CLEVELAND NURSING AND REHABILITATION CENTER
For profit - Limited Liability company
120 Beds
NORBERT BENNETT & DONALD DENZ
Data: November 2025
7 Immediate Jeopardy citations
Trust Grade
0/100
#104 of 200 in MS
Last Inspection: February 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Cleveland Nursing and Rehabilitation Center has received an F grade for its trust score, indicating significant concerns regarding care quality and safety. It ranks #104 out of 200 facilities in Mississippi, placing it in the bottom half, and #3 out of 5 in Bolivar County, meaning only two local options are considered better. The facility is showing signs of improvement, with issues decreasing from 8 in 2023 to 5 in 2024. Staffing is a strong point, with a 5-star rating and a turnover rate of 41%, which is better than the state average. However, the center has accumulated a concerning $229,213 in fines, indicating compliance problems that are higher than 98% of facilities in Mississippi. Serious incidents have raised alarms, including a tragic case where a resident committed suicide after the facility failed to provide necessary psychiatric services, despite the resident expressing suicidal thoughts during admission. There were also failures to report serious injuries, which highlights significant gaps in safety and oversight. While the staffing levels are commendable, these critical issues reflect a need for families to carefully consider the potential risks associated with this facility.
- Trust Score
- F
- In Mississippi
- #104/200
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 41% turnover. Near Mississippi's 48% average. Typical for the industry.
- Penalties ✓ Good
- $229,213 in fines. Lower than most Mississippi facilities. Relatively clean record.
- Skilled Nurses ○ Average
- Each resident gets 35 minutes of Registered Nurse (RN) attention daily — about average for Mississippi. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 17 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 48%
Review needed
8 → 5 violations
★★☆☆☆
2.0
Overall Rating
★★★★★
5.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2023: 8 issues
2024: 5 issues
The Good
-
5-Star Staffing Rating · Excellent nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (41%)
7 points below Mississippi average of 48%
Facility shows strength in staffing levels, fire safety.
The Bad
2-Star Overall Rating
Below Mississippi average (2.6)
Below average - review inspection findings carefully
Staff Turnover: 41%
Near Mississippi avg (46%)
Typical for the industry
Federal Fines: $229,213
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: NORBERT BENNETT & DONALD DENZ
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 17 deficiencies on record
7 life-threatening
Feb 2024
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff, and resident interviews the facility failed to correct maintenance issues in a resident bathroom f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff, and resident interviews the facility failed to correct maintenance issues in a resident bathroom for two (2) of 28 residents sampled. Residents #39 & #46
Findings Include:
Review of the written statement on facility letterhead dated 2/14/24 and signed by the Administrator revealed the facility does not have a policy regarding maintenance repairs.
An interview and observation on 02/12/24 at 11:06 AM, with Resident's #39 and #46 revealed the residents share a bathroom and the water in the bathroom will not turn on and there is a puddle of water in the floor approximately 2 feet wide by 2 feet wide between the toilet and the sink. Resident #39 & #46 revealed the sink has not worked in a long time and they both walk independently. When asked if the staff were aware their sink did not work and there appeared to be a leak, Resident #46 stated, Yes, they have come in and looked at it, but no one's fixed it.
An observation and interview on 02/13/24 at 10:30 AM, of Resident #39 & #46's shared room revealed there was still a puddle of water between the toilet and the sink that was approximately 2 feet wide by 2 feet long, that extended to the front of the toilet. Observation revealed the handle to the faucet was not attached. Resident #46 revealed that he did not know how to put the faucet handle back on.
An observation and interview on 2/13/24 at 10:35 AM, with Nurse Aide (NA) #1 confirmed there was water standing in the floor of Residents #39 & #46's bathroom and that they walked independently. She confirmed that the sink handle was loose and could be removed causing the sink not to be able to be turned on and that the puddle of water could have been a fall hazard for the residents. She revealed that she is not the residents NA, but that the staff are supposed to notify nurses or the maintenance man if there is an issue that needs to be repaired. She stated that a wet floor sign needed to be put up also.
An observation and interview on 2/13/24 at 10:40 AM, with NA #2 revealed she is Resident #39 & 46's nurse assistant, and she knew there was some sort of water leak in their bathroom, and she had reported it to one of the nurses but was not sure who. She stated, they have come and looked at it but cannot figure out where the leak is coming from. She confirmed the residents sink handle needed to be fixed, because the residents would not know how to reattach the handle on their own.
An interview and observation on 2/13/24 at 10:46 AM, with the Maintenance Supervisor revealed he was not aware that Resident #39 & #46's bathroom had a leak that was causing water to stand in the floor or that their sink faucet had come unattached. He stated, Someone just told me about it as I was walking down the hall. He revealed that normally the staff just verbally tell him when something needs to be fixed, there is no form to fill out or computer system for maintenance request. He confirmed there was water standing in the floor in the resident's bathroom and that the sink faucet handle was not permanently attached and needed to be fixed.
An interview on 2/13/24 at 10:50 AM, with Licensed Practical Nurse (LPN) #1 revealed that she has not been notified about a water leak or the sink faucet not being attached in Residents #39 & #46's room. She confirmed that staff should put a wet floor sign up and notify the staff or maintenance of the issue so it can be fixed.
An interview on 2/13/24 at 10:55 AM, with the Administrator confirmed that if the staff find a maintenance issue that needs to be fixed they should notify a nurse or maintenance.
Record review of Resident #39's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Other Recurrent Depressive Disorders.
Record review of Resident #39's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/23/24, revealed in Section C a Brief Interview for Mental Status (BIMS) score of 13, which indicates the resident is cognitively intact and in Section GG that the resident walked independently.
Record review of Resident #46's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Dementia and Unspecified Severity with Anxiety.
Record review of Resident #46's MDS with an ARD of 2/9/24 revealed in Section C a BIMS score of 6, which indicates the resident is severely cognitively impaired and in Section GG that the resident walked independently.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0638
(Tag F0638)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to ensure a quarterly Minimum Data Set (MDS) assessment was comp...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to ensure a quarterly Minimum Data Set (MDS) assessment was completed timely for one (1) of 28 resident's MDS reviewed. Resident #14
Findings include:
Record review of a document, on company letterhead, dated 2/14/24 provided by the Administrator revealed, The facility does not have a policy on MDS completion and scheduling. The facility follows the Resident Assessment Instrument (RAI) manual.
A record review of the RAI Version 3.0 Manual, dated October 2023, Chapter 2, Assessments for the RAI page 2-35, 05. Quarterly Assessment, revealed The Quarterly assessment .must be completed at least every 92 days following the previous Omnibus Budget Reconciliation Act (OBRA) assessment of any type .
Record review of the Minimum Data Set (MDS) 3.0 Nursing Home (NH) Final Validation Report, dated 2/9/24, revealed that the Quarterly MDS, with an assessment reference date (ARD) of 1/25/24, for Resident #14 was completed late.
During an interview with MDS Registered Nurse (MDS RN) on 2/14/24 at 10:25 AM, she stated that the Quarterly MDS for Resident #14 was completed late. She verified that the assessment was greater than 120 days old.
In an interview on 2/14/24 at 10:27 AM, the MDS RN and MDS Licensed Practical Nurse (MDS LPN) stated that they had identified on Friday that the assessment was late but at that point there was nothing that could be done. The MDS LPN stated she is responsible for scheduling assessments and that the assessment was just missed. She stated that she thinks she may have gotten this resident mixed up with another resident with the same last name. They stated the purpose for the MDS was to have an assessment of the resident to create the care plan and know how to take care of the resident. Both MDS Nurses agreed that not completing the MDS timely could result in not having an accurate assessment of the resident's needs causing the resident not to receive appropriate care .
During an interview with the Administrator on 12/14/24 at 10:35 AM, she verified that the Quarterly MDS for Resident #14 was completed late and agreed it was her expectation that the MDS would be completed on time.
A record review of Resident #14's Face Sheet revealed he was admitted to the facility on [DATE], with a diagnosis of Cerebral Palsy.
A record review of Resident #14's Quarterly MDS revealed an ARD of 1/25/24 and a completion date of 2/2/24.
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 observation, staff interview, record review and facility policy review the facility failed to implement a care plan for...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review and facility policy review the facility failed to implement a care plan for a resident requiring two person assistance utilizing a total lift with transfers for one (1) of 28 resident care plans reviewed. Resident #55
Findings Include:
Record review of the facility policy titled Comprehensive Person-Centered Care Plan with a revision date of 3/18 revealed Policy .Each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care .
Record review of Resident #55's Care Plans revealed a care plan with a problem onset date of 3/13/23, that indicated the resident required assistance with ADL's (Activities of Daily Living) related to resident has diagnosis of Cerebral Palsy with decrease mobility with interventions that included transfer assistance of two (2) staff members with the total mechanical lift.
On 02/12/24 at 01:34 PM, an observation and interview revealed Nurse Assistant (NA) #3 had Resident #55 up in the total lift sling hovering over her wheelchair with no other staff member in the resident's room. An interview with NA #3 revealed she knows she is supposed to have a certified or licensed staff member with her when she uses a total lift.
An interview on 2/14/24 at 1:30 PM, with Certified Nurse Assistant (CNA) #4 confirmed that Resident #55's care plan indicated the resident needed a two (2) person assist with transfers. She revealed that the staff have pocket care guides which are the residents' care plans.
An interview on 2/14/24 at 2:15 PM, with the Administrator confirmed that Resident #55 had a care plan and a pocket care guide that indicated the resident should have two people assisting with the total body lift and since the staff did not use two (2) people then the care plan was not implemented. She revealed the purpose of a care plan and pocket care guide was to provide the information the staff need to care for the residents.
An interview on 2/15/24 at 8:20 AM, with the Director of Nursing (DON) confirmed that Resident #55's care plan indicated the need for two persons assist with the total body lift and since NA #3 did not use two (2) people then the care plan was not implemented.
Record review of Resident #55's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Cerebral Palsy.
Record review of Resident #55's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/7/23 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 14, which indicates the resident is cognitively intact and in Section G that the resident needed a two-person physical assist with transfers.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, record review and facility policy review, the facility failed to ensure an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, record review and facility policy review, the facility failed to ensure an environment free of accident hazards as evidenced by one staff member using a two-person total body lift to transfer Resident #55 and standing water in a bathroom (Resident's #39 & 46) for three (3) of 28 residents reviewed on sample.
Findings Include
Review of the typed statement on facility letterhead dated 2/14/24 and signed by the Administrator revealed the facility does not have a policy regarding accident and hazard prevention.
Review of the facility policy titled, Invacare Total Lift with a revision date of 8/16 revealed under the Policy .The Invacare Total Lift is used for total lifts and/or to obtain a resident's weight from bed to chair, chair to bed, or from the floor .
Resident #55
An observation and interview on 02/12/24 at 01:34 PM, revealed Nurse Assistant (NA) #3 had Resident #55 up in the total lift sling hovering over her wheelchair with no other staff member in the resident's room. An interview with NA #3 revealed she is not certified, and she knows she is supposed to have a certified or licensed staff member with her when she uses a total lift because of the risk of the resident falling or slipping out of the sling. She stated the resident was so wet and needed changing and she just could not find anyone to help her. This interview continued at the nurse's station where we found Licensed Practical Nurse (LPN) #2 and Registered Nurse (RN) #1. NA #3 informed them that she had lifted the resident with a total lift and no assistance from another staff member. RN #1 stated, why did you not come get one of us and NA #3 stated she could not find anyone. RN #1 and LPN #2 revealed that the resident needs a two person assist with a total lift to prevent falls. NA #3 stated that she had been in-serviced on how to use the total lift and knows that she should have just waited to get help from another staff member.
An interview on 2/14/24 at 1:30 PM, with Certified Nurse Assistant (CNA) #4 confirmed that sometimes the aides use the total lifts alone because there is not enough staff to help. She stated we usually know the residents that we can use one person with the total lift and those that would need two (2). She stated that the policy is to use two (2)staff members with a total body lift and has been in-serviced. She stated that to be honest we just do the only thing we can.
An interview on 2/14/24 at 2:15 PM, with the Administrator revealed that the staff have Pocket Care Guides that tell them what each resident's care needs are and that Resident #55's indicated she needed a two person assist with total lifts.
An interview on 2/15/24 at 8:20 AM, with the Director of Nursing (DON) confirmed that staff are expected to use two (2) people with the total body lift and the NA should have gone out and got someone to help her. She confirmed that the aides have a pocket care guide, and she expects them to use it. She confirmed that the staff receive in-services and training regarding using the total body lift on hire and annually. She confirmed that NA #3 was in-serviced on the use of the total body lift.
Record review of NA #3 State approved Nurse Aide Training Program (NATP) certificated revealed it was completed on 11/17/23.
Record review of the facility in-services revealed the facility had an in-service dated 11/15/23 regarding full body lifts and that noncertified staff were not to use the lift and that was attended by nursing staff including NA #3. Another in-service was completed on 12/9/23 regarding full body lifts, students cannot use lift without a certified CNA and to follow the pocket care guide that was attended by NA #3.
Record review revealed NA #3 had received a Competency Evaluation and Assessment Total Lift on 12/9/23 that indicated the staff member demonstrated proper use of the total lift.
Review of the Manufacturers General Guidelines for the Total Body Lift indicated under Operating the Lift .The use of one assistant is based on the evaluation of the health care professional for each individual case.
Record review of Resident #55's Admission/readmission Evaluation dated 3/13/23, revealed under Mobility-that the resident needed a two (2) person assist with a full body lift.
Record review of Resident #55's Daily Care Guide revealed the resident needed a two (2) person assist with a total mechanical lift for transfers.
Record review of Resident #55's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Cerebral Palsy.
Record review of Resident #55's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/7/23 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 14, which indicates the resident is cognitively intact and in Section G that the resident needed a two-person physical assist with transfers.
Resident #39 and #46
During an interview and observation on 02/12/24 at 11:06 AM, with Resident's #39 and 46 revealed the resident's bathroom had a puddle of water in the floor approximately two (2) feet wide by two (2) feet wide between the toilet and the sink. An interview with Resident #39 & 46 revealed they both walk independently. When asked if the staff were aware there was a possible leak, Resident #46 stated, yes, they have come in and looked at it, but no one's fixed it.
During an observation and interview on 02/13/24 at 10:30 AM, of Resident #39 & 46's bathroom revealed there was still a puddle of water between the toilet and the sink that was approximately two (2) feet wide by two (2) feet long, that extended to the front of the toilet.
In an interview on 2/13/24 at 10:50 AM, with Licensed Practical Nurse (LPN) #1 revealed that she has not been notified about a water leak in Residents #39 & 46's room. She confirmed that staff should put a wet floor sign up and notify the staff or maintenance of the issue so it can be fixed. She confirmed that both of those residents walk independently, and it could have been a fall hazard.
During an interview on 2/13/24 at 10:55 AM, with the Administrator confirmed that if the staff find a maintenance issue that needs to be fixed then they need to notify a nurse or maintenance. She confirmed that the water in the floor could have been a fall hazard for the residents in that room.
Record review of Resident #39's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Other Recurrent Depressive Disorders.
Record review of Resident #39's MDS with an ARD of 1/23/24 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 13, which indicates the resident is cognitively intact and in Section GG that the resident walked independently.
Record review of Resident #46's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Dementia, Unspecified Severity with Anxiety.
Record review of Resident #46's MDS with an ARD of 2/9/24 revealed in Section C a BIMS score of 6, which indicates the resident is severely cognitively impaired and in Section GG that the resident walked independently.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
Based on observation, staff interview, Payroll Based Journal data, record review and facility policy review the facility failed to provide adequate staffing to provide nursing and related services to ...
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Based on observation, staff interview, Payroll Based Journal data, record review and facility policy review the facility failed to provide adequate staffing to provide nursing and related services to meet the residents' needs safely and in a timely manner for one (1) of 28 sampled residents during survey and five (5) of 5 weekends in July 2023.
Findings Include.
The Administrator (ADM) provided on facility letterhead that the facility does not have a policy on staffing, the facility follows the State Department of Health Licensure regulations.
A record review of PBJ Staffing Data Report CASPER Report 1705D FY (Fiscal Year) Quarter 4 2023 (July1-September 30), revealed Excessively Low Weekend Staffing - Triggered.
Triggered = Submitted Weekend Staffing data is excessively low.
During an observation and interview on 02/12/24 at 01:34 PM revealed Nurse Assistant (NA) #3 had Resident #55 up in the total lift sling hovering over her wheelchair with no other staff member in the resident's room. An interview with NA #3 revealed she is not certified, she stated she has completed her course but is waiting to take her exam and it has been close to four (4) months. She revealed she knows she is supposed to have a certified or licensed staff member with her when she uses a total lift, because of the risk of the resident falling or slipping out of the sling. She stated the resident was so wet and needed changing and she just could not find anyone to help her.
An interview on 2/12/24 at 1:38 PM with NA #3 revealed Licensed Practical Nurse (LPN) #2 and Registered Nurse (RN) #1 were sitting at the nurse's station. NA #3 informed them that she had lifted the resident with a total lift and no assistance from another staff member. RN #1 stated, why did you not come get one of us? NA #3 stated she could not find anyone. RN #1 and LPN #2 revealed that the resident needs a two person assist with a total lift to prevent falls. NA #3 admitted that she had been in-serviced on how to use the total lift and knows that she should have waited to get help from another staff member.
An interview on 02/14/24 at 9:00 AM, with the Staffing Coordinator confirmed that the number of staff needed daily in the facility for hands on care is determined by the number of residents inside of the facility and the acuity of those residents requiring care. She confirmed that if there are call-ins or shifts and she is unable to fill in, she notifies the Director of Nursing (DON) and then the DON attempts to get additional staff to come in for hands-on care. She stated the DON and ADM are made aware of additional needs on the schedule.
An interview on 2/14/24 at 1:30 PM, with Certified Nursing Assistance (CNA) #4 revealed she had been at the facility for years and she is now the restorative aide. She stated that she has never seen it as bad as it is right now with staffing, and we need more CNA's. She stated that they are doing the best they can and sometimes it's all they can do to turn them, clean them, and feed them, so they may not get three baths a week, they may only get two (2). She confirmed that sometimes the aides use the total lifts alone because there are not enough staff to help., She stated we usually know the residents that we can use one person with the total lift and those that would need 2. She revealed the policy states there must be 2 staff members with a total body lift and has been in-serviced on the policy, but to be honest we just do the only thing we can.
An interview on 02/14/24 at 2:54 PM with the ADM confirmed that she was not aware that the facility had triggered on the CASPER report for low weekend staffing. She stated that she has not seen a CASPER report and only receives a report from her corporate office. The ADM stated, I don't know how to pull that information, I have never pulled it.
An interview on 02/14/24 at 3:00 PM, with the Account Manager for the facility confirmed that she is unaware of how to pull a report to show where the facility triggered for low weekend staffing. The Account Manager stated, We use a system called Smart Link that pulls from the time clock when people clock in and we compare it to the schedule then reconcile with payroll and then we generate that information into the Payroll Based Journal (PBJ) system, but we don't get a message or a notice that the facility triggers for low staffing.
A record review of staffing numbers that the facility reported in the Payroll Based Journal (PBJ) revealed that the facility had excessively low staffing for five (5) out of 5 weekends during July 2023.
An interview on 02/15/24 at 8:00 AM, with the ADM confirmed that the facility was excessively low on staffing for 5 of 5 weekends in the month of July 2023. The ADM stated, I knew we were low on some of those dates, and we tried to get staff to come in.
An interview on 02/15/24 at 8:30 AM, with the DON confirmed that she was unaware of the facility was short on the weekends. She reported that when they don't have enough staff that they are supposed to call additional people in to work and that she doesn't look at the numbers to make sure that there was enough staff in the facility. The DON confirmed that staff are expected to use 2 people with the total body lift and the CNA should have gone to get someone to help her, anyone like a nurse. She stated they offer incentives to the CNA's when we are not fully staffed, but they quit offering incentive to the CNAs about a month ago.
Sept 2023
7 deficiencies
7 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy/procedure review, and interviews, the facility neglected to identify a crisis of suicidal ideatio...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy/procedure review, and interviews, the facility neglected to identify a crisis of suicidal ideation of Resident #1 and neglected to provide the psychiatric services that were necessary to prevent death for one (1) of seven (7) residents sampled as evidenced by Resident #1 committed suicide by hanging on [DATE] using the remote-control cord from his bed and using an exposed pipe on the ceiling in his room.
On [DATE], during the admission process Resident #1 told the admitting nurse that he wanted to call a friend to pick him up and take him to jump off a bridge. During the 11:00 PM to 7:00 AM shift, on [DATE], a Medical Doctor's (MD) order was written for a psychiatric (psych) evaluation. On [DATE], Resident #1 elected to be admitted to hospice services. Another MD order was written on [DATE] to discontinue (D/C) the psych evaluation and resident was admitted to contract hospice services. An order was written on [DATE] with no time noted to place Resident #1 on one-on-one monitoring due to suicidal ideation. He remained on one-on-one observation through to [DATE] when the facility reduced the resident's supervision from one-on-one to every hour observation due to improved mood. LPN #1 took Resident #1's breakfast tray to his room at 8:30 AM and when the door was opened, Resident #1 was observed hanging from a pipe with the bed remote control cord wrapped around his neck. He was noted to be warm. LPN #1 yelled for help and LPN #2 responded. LPN #2 cut Resident #1 down and began doing sternal rubs with no response. Emergency Medical Services (EMS) were called as were hospice services. EMS arrived to the facility and found Resident #1 with no heart activity and he was pronounced dead at 9:00 AM.
The facility's failure to provide psychiatric services including a psych evaluation for Resident #1 placed this resident in a situation that likely led to death and placed other resident in a situation that could likely lead to serious injury, impairment or death.
The State Agency (SA) investigated the death of Resident #1 on [DATE] through [DATE]. After SA review, the SA extended the survey on [DATE] through [DATE] and the situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) when began on [DATE] when the physician's order for a psychiatric evaluation for Resident #1 written on [DATE] was discontinued on [DATE].
The IJ and SQC existed at:
42 CFR 483.12 (a)(1)Freedom from Abuse, Neglect, Exploitation- F600 - Scope/Severity J and SQC.
The SA notified the facility's Administrator of the IJ and SQC on [DATE] at 12:30 PM and provided the Administrator with the IJ template.
The facility submitted an acceptable Removal Plan on [DATE], in which they alleged all corrective actions to remove the IJ and SQC were completed on [DATE] and the IJ was removed on [DATE].
The SA validated the Removal Plan on [DATE] and determined the IJ and SQC was removed on [DATE], prior to exit. Therefore, the scope and severity of 42 CFR 483.12 (a)(1) Freedom from Abuse, Neglect, Exploitation (F600) was lowered to a Scope and Severity of D while the facility develops a plan of correction to monitor the effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements.
Findings include:
Record review of the facility's Abuse Prevention last dated 10/22 revealed Definition: f) Neglect: A failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, mental anguish, emotional distress, or pain.
Record review of the facility policy Physician Orders history 1/15 ( A.15) revealed .Procedure .4. The .time of the order must appear .
Policy/procedure review of the facility's policy/procedure for Suicide Precautions, last revised 2/19 revealed .Procedure 8. Undertake emergency transfer of resident to appropriate treatment setting.
Record review of Resident #1's Face Sheet revealed he was admitted on [DATE] to the facility with diagnoses which included Malignant Neoplasm of Larynx, unspecified, Restlessness and Agitation and Depression, unspecified.
Record review revealed no order for an emergency transfer of Resident #1 to an acute care facility.
Record review of Resident #1's Physician Orders for [DATE] revealed Do Not Resuscitate (DNR). The orders also revealed a Handwritten Physician Telephone Order dated [DATE] read psychiatric consult for evaluation/treatment with no time documented that the order was given.
Physician Telephone Order dated [DATE] read d/c (discontinue) psychiatric consult d/t (due to) admit to hospice with no time that order was given.
Record review revealed a printed Physician's Telephone Order dated [DATE] with a time of 4:00 PM to Admit to hospice (proper name) related to diagnosis of malignant neoplasm of larynx.
Record review revealed there were no printed physician orders for a psychiatric consult on [DATE] or to d/c a psychiatric consult on [DATE].
Record review of the MD's (Medical Doctor) order to discontinue the psych evaluation written on [DATE] revealed the Administrator, a Registered Nurse, wrote the order to discontinue the psych. evaluation.
Interview with Resident #1's Medical Doctor (MD) on [DATE] at 8:30 AM revealed that the psychiatric evaluation was discontinued because hospice won't pay for psych. He also revealed that he didn't know the psychiatric evaluation had been discontinued until [DATE], which was three days after the suicide.
Interview with the Administrator, [DATE] at 4:10 PM, regarding the discontinued psychiatric (psych) evaluation order on [DATE] revealed He went on hospice. That is why the order was discontinued. Hospice won't pay for a psych eval. He knew he had a psych evaluation ordered and was one on one due to what he said about jumping off a bridge. We told him we were dc'ing (discontinuing) the psych evaluation because hospice would provide for his needs. He said he understood.
Interview with the Administrator on [DATE] at 10:45 AM revealed LPN #3 did call me on [DATE] and let me know what Resident #1 said during the admission process. She stated she immediately put him one on one and got a psychiatric consult order from the Medical Director, who was the resident's primary physician. On [DATE], Resident #1 wanted to be admitted to hospice. He went on hospice on [DATE]. Hospice isn't going to pay for consults, so the psychiatric consult was discontinued. If a resident is a Do Not Resuscitate (DNR) and on hospice or palliative care only, any consults will be discontinued. The Administrator stated that the decision to send a resident for emergency care would depend on the resident and their specific situation.
Interview with Licensed Practical Nurse (LPN)/admitting nurse/Unit Manager on [DATE] at 10:35 AM revealed, It didn't cross my mind to send him out for an emergency evaluation related to the suicidal ideation he had voiced.
Record review of the Departmental Notes with a Category: Nursing dated [DATE] at 9:31 PM revealed, .Resident stated that he's scared of been in (being) in facility and in room by himself Please don't leave me alone, I'm scared .Resident states he doesn't want to die here .Resident not adjusting to new surroundings well. Resident hollering out loud .Resident refuse to stay in his room due to he's scared of been (being) alone .Stating that he wants to call his friend to pick him up so he can jump off bridge cause he's tired of living . He was placed one on one observation with staff after making that comment.
Record review of the Departmental Notes with a Category: Nursing dated [DATE] at 7:21 AM revealed, .Resident constantly states he wants to die. He wrapped oxygen tubing around his neck .Resident asked staff if he hit his head against the wall will go ahead and take him out . On [DATE] at 6:23 AM, Resident #1 ambulated to the nursing station and stated he had slipped. A laceration on his face and skin tear on his arm were cleaned. Resident #1 was observed by Licensed Practical Nurse #1 at 7:15 AM lying in his bed with his eyes closed. LPN#1 took Resident #1's breakfast tray to his room at 8:30 AM and when the door was opened, Resident #1 was observed hanging from a pipe with the bed remote control cord wrapped around his neck. He was noted warm. LPN #1 yelled for help and LPN #2 responded. LPN #2 cut Resident #1 down using bandage scissors and began doing sternal rubs with no response. The facility called Emergency Medical Services (EMS) and hospice services. EMS arrived at the facility and found Resident #1 with no heart activity, and he was pronounced dead at 9:00 AM. Hospice contacted the coroner, and the body was released to the Medical Examiner.
An interview with LPN #2 on [DATE] at 8:55 AM, revealed that he heard LPN #1 call for help and immediately went to help. He stated that Resident #1 was hanging from a pipe near the ceiling. He stated he cut the cord which was a bed control cord. The cord was removed from around the resident's neck. He stated the resident still felt warm and had a faint pulse for three (3) minutes. He did sternal rubs to see if the resident would respond and there was no response. He said that staff had called the EMS (emergency medical services) and they arrived. The EMS did an EKG and there was no heart activity. Hospice arrived and called the coroner and family.
During an interview with Certified Nursing Assistant (CNA) #1 on [DATE] at 9:20 AM, CNA #1 revealed that she saw Resident #1 on [DATE] around 7:36 AM. She stated she was walking by his room and saw his door open. She saw him again lying in bed with his legs moving at 8:00 AM. She stated her assignment changed after 8:00 AM and she was no longer his assigned CNA. She stated that a little later she heard a nurse scream.
