LAKEVIEW NURSING CENTER
For profit - Corporation
105 Beds
Independent
Data: November 2025
6 Immediate Jeopardy citations
Trust Grade
0/100
Photo by Kim Crothers
Last Inspection: April 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Lakeview Nursing Center in Gulfport, Mississippi has received a Trust Grade of F, indicating significant concerns about the facility's quality of care. It ranks at the bottom, with no other facilities in Mississippi or Harrison County listed, meaning families have no better local options. The condition of the facility is worsening, with reported issues increasing from 3 in 2024 to 8 in 2025. Staffing is a major concern, as the turnover rate is 59%, significantly higher than the state average, which suggests that staff frequently leave, impacting continuity of care. Additionally, the facility has faced a staggering $450,136 in fines, the highest in the state, pointing to serious compliance problems. Specific incidents include a failure to implement bowel care plans for multiple residents, which tragically resulted in the death of one resident due to complications from a bowel obstruction. Other residents were also put at risk due to the lack of proper monitoring and care related to bowel functioning, showing a pattern of neglect. While the high RN coverage provides some reassurance, the overall lack of adequate care and the increasing number of serious violations raise significant red flags for families considering this facility.
- Trust Score
- F
- In Mississippi
- #112/223
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 59% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $450,136 in fines. Lower than most Mississippi facilities. Relatively clean record.
- Skilled Nurses ○ Average
- Each resident gets 37 minutes of Registered Nurse (RN) attention daily — about average for Mississippi. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 32 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Top 50%
Review needed
3 → 8 violations
☆☆☆☆☆
0.0
Overall Rating
☆☆☆☆☆
0.0
Staff Levels
☆☆☆☆☆
0.0
Care Quality
☆☆☆☆☆
0.0
Inspection Score
↔
Stable
2024: 3 issues
2025: 8 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
Staff Turnover: 59%
12pts above Mississippi avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $450,136
Well above median ($33,413)
Significant penalties indicating serious issues
Staff turnover is elevated (59%)
11 points above Mississippi average of 48%
The Ugly 32 deficiencies on record
6 life-threatening 2 actual harm
Apr 2025
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0646
(Tag F0646)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy review, the facility failed to complete a Change in Status Form to gener...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy review, the facility failed to complete a Change in Status Form to generate a request for a Preadmission Screening and Resident Review (PASRR) Level Two (II) Assessment, for a resident with a mental status change, for one (1) of 18 residents reviewed for PASRR. Resident #37.
Findings include:
A record review of the facility's policy Resident Assessment-Coordination with PASARR (Preadmission Screening and Resident Review) Program, dated 01/10/25 revealed .This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs . Policy Explanation and Guidelines .9. Any residents who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Examples include .c. A resident transferred, admitted , or readmitted to the facility following an inpatient psychiatric stay or equally intensive treatment.
On 03/30/25 at 11:31 AM, during an interview, Resident #37 reported that he was sent to a Behavioral Health Unit (BHU) last year because he would throw his unwanted food on the floor.
A record review of the Transfer/Discharge Report revealed the facility admitted Resident #37 on 11/15/2019 with current diagnoses including Anxiety Disorder,
A record review of the Physician's Order Sheet dated 05/15/24 revealed .Send to (Proper Name) Behavioral Health for eval (evaluation) and treatment .
A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/07/25 revealed Resident #37 required a staff assessment for mental status and his cognitive skills for daily decision making he made decisions regarding tasks of daily life with modified independence with some difficulty in new situations only.
Record review of the medical record revealed there was no Change in Status Form completed or submitted to the mental health authority for a Level II resident review after Resident #37 returned from an inpatient psychiatric facility in which he was admitted on [DATE].
On 03/31/25 at 10:05 AM, during an interview with Social Services #1, she confirmed a Change in Status Form was not completed for Resident #37 that would have generated a request for a PASRR Level II assessment. She explained that the only time a Change in Status form for a Level II assessment was completed was when a resident received a new diagnosis of mental illness.
On 04/01/25 at 03:00 PM, during an interview with the Director of Nursing (DON), she confirmed Resident #37 was admitted to a BHU in May of 2024.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, interview, record review, and facility policy review, the facility failed to ensure the resident environment remained free of accident hazards when a fall mat intended to prevent...
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Based on observation, interview, record review, and facility policy review, the facility failed to ensure the resident environment remained free of accident hazards when a fall mat intended to prevent injury during falls was not properly placed for one (1) of three (3) residents reviewed for accidents/hazards, Resident #13.
Findings included:
A review of the facility's policy titled Accidents and Supervision, dated 2/19/2019 and revised 12/9/2020, revealed, .The resident environment will remain free of accidents hazards as is possible .this includes .3. Implementing interventions to reduce hazard(s) and risk(s) .
On 03/30/25 at 11:16 AM, during an observation, Resident #13 was lying in bed with a fall mat folded at the head of the bed and not unfolded on the floor positioned in a way to prevent injury in the event the resident fell from the bed.
On 04/01/25 at 11:01 AM, during an observation and interview, Licensed Practical Nurse (LPN) #1 confirmed that Resident #13 was in bed and the fall mat was folded on the left side of the bed, instead of being unfolded on the floor bedside the bed in a position to prevent injury from falling. LPN #1 stated the fall mat was not supposed to be folded and should be laid out on the floor beside the bed.
On 04/02/25 at 9:56 AM, during an interview with the Director of Nursing (DON), she explained that staff were trained to keep fall mats flat on the floor to prevent injuries from falls.
A record review of Resident #13's admission Record revealed the facility admitted the resident on 8/6/2024 and she had current diagnoses including Alzheimer's Disease.
A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/21/25 revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. Further review revealed she had falls since admission.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, and facility policy review, the facility failed to store food using sanitary methods to prevent cross-contamination, as evidenced by a plastic cup used as a scoo...
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Based on observation, staff interview, and facility policy review, the facility failed to store food using sanitary methods to prevent cross-contamination, as evidenced by a plastic cup used as a scoop stored directly inside a container of cornmeal for one (1) of four (4) days of kitchen observations.
Findings included:
A review of the facility's document ServeSafe Manager, undated, revealed, .Preventing Cross-Contamination .Food, equipment, utensils .must be stored in ways that prevent cross-contamination .Storing .you need to store items in a way that prevents cross-contamination .
On 03/30/25 at 10:34 AM, during an observation of the kitchen and interview with the Dietary Manager, there was a clear plastic cup inside the fish fry/corn meal container dry goods container. The Dietary Manager confirmed the clear plastic cup was being used as a scoop and acknowledged this constituted cross-contamination.
On 04/01/25 at 12:25 PM, during an interview with the Registered Dietitian (RD), she explained the dietary department uses Serve Safe guidelines for policy and procedures related to food handling. She confirmed she had been made aware of a plastic cup used as a scoop was stored inside the corn meal container.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected 1 resident
Based on record review, staff interview, and facility policy review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to sustain corrective actions to prevent recur...
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Based on record review, staff interview, and facility policy review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to sustain corrective actions to prevent recurrence of previously cited deficiencies, specifically, the facility was cited for failing to maintain a clean environment and implement comprehensive care plan interventions during an annual recertification survey on 7/20/2023 and was cited again for the same deficiencies during the current survey, demonstrating that QAPI failed to sustain ongoing monitoring and oversight to prevent recurrence for two (2) of eight (8) deficiencies cited. F584 and F656.
Findings Include:
Record review of the facility's policy, Quality Assessment and Performance Improvement, dated 2/24/2021, revealed, .It is the policy of this facility to .maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life .Policy Explanation and Compliance Guidelines .2. The QA Committee shall .c. Develop and implement appropriate plans of action to correct identified quality deficiencies .
Record review of the Provider History Profile revealed the facility received a citation for F584-Safe/Clean/Comfortable/Homelike Environment and F656-Develop/Implement Comprehensive Care Plan.
Record review of the CMS-2567 (a record that identifies the federal regulation in violation and describes the findings of noncompliance and the facility's plan of correction), with a survey date of 7/20/2023, revealed the facility received a citation for F584, .Based on observation, interviews, record review, and facility policy review, the facility failed to maintain a clean environment for two (2) of 20 resident rooms . and for F656, .Based on interview, record review, and facility policy review, the facility failed to develop a comprehensive care plan .
Record review of the Statement of Deficiencies and Plan of Correction (Form 2567) from the previous annual survey in July 2023, revealed F584 was cited due to stains on the privacy curtain and large pieces of missing paint on the wall behind the bed and F656 was cited regarding prescription medicine being left on the residents overbed table.
During the current recertification survey, failed to ensure a resident's right to a clean, comfortable, homelike environment for two (2) of four (4) days of survey and failed to implement a care-planned intervention related to falls for one (1) of eighteen (18) sampled residents.
On 04/02/25 at 03:52 PM, during an interview with the Administrator, she affirmed that deficiencies from the previous annual survey were found during the current survey. The Administrator reported the facility has hired several new staff and particularly a floor tech to keep the facility clean. The Administrator stated the facility staff are working to make things better and keep the facility clean and free of odors. The Administrator stated she will have a meeting with the nursing staff to come up with a plan to meet the residents' needs and promote individualized care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy review, the facility failed to ensure timely administration of pneumonia...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy review, the facility failed to ensure timely administration of pneumonia vaccinations for one (1) of five (5) residents reviewed for immunizations (Residents #70).
Findings include:
A record review of the facility's policy, Pneumococcal Vaccine (Series), dated 6/19/23, revealed .It is our policy to offer residents .immunizations against pneumococcal disease in accordance with current CDC (Center for Disease Control) guidelines and recommendations. Policy Explanation and Compliance Guidelines: 1. Each resident will be assessed for pneumococcal immunization upon admission .2 .Following assessment for any medical contraindications, the immunization may be administered in accordance with physician-approved standing orders .
A record review of the admission Record revealed the facility admitted Resident #70 on 2/3/25 with diagnoses including Encounter for Surgical Aftercare following surgery on the Digestive System.
A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/10/25 revealed Resident #70 had a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment.
A record review of the Vaccination Record, dated 2/3/25, revealed Resident #70 had not received the Pneumonia vaccine and requested to receive the vaccine upon the Physician's recommendation.
On 04/02/25 at 9:58 AM, an interview with the Resident Representative (RR) for Resident #70 revealed she acknowledged the resident was admitted on [DATE] and the consent to receive the pneumonia vaccine was signed 2/3/25. The RR acknowledged that she was not informed of any delay in getting the vaccine and was unaware that the resident had not received her pneumonia vaccine. The RR stated she expected the resident to have had his pneumonia vaccine.
On 04/02/25 at 10:15 AM, an interview with the Infection Preventionist (IP) revealed she acknowledged Resident #70 have not received their pneumonia vaccine from time they were admitted . The IP nurse confirmed it was her responsibility to ensure residents received vaccines and the process was to allow a couple of residents to be admitted to the facility before she calls the pharmacist to administer the vaccines. The IP nurse stated she has been focusing on the flu vaccines and had hoped to get the pneumonia vaccines caught up this April.
On 04/02/25 at 1:05 PM, an interview with the Director of Nursing (DON) revealed she acknowledged that Residents #70 had not received the pneumonia vaccinations since admission. The DON stated it was the responsibility of the IP nurse to make sure the residents are vaccinated. The DON noted that going forward she will arrange to have the immunizations done in-house rather than outsourcing to pharmacies to help get better control the timeliness of administering the pneumonia vaccine.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident's right to a clean, comfortable, homelike environment for two (2) of four (4) days...
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Based on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident's right to a clean, comfortable, homelike environment for two (2) of four (4) days of survey.
Findings included:
A review of the facility's policy titled, Safe and Homelike Environment, revised 07/24/2023, revealed, . In accordance with residents' rights, the facility will provide a safe, clean, comfortable, and homelike environment . Policy Explanation and Compliance Guidelines: . 3. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment .
A review of the facility's document related to Housekeeping, undated, revealed, . Duties and Responsibilities: Ensures the provision of a clean environment for our residents and staff, providing high quality services and high standards of cleanliness .Functions .2. Ensures that daily and deep cleaning schedules are adhered to .14. Clean floors, to include sweeping, dusting, damp/wet mopping, stripping, waxing, buffing, disinfecting .22. Moves furniture and other heavy objects as required .
On 03/30/25 at 11:52 AM, during an observation and interview, Resident #17 was observed in bed with a family member at the bedside. The family member reported that his primary concern was the cleanliness of the room, and he expected his mother's room to be clean when he visits. He stated the floors are always dirty and appear not to be wiped down. Dirt and loose particles were observed under the bed and around the nightstand.
On 03/31/25 at 2:15 PM, during an interview and observation of Resident #17's room, Housekeeper #2 explained that each housekeeper had assigned halls, but recently the housekeepers were required to split halls due to staffing issues. She stated every room is cleaned daily and that cleaning duties include mopping, dusting, bathroom sanitation, trash removal, and restocking paper supplies. She explained she does not move furniture or beds when residents are present. Housekeeper #2 confirmed debris and dirt were present around the visitor chair, nightstand, and under the resident's bed.
On 04/01/25 at 3:00 PM, during an interview with Housekeeper #4, she stated that all rooms are cleaned daily, including sweeping, mopping, wiping furniture, and cleaning bedrails. She stated that if a resident is present, she will return later to clean, and that although she attempts to complete all cleaning tasks, sometimes it is difficult due to picking up extra rooms.
On 04/02/25 at 2:14 PM, during an interview with the Administrator, she stated that the facility had been actively working on improving the facility's cleanliness and had recently hired a new housekeeper. She stated that her expectation was that staff complete all duties, even on weekends, and ensure rooms are maintained in a clean condition.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
Based on observation, interview, record review, and facility policy review, the facility failed to implement a care-planned intervention related to falls for one (1) of eighteen (18) sampled residents...
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Based on observation, interview, record review, and facility policy review, the facility failed to implement a care-planned intervention related to falls for one (1) of eighteen (18) sampled residents. Resident #13.
Findings included:
A review of the facility's policy, Comprehensive Care Plans, dated 3/5/2025, revealed, .It is the policy of this facility to . implement a comprehensive person-centered care plan for each resident . that includes measurable objectives .and meet professional standards of quality .Policy Explanation and Compliance Guidelines .8. Qualified staff responsible for carrying out interventions specified in the care plan will be of their roles and responsibilities for carrying out the interventions, initially and when changes are made .
During an observation on 03/30/25 at 11:16 AM, Resident #13 was lying in bed with a fall mat folded at the head of the bed and not unfolded on the floor positioned in a way to prevent injury in the event the resident fell from the bed.
