Review of R55's medical record failed to identify any ongoing communication or attempt by the facility to resolve the resident's dental concern after antibiotic medication was completed on 08/10/24, the resident was not seen by the 360 dental group on 08/14/24 and continued to be in documented pain without resolution. Review of R55's medical record failed to identify any follow-up or communication with the family or outside resources to provide dental care in the community to address the acute change in condition in a timely manner. During an observation and interview on 08/27/24 at 11:04 AM, R55 stated he/she had dental pain and was supposed to see the dentist at the facility on 08/30/24. He/She said they were receiving pain medication and gel for the dental pain. He/She was observed touching and rubbing the left side of her lower jaw, grimacing, during the interview. During an observation and interview on 08/28/24 at 12:40 PM, R55 was observed in his/her room with their lunch tray placed in front of them on their bedside table, untouched. His/Her meal ticket revealed they was on a Soft diet. He/She said that they were uncomfortable and did not want to eat because he/she had tooth pain. He/She stated that they did not understand why they had not seen the dentist yet. He/She was again observed holding and rubbing the lower left side of his/her jaw while they grimaced in pain. During an observation and interview on 08/29/24 at 11:25 AM, R55 stated they had pain in her tooth, especially when their tongue touched it. R55 said that they needed to be seen by a dentist, because they had enough wrong already without the tooth pain. He/She was again observed rubbing and holding their lower left jaw while grimacing. During an interview on 08/28/24 at 12:44 PM, the Admissions Coordinator (ADM) stated that the facility nursing staff would go to the Medical Records/Scheduling (MR) if a resident needed an appointment with dental. During an interview on 08/28/24 at 12:50 PM, the Medical Records/Social Services (MR/SS) said that the facility had been trying to get R55 seen by a dentist. She stated that the facility used a dental group called 360 that had been in to see residents recently, and that the dental group would have a list of residents they intended to see when they arrived. The MR/SS confirmed that R55 was not seen by the dental group on the most recent visit in August. She stated that if the dental group documented that they could not see a resident due to a time constraint it was because the dental group had other facilities to go to. She said that she had contacted the resident's family member during this current week to determine who R55 had seen for dental care in the community prior to admission, but still needed to contact that dental provider to see if they could see the resident. During a subsequent interview on 08/28/24 at 1:27 PM, the MR/SS stated that she had just spoken to Accounting (AC) and R55 would not qualify for dental services by the 360 dental group until September 2024, so there should not have been any documentation of 360 dental group coming in to see the resident. During an interview on 08/28/24 at 2:00 PM, Geriatric Medication Assistant (GMA) said that she was familiar with R55. She confirmed that the resident had been complaining of lower left tooth pain for a few weeks. She stated that the resident had a darkened tooth that appeared to be broken and decayed. The GMA said that the resident had been prescribed antibiotics for the tooth because they thought it might be an infection. He/She stated that the resident had finished their antibiotics a while ago and still had the pain. He/She said that the resident still had a problem, and not just an infection. He/She stated the resident had a tough time eating because of it, and that nurses often had to provide the resident pain medication for the problem. The GMA was not aware if the resident had been seen by a dentist yet or not. During an interview on 08/28/24 at 2:40 PM, the AC said that R55 did not have coverage with the 360 dental group, and that the resident's representative had come into the facility on [DATE] to sign the application so that they could be seen with the dental group. She said the resident would not be covered until the following month and would not have been qualified to be scheduled to be seen by 360 dental group in August 2024. The AC said that the Medical Records/Scheduling (MR) should have known that R55 could not been seen by the 360 dental group by the middle of August 2024. She was not aware of why documentation continued to show the R55 was going to be seen by this dental group. During an interview on 08/28/24 at 3:22 PM, the MR said that she handled scheduling and transportation for residents. She said that nurses let her know who needs an appointment. She stated that for dental needs, she would look on her list to see if the resident was on the 360 dental group list and if they were not, she would try to find out who the resident used to see in the community and try to connect them back to that old dentist. The MR stated that the 360 dental group usually contacted her with a list of residents they would be seeing on their next visit, which she would then place at the nurse stations to let staff know who is going to be seen. She said that the facility also had a wheelchair van and Medicare transportation that they could use to send residents out for dental