During an interview with LPN #1 on [DATE] at 9:58 AM, revealed that she was Resident #1's assigned nurse on [DATE] on the 7-3 shift. She first saw him at 7:15 AM on [DATE], he was lying in bed with his eyes closed. She went to his room at 8:30 AM to assist with his breakfast. She opened the room door and saw him hanging from an exposed pipe going across his ceiling. She attempted to get him down but was too short and yelled for help. LPN #2 came to help and had his bandage scissors in his pocket. He cut the cord and they laid the resident down. She stated that LPN #2 did sternal rubs. Staff called 911 for an ambulance and hospice. She stated LPN #2 stated he felt a faint pulse. She stated it appeared he stood on the wheelchair (w/c) to get to the pipe. His w/c was close to where he was hanging. She stated he was warm but unresponsive. She stated he had an order to Do Not Resuscitate (DNR) so Cardiopulmonary Resuscitation (CPR) was not started. She stated the Emergency Medical Services (EMS)'s ran an Electrocardiogram (EKG) and found no heart activity. The coroner was called by the hospice staff when they got here.
Record review of the Patient Care Report by the Emergency Medical Services (EMS) that responded to the facility's call for assistance on [DATE] revealed that EMS received notification at 08:52 [DATE] and were at patient 08:59 [DATE]. The NARRATIVE CHIEF COMPLAINT revealed that EMS found Resident #1 Unresponsive, apneic, and pulseless in bed covered up with blankets by staff. CPR not in progress. Staff states that patient is a DNR (Do Not Resuscitate) and wanted to confirm death by EMS, according to staff, patient was last seen alive 20-30 minutes ago. Resident #1 was found unresponsive, apneic, and pulseless with airway patent, breathing is absent, skin is pale in color, warm to touch and pupils dilated. The Narrative concludes with DOA-no resuscitation, no transport, (name of county) coroner notified and patient's remains left with nursing staff awaiting coroner. The Patient Care Report revealed EMS leave scene 09:11 [DATE].
Record Review of the REPORT OF DEATH INVESTIGATION revealed the death of Resident #1 was confirmed by EMS on 8-19-23 9:00, Coroner notified 8-19-23 09:30 and View of Body 8-19-23 10:05.
The report has the Manner of Death is pending autopsy. The reports Probable Cause of Death: 1. Pending Hanging/Strangulation.
Record Review of the Reason for Assuming Medical Examiner Jurisdiction, undated with no time revealed Suicide with a check mark and Medical History Cancer has a check mark. The Narrative Summary of Circumstances Surrounding Death revealed Called to (name of long term care facility) to find a 61 y/o W/M lying supine in bed with what appeared to be ligature marks to the front of his neck. The decedent body was cool to touch with no other obvious injuries. The decedent was taken to (Name of local hospital) to hold for autopsy. The cord used was also sent for evident with decedent. There is a diagram of a body with a line drawn across the neck.
The facility provided the following Removal Plan:
Resident #1 was admitted on [DATE]. Resident #1 expressed that he wanted to sign up for hospice services on admission due to him being tired. He stated I been suffering from throat cancer for seven years. I'm just tired. Resident #1 expressed that he wanted to call his friend so that he could jump off a bridge. On [DATE], a psychiatric consult was ordered. The resident was admitted to hospice on [DATE]. The psychiatric consult was discontinued on [DATE] by the physician after he elected hospice services. The facility failed to adequately meet Resident #1's mental health needs when the facility did not provide a psychiatric evaluation on [DATE], after Resident # 1 stated that he wanted to jump off a bridge. The facility failed to ensure the Medical Director evaluated and acted on reported deficient practices related to Resident #1's actual suicide and failed to ensure that orders for the psychological evaluations were carried out as ordered. The facility failed to adequately meet Resident #1's mental health needs when the facility did not complete a status change PASARR when, on [DATE], Resident #1 verbalized suicidal ideations. The facility neglected to provide psychological interventions upon admission, on [DATE], to protect Resident #1, who expressed suicidal ideations and ultimately was found hanging in the facility on [DATE]. The facility failed to accurately report an actual suicide for Resident #1 when he was found hanging from the pipes in the ceiling at 8:15 AM on [DATE]. The incident was reported as an attempted suicide to the department of licensure and certification (L&C) at 9:57 AM on [DATE]. The incident was not reported to the appropriate state agencies within the specific time frame, as required by federal guidance. The Administrator/Executive Director failed to ensure that Resident #1's psychological needs were addressed by a lack of immediate intervention and a lack of carrying out of a physician order for a psychological evaluation, which resulted in Resident #1's death.
Interventions
* The facility held an emergency meeting on [DATE] at 1:00 PM, with the Quality Assurance team to discuss and implement removal plans for citations F600, F609, F644, F835, F841, related to Resident #1's suicide on [DATE]. The Administrator/Executive Director, the DON/IP, the unit manager, the Medical Director, the activities director, the [NAME] President to the Administrator/Executive Director, social worker #1, and social worker #2 were in attendance.
*On [DATE], a new preadmission screening and resident review (PASARR) policy was created for the facility to coincide with federal and state guidelines. The policy was created by the Executive Director/Administrator of the facility and the governing body.
*The facility implemented the policy for PASARR, to coincide with state and federal regulations. The policy was approved in the Emergency Quality and Assurance meeting held on [DATE], at 1:00 PM
*An in-service on neglect and abuse was provided to all staff on [DATE], at 1:30 PM, by the Director of Nursing/Infection Preventionist (DON/IP). The information covered in the in-service included the definition of abuse and neglect, the different types of abuse and neglect, and what steps to take if abuse or neglect is witnessed or suspected.
*An in-service education on self reporting requirements was provided to the Administrator/Executive Director and the DON/IP to include reporting accurately to state agencies on [DATE] at 2:00 PM, by the [NAME] President to the Administrator. The abuse and neglect policy was reviewed in the in-service which included the types of incidents that must be reported, the time frame in which to report, and the entities (Attorney General's Office, Licensure and Certification, Ombudsman) that must be reported to.
*An in-service education was provided with all licensed nurses by the DON on [DATE] at 3:00 PM to review the policy on physician orders including, The signature of the nurse receiving the order and the time of the order must appear.
*An in-service education was provided to social service on [DATE], at 3:30 PM, by the Administrator/Executive Director, to include an increase in social visits for all residents with suicidal ideation to be seen by social service at least 3 times weekly, until they no longer have suicidal ideation.
*An in-service education on the Administrator's job description was provided to the Administrator/Executive Director to include that the Administrator must provide oversight to provide the necessary care for residents who express suicidal ideation and for residents who have psychosocial needs that are not met. This was completed [DATE], at 4:00 PM, by the [NAME] President to the Administrator/Executive Director.
*An in-service education was provided on PASARR to Social Services on [DATE], by the Administrator/Executive Director. Another PASARR in-service/education was completed on [DATE], at 4:30 PM by the [NAME] President to the Administrator, the DON/IP, Social Services, the Medical Director, and the Director of Admission. The information covered in the in-service included when to complete a new PASARR and the appropriate agency to send the completed forms to.
*An in-service education on the Medical Director Policy was provided to the Medical Director on [DATE], at 5:00 PM, by the Administrator/Executive Director. The information covered in the in-service included the role and responsibilities of the Medical Director and leading the continuity of care with nursing services to include physician orders with accurate times and dates.
*A one hundred percent audit was completed on [DATE], by the Administrator/Executive Director, of all current resident's PASARRs to ensure status change of assessment has been completed to include new diagnosis and to reflect that mood and behavior changes are included in the status change. Fifty-eight resident's status change forms were sent to the state mental health authority for a status change on [DATE] at 8:00 PM.
*A resident council meeting was completed by the activities director on [DATE], at 2:30 PM. The residents were encouraged to express their feelings. An additional follow up resident counsel meeting was held on [DATE] at 2:00 PM by the activities director. No negative effects reported from the residents.
*An education/in-service was provided to social service and nursing staff to immediately get psychiatric evaluation for residents with any new behaviors to include suicidal ideation. This was completed [DATE], at 5:00 PM, by the Administrator/Executive Director and the DON/IP. A memo was placed at each nurses station to reflect the instructions of the in-service completed by 4:00 PM on [DATE], by the DON/IP.
*Six residents with history of suicide ideation were seen per the psychiatric nurse practitioner, on [DATE] and [DATE]. All residents denied suicidal ideations on evaluation per the psychiatric nurse practitioner.
*A phone meeting was held with the Administrator/Executive Director and the area [NAME] President of Sales for hospice on [DATE], at 9:00 AM, concerning communication and collaboration between hospice and facility to provide better service for the residents receiving hospice care in the nursing facility. On [DATE] a new system change included a hospice communication book was placed at each nurse's station for any change in condition to hospice residents.
*A grief counseling meeting was conducted by the hospice Chaplin on [DATE], from 11:00 AM until 3:00 PM for the residents and staff.
*An in-service/education was provided to all the licensed nursing staff to notify hospice of all changes in condition, this will include condition changes such as, decline or improvement, medication changes, new orders of any type, and psychiatric needs and/or evaluations. All communication with hospice will be documented in the interdisciplinary notes and placed on hospice notification form (Form #1) in the hospice communication book. The in-service was completed by the DON/IP on [DATE] by 5:30 PM.
*A second emergency Quality Assurance meeting held to discuss the new system implemented to communicate with hospice, the new hospice form #1, and communication book. This meeting was held on [DATE] at 5:00 PM. In attendance were the Administrator/Executive Director, the DON/IP, the Unit Manager, Social Worker #1, Social Worker #2 and the Medical Director per phone.
*Any employee that has not been in-serviced will not be allowed to return to work until all in-services are completed.
*On [DATE], the Emergency Medical Services were notified at 8:51 AM, along with hospice, the coroner, the Department of Health, and the resident's responsible party.
*The State Health Department was notified on [DATE] at 9:57 AM, by the Executive Director/Administrator. The Attorney General's Office (AG) was notified on [DATE] by the Executive Director/Administrator at 8:30 AM while at the facility investigating the incident.
*The Sheriff's Department was notified on [DATE], at 1:00 PM, while at the facility investigating the incident by the Executive Director/Administrator. The Ombudsman was notified by phone on [DATE], at 11:00 AM, by the Executive Director/Administrator.
*On [DATE], at 12:30 PM, an emergency Quality Assurance meeting was held to discuss immediate interventions completed and interventions to be put in place related to Resident #1's suicide. In attendance was the Director of Nursing/Infection Preventionist, the Executive Director/Administrator, the House Supervisor, Social Worker #1, Social Worker #2 and the Medical Director by phone.
*A trauma screening was performed on each resident in the facility. No issues were found. This was completed on [DATE] between 10:00 AM and 12:00 PM, by social services.
*All staff was in-serviced on abuse, neglect, and suicide precautions starting at 10:00 AM on [DATE], by the DON/IP.
*All care plans of residents with a history of suicidal ideation were updated to include the following interventions, residents that express feelings of harming themselves will be immediately placed on one on one and seen by the psychiatric nurse practitioner or a physician. If the psychiatric nurse practitioner or the physician are not available, then the resident will be sent to the emergency room for evaluation.
*These interventions were added to the plans of care of six residents on [DATE] between 1:00 PM and 2:00 PM, by social services.
*100% audit of all beds to ensure bed remote secured to bed by social service, this was completed [DATE], by 3:00 PM. There were two beds that required maintenance to secure the cord to the bed. The cords were secured immediately.
*For residents protection, all residents with a history of suicidal ideation were assessed for thoughts of self harm between the hours of 1:00 PM and 3:00 PM on [DATE], by social services. No resident reported thoughts of self harm.
*An in-service was provided to social services to ensure that all residents with suicidal ideation will be seen by social service at least weekly, until they no longer have suicidal ideation. This in-service was completed by the DON/IP on [DATE], at 5:00 PM.
*An in-service was completed with all staff by the DON/IP at 6:00 PM on [DATE]. Training included that all residents that express feelings of harming themselves will be immediately placed on one on one and seen by the psychiatric nurse practitioner or a physician. If the psychiatric nurse practitioner or the physician are not available, then the resident will be sent to the emergency room for evaluation.
Facility alleged compliance on [DATE].
On [DATE], the State Agency (SA) validated the facility's Removal Plan by staff interviews, record reviews, and review of the in-service sign in sheets. The SA verified the facility had implemented the following measures to remove the IJ:
The SA validated through interviews and record review that the facility held an emergency meeting on [DATE] at 1:00 PM, with the Quality Assurance team to discuss and implement removal plans for citations F600, F609, F644, F835, F841, related to Resident #1's suicide on [DATE]. Interviews with the Administrator/Executive Director, the DON/IP, the unit manager, the Medical Director, the [NAME] President to the Administrator/Executive Director, social worker #1, and social worker #2 confirmed all were in attendance.
The SA validated through record review and interviews with the Administrator/Executive Director, Director of Nurses (DON), Social Worker #1, Social Worker #2 that on [DATE], a new preadmission screening and resident review (PASARR) policy was created for the facility to coincide with federal and state guidelines. The policy was created by the Executive Director/Administrator of the facility and the governing body.
The SA validated through record review and interviews with the Administrator/Executive Director, DON, Social Worker #1, Social Worker #2, Medical Director, Unit Manager that the facility implemented the policy for PASARR, to coincide with state and federal regulations. The policy was approved in the Emergency Quality and Assurance meeting held on [DATE], at 1:00 PM.
The SA validated through record review and interviews with four Registered Nurses, five Licensed Practical Nurses, eight Certified Nurse Aides, one Laundry staff, three Housekeepers, two Social Workers, one Medical Director, one Administrator/Executive Director that an in-service on neglect and abuse was provided to all staff on [DATE], at 1:30 PM, by the Director of Nursing/Infection Preventionist (DON/IP). The information covered in the in-service included the definition of abuse and neglect, the different types of abuse and neglect, and what steps to take if abuse or neglect is witnessed or suspected.
The SA validated through record review and interviews with the Director of Nurses (DON) and Administrator/Executive Director that an in-service education on self reporting requirements was provided to the Administrator/Executive Director and the DON/IP to include reporting accurately to state agencies on [DATE] at 2:00 PM, by the [NAME] President to the Administrator. The abuse and neglect policy was reviewed in the in-service which included the types of incidents that must be reported, the time frame in which to report, and the entities (Attorney General's Office, Licensure and Certification, Ombudsman) that must be reported to.
The SA validated through record review and interviews with the Administrator/Executive Director, four RN's and five LPN's that an in-service education was provided with all licensed nurses by the DON on [DATE] at 3:00 PM to review the policy on physician orders including, The signature of the nurse receiving the order and the time of the order must appear.
The SA validated through record review and interviews with two Social Workers and Administrator/Executive Director that an in-service education was provided to social service on [DATE], at 3:30 PM, by the Administrator/Executive Director, to include an increase in social visits for all residents with suicidal ideation to be seen by social service at least 3 times weekly, until they no longer have suicidal ideation.
The SA validated through interview with the Administrator/Executive Director and record review that an in-service education on the Administrator's job description was provided to the Administrator/Executive Director to include that the Administrator must provide oversight to provide the necessary care for residents who express suicidal ideation and for residents who have psychosocial needs that are not met. This was completed [DATE], at 4:00 PM, by the [NAME] President to the Administrator/Executive Director.
The SA validated through record review and interviews with two Social Workers and the Administrator/Executive Director that an in-service education was provided on PASARR to Social Services on [DATE], by the Administrator/Executive Director. Another PASARR in-service/education was completed on [DATE], at 4:30 PM by the [NAME] President to the Administrator, the DON/IP, Social Services, the Medical Director, and the Director of Admission. The information covered in the in-service included when to complete a new PASARR and the appropriate agency to send the completed forms to.
The SA validated through record review and interviews with the Medical Director and Administrator/Executive Director that an in-service education on the Medical Director Policy was provided to the Medical Director on [DATE], at 5:00 PM, by the Administrator/Executive Director. The information covered in the in-service included the role and responsibilities of the Medical Director and leading the continuity of care with nursing services to include physician orders with accurate times and dates.
The SA validated by record review and interviews with the Administrator/Executive Director and two Social Workers that a one hundred percent audit was completed on [DATE], by the Administrator/Executive Director, of all current resident's PASARRs to ensure status change of assessment has been completed to include new diagnosis and to reflect that mood and behavior changes are included in the status change. The SA validated fifty-eight resident's status change forms were sent to the state mental health authority for a status change on [DATE] at 8:00 PM.
The SA validated through interviews with the Administrator, DON and SW #1 and record review a resident council meeting was completed by the activities director on [DATE], at 2:30 PM. The residents were encouraged to express their feelings. An additional follow up resident counsel meeting was held on [DATE] at 2:00 PM by the activities director. No negative effects reported from the residents.
The SA validated through interviews with five LPN's, one Activity Director, two Social Workers, one Director of Admissions, three RN's and five CNA's that an education/in-service was provided to social service and nursing staff to immediately get psychiatric evaluation for residents with any new behaviors to include suicidal ideation. This was completed [DATE], at 5:00 PM, by the Administrator/Executive Director and the DON/IP. A memo was placed at each nurses station to reflect the instructions of the in-service completed by 4:00 PM on 8/[TRUNCATED]
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Report Alleged Abuse
(Tag F0609)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy/procedure review and interviews, the facility failed to report an injury of unknown origin result...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy/procedure review and interviews, the facility failed to report an injury of unknown origin resulting in a serious bodily injury to law enforcement agencies after the death of one (1) of seven (7) residents sampled, Resident #1 as evidenced by Resident #1's suicide on [DATE].
Resident #1 told the admitting nurse during the admission process on [DATE] that he wanted to call a friend to pick him up and take him to jump off a bridge. During the 11:00 PM to 7:00 AM shift, on [DATE], a Medical Doctor's (MD) order was written for a psychiatric (psych) evaluation. On [DATE], Resident #1 wanted to be admitted to hospice services. Another MD order was written on [DATE] to discontinue (D/C) the psych evaluation and resident was admitted to contract hospice services. He remained on one-on-one observation through to [DATE] when he went to every hour observations. Resident #1 was observed by Licensed Practical Nurse (LPN) #1 at 7:15 AM lying in his bed with his eyes closed. LPN #1 took Resident #1's breakfast tray to his room at 8:30 AM and when the door was opened, Resident #1 was observed hanging from a pipe with the bed remote control cord wrapped around his neck. He was noted to be warm. LPN #1 yelled for help and LPN #2 responded. LPN #2 cut Resident #1 down and began doing sternal rubs with no response. Emergency Medical Services (EMS) were called as were hospice services. EMS arrived to the facility and found Resident #1 with no heart activity and he was pronounced dead at 9:00 AM.
The facility made an initial notification to the State Department of Health Licensure and Certification hotline regarding Resident #1 on [DATE] at 9:58 am that reported an attempted suicide. Resident #1 was pronounced dead at the facility on [DATE] at 9:00 am.
Resident #1's Resident Representative (RR) notified the local sheriff department and Attorney General's office of the suicide of Resident #1. The facility did not report to these agencies.
The facility's failure to report after the suicide of Resident #1 delayed the investigation of his unusual death in the facility and placed residents in a situation that was likely to cause serious injury, harm, impairment, or death.
The State Agency (SA) investigated the death of Resident #1 on [DATE] through [DATE]. After review by the SA, the SA extended the survey on [DATE] through [DATE] and the situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on [DATE], when the facility failed to notify the local law enforcement and the State Attorney General Office of the suicide of Resident #1.
The IJ and SQC existed at:
42 CFR 483.12(c)(1) Reporting of Alleged Violations - F609 Scope/Severity J
The SA notified the facility's Administrator of the IJ and SQC on [DATE] at 12:30 PM and provided the Administrator with the IJ template.
The facility submitted an acceptable Removal Plan on [DATE], in which they alleged all corrective actions to remove the IJ and SQC were completed on [DATE] and the IJ was removed on [DATE].
The SA validated the Removal Plan on [DATE] and determined the IJ and SQC was removed on [DATE], prior to exit. Therefore, the scope and severity of 42 CFR 483.12(c)(1) Reporting of Alleged Violations - F609 was lowered to a D while the facility develops a plan of correction to monitor the effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements.
Findings include:
Record review of the facility's policy/procedure for Abuse Prevention last dated 10/22 revealed REPORTING: Alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including State Survey Agency, Adult Protective Services (APS) , and local law enforcement as required).
Record review of the initial notification to the State Department of Health Licensure and Certification hotline regarding the suicide of Resident #1 on [DATE] revealed the facility reported an attempted suicide on [DATE] at 9:58 am.
An interview with the Administrator on [DATE] at 3:10 PM regarding reporting incidents to the State Agency (SA) revealed, I called and left a voicemail reporting a suicide attempt. He died a little after 9:00 AM. He was pronounced here by Emergency Medical Service (EMS). He was found around 8:30 AM and had a pulse. He was a DNR. They did call the ambulance and hospice right after he was found. She revealed she was told to report the incident as a suicide attempt by the facility's Regional Nurse Consultant.
Interview with the local Ombudsman on [DATE] at 2:30 PM, revealed she had not been contacted by the facility regarding a possible suicide.
Interview with the Administrator on [DATE] at 10:45 AM, confirms that she did not contact the Ombudsman regarding the suicide of Resident #1. She revealed that the Attorney General (AG) Investigator had been at the facility earlier on [DATE] and interviewed two (2) staff members about Resident #1's suicide. She stated she had not contacted the Attorney General (AG) office about Resident #1's suicide and assumed the SA had. She revealed she did not know she should have contacted the AG office.
Interview with Resident #1's Resident Representative (RR), on [DATE] at 1:00 PM, revealed that she called the police and sheriff department on [DATE] after her brother had committed suicide.
Interview with the Director of Nurses (DON) on [DATE] at 2:00 PM, revealed that No, we didn't call the police after he died. The sheriff officer showed up here around lunch. His body wasn't here anymore.
Interview with the AG Investigator on [DATE] at 10:37 AM, revealed the AG office did not receive notification of this suicide from the facility. He stated the resident's sister contacted the AG office on [DATE]. He said the Administrator said she didn't know she had to report to the AG office.
Record review by the State Agency (SA) of Resident #1's Face Sheet revealed he was admitted on [DATE] to the facility with diagnoses which included Malignant Neoplasm of Larynx, unspecified and Depression, unspecified.
Record review of the Departmental Notes with a Category: Nursing dated [DATE] at 9:31 PM revealed, .Resident stated that he's scared of been in (being) in facility and in room by himself Please don't leave me alone, I'm scared .Resident states he doesn't want to die here .Resident not adjusting to new surroundings well. Resident hollering out loud .Resident refuse to stay in his room due to he's scared of been (being) alone .Stating that he wants to call him friend to pick him up so he can jump off bridge cause he's tired of living . He was placed one on one observation with staff after making that comment. Record review of the Departmental Notes with a Category: Nursing dated [DATE] at 7:21 AM revealed, .Resident constantly states he wants to die. He wrapped oxygen tubing around his neck .Resident asked staff if he hit his head against the wall will go ahead and take him out . On [DATE] at 6:23 AM, Resident #1 ambulated to the nursing station and stated he had slipped. A laceration on his face and skin tear on his arm were cleaned. Resident #1 was observed by Licensed Practical Nurse #1 at 7:15 AM lying in his bed with his eyes closed. LPN#1 took Resident #1's breakfast tray to his room at 8:30 AM and when the door was opened, Resident #1 was observed hanging from a pipe with the bed remote control cord wrapped around his neck. He was noted warm. LPN #1 yelled for help and LPN #2 responded. LPN #2 cut Resident #1 down using bandage scissors and began doing sternal rubs with no response. The facility called Emergency Medical Services (EMS) and hospice services. EMS arrived at the facility and found Resident #1 with no heart activity, and he was pronounced dead at 9:00 AM. Hospice contacted the coroner, and the body was released to the Medical Examiner.
The facility provided the following Removal Plan:
Resident #1 was admitted on [DATE]. Resident #1 expressed that he wanted to sign up for hospice services on admission due to him being tired. He stated I been suffering from throat cancer for seven years. I'm just tired. Resident #1 expressed that he wanted to call his friend so that he could jump off a bridge. On [DATE], a psychiatric consult was ordered. The resident was admitted to hospice on [DATE]. The psychiatric consult was discontinued on [DATE] by the physician after he elected hospice services. The facility failed to adequately meet Resident #1's mental health needs when the facility did not provide a psychiatric evaluation on [DATE], after Resident # 1 stated that he wanted to jump off a bridge. The facility failed to ensure the Medical Director evaluated and acted on reported deficient practices related to Resident #1's actual suicide and failed to ensure that orders for the psychological evaluations were carried out as ordered. The facility failed to adequately meet Resident #1's mental health needs when the facility did not complete a status change PASARR when, on [DATE], Resident #1 verbalized suicidal ideations. The facility neglected to provide psychological interventions upon admission, on [DATE], to protect Resident #1, who expressed suicidal ideations and ultimately was found hanging in the facility on [DATE]. The facility failed to accurately report an actual suicide for Resident #1 when he was found hanging from the pipes in the ceiling at 8:15 AM on [DATE]. The incident was reported as an attempted suicide to the department of licensure and certification (L&C) at 9:57 AM on [DATE]. The incident was not reported to the appropriate state agencies within the specific time frame, as required by federal guidance. The Administrator/Executive Director failed to ensure that Resident #1's psychological needs were addressed by a lack of immediate intervention and a lack of carrying out of a physician order for a psychological evaluation, which resulted in Resident #1's death.
Interventions
* The facility held an emergency meeting on [DATE] at 1:00 PM, with the Quality Assurance team to discuss and implement removal plans for citations F600, F609, F644, F835, F841, related to Resident #1's suicide on [DATE]. The Administrator/Executive Director, the DON/IP, the unit manager, the Medical Director, the activities director, the [NAME] President to the Administrator/Executive Director, social worker #1, and social worker #2 were in attendance.
*On [DATE], a new preadmission screening and resident review (PASRR) policy was created for the facility to coincide with federal and state guidelines. The policy was created by the Executive Director/Administrator of the facility and the governing body.
*The facility implemented the policy for PASARR, to coincide with state and federal regulations. The policy was approved in the Emergency Quality and Assurance meeting held on [DATE], at 1:00 PM
*An in-service on neglect and abuse was provided to all staff on [DATE], at 1:30 PM, by the Director of Nursing/Infection Preventionist (DON/IP). The information covered in the in-service included the definition of abuse and neglect, the different types of abuse and neglect, and what steps to take if abuse or neglect is witnessed or suspected.
*An in-service education on self reporting requirements was provided to the Administrator/Executive Director and the DON/IP to include reporting accurately to state agencies on [DATE] at 2:00 PM, by the [NAME] President to the Administrator. The abuse and neglect policy was reviewed in the in-service which included the types of incidents that must be reported, the time frame in which to report, and the entities (Attorney General's Office, Licensure and Certification, Ombudsman) that must be reported to.
*An in-service education was provided with all licensed nurses by the DON on [DATE] at 3:00 PM to review the policy on physician orders including, The signature of the nurse receiving the order and the time of the order must appear.
*An in-service education was provided to social service on [DATE], at 3:30 PM, by the Administrator/Executive Director, to include an increase in social visits for all residents with suicidal ideation to be seen by social service at least 3 times weekly, until they no longer have suicidal ideation.
*An in-service education on the Administrator's job description was provided to the Administrator/Executive Director to include that the Administrator must provide oversight to provide the necessary care for residents who express suicidal ideation and for residents who have psychosocial needs that are not met. This was completed [DATE], at 4:00 PM, by the [NAME] President to the Administrator/Executive Director.
*An in-service education was provided on PASARR to Social Services on [DATE], by the Administrator/Executive Director. Another PASARR in-service/education was completed on [DATE], at 4:30 PM by the [NAME] President to the Administrator, the DON/IP, Social Services, the Medical Director, and the Director of Admission. The information covered in the in-service included when to complete a new PASARR and the appropriate agency to send the completed forms to.
*An in-service education on the Medical Director Policy was provided to the Medical Director on [DATE], at 5:00 PM, by the Administrator/Executive Director. The information covered in the in-service included the role and responsibilities of the Medical Director and leading the continuity of care with nursing services to include physician orders with accurate times and dates.
*A one hundred percent audit was completed on [DATE], by the Administrator/Executive Director, of all current resident's PASARRs to ensure status change of assessment has been completed to include new diagnosis and to reflect that mood and behavior changes are included in the status change. Fifty-eight resident's status change forms were sent to the state mental health authority for a status change on [DATE] at 8:00 PM.