During an observation and interview on 04/01/25 at 11:01 AM, Licensed Practical Nurse (LPN) #1 confirmed that Resident #13 was in bed and the fall mat was folded on the left side of the bed, instead of unfolded on the floor bedside the bed in a position to prevent injury from falling. LPN #1 stated the fall mat was not supposed to be folded and should be laid out on the floor beside the bed.
During an interview on 04/02/25 at 9:56 AM, the Director of Nursing (DON) explained that staff were trained to keep fall mats flat on the floor to prevent injuries from falls. The DON stated that she expected the staff to implement care plan interventions.
A record review of Resident #13's admission Record revealed the facility admitted the resident on 8/6/2024 and she had current diagnoses including Alzheimer's Disease.
A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/21/25 revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. Further review revealed she has had falls since admission.
A record review of the Comprehensive Care Plan revealed Resident #13 was at risk for falls related to decreased mobility, generalized weakness, and a history of a fall with a hip fracture. The care plan included an intervention, initiated on 12/6/24, for Floor mats on both side of bed .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Data
(Tag F0851)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to accurately report staffing data to the Centers for Medicare and Medicaid Services (CMS) using payroll and other verifiable sources in a uni...
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Based on record review and interview, the facility failed to accurately report staffing data to the Centers for Medicare and Medicaid Services (CMS) using payroll and other verifiable sources in a uniform format, for one (1) of four (4) quarters reviewed, resulting in the facility triggering for excessively low weekend staffing, no Registered Nurse (RN) hours, and no licensed nursing coverage 24 hours/day.
Findings included:
A record review of the Payroll Based Journal (PBJ) Staffing Data Report for the fourth (4th) quarter (July 1-September 30, 2024) revealed the facility triggered for Excessively Low Weekend Staffing, No RN Hours, and Failed to Have Licensed Nursing Coverage 24 Hours/Day. Further review revealed the Infraction Dates for No RN Hours and Failure to Have Licensed Nursing Coverage 24 Hours/Day were 7/6, 7/7, 7/13, and 7/14 of 2024.
A record review of the Staffing Grid completed by the Director of Nursing (DON) revealed the facility had RN and nursing coverage on 7/6/24, 7/7/24, 7/13/24 and 7/14/24.
On 03/31/25 at 1:30 PM, during an interview with the Administrator, DON, Human Resources (HR) Director, and [NAME] Manager, the Administrator explained the facility became aware there was a reporting issue at the end of the quarter, ending September 2024. She confirmed the facility had nursing coverage for those dates; however, by the time the issue was identified, it was too late to submit corrections. The Administrator explained the current process is that nurses and Certified Nurse Aides (CNAs) clock in using their handprint. The [NAME] Manager manually enters time and makes adjustments when salaried staff perform direct care, such as when the Minimum Data Set (MDS) nurse takes a medication cart. The [NAME] Manager believed there was a coding error in the reporting by the payroll vendor system. The HR Director now reviews daily hours worked for RNs, Licensed Practical Nurses (LPNs), and CNAs and balances this data against what is submitted in PBJ to ensure accuracy. The Administrator stated the facility does not have any contract direct care nurses or CNAs. The error was discovered while reviewing the MDS PBJ Report 17025, which provides a breakdown of staffing hours. The Administrator stated they worked hard to determine what occurred during the two weekends in question and believes the issue was a reporting and/or coding error.
Jul 2024
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
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interviews and facility policy review, the facility failed to ensure infection control measures were consistently implemented to prevent the development and/or transmission of in...
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Based on observation, interviews and facility policy review, the facility failed to ensure infection control measures were consistently implemented to prevent the development and/or transmission of infection, for one (1) of four (4) observations of staff entering and exiting residents' rooms.
Findings include:
Record review of the facility's policy titled, Hand Hygiene: Clean Hands Save Lives, with date implemented 1/21/21 revealed, . It is the policy of this facility that hand hygiene will be handled as follows: . Hand hygiene is a way of cleaning one's hands that substantially reduces potential pathogens (harmful microorganisms) on the hands . Facts to Consider: .Germs can spread from .surfaces when you .touch a contaminated surface or objects .Washing hands can keep you healthy and prevent the spread of .infections from one person to the next .
Record review of the facility's policy titled, Perineal Care Policy, revised 2/21 revealed, .Policy: Peri care is to be performed following this procedure to ensure . cross contamination if avoided remove gloves .wash hands with soap and water.
On 7/2/24 at 12:15 PM, during an observation and interview Certified Nurse Aide (CNA) #1, was observed coming out of a resident's room on the 400 Hall, with a brief rolled up in her gloved hands. CNA#1 was observed walking down the hall to the soiled utility room and opened the door with her gloved hand and entered the room. CNA #1 was not observed using hand sanitizer or washing her hands. During an interview with CNA #1, she confirmed that she had a brief in her gloved hands. She explained she did not have a trash bag to put the brief into, so she just took it to the soiled room. She reported the brief should have been placed in a trash bag and then taken to the soiled room and she knows not to wear gloves in the hallway.
On 7/2/24 at 12:50 PM, during an interview with the Infection Preventionist (IP) Nurse/Registered Nurse #1, she confirmed a staff member should never come out of a resident's room with a soiled brief in their hands and gloves on. The IP Nurse stated all staff have had education regarding the importance of not wearing gloves in the hallways. The IP Nurse added that CNA #1 should have placed the brief in a bag and disposed of it properly.
At 1:00 PM on 7/2/24, during an interview with the Director of Nursing (DON), she confirmed CNA #1 had reported to her that she was wearing gloves and had a brief rolled up in her hands while she transported the soiled brief to the soiled utility room. The DON stated she expects all staff to follow infection control guidelines at all times.
Feb 2024
2 deficiencies
2 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Comprehensive Care Plan
(Tag F0656)
A resident was harmed · This affected 1 resident
Based on interviews, record reviews, and facility policy reviews, the facility failed to implement care plan approaches related to prohibiting the use of oxygen in the smoking area for one (1) of four...
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Based on interviews, record reviews, and facility policy reviews, the facility failed to implement care plan approaches related to prohibiting the use of oxygen in the smoking area for one (1) of four (4) sampled resident's care plans. Resident #1.
Findings Include:
Record review of the facility's Comprehensive Care Plans policy date implemented 4/3/20, revealed, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .
A record review of the Care Plan with a problem onset date of 11/6/23 revealed Problem/Need: SMOKING I am a smoker and requires supervision .Approaches .Supervise all smoking .Prohibition of oxygen use in the smoking area .
A record review of the facility investigation revealed on 2/21/24, the Activities Director (AD) was assisting with the smoke break at the facility with her back turned and heard a popping/clicking sound. Upon turning, she observed sparks coming from Resident #1's nasal cannula. She immediately removed the cannula and turned his oxygen off.
Record review of the Physician Orders for February 2024 revealed Resident #1 had a physician order dated 11/9/23 for .Oxygen at 2 LPM (liters per minute) VIA (by way of) nasal cannula .
During an interview on 2/26/24 at 3:45 PM, with Resident #1, he confirmed on 2/21/24 that while in his wheelchair with his oxygen on, he went to the smoking area without having his oxygen removed before entering the smoking area.
In an interview on 2/27/24 at 10:21 AM, with the AD confirmed on 2/21/24 she failed to remove Resident #1's oxygen canister from his wheelchair before he entered the smoking area.
On 2/27/24 at 11:00 AM, during an interview with Registered Nurse (RN) #1/Minimum Data Set (MDS) nurse, confirmed Resident #1's care plan was not implemented because his oxygen tank and nasal cannula were still on the resident's wheelchair before he entered the smoking area. She revealed that care plans are individualized for each resident and provide direction for the staff on providing care. She confirmed that she expects staff to follow the care plans.
During an interview with the Director of Nurses (DON), on 2/27/24 at 12:00 PM, confirmed Resident #1 was brought to the smoking area with his oxygen and nasal cannula still present. The DON stated the staff did not follow the care plans for removing the resident's oxygen canister before he entered the smoking area. The care plans are in place for staff to care for the residents. It is expected that the facility staff will follow the residents' care plans.
A record review of the Face Sheet revealed the facility admitted Resident #1 on 11/6/23 with diagnoses that included Chronic obstructive pulmonary disease and Heart failure.
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
Based on observation, interviews, record review, and facility policy review, the facility failed to provide a safe smoking environment when the facility staff did not remove an oxygen (O2) canister fr...
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Based on observation, interviews, record review, and facility policy review, the facility failed to provide a safe smoking environment when the facility staff did not remove an oxygen (O2) canister from Resident #1 prior to entering the smoking area and did not secure a cigarette lighter to prevent Resident #1 from lighting a cigarette. This failure resulted in Resident #1 receiving burns to his face. This was for one (1) of three (3) sampled residents reviewed for smoking.
Findings Include:
Review of the facility's policy, Accidents and Supervision, dated 12/9/2020, revealed, Policy: The resident environment will remain as free of accident hazards as is possible .This includes .3. Implementing interventions to reduce hazard(s) and risk(s) . Policy Explanation and Compliance Guidelines .3. Implementation of Interventions .i. Resident-directed approaches may include .supervising .residents .
Review of the facility's policy, Resident Smoking, Smokeless Tobacco, and Vaping Policy, dated 3/29/22, revealed, Policy: This facility provides a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking .Policy Explanation and Compliance Guidelines .2. Safety measures for the designated smoking area will include .e. Prohibition of oxygen use in the smoking area .11. All safe smoking measures will be documented on each resident's care plan and communicated to all staff .who will be responsible for supervising residents while smoking .14. All smoking materials of residents will be maintained by nursing and/or activity staff .
A record review of the facility's investigation, dated 2/23/24, revealed on 2/21/24, when the Activities Director (AD) was assisting with the smoke breaks with her back turned, she heard a popping/clicking sound. Upon turning, she observed sparks coming from Resident #1's oxygen nasal cannula. She immediately removed the cannula and turned his oxygen off.
Record review of the local hospital report, dated 2/21/24, revealed . Arrival Complaint FACIAL BURN Chief Complaint . Complaint of facial burns to bilateral nostrils after lighting a cigarette while wearing home O2 .singed hair at nares .Final diagnoses Second degree burn of nose. Partial thickness burns of face . Discharge Orders revealed Resident #1 received Keflex (antibiotic medication) and a Bacitracin Ointment (treatment order) upon discharge.
Record review of the Physician Orders for the month of February 2024 revealed Resident #1 had an order, dated 11/9/23, for Oxygen at 2 LPM (Liters per minute) via nasal cannula as needed .
A record review of the Resident Safe Smoking Assessment, dated 11/13/23, revealed Resident #1 was able to verbalize the safety risks of smoking and was aware of smoking procedures.
On 2/26/24 at 3:45 PM, during an interview with Resident #1, he confirmed on 2/21/24, he went into the smoking area with an O2 canister on the back of his wheelchair and the O2 was being delivered through a nasal cannula. Resident #1 expressed that it was his fault because he was rushing to make it to the smoke area and forgot to have his oxygen canister removed from his wheelchair. He said he was anxious about being late, so he got the lighter from the box that holds the smoking items and he lit his cigarette instead of waiting for staff to light it for him. He stated that the lighter sparked and he pulled the nasal cannula off. He said that it did not hurt him and he did not want to go to the hospital, but the facility insisted he get checked out.
On 2/26/24 at 4:00 PM, during an observation of the residents during the smoking break, the cigarettes and lighters were observed in a plastic container with the top not secured on a table in the smoking area. There were two (2) facility staff supervising and assisting the residents and were using the container to pass out cigarettes for the residents and then using a lighter to light the cigarettes.
On 2/27/24 at 10:21 AM, during an interview with the AD, she confirmed that on 2/21/24 at approximately 4:00 PM, she assisted Resident #1 during the smoke break. She confirmed that she did not remove his oxygen canister as she usually did before he entered the smoke area. The AD explained Resident #1 was late getting to the smoking area and while she was assisting another resident through the doorway, he got a lighter out of the box that was left on a table. She heard a clicking/popping sound and observed sparks coming from the nasal cannula. She assisted with removing the nasal cannula, turned the oxygen off, and got a nurse to assist.
On 2/27/24 at 10:50 AM, during an interview with License Practical Nurse (LPN) #1, she confirmed on 2/21/24, the AD called out for assistance in the smoking area. LPN #1 stated she observed Resident #1 having soot (ashes) on his nasal passages, bridge of his nose, and inside his nares, face, and right shoulder. She explained that the sparks had been put out before she went to the smoking area. She stated that she immediately notified the Director of Nursing (DON) and the Administrator.
On 2/27/24 at 12:00 PM, during an interview with the DON, confirmed that Resident #1 was brought to the smoking area while wearing O2 and had an O2 canister on the back of his wheelchair. The DON stated the AD failed to remove both the resident's oxygen and nasal cannula during his smoke break, which caused sparks. Resident #1 went to the hospital and was treated for a second degree burn of the nose and partial thickness burn of the face.
During an interview with the Administrator on 2/27/24 at 2:33 PM, she confirmed that on 2/21/24, Resident #1 lit his cigarette before the AD checked or removed his O2. The Administrator stated safety is the utmost priority of the facility, and moving forward, the facility has placed more checks and balances to prevent further incidents or accidents.
A record review of the Face Sheet revealed the facility admitted Resident #1 on 11/6/23 with current diagnoses including Chronic Obstructive Pulmonary Disease and Heart Failure.
Record review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/15/23 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated he was cognitively intact. Section J revealed Resident #1 currently uses tobacco. Section O revealed Resident #1 used oxygen therapy.
Jul 2023
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, interviews, record review and facility policy review the facility failed to provide a privacy bag for a resident with an indwelling catheter for one (1) of five (5) residents wit...
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Based on observation, interviews, record review and facility policy review the facility failed to provide a privacy bag for a resident with an indwelling catheter for one (1) of five (5) residents with urinary catheters. Resident #235.
Findings Include:
Record review of the facility's policy titled Catheter Care, undated, revealed Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. Policy Explanation .2. Privacy bags will be available and catheter drainage bag will be covered at all times while in use .
On 07/17/2023 at 11:00 AM, during an observation, Resident #235 was lying in bed and had an indwelling catheter drainage bag that had yellow urine visible from the doorway and hallway.
On 07/19/2023 at 01:15 PM, during an observation, Resident #235 was lying in bed talking to a visitor. The visitor was at the bedside of the resident and the indwelling catheter drainage bag was not covered and urine was visible in his room and hallway.
On 07/20/2023 at 08:55 AM, an observation and interview with the Director of Nursing (DON) in Resident #235's room, she confirmed there was no privacy cover on his catheter drainage bag and the urine in the bag was visible. She stated that the drainage bag was not the kind of bag that the facility used, and it should have had a dignity cover over the bag to keep the urine from being seen. She explained that it was the facility policy for the drainage bag to be covered.