appointments. She stated that if a resident had an acute dental need, she would let a dentist know as soon as possible so they can be seen but could not recall any residents recently having an acute situation. The MR said that she had not been working when R55's tooth became a problem, but when she returned on 08/12/24 she found out the resident had not qualified to be seen by the 360 dental group until 09/01/24. She stated that she had been told that sometimes the resident had pain and sometimes she did not, so she did not feel it was urgent to get her seen acutely. She said that in morning meetings she was told that the resident was not being seen by the dentist. The MR said that on 08/27/24 she found out that the delay in dental care needed to be pursued by communicating with the family. She confirmed that she was not aware that the resident was in that much pain. During an interview on 08/28/24 at 3:45 PM, the Director of Nursing (DON) said that the facility had 360 dental group come to the facility to see the Medicaid and private pay residents that wanted to be seen. She said they generated a list, and if a resident had complaints, they put them on the list, too. The Director of Nursing said that the Attending Physician was made aware of anything unusual. She said that if the resident was not on the 360 dental group list they would send the resident to the community for dental services. She said that R55's dental concern was a new problem and that she had been complaining about her pain. She confirmed that the resident had been on antibiotics and that they thought she was supposed to be seen by the 360 dental group when they came in recently, but they left the facility without seeing her. She stated that the resident had a cavity and needed to be seen. She said that the family was involved, and that the facility was giving the resident medication for tooth pain. The Director of Nursing confirmed that if a resident had dental pain the facility would try to get them in right away, and not hold off on treatment. During an interview on 08/28/24 at 4:05 PM, Licensed Practical Nurse (LPN) 1 said that R55 had told her that part of the resident's tooth had broken off a while ago, and that she had dental pain. LPN1 said that she had been under the impression that R55 was being seen by a dentist, and did not realize the resident still had not been seen. She said that R55 received Tylenol, Norco, and Tramadol as needed for the dental pain, including in the last few days. The LPN1 said that the resident had been prescribed antibiotics, which she assumed was to be administered so that he/she could be seen afterwards for a dental procedure. During an interview on 08/29/24 at 10:22 AM, the DON confirmed that the facility did not have a policy that addressed dental concerns. During an interview on 08/29/24 at 10:31 AM, the Registered Dietitian (RD) stated that R55 had a problem with their tooth. She said it was giving the resident pain. The RD said that she believed that the facility was trying to get the resident a dental appointment since they had not been qualified to see the 360 dental group. She said that the resident's diet had been downgraded because of the dental pain, and that the resident needed to be seen to address the tooth pain. The RD said R55 had regular pain concerns, but the tooth pain was a new concern. She said that she hoped that after the resident was seen by a dentist, she could get her back onto a regular diet so she could continue to eat. The RD confirmed that the resident had lost weight during this time. She confirmed that the confusion in getting the resident seen by a dentist for dental pain had delayed in R55 getting seen promptly. During an interview on 08/29/24 at 11:10 AM, the Minimum Data Set Coordinator (MDS) said that R55's bottom tooth was bothering them, and he/she was supposed to see the 360 dental group when they came in, but they did not get to see them. She stated that she had observed the tooth to be discolored, and that the resident had complained of tooth pain after she had looked in R55's mouth. During an interview on 08/29/24 at 11:56 AM, the Attending Physician stated that the facility had 360 dental group come into the facility to see residents, but that the dental group had not seen the resident in August 2024 due to an insurance or something. He stated that he had prescribed R55 antibiotics early on with the plan of then seeing the dentist. The Attending Physician confirmed that he would have expected the resident to have been seen by a dentist by now. During a phone interview on 08/29/24 at 12:17 PM, a resident representative for R55 said that the facility had contacted her this current week to see who the resident had seen for dental care in the past. She said that the resident had broken her tooth, and that it had been going on for over a month. She stated that she thought R55 was going to be seen by the '360 dental group approximately August 14. The resident representative stated that the dental concern should be addressed sooner rather than later. During an interview on 08/29/24 at 3:52 PM, the Administrator said that the facility used 360 dental group for residents. She said that if a resident needed to be seen by a dentist, MR and/or MR/SS did the paperwork. The Administrator stated that if a resident needed dental emergency services, they could get it done because they did not let anyone stay in pain.