*A resident council meeting was completed by the activities director on [DATE], at 2:30 PM. The residents were encouraged to express their feelings. An additional follow up resident counsel meeting was held on [DATE] at 2:00 PM by the activities director. No negative effects reported from the residents.
*An education/in-service was provided to social service and nursing staff to immediately get psychiatric evaluation for residents with any new behaviors to include suicidal ideation. This was completed [DATE], at 5:00 PM, by the Administrator/Executive Director and the DON/IP. A memo was placed at each nurses station to reflect the instructions of the in-service completed by 4:00 PM on [DATE], by the DON/IP.
*Six residents with history of suicide ideation were seen per the psychiatric nurse practitioner, on [DATE] and [DATE]. All residents denied suicidal ideations on evaluation per the psychiatric nurse practitioner.
*A phone meeting was held with the Administrator/Executive Director and the area [NAME] President of Sales for hospice on [DATE], at 9:00 AM, concerning communication and collaboration between hospice and facility to provide better service for the residents receiving hospice care in the nursing facility. On [DATE] a new system change included a hospice communication book was placed at each nurse's station for any change in condition to hospice residents.
*A grief counseling meeting was conducted by the hospice Chaplin on [DATE], from 11:00 AM until 3:00 PM for the residents and staff.
*An in-service/education was provided to all the licensed nursing staff to notify hospice of all changes in condition, this will include condition changes such as, decline or improvement, medication changes, new orders of any type, and psychiatric needs and/or evaluations. All communication with hospice will be documented in the interdisciplinary notes and placed on hospice notification form (Form #1) in the hospice communication book. The in-service was completed by the DON/IP on [DATE] by 5:30 PM.
*A second emergency Quality Assurance meeting held to discuss the new system implemented to communicate with hospice, the new hospice form #1, and communication book. This meeting was held on [DATE] at 5:00 PM. In attendance were the Administrator/Executive Director, the DON/IP, the Unit Manager, Social Worker #1, Social Worker #2 and the Medical Director per phone.
*Any employee that has not been in-serviced will not be allowed to return to work until all in-services are completed.
*On [DATE], the Emergency Medical Services were notified at 8:51 AM, along with hospice, the coroner, the Department of Health, and the resident's responsible party.
*The State Health Department was notified on [DATE] at 9:57 AM, by the Executive Director/Administrator. The Attorney General's Office (AG) was notified on [DATE] by the Executive Director/Administrator at 8:30 AM while at the facility investigating the incident.
*The Sheriff's Department was notified on [DATE], at 1:00 PM, while at the facility investigating the incident by the Executive Director/Administrator. The Ombudsman was notified by phone on [DATE], at 11:00 AM, by the Executive Director/Administrator.
*On [DATE], at 12:30 PM, an emergency Quality Assurance meeting was held to discuss immediate interventions completed and interventions to be put in place related to Resident #1's suicide. In attendance was the Director of Nursing/Infection Preventionist, the Executive Director/Administrator, the House Supervisor, Social Worker #1, Social Worker #2 and the Medical Director by phone.
*A trauma screening was performed on each resident in the facility. No issues were found. This was completed on [DATE] between 10:00 AM and 12:00 PM, by social services.
*All staff was in-serviced on abuse, neglect, and suicide precautions starting at 10:00 AM on [DATE], by the DON/IP.
*All care plans of residents with a history of suicidal ideation were updated to include the following interventions, residents that express feelings of harming themselves will be immediately placed on one on one and seen by the psychiatric nurse practitioner or a physician. If the psychiatric nurse practitioner or the physician are not available, then the resident will be sent to the emergency room for evaluation.
*These interventions were added to the plans of care of six residents on [DATE] between 1:00 PM and 2:00 PM, by social services.
*100% audit of all beds to ensure bed remote secured to bed by social service, this was completed [DATE], by 3:00 PM. There were two beds that required maintenance to secure the cord to the bed. The cords were secured immediately.
*For residents protection, all residents with a history of suicidal ideation were assessed for thoughts of self harm between the hours of 1:00 PM and 3:00 PM on [DATE], by social services. No resident reported thoughts of self harm.
*An in-service was provided to social services to ensure that all residents with suicidal ideation will be seen by social service at least weekly, until they no longer have suicidal ideation. This in-service was completed by the DON/IP on [DATE], at 5:00 PM.
*An in-service was completed with all staff by the DON/IP at 6:00 PM on [DATE]. Training included that all residents that express feelings of harming themselves will be immediately placed on one on one and seen by the psychiatric nurse practitioner or a physician. If the psychiatric nurse practitioner or the physician are not available, then the resident will be sent to the emergency room for evaluation.
Facility alleged compliance on [DATE].
On [DATE], the State Agency (SA) validated the facility's Removal Plan by staff interviews, record reviews, and review of the in-service sign in sheets. The SA verified the facility had implemented the following measures to remove the IJ:
The SA validated through interviews and record review that the facility held an emergency meeting on [DATE] at 1:00 PM, with the Quality Assurance team to discuss and implement removal plans for citations F600, F609, F644, F835, F841, related to Resident #1's suicide on [DATE]. Interviews with the Administrator/Executive Director, the DON/IP, the unit manager, the Medical Director, the [NAME] President to the Administrator/Executive Director, social worker #1, and social worker #2 confirmed all were in attendance.
The SA validated through record review and interviews with the Administrator/Executive Director, Director of Nurses (DON), Social Worker #1, Social Worker #2 that on [DATE], a new preadmission screening and resident review (PASARR) policy was created for the facility to coincide with federal and state guidelines. The policy was created by the Executive Director/Administrator of the facility and the governing body.
The SA validated through record review and interviews with the Administrator/Executive Director, DON, Social Worker #1, Social Worker #2, Medical Director, Unit Manager that the facility implemented the policy for PASARR, to coincide with state and federal regulations. The policy was approved in the Emergency Quality and Assurance meeting held on [DATE], at 1:00 PM.
The SA validated through record review and interviews with four Registered Nurses, five Licensed Practical Nurses, eight Certified Nurse Aides, one Laundry staff, three Housekeepers, two Social Workers, one Medical Director, one Administrator/Executive Director that an in-service on neglect and abuse was provided to all staff on [DATE], at 1:30 PM, by the Director of Nursing/Infection Preventionist (DON/IP). The information covered in the in-service included the definition of abuse and neglect, the different types of abuse and neglect, and what steps to take if abuse or neglect is witnessed or suspected.
The SA validated through record review and interviews with the Director of Nurses (DON) and Administrator/Executive Director that an in-service education on self reporting requirements was provided to the Administrator/Executive Director and the DON/IP to include reporting accurately to state agencies on [DATE] at 2:00 PM, by the [NAME] President to the Administrator. The abuse and neglect policy was reviewed in the in-service which included the types of incidents that must be reported, the time frame in which to report, and the entities (Attorney General's Office, Licensure and Certification, Ombudsman) that must be reported to.
The SA validated through record review and interviews with the Administrator/Executive Director, four RN's and five LPN's that an in-service education was provided with all licensed nurses by the DON on [DATE] at 3:00 PM to review the policy on physician orders including, The signature of the nurse receiving the order and the time of the order must appear.
The SA validated through record review and interviews with two Social Workers and Administrator/Executive Director that an in-service education was provided to social service on [DATE], at 3:30 PM, by the Administrator/Executive Director, to include an increase in social visits for all residents with suicidal ideation to be seen by social service at least 3 times weekly, until they no longer have suicidal ideation.
The SA validated through interview with the Administrator/Executive Director and record review that an in-service education on the Administrator's job description was provided to the Administrator/Executive Director to include that the Administrator must provide oversight to provide the necessary care for residents who express suicidal ideation and for residents who have psychosocial needs that are not met. This was completed [DATE], at 4:00 PM, by the [NAME] President to the Administrator/Executive Director.
The SA validated through record review and interviews with two Social Workers and the Administrator/Executive Director that an in-service education was provided on PASARR to Social Services on [DATE], by the Administrator/Executive Director. Another PASARR in-service/education was completed on [DATE], at 4:30 PM by the [NAME] President to the Administrator, the DON/IP, Social Services, the Medical Director, and the Director of Admission. The information covered in the in-service included when to complete a new PASARR and the appropriate agency to send the completed forms to.
The SA validated through record review and interviews with the Medical Director and Administrator/Executive Director that an in-service education on the Medical Director Policy was provided to the Medical Director on [DATE], at 5:00 PM, by the Administrator/Executive Director. The information covered in the in-service included the role and responsibilities of the Medical Director and leading the continuity of care with nursing services to include physician orders with accurate times and dates.
The SA validated by record review and interviews with the Administrator/Executive Director and two Social Workers that a one hundred percent audit was completed on [DATE], by the Administrator/Executive Director, of all current resident's PASARRs to ensure status change of assessment has been completed to include new diagnosis and to reflect that mood and behavior changes are included in the status change. Fifty-eight resident's status change forms were sent to the state mental health authority for a status change on [DATE] at 8:00 PM.
The SA validated through interviews with the Administrator, DON and SW #1 and record review a resident council meeting was completed by the activities director on [DATE], at 2:30 PM. The residents were encouraged to express their feelings. An additional follow up resident counsel meeting was held on [DATE] at 2:00 PM by the activities director. No negative effects reported from the residents.
The SA validated through interviews with five LPN's, one Activity Director, two Social Workers, one Director of Admissions, three RN's and five CNA's that an education/in-service was provided to social service and nursing staff to immediately get psychiatric evaluation for residents with any new behaviors to include suicidal ideation. This was completed [DATE], at 5:00 PM, by the Administrator/Executive Director and the DON/IP. A memo was placed at each nurses station to reflect the instructions of the in-service completed by 4:00 PM on [DATE], by the DON/IP.
The SA validated through interviews with the Administrator, DON and SW and record review that six residents with history of suicide ideation were seen per the psychiatric nurse practitioner, on [DATE] and [DATE]. All residents denied suicidal ideations on evaluation per the psychiatric nurse practitioner.
The SA validated through interviews with the Administrator and the [NAME] President of sales for hospice and record review that a phone meeting was held with the Administrator/Executive Director and the area [NAME] President of Sales for hospice on [DATE], at 9:00 AM, concerning communication and collaboration between hospice and facility to provide better service for the residents receiving hospice care in the nursing facility. On [DATE] a new system change included a hospice communication book was placed at each nurse's station for any change in condition to hospice residents.
The SA validated through interviews with the Administrator, DON and SW and a record review that a grief counseling meeting was conducted by the hospice Chaplin on [DATE], from 11:00 AM until 3:00 PM for the residents and staff.
The SA validated through interviews with five LPN's, one Activity Director, two Social Workers, one Director of Admissions, three RN's and five CNA's an in-service/education was provided to all the licensed nursing staff to notify hospice of all changes in condition, this will include condition changes such as, decline or improvement, medication changes, new orders of any type, and psychiatric needs and/or evaluations. All communication with hospice will be documented in the interdisciplinary notes and placed on hospice notification form (Form #1) in the hospice communication book. The in-service was completed by the DON/IP on [DATE] by 5:30 PM.
The SA validated through interviews with the Administrator, DON, Medical Director and SW and record review that a second emergency Quality Assurance meeting held to discuss the new system implemented to communicate with hospice, the new hospice form #1, and communication book. This meeting was held on [DATE] at 5:00 PM. In attendance were the Administrator/Executive Director, the DON/IP, the Unit Manager, Social Worker #1, Social Worker #2 and the Medical Director per phone.
Any employee that has not been in-serviced will not be allowed to return to work until all in-services are completed.
The SA validated through interviews with the Administrator and DON and record review that on [DATE], the Emergency Medical Services were notified at 8:51 AM, along with hospice, the coroner, the Department of Health, and the resident's responsible party.
The SA validated through interviews with the Administrator and DON that The State Health Department was notified on [DATE] at 9:57 AM, by the Executive Director/Administrator. The Attorney General's Office (AG) was notified on [DATE] by the Executive Director/Administrator at 8:30 AM while at the facility investigating the incident.
The SA validated through interview with the Administrator that the Sheriff's Department was notified on [DATE], at 1:00 PM, while at the facility investigating the incident by the Executive Director/Administrator. The Ombudsman was notified by phone on [DATE], at 11:00 AM, by the Executive Director/Administrator.
The SA validated through record review and interviews with the Administrator, DON, SW #1 and Medical Director that on [DATE], at 12:30 PM, an emergency Quality Assurance meeting was held to discuss immediate interventions completed and interventions to be put in place related to Resident #1's suicide. In attendance was the Director of Nursing/Infection Preventionist, the Executive Director/Administrator, the House Supervisor, Social Worker #1, Social Worker #2 and the Medical Director by phone.
The SA validated through record review and interviews with the Administrator, DON and SW that a trauma screening was performed on each resident in the facility. No issues were found. This was completed on [DATE] between 10:00 AM and 12:00 PM, by social services.
The SA validated through record review and interviews with five LPN's, one Activity Director, two Social Workers, one Director of Admissions, three RN's and five CNA's that all staff was in-serviced on abuse, neglect, and suicide precautions starting at 10:00 AM on [DATE], by the DON/IP.
The SA validated through record review and interviews with the Administrator and DON that all care plans of residents with a history of suicidal ideation were updated to include the following interventions, residents that express feelings of harming themselves will be immediately placed on one on one and seen by the psychiatric nurse practitioner or a physician. If the psychiatric nurse practitioner or the physician are not available, then the resident will be sent to the emergency room for evaluation. These interventions were added to the plans of care of six residents on [DATE] between 1:00 PM and 2:00 PM, by social services.
The SA va[TRUNCATED]
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
PASARR Coordination
(Tag F0644)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to coordinate a resident review with the Preadmission Screening...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to coordinate a resident review with the Preadmission Screening and Resident Review (PASARR) program under Medicaid by not referring a resident that expressed suicidal ideations on admission for a significant change in status assessment for review by the State Designated Authority for one (1) of seven (7) residents sampled. Resident #1.
During the admission process on 8/8/23, Resident #1 told the admitting nurse that he wanted to call a friend to pick him up and take him to jump off a bridge. During the 11:00 PM to 7:00 AM shift, on 8/9/23, a Medical Doctor's (MD) order was written for a psychiatric (psych) evaluation. On 8/9/23, Resident #1 wanted to be admitted to hospice services. Another MD order was written on 8/9/23 to discontinue (D/C) the psych evaluation and resident was admitted to contract hospice services. He remained on one-on-one observation through to 8/17/23 when he went to every hour observations. Resident #1 was observed by Licensed Practical Nurse (LPN) #1 at 7:15 AM lying in his bed with his eyes closed. LPN #1 took Resident #1's breakfast tray to his room at 8:30 AM and when the door was opened, Resident #1 was observed hanging from a pipe with the bed remote control cord wrapped around his neck. He was noted to be warm. LPN #1 yelled for help and LPN #2 responded. LPN #2 cut Resident #1 down and began doing sternal rubs with no response. Emergency Medical Services (EMS) were called as were hospice services. EMS arrived at the facility and found Resident #1 with no heart activity, and he was pronounced dead at 9:00 AM.
The facility's failure to submit a significant change in status assessment for review by the State Designated Authority to ensure Resident #1 received the care and services in the most appropriate setting for his needs after he expressed suicidal ideations on admission and during the next shift placed this resident and other residents in a situation that was likely to cause serious injury, harm, impairment, or death.
The State Agency (SA) investigated the death of Resident #1 on 8/22/23 through 8/28/23. After SA review, the SA extended the survey on 9/7/23 through 9/11/23 and the situation was determined to be an Immediate Jeopardy (IJ) when began on 8/9/23 when the physician's order for a psychiatric evaluation for Resident #1 written on 8/9/23 was discontinued on 8/9/23 and the facility failed to refer the resident to the State Designated Authority for evaluation.
The IJ existed at:
42 CFR 483.20(e)(2) Coordination of PASARR and Assessments - F644 Scope/Severity J
The SA notified the notified the facility's Administrator of the IJ on 9/7/23 at 12:30 PM and provided the Administrator with the IJ template.
The facility submitted an acceptable Removal Plan on 9/8/23, in which they alleged all corrective actions to remove the IJ was completed on 9/7/23 and the IJ was removed on 9/8/23.
The SA validated the Removal Plan on 9/11/23 and determined the IJ was removed on 9/8/23, prior to exit. Therefore, the scope and severity of 42 CFR 483.20(e)(2) Coordination of PASARR and Assessments (F644) was lowered to a Scope and Severity of D while the facility develops a plan of correction to monitor the effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements.
Findings Include:
The Administrator provided a statement on a facility letter head revealing the facility had no policy or procedure addressing the process of completing a PASARR significant change in status assessment.
An interview with the Administrator on 8/23/23 at 4:10 PM revealed the facility did not do a change of status PASARR for Resident #1 after he had expressed suicidal ideations. She stated, We don't have a specific policy or procedure for doing the PASARR.
Record review of the Screening Questionnaire dated 8/7/23 revealed 19. In the last 3 days, has (formal first name of Resident #1) had any of the following problems .e. Displayed self-injurious behavior? The response is Present but not exhibited in last 3 days . 31. Does (formal first name of Resident #1) have any history of mental illness? Mental illness includes any concerns about emotional wellness that interfere with quality of life or daily functioning. This includes depression, anxiety, psychosis, loss of interest in daily activities, etc. The response is checked Yes.
Record review of the State Designated Authority's response to the facility Level 1, admission Pre-admission Screening (PAS), dated 8/8/23 at 12:48 PM revealed, Resident #1 was appropriate for nursing facility placement.
Record review of Resident #1's Face Sheet revealed he was admitted on [DATE] to the facility with diagnoses which included Malignant Neoplasm of Larynx, Restlessness and Agitation, unspecified and Depression, unspecified.
Record review of Resident #1's PASARR information revealed that there was not a change of status form completed and sent to the State Designated Authority for a reassessment after Resident #1 made suicidal ideation statements on 8/8/23 during his admission to the facility.
An interview with the Administrator on 8/28/23 at 10:50 AM revealed the Social Worker was responsible for completing the change of status assessment form for the PASARR.
An interview with the Social Worker on 8/28/23 at 10:58 AM confirmed she did not submit a change in status PASARR for Resident #1. The Social Worker stated, Because he (Resident #1) was on hospice, my understanding was I didn't have to submit a change in status form to send to the proper State Designated Authority (proper name).
An interview with a staff member at the State Designated Authority on 8/28/23 at 11:10 AM revealed that if a resident is voicing suicidal ideations a change of status assessment should be done, even if the resident was admitted to Hospice. She stated that the two (2) incidents are separate. The regulations are giving guidance that states a change of status assessment does not have to be completed anytime a resident is admitted to Hospice if that is the only change in care.
Record review of the Departmental Notes with a Category: Nursing dated 8/8/21 at 9:31 PM revealed, .Resident stated that he's scared of been in (being) in facility and in room by himself Please don't leave me alone, I'm scared .Resident states he doesn't want to die here .Resident not adjusting to new surroundings well. Resident hollering out loud .Resident refuse to stay in his room due to he's scared of been (being) alone .Stating that he wants to call him friend to pick him up so he can jump off bridge cause he's tired of living . He was placed one on one observation with staff after making that comment. Record review of the Departmental Notes with a Category: Nursing dated 8/9/21 at 7:21 AM revealed, .Resident constantly states he wants to die. He wrapped oxygen tubing around his neck .Resident asked staff if he hit his head against the wall will go ahead and take him out . On 8/19/23 at 6:23 AM, Resident #1 ambulated to the nursing station and stated he had slipped. A laceration on his face and skin tear on his arm were cleaned. Resident #1 was observed by Licensed Practical Nurse #1 at 7:15 AM lying in his bed with his eyes closed. LPN#1 took Resident #1's breakfast tray to his room at 8:30 AM and when the door was opened, Resident #1 was observed hanging from a pipe with the bed remote control cord wrapped around his neck. He was noted warm. LPN #1 yelled for help and LPN #2 responded. LPN #2 cut Resident #1 down using bandage scissors and began doing sternal rubs with no response. The facility called Emergency Medical Services (EMS) and hospice services. EMS arrived at the facility and found Resident #1 with no heart activity, and he was pronounced dead at 9:00 AM. Hospice contacted the coroner, and the body was released to the Medical Examiner.
The facility provided the following Removal Plan:
Resident #1 was admitted on [DATE]. Resident #1 expressed that he wanted to sign up for hospice services on admission due to him being tired. He stated I been suffering from throat cancer for seven years. I'm just tired. Resident #1 expressed that he wanted to call his friend so that he could jump off a bridge. On 08/09/2023, a psychiatric consult was ordered. The resident was admitted to hospice on 8/9/2023. The psychiatric consult was discontinued on 8/9/2023 by the physician after he elected hospice services. The facility failed to adequately meet Resident #1's mental health needs when the facility did not provide a psychiatric evaluation on 8/8/2023, after Resident # 1 stated that he wanted to jump off a bridge. The facility failed to ensure the Medical Director evaluated and acted on reported deficient practices related to Resident #1's actual suicide and failed to ensure that orders for the psychological evaluations were carried out as ordered. The facility failed to adequately meet Resident #1's mental health needs when the facility did not complete a status change PASARR when, on 8/8/23, Resident #1 verbalized suicidal ideations. The facility neglected to provide psychological interventions upon admission, on 8/8/23, to protect Resident #1, who expressed suicidal ideations and ultimately was found hanging in the facility on 8/19/23. The facility failed to accurately report an actual suicide for Resident #1 when he was found hanging from the pipes in the ceiling at 8:15 AM on 8/19/2023. The incident was reported as an attempted suicide to the department of licensure and certification (L&C) at 9:57 AM on 8/19/2023. The incident was not reported to the appropriate state agencies within the specific time frame, as required by federal guidance. The Administrator/Executive Director failed to ensure that Resident #1's psychological needs were addressed by a lack of immediate intervention and a lack of carrying out of a physician order for a psychological evaluation, which resulted in Resident #1's death.
Interventions
* The facility held an emergency meeting on 9/7/2023 at 1:00 PM, with the Quality Assurance team to discuss and implement removal plans for citations F600, F609, F644, F835, F841, related to Resident #1's suicide on 8/19/23. The Administrator/Executive Director, the DON/IP, the unit manager, the Medical Director, the activities director, the [NAME] President to the Administrator/Executive Director, social worker #1, and social worker #2 were in attendance.
*On 9/7/2023, a new preadmission screening and resident review (PASARR) policy was created for the facility to coincide with federal and state guidelines. The policy was created by the Executive Director/Administrator of the facility and the governing body.
*The facility implemented the policy for PASARR, to coincide with state and federal regulations. The policy was approved in the Emergency Quality and Assurance meeting held on 9/7/23, at 1:00 PM
*An in-service on neglect and abuse was provided to all staff on 9/7/2023, at 1:30 PM, by the Director of Nursing/Infection Preventionist (DON/IP). The information covered in the in-service included the definition of abuse and neglect, the different types of abuse and neglect, and what steps to take if abuse or neglect is witnessed or suspected.
*An in-service education on self reporting requirements was provided to the Administrator/Executive Director and the DON/IP to include reporting accurately to state agencies on 9/7/2023 at 2:00 PM, by the [NAME] President to the Administrator. The abuse and neglect policy was reviewed in the in-service which included the types of incidents that must be reported, the time frame in which to report, and the entities (Attorney General's Office, Licensure and Certification, Ombudsman) that must be reported to.
*An in-service education was provided with all licensed nurses by the DON on 9/7/2023 at 3:00 PM to review the policy on physician orders including, The signature of the nurse receiving the order and the time of the order must appear.
*An in-service education was provided to social service on 9/7/2023, at 3:30 PM, by the Administrator/Executive Director, to include an increase in social visits for all residents with suicidal ideation to be seen by social service at least 3 times weekly, until they no longer have suicidal ideation.
*An in-service education on the Administrator's job description was provided to the Administrator/Executive Director to include that the Administrator must provide oversight to provide the necessary care for residents who express suicidal ideation and for residents who have psychosocial needs that are not met. This was completed 9/7/2023, at 4:00 PM, by the [NAME] President to the Administrator/Executive Director.
*An in-service education was provided on PASARR to Social Services on 8/23/2023, by the Administrator/Executive Director. Another PASARR in-service/education was completed on 9/7/23, at 4:30 PM by the [NAME] President to the Administrator, the DON/IP, Social Services, the Medical Director, and the Director of Admission. The information covered in the in-service included when to complete a new PASARR and the appropriate agency to send the completed forms to.
*An in-service education on the Medical Director Policy was provided to the Medical Director on 9/7/23, at 5:00 PM, by the Administrator/Executive Director. The information covered in the in-service included the role and responsibilities of the Medical Director and leading the continuity of care with nursing services to include physician orders with accurate times and dates.
*A one hundred percent audit was completed on 08/31/23, by the Administrator/Executive Director, of all current resident's PASARRs to ensure status change of assessment has been completed to include new diagnosis and to reflect that mood and behavior changes are included in the status change. Fifty-eight resident's status change forms were sent to the state mental health authority for a status change on 9/7/23 at 8:00 PM.
*A resident council meeting was completed by the activities director on 08/21/2023, at 2:30 PM. The residents were encouraged to express their feelings. An additional follow up resident counsel meeting was held on 9/5/2023 at 2:00 PM by the activities director. No negative effects reported from the residents.
*An education/in-service was provided to social service and nursing staff to immediately get psychiatric evaluation for residents with any new behaviors to include suicidal ideation. This was completed 08/21/2023, at 5:00 PM, by the Administrator/Executive Director and the DON/IP. A memo was placed at each nurses station to reflect the instructions of the in-service completed by 4:00 PM on 8/21/2023, by the DON/IP.
*Six residents with history of suicide ideation were seen per the psychiatric nurse practitioner, on 08/21/2023 and 08/22/2023. All residents denied suicidal ideations on evaluation per the psychiatric nurse practitioner.
*A phone meeting was held with the Administrator/Executive Director and the area [NAME] President of Sales for hospice on 08/23/2023, at 9:00 AM, concerning communication and collaboration between hospice and facility to provide better service for the residents receiving hospice care in the nursing facility. On 8/23/2023 a new system change included a hospice communication book was placed at each nurse's station for any change in condition to hospice residents.
*A grief counseling meeting was conducted by the hospice Chaplin on 08/23/2023, from 11:00 AM until 3:00 PM for the residents and staff.
*An in-service/education was provided to all the licensed nursing staff to notify hospice of all changes in condition, this will include condition changes such as, decline or improvement, medication changes, new orders of any type, and psychiatric needs and/or evaluations. All communication with hospice will be documented in the interdisciplinary notes and placed on hospice notification form (Form #1) in the hospice communication book. The in-service was completed by the DON/IP on 08/23/2023 by 5:30 PM.
*A second emergency Quality Assurance meeting held to discuss the new system implemented to communicate with hospice, the new hospice form #1, and communication book. This meeting was held on 08/23/2023 at 5:00 PM. In attendance were the Administrator/Executive Director, the DON/IP, the Unit Manager, Social Worker #1, Social Worker #2 and the Medical Director per phone.
*Any employee that has not been in-serviced will not be allowed to return to work until all in-services are completed.
*On 08/19/2023, the Emergency Medical Services were notified at 8:51 AM, along with hospice, the coroner, the Department of Health, and the resident's responsible party.
*The State Health Department was notified on 08/19/2023 at 9:57 AM, by the Executive Director/Administrator. The Attorney General's Office (AG) was notified on 08/23/2023 by the Executive Director/Administrator at 8:30 AM while at the facility investigating the incident.
*The Sheriff's Department was notified on 08/19/2023, at 1:00 PM, while at the facility investigating the incident by the Executive Director/Administrator. The Ombudsman was notified by phone on 08/23/2023, at 11:00 AM, by the Executive Director/Administrator.
*On 8/19/2023, at 12:30 PM, an emergency Quality Assurance meeting was held to discuss immediate interventions completed and interventions to be put in place related to Resident #1's suicide. In attendance was the Director of Nursing/Infection Preventionist, the Executive Director/Administrator, the House Supervisor, Social Worker #1, Social Worker #2 and the Medical Director by phone.
*A trauma screening was performed on each resident in the facility. No issues were found. This was completed on 8/19/2023 between 10:00 AM and 12:00 PM, by social services.
*All staff was in-serviced on abuse, neglect, and suicide precautions starting at 10:00 AM on 8/19/2023, by the DON/IP.
*All care plans of residents with a history of suicidal ideation were updated to include the following interventions, residents that express feelings of harming themselves will be immediately placed on one on one and seen by the psychiatric nurse practitioner or a physician. If the psychiatric nurse practitioner or the physician are not available, then the resident will be sent to the emergency room for evaluation.