Record review of the Physician Order Sheet for Foley Catheter dated 7/11/2023, revealed Foley catheter 16 French 10 cc (cubic centimeter) bulb to gravity .
Record review of the Face Sheet revealed the facility admitted Resident # 235 on 7/10/23 with diagnoses including Retention of Urine and Acute Kidney Failure.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observation, interviews, record review and facility policy review the facility failed to maintain a clean environment for two (2) of 20 resident rooms. Resident #54 and Resident #76
Findings ...
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Based on observation, interviews, record review and facility policy review the facility failed to maintain a clean environment for two (2) of 20 resident rooms. Resident #54 and Resident #76
Findings Include:
Review of the facility's policy, Routine Cleaning and Disinfection, dated 5/12/23, revealed, Policy: It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment .Policy Explanation and Compliance Guidelines .13. Cleaning of walls .will be conducted when visibly soiled. 14. Privacy curtains in resident rooms will be changed when visibly dirty .
Resident #54
On 7/17/23 at 12:20 PM, in an observation and interview with Resident #54, the privacy curtain facing the resident had large visible stains and was soiled. The resident stated that the curtain had been in that condition for a while and no one had said anything to him about replacing it. He said he was sure staff had noticed it but had not done anything about it.
On 07/18/23 at 01:53 PM, in an interview and observation with Certified Nurse Aide (CNA) #1, she confirmed that the privacy curtain for Resident #54 was soiled and stained and stated that the privacy curtain was not appropriate. CNA #1 explained that if she saw a privacy curtain that needed to be changed, she would tell housekeeping or maintenance. Then either herself or housekeeping would enter a request for the curtain to be changed in the maintenance log located at the nurse's station. CNA #1 reported that she had not placed a request in the log for the soiled privacy curtain for Resident #54.
On 07/18/23 at 02:40 PM, in an interview and observation of the maintenance log with Maintenance #2, he confirmed there had not been a request recorded in the log to change the privacy curtain for Resident #54. He stated that staff added items to the daily log and when the task was completed, it was signed or initialed by the maintenance staff. He confirmed that extra privacy curtains were available for use.
On 07/20/23 at 01:42 PM, in an interview with the Director of Nursing (DON) and the Administrator, the Administrator stated that she had been made aware of the soiled privacy curtain. She stated that the facility had ordered new privacy curtains and they were expected to be delivered soon.
Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/10/2023 revealed Resident #54 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated he was cognitively intact.
Resident #76
On 7/17/23 at 11:20 AM, in an observation of Resident #76's room revealed the wall behind the bed, facing the entrance to the room, had large pieces of missing paint. The wall was soiled and had visible stains.
During an interview on 07/19/23 at 10:35 AM, with Maintenance Staff #1, he confirmed that the wall on Resident #76's side of the room nearest the window had peeling paint and was visibly soiled. He said that the reason the wall was missing paint was because the bed was too close to the wall and when the resident raised the bed, it scraped the paint off the wall. He confirmed that though the paint was missing, it did not prevent housekeeping from cleaning the walls. He stated that he had previously repaired the wall, and that he would repair it again.
On 07/19/23 at 11:00 AM, an observation and interview with the Director of Nurses (DON) and the Administrator revealed the wall in Resident #76's room had peeling paint and was soiled. She stated that the wall was damaged because the bed was too close to the wall and when staff would raise or lower the bed, it damaged the wall. The DON confirmed the wall was soiled and housekeeping should have cleaned the walls and the room was not conducive to a home-like environment.
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
Based on interview, record review, and facility policy review, the facility failed to develop a comprehensive care plan related to a medication for one (1) of (20) care plans reviewed. Resident #54
Fi...
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Based on interview, record review, and facility policy review, the facility failed to develop a comprehensive care plan related to a medication for one (1) of (20) care plans reviewed. Resident #54
Findings Include:
Review of the facility's policy, Comprehensive Care Plans, undated, revealed, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .Policy Explanation and Compliance Guidelines .3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .
In an observation and interview on 7/17/23 at 12:20 PM, with Resident #54 he was lying in the bed and there was a container of medication on his overbed table in front of him. The container of cream, which had a pharmacy label, was prescribed to Resident #54 and was labeled as Triamcinolone Acetonide. Resident #54 stated he had gotten the cream when he went to the doctor several months ago for eczema and the cream had remained on his overbed table since he received the medication.
Record review of a Physician's Order Sheet, dated 1/24/23, revealed a handwritten order Triamcinolone Acetonide 0.1% topical cream. Apply to affected areas on face and scalp twice daily for one-two weeks then as needed for flares.
Review of the medical record revealed there was no comprehensive care plan developed for Resident #54 related to his skin condition of eczema or an approach developed for the Triamcinolone cream as ordered by the physician.
On 07/20/23 at 11:34 AM, in an interview with Registered Nurse (RN) #2 and Licensed Practical Nurse (LPN #3), RN #2 explained that the facility developed the comprehensive care plans based on the comprehensive Minimum Data Set (MDS) assessments and any other relevant information, including physician orders. RN #2 and LPN #3 stated that Resident #54 went to a dermatology appointment, had a biopsy procedure, and returned to the facility with multiple physician orders. RN #2 and LPN #3 confirmed that although there had been a care plan developed for the skin condition related to the biopsy and that care plan had been resolved, there was no care plan developed related to the eczema flare ups and the medication to be administered as needed.
On 07/20/23 at 12:20 PM, during an interview with the Director of Nursing (DON), she stated that care plans should be developed and are used to provide individualized care to residents and to ensure their needs are met according to the physician's order.
Record review of the Face Sheet revealed the facility admitted Resident #54 on 11/15/2019 with a diagnosis of Hemiplegia.
Record review of the MDS with an Assessment Reference Date (ARD) of 4/10/2023 revealed Resident #54 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated he was cognitively intact.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation, interviews, record review and facility policy review the facility failed to provide nail care for a resident who was unable to carry out Activities of Daily Living (ADLs) for one...
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Based on observation, interviews, record review and facility policy review the facility failed to provide nail care for a resident who was unable to carry out Activities of Daily Living (ADLs) for one (1) of (20) sampled residents. Resident #76.
Findings include:
Record review of the facility's policy, Activities of Daily Living (ADLs), dated 10/28/2021, revealed, .The staff will provide care on a timely basis to promote and prevent avoidable changes in care. This includes the residents ability to: 1. Bathe, dress, and groom .Policy Explanation and Compliance Guidelines .3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming and personal oral hygiene as documented in the resident's care plan .
During an observation on 07/17/23 at 11:49 AM, Resident # 76 was in bed, and he had fingernails on both hands that were thick, jagged, and had a dark discoloration. The middle three fingernails on both hands were curved beyond the nail bed.
During an interview on 7/18/23 at 4:15 PM, with Certified Nurse Aide (CNA) #2, she stated that she cleaned the resident's nails but did not cut his nails because they were thick and jagged. She explained that the nurse performed nail care for that type of nail.
An observation and interview on 7/18/23 at 4:25 PM, with Licensed Practical Nurse (LPN) #1, the Director of Nursing (DON), and Registered Nurse (RN) #3, revealed Resident #76 had nails that were thick, discolored, and had been for an undetermined amount of time. LPN #1 explained that she had not provided any care for the nail herself. The DON stated that she was aware that Resident #76 had bilateral long, thick, and discolored nails and there was no Physician Order to perform nail care.
Record review of the Face Sheet revealed Resident #76 was admitted by the facility on 10/12/22 with diagnoses that included Cerebral Infarction and Contracture, right hand.
Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/15/23 revealed Resident #76 was totally dependent upon staff for bathing and required extensive assistance with personal hygiene.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident had been assessed for safe self-administration of medication and failed to ensure ...
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Based on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident had been assessed for safe self-administration of medication and failed to ensure a physician's order was transcribed accurately for one (1) of (20) sampled residents. Resident #54
Findings Include:
Record review of the facility's policy, Resident Self-Administration of Medication dated 6/23/2023, revealed, Policy .A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely .
Record review of the facility's policy, Medication Orders, undated, revealed, .Policy Explanation and Compliance Guidelines . 4. Documentation of Medication Orders .f. Transcribe newly prescribed medications on the .treatment record .
During an observation on 7/17/23 at 12:20 PM, Resident #54, was lying in the bed and there was a container of medication on his overbed table in front of him. The container of cream, which had a pharmacy label, was prescribed to Resident #54 and was labeled as Triamcinolone Acetonide. Resident #54 stated he had gotten the cream when he went to the doctor several months ago for eczema and the cream had remained on his overbed table since he received the medication. He said that he used the cream whenever he needed it.
Record review of Departmental Notes, dated 1/24/23 at 11:55 PM, revealed Late entry for 1/23/23 Resident returned to facility .with new orders noted from Derm (Dermatology) clinic has bandage noted to left side of face .
Record review of a Physician's Order Sheet, dated 1/24/23, revealed a handwritten order Triamcinolone Acetonide 0.1% topical cream. Apply to affected areas on face and scalp twice daily for one-two weeks then as needed for flares.
Record review of the Physician Orders For the month of: February 2023, revealed a Physician's Order, with an order date and start date of 1/24/23 for Triamcinolone 0.1% cream .apply to affected areas on face and scalp twice daily for 1-2 weeks then as needed for flares .Stop date: 2/6/23. The interval code on the order was listed as Daily. There was no entry for an interval code to apply the medication as needed.
On 07/18/23 at 1:50 PM, during an observation and interview with Licensed Practical Nurse (LPN) #1 in the room of Resident #54, she asked Resident #54 if the nurses were applying the cream and he responded No.He explained that he applied the cream himself. LPN #1 asked Resident #54 where he applied the cream and he stated that he used it on his face whenever he thought he needed it, and he did not tell the nurses whenever he used it.
On 07/18/23 at 02:00 PM, in an interview with Registered Nurse (RN) #1, she stated that Resident #54 was very particular and liked things a certain way in his room and on his overbed table. She stated he had a high Brief Inteview for Mental Status (BIMS) score and was able to follow directions, but he had not been assessed to determine if he could safely self-administer the medication. He had not been advised to tell the nurse when he administered the medication so that it could be recorded.
On 7/18/23 at 2:30 PM, in an interview with the Director of Nursing (DON), she confirmed there was no Physician's Order in the system for Triamcinolone to be administered as needed. She stated when the nurse entered the Physician's Order into the electronic health record, she should have entered two separate orders, one order for the daily administration of 1-2 weeks with a stop date, and one order to administer as needed without a stop date. She stated the nurse who entered the Physician's Order had not worked at the facility in several months.
On 07/20/23 at 08:49 AM, in an interview with the facility's Pharmacist, he confirmed that resident self-administration of medications should be consistent with the facility's policies and regulations for safety and that if a resident self-administers any medication, there should be documentation of the administration. He also confirmed that Physician Orders should be carried out per the facility's policy.
On 07/20/23 at 12:20 PM, during an interview with the DON, she stated that it is her expectation that staff inputs Physician's Orders accurately into the electronic medical records. She stated that the nurses are trained upon hire and as needed to input orders. She also confirmed that a resident must be determined to be able to safely administer medications and the physician's order would need to be written for the resident to self-administer. She said that Resident #54 had not been assessed to self-administer medications. The DON explained that the process for ensuring accuracy of physician's orders is for the Quality Assurance (QA) nurse to check behind the nurses and use the yellow copies of the duplicate Physician's Order form to insure orders are entered correctly. She further explained that neither herself nor the current QA nurse was at the facility on 1/24/23 when the transcription error occurred.
Record review of the Face Sheet revealed the facility admitted Resident #54 on 11/15/2019 with a diagnosis of Hemiplegia.
Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/10/2023 revealed Resident #54 had a BIMS score of 15 which indicated he was cognitively intact.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, interviews, record review, and facility policy review, the facility failed to ensure cautionary signage was posted related to oxygen usage for one (1) of one (1) resident reviewe...
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Based on observation, interviews, record review, and facility policy review, the facility failed to ensure cautionary signage was posted related to oxygen usage for one (1) of one (1) resident reviewed for respiratory conditions. Resident #26
Findings Include:
Review of the facility's policy, Oxygen Administration, dated 6/23/23, revealed, .Policy Explanation and Compliance Guidelines .6. Oxygen warning signs must be placed on the door of the resident's room where oxygen is in use .
On 07/17/23 at 11:12 AM, Resident #26 was sitting in a wheelchair next to his bed. There was an oxygen (O2) concentrator in the corner of the room, with a nasal cannula stored on the back of the concentrator. Resident #26 was not wearing the nasal cannula and was unable to communicate if he had removed the cannula himself. There was no cautionary signage on the door of the room indicating that oxygen was being administered.
Record review of the Physician's Order Sheet' revealed a Physician's Order dated 7/9/23 for Oxygen at 2L (liters) continuous r/t (related to) hypoxia.
Record review of the Departmental Notes for Resident #26, dated 7/17/23 at 4:50 AM, revealed, . SPO2 (Saturation of peripheral oxygen) 94% on 2 lpm (liters per minute) via nasal cannula .
On 07/18/23 at 02:00 PM, in an interview and observation with Licensed Practical Nurse (LPN) #2, she confirmed there was an O2 concentrator in the room for Resident #26. She also confirmed that there were no cautionary signs on the door indicating use of oxygen.
On 07/20/23 at 12:27 PM, in an interview with the Director of Nursing (DON), she stated it was her expectation that all residents receiving oxygen therapy have cautionary signage for safety of the resident.
Record review of the Face Sheet revealed the facility admitted Resident #26 on 3/14/23 and he had diagnoses including Obstructive Sleep Apnea and Diabetes Mellitus.
Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/14/2023 revealed Resident #26 had a Brief Interview of Mental Status (BIMS) score of 6 which indicated he had severe cognitive impairment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interviews, record review and facility policy review, the facility failed to properly secure a medication for one (1) of (20) sampled residents. Resident #54
Findings Include:
R...
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Based on observation, interviews, record review and facility policy review, the facility failed to properly secure a medication for one (1) of (20) sampled residents. Resident #54
Findings Include:
Review of the facility's policy, Medication Storage, reviewed/revised 6/20/23, revealed, .It is the policy of this facility to ensure all medications housed on our premises will be stored in the .medication rooms .Policy Explanation and Compliance Guidelines 1. General Guidelines a. All drugs and biologicals will be stored in locked compartments .