Based on resident interview, staff interview, clinical record review, and a review of the facility abuse investigation it was determined that the facility staff failed to ensure residents were free from abuse (#36). This was evident for 1 out of 2 residents reviewed for a reportable incident. The findings include: A review of Resident #36's clinical record and the facility investigation revealed that the resident alleged to the Assistant Director of Nursing (ADON) and to the Administrator that geriatric nursing assistant (GNA) #23 had used a dry towel to apply lotion to his/her face and nose. The resident complained during the facility investigation that the towel was rough, and it hurt. The resident further informed the facility during their investigation that GNA #23 then shoved the towel in the resident's mouth. The resident was quoted during the facility investigation stating: He hurt me. I thought a tooth had broke. A review of the facility clinical record revealed that the resident was assessed. A review of a nursing note written on 4/18/19 noted: Redness and scratch marks were on the resident's face. Redness and bumps on nose and left cheek. Redness under chin. No sign of a broken tooth. Acetaminophen (an analgesic) was administered as a result. A review of the resident's clinical record revealed that the resident stated that he/she did not want any new medications as a result of the incident but did agree to receive acetaminophen to treat facial pain. The Sheriff's office was called at 12:15 PM on 4/18/19 and a deputy responded by 1:40 PM. He talked with the resident who had made the allegation. The resident did not want charges against the employee filed. The ADON and the Administrator talked with the staff member. He did not deny what the resident had alleged. The employee was terminated immediately on 4/18/19. A mandatory in-service was held with other facility employees. The family was notified at 1:15 PM on 4/18/19, primary physician was notified at 1:30 PM on 4/18/19, and the Ombudsman was called at 1:50 PM on 4/18/19. The Administrator was interviewed on 6/12/19 at 9:04 AM. She confirmed the preceding information. Stated that the resident did not want to press charges. She said GNA #23 admitted to the incident and told her that his career would be over. Resident #36 was interviewed on 6/12/19 at 10:34 AM. The resident said, Well, he was giving me a bath, he then did his usual habit of getting a cold bottle of lotion and dripped it on my body, he got me a towel, I complained about it and asked why he does this. He replied something like 'I don't know why'. GNA then jumped on bed and rubbed towel on my face. He then shoved the towel down my mouth. I haven't seen him since. Whenever I look out the window I wonder if he is in the parking lot. GNA said in the past that he owns two pistols. Told him I can get him fired and he replied that he didn't care. 'I can get a job anywhere'. He was a nasty [expletive]. He often left room with his shoes untied. GNA said he was too lazy to tie his shoes. Resident said he/she had a sore mouth and a sore on the tip of the nose as a result. GNA #10 was interviewed on 6/12/19 at 3:40 PM. She said a staff member told her that the resident was complaining about GNA #23 and she went in to see the resident. The resident's face was red and had scratch marks on it. She stated she asked the resident what happened, and he/she said GNA #23 rubbed his/her face real hard and felt like he/she was being pushed down. Resident then alleged that it felt like the towel was being pushed into his/her mouth. Prior to this incident the resident said GNA #23 would pour the shampoo directly on the resident rather than on a towel. She confirmed that the marks were not on the resident prior to the incident. GNA #10 said she reported it to the Administrator who interviewed the resident immediately and the story did not change. RN #11 was interviewed on 6/13/19 at 8:20 AM. She said she recognized the resident's face was red and the resident was out of bed in his/her chair. The resident's face was fine that morning. The resident had red bumps on his/her face. She went to the nurse and asked if she knew what happened. The nurse immediately went to the room. She could not remember who told the Administrator. The resident told her that GNA #23 was rough with him/her. It was just the two of them. No other staff was present. She said they did not get along. RN#11 indicated the resident stated he/she not care for GNA #23 but would not say why.