*These interventions were added to the plans of care of six residents on 8/19/2023 between 1:00 PM and 2:00 PM, by social services.
*100% audit of all beds to ensure bed remote secured to bed by social service, this was completed 08/19/2023, by 3:00 PM. There were two beds that required maintenance to secure the cord to the bed. The cords were secured immediately.
*For residents protection, all residents with a history of suicidal ideation were assessed for thoughts of self harm between the hours of 1:00 PM and 3:00 PM on 08/19/2023, by social services. No resident reported thoughts of self harm.
*An in-service was provided to social services to ensure that all residents with suicidal ideation will be seen by social service at least weekly, until they no longer have suicidal ideation. This in-service was completed by the DON/IP on 08/19/2023, at 5:00 PM.
*An in-service was completed with all staff by the DON/IP at 6:00 PM on 08/19/2023. Training included that all residents that express feelings of harming themselves will be immediately placed on one on one and seen by the psychiatric nurse practitioner or a physician. If the psychiatric nurse practitioner or the physician are not available, then the resident will be sent to the emergency room for evaluation.
Facility alleged compliance on 9/8/2023.
On 9/11/23, the State Agency (SA) validated the facility's Removal Plan by staff interviews, record reviews, and review of the in-service sign in sheets. The SA verified the facility had implemented the following measures to remove the IJ:
The SA validated through interviews and record review that the facility held an emergency meeting on 9/7/2023 at 1:00 PM, with the Quality Assurance team to discuss and implement removal plans for citations F600, F609, F644, F835, F841, related to Resident #1's suicide on 8/19/23. Interviews with the Administrator/Executive Director, the DON/IP, the unit manager, the Medical Director, the [NAME] President to the Administrator/Executive Director, social worker #1, and social worker #2 confirmed all were in attendance.
The SA validated through record review and interviews with the Administrator/Executive Director, Director of Nurses (DON), Social Worker #1, Social Worker #2 that on 9/7/2023, a new preadmission screening and resident review (PASARR) policy was created for the facility to coincide with federal and state guidelines. The policy was created by the Executive Director/Administrator of the facility and the governing body.
The SA validated through record review and interviews with the Administrator/Executive Director, DON, Social Worker #1, Social Worker #2, Medical Director, Unit Manager that the facility implemented the policy for PASARR, to coincide with state and federal regulations. The policy was approved in the Emergency Quality and Assurance meeting held on 9/7/23, at 1:00 PM.
The SA validated through record review and interviews with four Registered Nurses, five Licensed Practical Nurses, eight Certified Nurse Aides, one Laundry staff, three Housekeepers, two Social Workers, one Medical Director, one Administrator/Executive Director that an in-service on neglect and abuse was provided to all staff on 9/7/2023, at 1:30 PM, by the Director of Nursing/Infection Preventionist (DON/IP). The information covered in the in-service included the definition of abuse and neglect, the different types of abuse and neglect, and what steps to take if abuse or neglect is witnessed or suspected.
The SA validated through record review and interviews with the Director of Nurses (DON) and Administrator/Executive Director that an in-service education on self reporting requirements was provided to the Administrator/Executive Director and the DON/IP to include reporting accurately to state agencies on 9/7/2023 at 2:00 PM, by the [NAME] President to the Administrator. The abuse and neglect policy was reviewed in the in-service which included the types of incidents that must be reported, the time frame in which to report, and the entities (Attorney General's Office, Licensure and Certification, Ombudsman) that must be reported to.
The SA validated through record review and interviews with the Administrator/Executive Director, four RN's and five LPN's that an in-service education was provided with all licensed nurses by the DON on 9/7/2023 at 3:00 PM to review the policy on physician orders including, The signature of the nurse receiving the order and the time of the order must appear.
The SA validated through record review and interviews with two Social Workers and Administrator/Executive Director that an in-service education was provided to social service on 9/7/2023, at 3:30 PM, by the Administrator/Executive Director, to include an increase in social visits for all residents with suicidal ideation to be seen by social service at least 3 times weekly, until they no longer have suicidal ideation.
The SA validated through interview with the Administrator/Executive Director and record review that an in-service education on the Administrator's job description was provided to the Administrator/Executive Director to include that the Administrator must provide oversight to provide the necessary care for residents who express suicidal ideation and for residents who have psychosocial needs that are not met. This was completed 9/7/2023, at 4:00 PM, by the [NAME] President to the Administrator/Executive Director.
The SA validated through record review and interviews with two Social Workers and the Administrator/Executive Director that an in-service education was provided on PASARR to Social Services on 8/23/2023, by the Administrator/Executive Director. Another PASARR in-service/education was completed on 9/7/23, at 4:30 PM by the [NAME] President to the Administrator, the DON/IP, Social Services, the Medical Director, and the Director of Admission. The information covered in the in-service included when to complete a new PASARR and the appropriate agency to send the completed forms to.
The SA validated through record review and interviews with the Medical Director and Administrator/Executive Director that an in-service education on the Medical Director Policy was provided to the Medical Director on 9/7/23, at 5:00 PM, by the Administrator/Executive Director. The information covered in the in-service included the role and responsibilities of the Medical Director and leading the continuity of care with nursing services to include physician orders with accurate times and dates.
The SA validated by record review and interviews with the Administrator/Executive Director and two Social Workers that a one hundred percent audit was completed on 08/31/23, by the Administrator/Executive Director, of all current resident's PASARRs to ensure status change of assessment has been completed to include new diagnosis and to reflect that mood and behavior changes are included in the status change. Fifty-eight resident's status change forms were sent to the state mental health authority for a status change on 9/7/23 at 8:00 PM.
The SA validated through interviews with the Administrator, DON and SW #1 and record review a resident council meeting was completed by the activities director on 08/21/2023, at 2:30 PM. The residents were encouraged to express their feelings. An additional follow up resident counsel meeting was held on 9/5/2023 at 2:00 PM by the activities director. No negative effects reported from the residents.
The SA validated through interviews with five LPN's, one Activity Director, two Social Workers, one Director of Admissions, three RN's and five CNA's that an education/in-service was provided to social service and nursing staff to immediately get psychiatric evaluation for residents with any new behaviors to include suicidal ideation. This was completed 08/21/2023, at 5:00 PM, by the Administrator/Executive Director and the DON/IP. A memo was placed at each nurses station to reflect the instructions of the in-service completed by 4:00 PM on 8/21/2023, by the DON/IP.
The SA validated through interviews with the Administrator, DON and SW and record review that six residents with history of suicide ideation were seen per the psychiatric nurse practitioner, on 08/21/2023 and 08/22/2023. All residents denied suicidal ideations on evaluation per the psychiatric nurse practitioner.
The SA validated through interviews with the Administrator and the [NAME] President of sales for hospice and record review that a phone meeting was held with the Administrator/Executive Director and the area [NAME] President of Sales for hospice on 08/23/2023, at 9:00 AM, concerning communication and collaboration between hospice and facility to provide better service for the residents receiving hospice care in the nursing facility. On 8/23/2023 a new system change included a hospice communication book was placed at each nurse's station for any change in condition to hospice residents.
The SA validated through interviews with the Administrator, DON and SW and a record review that a grief counseling meeting was conducted by the hospice Chaplin on 08/23/2023, from 11:00 AM until 3:00 PM for the residents and staff.
The SA validated through interviews with five LPN's, one Activity Director, two Social Workers, one Director of Admissions, three RN's and five CNA's an in-service/education was provided to all the licensed nursing staff to notify hospice of all changes in condition, this will include condition changes such as, decline or improvement, medication changes, new orders of any type, and psychiatric needs and/or evaluations. All communication with hospice will be documented in the interdisciplinary notes and placed on hospice notification form (Form #1) in the hospice communication book. The in-service was completed by the DON/IP on 08/23/2023 by 5:30 PM.
The SA validated through interviews with the Administrator, DON, Medical Director and SW and record review that a second emergency Quality Assurance meeting held to discuss the new system implemented to communicate with hospice, the new hospice form #1, and communication book. This meeting was held on 08/23/2023 at 5:00 PM. In attendance were the Administrator/Executive Director, the DON/IP, the Unit Manager, Social Worker #1, Social Worker #2 and the Medical Director per phone.
Any employee that has not been in-serviced will not be allowed to return to work until all in-services are completed.
The SA validated through interviews with the Administrator and DON and record review that on 08/19/2023, the Emergency Medical Services were notified at 8:51 AM, along with hospice, the coroner, the Department of Health, and the resident's responsible party.
The SA validated through interviews with the Administrator and DON that The State Health Department was notified on 08/19/2023 at 9:57 AM, by the Executive Director/Administrator. The Attorney General's Office (AG) was notified on 08/23/2023 by the Executive Director/Administrator at 8:30 AM while at the facility investigating the incident.
The SA validated through interview with the Administrator that the Sheriff's Department was notified on 08/19/2023, at 1:00 PM, while at the facility investigating the incident by the Executive Director/Administrator. The Ombudsman was notified by phone on 08/23/2023, at 11:00 AM, by the Executive Director/Administrator.
The SA validated through record review and interviews with the Administrator, DON, SW #1 and Medical Director that on 8/19/2023, at 12:30 PM, an emergency Quality Assurance meeting was held to discuss immediate interventions completed and interventions to be put in place related to Resident #1's suicide. In attendance was the Director of Nursing/Infection Preventionist, the Executive Director/Administrator, the House Supervisor, Social Worker #1, Social Worker #2 and the Medical Director by phone.
The SA validated through record review and interviews with the Administrator, DON and SW that a trauma screening was performed on each resident in the facility. No issues were found. This was completed on 8/19/2023 between 10:00 AM and 12:00 PM, by social services.
The SA validated through record review and interviews with five LPN's, one Activity Director, two Social Workers, one Director of Admissions, three RN's and five CNA's that all staff was in-serviced on abuse, neglect, and suicide precautions starting at 10:00 AM on 8/19/2023, by the DON/IP.
The SA validated through record review and interviews with the Administrator and DON that all care plans of residents with a history of suicidal ideation were updated to include the following interventions, residents that express feelings of harming themselves will be immediately placed on one on one and seen by the psychiatric nurse practitioner or a physician. If the psychiatric nurse practitioner or the physician are not available, then the resident will be sent to the emergency room for evaluation. These interventions were added to the plans of care of six residents on 8/19/2023 between 1:00 PM and 2:00 PM, by social services.
The SA validated with record review and interviews with the Administrator and DON that 100% audit of all beds to ensure bed remote secured to bed by social service, this was completed 08/19/2023, by 3:00 PM. There were two beds that required maintenance to secure the cord to the bed. The cords were secured immediately.
The SA validated through record review and interviews with the Administrator, DON and SW that for residents protection, all residents with a history of suicidal ideation were assessed for thoughts of self harm b[TRUNCATED]
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0740
(Tag F0740)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy and procedure review, record review, and staff interviews, the facility failed to provide behavioral health serv...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy and procedure review, record review, and staff interviews, the facility failed to provide behavioral health services to address a resident's needs as evidenced by failure to act upon Resident #1's verbalized suicidal ideations which resulted in Resident #1's suicide in the facility for one (1) of seven (7) residents sampled.
During the admission process on [DATE], Resident #1 expressed suicidal thoughts when he told the admitting nurse that he wanted to call a friend to pick him up and take him to jump off a bridge. On [DATE], the facility obtained an physician order for a psychiatric evaluation. On the same day [DATE], the facility obtained a physician order for hospice services and obtained a second physician order to discontinue the psychiatric evaluation. The facility did not notify hospice services of the order for a psychiatric evaluation or the order to D/C (discontinue) the psychiatric evaluation. Record review revealed a physician order dated [DATE], with no time noted, to place Resident #1 on one-on-one monitoring due to suicidal ideation. Resident #1 remained on one-on-one observation through to [DATE] when the facility obtained an order for every hour observations due to improved mood.
On [DATE], Resident #1 was observed by Licensed Practical Nurse (LPN) #1 at 7:15 AM lying in his bed with his eyes closed. LPN #1 took Resident #1's breakfast tray to his room at 8:30 AM and when she opened the door, LPN #1 observed Resident #1 was hanging from an exposed ceiling pipe with the bed remote control cord wrapped around his neck. He was noted to be warm. LPN #1 yelled for help and LPN #2 responded. LPN #2 cut Resident #1 down using bandage scissors and performed sternal rubs with no response. Emergency Medical Services (EMS) were called as were hospice services. EMS arrived at the facility and found Resident #1 with no heart activity, and he was pronounced dead at 9:00 AM.
The facility's failure to provide a psychiatric evaluation for Resident #1 placed this resident and other residents in a situation that lead to Resident #1's death and was likely to cause serious injury, harm, impairment, or death of other residents.
The situation was determined to be an Immediate Jeopardy (IJ) which began on [DATE] when the facility failed to notify hospice of the physician's order for the psychiatric evaluation and discontinuation of the order.
The State Agency (SA) investigated the death of Resident #1 on [DATE] through [DATE]. After review by the SA, the SA extended the survey from [DATE] through [DATE].
The State Agency identified Immediate Jeopardy at:
CFR 483.40 Behavioral health services (F740)-Scope and Severity of J.
The SA (State Agency) notified the facility's Administrator of the IJ on [DATE] at 5:15 PM and provided the Administrator with the IJ template.
The facility submitted an acceptable Removal Plan on [DATE], in which they alleged all corrective actions to remove the IJ were completed on [DATE] and the IJ was removed on [DATE].
The SA validated the Removal Plan on [DATE] and determined the IJ was removed on [DATE], prior to exit. Therefore, the scope and severity for CFR 483.40 Behavioral health services (F740) was lowered from a J to a D while the facility develops a plan of correction to monitor the effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements.
Findings Include:
On [DATE] a review of the facility's policy/procedure for Behavior Management and Psycho-pharmacological Medications Monitoring Protocol, last revised 3/18 revealed, Purpose: Residents with behaviors that are displayed routinely, that effect the resident's psychosocial well-being or that of other residents, or behaviors that can have potential for harm to self or others will be assessed with the development of a behavior program.
Policy/procedure review of the facility's policy/procedure for Suicide Precautions, last revised 2/19 revealed .Procedure 8. Undertake emergency transfer of resident to appropriate treatment setting.
Record review of Resident #1's Face Sheet revealed that he was admitted on [DATE] to the facility with diagnoses including Malignant Neoplasm of Larynx, unspecified, and Depression, unspecified.
Record review of Resident #1's Physician Orders for [DATE] revealed an order for psych. (psychiatric) consult for evaluation/treatment with no time provided. A Physician Telephone Order dated [DATE] read to d/c (discontinue) psych consult d/t (due to) admit to hospice with no time provided. Record review also revealed a printed Physician's Telephone Order dated [DATE] with a time of 4:00 PM to Admit to hospice (proper name) related to diagnosis of malignant neoplasm of larynx.
Record review of the Departmental Notes with a Category: Nursing dated [DATE] at 9:31 PM revealed, .Resident stated that he's scared of been in (being) in facility and in room by himself Please don't leave me alone, I'm scared .Resident states he doesn't want to die here .Resident not adjusting to new surroundings well. Resident hollering out loud .Resident refuse to stay in his room due to he's scared of been (being) alone .Stating that he wants to call him friend to pick him up so he can jump off bridge cause he's tired of living . He was placed one on one observation with staff after making that comment.
Record review of the Departmental Notes with a Category: Nursing dated [DATE] at 7:21 AM revealed, .Resident constantly states he wants to die. He wrapped oxygen tubing around his neck .Resident asked staff if he hit his head against the wall will go ahead and take him out . On [DATE] at 6:23 AM, Resident #1 ambulated to the nursing station and stated he had slipped. A laceration on his face and skin tear on his arm were cleaned. Resident #1 was observed by Licensed Practical Nurse #1 at 7:15 AM lying in his bed with his eyes closed. LPN#1 took Resident #1's breakfast tray to his room at 8:30 AM and when the door was opened, Resident #1 was observed hanging from a pipe with the bed remote control cord wrapped around his neck. He was noted warm. LPN #1 yelled for help and LPN #2 responded. LPN #2 cut Resident #1 down using bandage scissors and began doing sternal rubs with no response. The facility called Emergency Medical Services (EMS) and hospice services. EMS arrived at the facility and found Resident #1 with no heart activity, and he was pronounced dead at 9:00 AM. Hospice contacted the coroner, and the body was released to the Medical Examiner.
An interview with the Administrator on [DATE] at 4:10 PM, regarding the discontinued psych. evaluation order written on [DATE] revealed He went on hospice. That is why the order was discontinued. Hospice won't pay for a psychiatric (psych.) evaluation. He knew he had a psych evaluation ordered and was one (1) on 1 due to what he said about jumping off a bridge. We told him we were discontinuing the psych.evaluation because hospice would provide for his needs. He said he understood. No, I didn't contact his Responsible Party (RP).
Record review of the MD's (Medical Doctor) order to discontinue the psych evaluation written on [DATE] revealed the administrator is also a Registered Nurse and wrote the order to discontinue the psych. evaluation.
An interview with Resident #1's Medical Doctor (MD) on [DATE] at 8:30 AM, revealed that the psych evaluation was discontinued because hospice won't pay for psych.
Interview with LPN #2 on [DATE] at 8:55 AM, revealed that he heard LPN #1 call for help and immediately went to help. He stated that Resident #1 was hanging from a pipe near the ceiling. He stated he cut the cord which was a bed control cord. The cord was removed from around the resident's neck. He stated the resident still felt warm and had a faint pulse for three (3) minutes. He did sternal rubs to see if the resident would respond and there was no response. He said that staff had called the EMS (emergency medical services) and they arrived. The EMS did an EKG and there was no heart activity. Hospice arrived and called the coroner and family.
An interview with Certified Nursing Assistant (CNA) #1 on [DATE] at 9:20 AM, revealed that she saw Resident #1 on [DATE] around 7:36 AM. She stated she was walking by his room and saw his door open. She saw him again lying in bed with his legs moving at 8:00 AM. She stated her assignment changed after 8:00 AM and she was no longer his assigned CNA. She stated that a little later she heard a nurse scream.
An interview with LPN #1 on [DATE] at 9:58 AM, revealed that she was Resident #1's assigned nurse on [DATE] on the 7-3 shift. She first saw him at 7:15 AM on [DATE], he was lying in bed with his eyes closed. She went to his room at 8:30 AM to assist with his breakfast. She opened the room door and saw him hanging from an exposed pipe going across his ceiling. She attempted to get him down but was too short and yelled for help. LPN #2 came to help and had his bandage scissors in his pocket. He cut the cord and they laid the resident down. She stated that LPN #2 did sternal rubs. Staff called 911 for an ambulance and hospice. She stated LPN #2 stated he felt a faint pulse. She stated it appeared he stood on the wheelchair (w/c) to get to the pipe. His w/c was close to where he was hanging. She stated he was warm but unresponsive. She stated he had an order to Do Not Resuscitate (DNR) so Cardiopulmonary Resuscitation (CPR) was not started. She stated the Emergency Medical Services (EMS)'s ran an Electrocardiogram (EKG) and found no heart activity. The coroner was called by the hospice staff when they got here.
The facility provided the following Removal Plan:
Resident #1 was admitted on [DATE]. Resident #1 expressed that he wanted to sign up for hospice services on admission due to him being tired. He stated I been suffering from throat cancer for seven years. I'm just tired. Resident #1 expressed that he wanted to call his friend so that he could jump off a bridge. On [DATE], a psychiatric consult was ordered. The resident was admitted to hospice on [DATE]. The psychiatric consult was discontinued on [DATE] by the physician after he elected hospice services. The facility failed to adequately meet Resident #1's mental health needs when the facility did not provide a psychiatric evaluation on [DATE], after Resident # 1 stated that he wanted to jump off a bridge. The facility failed to ensure the Medical Director evaluated and acted on reported deficient practices related to Resident #1's actual suicide and failed to ensure that orders for the psychological evaluations were carried out as ordered. The facility failed to adequately meet Resident #1's mental health needs when the facility did not complete a status change PASARR when, on [DATE], Resident #1 verbalized suicidal ideations. The facility neglected to provide psychological interventions upon admission, on [DATE], to protect Resident #1, who expressed suicidal ideations and ultimately was found hanging in the facility on [DATE]. The facility failed to accurately report an actual suicide for Resident #1 when he was found hanging from the pipes in the ceiling at 8:15 AM on [DATE]. The incident was reported as an attempted suicide to the department of licensure and certification (L&C) at 9:57 AM on [DATE]. The incident was not reported to the appropriate state agencies within the specific time frame, as required by federal guidance. The Administrator/Executive Director failed to ensure that Resident #1's psychological needs were addressed by a lack of immediate intervention and a lack of carrying out of a physician order for a psychological evaluation, which resulted in Resident #1's death.
Interventions
* The facility held an emergency meeting on [DATE] at 1:00 PM, with the Quality Assurance team to discuss and implement removal plans for citations F600, F609, F644, F835, F841, related to Resident #1's suicide on [DATE]. The Administrator/Executive Director, the DON/IP, the unit manager, the Medical Director, the activities director, the [NAME] President to the Administrator/Executive Director, social worker #1, and social worker #2 were in attendance.
*On [DATE], a new preadmission screening and resident review (PASARR) policy was created for the facility to coincide with federal and state guidelines. The policy was created by the Executive Director/Administrator of the facility and the governing body.
*The facility implemented the policy for PASARR, to coincide with state and federal regulations. The policy was approved in the Emergency Quality and Assurance meeting held on [DATE], at 1:00 PM
*An in-service on neglect and abuse was provided to all staff on [DATE], at 1:30 PM, by the Director of Nursing/Infection Preventionist (DON/IP). The information covered in the in-service included the definition of abuse and neglect, the different types of abuse and neglect, and what steps to take if abuse or neglect is witnessed or suspected.
*An in-service education on self reporting requirements was provided to the Administrator/Executive Director and the DON/IP to include reporting accurately to state agencies on [DATE] at 2:00 PM, by the [NAME] President to the Administrator. The abuse and neglect policy was reviewed in the in-service which included the types of incidents that must be reported, the time frame in which to report, and the entities (Attorney General's Office, Licensure and Certification, Ombudsman) that must be reported to.
*An in-service education was provided with all licensed nurses by the DON on [DATE] at 3:00 PM to review the policy on physician orders including, The signature of the nurse receiving the order and the time of the order must appear.
*An in-service education was provided to social service on [DATE], at 3:30 PM, by the Administrator/Executive Director, to include an increase in social visits for all residents with suicidal ideation to be seen by social service at least 3 times weekly, until they no longer have suicidal ideation.
*An in-service education on the Administrator's job description was provided to the Administrator/Executive Director to include that the Administrator must provide oversight to provide the necessary care for residents who express suicidal ideation and for residents who have psychosocial needs that are not met. This was completed [DATE], at 4:00 PM, by the [NAME] President to the Administrator/Executive Director.
*An in-service education was provided on PASARR to Social Services on [DATE], by the Administrator/Executive Director. Another PASARR in-service/education was completed on [DATE], at 4:30 PM by the [NAME] President to the Administrator, the DON/IP, Social Services, the Medical Director, and the Director of Admission. The information covered in the in-service included when to complete a new PASARR and the appropriate agency to send the completed forms to.
*An in-service education on the Medical Director Policy was provided to the Medical Director on [DATE], at 5:00 PM, by the Administrator/Executive Director. The information covered in the in-service included the role and responsibilities of the Medical Director and leading the continuity of care with nursing services to include physician orders with accurate times and dates.
*A one hundred percent audit was completed on [DATE], by the Administrator/Executive Director, of all current resident's PASARRs to ensure status change of assessment has been completed to include new diagnosis and to reflect that mood and behavior changes are included in the status change. Fifty-eight resident's status change forms were sent to the state mental health authority for a status change on [DATE] at 8:00 PM.
*A resident council meeting was completed by the activities director on [DATE], at 2:30 PM. The residents were encouraged to express their feelings. An additional follow up resident counsel meeting was held on [DATE] at 2:00 PM by the activities director. No negative effects reported from the residents.
*An education/in-service was provided to social service and nursing staff to immediately get psychiatric evaluation for residents with any new behaviors to include suicidal ideation. This was completed [DATE], at 5:00 PM, by the Administrator/Executive Director and the DON/IP. A memo was placed at each nurses station to reflect the instructions of the in-service completed by 4:00 PM on [DATE], by the DON/IP.
*Six residents with history of suicide ideation were seen per the psychiatric nurse practitioner, on [DATE] and [DATE]. All residents denied suicidal ideations on evaluation per the psychiatric nurse practitioner.
*A phone meeting was held with the Administrator/Executive Director and the area [NAME] President of Sales for hospice on [DATE], at 9:00 AM, concerning communication and collaboration between hospice and facility to provide better service for the residents receiving hospice care in the nursing facility. On [DATE] a new system change included a hospice communication book was placed at each nurse's station for any change in condition to hospice residents.
*A grief counseling meeting was conducted by the hospice Chaplin on [DATE], from 11:00 AM until 3:00 PM for the residents and staff.
*An in-service/education was provided to all the licensed nursing staff to notify hospice of all changes in condition, this will include condition changes such as, decline or improvement, medication changes, new orders of any type, and psychiatric needs and/or evaluations. All communication with hospice will be documented in the interdisciplinary notes and placed on hospice notification form (Form #1) in the hospice communication book. The in-service was completed by the DON/IP on [DATE] by 5:30 PM.
*A second emergency Quality Assurance meeting held to discuss the new system implemented to communicate with hospice, the new hospice form #1, and communication book. This meeting was held on [DATE] at 5:00 PM. In attendance were the Administrator/Executive Director, the DON/IP, the Unit Manager, Social Worker #1, Social Worker #2 and the Medical Director per phone.
*Any employee that has not been in-serviced will not be allowed to return to work until all in-services are completed.
*On [DATE], the Emergency Medical Services were notified at 8:51 AM, along with hospice, the coroner, the Department of Health, and the resident's responsible party.
*The State Health Department was notified on [DATE] at 9:57 AM, by the Executive Director/Administrator. The Attorney General's Office (AG) was notified on [DATE] by the Executive Director/Administrator at 8:30 AM while at the facility investigating the incident.
*The Sheriff's Department was notified on [DATE], at 1:00 PM, while at the facility investigating the incident by the Executive Director/Administrator. The Ombudsman was notified by phone on [DATE], at 11:00 AM, by the Executive Director/Administrator.
*On [DATE], at 12:30 PM, an emergency Quality Assurance meeting was held to discuss immediate interventions completed and interventions to be put in place related to Resident #1's suicide. In attendance was the Director of Nursing/Infection Preventionist, the Executive Director/Administrator, the House Supervisor, Social Worker #1, Social Worker #2 and the Medical Director by phone.
*A trauma screening was performed on each resident in the facility. No issues were found. This was completed on [DATE] between 10:00 AM and 12:00 PM, by social services.
*All staff was in-serviced on abuse, neglect, and suicide precautions starting at 10:00 AM on [DATE], by the DON/IP.
*All care plans of residents with a history of suicidal ideation were updated to include the following interventions, residents that express feelings of harming themselves will be immediately placed on one on one and seen by the psychiatric nurse practitioner or a physician. If the psychiatric nurse practitioner or the physician are not available, then the resident will be sent to the emergency room for evaluation.
*These interventions were added to the plans of care of six residents on [DATE] between 1:00 PM and 2:00 PM, by social services.
*100% audit of all beds to ensure bed remote secured to bed by social service, this was completed [DATE], by 3:00 PM. There were two beds that required maintenance to secure the cord to the bed. The cords were secured immediately.
*For residents protection, all residents with a history of suicidal ideation were assessed for thoughts of self harm between the hours of 1:00 PM and 3:00 PM on [DATE], by social services. No resident reported thoughts of self harm.
*An in-service was provided to social services to ensure that all residents with suicidal ideation will be seen by social service at least weekly, until they no longer have suicidal ideation. This in-service was completed by the DON/IP on [DATE], at 5:00 PM.
*An in-service was completed with all staff by the DON/IP at 6:00 PM on [DATE]. Training included that all residents that express feelings of harming themselves will be immediately placed on one on one and seen by the psychiatric nurse practitioner or a physician. If the psychiatric nurse practitioner or the physician are not available, then the resident will be sent to the emergency room for evaluation.
Facility alleged compliance on [DATE].