Review of the facility's policy, Resident Self-Administration of Medication, dated 6/23/23, revealed, .Policy Explanation and Compliance Guidelines .7. All nurses and aides are required to report to the charge nurse on duty any medication found at the bedside not authorized for bedside storage .
On 7/17/23 at 12:20 PM, Resident #54 was observed lying in the bed. There was a container of medication on his overbed table in front of him. The container of cream, which had a pharmacy label, was prescribed to Resident #54, and was labeled as Triamcinolone Acetonide. Resident #54 stated he had gotten the cream when he went to the doctor several months ago for eczema and the cream had remained on his overbed table since he had received the medication.
Record review of Departmental Notes, dated 1/24/23 at 11:55 PM, revealed Late entry for 1/23/23 Resident returned to facility .with new orders noted from Derm (Dermatology) clinic has bandage noted to left side of face .
Record review of a Physician's Order Sheet, dated 1/24/23, revealed a handwritten order Triamcinolone Acetonide 0.1% topical cream. Apply to affected areas on face and scalp twice daily for one-two weeks then as needed for flares.
Record review of a handwritten Physician's Order, dated 1/24/23, revealed, Triamcinolone 0.1% cream .apply to affected areas on face and scalp twice daily for 1-2 weeks then as needed for flares .
Record review of the Physician Orders for the month of February 2023, revealed a Physician's Order, with an order date and start date of 1/24/23 for Triamcinolone 0.1% cream .apply to affected areas on face and scalp twice daily for 1-2 weeks then as needed for flares .Stop date: 2/6/23. The interval code on the order was listed as Daily. There was no interval code to apply the medication as needed.
During an interview and observation with Licensed Practical Nurse (LPN) #1, on 07/18/23 at 1:50 PM, revealed that LPN #1 was unaware that Resident #54 had the medication at his bedside. She stated she had not noticed the container of Triamcinolone was on his bedside table. She confirmed that the medication should not have been stored at his bedside and she removed it from the resident's room.
In an interview on 07/20/23 at 08:49 AM, with the facility's Pharmacist, he confirmed that the medications should be stored according to the facility's policies and regulations for safety.
During an interview with the Director of Nursing (DON) 07/20/23 at 12:20 PM, she stated that it is her expectation that medications be stored appropriately by being locked in the nurses cart or the medication rooms and she confirmed that medication should not be stored at the resident's bedside.
Record review of the Face Sheet revealed the facility admitted Resident #54 on 11/15/2019 with a diagnosis of Hemiplegia.
Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/10/2023 revealed Resident #54 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated he was cognitively intact.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0865
(Tag F0865)
Could have caused harm · This affected 1 resident
Based on staff interviews and facility policy review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to ensure the program was sustained and interventions were mo...
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Based on staff interviews and facility policy review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to ensure the program was sustained and interventions were monitored for effectiveness for one (1) repeated deficiency related to Physician Order transcription errors that was cited in May 2022 and October 2022. The facility's continued failure during three surveys shows a pattern of the facility's inability to sustain an effective QAPI Committee for three (3) of (3) previous surveys reviewed.
Findings Include:
Record review of the facility's policy, Quality Assurance Performance Improvement, dated 2/24/2021, revealed, Policy: It is the policy of this facility to .maintain an effective .QAPI program .
During this recertification survey, the facility was cited F684 (Quality of Care). The facility failed to ensure a physician's order was transcribed accurately.
In May 2022, the facility was cited F684 for failure to ensure a physician's order was transcribed accurately.
In October 2022, the facility was again cited F684 for failure to ensure a physician's order was transcribed accurately.
On 07/20/23 at 01:42 PM, in an interview with the Director of Nursing (DON) and the Administrator, the Administrator stated that she expected the staff to be in compliance with the regulations regarding the accurate transcription of physician orders. She confirmed that the facility has QAPI meetings monthly and interventions are monitored for effectiveness and results of the monitoring is discussed in the QA and standup meetings. The Administrator stated that she was at the facility for the previous surveys and aware of the previous citations for the medication transcription errors.
MINOR
(C)
Minor Issue - procedural, no safety impact
Transfer Notice
(Tag F0623)
Minor procedural issue · This affected most or all residents
Based on interviews, record review, and facility policy review, the facility failed to provide written notification to the resident and the resident's representative, in a language they could understa...
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Based on interviews, record review, and facility policy review, the facility failed to provide written notification to the resident and the resident's representative, in a language they could understand, the reason a resident was transferred to the hospital for one (1) of one (1) resident records reviewed for hospitalizations. Resident #12
Findings include:
Review of the facility's policy, Transfer and Discharge (including AMA), revised 6/23/23, revealed, Policy: It is the policy of this facility to permit each resident to remain in the facility, and not initiate transfer or discharge for the resident from the facility, except in limited circumstances . Policy Explanation and Compliance Guidelines: . 4. The facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand. The notice will include all the following at the time it is provided: a. The specific reason and basis for transfer or discharge. b. The effective date of transfer or discharge. c. The specific location . to which the resident is to be transferred to or discharged .
A record review of the facility's, Notice of Resident Transfer or Discharge form, dated 5/28/23 and addressed to the Resident/Representative of Resident # 12, revealed . The reason for the transfer/discharge is for the following reason(s): The transfer is necessary for the resident's welfare and the resident's needs cannot be met by the facility (i.e. urgent medical need). Specify: Acute Care- Hospital .
Record review of the facility's, Departmental Notes, dated 5/28/23 at 7:15 PM revealed, . Res (Resident) complaining of chest pain .I want to go to the hospital . Notified MD (Medical Doctor) . Res left facility at 13:30 (:30 PM), via (Proper name of local ambulance service .
The Director of Nurses (DON), confirmed in an interview on 7/19/23 at 2:19 PM, Resident #12 was admitted to the local hospital because of chest pain.
During an interview on 7/20/23 at 9:00 AM, Resident #12's son stated he doesn't remember how he was notified that his mother was sent to the hospital, but he thinks they told him when he called the facility asking about his mother. The son denied receiving written notification of his mother's transfer to the hospital.
An interview on 7/20/23 at 12:33 PM, with the Supply Manager, revealed she receives copies of the orders (pink slips) for the residents transferred to the hospital or discharged and emails a copy of the order to the [NAME] Office Manager. The Supply Manager confirmed that the pink slips do not have the reason for the transfer or discharge.
During an interview on 7/20/23 at 12:39 PM, the [NAME] Office Manager (BOM) confirmed she receives the emailed copy of the resident's transfer order and uses that information to notify the resident's family of the transfer. The BOM explained that the transfer orders (pink slips) do not include the reason for the transfer and therefore, she thought informing the family that the resident needed acute care was enough.
During an interview on 7/20/23 at 1:00 PM, with the Administrator she revealed she wasn't aware that the pink slip does not have the reason the resident was transferred to the hospital.
May 2023
2 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
Based on observation, interviews, record review, and facility policy review, the facility failed to provide adequate supervision to prevent the elopement of Resident #1 for one (1) of four (4) residen...
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Based on observation, interviews, record review, and facility policy review, the facility failed to provide adequate supervision to prevent the elopement of Resident #1 for one (1) of four (4) residents reviewed with wandering and elopement behaviors.
Resident #1 exited the facility through a window, unnoticed and unsupervised until License Practical Nurse (LPN) #2 found Resident #1 approximately 500 feet from the facility sitting on a tree stump at the front east side of the property.
The facility's failure to provide supervision for Resident #1, with a known elopement risk, put Resident #1 and all other residents with wandering and elopement behaviors, at risk for serious injury, harm, impairment, or death.
The situation was determined to be an Immediate Jeopardy (IJ) that began on 5/11/23 when Resident #1 exited the facility through a window in her room. The facility Administrator was notified of the IJ on 5/17/23 at 1:00 PM and provided an IJ Template.
Based on the facility's implementation of corrective actions on 5/11/23, the SA determined the IJ and Substandard Quality of Care (SQC) to be Past Non-Compliance (PNC) and the IJ was removed as of 5/12/23, prior to the SA's first entrance on 5/16/23.
Findings include:
A review of the facility's Elopement Policy, revised 12/28/20, revealed, .Definition: An Elopement is considered to be when a (cognitively impaired resident, wanders without staff visually monitoring to an unsafe place inside or outside the facility .Facts to Consider .Anytime a resident is successful in exiting the facility unsupervised, this constitutes elopement .
On 5/16/23 at 4:00 PM, in an interview with the Administrator, she stated that Resident #1 was admitted by the facility on 2/6/23, had a diagnosis of Alzheimer's disease, and was assessed for wandering and exit seeking behaviors. Resident #1 was deemed to be an elopement risk at that time because she exhibited wandering behaviors and made statements that she wanted to go home. On 5/11/23, the resident exited the facility through her window and was last seen by facility staff at 3:20 PM. At 4:00 PM, a nurse saw that the resident's windows were opened, and the window screens were outside of her windows, as if they had been pushed out. The Administrator confirmed that Resident #1 was located at 4:15 PM, approximately 500 feet from her room on the east side of the facility. Resident #1 was calm and approachable, and she was fully clothed in pants, a top, a jacket, and shoes. She had a skin tear on her wrist. She was transferred to the local Emergency Department (ED) for evaluation and returned to the facility the same day. The Administrator commented that following the incident, all residents were accounted for and were assessed for wandering behaviors. Resident #1 was placed on one-on-one supervision when she returned to the facility from the ED and window screws were installed so the windows would only open to six (6) inches for residents with exit-seeking behaviors.
On 5/16/23 at 4:30 PM, during an observation, Resident #1's windows were approximately eight (8) feet from the ground (sidewalk). The outside of the building was brick. The SA walked with the Administrator and Director of Nurses (DON) the route the resident most likely took when she exited the facility. The area was a scattered growth of bushes and trees with a trail, and the ground was flat, with no large holes.
On 5/16/23 at 4:40 PM, in an observation and interview with Resident #1, she was resting in her bed and was able to state her name, however, she was unable to recall the current date, time, or her whereabouts. She stated that she just wanted to go home.
On 5/17/23 at 9:00 AM, in an interview with LPN #1, she confirmed on 5/11/23 at approximately 3:20 PM, she observed Resident #1 lying on the bed in her room. She stated that at 4:00 PM, while conducting her medication pass, she observed that the resident's door was closed. She entered the resident's room and noticed her windows were open and the window screens were missing. LPN #1 said she looked for the resident in the room and then immediately notified the charge nurse that Resident #1 was missing. She said that prior to the event, Resident #1 was calm and was not exhibiting exiting seeking behaviors.
On 5/17/23 at 9:30 AM, an interview with LPN #2, she stated that on 5/11/23 at approximately 4:00 PM, she was informed that Resident #1 was missing from her room, and she began searching for the resident outside. She started walking and calling for the resident and then spotted her at 4:15 PM, sitting on a tree stump. She had stains on her clothing that appeared to be from dirt.
On 5/17/23 at 11:00 AM, in an interview with the Maintenance Manager, he stated that following the elopement of Resident #1, he evaluated all resident windows to ensure there were no problems with the windows. He installed window screws so the windows would only open six (6) inches for the residents identified as an elopement risk.
Record review of the facility's investigation, dated 5/12/2023, completed by the Administrator revealed, .Incident report date: 05/11/2023 .1520 (3:20 PM) 3-11 (shift) cart nurse observed resident lying in bed 1600 (4:00 PM) 3-11 nurse passed resident room and noticed resident was missing and both windows were open. Nurse searched resident's bathroom and immediately notified charge nurse of resident missing and window open. All staff immediately began looking for resident .1612 (4:12 PM) the administrator was notified .of resident missing. 1613 (4:13 PM) DON was notified .of resident missing .1615 (4:15 PM) resident was located on the front eastside of property sitting on a stump .Resident placed on 1:1 (one on one) staff monitoring .
Record review of the weather history for 5/11/23 revealed the weather at 3:53 PM was cloudy and 79 degrees.
Record review of the Face Sheet revealed the facility admitted Resident #1 on 2/6/23 with a diagnosis of Alzheimer's disease with late onset.
Record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/13/23 revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 6, which indicated she had severe cognitive impairment.
Record review of the Risk Factors For Elopement for Resident #1, dated 2/6/23, revealed, .Elopement Risk Summary .High Risk .
The facility implemented the following Corrective Action Plan prior to the SA's entrance on 5/16/23:
1. Brief summary of events: Resident #1 exited the building through her window on 05/11/2023. She was reported missing by Licensed Practical Nurse (LPN) #1 at 4 pm. Resident was located and assessed at 4:15pm by LPN #2 and transferred to the hospital for further assessment on 05/11/2023. Resident returned to the facility at 10:49pm on 05/11/2023 with no major injuries noted. Upon arrival resident #1 was moved to an interior room opening only to the enclosed courtyard and placed on 1:1 supervision. Care Plan was updated by Minimum Data Set (MDS) nurses registered nurse (RN) #1 and LPN 3#. The state agency (SA) presented the administrator with an immediate jeopardy (IJ) template.
2. All residents who are at risk for wandering have the potential to be affected by this same deficient practice.
3. An Emergency Quality Assurance (QA) meeting was held on 05/11/2023 at 4:43pm to include: The Administrator, Director of Nursing, Medical Director, Nurse Practitioner, Infection Preventionist (IP), MDS RN #1, MDS LPN #3, QA RN #2, and QA LPN #4 regarding Resident #1 exiting the building on 05/11/2023. Elopement and Missing Resident policies were discussed and no changes made to policies.
4. All residents were assessed for elopement risk by MDS RN#1, MDS LPN #3 and QA LPN #4 on 05/11/2023 and one additional resident was identified at risk.
5. The resident care plan was updated on 05/11/2023 by MDS RN #1 and Elopement binders at both nurse's stations were updated by QA RN #2 and DON RN #3 to include a picture of resident identified.
6. Wander guard placed by QA RN #2 on 05/11/2023 to resident identified.
7. All windows in residential area were checked by Maintenance and RN#3 on 05/11/2023 at 6:20pm to ensure there were no cracks, to make sure windows locked and that there were screens on windows. Windows of residents who are at risk for wandering were secured to open six inches on 05/11/2023 by maintenance.
8. In-services of elopement and missing person policies were started on 05/11/2023 with present staff. All other staff were in-serviced prior to beginning their next shift. No staff is allowed to work before being in-serviced.
9. All wander guard and security doors were checked by maintenance on 05/11/2023 to make sure all were functioning properly.
10. Monitoring procedures are: Quarterly elopement drills beginning 05/15/2023 Residents at risk for elopement reviewed at weekly Patients at Risk (PAR) meeting on 05/24/2023 for new interventions needed and care plans updated, QA will monitor the resident at risk for elopement procedures in the QA meeting for three months beginning 05/11/2023.