Based on a facility reported incident, review of a medical record, and staff interview, it was determined that a facility staff member failed to follow a resident's care plan to prevent the resident from sustaining a laceration to the leg which required laceration repair. This occurred for 1 (Resident #50) of 8 residents reviewed for accidents during an annual recertification survey. The findings include: Review of facility reported incident MD00134122 on 06/10/19 revealed an allegation Resident #50 sustained a laceration to the right lower leg during a transfer on 11/25/18. Review of Resident #50's medical record on 06/10/19 revealed Resident #50 had a history of a right fractured femur and was totally dependent upon staff for all of his/her care. Resident #50 was also noted to be at risk for non-pressure related skin impairment (skin tears) related to poor safety awareness. On 11/01/18 at 8:10 AM, Resident #50 suffered a skin tear to the right lower leg while being transferred from the bed to his/her wheel chair. Resident #50's injury was cleansed with normal saline and steri strips were applied. A review of the facility investigation into Resident #50's 11/01/18 right lower leg skin tear revealed that two staff were present The facility staff also conducted a post incident care plan review on 11/01/18 and determined that the nursing staff should start using a mechanical lift along with the use of two staff members when transferring Resident #50 from the bed to the wheel chair. Medical record review on 6/10/19 verified that the nursing staff updated Resident #50's care plans to include this new intervention, and updated the geriatric nursing assistants care guide on 11/01/18. In an interview with geriatric nursing assistant GNA #13 on 06/12/19 at 5:37 PM, GNA #13 stated she recalled transferring Resident #50 from the bed to the wheel chair with GNA #14. GNA #13 stated that s/he and GNA #14 each lifted Resident #50 under his/her arms and pivoted Resident #50 into his/her wheel chair. GNA #13 stated that s/he was not aware that Resident #50 had a cut on his/her leg during the transfer. GNA #13 stated that s/he was aware Resident #50 had delicate skin and that Resident #50 must have scratched his/her leg on one of the wheel-chair leg rests during the transfer. Further review of Resident #50's medical record revealed that on 11/25/18 at 7:11 AM, Resident #50 sustained another skin tear to the right lower leg during a transfer. A review of the facility investigation indicated Resident #50 sustained a skin tear to the right lower leg when being transferred from the bed into the wheelchair by GNA #16 while using a stand pivot transfer. Resident #50 was subsequently sent to the local hospital emergency room and was diagnosed with an 8 cm (centimeter) long by 5 cm wide skin tear. Resident #50's right lower leg wound was also diagnosed with a 3 cm laceration. The emergency room staff performed a laceration repair of the right lower extremity. The facility investigation indicated GNA #16 inappropriately transferred Resident #50 by himself/herself using a stand pivot transfer which resulted in Resident #50 sustaining the skin injury to his/her right lower leg. In an interview with GNA #16, on 06/12/19 at 4:22 PM, GNA #16 stated that s/he was not aware Resident #50 required the use of a mechanical lift and the use of two staff members when being transferred from the bed to the wheel chair. GNA #16 stated s/he was not aware of the policy change at the time. GNA #16 stated specifically, that s/he transferred Resident #50 using the stand pivot transfer when s/he worked with Resident #50 during the morning of 11/25/18. A review of GNA #16's training records on 06/11/19 failed to reveal that s/he received the education that Resident #50 was to be transferred, after 11/01/18, by two staff members using a mechanical Hoyer lift. The facility conducted an investigation and subsequently terminated GNA #16 for failure to follow a resident's plan of care.