On [DATE], the State Agency (SA) validated the facility's Removal Plan by staff interviews, record reviews, and review of the in-service sign in sheets. The SA verified the facility had implemented the following measures to remove the IJ:
The SA validated through interviews and record review that the facility held an emergency meeting on [DATE] at 1:00 PM, with the Quality Assurance team to discuss and implement removal plans for citations F600, F609, F644, F835, F841, related to Resident #1's suicide on [DATE]. Interviews with the Administrator/Executive Director, the DON/IP, the unit manager, the Medical Director, the [NAME] President to the Administrator/Executive Director, social worker #1, and social worker #2 confirmed all were in attendance.
The SA validated through record review and interviews with the Administrator/Executive Director, Director of Nurses (DON), Social Worker #1, Social Worker #2 that on [DATE], a new preadmission screening and resident review (PASARR) policy was created for the facility to coincide with federal and state guidelines. The policy was created by the Executive Director/Administrator of the facility and the governing body.
The SA validated through record review and interviews with the Administrator/Executive Director, DON, Social Worker #1, Social Worker #2, Medical Director, Unit Manager that the facility implemented the policy for PASARR, to coincide with state and federal regulations. The policy was approved in the Emergency Quality and Assurance meeting held on [DATE], at 1:00 PM.
The SA validated through record review and interviews with four Registered Nurses, five Licensed Practical Nurses, eight Certified Nurse Aides, one Laundry staff, three Housekeepers, two Social Workers, one Medical Director, one Administrator/Executive Director that an in-service on neglect and abuse was provided to all staff on [DATE], at 1:30 PM, by the Director of Nursing/Infection Preventionist (DON/IP). The information covered in the in-service included the definition of abuse and neglect, the different types of abuse and neglect, and what steps to take if abuse or neglect is witnessed or suspected.
The SA validated through record review and interviews with the Director of Nurses (DON) and Administrator/Executive Director that an in-service education on self reporting requirements was provided to the Administrator/Executive Director and the DON/IP to include reporting accurately to state agencies on [DATE] at 2:00 PM, by the [NAME] President to the Administrator. The abuse and neglect policy was reviewed in the in-service which included the types of incidents that must be reported, the time frame in which to report, and the entities (Attorney General's Office, Licensure and Certification, Ombudsman) that must be reported to.
The SA validated through record review and interviews with the Administrator/Executive Director, four RN's and five LPN's that an in-service education was provided with all licensed nurses by the DON on [DATE] at 3:00 PM to review the policy on physician orders including, The signature of the nurse receiving the order and the time of the order must appear.
The SA validated through record review and interviews with two Social Workers and Administrator/Executive Director that an in-service education was provided to social service on [DATE], at 3:30 PM, by the Administrator/Executive Director, to include an increase in social visits for all residents with suicidal ideation to be seen by social service at least 3 times weekly, until they no longer have suicidal ideation.
The SA validated through interview with the Administrator/Executive Director and record review that an in-service education on the Administrator's job description was provided to the Administrator/Executive Director to include that the Administrator must provide oversight to provide the necessary care for residents who express suicidal ideation and for residents who have psychosocial needs that are not met. This was completed [DATE], at 4:00 PM, by the [NAME] President to the Administrator/Executive Director.
The SA validated through record review and interviews with two Social Workers and the Administrator/Executive Director that an in-service education was provided on PASARR to Social Services on [DATE], by the Administrator/Executive Director. Another PASARR in-service/education was completed on [DATE], at 4:30 PM by the [NAME] President to the Administrator, the DON/IP, Social Services, the Medical Director, and the Director of Admission. The information covered in the in-service included when to complete a new PASARR and the appropriate agency to send the completed forms to.
The SA validated through record review and interviews with the Medical Director and Administrator/Executive Director that an in-service education on the Medical Director Policy was provided to the Medical Director on [DATE], at 5:00 PM, by the Administrator/Executive Director. The information covered in the in-service included the role and responsibilities of the Medical Director and leading the continuity of care with nursing services to include physician orders with accurate times and dates.
The SA validated by record review and interviews with the Administrator/Executive Director and two Social Workers that a one hundred percent audit was completed on [DATE], by the Administrator/Executive Director, of all current resident's PASARRs to ensure status change of assessment has been completed to include new diagnosis and to reflect that mood and behavior changes are included in the status change. Fifty-eight resident's status change forms were sent to the state mental health authority for a status change on [DATE] at 8:00 PM.
The SA validated through interviews with the Administrator, DON and SW #1 and record review a resident council meeting was completed by the activities director on [DATE], at 2:30 PM. The residents were encouraged to express their feelings. An additional follow up resident counsel meeting was held on [DATE] at 2:00 PM by the activities director. No negative effects reported from the residents.
The SA validated through interviews with five LPN's, one Activity Director, two Social Workers, one Director of Admissions, three RN's and five CNA's that an education/in-service was provided to social service and nursing staff to immediately get psychiatric evaluation for residents with any new behaviors to include suicidal ideation. This was completed [DATE], at 5:00 PM, by the Administrator/Executive Director and the DON/IP. A memo was placed at each nurses station to reflect the instructions of the in-service completed by 4:00 PM on [DATE], by the DON/IP.
The SA validated through interviews with the Administrator, DON and SW and record review that six residents with history of suicide ideation were seen per the psychiatric nurse practitioner, on [DATE] and [DATE]. All residents denied suicidal ideations on evaluation per the psychiatric nurse practitioner.
The SA validated through interviews with the Administrator and the [NAME] President of sales for hospice and record review that a phone meeting was held with the Administrator/Executive Director and the area [NAME] President of Sales for hospice on [DATE], at 9:00 AM, concerning communication and collaboration between hospice and facility to provide better service for the residents receiving hospice care in the nursing facility. On [DATE] a new system change included a hospice communication book was placed at each nurse's station for any change in condition to hospice residents.
The SA validated through interviews with the Administrator, DON and SW and a record review that a grief counseling meeting was conducted by the hospice Chaplin on [DATE], from 11:00 AM until 3:00 PM for the residents and staff.
The SA validated through interviews with five LPN's, one Activity Director, two Social Workers, one Director of Admissions, three RN's and five CNA's an in-service/education was provided to all the licensed nursing staff to notify hospice of all changes in condition, this will include condition changes such as, decline or improvement, medication changes, new orders of any type, and psychiatric needs and/or evaluations. All communication with hospice will be documented in the interdisciplinary notes and placed on hospice notification form (Form #1) in the hospice communication book. The in-service was completed by the DON/IP on [DATE] by 5:30 PM.
The SA validated through interviews with the Administrator, DON, Medical Director and SW and record review that a second emergency Quality Assurance meeting held to discuss the new system implemented to communicate with hospice, the new hospice form #1, and communication book. This meeting was held on [DATE] at 5:00 PM. In attendance were the Administrator/Executive Director, the DON/IP, the Unit Manager, Social Worker #1, Social Worker #2 and the Medical Director per phone.
Any employee that has not been in-serviced will not be allowed to return to work until all in-services are completed.
The SA validated through interviews with the Administrator and DON and record review that on [DATE], the Emergency Medical Services were notified at 8:51 AM, along with hospice, the coroner, the Department of Health, and the resident's responsible party.
The SA validated through interviews with the Administrator and DON that The State Health Department was notified on [DATE] at 9:57 AM, by the Executive Director/Administrator. The Attorney General's Office (AG) was notified on [DATE] by the Executive Director/Administrator at 8:30 AM while at the facility investigating the incident.
The SA validated through interview with the Administrator that the Sheriff's Department was notified on [DATE], at 1:00 PM, while at the facility investigating the incident by the Executive Director/Administrator. The Ombudsman was notified by phone on [DATE], at 11:00 AM, by the Executive Director/Administrator.
The SA validated through record review and interviews with the Administrator, DON, SW #1 and Medical Director that on [DATE], at 12:30 PM, an emergency Quality Assurance meeting was held to discuss immediate interventions completed and interventions to be put in place related to Resident #1's suicide. [TRUNCATED]
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Administration
(Tag F0835)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy/procedure review and interviews, the facility failed to be administered effectively and efficient...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy/procedure review and interviews, the facility failed to be administered effectively and efficiently to provide the mental health care for one (1) of seven (7) residents, Resident #1, as evidenced by Resident #1 committed suicide by hanging on [DATE] using the remote control cord from his bed and using an exposed pipe on the ceiling in his room.
During the admission process on [DATE], Resident #1 told the admitting nurse that he wanted to jump off a bridge. During the 11:00 PM to 7:00 AM shift, on 8/ On [DATE], a Medical Doctor's (MD) order was written for a psychiatric (psych) evaluation. On [DATE], Resident #1 wanted to be admitted to hospice services. Another MD order was written on [DATE] to discontinue (D/C) the psych evaluation and resident was admitted to contract hospice services. He remained one-on-one observation through to [DATE] when he went to every hour observations. Resident #1 was observed by Licensed Practical Nurse (LPN) #1 at 7:15 AM lying in his bed with his eyes closed. LPN #1 took Resident #1's breakfast tray to his room at 8:30 AM and when the door was opened, Resident #1 was observed hanging from a pipe with the bed remote control cord wrapped around his neck. He was noted to be warm. LPN #1 yelled for help and LPN #2 responded. LPN #2 cut Resident #1 down and began doing sternal rubs with no response. Emergency Medical Services (EMS) were called as were hospice services. EMS arrived to the facility and found Resident #1 with no heart activity and he was pronounced dead at 9:00 AM.
The facility's failure to be administered efficiently and effectively lead to the death of Resident #1 and placed other residents in a situation that was likely to cause serious injury, harm, impairment, or death.
The State Agency (SA) investigated the death of Resident #1 on [DATE] through [DATE]. After the SA review, the SA extended the survey on [DATE] through [DATE] and the situation was determined to be an Immediate Jeopardy (IJ) which began on [DATE] when the physician's order for a psychiatric evaluation for Resident #1 written on [DATE] was discontinued on [DATE].
The IJ existed at:
42 CFR 483.70 Administration F835-Scope and Severity at a J
The SA notified the notified the facility's Administrator of the IJ on [DATE] at 12:30 PM and provided the Administrator with the IJ template.
The facility submitted an acceptable Removal Plan on [DATE], in which they alleged all corrective actions to remove the IJ were completed on [DATE] and the IJ was removed on [DATE].
The SA validated the Removal Plan on [DATE] and determined the IJ and SQC was removed on [DATE], prior to exit. Therefore, the scope and severity of at 42 CFR 483.70 Administration F835 was lowered to a Scope and Severity of D while the facility develops a plan of correction to monitor the effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements.
Findings Include:
Record review of the facility's Job Description for the Administrator/Executive Director dated 8/2012 revealed General Description The Executive Director leads and directs the overall operation of the Facility in accordance with resident needs, government regulations and Facility policies so as to maintain quality care for the residents while achieving the Facility's business objectives. The Job Description for the Executive Director revealed Essential Duties 13. Demonstrates knowledge of all State Department of Health rules and regulations and provides adequate instruction regarding such rules and regulations to appropriate staff. The Job Description revealed Standard Requirements 6. Immediately reports incidents of alleged resident abuse or neglect or alleged violations of resident' rights to appropriate authorities.
Policy/procedure review of the facility's policy/procedure for Suicide Precautions, last revised 2/19 revealed .Procedure 8. Undertake emergency transfer of resident to appropriate treatment setting.
Record review of Resident #1's Face Sheet revealed he was admitted on [DATE] to the facility with diagnoses which included Malignant Neoplasm of Larynx, unspecified and Depression, unspecified.
Record review of the initial notification to the State Department of Health Licensure and Certification hotline regarding the suicide of Resident #1 on [DATE] revealed the facility reported an attempted suicide on [DATE] at 9:58 am.
Interview with the Administrator on [DATE] at 3:10 PM regarding reporting incidents to the State Agency (SA). The Administrator stated I called and left a voicemail reporting a suicide attempt. He died a little after 9:00 AM. He was pronounced here by Emergency Medical Service (EMS). He was found around 8:30 AM and had a pulse. He was a DNR. They did call the ambulance and hospice right after he was found. I did not update the SA office when he died. The sheriff came after the resident was removed from the facility. We notified EMS, Coroner, hospice, and the sheriff. His body is going to the state crime lab. The coroner took the cord with the body. She revealed she was told to report the incident as a suicide attempt by the facility's Regional Nurse Consultant.
Interview with Resident #1's Responsible Party on [DATE] at 1:00 PM revealed that she called the police and sheriff department on [DATE] after her brother had committed suicide.
Interview with the Director of Nurses (DON) on [DATE] at 2:00 PM revealed No, we didn't call the police after he died. The sheriff officer just showed up here around lunch. His body wasn't even here anymore. The medical examiner had picked him up earlier.
Interview with the Administrator, [DATE] at 4:10 PM regarding the discontinued psychiatric evaluation order written by her on [DATE] revealed He went on hospice. That is why the order was discontinued. Hospice won't pay for a psych eval. He (Resident #1) knew he had a psychiatric evaluation ordered and was (one) 1 on 1 due to what he said about jumping off a bridge. We told him we were dc'ing (discontinuing) the psych evaluation because hospice would provide for his needs. He said he understood.
Interview with the Administrator on [DATE] at 10:45 AM confirmed that she did not contact the Ombudsman regarding the suicide of Resident #1 until [DATE] at 11:00 AM.
Interview with the Administrator on [DATE] at 10:45 AM revealed I didn't report it to the AG office and that she didn't know she had to contact the AG office.
Interview with Attorney General Investigator on [DATE] at 10:37 AM revealed the AG office did not receive notification of this suicide from the facility. He stated it was the resident's sister that contacted the AG office on [DATE]. He said the administrator said she didn't know she had to report to the AG office.
Record review of Resident #1's Physician Orders for [DATE] revealed Do Not Resuscitate (DNR). Review of the handwritten Physician Telephone Order dated [DATE] read psychiatric consult for evaluation/treatment with no time that order was given. Physician Telephone Order dated [DATE] read d/c (discontinue) psychiatric consult d/t (due to) admit to hospice with no time that order was given. Review of a printed Physician's Telephone Order dated [DATE] with a time of 4:00 PM read Admit to hospice (proper name) related to diagnosis of malignant neoplasm of larynx.
Record review of the MD's (Medical Doctor) order to discontinue the psych evaluation written on [DATE] revealed the administrator, who is also a Registered Nurse, wrote the order to discontinue the psych evaluation.
Record review of the Departmental Notes with a Category: Nursing dated [DATE] at 9:31 PM revealed, .Resident stated that he's scared of been in (being) in facility and in room by himself Please don't leave me alone, I'm scared .Resident states he doesn't want to die here .Resident not adjusting to new surroundings well. Resident hollering out loud .Resident refuse to stay in his room due to he's scared of been (being) alone .Stating that he wants to call him friend to pick him up so he can jump off bridge cause he's tired of living . He was placed one on one observation with staff after making that comment. Record review of the Departmental Notes with a Category: Nursing dated [DATE] at 7:21 AM revealed, .Resident constantly states he wants to die. He wrapped oxygen tubing around his neck .Resident asked staff if he hit his head against the wall will go ahead and take him out . On [DATE] at 6:23 AM, Resident #1 ambulated to the nursing station and stated he had slipped. A laceration on his face and skin tear on his arm were cleaned. Resident #1 was observed by Licensed Practical Nurse #1 at 7:15 AM lying in his bed with his eyes closed. LPN#1 took Resident #1's breakfast tray to his room at 8:30 AM and when the door was opened, Resident #1 was observed hanging from a pipe with the bed remote control cord wrapped around his neck. He was noted warm. LPN #1 yelled for help and LPN #2 responded. LPN #2 cut Resident #1 down using bandage scissors and began doing sternal rubs with no response. The facility called Emergency Medical Services (EMS) and hospice services. EMS arrived at the facility and found Resident #1 with no heart activity, and he was pronounced dead at 9:00 AM. Hospice contacted the coroner, and the body was released to the Medical Examiner.
Record review of the Patient Care Report by the Emergency Medical Services (EMS) that responded to the facility's call for assistance on [DATE] revealed that EMS received notification at 08:52 [DATE] and were at patient 08:59 [DATE]. The NARRATIVE CHIEF COMPLAINT revealed that EMS found Resident #1 Unresponsive, apneic, and pulseless in bed covered up with blankets by staff. CPR not in progress. Staff states that patient is a DNR (Do Not Resuscitate) and wanted to confirm death by EMS, according to staff, patient was last seen alive 20-30 minutes ago. Resident #1 was found unresponsive, apneic, and pulseless with airway patent, breathing is absent, skin is pale in color, warm to touch and pupils dilated. The Narrative concludes with DOA-no resuscitation, no transport, (name of county) coroner notified and patient's remains left with nursing staff awaiting coroner. The Patient Care Report revealed EMS leave scene 09:11 [DATE].
Record Review of the REPORT OF DEATH INVESTIGATION revealed the death of Resident #1 was confirmed by EMS on 8-19-23 9:00, Coroner notified 8-19-23 09:30 and View of Body 8-19-23 10:05.
The report has the Manner of Death is pending autopsy. The reports Probable Cause of Death: 1. Pending Hanging/Strangulation.
Record Review of the Reason for Assuming Medical Examiner Jurisdiction, undated with no time revealed Suicide with a check mark and Medical History Cancer has a check mark. The Narrative Summary of Circumstances Surrounding Death revealed Called to (name of long term care facility) to find a 61 y/o W/M lying supine in bed with what appeared to be ligature marks to the front of his neck. The decedent body was cool to touch with no other obvious injuries. The decedent was taken to (Name of local hospital) to hold for autopsy. The cord used was also sent for evident with decedent. There is a diagram of a body with a line drawn across the neck.
The facility provided the following Removal Plan:
Resident #1 was admitted on [DATE]. Resident #1 expressed that he wanted to sign up for hospice services on admission due to him being tired. He stated I been suffering from throat cancer for seven years. I'm just tired. Resident #1 expressed that he wanted to call his friend so that he could jump off a bridge. On [DATE], a psychiatric consult was ordered. The resident was admitted to hospice on [DATE]. The psychiatric consult was discontinued on [DATE] by the physician after he elected hospice services. The facility failed to adequately meet Resident #1's mental health needs when the facility did not provide a psychiatric evaluation on [DATE], after Resident # 1 stated that he wanted to jump off a bridge. The facility failed to ensure the Medical Director evaluated and acted on reported deficient practices related to Resident #1's actual suicide and failed to ensure that orders for the psychological evaluations were carried out as ordered. The facility failed to adequately meet Resident #1's mental health needs when the facility did not complete a status change PASARR when, on [DATE], Resident #1 verbalized suicidal ideations. The facility neglected to provide psychological interventions upon admission, on [DATE], to protect Resident #1, who expressed suicidal ideations and ultimately was found hanging in the facility on [DATE]. The facility failed to accurately report an actual suicide for Resident #1 when he was found hanging from the pipes in the ceiling at 8:15 AM on [DATE]. The incident was reported as an attempted suicide to the department of licensure and certification (L&C) at 9:57 AM on [DATE]. The incident was not reported to the appropriate state agencies within the specific time frame, as required by federal guidance. The Administrator/Executive Director failed to ensure that Resident #1's psychological needs were addressed by a lack of immediate intervention and a lack of carrying out of a physician order for a psychological evaluation, which resulted in Resident #1's death.
Interventions
* The facility held an emergency meeting on [DATE] at 1:00 PM, with the Quality Assurance team to discuss and implement removal plans for citations F600, F609, F644, F835, F841, related to Resident #1's suicide on [DATE]. The Administrator/Executive Director, the DON/IP, the unit manager, the Medical Director, the activities director, the [NAME] President to the Administrator/Executive Director, social worker #1, and social worker #2 were in attendance.
*On [DATE], a new preadmission screening and resident review (PASARR) policy was created for the facility to coincide with federal and state guidelines. The policy was created by the Executive Director/Administrator of the facility and the governing body.
*The facility implemented the policy for PASARR, to coincide with state and federal regulations. The policy was approved in the Emergency Quality and Assurance meeting held on [DATE], at 1:00 PM
*An in-service on neglect and abuse was provided to all staff on [DATE], at 1:30 PM, by the Director of Nursing/Infection Preventionist (DON/IP). The information covered in the in-service included the definition of abuse and neglect, the different types of abuse and neglect, and what steps to take if abuse or neglect is witnessed or suspected.
*An in-service education on self reporting requirements was provided to the Administrator/Executive Director and the DON/IP to include reporting accurately to state agencies on [DATE] at 2:00 PM, by the [NAME] President to the Administrator. The abuse and neglect policy was reviewed in the in-service which included the types of incidents that must be reported, the time frame in which to report, and the entities (Attorney General's Office, Licensure and Certification, Ombudsman) that must be reported to.
*An in-service education was provided with all licensed nurses by the DON on [DATE] at 3:00 PM to review the policy on physician orders including, The signature of the nurse receiving the order and the time of the order must appear.
*An in-service education was provided to social service on [DATE], at 3:30 PM, by the Administrator/Executive Director, to include an increase in social visits for all residents with suicidal ideation to be seen by social service at least 3 times weekly, until they no longer have suicidal ideation.
*An in-service education on the Administrator's job description was provided to the Administrator/Executive Director to include that the Administrator must provide oversight to provide the necessary care for residents who express suicidal ideation and for residents who have psychosocial needs that are not met. This was completed [DATE], at 4:00 PM, by the [NAME] President to the Administrator/Executive Director.
*An in-service education was provided on PASARR to Social Services on [DATE], by the Administrator/Executive Director. Another PASARR in-service/education was completed on [DATE], at 4:30 PM by the [NAME] President to the Administrator, the DON/IP, Social Services, the Medical Director, and the Director of Admission. The information covered in the in-service included when to complete a new PASARR and the appropriate agency to send the completed forms to.
*An in-service education on the Medical Director Policy was provided to the Medical Director on [DATE], at 5:00 PM, by the Administrator/Executive Director. The information covered in the in-service included the role and responsibilities of the Medical Director and leading the continuity of care with nursing services to include physician orders with accurate times and dates.
*A one hundred percent audit was completed on [DATE], by the Administrator/Executive Director, of all current resident's PASARRs to ensure status change of assessment has been completed to include new diagnosis and to reflect that mood and behavior changes are included in the status change. Fifty-eight resident's status change forms were sent to the state mental health authority for a status change on [DATE] at 8:00 PM.
*A resident council meeting was completed by the activities director on [DATE], at 2:30 PM. The residents were encouraged to express their feelings. An additional follow up resident counsel meeting was held on [DATE] at 2:00 PM by the activities director. No negative effects reported from the residents.
*An education/in-service was provided to social service and nursing staff to immediately get psychiatric evaluation for residents with any new behaviors to include suicidal ideation. This was completed [DATE], at 5:00 PM, by the Administrator/Executive Director and the DON/IP. A memo was placed at each nurses station to reflect the instructions of the in-service completed by 4:00 PM on [DATE], by the DON/IP.
*Six residents with history of suicide ideation were seen per the psychiatric nurse practitioner, on [DATE] and [DATE]. All residents denied suicidal ideations on evaluation per the psychiatric nurse practitioner.
*A phone meeting was held with the Administrator/Executive Director and the area [NAME] President of Sales for hospice on [DATE], at 9:00 AM, concerning communication and collaboration between hospice and facility to provide better service for the residents receiving hospice care in the nursing facility. On [DATE] a new system change included a hospice communication book was placed at each nurse's station for any change in condition to hospice residents.
*A grief counseling meeting was conducted by the hospice Chaplin on [DATE], from 11:00 AM until 3:00 PM for the residents and staff.
*An in-service/education was provided to all the licensed nursing staff to notify hospice of all changes in condition, this will include condition changes such as, decline or improvement, medication changes, new orders of any type, and psychiatric needs and/or evaluations. All communication with hospice will be documented in the interdisciplinary notes and placed on hospice notification form (Form #1) in the hospice communication book. The in-service was completed by the DON/IP on [DATE] by 5:30 PM.
*A second emergency Quality Assurance meeting held to discuss the new system implemented to communicate with hospice, the new hospice form #1, and communication book. This meeting was held on [DATE] at 5:00 PM. In attendance were the Administrator/Executive Director, the DON/IP, the Unit Manager, Social Worker #1, Social Worker #2 and the Medical Director per phone.
*Any employee that has not been in-serviced will not be allowed to return to work until all in-services are completed.
*On [DATE], the Emergency Medical Services were notified at 8:51 AM, along with hospice, the coroner, the Department of Health, and the resident's responsible party.
*The State Health Department was notified on [DATE] at 9:57 AM, by the Executive Director/Administrator. The Attorney General's Office (AG) was notified on [DATE] by the Executive Director/Administrator at 8:30 AM while at the facility investigating the incident.
*The Sheriff's Department was notified on [DATE], at 1:00 PM, while at the facility investigating the incident by the Executive Director/Administrator. The Ombudsman was notified by phone on [DATE], at 11:00 AM, by the Executive Director/Administrator.
*On [DATE], at 12:30 PM, an emergency Quality Assurance meeting was held to discuss immediate interventions completed and interventions to be put in place related to Resident #1's suicide. In attendance was the Director of Nursing/Infection Preventionist, the Executive Director/Administrator, the House Supervisor, Social Worker #1, Social Worker #2 and the Medical Director by phone.
*A trauma screening was performed on each resident in the facility. No issues were found. This was completed on [DATE] between 10:00 AM and 12:00 PM, by social services.
*All staff was in-serviced on abuse, neglect, and suicide precautions starting at 10:00 AM on [DATE], by the DON/IP.
*All care plans of residents with a history of suicidal ideation were updated to include the following interventions, residents that express feelings of harming themselves will be immediately placed on one on one and seen by the psychiatric nurse practitioner or a physician. If the psychiatric nurse practitioner or the physician are not available, then the resident will be sent to the emergency room for evaluation.
*These interventions were added to the plans of care of six residents on [DATE] between 1:00 PM and 2:00 PM, by social services.
*100% audit of all beds to ensure bed remote secured to bed by social service, this was completed [DATE], by 3:00 PM. There were two beds that required maintenance to secure the cord to the bed. The cords were secured immediately.
*For residents protection, all residents with a history of suicidal ideation were assessed for thoughts of self harm between the hours of 1:00 PM and 3:00 PM on [DATE], by social services. No resident reported thoughts of self harm.
*An in-service was provided to social services to ensure that all residents with suicidal ideation will be seen by social service at least weekly, until they no longer have suicidal ideation. This in-service was completed by the DON/IP on [DATE], at 5:00 PM.
*An in-service was completed with all staff by the DON/IP at 6:00 PM on [DATE]. Training included that all residents that express feelings of harming themselves will be immediately placed on one on one and seen by the psychiatric nurse practitioner or a physician. If the psychiatric nurse practitioner or the physician are not available, then the resident will be sent to the emergency room for evaluation.
Facility alleged compliance on [DATE].
On [DATE], the State Agency (SA) validated the facility's Removal Plan by staff interviews, record reviews, and review of the in-service sign in sheets. The SA verified the facility had implemented the following measures to remove the IJ:
The SA validated through interviews and record review that the facility held an emergency meeting on [DATE] at 1:00 PM, with the Quality Assurance team to discuss and implement removal plans for citations F600, F609, F644, F835, F841, related to Resident #1's suicide on [DATE]. Interviews with the Administrator/Executive Director, the DON/IP, the unit manager, the Medical Director, the [NAME] President to the Administrator/Executive Director, social worker #1, and social worker #2 confirmed all were in attendance.
The SA validated through record review and interviews with the Administrator/Executive Director, Director of Nurses (DON), Social Worker #1, Social Worker #2 that on [DATE], a new preadmission screening and resident review (PASARR) policy was created for the facility to coincide with federal and state guidelines. The policy was created by the Executive Director/Administrator of the facility and the governing body.
The SA validated through record review and interviews with the Administrator/Executive Director, DON, Social Worker #1, Social Worker #2, Medical Director, Unit Manager that the facility implemented the policy for PASARR, to coincide with state and federal regulations. The policy was approved in the Emergency Quality and Assurance meeting held on [DATE], at 1:00 PM.
The SA validated through record review and interviews with four Registered Nurses, five Licensed Practical Nurses, eight Certified Nurse Aides, one Laundry staff, three Housekeepers, two Social Workers, one Medical Director, one Administrator/Executive Director that an in-service on neglect and abuse was provided to all staff on [DATE], at 1:30 PM, by the Director of Nursing/Infection Preventionist (DON/IP). The information covered in the in-service included the definition of abuse and neglect, the different types of abuse and neglect, and what steps to take if abuse or neglect is witnessed or suspected.