11. The facility alleges all corrective actions were completed on 5/11/23 and the immediate jeopardy was removed on 05/12/2023.
The SA validated the facility's corrective action on 5/22/23:
The SA validated through record review and interviews that the facility discussed Resident #1's incident of elopement from the facility at an emergency Quality Assurance and Performance Improvement (QAPI) meeting on 5/11/23. The actions taken to ensure the provision of adequate supervision to meet Resident #1's needs were verified with evidence of verification of the in-services, elopement drills, re-assessments, and wander guard checks.
The SA verified that LPN #2 had located Resident #1 on 5/11/23 at 4:15 PM, she was transported to a local hospital and returned to the facility with no adverse findings.
The SA verified all residents were assessed for elopement risk by MDS RN#1, MDS LPN #3 and QA LPN #4 on 05/11/2023 and one additional resident was identified at risk.
The SA validated through record review and interviews, care plan was updated on 05/11/2023 by MDS RN #1 and Elopement binders at both nurse's stations were updated by QA RN #2 and DON RN #3 to include a picture of resident identified.
The SA validated through record review and interviews wander guard placed by QA RN #2 on 05/11/2023 to the resident identified.
The SA validated through observation, interviews and record review that all windows in the residential area were checked by Maintenance and RN#3 on 05/11/2023 at 6:20 pm to ensure there were no cracks, to make sure windows were locked, and that there were screens on windows. Windows of residents at risk for wandering were secured to open six inches on 05/11/2023 by maintenance. The SA observed the windows of residents identified as exit seekers to only open six (6) inches.
The SA validated through interviews and record reviews in-services of elopement and missing person policies were started on 05/11/2023 with present staff. All other staff were in-serviced prior to beginning their next shift. No staff is allowed to work before being in-serviced.
The SA validated through interviews and record reviews, wander guard and security doors were checked by maintenance on 05/11/2023 to make sure all were functioning properly.
The SA validated through interviews and record reviews, monitoring procedures are: Quarterly elopement drills beginning 05/15/2023 Residents at risk for elopement reviewed at weekly Patients at Risk (PAR) meeting on 05/24/2023 for new interventions needed and care plans updated, QA will monitor the resident at risk for elopement procedures in the QA meeting for three months beginning 05/11/2023.
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
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on staff interviews, record review and facility policy review the facility failed to prevent staff to resident verbal abuse for one (1) of four (4) sampled residents. Resident #2.
Findings incl...
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Based on staff interviews, record review and facility policy review the facility failed to prevent staff to resident verbal abuse for one (1) of four (4) sampled residents. Resident #2.
Findings include:
A review of the facility's Abuse, Neglect and Exploitation/Misappropriation Policy,, revised 3/19/2020, revealed, .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by .implementing written policies and procedures that prohibit and prevent abuse .'Verbal Abuse' means the use of oral .communication .that willfully includes disparaging and derogatory terms to residents .or within their hearing distance .
On 5/19/23 at 10:00 AM, in an interview with the Administrator, she stated that earlier today (5/19/23), Resident #2 had asked Licensed Practical Nurse (LPN) #5 for his medications and then both began exchanging harsh, loud words. Following the incident, the Director of Nursing (DON) and the Administrator had a conference with LPN #5 and he confirmed that during his morning medication pass, Resident #2 was upset about his medications. He stated that Resident #2 called him a harsh name and LPN #5 then called the resident the same name. The Administrator terminated LPN #5 for unprofessional conduct toward the resident.
On 5/19/23 at 1:50 PM, in an interview with LPN #5, he confirmed that he called the resident an asshole because the resident had called him names and said mean things to him. The resident was angry because he felt the nurse was late administering his medications.
On 5/19/23 at 2:00 PM, in an interview with the Occupational Therapist (OT), she stated that this morning (5/19/23) at about 9:15 AM, she was in her office in the therapy gym and the door was open. Resident #2 was in his wheelchair at the therapy gym entrance. She heard loud, harsh talking between two males, so she stepped out of her office and noticed it was Resident #2 and LPN #5 arguing about the resident's medication being late. The resident informed the nurse, You are not a doctor, then the nurse said, I'm a nurse. Resident #2 said, No, you are an asshole, then the nurse said, No, you are an asshole. She stated they were both talking in a loud voice and hollering. She confirmed that she and another nurse separated the resident and the nurse.
On 5/19/23 at 2:30 PM, in an interview with Resident #2, he confirmed that he was upset because he felt his medications were late and he was upset. He said that when LPN #5 brought his medications, the nurse was being rude, and they both began calling each other names in a loud voice.
On 5/22/23 at 11:46 AM, in an interview with the Certified Occupational Therapist Assistant (COTA-L) she confirmed that on the morning of 5/19/23, Resident #2 had requested his medications and was upset because he felt they were late. She said that she was in the therapy room, and Resident #2 was outside of the therapy room door when she heard Resident #2 and LPN #5 yelling back and forth with each other and name-calling. She then heard each of them call each other asshole.
A record review of the facility's investigation, dated 5/19/2023, revealed that Resident #2 expressed to the COTA/L that he had not received his morning medication. The COTA/L informed LPN #5 that Resident #2 was requesting his medication, and he was upset. Resident #2 and LPN #5 had a verbal altercation calling each other names in a loud voice. Following the investigation, LPN #5 was escorted out of the building and terminated for unprofessional conduct toward a resident.
Record review of the Face Sheet revealed the facility admitted Resident #2 on 5/1/23 and he had diagnoses including Fracture of Left Arm and Hemiplegia following Cerebral Infarction.
Record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/8/23 revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated his cognition was moderately impaired.
Mar 2023
5 deficiencies
5 IJ (4 facility-wide)
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, staff interview, and policy and procedure review the facility failed to report to the proper authorities...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy and procedure review the facility failed to report to the proper authorities the neglect of Resident (Res) #1 who was admitted to the hospital on [DATE] from the facility with a bowel impaction that ultimately caused Res #1 to die in the hospital on [DATE] for one (1) of five (5) sampled residents. Resident #1
The facility's failure to report negligence to render the care and services necessary to prevent constipation which resulted in the ultimate death of Resident #1 placed all residents in a situation that caused or was likely to cause serious harm, serious injury, serious impairment or death.
The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on [DATE] when the facility failed to report the neglect that resulted in Res #1 being admitted to the local hospital on [DATE] with vomiting and stomach pain and died on [DATE] as a result of aspiration from vomiting due to a bowel impaction.
On [DATE] at 5:30 PM the SA notified the facility Administrator, and the Director of Nursing of the IJ and SQC and provided the facility with the IJ template for F609. The facility submitted an acceptable Removal Plan on [DATE], in which the facility alleged that the immediacy of the Jeopardy was removed on [DATE] 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 483.12 (a)(1) Reporting (F609) was lowered from an J to a D while the facility developed a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements.
Findings include:
Record review of the facility's policy and procedure titled Reporting Alleged Violations with a revision date of [DATE] revealed, Policy: The purpose of this policy is to ensure that all alleged violations involving . neglect .are reported immediately to the administrator of the facility and to other state officials in accordance with State Law through established procedures (including to the State survey and certification agency) .Compliance Guidelines: 2. If the alleged violation involves abuse or results in serious bodily injury it must be reported immediately but no later than 2 hours after the allegation is made . Neglect: Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness .
Record review of the facility policy and procedure titled Abuse Neglect and Exploitation/Misappropriation Policy with a revision date of [DATE] revealed It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress
Record review the facility policy titled Recognizing Signs and Symptoms of Abuse, Neglect, Exploitation/Misappropriation with a revision date of [DATE] revealed . Signs of Physical Neglect: Improper use/ administration of medication; Inadequate provision of care
Interview on [DATE] at 12:00 PM, with the Director of Nursing (DON) and the facility Administrator (ADM) revealed the DON stated that she had not reported any incidents of Neglect/Abuse to the State Agencies (SA). The DON stated that the ADM was responsible for all Reporting to (SA). The ADM stated that Res #1 had been sent out to the hospital and later passed away. The ADM stated that she had not reported any Neglect/Abuse to the State Agency (SA) in the past three months (Jan-[DATE]).
Interview on [DATE] at 3:30 PM with the DON (RN#1) revealed that the facility did not have documentation to ensure that the Activities of Daily Living (ADL) care and Bowel Movement (BM's) had been implemented according to the facility's policies and procedures. The CNA's did not document the Bowel Movements (BM's) on the ADL sheets for the residents on each shift. The nurses did not supervise the CNA's documentation of BM's for Res #1. The facility staff did not provide the care and services for Res #1 to prevent a bowel impaction. DON stated the documented information needed for bowel movements on (Res #1) was not in the medical records. The DON confirmed that she had not reported the neglect of Res #1 to any SA.
Interview with the DON (RN#1) on [DATE] at 9:00 AM, The DON stated that the facility ADM was responsible for reporting to the State Agencies (SA). DON stated that she did not report to the State Agencies (SA). DON stated that the CNA's and licensed nurses had neglected to document and monitor the input and out put of Res #1 which led to her hospital transfer and ultimately led to Res #1's death from an impaction. DON stated that she had read the hospital report for Res #1's admission and the ER had documented that Res #1's cause of death was aspiration due to vomiting as a result of a bowel impaction.
Record review of Res #1's medical records from [DATE] - [DATE] confirmed that the facility had not provided the treatments and services to Res #1 to prevent constipation and/or a bowel impaction.
Record review of the facility's ADL care sheets for January -[DATE] were reviewed for Res #1 and was lacking documentation for Res #1's BM's and intake and output on each eight (8) hour shift. The ADL care sheet for [DATE] revealed the CNA's had documented that Res #1 had three (3) BM's during the dates of [DATE]-[DATE]. From [DATE]-[DATE], Res #1 had no (zero) BM's documented on the ADL care sheets which confirms that Resident #1 went eight (8) days without having a BM. There was no documentation in the medical record of Res #1 to indicate that the CNA's had notified the licensed nurses that Res #1 had no BM's for eight (8) days. The record review revealed that the Progress Notes for [DATE] did not contain any documentation that spoke to Res #1's lack of BM's or that the licensed nurses had monitored the BM's of Res #1 or that Res #1 had received treatment and services for the lack of BM's during the month of [DATE]. The ADL care sheet dated February 1, 2023-February 15, 2023 documented/recorded that Res #1 had no BM's from February 7, 2023-February 15, 2023. The ADL care sheet for Res #1 dated February 16, 2023-February 28, 2023 documented/recorded that Res #1 had two (2) BM's during this time period. The facility documentation that was provided for Res #1's BM's for [DATE]-[DATE] indicated that Res #1 had two (2) BM's recorded during a 13 day period. The Medication Administration Record (MAR) did not document that Res #1 received bowel functioning treatment and services for the month of February 2023.
Record review of the NP progress note date [DATE] at 2:39 PM revealed: Acute Visit [DATE] Chef Complaint: Nausea, vomiting coffee-ground emesis, and abdominal distention. The patient also has associated abdominal distention with some tenderness to palpation worse on left upper and lower quadrants. Patient symptoms started today this morning nothing making it better or worse. We will send patient to (name of hospital) for further evaluation and treatment.
Record review of the medical records from the hospital dated [DATE]-[DATE] for Res #1 revealed: Patient was admitted with consult to gastroenterology and general surgery. Patient was made NPO (Nothing by mouth) and evaluated by general surgery. Was not felt necessary to place NG tube but instead was given some measures in an attempt to relieve fecal impaction. She did have a small bowel movement. Patient found to have urinary tract infection and started on antibiotics. Discussion with family led to revelation patient wishes to be DO NOT RESUSCITATE/DO NOT INTUBATE. Unfortunately, shortly thereafter patient vomited as witnessed by nursing staff and as a result of aspiration had respiratory arrest and died. Cause of death Aspiration due to vomiting due to small bowel obstruction. Time of death 1200 on 3 [DATE].
Interview on [DATE] at 12:00 PM, the ADM confirmed that she had not reported the incident of Res #1's impaction because she was unaware that the facility had failed to monitor and document. ADM stated that she was unaware that the lack of documentation of bowel movements was neglect. The ADM stated that she never told any staff not to report the incident because she did not know neglect was an issue for Res #1.
Interview on [DATE] at 2:15 PM, with the DON stated that they knew on [DATE] when Res #1 died, that there was a problem with the monitoring of the BM's and that was why she had asked the QA nurses to do an investigation. She stated that the written QA report was given to her and to the ADM by the QA nurses.
Interview on [DATE] at 3:00 PM, with the QA nurses RN#2 and LPN#1 revealed that they were asked by the DON to conduct an investigation of the incident involving Res #1 and they gave a written report to the DON and she gave it to the ADM. The QA nurses both confirmed that they did not report the findings of their investigation to the (SA).
Interview at 9:30 AM on [DATE], the ADM confirmed that on [DATE] at 5:00 AM she called the incident of alleged neglect in to the required State Agencies (SA).
Summary:
Record review of the ADL sheets for (5) of (5) sampled residents Res #1, Res #2, Res #3, and Res #4, revealed that the BM's had not been appropriately documented/recorded on the ADL sheets by the CNA's and there was no MAR documentation of the BM's as per the facility policies and procedures. The nursing progress notes had not been documented for Resident #1 for the month of February 2023; and five (5) of five (5) residents nursing progress notes contained no information of BM functioning as outlined in the facility's policies and procedures for documenting BM functioning. The medical record of Res #1 contained no monitoring of her BM's by the licensed nursing staff. As a result of neglecting to accurately and appropriately document/measure the BM's of the residents led to Res #1 having un-treated serious constipation which led to a bowel impaction and hospital admission on [DATE] and ultimately led to the death of Res #1 at the hospital on [DATE]. The DON and the QA nurses (RN#3 and LPN#2) confirmed through interviews that Res #1 had not been properly monitored for BM's for [DATE]-February 2023 and that on [DATE] Res #1 suffered a bowel obstruction and was sent out to the hospital. Confirmed through record reviews and through interviews that Res #1's BM's were not appropriately monitored for BM's by the CNA's, and the licensed nurses had neglected to monitor Res #1's BM's which ultimately resulted in Res #1's death at the hospital on [DATE]. The facility had not reported the incident of neglect to the required SA's. The facility ADM reported the incident of neglect to the SA's on [DATE] at 5:00 AM as per the facility IJ Removal Plan.
The facility provided an acceptable Removal Plan on [DATE]. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ:
Removal Plan:
On [DATE], Resident #1 began vomiting coffee ground emesis and was transferred to the hospital and expired at the hospital on [DATE]. The facility determined that Certified Nursing Assistants (CNA's) were documenting bowel movements inaccurately on the paper records. No one was assigned to check the CNA documentation. The facility's failure likely placed residents who reside in the facility at risk for serious adverse outcomes. The administration must take immediate action to monitor staff actions to prevent likelihood of serious harm, impairment or death.
The State Survey Agency (SA) called Immediate Jeopardy (IJ) and provided the facility with IJ templates on [DATE] for neglect, failure to maintain accurate documentation, failure to implement care plans, and failure to provide residents with necessary treatments. The SA provided an IJ template on [DATE] for failure to administer the facility effectively.
All 88 residents were assessed for being at risk of no bowel movement. The Bowel Program policy to include the standing orders was initiated for residents identified at risk by Registered Nurse (RN#1), RN#2, RN#3, RN#4, and RN#5 on [DATE].
Certified Nursing Assistants (CNA's) that have worked were in-serviced on the Bowel Care Task documentation via the kiosk, to include whether they are continent, incontinent or colostomy as well as bowel characteristics of size and consistency with a prompt to notify nurse if stool is hard or watery. This in-service was conducted by Quality Assurance (QA) RN#2. This in-service began on [DATE]. Medication nurses that worked were in-serviced by Director of Nursing, RN#1, QA nurse RN#2 and Licensed Practical Nurse (LPN#1), in reference to checking the completion of documentation by the CNA's per shift. This in-service began on [DATE]. No staff will be allowed to work until the in-service training has been completed.
CNA's have documented bowel movements via the kiosk on [DATE]. 45 minutes prior to the end of each shift the medication nurse on each hall checked CNA documentation for completion, beginning [DATE]. Medication nurses who have residents at risk initiated standing orders for no bowel movement protocol. The standing orders are as follows: If a resident goes 3 days with no bowel movement (BM) initiate the standing orders. Obtain vital signs, check abdomen for distention/pain. Auscultate bowel sounds. Administer Dulcolax suppository x 1 dose. Reassess resident. If no BM in 24 hours give fleet enema x 1 dose. Reassess resident. If no BM 30 minutes after enema, notify Medical Doctor (MD)/Nurse Practitioner (NP).
All staff that worked were in-serviced on the duty to report signs and symptoms of abuse and neglect immediately to their supervisor, who will report to the DON and Administrator. They were also in-serviced that it is the duty of anyone to report suspected abuse or neglect. This in-service was conducted by RN#1, RN#2 and LPN#1. This in-service began on [DATE] and no staff will be allowed to work until the in-service training has been completed. On Friday [DATE] and Monday [DATE] the Attorney General Office came to the facility and in-serviced all Administrative staff including the Administrator, DON, and facility staff on Abuse and Neglect.
CNA's and License Practical Nurse's (LPN) and RN's that worked were in-serviced on the importance of reviewing and following resident care plans to prevent potentially serious outcomes. This in-service training was conducted by RN#1, RN#2, and LPN#1. This in-service was complete on 03//29/2023 for staff that worked and no staff will be allowed to work until the in-service training has been completed. All care plans related to residents at risk for constipation were reviewed by Minimum Data Set (MDS) assessment nurses on [DATE]. The standing orders were initiated for all residents identified at risk. All care plans have bowel interventions in place.
An emergency QA meeting was held on [DATE]. In attendance were the Administrator, DON/Infection Preventionist (IP), Assistant Director of Nursing, QA RN#2 and QA LPN#1, MDS RN#3 and MDS LPN#2, the Social Service Director and the Nurse Practitioner. Changes in CNA charting from paper to kiosk was discussed. Staff in-service on constipation and standing orders were discussed and initiated by RN#2. It was decide to hire staff Development nurse.
An Emergency QA meeting was held on [DATE]. In attendance was the Medical Director, Administrator, DON/IP, QA RN#2, QA LPN#1, MDS LPN #2 and Accounts Manager. Immediate Jeopardy deficiencies and immediate Action Plan was discussed.
We allege the immediacy of the jeopardy was removed on [DATE] and the IJ was removed on [DATE].
VALIDATION:
On [DATE], the SA validated the facility had implemented the following measures to remove the Immediate Jeopardy (IJ). The Removal Plan was verified by staff interviews and record reviews of in-services and sign-in sheets.
On [DATE] the SA confirmed through interviews with DON (RN#1), interviews with the x2 QA nurses (RN#2 and LPN#1), interview with the ADON (RN#3), interview with the Wound Care Nurse (RN#4), and interview with MDS/Care Plan nurse (RN#5), and validated that the five (5) Registered Nurses assessed all 88 residents at risk of no bowel movements (BM's) and they initiated the Bowel Program policy and procedure for those residents that were identified.
The SA validated through interviews and record review of the in-service sign in sheets that eight (8) CNA's working in the building on all three (3) shifts on [DATE] had attended in-service training beginning on [DATE] in reference of documentation of BM's in the kiosk. Interviews with six (6) RN's and five (5) LPN's confirmed that they had been in-serviced to supervise the CNA's documentation and to check the kiosk documentation after the CNA's had documented.
On [DATE] the SA confirmed through interviews that the CNA's (CNA#1, #2, #3, #4, #5, #6, #7, and CNA#8) that they had begun digital documentation of the residents ADL's and BM's in the kiosk on [DATE]. Validated through interviews with five (5) LPN's and one (6) RN's that they were instituting the no bowel movement protocol. All interviewed licensed nurses confirmed that they would contact the NP or the MD if the no bowel movement protocol did not produce BM results.
The SA confirmed through interviews and record reviews with six (6) Registered Nurses (RN's), eight (8) CNA's, five (5) LPN's, and the facility Administrator that all facility staff had been in-serviced on Abuse and Neglect and all staff knew that any signs and symptoms of abuse would be reported immediately to their supervisors and to the DON and ADM. The ADM and the DON both confirmed and produced the sign in sheets for review for the Abuse and Neglect in-service that was conducted on Friday [DATE] and on Monday [DATE] presented by the AGO.
Confirmed through record review of in-services and through interview with RN#1, RN#2 and LPN#1 that they conducted in-service training of all staff that had worked on the importance of reviewing and following the care plans of all residents in order to prevent serious negative outcomes. Confirmed through interview with the two (2) MDS/Care Plan nurses (RN#5 and LPN#2) that all 88 resident care plans have bowel interventions in place.
The QA Nurse (RN#2) and (LPN#1) confirmed through interview that the facility conducted an Emergency QA committee meeting on [DATE] to discuss the bowel program and the documentation of BM's and that there would be changes in the documentation by the CNA's to the new kiosk system rather than the paper documentation. The x 2 QA nurses confirmed through interview that a new Staff Development nurse had been hired and she had begun on [DATE] with in-servicing of facility staff. The ADM confirmed through interview that the QA meeting on [DATE] had all members in attendance except the MD and the ADM confirmed that the DON is the certified (IP).
The SA validated through interviews with the ADM that the facility QA committee had held a second QA committee meeting on [DATE] to discuss the deficiencies from the IJ and to discuss the Action Plan for removing the immediacy of the IJ. The ADM confirmed through interview that the QA meeting on [DATE] had all required members present including the MD and the IP.
Staff interviewed on [DATE] for Validations of the facility's Removal Plan were: eight (8) CNA's; six (6) RN's; five (5) LPN's; one (1) Activities Director; one (1) facility ADM; and one (1) DON.
CRITICAL
(L)
📢 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 most or all residents
⚠️ Facility-wide issue
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, staff interviews, resident interviews, Resident Representative (RR) interview, job description reviews,...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, staff interviews, resident interviews, Resident Representative (RR) interview, job description reviews, and policy and procedure reviews, the facility failed to prevent neglect of a resident (Res) #1 from occurring by neglecting to document/record the treatment and services accessible to five (5) of five sampled residents reviewed for bowel functioning programs. Res. #1, #2, #3, #4 and #5. This failure had the potential to affect all residents in the facility.
Resident #1 was admitted to the hospital with vomiting and stomach pain on [DATE] and later died from aspiration due to vomiting as a result of a bowel impaction on [DATE]. Resident #1 had no documented bowel movements (BM's) for 11 days prior to the hospital admission on [DATE]. Res #1 had no bowel programs/interventions documented on the Medication Administration Records (MAR) for January and February 2023, and Res #1 had no bowel programs/interventions nor any care and services rendered to Res #1 documented in the nursing notes for the month of February 2023.
The facility's failure to prevent Res #1's constipation resulted in neglect of Res #1. The facility's failure to render the care and services necessary to prevent constipation resulted in the ultimate death of Resident #1. The facility's failure to provide the care and services necessary to prevent constipation put all residents in the facility at risk for serious injury, harm, impairment and possible death.
The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on [DATE] when Res #1 began vomiting and complaining of stomach pain. Res #1 was admitted to the local hospital on [DATE] with vomiting and stomach pain and died on [DATE] as a result of aspiration from vomiting due to a bowel impaction.
On [DATE] at 5:30 PM, the SA notified the facility Administrator (ADM) and the Director of Nursing (DON) of the IJ and SQC and provided the facility with the IJ template.
The facility submitted an acceptable Removal Plan on [DATE], in which the facility alleged that the immediacy of the Jeopardy was removed on [DATE] 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 483.12 (a) (1) Freedom from Abuse and Neglect (F600) was lowered from an L to an F, while the facility developed a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements.
Findings include:
Record review of the facility policy and procedure titled Abuse Neglect and Exploitation/Misappropriation Policy with a revision date of [DATE] revealed It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress
Record review the facility policy titled Recognizing Signs and Symptoms of Abuse, Neglect, Exploitation/Misappropriation with a revision date of [DATE] revealed . Signs of Physical Neglect: Improper use/ administration of medication; Inadequate provision of care
Record review of the facility policy and procedure titled: Bowel Program Policy dated [DATE] revealed, Purpose: Monitoring of bowel movements are important to the general health and well being of the resident. Policy: A daily BM record will be monitored by the Charge Nurse on a daily basis. Should there be no BM of three consecutive days a Bowel Program will be initiated based on our Physicians standing orders. 1. Check abdomen for distention/pain. Auscultate bowel sounds. 2. Dulcolax suppository x (times) 1 dose. 3. If no BM in 24 hours give fleets enema x 1 dose. 4. If no BM after enema, notify MD/NP (Medical Doctor/Nurse Practitioner).
Record review of the Certified Nursing Assistant Job Description, undated, revealed Objective: Assists nursing personnel in provision of basic care for residents and necessary unit tasks and functions in compliance with (Formal name of facility) policies and procedures, applicable health care standards and (Formal name of State Agency). Organization: The Certified Nurses Aide functions as a member of the health care team under the direction of the RN (Registered Nurse) or LPN (Licensed Practical Nurse) and reports to the Director of Nursing or ADON (Assistant Director of Nurses) in conformity with (Formal name of facility) and regulatory policy . Responsibilities: Assists patients in the following areas: .c. Toileting (bedpan, urinal, commode and/or toilet) . 2. Assists with feeding of residents. 3. Measuring and recording intake and output. 10. Accurate documentation of all ADL's (Activities of Daily Living) by the end of each shift. Real time charting is required .17. Immediately report any changes in resident's condition or incidents to the Nursing Supervisor .
Interviews on [DATE] at 12:00 PM, with the DON and the facility ADM, the DON stated that the Activities of Daily Living (ADL) care sheets were kept in a binder at the nursing stations and that they were accessible to all staff. The Certified Nursing Assistants ( CNAs) documented the ADL's for each resident at the end of each eight (8) hour shift. The Care Tracker Documentation Record ADL sheets were devised per the individual care plan of each resident. The ADL sheets were the venue in which the care plans are followed and instituted for each resident. The DON confirmed that there were two (2) care plan nurses working in the facility on [DATE]. The DON stated that if something was not completed or a resident had issues the CNA's report that to the Licensed Practical Nurses (LPN) medication cart nurses or to the Registered Nurse (RN) or Charge Nurse for the 7-3 and 3-11 shifts. The DON revealed that for over a year the CNA's charted manually on paper charts and on [DATE] the facility installed computers (Kiosk) systems that now the CNA's digitally chart on each resident at the end of each 8 hour shift. If a resident does not have a bowel movement (BM) during that shift the CNA's report that to the Charge Nurse or to the medication cart nurses. BM's can only be reported once per shift in the digital system. On the manual (paper) system the CNA's can record/documented the number of BM's during the shift, that the resident had. The ADM stated that one (1) Resident #1 (Res #1) had been sent out to the hospital and later passed away. But (Res #1) did not have an infection and did not have a known bowel issue, I was informed by the nurses that she (Res #1) was not dependent upon staff for toileting.
Interview on [DATE] at 3:30 PM, with the DON revealed that the facility did not have documentation to ensure that the Activities of Daily Living (ADL) care and Bowel Movement (BM's) had been implemented according to the residents care plans. The DON stated, We are not going to be able to provide for you what you are looking for. The CNA's did not document the Bowel Movements (BM's) on the ADL sheets for the residents on each shift. The CNA's have been documenting manually on ADL sheets for approximately one (1) year due to no computer/kiosk' system available to CNA's. They had been told to manually document the BM's on the ADL sheets and if there had been no BM for that 8 hour shift they were instructed to tell the med cart nurse and the med cart nurse was to check the resident and decide the appropriate method for the resident's BM per the Bowel policy and procedure. The nurses were to document in the progress notes what they did and the results of the method for BM's. The DON stated that the nurses had not appropriately documented the BM's in the residents medical records. She stated that the ADL sheets had all been reviewed and an investigation completed by the two Quality Assurance (QA) nurses and there was no documentation of BM's on the ADL sheets and no documentation that the nurses had been notified of no BM's for the residents. The DON stated that they had no nursing notes and no documentation for Res #1 that she had BM's prior to her admission to the hospital on [DATE]. The DON thought that the med cart nurses were supervising the CNA's more closely, but they had not. The DON stated that the Bowel policy and procedure had not been followed and the ADL sheets had not been documented appropriately for each resident and the licensed nurses had not documented in the progress notes appropriately or often enough for each resident . She stated the documented information needed for bowel movements on (Res #1) was not in the medical records.