The SA validated through record review and interviews with the Director of Nurses (DON) and Administrator/Executive Director that an in-service education on self reporting requirements was provided to the Administrator/Executive Director and the DON/IP to include reporting accurately to state agencies on [DATE] at 2:00 PM, by the [NAME] President to the Administrator. The abuse and neglect policy was reviewed in the in-service which included the types of incidents that must be reported, the time frame in which to report, and the entities (Attorney General's Office, Licensure and Certification, Ombudsman) that must be reported to.
The SA validated through record review and interviews with the Administrator/Executive Director, four RN's and five LPN's that an in-service education was provided with all licensed nurses by the DON on [DATE] at 3:00 PM to review the policy on physician orders including, The signature of the nurse receiving the order and the time of the order must appear.
The SA validated through record review and interviews with two Social Workers and Administrator/Executive Director that an in-service education was provided to social service on [DATE], at 3:30 PM, by the Administrator/Executive Director, to include an increase in social visits for all residents with suicidal ideation to be seen by social service at least 3 times weekly, until they no longer have suicidal ideation.
The SA validated through interview with the Administrator/Executive Director and record review that an in-service education on the Administrator's job description was provided to the Administrator/Executive Director to include that the Administrator must provide oversight to provide the necessary care for residents who express suicidal ideation and for residents who have psychosocial needs that are not met. This was completed [DATE], at 4:00 PM, by the [NAME] President to the Administrator/Executive Director.
The SA validated through record review and interviews with two Social Workers and the Administrator/Executive Director that an in-service education was provided on PASARR to Social Services on [DATE], by the Administrator/Executive Director. Another PASARR in-service/education was completed on [DATE], at 4:30 PM by the [NAME] President to the Administrator, the DON/IP, Social Services, the Medical Director, and the Director of Admission. The information covered in the in-service included when to complete a new PASARR and the appropriate agency to send the completed forms to.
The SA validated through record review and interviews with the Medical Director and Administrator/Executive Director that an in-service education on the Medical Director Policy was provided to the Medical Director on [DATE], at 5:00 PM, by the Administrator/Executive Director. The information covered in the in-service included the role and responsibilities of the Medical Director and leading the continuity of care with nursing services to include physician orders with accurate times and dates.
The SA validated by record review and interviews with the Administrator/Executive Director and two Social Workers that a one hundred percent audit was completed on [DATE], by the Administrator/Executive Director, of all current resident's PASARRs to ensure status change of assessment has been completed to include new diagnosis and to reflect that mood and behavior changes are included in the status change. Fifty-eight resident's status change forms were sent to the state mental health authority for a status change on [DATE] at 8:00 PM.
The SA validated through interviews with the Administrator, DON and SW #1 and record review a resident council meeting was completed by the activities director on [DATE], at 2:30 PM. The residents were encouraged to express their feelings. An additional follow up resident counsel meeting was held on [DATE] at 2:00 PM by the activities director. No negative effects reported from the residents.
The SA validated through interviews with five LPN's, one Activity Director, two Social Workers, one Director of Admissions, three RN's and five CNA's that an education/in-service was provided to social service and nursing staff to immediately get psychiatric evaluation for residents with any new behaviors to include suicidal ideation. This was completed [DATE], at 5:00 PM, by the Administrator/Executive Director and the DON/IP. A memo was placed at each nurses station to reflect the instructions of the in-service completed by 4:00 PM on [DATE], by the DON/IP.
The SA validated through interviews with the Administrator, DON and SW and record review that six residents with history of suicide ideation were seen per the psychiatric nurse practitioner, on [DATE] and [DATE]. All residents denied suicidal ideations on evaluation per the psychiatric nurse practitioner.
The SA validated through interviews with the Administrator and the [NAME] President of sales for hospice and record review that a phone meeting was held with the Administrator/Executive Director and the area [NAME] President of Sales for hospice on [DATE], at 9:00 AM, concerning communication and collaboration between hospice and facility to provide better service for the residents receiving hospice care in the nursing facility. On [DATE] a new system change included a hospice communication book was placed at each nurse's station for any change in condition to hospice residents.
The SA validated through interviews with the Administrator, DON and SW and a record review that a grief counseling meeting was conducted by the hospice Chaplin on [DATE], from 11:00 AM until 3:00 PM for the residents and staff.
The SA validated through interviews with five LPN's, one Activity Director, two Social Workers, one Director of Admissions, three RN's and five CNA's an in-service/education was provided to all the licensed nursing staff to notify hospice of all changes in condition, this will include condition changes such as, decline or improvement, medication changes, new orders of any type, and psychiatric needs and/or evaluatio[TRUNCATED]
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0841
(Tag F0841)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy/procedure review and interviews, the Medical Director failed to coordinate, implement and evaluat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy/procedure review and interviews, the Medical Director failed to coordinate, implement and evaluate the facility's care of one (1) of seven (7) residents, Resident #1, as evidence by Resident #1 committed suicide by hanging himself with the remote control cord of his bed on an exposed pipe in the ceiling of his room [ROOM NUMBER] days after the Medical Director discontinued the Physician Order for a Psychiatric (psych) Evaluation (eval) for suicidal ideations.
During the admission process on 8/9/23, Resident #1 told the admitting nurse that he wanted to call a friend to pick him up and take him to jump off a bridge. On 8/9/23, a Medical Doctor's (MD) order was written for a psychiatric evaluation. On 8/9/23, Resident #1 wanted to be admitted to hospice services. Another order was written on 8/9/23 to discontinue (D/C) the psych evaluation and resident was admitted to contract hospice services. He remained one-on-one observation through to 8/17/23 when he went to every hour observations. Resident #1 was observed by Licensed Practical Nurse (LPN) #1 at 7:15 AM lying in his bed with his eyes closed. An interview with Certified Nursing Assistant (CNA) #1 revealed that she saw Resident #1 on 8/19/23 around 7:36 AM. LPN #1 took Resident #1's breakfast tray to his room at 8:30 AM and when the door was opened, Resident #1 was observed hanging from a pipe with the bed remote control cord wrapped around his neck. He was noted to be warm. LPN #1 yelled for help and LPN #2 responded. LPN #2 cut Resident #1 down and began doing sternal rubs with no response. Emergency Medical Services (EMS) were called as were hospice services. EMS arrived to the facility and found Resident #1 with no heart activity and he was pronounced dead at 9:00 AM.
The Medical Director failed to oversee the medical care and other designated care and services available for Resident #1 after he expressed suicidal ideations on 8/8/23 and committed suicide on 8/19/23 by hanging himself with the remote control of his bed on an exposed pipe in the ceiling of his room. This placed other residents at risk of serious injury, harm, impairment or death.
The State Agency (SA) investigated the death of Resident #1 on 8/22/23 through 8/28/23. After SA review, the SA extended the survey on 9/7/23 through 9/11/23 and the situation was determined to be an Immediate Jeopardy (IJ) when began on 8/9/23 when the physician's order for a psychiatric evaluation for Resident #1 written on 8/9/23 was discontinued on 8/9/23.
The IJ existed at:
42 CFR 483.70(h)(2)(ii) Responsibilities of Medical Director - F841 - Scope/Severity J
The SA notified the notified the facility's Administrator of the IJ on 9/7/23 at 12:30 PM and provided the Administrator with the IJ template.
The facility submitted an acceptable Removal Plan on 9/8/23, in which they alleged all corrective actions to remove the IJ were completed on 9/7/23 and the IJ was removed on 9/8/23.
The SA validated the Removal Plan on 9/11/23 and determined the IJ was removed on 9/8/23, prior to exit. Therefore, the scope and severity of 42 CFR 483.70(h)(2)(ii) Responsibilities of Medical Director (F841) was lowered to a Scope and Severity of D while the facility develops a plan of correction to monitor the effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements.
Findings Include:
Record review of the facility's policy/procedure for MEDICAL DIRECTOR last revised 1/16 revealed the PURPOSE: To ensure the presence of a Medical Director to coordinate medical care and to be responsible for implementation of resident care policies, in compliance with applicable regulations.
Record review of Resident #1's face sheet revealed he was admitted on [DATE] to the facility with diagnoses which included Malignant Neoplasm of Larynx, unspecified and Depression, unspecified.
Record review of a handwritten physician order Physician Telephone Order dated 8/9/23 read psychiatric consult for evaluation/treatment with no time that order was given and review of Physician Telephone Order dated 8/9/23 read d/c (discontinue) psychiatric consult d/t (due to) admit to hospice with no time that order was given. Both of these orders were signed by the Resident's physician who is also the Medical Director but did not have a date of the signature.
Record review of the printed Physician's Telephone Order dated 8/9/23 with a time of 4:00 PM revealed to Admit to hospice (proper name) related to diagnosis of malignant neoplasm of larynx. There were no printed orders for either the psychiatric evaluation on 8/9/23 or the discontinuation of the psychiatric evaluation on 8/9/23.
Record review of the MD's (Medical Doctor) order to discontinue the psych evaluation written on 8/9/23 revealed the administrator, who is also a Registered Nurse, wrote the order to discontinue the psych evaluation.
Interview with the Administrator, 8/24/23 at 4:10 PM regarding the discontinued psychiatric (psych) evaluation order on 8/9/23 revealed He (Resident #1) went on hospice. That is why the order was discontinued. Hospice won't pay for a psych eval. He (Resident #1) knew he had a psych evaluation ordered and was (one) 1 on 1 due to what he said about jumping off a bridge. We told him we were dc'ing (discontinuing) the psych evaluation because hospice would provide for his needs. He said he understood.
Interview with Resident #1's physician, who is also the Facility Medical Director on 8/24/23 at 8:30 AM revealed that the psychiatric evaluation was discontinued because hospice won't pay for psych. The Medical Director went on to say that I didn't know the psych eval had been dc'd (discontinued) until this past Tuesday. The Tuesday referenced by the Medical Director was 8/22/23 which was three (3) days following the death of the resident.
A follow-up interview with the Facility Medical Director on 8/24/23 at 1:05 PM confirmed he was unaware of the psychiatric evaluation being discontinued until 8/22/23. The Medical Director stated, I sign hundreds of things when I visit on Tuesdays, and it must have slipped through without me noticing.
Record review of the Departmental Notes with a Category: Nursing dated 8/8/21 at 9:31 PM revealed, .Resident stated that he's scared of been in (being) in facility and in room by himself Please don't leave me alone, I'm scared .Resident states he doesn't want to die here .Resident not adjusting to new surroundings well. Resident hollering out loud .Resident refuse to stay in his room due to he's scared of been (being) alone .Stating that he wants to call him friend to pick him up so he can jump off bridge cause he's tired of living . He was placed one on one observation with staff after making that comment. Record review of the Departmental Notes with a Category: Nursing dated 8/9/21 at 7:21 AM revealed, .Resident constantly states he wants to die. He wrapped oxygen tubing around his neck .Resident asked staff if he hit his head against the wall will go ahead and take him out . On 8/19/23 at 6:23 AM, Resident #1 ambulated to the nursing station and stated he had slipped. A laceration on his face and skin tear on his arm were cleaned. Resident #1 was observed by Licensed Practical Nurse #1 at 7:15 AM lying in his bed with his eyes closed. LPN#1 took Resident #1's breakfast tray to his room at 8:30 AM and when the door was opened, Resident #1 was observed hanging from a pipe with the bed remote control cord wrapped around his neck. He was noted warm. LPN #1 yelled for help and LPN #2 responded. LPN #2 cut Resident #1 down using bandage scissors and began doing sternal rubs with no response. The facility called Emergency Medical Services (EMS) and hospice services. EMS arrived at the facility and found Resident #1 with no heart activity, and he was pronounced dead at 9:00 AM. Hospice contacted the coroner, and the body was released to the Medical Examiner.
The facility provided the following Removal Plan:
Resident #1 was admitted on [DATE]. Resident #1 expressed that he wanted to sign up for hospice services on admission due to him being tired. He stated I been suffering from throat cancer for seven years. I'm just tired. Resident #1 expressed that he wanted to call his friend so that he could jump off a bridge. On 08/09/2023, a psychiatric consult was ordered. The resident was admitted to hospice on 8/9/2023. The psychiatric consult was discontinued on 8/9/2023 by the physician after he elected hospice services. The facility failed to adequately meet Resident #1's mental health needs when the facility did not provide a psychiatric evaluation on 8/8/2023, after Resident # 1 stated that he wanted to jump off a bridge. The facility failed to ensure the Medical Director evaluated and acted on reported deficient practices related to Resident #1's actual suicide and failed to ensure that orders for the psychological evaluations were carried out as ordered. The facility failed to adequately meet Resident #1's mental health needs when the facility did not complete a status change PASARR (Pre-admission Screening and Resident Review) when, on 8/8/23, Resident #1 verbalized suicidal ideations. The facility neglected to provide psychological interventions upon admission, on 8/8/23, to protect Resident #1, who expressed suicidal ideations and ultimately was found hanging in the facility on 8/19/23. The facility failed to accurately report an actual suicide for Resident #1 when he was found hanging from the pipes in the ceiling at 8:15 AM on 8/19/2023. The incident was reported as an attempted suicide to the department of licensure and certification (L&C) at 9:57 AM on 8/19/2023. The incident was not reported to the appropriate state agencies within the specific time frame, as required by federal guidance. The Administrator/Executive Director failed to ensure that Resident #1's psychological needs were addressed by a lack of immediate intervention and a lack of carrying out of a physician order for a psychological evaluation, which resulted in Resident #1's death.
Interventions:
*The facility held an emergency meeting on 9/7/2023 at 1:00 PM, with the Quality Assurance team to discuss and implement removal plans for citations F600, F609, F644, F835, F841, related to Resident #1's suicide on 8/19/23. The Administrator/Executive Director, the DON/IP, the unit manager, the Medical Director, the activities director, the [NAME] President to the Administrator/Executive Director, social worker #1, and social worker #2 were in attendance.
*On 9/7/2023, a new preadmission screening and resident review (PASARR) policy was created for the facility to coincide with federal and state guidelines. The policy was created by the Executive Director/Administrator of the facility and the governing body.
*The facility implemented the policy for PASARR, to coincide with state and federal regulations. The policy was approved in the Emergency Quality and Assurance meeting held on 9/7/23, at 1:00 PM.
*An in-service on neglect and abuse was provided to all staff on 9/7/2023, at 1:30 PM, by the Director of Nursing/Infection Preventionist (DON/IP). The information covered in the in-service included the definition of abuse and neglect, the different types of abuse and neglect, and what steps to take if abuse or neglect is witnessed or suspected.
*An in-service education on self-reporting requirements was provided to the Administrator/Executive Director and the DON/IP to include reporting accurately to state agencies on 9/7/2023 at 2:00 PM, by the [NAME] President to the Administrator. The abuse and neglect policy was reviewed in the in-service which included the types of incidents that must be reported, the time frame in which to report, and the entities (Attorney General's Office, Licensure and Certification, Ombudsman) that must be reported to.
*An in-service education was provided with all licensed nurses by the DON on 9/7/2023 at 3:00 PM to review the policy on physician orders including, The signature of the nurse receiving the order and the time of the order must appear.
*An in-service education was provided to social service on 9/7/2023, at 3:30 PM, by the Administrator/Executive Director, to include an increase in social visits for all residents with suicidal ideation to be seen by social service at least 3 times weekly, until they no longer have suicidal ideation.
*An in-service education on the Administrator's job description was provided to the Administrator/Executive Director to include that the Administrator must provide oversight to provide the necessary care for residents who express suicidal ideation and for residents who have psychosocial needs that are not met. This was completed 9/7/2023, at 4:00 PM, by the [NAME] President to the Administrator/Executive Director.
*An in-service education was provided on PASARR to Social Services on 8/23/2023, by the Administrator/Executive Director. Another PASARR in-service/education was completed on 9/7/23, at 4:30 PM by the [NAME] President to the Administrator, the DON/IP, Social Services, the Medical Director, and the Director of Admission. The information covered in the in-service included when to complete a new PASARR and the appropriate agency to send the completed forms to.
*An in-service education on the Medical Director Policy was provided to the Medical Director on 9/7/23, at 5:00 PM, by the Administrator/Executive Director. The information covered in the in-service included the role and responsibilities of the Medical Director and leading the continuity of care with nursing services to include physician orders with accurate times and dates.
*A one hundred percent audit was completed on 08/31/23, by the Administrator/Executive Director, of all current resident's PASARRs to ensure status change of assessment has been completed to include new diagnosis and to reflect that mood and behavior changes are included in the status change. Fifty-eight resident's status change forms were sent to the state mental health authority for a status change on 9/7/23 at 8:00 PM.
*A resident council meeting was completed by the activities director on 08/21/2023, at 2:30 PM. The residents were encouraged to express their feelings. An additional follow up resident council meeting was held on 9/5/2023 at 2:00 PM by the activities director. No negative effects reported from the residents.
*An education/in-service was provided to social service and nursing staff to immediately get psychiatric evaluation for residents with any new behaviors to include suicidal ideation. This was completed 08/21/2023, at 5:00 PM, by the Administrator/Executive Director and the DON/IP. A memo was placed at each nurse's station to reflect the instructions of the in-service completed by 4:00 PM on 8/21/2023, by the DON/IP.
*Six residents with history of suicide ideation were seen per the psychiatric nurse practitioner, on 08/21/2023 and 08/22/2023. All residents denied suicidal ideations on evaluation per the psychiatric nurse practitioner.
*A phone meeting was held with the Administrator/Executive Director and the area [NAME] President of Sales for hospice on 08/23/2023, at 9:00 AM, concerning communication and collaboration between hospice and facility to provide better service for the residents receiving hospice care in the nursing facility. On 8/23/2023 a new system change included a hospice communication book was placed at each nurse's station for any change in condition to hospice residents.
*A grief counseling meeting was conducted by the hospice Chaplin on 08/23/2023, from 11:00 AM until 3:00 PM for the residents and staff.
*An in-service/education was provided to all the licensed nursing staff to notify hospice of all changes in condition, this will include condition changes such as, decline or improvement, medication changes, new orders of any type, and psychiatric needs and/or evaluations. All communication with hospice will be documented in the interdisciplinary notes and placed on hospice notification form (Form #1) in the hospice communication book. The in-service was completed by the DON/IP on 08/23/2023 by 5:30 PM.
*A second emergency Quality Assurance meeting held to discuss the new system implemented to communicate with hospice, the new hospice form #1, and communication book. This meeting was held on 08/23/2023 at 5:00 PM. In attendance were the Administrator/Executive Director, the DON/IP, the Unit Manager, Social Worker #1, Social Worker #2 and the Medical Director per phone.
*Any employee that has not been in-serviced will not be allowed to return to work until all in-services are completed.
*On 08/19/2023, the Emergency Medical Services were notified at 8:51 AM, along with hospice, the coroner, the Department of Health, and the resident's responsible party.
*The State Health Department was notified on 08/19/2023 at 9:57 AM, by the Executive Director/Administrator. The Attorney General's Office (AG) was notified on 08/23/2023 by the Executive Director/Administrator at 8:30 AM while at the facility investigating the incident.
*The Sheriff's Department was notified on 08/19/2023, at 1:00 PM, while at the facility investigating the incident by the Executive Director/Administrator. The Ombudsman was notified by phone on 08/23/2023, at 11:00 AM, by the Executive Director/Administrator.
*On 8/19/2023, at 12:30 PM, an emergency Quality Assurance meeting was held to discuss immediate interventions completed and interventions to be put in place related to Resident #'1's suicide. In attendance was the Director of Nursing/Infection Preventionist, the Executive Director/Administrator, the House Supervisor, Social Worker #1, Social Worker #2 and the Medical Director by phone.
*A trauma screening was performed on each resident in the facility. No issues were found. This was completed on 8/19/2023 between 10:00 AM and 12:00 PM, by social services.
*All staff was in-serviced on abuse, neglect, and suicide precautions starting at 10:00 AM on 8/19/2023, by the DON/IP.
*All care plans of residents with a history of suicidal ideation were updated to include the following interventions, residents that express feelings of harming themselves will be immediately placed on one on one and seen by the psychiatric nurse practitioner or a physician. If the psychiatric nurse practitioner or the physician are not available, then the resident will be sent to the emergency room for evaluation.
*These interventions were added to the plans of care of six residents on 8/19/2023 between 1:00 PM and 2:00 PM, by social services.
*100% audit of all beds to ensure bed remote secured to bed by social service, this was completed 08/19/2023, by 3:00 PM. There were two beds that required maintenance to secure the cord to the bed. The cords were secured immediately.
*For residents' protection, all residents with a history of suicidal ideation were assessed for thoughts of self-harm between the hours of 1:00 PM and 3:00 PM on 08/19/2023, by social services. No resident reported thoughts of self harm.
*An in-service was provided to social services to ensure that all residents with suicidal ideation will be seen by social service at least weekly, until they no longer have suicidal ideation. This in-service was completed by the DON/IP on 08/19/2023, at 5:00 PM.
*An in-service was completed with all staff by the DON/IP at 6:00 PM on 08/19/2023. Training included that all residents that express feelings of harming themselves will be immediately placed on one on one and seen by the psychiatric nurse practitioner or a physician. If the psychiatric nurse practitioner or the physician are not available, then the resident will be sent to the emergency room for evaluation.
Facility alleged compliance on 9/8/2023.
On 9/11/23, the State Agency (SA) validated the facility's Removal Plan by staff interviews, record reviews, and review of the in-service sign in sheets. The SA verified the facility had implemented the following measures to remove the IJ:
The SA validated through interviews and record review that the facility held an emergency meeting on 9/7/2023 at 1:00 PM, with the Quality Assurance team to discuss and implement removal plans for citations F600, F609, F644, F835, F841, related to Resident #1's suicide on 8/19/23. Interviews with the Administrator/Executive Director, the DON/IP, the unit manager, the Medical Director, the [NAME] President to the Administrator/Executive Director, social worker #1, and social worker #2 confirmed all were in attendance.
The SA validated through record review and interviews with the Administrator/Executive Director, Director of Nurses (DON), Social Worker #1, Social Worker #2 that on 9/7/2023, a new preadmission screening and resident review (PASARR) policy was created for the facility to coincide with federal and state guidelines. The policy was created by the Executive Director/Administrator of the facility and the governing body.
The SA validated through record review and interviews with the Administrator/Executive Director, DON, Social Worker #1, Social Worker #2, Medical Director, Unit Manager that the facility implemented the policy for PASARR, to coincide with state and federal regulations. The policy was approved in the Emergency Quality and Assurance meeting held on 9/7/23, at 1:00 PM.
The SA validated through record review and interviews with four Registered Nurses, five Licensed Practical Nurses, eight Certified Nurse Aides, one laundry staff, three Housekeepers, two Social Workers, one Medical Director, one Administrator/Executive Director that an in-service on neglect and abuse was provided to all staff on 9/7/2023, at 1:30 PM, by the Director of Nursing/Infection Preventionist (DON/IP). The information covered in the in-service included the definition of abuse and neglect, the different types of abuse and neglect, and what steps to take if abuse or neglect is witnessed or suspected.
The SA validated through record review and interviews with the Director of Nurses (DON) and Administrator/Executive Director that an in-service education on self-reporting requirements was provided to the Administrator/Executive Director and the DON/IP to include reporting accurately to state agencies on 9/7/2023 at 2:00 PM, by the [NAME] President to the Administrator. The abuse and neglect policy was reviewed in the in-service which included the types of incidents that must be reported, the time frame in which to report, and the entities (Attorney General's Office, Licensure and Certification, Ombudsman) that must be reported to.
The SA validated through record review and interviews with the Administrator/Executive Director, four RN's and five LPN's that an in-service education was provided with all licensed nurses by the DON on 9/7/2023 at 3:00 PM to review the policy on physician orders including, The signature of the nurse receiving the order and the time of the order must appear.
The SA validated through record review and interviews with two Social Workers and Administrator/Executive Director that an in-service education was provided to social service on 9/7/2023, at 3:30 PM, by the Administrator/Executive Director, to include an increase in social visits for all residents with suicidal ideation to be seen by social service at least 3 times weekly, until they no longer have suicidal ideation.
The SA validated through interview with the Administrator/Executive Director and record review that an in-service education on the Administrator's job description was provided to the Administrator/Executive Director to include that the Administrator must provide oversight to provide the necessary care for residents who express suicidal ideation and for residents who have psychosocial needs that are not met. This was completed 9/7/2023, at 4:00 PM, by the [NAME] President to the Administrator/Executive Director.
The SA validated through record review and interviews with two Social Workers and the Administrator/Executive Director that an in-service education was provided on PASARR to Social Services on 8/23/2023, by the Administrator/Executive Director. Another PASARR in-service/education was completed on 9/7/23, at 4:30 PM by the [NAME] President to the Administrator, the DON/IP, Social Services, the Medical Director, and the Director of Admission. The information covered in the in-service included when to complete a new PASARR and the appropriate agency to send the completed forms to.
The SA validated through record review and interviews with the Medical Director and Administrator/Executive Director that an in-service education on the Medical Director Policy was provided to the Medical Director on 9/7/23, at 5:00 PM, by the Administrator/Executive Director. The information covered in the in-service included the role and responsibilities of the Medical Director and leading the continuity of care with nursing services to include physician orders with accurate times and dates.
The SA validated by record review and interviews with the Administrator/Executive Director and two Social Workers that a one hundred percent audit was completed on 08/31/23, by the Administrator/Executive Director, of all current resident's PASRRs to ensure status change of assessment has been completed to include new diagnosis and to reflect that mood and behavior changes are included in the status change. Fifty-eight resident's status change forms were sent to the state mental health authority for a status change on 9/7/23 at 8:00 PM.
The SA validated through interviews with the Administrator, DON and SW #1 and record review a resident council meeting was completed by the activities director on 08/21/2023, at 2:30 PM. The residents were encouraged to express their feelings. An additional follow up resident council meeting was held on 9/5/2023 at 2:00 PM by the activities director. No negative effects reported from the residents.
The SA validated through interviews with five LPN's, one Activity Director, two Social Workers, one Director of Admissions, three RN's and five CNA's that an education/in-service was provided to social service and nursing staff to immediately get psychiatric evaluation for residents with any new behaviors to include suicidal ideation. This was completed 08/21/2023, at 5:00 PM, by the Administrator/Executive Director and the DON/IP. A memo was placed at each nurse's station to reflect the instructions of the in-service completed by 4:00 PM on 8/21/2023, by the DON/IP.
The SA validated through interviews with the Administrator, DON and SW and record review that six residents with history of suicide ideation were seen per the psychiatric nurse practitioner, on 08/21/2023 and 08/22/2023. All residents denied suicidal ideations on evaluation per the psychiatric nurse practitioner.
The SA validated through interviews with the Administrator and the [NAME] President of sales for hospice and record review that a phone meeting was held with the Administrator/Executive Director and the area [NAME] President of Sales for hospice on 08/23/2023, at 9:00 AM, concerning communication and collaboration between hospice and facility to provide better service for the residents receiving hospice care in the nursing facility. On 8/23/2023 a new system change included a hospice communication book was placed at each nurse's station for any change in condition to hospice residents.
The SA validated through interviews with the Administrator, DON and SW and a record review that a grief counseling meeting was conducted by the hospice Chaplin on 08/23/2023, from 11:00 AM until 3:00 PM for the residents and staff.
The SA validated through interviews with five LPN's, one Activity Director, two Social Workers, one Director of Admissions, three RN's and five CNA's an in-service/education was provided to all the licensed nursing staff to notify hospice of all changes in condition, this will include condition changes such as, decline or improvement, medication changes, new orders of any type, and psychiatric needs and/or evaluations. All communication with hospice will be documented in the interdisciplinary notes and placed on hospice notification form (Form #1) in the hospice communication book. The in-service was completed by the DON/IP on 08/23/2023 by 5:30 PM.
The SA validated through interviews with the Administrator, DON, Medical Director and SW and record review that a second emergency Quality Assurance meeting held to discuss the new system implemented to communicate with hospice, the new hospice form #1, and communication book. This meeting was held on 08/23/2023 at 5:00 PM. In attendance were the Administrator/Executive Director, the DON/IP, the Unit Manager, Social Worker #1, Social Worker #2 and the Medical Director per phone.
Any employee that has not been in-serviced will not be allowed to return to work until all in-services are completed.
The SA validated through interviews with the Administrator and DON and record review that on 08/19/2023, the Emergency Medical Services were notified at 8:51 AM, along with hospice, the coroner, the Department of Health, and the resident's responsible party.
The SA validated through interviews with the Administrator and DON that The State Health Department was notified on 08/19/2023 at 9:57 AM, by the Executive Director/Administrator. The Attorney General's Office (AG) was notified on 08/23/2023 by the Executive Director/Administrator at 8:30 AM while at the facility investigating the incident.
The SA validated through interview with the Administrator that the Sheriff's Department was notified on 08/19/2023, at 1:00 PM, while at the facility investigating the incident by the Executive Director/Administrator. The Ombudsman was notified by phone on 08/23/2023, at 11:00 AM, by the Executive Director/Administrator.
The SA validated through record review and interviews with the Administrator, DON, SW #1 and Medical Director that on 8/19/2023, at 12:30 PM, an emergency Quality Assurance meeting was held to discuss immediate interventions completed and interventions to be put in place related to Resident #'1's suicide. In attendance was the Director of Nursing/Infection Preventionist, the Executive Director/Administrator, the House Supervisor, Social Worker #1, Social Worker #2 and the Medical Director by phone.
The SA validated through record review and interviews with the Administrator, DON and SW that a trauma screening was performed on each resident in the facility. No issues were found. This was completed on 8/19/2023 between 10:00 AM and 12:00 PM, by social services.
The SA validated through record review and interviews with five LPN's, one Activity Director, two Social Workers, one Director of Admissions, three RN's and five CNA's that all staff was in-serviced on abuse, neglect, and suicide precautions starting at 10:00 AM on 8/19/2023, by the DON/IP.
The SA validated through record review and interviews with the Administrator and DON that all care plans of residents with a history of suicidal ideation were updated to include the following interventions, residents that express feelings of harming themselves will be immediately placed on one on one and seen by the psychiatric nurse practitioner or a physician. If the psychiatric nurse practitioner or the physician are not available, then the resident will be sent to the emergency room for evaluation. These interventions were added to the plans of care of six residents on 8/19/2023 between 1:00 PM and 2:00 PM, by social services.
The SA validated with record review and interviews with the Administrator and DON that 100% audit of all beds to ensure bed remote secured to bed by social service, this was completed 08/19/2023, by 3:00 PM. There were two beds that required maintenance to secure the cord to the bed. The[TRUNCATED]
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0849
(Tag F0849)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy/procedure review and interviews, the facility failed to ensure an effective communication process...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy/procedure review and interviews, the facility failed to ensure an effective communication process, including how the communication would be documented between the Long-Term Care (LTC) facility and the hospice provider, to ensure that the needs of the resident were addressed and met 24 hours a day for one (1) of seven (7) residents sampled. Resident #1.
During the admission process on 8/8/23, Resident #1 told the admitting nurse that he wanted to call a friend to pick him up and take him to jump off a bridge. On 8/9/23, a Medical Doctor's (MD) order was written for a psychiatric (psych) evaluation. On 8/9/23, Resident #1 wanted to be admitted to hospice services. Another MD order was written on 8/9/23 to discontinue (D/C) the psych evaluation and resident was admitted to contract hospice services. He remained on one-on-one observation through to 8/17/23 when he went to every hour observations. Resident #1 was observed by Licensed Practical Nurse (LPN) #1 at 7:15 AM lying in his bed with his eyes closed. LPN #1 took Resident #1's breakfast tray to his room at 8:30 AM and when the door was opened, Resident #1 was observed hanging from a pipe with the bed remote control cord wrapped around his neck. He was noted to be warm. LPN #1 yelled for help and LPN #2 responded. LPN #2 cut Resident #1 down and began doing sternal rubs with no response. Emergency Medical Services (EMS) were called as were hospice services. EMS arrived at the facility and found Resident #1 with no heart activity and he was pronounced dead at 9:00 AM.
The facility's failure to provide communication with the hospice provider for Resident #1 lead to Resident #1's death and placed other residents in a situation that was likely to cause serious injury, harm, impairment, or death.
The situation was determined to be an Immediate Jeopardy (IJ) which began on 8/9/23 when the facility failed to assure and notify hospice of the physician's order for the psychiatric evaluation and discontinuation of the order.
The State Agency (SA) investigated the death of Resident #1 on 8/22/23 through 8/28/23. After review by the SA, the SA extended the survey from 9/7/23 through 9/11/23 and the situation was determined to be an Immediate Jeopardy (IJ) when began on 8/9/23 when the physician's order for a psychiatric evaluation for Resident #1 written on 8/9/23 was discontinued on 8/9/23.
The State Agency identified Immediate Jeopardy at:
CFR 483.70(o)(2)(ii)(D)(E)(1)(2) Hospice Services (849)-Scope and Severity of J.
The State Agency (SA) notified the facility's Administrator of the IJ on 8/24/23 at 5:15 PM and provided the Administrator with the IJ template.
The facility submitted an acceptable Removal Plan on 9/8/23, in which they alleged all corrective actions to remove the IJ were completed on 9/7/23 and the IJ was removed on 9/8/23.
The SA validated the Removal Plan on 9/11/23 and determined the IJ was removed on 9/8/23, prior to exit. Therefore, the scope and severity for CFR 483.70(o)(2)(ii)(D)(E)(1)(2) Hospice Services (849) was lowered to a D while the facility develops a plan of correction to monitor the effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements.
Findings Include:
Interview on 8/24/23 at 4:00 PM, revealed the administrator stated that the facility does not have a specific policy/procedure for hospice services but does have one for palliative care for residents.
Policy/Procedure review of the facility's Palliative Care policy/procedure last reviewed on 1/15 revealed the Definition: Palliative care is defined as measures and treatments provided to offer comfort to the resident, neither hastening nor prolonging the natural process of dying.
Record review by the State Agency (SA) of Resident #1's Face Sheet revealed he was admitted on [DATE] to the facility with diagnoses which included Malignant Neoplasm of Larynx, unspecified and Depression, unspecified.
Record review of Resident #1's Physician Orders for August 2023 revealed Do Not Resuscitate (DNR). Record review also revealed a handwritten Physician Telephone Order dated 8/9/23 that read, psychiatric (psych) consult for evaluation/treatment with no time that order was given. Record review further revealed a Physician Telephone Order dated 8/9/23 that read d/c (discontinue) psychiatric consult d/t (due to) admit to hospice with no time that order was given. Review of a printed Physician's Telephone Order dated 8/9/23 with a time of 4:00 PM read to Admit to hospice (proper name) related to diagnosis of malignant neoplasm of larynx.
An interview with Resident #1's Medical Doctor (MD) on 8/24/23 at 8:30 AM revealed that the psychiatric evaluation was discontinued because hospice won't pay for psych.
The SA interview on 8/24/23 at 12:45 PM, with the Executive Director of the hospice company, revealed that if a resident of a nursing home and a patient of their hospice needed a psychiatric (psych) evaluation that they can have a psych evaluation. She said they were not aware of the psych evaluation being ordered or discontinued. She said anyone they admit, their social worker goes for the first visit within 24 hours of admit. If it was necessary for him to have a psych evaluation, we would cover the cost. No one ever expressed anything at all regarding a psych evaluation. She looked at the nursing home orders for Resident #1 and did not have the handwritten or a printed order for the psych evaluation or the discontinued order for the psych evaluation. She stated Resident #1 never expressed to hospice staff any suicidal ideations. She said the hospice chaplain went and visited him and the hospice social worker went several times. We knew he had verbalized suicidal ideations because the nursing home staff did tell the hospice staff what he said. We were never called to a care plan meeting. I have no handwritten orders at all on Resident #1. If we have a cardiac patient that wants to see their cardiologist, we would actually cover it.
An interview with the Administrator on 8/24/23 at 4:10 PM revealed the facility did not communicate with hospice that Resident #1's psych evaluation had been dc'd (discontinued). The adminstrator stated she did not the facility did not communicate with hospice when the facility was decreasing monitoring of the resident from one-on-one observation to every hour observation. The administrator stated she had a telephone meeting with the [NAME] President of sales for the hospice company 8/23/23 before 10:30 AM. The administrator stated we discussed better communication between hospice staff, the Nurse Practitioner, Nurse and nursing home staff and me. The Administrator stated she wanted to know what is going on with the facility's hospice patients. I asked if hospice had a policy on providing psych services if needed and was told they didn't have one. I told the [NAME] President of sales I felt the hospice wasn't communicating with me when there are changes with a hospice resident.
SA interview with [NAME] President of Sales for hospice company by phone on 8/24/23 at 4:25 PM, confirmed he did talk with the Administrator about how the facility nurses can better communicate with hospice staff.
The SA interview with the Account Executive for hospice company, on 8/24/23 at 4:30 PM revealed that the hospice company does not have a policy/procedure for psych services. Yes, we talked about better communication when a resident is declining. We spoke about having our staff talk with the nursing home's staff.
The facility provided the following Removal Plan:
Resident #1 was admitted on [DATE]. Resident #1 expressed that he wanted to sign up for hospice services on admission due to him being tired. He stated I been suffering from throat cancer for seven years. I'm just tired. Resident #1 expressed that he wanted to call his friend so that he could jump off a bridge. On 08/09/2023, a psychiatric consult was ordered. The resident was admitted to hospice on 8/9/2023. The psychiatric consult was discontinued on 8/9/2023 by the physician after he elected hospice services. The facility failed to adequately meet Resident #1's mental health needs when the facility did not provide a psychiatric evaluation on 8/8/2023, after Resident # 1 stated that he wanted to jump off a bridge. The facility failed to ensure the Medical Director evaluated and acted on reported deficient practices related to Resident #1's actual suicide and failed to ensure that orders for the psychological evaluations were carried out as ordered. The facility failed to adequately meet Resident #1's mental health needs when the facility did not complete a status change PASARR when, on 8/8/23, Resident #1 verbalized suicidal ideations. The facility neglected to provide psychological interventions upon admission, on 8/8/23, to protect Resident #1, who expressed suicidal ideations and ultimately was found hanging in the facility on 8/19/23. The facility failed to accurately report an actual suicide for Resident #1 when he was found hanging from the pipes in the ceiling at 8:15 AM on 8/19/2023. The incident was reported as an attempted suicide to the department of licensure and certification (L&C) at 9:57 AM on 8/19/2023. The incident was not reported to the appropriate state agencies within the specific time frame, as required by federal guidance. The Administrator/Executive Director failed to ensure that Resident #1's psychological needs were addressed by a lack of immediate intervention and a lack of carrying out of a physician order for a psychological evaluation, which resulted in Resident #1's death.
Interventions
* The facility held an emergency meeting on 9/7/2023 at 1:00 PM, with the Quality Assurance team to discuss and implement removal plans for citations F600, F609, F644, F835, F841, related to Resident #1's suicide on 8/19/23. The Administrator/Executive Director, the DON/IP, the unit manager, the Medical Director, the activities director, the [NAME] President to the Administrator/Executive Director, social worker #1, and social worker #2 were in attendance.
*On 9/7/2023, a new preadmission screening and resident review (PASARR) policy was created for the facility to coincide with federal and state guidelines. The policy was created by the Executive Director/Administrator of the facility and the governing body.
*The facility implemented the policy for PASARR, to coincide with state and federal regulations. The policy was approved in the Emergency Quality and Assurance meeting held on 9/7/23, at 1:00 PM
*An in-service on neglect and abuse was provided to all staff on 9/7/2023, at 1:30 PM, by the Director of Nursing/Infection Preventionist (DON/IP). The information covered in the in-service included the definition of abuse and neglect, the different types of abuse and neglect, and what steps to take if abuse or neglect is witnessed or suspected.
*An in-service education on self reporting requirements was provided to the Administrator/Executive Director and the DON/IP to include reporting accurately to state agencies on 9/7/2023 at 2:00 PM, by the [NAME] President to the Administrator. The abuse and neglect policy was reviewed in the in-service which included the types of incidents that must be reported, the time frame in which to report, and the entities (Attorney General's Office, Licensure and Certification, Ombudsman) that must be reported to.
*An in-service education was provided with all licensed nurses by the DON on 9/7/2023 at 3:00 PM to review the policy on physician orders including, The signature of the nurse receiving the order and the time of the order must appear.
*An in-service education was provided to social service on 9/7/2023, at 3:30 PM, by the Administrator/Executive Director, to include an increase in social visits for all residents with suicidal ideation to be seen by social service at least 3 times weekly, until they no longer have suicidal ideation.
*An in-service education on the Administrator's job description was provided to the Administrator/Executive Director to include that the Administrator must provide oversight to provide the necessary care for residents who express suicidal ideation and for residents who have psychosocial needs that are not met. This was completed 9/7/2023, at 4:00 PM, by the [NAME] President to the Administrator/Executive Director.
*An in-service education was provided on PASARR to Social Services on 8/23/2023, by the Administrator/Executive Director. Another PASARR in-service/education was completed on 9/7/23, at 4:30 PM by the [NAME] President to the Administrator, the DON/IP, Social Services, the Medical Director, and the Director of Admission. The information covered in the in-service included when to complete a new PASARR and the appropriate agency to send the completed forms to.
*An in-service education on the Medical Director Policy was provided to the Medical Director on 9/7/23, at 5:00 PM, by the Administrator/Executive Director. The information covered in the in-service included the role and responsibilities of the Medical Director and leading the continuity of care with nursing services to include physician orders with accurate times and dates.
*A one hundred percent audit was completed on 08/31/23, by the Administrator/Executive Director, of all current resident's PASARRs to ensure status change of assessment has been completed to include new diagnosis and to reflect that mood and behavior changes are included in the status change. Fifty-eight resident's status change forms were sent to the state mental health authority for a status change on 9/7/23 at 8:00 PM.
*A resident council meeting was completed by the activities director on 08/21/2023, at 2:30 PM. The residents were encouraged to express their feelings. An additional follow up resident counsel meeting was held on 9/5/2023 at 2:00 PM by the activities director. No negative effects reported from the residents.
*An education/in-service was provided to social service and nursing staff to immediately get psychiatric evaluation for residents with any new behaviors to include suicidal ideation. This was completed 08/21/2023, at 5:00 PM, by the Administrator/Executive Director and the DON/IP. A memo was placed at each nurses station to reflect the instructions of the in-service completed by 4:00 PM on 8/21/2023, by the DON/IP.
*Six residents with history of suicide ideation were seen per the psychiatric nurse practitioner, on 08/21/2023 and 08/22/2023. All residents denied suicidal ideations on evaluation per the psychiatric nurse practitioner.
*A phone meeting was held with the Administrator/Executive Director and the area [NAME] President of Sales for hospice on 08/23/2023, at 9:00 AM, concerning communication and collaboration between hospice and facility to provide better service for the residents receiving hospice care in the nursing facility. On 8/23/2023 a new system change included a hospice communication book was placed at each nurse's station for any change in condition to hospice residents.
*A grief counseling meeting was conducted by the hospice Chaplin on 08/23/2023, from 11:00 AM until 3:00 PM for the residents and staff.
*An in-service/education was provided to all the licensed nursing staff to notify hospice of all changes in condition, this will include condition changes such as, decline or improvement, medication changes, new orders of any type, and psychiatric needs and/or evaluations. All communication with hospice will be documented in the interdisciplinary notes and placed on hospice notification form (Form #1) in the hospice communication book. The in-service was completed by the DON/IP on 08/23/2023 by 5:30 PM.
*A second emergency Quality Assurance meeting held to discuss the new system implemented to communicate with hospice, the new hospice form #1, and communication book. This meeting was held on 08/23/2023 at 5:00 PM. In attendance were the Administrator/Executive Director, the DON/IP, the Unit Manager, Social Worker #1, Social Worker #2 and the Medical Director per phone.
*Any employee that has not been in-serviced will not be allowed to return to work until all in-services are completed.
*On 08/19/2023, the Emergency Medical Services were notified at 8:51 AM, along with hospice, the coroner, the Department of Health, and the resident's responsible party.
*The State Health Department was notified on 08/19/2023 at 9:57 AM, by the Executive Director/Administrator. The Attorney General's Office (AG) was notified on 08/23/2023 by the Executive Director/Administrator at 8:30 AM while at the facility investigating the incident.
*The Sheriff's Department was notified on 08/19/2023, at 1:00 PM, while at the facility investigating the incident by the Executive Director/Administrator. The Ombudsman was notified by phone on 08/23/2023, at 11:00 AM, by the Executive Director/Administrator.
*On 8/19/2023, at 12:30 PM, an emergency Quality Assurance meeting was held to discuss immediate interventions completed and interventions to be put in place related to Resident #1's suicide. In attendance was the Director of Nursing/Infection Preventionist, the Executive Director/Administrator, the House Supervisor, Social Worker #1, Social Worker #2 and the Medical Director by phone.
*A trauma screening was performed on each resident in the facility. No issues were found. This was completed on 8/19/2023 between 10:00 AM and 12:00 PM, by social services.
*All staff was in-serviced on abuse, neglect, and suicide precautions starting at 10:00 AM on 8/19/2023, by the DON/IP.
*All care plans of residents with a history of suicidal ideation were updated to include the following interventions, residents that express feelings of harming themselves will be immediately placed on one on one and seen by the psychiatric nurse practitioner or a physician. If the psychiatric nurse practitioner or the physician are not available, then the resident will be sent to the emergency room for evaluation.
*These interventions were added to the plans of care of six residents on 8/19/2023 between 1:00 PM and 2:00 PM, by social services.
*100% audit of all beds to ensure bed remote secured to bed by social service, this was completed 08/19/2023, by 3:00 PM. There were two beds that required maintenance to secure the cord to the bed. The cords were secured immediately.
*For residents protection, all residents with a history of suicidal ideation were assessed for thoughts of self harm between the hours of 1:00 PM and 3:00 PM on 08/19/2023, by social services. No resident reported thoughts of self harm.
*An in-service was provided to social services to ensure that all residents with suicidal ideation will be seen by social service at least weekly, until they no longer have suicidal ideation. This in-service was completed by the DON/IP on 08/19/2023, at 5:00 PM.
*An in-service was completed with all staff by the DON/IP at 6:00 PM on 08/19/2023. Training included that all residents that express feelings of harming themselves will be immediately placed on one on one and seen by the psychiatric nurse practitioner or a physician. If the psychiatric nurse practitioner or the physician are not available, then the resident will be sent to the emergency room for evaluation.
Facility alleged compliance on 9/8/2023.
On 9/11/23, the State Agency (SA) validated the facility's Removal Plan by staff interviews, record reviews, and review of the in-service sign in sheets. The SA verified the facility had implemented the following measures to remove the IJ:
The SA validated through interviews and record review that the facility held an emergency meeting on 9/7/2023 at 1:00 PM, with the Quality Assurance team to discuss and implement removal plans for citations F600, F609, F644, F835, F841, related to Resident #1's suicide on 8/19/23. Interviews with the Administrator/Executive Director, the DON/IP, the unit manager, the Medical Director, the [NAME] President to the Administrator/Executive Director, social worker #1, and social worker #2 confirmed all were in attendance.
The SA validated through record review and interviews with the Administrator/Executive Director, Director of Nurses (DON), Social Worker #1, Social Worker #2 that on 9/7/2023, a new preadmission screening and resident review (PASARR) policy was created for the facility to coincide with federal and state guidelines. The policy was created by the Executive Director/Administrator of the facility and the governing body.
The SA validated through record review and interviews with the Administrator/Executive Director, DON, Social Worker #1, Social Worker #2, Medical Director, Unit Manager that the facility implemented the policy for PASARR, to coincide with state and federal regulations. The policy was approved in the Emergency Quality and Assurance meeting held on 9/7/23, at 1:00 PM.
The SA validated through record review and interviews with four Registered Nurses, five Licensed Practical Nurses, eight Certified Nurse Aides, one Laundry staff, three Housekeepers, two Social Workers, one Medical Director, one Administrator/Executive Director that an in-service on neglect and abuse was provided to all staff on 9/7/2023, at 1:30 PM, by the Director of Nursing/Infection Preventionist (DON/IP). The information covered in the in-service included the definition of abuse and neglect, the different types of abuse and neglect, and what steps to take if abuse or neglect is witnessed or suspected.
The SA validated through record review and interviews with the Director of Nurses (DON) and Administrator/Executive Director that an in-service education on self reporting requirements was provided to the Administrator/Executive Director and the DON/IP to include reporting accurately to state agencies on 9/7/2023 at 2:00 PM, by the [NAME] President to the Administrator. The abuse and neglect policy was reviewed in the in-service which included the types of incidents that must be reported, the time frame in which to report, and the entities (Attorney General's Office, Licensure and Certification, Ombudsman) that must be reported to.
The SA validated through record review and interviews with the Administrator/Executive Director, four RN's and five LPN's that an in-service education was provided with all licensed nurses by the DON on 9/7/2023 at 3:00 PM to review the policy on physician orders including, The signature of the nurse receiving the order and the time of the order must appear.
The SA validated through record review and interviews with two Social Workers and Administrator/Executive Director that an in-service education was provided to social service on 9/7/2023, at 3:30 PM, by the Administrator/Executive Director, to include an increase in social visits for all residents with suicidal ideation to be seen by social service at least 3 times weekly, until they no longer have suicidal ideation.
The SA validated through interview with the Administrator/Executive Director and record review that an in-service education on the Administrator's job description was provided to the Administrator/Executive Director to include that the Administrator must provide oversight to provide the necessary care for residents who express suicidal ideation and for residents who have psychosocial needs that are not met. This was completed 9/7/2023, at 4:00 PM, by the [NAME] President to the Administrator/Executive Director.
The SA validated through record review and interviews with two Social Workers and the Administrator/Executive Director that an in-service education was provided on PASARR to Social Services on 8/23/2023, by the Administrator/Executive Director. Another PASARR in-service/education was completed on 9/7/23, at 4:30 PM by the [NAME] President to the Administrator, the DON/IP, Social Services, the Medical Director, and the Director of Admission. The information covered in the in-service included when to complete a new PASARR and the appropriate agency to send the completed forms to.
The SA validated through record review and interviews with the Medical Director and Administrator/Executive Director that an in-service education on the Medical Director Policy was provided to the Medical Director on 9/7/23, at 5:00 PM, by the Administrator/Executive Director. The information covered in the in-service included the role and responsibilities of the Medical Director and leading the continuity of care with nursing services to include physician orders with accurate times and dates.
The SA validated by record review and interviews with the Administrator/Executive Director and two Social Workers that a one hundred percent audit was completed on 08/31/23, by the Administrator/Executive Director, of all current resident's PASARRs to ensure status change of assessment has been completed to include new diagnosis and to reflect that mood and behavior changes are included in the status change. Fifty-eight resident's status change forms were sent to the state mental health authority for a status change on 9/7/23 at 8:00 PM.
The SA validated through interviews with the Administrator, DON and SW #1 and record review a resident council meeting was completed by the activities director on 08/21/2023, at 2:30 PM. The residents were encouraged to express their feelings. An additional follow up resident counsel meeting was held on 9/5/2023 at 2:00 PM by the activities director. No negative effects reported from the residents.
The SA validated through interviews with five LPN's, one Activity Director, two Social Workers, one Director of Admissions, three RN's and five CNA's that an education/in-service was provided to social service and nursing staff to immediately get psychiatric evaluation for residents with any new behaviors to include suicidal ideation. This was completed 08/21/2023, at 5:00 PM, by the Administrator/Executive Director and the DON/IP. A memo was placed at each nurses station to reflect the instructions of the in-service completed by 4:00 PM on 8/21/2023, by the DON/IP.
The SA validated through interviews with the Administrator, DON and SW and record review that six residents with history of suicide ideation were seen per the psychiatric nurse practitioner, on 08/21/2023 and 08/22/2023. All residents denied suicidal ideations on evaluation per the psychiatric nurse practitioner.
The SA validated through interviews with the Administrator and the [NAME] President of sales for hospice and record review that a phone meeting was held with the Administrator/Executive Director and the area [NAME] President of Sales for hospice on 08/23/2023, at 9:00 AM, concerning communication and collaboration between hospice and facility to provide better service for the residents receiving hospice care in the nursing facility. On 8/23/2023 a new system change included a hospice communication book was placed at each nurse's station for any change in condition to hospice residents.
The SA validated through interviews with the Administrator, DON and SW and a record review that a grief counseling meeting was conducted by the hospice Chaplin on 08/23/2023, from 11:00 AM until 3:00 PM for the residents and staff.
The SA validated through interviews with five LPN's, one Activity Director, two Social Workers, one Director of Admissions, three RN's and five CNA's an in-service/education was provided to all the licensed nursing staff to notify hospice of all changes in condition, this will include condition changes such as, decline or improvement, medication changes, new orders of any type, and psychiatric needs and/or evaluations. All communication with hospice will be documented in the interdisciplinary notes and placed on hospice notification form (Form #1) in the hospice communication book. The in-service was completed by the DON/IP on 08/23/2023 by 5:30 PM.
The SA validated through interviews with the Administrator, DON, Medical Director and SW and record review that a second emergency Quality Assurance meeting held to discuss the new system implemented to communicate with hospice, the new hospice form #1, and communication book. This meeting was held on 08/23/2023 at 5:00 PM. In attendance were the Administrator/Executive Director, the DON/IP, the Unit Manager, Social Worker #1, Social Worker #2 and the Medical Director per phone.
Any employee that has not been in-serviced will not be allowed to return to work until all in-services are completed.
The SA validated through interviews with the Administrator and DON and record review that on 08/19/2023, the Emergency Medical Services were notified at 8:51 AM, along with hospice, the coroner, the Department of Health, and the resident's responsible party.
The SA validated through interviews with the Administrator and DON that The State Health Department was notified on 08/19/2023 at 9:57 AM, by the Executive Director/Administrator. The Attorney General's Office (AG) was notified on 08/23/2023 by the Executive Director/Administrator at 8:30 AM while at the facility investigating the incident.
The SA validated through interview with the Administrator that the Sheriff's Department was notified on 08/19/2023, at 1:00 PM, while at the facility investigating the incident by the Executive Director/Administrator. The Ombudsman was notified by phone on 08/23/2023, at 11:00 AM, by the Executive Director/Administrator.
The SA validated through record review and interviews with the Administrator, DON, SW #1 and Medical Director that on 8/19/2023, at 12:30 PM, an emergency Quality Assurance meeting was held to discuss immediate interventions completed and interventions to be put in place related to Resident #1's suicide. In attendance was the Director of Nursing/Infection Preventionist, the Executive Director/Administrator, the House Supervisor, Social Worker #1, Social Worker #2 and the Medical Director by phone.
The SA validated through record review and interviews with the Administrator, DON and SW that a trauma screening was performed on each resident in the facility. No issues were found. This was completed on 8/19/2023 between 10:00 AM and 12:00 PM, by social services.
The SA validated through record review and interviews with five LPN's, one Activity Director, two Social Workers, one Director of Admissions, three RN's and five CNA's that all staff was in-serviced on abuse, neglect, and suicide precautions starting at 10:00 AM on 8/19/2023, by the DON/IP.
The SA validated through record review and interviews with the Administrator and DON that all care plans of residents with a history of suicidal ideation were updated to include the following interventions, residents that express feelings of harming themselves will be immediately placed on one on one and seen by the psychiatric nurse practitioner or a physician. If the psychiatric nurse practitioner or the physician are not available, then the resident will be sent to the emergency room for evaluation. These interventions were added to the plans of care of six residents on 8/19/2023 between 1:00 PM and 2:00 PM, by social services.
The SA validated with record review and interviews with the Administrator and DON that 100% audit of all beds to ensure bed remote secured to bed by social service, this was completed 08/19/2023, by 3:00 PM. There were two beds that required maintenance to secure the cord to the bed. The cords were secured immediately.
The SA validated through record review and interviews with the Administrator, DON and SW that for residents protection, all residents with a history of suicidal ideation were assessed for thoughts of self harm between the hours of 1:00 PM and 3:00 PM on 08/19/2023, by social services. No resident reported thoughts of self harm.
The SA validated by record review and interviews with the Administrator, DON and SW that an in-service was provided [TRUNCATED]
Jun 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and facility policy review, the facility failed to timely notify a family of the death...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and facility policy review, the facility failed to timely notify a family of the death of a resident, for one (1) of five (5) residents reviewed for notification of change in condition. Resident #1
Findings include:
Record review of a statement on facility letterhead dated [DATE] and signed by the Administrator revealed, Facility does not have policy that speaks to notification of family regarding significant changes in for resident that are their own responsible party.
During the entrance conference interview on [DATE] at 02:55 PM, with the Administrator revealed the nursing facility did not have access to any contact information for Resident #1's family, that the facility did ask (local funeral home) to pick up Resident #1's body on [DATE]. She noted she received a call from the funeral home director on [DATE], and was told family had called the funeral home upset regarding not being notified but she was not aware of how family was contacted regarding Resident #1's death.