Resident #1:
Interview with the DON on [DATE] at 9:00 AM, revealed that Res #1 had been admitted to the hospital from the facility on [DATE] due to vomiting coffee ground looking substances (emesis) and for stomach pain. The DON stated that Res #1 was diagnosed at the hospital on [DATE] with an impaction and on [DATE] Res #1 died of aspiration due to vomiting because of the bowel obstruction/bowel impaction. The DON stated that the facility had no documentation that Res #1 's BM's were appropriately monitored as per the facility policy and procedure and the nursing staff had not documented on the Medication Administration Record (MAR) or in the nursing notes that the BM's had been monitored. The facility had not followed the policy and procedure for bowel movement programs. DON stated that she felt responsible because she had assumed that the med cart nurses had been monitoring and supervising the CNA's. She should not have assumed she should have followed up and she should have supervised the nursing staff more closely. DON stated that the Quality Assurance (QA) nurses had conducted an investigation of the incident with Res #1 and they had found that there was no documentation of BM monitoring for Res #1. DON stated that the CNA's and licensed nurses had neglected to document and monitor the input and out put of Res #1 which led to her hospital transfer and ultimately led to her death from an impaction.
Record review of the facility's Care Tracker Documentation Record ADL care sheets for January-[DATE] were reviewed for Res #1 and they were not appropriately documented for Res #1's BM's on each eight (8) hour shift. The input and out put of Res #1 was not appropriately documented on each eight (8) hour shift by the CNA's, in accordance to the facility policies and procedures. The CNA's had documented that Res #1 had three (3) BM's during the dates of [DATE]-[DATE]. The record review revealed that Res #1 had one (1) BM during the 3:00 PM-11:00 PM shift on [DATE]; on [DATE] there was one (1) BM documented on the 7:00 AM-3:00 PM shift; and on [DATE] the CNA's documented one (1) BM during the 7:00 AM -3:00 PM shift. From [DATE]-[DATE], Res #1 had no (zero) BM's documented on the ADL care sheets which confirms that Resident #1 went eight (8) days without having a BM. There was no documentation in the medical record of Res #1 to indicate that the CNA's had notified the licensed nurses that Res #1 had no BM's for eight (8) days. The record review revealed that the Progress Notes for [DATE] did not contain any documentation that spoke to Res #1's lack of BM's or that the licensed nurses had monitored the BM's of Res #1 or that Res #1 had received treatment and services for the lack of BM's during the month of [DATE]. There were no progress notes documented/recorded for Res #3 during the month of February 2023. The ADL care sheet dated February 1, 2023-February 15, 2023 had documentation that Res #1 had no BM's from February 7, 2023-February 15, 2023. The ADL care sheet for Res #1 dated February 16, 2023-February 28, 2023 had documentation that Res #1 had two (2) BM's during this time period, 1 BM recorded during the 3:00 PM-11:00 PM shift on [DATE], and1 BM on [DATE] during the 7:00 AM-3:00 PM shift. Res #1 had no BM's recorded on the ADL care sheets from [DATE]-[DATE]. The facility documentation that was provided for Res #1's BM's for [DATE]-[DATE] indicated that Res #1 had two (2) BM's recorded during a 13 day period. There was no progress notes in the medical record for Res #1 during the month of February 2023.
Record review of the Medication Administration Record (MAR) for the month of February 2023 revealed that Res #1 received no bowel functioning treatment and services.
The record review of the Nurse Practitioner's (NP) Progress Note date [DATE] at 2:39 PM revealed: Acute Visit [DATE] Chef Complaint: Nausea, vomiting coffee-ground emesis, and abdominal distention. The patient also has associated abdominal distention with some tenderness to palpation worse on left upper and lower quadrants. Patient symptoms started today this morning nothing making it better or worse. We will send patient to (name of hospital) for further evaluation and treatment.
Record review of the medical records from the hospital dated [DATE]-[DATE] for Res #1 revealed: Patient was admitted with consult to gastroenterology and general surgery. Abdominal Computerized Tomography (CT) scan findings were consistent with small bowel obstruction, fecal impaction and stercoral colitis without bowel perforation. Large amounts of stool throughout the rectum. History and Physical Reports revealed positive left-sided abdominal tenderness. The patient was made NPO (nothing by mouth) and evaluated by general surgery. Was not felt necessary to place NG tube but instead was given some measures in an attempt to relieve fecal impaction. Discussion with family led to revelation patient wishes to be DO NOT RESUSCITATE/DO NOT INTUBATE. Unfortunately, shortly thereafter patient vomited as witnessed by nursing staff and as a result of aspiration had respiratory arrest and died. Cause of death Aspiration due to vomiting due to small bowel obstruction. Time of death 1200 on 3 [DATE].
Interview on [DATE] at 12:00 PM, with the facility ADM revealed that she never knew that the facility had not monitored the BM's of Res #1 and never was told of the bowel impaction of Res #1. ADM stated that she was unaware that the lack of documentation of bowel movements was neglect.
Interview on [DATE] at 2:15 PM, with the DON she stated that they knew on [DATE] when Res #1 died, that there was a problem with the monitoring of the BM's and that was why she had asked the Quality Assurance (QA) nurses to do an investigation. She stated that the written QA report was given to her and to the ADM by the QA nurses.
Interview on [DATE] at 2:50 PM, with the Assistant Director of Nursing (ADON) stated that no one had ever asked her to monitor the ADL sheets or the charting of nursing staff. She stated that she had been working the unit on [DATE] when the NP had called for her to assess Res #1, who was vomiting. ADON went to Res #1 and found her with coffee ground vomit on her clothing and on the floor. The ADON stated that Res #1 was complaining of stomach pain and her stomach was distended. She called 911 and stayed with Res #1 until the ambulance came to pick up Res #1. The ADON stated that she reported to the NP that Res #1 appeared to possibly have a GI bleed from the looks of the coffee ground vomit. ADON stated that she learned the next day that Res #1 had passed away at the hospital on [DATE] and that the hospital had reported that her death was due to an impaction/bowel obstruction. ADON stated that the nurses should document in the progress notes each shift on the residents and should document in the progress notes when they give certain medications such as PRN's (as needed medications). She stated that there were no documented nursing progress notes for the month of February 2023. ADON stated that no one had asked her to monitor charts. ADON stated that she had assumed that the DON was monitoring the ADL sheets and the nursing progress notes.
Interview on [DATE] at 3:00 PM, with the two (2) QA nurses RN#2 and LPN#1 revealed that they were asked by the DON to conduct an investigation of the incident involving Res #1 and they gave a written report to the DON and she gave it to the ADM. Then they had an emergency QA meeting with all the committee members to discuss the findings. They discovered that the CNA's had not documented on the ADL sheets the BM's of the residents and the nursing staff had not documented what actions they took to monitor the ADL's. The QA nurses stated that the BM's of Res #1 had not been recorded on the ADL sheets per their policy and procedure and the nurses had not documented in the progress notes for Res #1 during the month of February 2023. Resident #1 was sent out to the hospital on [DATE] for vomiting and then Resident #1 died on [DATE].
Interview on [DATE] at 4:10 PM, with the Administrator (ADM) she stated that she had no idea that Res #1 was impacted. All I was told was that Res #1 was sent out to the hospital because she was vomiting. I was told later by QA nurses that Res #1 only had seven (7) days that the BM's weren't recorded/documented. No one ever told me that was a problem, I'm not a nurse. I trusted what the nurses said. ADM stated that she had not read the hospital report for Res #1.
At 8:20 AM on [DATE] interviews and record reviews were completed along with the former Administrator (ADM #2) and the current ADM. They confirmed that the ADL sheets for Res #1 were not completed for BM's for at least the last 11 days in February 2023 and that there was no documented nursing notes/progress notes for the entire month of February 2023 regarding Res #1. They confirmed that the MAR's had no documented laxatives or stool softeners recorded for January-[DATE] for Res #1. They both confirmed the facility policy and procedure for bowel programs had not been followed. (ADM#2) stated that she learned a long time ago that if it was not written down in the medical records it did not happen.
In an interview on [DATE] at 10:25 AM, with the ADON she confirmed that after the death of Res #1 on [DATE] that the facility had a QA committee meeting to discuss the lack of documentation for the BM's of Res #1 and the lack of nursing progress notes. The facility also discussed the need to return to using the kiosk so the monitoring would be easier to track. The facility reinstated the CNA's kiosk system on [DATE]. The ADON stated that she would be responsible for monitoring the ADL's through the week days and would do chart audits on the day shift 8:00AM-3:00PM Mon-Fri. and the weekend Charge Nurse would monitor the ADL sheets on the weekends. ADON stated that the facility was hiring a new Staff Development nurse and she would also monitor charts.
Interview on [DATE] at 1:00 PM, with the Resident Representative (RR) of Resident #1 revealed that she had been at the facility visiting Res #1 on [DATE] or [DATE] when Res #1 told her that her stomach was hurting and that she was in pain. RR stated that (Res #1) had dementia and had some cognitive difficulties but that she would talk and did at times complain of generalized pain, but on this day she was specific with where the pain was located in her stomach. RR stated that Res #1 told her that she had told the nurse and the RR stated that she did not know who the nurse was but the nurse was told by Res #1 that her stomach hurt. I am positive that Res #1 reported not feeling well to the nurse, but I do not know who. RR did not witness the nurse evaluating Res #1. RR stated that the next day early in the morning at approximately 9:00 AM she was contacted by the facility that Res #1 was going to be transferred to the emergency room (ER) due to vomiting and stomach pain. RR met Res #1 at the hospital and stayed with her there. The hospital physician told RR that Res #1 had been vomiting due to a possible GI bleed and that they would run a test to see where the blood was coming from because she had vomit that looked like possible old blood was present somewhere. The hospital did the test and found that there was no GI bleed that Res #1 had a bowel impaction and that was why she was vomiting. The next day on [DATE] Res #1 passed away. RR stated that she had no Death Certificate as of yet but the hospital staff told her that the cause of death was due to an impaction. RR stated that she could not figure out how that could happen. RR stated that Res #1 was incontinent of bowel and bladder but at times she would ask to be assisted to the bathroom. RR stated that she had not obtained copies of the hospital records. RR stated that Res #1 had not received laxatives very much because she never knew of her having constipation issues.
Interview on [DATE] at 2:00 PM, with LPN#3 med cart nurse, revealed that she was the nurse for Res #1 everyday that Res #1 was living in the facility. LPN#3 confirmed that she worked days 7:00 AM-7:00 PM and she was never told that Res #1 was not having BM's. The CNA's did not report any negative findings to her for Res #1. LPN#3 also stated that she did not chart in Res #1's nursing notes because she was not aware of any findings that required documentation in the progress notes for Res #1. LPN#3 stated that Res #1 was incontinent of bowel and bladder and that she (LPN#3) was told that Res #1 took herself to the toilet and was independent with toileting. LPN#3 stated that she would have given Res #1 a stool softener and followed the physician's orders had she been told by the CNA's that Res #1 had not had a BM within three (3) days. LPN#3 stated that it was the facility policy that if a resident had not had a BM in three (3) days then the CNA would report it to the med cart nurse. The CNA never reported to me that Res #1 had not had a BM. I was shocked to hear about what happened to Res #1. LPN#3 confirmed that she had never been told to monitor the CNA's ADL sheets. She confirmed that she now knows to monitor the ADL's and bowel movements (BM's) that the CNA's document in the kiosk. LPN#3 stated that the kiosk had been up and running since the middle of March. LPN#3 stated that she had been in-serviced on Abuse/Neglect many times and that she understood that neglect meant not providing services to residents. LPN#3 stated that she believed that Res #1 did not receive the treatments and services that she deserved.
Interview on [DATE] at 2:00 PM, with the DON (RN#1) revealed that she had learned in the Attorney General's (AG's) in-service that neglect was defined as when services are not provided to residents that may cause disfavorable out comes. The DON stated that Res #1's death met the definition of neglect.
Resident #2:
Observation of Res #2 on [DATE] at 12:30 PM, revealed that Res #2 was sitting in a wheelchair outside of her room. Res #2 was not interviewable.
Record review of Res #2's Care Tracker Documentation Record ADL sheet dated [DATE] revealed Res #2 had no BM's recorded for five (5) consecutive days for [DATE]-[DATE]. Res #2 had five (5) BM's recorded/documented on the ADL sheets for February 1, 2023-February 15, 2023. Res #2 had no BM's documented on the ADL sheets for three (3) consecutive days from [DATE]-[DATE]; and Res #2 had no BM's recorded on the ADL sheets for five (5) consecutive days of [DATE]-[DATE]. Res #2 had no progress notes documented in the medical record for the month of February 2023. Res #2 had one (1) progress note recorded for [DATE] and one (1) progress note recorded for [DATE]. No progress notes were recorded/documented for Res #2 pertaining to her ADL care and services for [DATE]-[DATE].
Interview on [DATE] at 12:35 PM, with CNA#1 stated that she was the CNA for Res #2 on [DATE]. CNA#1 stated that she would record the bowel movements of the residents she worked with on each of her eight (8) hour shifts. At the end of the eight (8) hour shift if the resident had not had a BM in eight (8) hours the CNA's were to report that to the med cart nurse.
Record review of Res #2 revealed a Face Sheet with an admission date of [DATE] and diagnosis of Hemiplgia following cerebral infraction affecting right dominant side, among other diagnoses.
Record review revealed a MDS dated [DATE] that contained a BIMS score of 3 which indicated that Res #2 was severely cognitively impaired.
Resident #3:
Observation on [DATE] at 12:20 PM revealed that Res #3, was lying in her bed. Res #3 was not interviewable.
Record review of the Care Tracker Documentation Record ADL sheets for January and February 2023 for Res #3 were not documented by the CNA's for every eight (8) hour shift seven (7) days per week as outlined in the CNA's Job Description.
Record review of Res #3 revealed that she had a Minimum Data Set (MDS) dated [DATE] that contained a Brief Interview of Mental Status (BIMS) score of 0 (Blank) which indicated that Res #3 was severely cognitively impaired.
Record review of Res #3's Face Sheet revealed an admission date of [DATE] and diagnoses including Constipation, Heart Failure; and Hemiplegia following cerebral infract affecting right dominant side.
Res #3 had no nursing progress notes written/recorded during the month of February 2023 addressing the constipation risk. There was one nursing progress note documented for the month of February dated [DATE] which did not address Res #3's ADL's or bowel program. Res #3 had one (1) documented progress note dated [DATE] written by the social worker. No progress notes were documented for [DATE] by nursing staff.
Interview on [DATE] at 1:00 PM with CNA #2 stated that she was assigned to work with Res #3 on [DATE] on the first (1st) shift. CNA#2 stated that she documented on the ADL sheets prior to [DATE] the BM's for residents on every shift. She stated that currently when she completed a shift she documented in the kiosk at the end of each eight (8) hour shift the ADL's and the BM's. If a resident does not have a BM on the eight (8) hour shift it is reported to the med cart nurse. The med cart nurse was responsible for checking the resident after the CNA reported to them.