A telephone interview on [DATE] at 4:20 PM with the Funeral Home Director revealed he was the one who picked up Resident #1's body from the nursing home on Saturday, [DATE], at the facility's request. He also revealed that he was informed by the nursing facility that there was no family available nor contact information for family members. He shared information regarding receiving a call from a female family member for Resident #1 on [DATE], and the family member stated she had just been informed by the nursing facility that Resident #1 had expired.
An interview on [DATE] at 10:35 AM, with Social Services, revealed that she only used the Face Sheet to look for family contact numbers for a resident. She also revealed that she did not attempt to read the hospital social worker's notes from the referring facility to attempt to find contact information. She noted she had called the staff member at Resident #1's former placement facility and was told they did not have any contact numbers for family. She denied calling the hospital social worker that referred Resident #1 to the nursing facility to inquire for family contact information.
A telephone interview on [DATE] at 11:15 AM, with the Hospital Social Work Supervisor revealed she had spoken with the admission Coordinator for the nursing facility and provided contact information for Resident #1's mother prior to Resident #1 leaving the hospital for admission to the nursing facility.
A telephone interview on [DATE] at 11:19 AM, with Resident #1's Mother revealed she had spoken with Resident #1 on several occasions while in the nursing facility. She noted she received a call from the nursing facility two (2) weeks after Resident #1 was admitted and she thought it was a social worker who called her. She revealed that the nursing facility called her on the [DATE], after Resident #1 passed away on [DATE], and told her that the nursing facility had sent her body to the funeral home because they had no telephone number to call family until that day.
A telephone interview on [DATE] at 11:59 AM, with Resident #1's Sister revealed she had spoken with Licensed Practical Nurse (LPN) #1 on [DATE], after Resident #1 passed away. She revealed LPN#1 told her there were no contact numbers in the chart for family and that she had just gotten a contact number for the mother on that day. She also noted there had also been family calls made to the nursing facility to follow up on how Resident #1 was doing. She shared that LPN#1 told her that Resident #1 had been sent to the funeral home. The Sister revealed she did talk with the funeral home director, and he told her the funeral home had Resident #1's body because they were called by the nursing facility to provide the funeral services, due to there being no family available.
An interview and record review on [DATE] at 11:35 AM, with the admission Coordinator revealed she had spoken with the Hospital Social Work Supervisor, and she did not give her a contact number for the mother of Resident #1. She noted she was informed by the Hospital Social Work Supervisor that they had not spoken to any family members and had no way of calling any family for Resident #1. SA reviewed a copy of the documentation for the social worker from the hospital's medical record with the admission Coordinator and she confirmed she had received it in the referral packet for Resident #1. The record review revealed the hospital social worker had spoken with Resident #1's mother twice over the telephone regarding discharge planning. The admission Coordinator confirmed the she did not know that information was in the medical record and that she did not review the documentation when the referral was submitted.
An interview on [DATE] at 12:00 PM, with Licensed Practical Nurse (LPN)#1 revealed she spoke with Resident #1's mother and sister on [DATE], and informed them that Resident #1 expired on [DATE], and she was transported to the funeral home on that date. She noted there was no contact information for family members in the medical record and had received the telephone number, for Resident #1's mother, on [DATE], from the Business Office Manager (BOM).
An interview on [DATE] at 01:16 PM, with the BOM revealed she had obtained Resident #1's mother's telephone number from Resident #1 prior to Resident #1's death. She noted she did not add the telephone number to the medical record because she did not ask for Resident #1's permission to do so. She also noted she did not communicate having the telephone number with the Social Worker to allow her to assist in getting the telephone number added to the medical record.
An interview on [DATE] at 1:30 PM, with the Administrator confirmed she was aware on [DATE] that the BOM provided Resident #1's mother's telephone number to LPN #1, that LPN #1 had contacted the family to inform them of Resident #1's death and transport of her body to the funeral home on [DATE]. She confirmed the BOM did not communicate having the contact number to any other staff members. The Administrator confirmed the facility failed to timely notify Resident #1's family of her death.
Record review of the Billing Notes for Resident #1 revealed [DATE] . Noted by: (BOM) .I have spoken with (Resident #1) and she gave me the mother's number . I called and spoke with (Resident #1's mother).
Record review of the Departmental Notes for Resident #1 revealed [DATE] 3:03 PM . 2:36 PM CPR (cardio-pulmonary resuscitation) STOPPED BY EMS (Emergency Medical Services). 2:40 MD (Medical Doctor) NOTIFIED OF RESIDENT EXPIRED . UNABLE TO REACH RP (Responsible Party) DUE TO NO FAMILY LISTED . INFORMATION GIVEN TO TRANSFER BODY TO FUNERAL HOME . FUNERAL HOME HERE TO TRANSPORT BODY.
Record of the MORTICIAN RECORD/RECORD OF DEATH dated [DATE], for Resident #1, revealed date of death : [DATE] . Name of Person Notified/Relationship: Unable to Reach. No RP (Responsible Party) listed .
Record review of the Face Sheet for Resident #1 revealed an admission date of [DATE] and diagnoses of Human Immunodeficiency Virus (HIV) Disease, Hyperlipidemia, Unspecified, Hyperkalemia, and Essential (Primary) Hypertension.
Jun 2022
1 deficiency
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observations, staff interviews, facility policy review, and in-service record review the facility failed to prevent the potential for the spread of infection as evidenced by all staff not wea...
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Based on observations, staff interviews, facility policy review, and in-service record review the facility failed to prevent the potential for the spread of infection as evidenced by all staff not wearing or improperly wearing a face mask for one (1) of four (4) days of survey.
Findings include:
Review of the facility policy titled, Coronavirus (COVID-19) with a revision date of 02/22 revealed Policy .It shall be the policy to utilize accepted infection control methods to prevent and control the spread of a respiratory illness caused by novel Coronavirus (COVID-19) .
Review of the facility policy titled Infection Control-Personal Protective Equipment-Using Face Masks with no revision date revealed under Policy .Personal protective equipment, and training on the proper use of such, will be provided to all staff with direct resident contact.
An observation on 06/26/22 at 03:30 PM, on entrance into the facility revealed Housekeeper # 1 sitting at a desk screening visitors and staff for COVID19 without a face mask.
An interview on 6/26/22 at 03:32 PM, with Housekeeper # 1 revealed she works in both housekeeping and screening at the front entrance.
An observation on 6/26/22 at 3:35 PM, revealed Housekeeper #1 leave the front desk to notify the charge nurse that the State Agency (SA) was at the facility and when Housekeeper # 1 returned she was wearing a face mask.
An interview on 6/26/22 at 3:45 PM, with Housekeeper # 1 confirmed she was not wearing a mask when the SA entered the building because she had taken her mask off to catch her breath. Housekeeper # 1 confirmed she is supposed to always wear a mask and she has been in-serviced on the need for all staff to wear a face mask while inside the facility.
An observation on 6/26/22 at 3:55 PM, revealed Licensed Practical Nurse (LPN) # 2 and LPN # 3 with their face mask pulled down under their nose working on their South hall medication carts.
An interview on 6/26/22 at 4:00 PM, with Registered Nurse (RN) # 1 confirmed it is the policy of the facility that all staff members always wear a face mask inside the facility that covers their mouth and nose to help prevent the spread of COVID19.
An interview on 6/26/22 at 4:15 PM, with LPN # 2 confirmed she should have had her mask pulled up over her nose. LPN #2 revealed she had pulled it down to defog her glasses. LPN #2 revealed it is the policy of the facility that all staff members wear a mask covering their mouth and nose to prevent the spread of COVID19.
An interview on 6/26/22 at 4:25 PM, with LPN # 3 confirmed she should have had her mask pulled up over her nose. She revealed she had just pulled it down to catch her breath. She confirmed that she had been in-serviced on the proper use of PPE and that all staff are to wear a mask properly to prevent the spread of COVID19.
An interview on 6/28/22 at 8:00 AM, with the Administrator confirmed it is the policy of this facility that all staff always wear a mask while inside the facility to cut down on the spread of COVID19. She confirmed that LPN # 1 was the nurse that came to meet us at the front door with no mask on and she is the Staff Development nurse. She revealed that LPN # 1 informed her that she had come from her office and met us at the door with no mask. The Administrator stated, Of all things, the Staff Development nurse did not have a mask on inside the building.
An interview on 6/28/22 at 8:30 AM, with LPN # 1 confirmed she did not have a mask on when she was in the facility 6/26/22. She revealed she had entered the building to get her phone charger out of her office and was leaving when the SA arrived. She confirmed it is the policy of this facility that all staff always wear mask inside the building. She confirmed the reason for wearing a mask is to help prevent the spread of COVID19.
Review of the facility in-service dated 2/11/22 and attended by all departments titled, COVID Precautions revealed COVID -19 GENERAL PRECAUTIONS . 2. Every employee is required to wear a face mask (no cloth/handmade masks) and goggles/face shield while in the facility .
Jun 2019
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
Based on observation, resident interview, staff interview, record review, and facility policy review, the facility failed to honor resident food preferences at mealtime for one (1) of 14 residents int...
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Based on observation, resident interview, staff interview, record review, and facility policy review, the facility failed to honor resident food preferences at mealtime for one (1) of 14 residents interviewed during initial tour, Resident #33.
Findings include:
Review of the facility's Food Preferences policy, dated 2016, revealed the guideline for food and nutrition services department will gather information upon admission to the facility regarding resident food preferences. Following admission to the facility, and periodically as necessary, the Director of Food and Nutrition Services and/or Registered Dietitian will interview the resident to determine foods preferred and inform resident about meal services at community. A form such as a Food Preferences Form may be used to document this information and filed in the Food and Nutrition Services department or the medical record according to facility practice. The resident food preferences are kept on file in the Food and Nutrition Services Department and used to ensure each resident's needs and desires are met.
On 06/04/19 at 4:00 PM, an interview with Resident #33 revealed they will not give me salads anymore and they only give me chopped up meat. He stated he doesn't like the chopped up meat and really want his salads back. Resident #33 revealed he was not sure why they changed his diet, because he did not get choked, he just has coughing spells. Resident #33 revealed he told several people he wanted his salads back.
On 06/04/19 at 5:20 PM, interview and observation of Resident #33 sitting at a table in the dining room revealed the resident being served his supper meal, which included chicken and dumplings, cornbread and fruit. Resident #33's meal ticket had chicken and dumplings, tossed salad, and fruit circled. No salad was served to the resident. Resident #33 revealed he was asked by a nurse what he wanted for supper and he told them salad.
On 06/04/19 at 5:35 PM, an interview with Registered Nurse (RN) #1, while in the dining room, revealed Resident #33 did not have a salad served to him for supper and salad was listed as a choice and was circled as his request for supper on his meal ticket.
On 06/06/19 at 11:30 AM, an interview with the Speech Therapist (ST) revealed she was not aware of Resident #33 not being served salads, and there had been no recommendation from Speech services that he not be served salads.
On 06/06/19 at 12:15 PM, an interview with the ST, while in the dining room observing Resident # 33 eating a salad, revealed she saw no issues with his eating the salad; no choking or difficulty swallowing. The ST stated she saw no problems with Resident #33 eating salads.
On 06/06/19 at 1:30 PM, an interview with the Dietary Manager (DM) revealed she was told by Licensed Practical Nurse (LPN) #3 that Resident #33 could not be served salads because he would get choked. The DM revealed she understood that if a resident was on a mechanical soft diet they could not have salads, but she found out yesterday that was not right. The DM revealed a Registered Nurse (RN) #1 was in the dining room on 6/4/19, and asked Resident #33 what he wanted for supper, the RN then circled the items he requested and gave the meal ticket to the Medical Records staff. The Medical Records staff then should have read the resident's request to the dietary department. The DM stated the salad was not read off to dietary on 6/4/19. The DM revealed she did not witness Resident #33 have a choking episode. The DM revealed she stopped giving Resident #33 salads a few weeks ago. The DM stated that before she was instructed not to give Resident #33 salads, he was asking for them and she would send them to him, but after she was told he could not have them, she quit sending them to him.
On 06/06/19 at 1:40 PM, an interview with LPN #3 revealed he understood that when a resident is on a mechanical soft diet they should not get salads, and he thought Resident #33 had choked on a salad. LPN #3 revealed Resident #33 was upset with him and blamed him for having his salads stopped.
On 06/6/19 at 1:50 PM, an interview with RN #1 revealed she did question Resident #33 on what he wanted for supper on 6/4/19, and he told her a salad, chicken and dumplings, corn bread, and the dessert of the day, so she marked that on his meal ticket and handed the ticket to the Medical Records staff.
On 06/06/19 at 2:00 PM, an interview with Medical Records staff revealed she did get Resident #33's ticket for requested lunch items and when she read it off to the dietary department, she told them he should not get the salad, because she understood he could not have a salad. She did not remember who told her that.
On 06/06/19 at 1:045 PM, an interview with the Director of Nursing (DON) revealed she did not know why some of the staff thought that Resident #33 could not get a salad. The DON stated she is not sure Resident #33 ever really got choked, or if he just had a coughing spell, due to his Chronic Obstructive Pulmonary Disease. The DON revealed the residents should have their food preferences honored if there is not an doctor's order contradicting their preference. The DON revealed Resident #33 should have been given the salad.
Record review of Resident #33's meal ticket, for 6/4/19 supper, revealed chicken and dumplings, with tossed salad, and fruit circled to be served. The resident was not served the salad.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on staff interview, resident interview, record review, and facility policy review, the facility failed to ensure residents were free from abuse for one (1) of five (5) residents reviewed for res...
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Based on staff interview, resident interview, record review, and facility policy review, the facility failed to ensure residents were free from abuse for one (1) of five (5) residents reviewed for resident to resident incidents, Residents #60.
Findings include:
Review of facility's Abuse Prevention policy, with an effective date July 1, 2003, revealed: The facility is committed to protecting the residents from abuse by anyone including, but not limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual.
Review of a Resident to Resident incident that occurred on 2/19/19 at 3:00 PM, revealed Resident #60 entered Resident #99's room at 3:00 PM, and a physical altercation occurred between the two (2) residents. This resident was last seen on 2/19/19 at 2:45 PM, and was not exhibiting any behaviors at that time. The facility staff were not able to determine who the aggressor was, but did witness Resident #99 make contact with Resident #60's face. Resident #60 had an abrasion under his left eye and to the left side of his forehead. Resident #99 was placed on one-on-one (1:1) observation and transferred to the Behavior Health Unit and Resident #60's medications were adjusted.
Review of an incident that occurred on 5/25/19, revealed Resident #99 and Resident #60 were involved in a physical altercation when Resident #60 entered Resident #99's room and Resident #99 asked him to leave and he wouldn't. Resident #99 hit Resident #60. Further review of Resident #60's record revealed he was transferred to the local hospital where X-rays were obtained and revealed a nasal fracture. Review of the physician documentation at the emergency room revealed the resident did not experience any loss of consciousness. The severity of the symptoms: At their worst the symptoms were mild and were unchanged in the Emergency Room. Review of the CT of Brain revealed Acute bilateral nasal bone fractures with minimal displacement.
On 6/4/19 at 5:00 PM, an interview with the Risk Manager stated when resident #60 was first admitted he was very lethargic and once the lethargy wore off resident became more aggressive and started to wander. The Risk Manager revealed Resident #60 is hard to redirect and will not sit any longer than it takes to eat, or a short activity. She stated when you try to redirect the resident he will become agitated and aggressive. The Risk Manager stated after the incident in February (2019) with Resident #99, Resident #60's medications were changed. She stated that Resident #60 was restarted on his Depakote 250 milligrams(mg) per feeding tube two (2) times a day and Zyprexa 5 mg per feeding tube daily. The Risk Manager stated that staff started involving the resident in more small group activities and this helped the resident's behaviors and wandering for a while. The Risk Manager revealed Resident #60 was wandering the day of the incident on 5/25/19, and had been redirected by staff. She stated he was last seen at 1:15 PM by staff, at the Memory Care Unit door, and was redirected to his room. The Risk Manager revealed that at 1:34 PM, Resident #99 hollered for staff to assist Resident #60. Resident #99 stated the resident came in his room and was messing with his stuff, and he asked him to get out and he wouldn't. When staff responded to the room they found Resident #60 laying on the floor with a bloody nose. The Risk Manager stated the physician and the Responsible Party were notified and Resident #60 was transferred to the hospital and diagnosed with a nasal fracture. The Risk Manager stated the resident's day to day activities have not been altered. She revealed that Resident #60 has not complained of any pain and continues with his normal activities.
On 6/04/19 at 4:00 PM, an observation of Resident #60 revealed he was in his room laying in his bed. Resident #60 appeared calm and resting.
On 6/05/19 at 10:00 AM, an observation of Resident #60 revealed he was outside with Activity staff. Resident #60 was noted with a broom in his hand, sweeping around patio area. Resident #60 was walking around outside. There were other residents in attendance along with staff and volunteers.
On 6/5/19 at 2:15 PM, an observation of Resident #60 revealed he was outside engaging in activities, Ball toss, sweeping, music being played, and swaying to the music at times. Resident #60 appeared calm.
On 6/5/19 at 3:00 PM, an interview with the Activity Director (AD) revealed Resident #60 likes to be outside; he enjoys sweeping, and cleaning up surroundings. The AD stated they (activity staff and volunteers) take him out at least twice a day. The AD stated the resident does not participate in group activities, only one to one activities.
During an interview on 6/06/19 at 11:24 AM, Resident #99 stated that man (Resident #60) had come into his room a couple of times and fooled with his stuff. Resident #99 stated, I asked him nicely to get out and he wouldn't. Resident #99 stated the resident said, Make me. Resident stated, That's just what I did. Resident #99 stated, I don't think I will have any more problems with him coming up in my cell. Resident #99 kept referring to his cell and people coming in that didn't have any business being in there. Resident #99 stated he couldn't call for help if someone comes in his room, because then he would be labeled a punk.
On 6/06/19 at 11:42 AM, an interview with Licensed Practical Nurse (LPN) #1 revealed she witnessed Resident #99 hit Resident #60 on 2/19/19. She stated she was at the Nurse's Station and heard a commotion coming from the direction of the resident's room and went to the room. LPN #1 stated as she was entering the room, she saw Resident #99 hit Resident #60. LPN #1 revealed Resident #60 had an abrasion under his left eye. She stated the residents were immediately separated and placed on one-on-one (1:1) until Resident #99 was transferred to the Behavior Unit. LPN #1 stated outside the room Resident #99 gets along well with all staff and residents. She stated he does not want anyone in his room, which he refers to as a cell.
During an interview on 06/06/19 at 1:30 PM, Certified Nursing Assistant (CNA) #1 revealed Resident #99 does for himself; she provides assistance with showers. She stated the resident is outgoing and friendly until someone goes in his room and then he gets upset and angry. CNA #1 stated she was working 5/25/19, the day he hit Resident #60, but she did not witness the altercation. CNA #1 stated she heard a commotion and went to the room and saw the resident on the floor. CNA #1 revealed she and other staff assisted him up and took him to the nurse's station.
On 6/06/19 at 1:42 PM, an interview with LPN #2 revealed Resident #60 required frequent redirection and will wander into other residents room. She stated the resident will get aggressive toward staff, but has never seen him be aggressive toward other residents. LPN #2 stated other residents will say this is not your room and you need to get out, and he will or they will call for help and staff will go in the room and assist the resident out. LPN #2 stated she has never witnessed the resident being aggressive toward any residents; only staff.
On 6/06/19 at 2:06 PM, an interview with CNA #2 revealed Resident #60 required frequent redirection and will try to fight staff if he's in a bad mood. She stated he spends a lot of time outside now and he really enjoys that. The CNA stated the activity staff take him outside with them.
On 6/06/19 at 2:15 PM, an interview with LPN #5 revealed she heard Resident #99 holler for someone to get this man out of his room. LPN #5 stated when she and other CNAs went in the room, Resident #60 was on the floor. She stated the residents were immediately separated. LPN #5 stated Resident #60 wanders and has to be redirected throughout the day. She stated Activity staff work hard to keep him engaged in activities but his attention span is so short that he can't remember.
On 6/06/19 at 4:00 PM, an interview with the Director of Nursing (DON) stated after the incident in February 2019, the Physician changed Resident #60's medications and staff implemented small group activities rather than encouraging large group activity participation, which the resident would not participate in. The DON stated after the incident in May 2019, staff implemented 1:1 activities throughout the day. She stated that Resident #60 continued to require redirection. She stated the CNAs care guide was also updated to include diversional activities when behaviors occur. The DON stated after the incident in February 2019, Resident #99 was sent to the Behavioral Health Unit and a stop sign was placed on the resident's door to discourage wanderers from entering his room. The DON stated the only time Resident #99 exhibits behaviors is if someone enters his room uninvited. She revealed Resident #99 refers to his room as his cell and protects his belongings. The DON stated after the incident in May 2019, Resident #99 was placed 1:1 until transferred out of the facility to the Behavioral Health Unit. The DON stated since the resident's return to the facility on 6/4/19, staff have added a second stop sign to the resident's door. The DON stated one is located at ambulatory height and the other is located at wheelchair height. She stated staff have also added a door alarm to the resident's door that alarms when the door is opened; this was done in an effort to keep wanderers from entering the resident's room.
Review of Resident #99's Face Sheet revealed the facility admitted him on 4/9/13, with diagnoses which included, Schizophrenia, and Hypertension.
Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/2/19, revealed Resident #99 had a Brief Interview for Mental Status score of 15, which indicated Resident #99 was cognitively intact.
Review of Resident #60's Face Sheet revealed the facility admitted him on 1/4/19, with diagnoses which included, Alzheimer's Disease, and Anxiety.
Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/8/19, revealed Resident #60 had a Brief Interview for Mental Status score of 3, which indicated Resident #60 was severely cognitively impaired.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, and facility policy review, the facility failed to prevent the possible spread of infection as evidence by failure to change gloves and wash hands appropriately ...
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Based on observation, staff interview, and facility policy review, the facility failed to prevent the possible spread of infection as evidence by failure to change gloves and wash hands appropriately and failure to provide a clean barrier for items taken into residents' rooms during medication administration, for two (2) of 12 residents observed for medication administration, Unsampled Resident #314 and Resident #264.
Findings include:
Review of the facility's policy titled Subject: Standard Precautions, HISTORY: (A) CMP 8/03; (B) P&P Comm 10/09, revealed, Policy: Standard Precautions will be utilized to provide a primary strategy for the prevention of healthcare-associated infectious (HAI) agents among patients and healthcare personnel.
Unsampled Resident #314
On 06/06/19 at 11:06 AM, an observation of Unsampled Resident #314 revealed that after blood glucose testing, Licensed Practical Nurse #2 brought a container of Super Sani-Cloth Germicidal Disposable Wipes into the resident's room and placed it on the over bed table while she cleaned the glucometer. She then took the wipe container into the bathroom and placed it on the resident's lavatory while she washed her hands. She took the container and placed it on top of the medication cart and prepared the resident's injection. After she gave the injection, she washed her hands and went to the cart to dispose of the syringe. She took the wipe container back into room and placed it on the over bed table while she cleaned the table with a Super Sani-Cloth. She then carried the container into bathroom and placed it on the toilet lid while she washed her hands. She placed the container back into the medication cart.
In an interview with Licensed Practical Nurse #2 on 06/06/19 at 2:25 PM, she stated that by taking the Super Sani-Cloths into the resident's room and placing them on the lavatory and toilet lid, it would be an infection control problem that could spread germs to the medication cart.
During an interview, with the Director of Nursing on 06/06/19 at 2:36 PM, she confirmed, This is an infection control problem, referring to the actions of the nurse taking the container of wipes into the resident's room and placing the container on several surfaces, then taking it back to the medication cart.
On 06/07/19, at 09:45 AM, during an interview with the Registered Nurse Risk Manager, she stated, It is an infection control problem. We don't teach them to take the wipe container into the room. I've never known anyone to do that. They always clean the glucometer on the cart. Sitting the container on the toilet could cause a lot of problems, because you don't know what kind of germs are on that toilet and then putting it in the med cart contaminated the cart.
Record review of an in-service performed by the Risk Manager on 2/19/19, titled Infection Control revealed that LPN#2 attended.
Resident #264
Review of the facility's Enteral Tube Medication Administration Procedures policy, amended 2/18, revealed the facility policy is to safely and accurately administer oral medications through an enteral tube. The procedure included, #1. Check Medication Administration Record. #2. Prepare medications for administration. #3. Provide privacy and position resident. #4. Wash hands and apply gloves.
The facility utilized the Association for Professionals in Infection Control and Epidemiology (APIC) Do's and Don'ts for Wearing Gloves in the Healthcare Environment. Review of this document revealed, Do clean hands and change gloves between each task (e.g., after contact with a contaminated surface or environment) and don't touch your face when wearing gloves.
An observation, on 6/6/19 at 1:45 PM, during medication pass, revealed Licensed Practical Nurse (LPN) #4 donned gloves and pushed her hair back, while wearing her gloves, during medication set up for Resident #264. LPN #4 then put her gloved hand inside the Silent Knight medication pouch and touched the inside of a medication cup with her gloves. She then took her keys out of her pocket and opened the medication cart and removed a bottle of water. She again pushed her hair back over her shoulder and removed a bagged 60 millimeter (mm) syringe from the medication cart drawer. She administered medications to Resident #264 via enteral tube. LPN #4 did not change gloves and/or wash her hands at any time during the medication pass for Resident #264. Upon completion of the medication administration, LPN #4 removed her gloves and washed her hands.
An interview on 6/6/19 at 2:11 PM, revealed LPN #4 stated she did not even realize she pushed her hair back with her gloves on. She confirmed that this contaminated her gloves and also touching her keys and opening the medication cart drawer also contaminated her gloves. She stated she contaminated everything she touched with her gloves. She stated that she should have changed her gloves and washed her hands during the medication pass.
An interview, on 6/6/19 at 4:02 PM, with the Director of Nursing (DON), revealed LPN #4 should have washed her hands and/or used hand sanitizer and changed her gloves when they got contaminated. The DON confirmed touching objects with contaminated gloves transferred germs and cross-contaminated whatever was touched. She stated LPN #4 should have changed her gloves two (2) or three (3) times during the procedure.
Record review revealed LPN #4 attended an in-service on Infection Control and Handwashing on 2/19/19.
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
- • 41% turnover. Below Mississippi's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: 7 life-threatening violation(s), $229,213 in fines, Payment denial on record. Review inspection reports carefully.
- • 17 deficiencies on record, including 7 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $229,213 in fines. Extremely high, among the most fined facilities in Mississippi. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has 7 Immediate Jeopardy findings. Serious concerns require careful evaluation.
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About This Facility
What is Cleveland's CMS Rating?
CMS assigns CLEVELAND NURSING AND REHABILITATION CENTER an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Mississippi, 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 Cleveland Staffed?
CMS rates CLEVELAND NURSING AND REHABILITATION CENTER's staffing level at 5 out of 5 stars, which is much above average compared to other nursing homes. Staff turnover is 41%, compared to the Mississippi average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Cleveland?
State health inspectors documented 17 deficiencies at CLEVELAND NURSING AND REHABILITATION CENTER during 2019 to 2024. These included: 7 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 10 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 Cleveland?
CLEVELAND NURSING AND REHABILITATION CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by NORBERT BENNETT & DONALD DENZ, a chain that manages multiple nursing homes. With 120 certified beds and approximately 109 residents (about 91% occupancy), it is a mid-sized facility located in CLEVELAND, Mississippi.
How Does Cleveland Compare to Other Mississippi Nursing Homes?
Compared to the 100 nursing homes in Mississippi, CLEVELAND NURSING AND REHABILITATION CENTER's overall rating (2 stars) is below the state average of 2.6, staff turnover (41%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Cleveland?
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 Cleveland Safe?
Based on CMS inspection data, CLEVELAND NURSING AND REHABILITATION CENTER has documented safety concerns. Inspectors have issued 7 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Mississippi. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Cleveland Stick Around?
CLEVELAND NURSING AND REHABILITATION CENTER has a staff turnover rate of 41%, which is about average for Mississippi nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Cleveland Ever Fined?
CLEVELAND NURSING AND REHABILITATION CENTER has been fined $229,213 across 1 penalty action. This is 6.5x the Mississippi average of $35,371. 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 Cleveland on Any Federal Watch List?
CLEVELAND NURSING AND REHABILITATION CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.