Resident #4:
Interview and observation on [DATE] at 1:10 PM, with Res #4, revealed that she was awake and alert and was a good historian. She stated that she had been living in the facility for a little over a year and was a retired Registered Nurse. I am able to do most things for myself , I just have bad knees and have a need to be assisted with my meds at times. I go to the bathroom by myself, I toilet my self, I bath my self and do most all things for myself. Res #4 stated that since she had been in the facility she had never been asked if she had had a bowel movement or what the consistency of her bowel movements were. Res #4 stated that she had never seen prune juice in the building and had never been offered a snack or juice of any type. No one had talked to her about her bowel movements. Res #4 stated that she thought that the reason why the staff had never asked her about her bowel movements was because she was cognitive and she was continent and had no bowel issues.
Record review of the Care Tracker Documentation Record ADL sheets revealed Res #4's bowel functioning was not addressed by the staff for [DATE] - [DATE].
Interview on [DATE] at 1:40 PM with CNA#3 revealed that they manually recorded the BM's on the ADL sheets for over a year because the kiosk were broken. She stated that if a resident did not have a BM during the 8 hour shift the CNA's reported it to the med nurse.
Record review of Res #4's Minimum Data Set (MDS) dated [DATE] contained a Brief Interview of Mental Status (BIMS) score of 14 which indicated that Res #4 was cognitively intact.
Record review of Res #4's Face Sheet revealed an admission date of [DATE] and diagnoses of Chronic Obstructive pulmonary disease; Gastro-escophageal reflux disease; among other diagnoses.
Record review revealed that Res #4 had one (1) progress note date [DATE] and one (1) progress note written on [DATE] neither of which addressed her ADL's or bowel functioning. Res #4 had no progress notes documented for [DATE].
Resident #5:
On [DATE] at 9:55 AM, during an interview and observation with Res #5 revealed she was lying in bed. She did answer questions asked of her. She stated that she wears briefs and has been incontinent of bowel and bladder. Res #5 stated that she has to have the assistance of staff for all her ADL's. Res #5 stated that the CNA's change her briefs for her on a regular basis. She stated that she had never been offered a stool softener or a laxative. She stated that a very few times she had been constipated and she had asked the nurse for Metamucil. Res #5 was unable to recall when the event occurred for the medication for constipation. Res #5 stated that she had more times that she had diarrhea or loose stools rather than constipation. She stated that she had never been offered Prune Juice and had never asked for Prune Juice. Res #5 stated that she had to have total assistance for all her ADL's.
Record review of the Face Sheet for Res #5 revealed a re-admission date of [DATE]. Res #5 had diagnoses of Acute heart disease of native coronary artery; Acute systolic (congestive) heart failure; among other diagnoses.
Record review of Res #5's MDS dated [DATE] contained a BIMS score of 14 which indicated that she was cognitively intact.
Record review of the Care Tracker Documentation Record [DATE] - [DATE] bowel function ADL sheet had Res #5 documented as having no bowel movements from [DATE]-[DATE] (3 consecutive days with no bowel movement) and from [DATE]-[DATE] (3 consecutive days with no bowel movement). There was no documentation in Res #5's medical record to indicate that the CNA's had notified the cart nurse of no BM's for Res #5.
Record review of the February 2023 Care Tracker Documentation Record bowel function section of the ADL sheet revealed documentation that Res #5 had no bowel movements (BM's) for February 1-3, 2023. Res #5 had no bowel movements recorded on the ADL sheet for the days of February 13, 2023-February 15, 2023 (three (3) consecutive days). There was no documentation in the medical records of Res #5 that the CNA's had notified the licensed nurses (med cart nurse) about the bowel function of Res #5. There was no documentation provided by the facility to confirm that the nurses (cart nurses) had been monitoring the BM's of Res #5 during the months of January-[DATE].
Summary:
Record review of the ADL sheets for (5) of (5) sampled residents revealed that the BM's had not been appropriately documented/recorded on the ADL sheets by the CNA's and there was no MAR documentation/recording of the BM's as per the facility policies and procedures. The nursing progress notes had not been documented for Resident #1 for the month of February 2023; and five (5) of five (5) residents nursing progress notes contained no information of ADL and/or BM functioning as outlined in the facility's policies and procedures for documenting BM functioning. The Care Plans for 5 of 5 Sampled Residents (Res #1; Res #2; Res #3; Res #4; and Res#5) had not been followed for bowel functioning /constipation risk, and ADL care. The medical record of Res #1 contained no monitoring of her BM's by the licensed nursing staff. As a result of neglecting to accurately and appropriately document/record the BM's of the residents led to[TRUNCATED]
CRITICAL
(L)
📢 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
Comprehensive Care Plan
(Tag F0656)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews and policy and procedure reviews the facility did develop and/or implement the bowel functio...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews and policy and procedure reviews the facility did develop and/or implement the bowel functioning Care Plans for five (5) of five (5) residents reviewed. Resident (Res) #1, Res #2, Res #3, Res #4, and Res #5 had no implemented bowel functioning programs maintained in the medical records. This failure had the potential to affect all residents in the facility.
The facility's failure to implement the bowel functioning/constipation care plan for Res #1 and to render the care and services necessary to prevent constipation resulted in her admission to the hospital on [DATE] and her death on [DATE] from aspiration from vomiting due to small bowel obstruction. The facility's failure develop and implement care plans to provide the care and services necessary to prevent constipation placed all residents in the facility at risk for serious injury, harm, impairment and possible death.
The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on [DATE] when Res #1 began vomiting and complaining of stomach pain. Res #1 was admitted to the local hospital on [DATE] with vomiting and stomach pain and died on [DATE] as a result of aspiration from vomiting due to a bowel impaction.
On [DATE] at 5:30 PM the SA notified the facility Administrator, and the Director of Nursing of the IJ and SQC and provided the facility with the IJ template for F656. The facility submitted an acceptable Removal Plan on [DATE], in which the facility alleged that the immediacy of the Jeopardy was removed on [DATE] 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 483.21 Develop/Implement Comprehensive Care Plans (F656) was lowered from an L to an F, while the facility developed a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements.
Findings include:
Record review of the facility policy and procedure titled: Comprehensive Care Plans undated revealed Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessments .
Record review of the facility policy and procedure titled: Bowel Program Policy dated [DATE] revealed, Purpose: Monitoring of bowel movements are important to the general health and well being of the resident. Policy: A daily BM record will be monitored by the Charge Nurse on a daily basis. Should there be no BM of three consecutive days a Bowel Program will be initiated based on our Physicians standing orders. 1. Check abdomen for distention/pain. Auscultate bowel sounds. 2. Dulcolax suppository x (times) 1 dose. 3. If no BM in 24 hours give fleets enema x 1 dose. 4. If no BM after enema, notify MD/NP (Medical Doctor/Nurse Practitioner).
Record review of the Certified Nursing Assistant Job Description, undated, revealed Objective: Assists nursing personnel in provision of basic care for residents and necessary unit tasks and functions in compliance with (Formal name of facility) policies and procedures, applicable health care standards and (Formal name of State Agency). Organization: The Certified Nurses Aide functions as a member of the health care team under the direction of the RN (Registered Nurse) or LPN (Licensed Practical Nurse) and reports to the Director of Nursing or ADON (Assistant Director of Nurses) in conformity with (Formal name of facility) and regulatory policy . Responsibilities: Assists patients in the following areas: .c. Toileting (bedpan, urinal, commode and/or toilet) . 2.Assists with feeding of residents. 3. Measuring and recording intake and output. 10. Accurate documentation of all ADL's (Activities of Daily Living) by the end of each shift. Real time charting is required .17. Immediately report any changes in resident's condition or incidents to the Nursing Supervisor .
Interviews on [DATE] at 12:00 PM, with the Director of Nursing (DON (RN#1) revealed that the Certified Nursing Assistants (CNAs') documented the Activities of Daily Living (ADL's) for each resident at the end of each eight (8) hour shift. The ADL sheets were devised per the individual care plan of each resident. The ADL sheets were the venue in which the care plans are followed and instituted for each resident. The DON stated that the Care Plans for the residents have not been followed and the nursing staff had not documented the bowel functions of each individual resident in accordance with the Care Plans. The DON confirmed that there were two (2) care plan nurses working in the facility on [DATE]. The DON stated that if a resident had bowel issues the CNAs' report that to the Licensed Practical Nurses (LPN) medication cart nurses or to the Registered Nurse (RN) or Charge Nurse. If a resident does not have a bowel movement (BM) during that shift the CNAs' report that to the Charge Nurse or to the medication cart nurses. The DON stated that the bowel functioning programs for the residents had been reviewed by the Care Plan nurses and the DON and they had not been followed or implemented.
Interview on [DATE] at 3:30 PM with the DON revealed the documented information needed for bowel movements on Res #1 was not in the medical records. The DON confirmed that the Care Plans for the residents had not been implemented.
Resident #1:
Record review of the Care Plan for Res #1 dated [DATE] revealed: Constipation I have constipation risk r/t (in reference to) advanced age, impaired mobility, meds does not take laxative/stool softener regularly Risk for constipation/diarrhea. Goal: Will have soft formed stool 2-3 x week (2-3 times per week) to next review [DATE] .Interventions: Administer meds as ordered Monitor & record frequency and amount of BM Note any problem with consistency or color of BM Encourage 100% fluid intake pm meal tray check bowel sounds prn (as needed) Administer PRN med a/o (as ordered) Monitor for effectiveness of prn offer Prune Juice prn Notify MD if needed.
Record review of the facility's ADL care sheets for January-[DATE] were reviewed for Res #1 and they were not appropriately documented for Res #1's BM's on each eight (8) hour shift. The input and out put of Res #1 was not appropriately documented on each eight (8) hour shift by the CNAs', in accordance to the facility policies and procedures. The CNAs' had documented that Res #1 had three (3) BM's during the dates of [DATE]-[DATE]. The record review revealed that Res #1 had one (1) BM during the 3:00 PM-11:00 PM shift on [DATE]; on [DATE] there was one (1) BM documented on the 7:00 AM-3:00 PM shift; and on [DATE] the CNAs' documented one (1) BM during the 7:00 AM -3:00 PM shift. From [DATE]-[DATE], Res #1 had no (zero) BM's documented on the ADL care sheets which confirms that Resident #1 went eight (8) days without having a BM. There was no documentation in the medical record of Res #1 to indicate that the CNAs' had notified the licensed nurses that Res #1 had no BM's for eight (8) days. The record review revealed that the Progress Notes for [DATE] did not contain any documentation that spoke to Res #1's lack of BM's or that the licensed nurses had monitored the BM's of Res #1 or that Res #1 had received treatment and services for the lack of BM's during the month of [DATE]. There were no progress notes documented/recorded for Res #3 during the month of February 2023. The ADL care sheet dated February 1, 2023-February 15, 2023 had documentation that Res #1 had no BM's from February 7, 2023-February 15, 2023. The ADL care sheet for Res #1 dated February 16, 2023-February 28, 2023 had documentation that Res #1 had two (2) BM's during this time period, 1 BM recorded during the 3:00 PM-11:00 PM shift on [DATE], and 1 BM on [DATE] during the 7:00 AM-3:00 PM shift. Res #1 had no BM's recorded on the ADL care sheets from [DATE]-[DATE]. The facility documentation that was provided for Res #1's BM's for [DATE]-[DATE] indicated that Res #1 had two (2) BM's recorded during a 13 day period. There was no progress notes in the medical record for Res #1 during the month of February 2023.
Interview with the DON on [DATE] at 9:00 AM, DON stated that the facility had no documentation that Res #1 's BM's were appropriately monitored as per the facility policy and procedure and the nursing staff had not documented on the Medication Administration Record (MAR) or in the nursing notes that the BM's had been monitored. The DON stated that the facility had not followed the care plan for Res #1 and the facility had not followed the policy and procedure for bowel movement programs. DON stated that the QA nurses had conducted an investigation of the incident with Res #1 and they had found that there was no documentation of BM monitoring for Res #1 as outlined in her care plan.
Interview on [DATE] at 2:15 PM with the DON, she stated that they knew on [DATE] when Res #1 died, that there was a problem with the monitoring of the BM's and that was why she had asked the Quality Assurance (QA) nurses to do an investigation. She stated that the written QA report was given to her and to the ADM by the QA nurses.
Interview on [DATE] at 2:50 PM with the Assistant Director of Nursing (ADON) stated that the Care Plan of Res #1 had not been implemented.
Interview on [DATE] at 3:00 PM with the two (2) QA nurses RN#2 and LPN#1 confirmed that the Care Plan of Res #1 had not been followed for Res #1's bowel program.
At 8:20 AM on [DATE], interviews and record reviews completed along with the former Administrator (ADM #2) and the current ADM both confirmed that the Care Plan had not been followed for ADL care and Constipation risk and the facility policy and procedure for bowel functioning programs had not been followed. ADM#2 stated that she learned a long time ago that if it was not written down in the medical records it did not happen.
Interview on [DATE] at 11:45 AM, with the two (2) care plan/MDS (Minimum Data Set) nurses RN #5 and LPN#2 both confirmed that the care plans for Res #1 had not been followed.
Resident #2:
Record review of Res #2's Care Plan dated [DATE] revealed there was no Care Plan submitted by the facility that outlined the bowel functioning of Res #2.
Record review of the Face Sheet revealed Resident #2 was admitted to the facility with an admission date of [DATE]. Diagnoses included Hemiplegia following cerebral infraction affecting right dominant side; Dysphagia; Speech and language deficits; Contracture of muscle, right hand; Dementia; Anxiety disorder; Anorexia.
Record review revealed a Minimum Data Set (MDS) dated [DATE] that contained a Brief Interview of Mental Status (BIMS) score of 3 which indicated that Res #2 was severely cognitively impaired.
Record review of Res #2's ADL sheet dated [DATE]-31, 2023 that had many days of missing documentation under the Bowel Function section [DATE] none of the three (3) eight (8) hour shifts had recorded any BM's for Res #2. There were 12 BM's recorded for Res #2 during the three (3) eight (8) hour shifts for the days of [DATE]-[DATE]. Res #2 had no BM's recorded for five (5) consecutive days for [DATE]-[DATE]. Res #2 had five (5) BM's recorded/documented on the ADL sheets for February 1, 2023-February 15, 2023. Res #2 had no BM's recorded/documented on the ADL sheets for three (3) consecutive days from [DATE]-[DATE]; no BM's recorded on the ADL sheets for five (5) consecutive days of [DATE]-[DATE]. Res #2 had no progress notes documented/recorded in the medical record for the month of February 2023. Res #2 had one (1) progress note recorded for [DATE] and one (1) progress note recorded for [DATE]. No progress notes were recorded/documented for Res #2 pertaining to her ADL care and services for [DATE]-[DATE].
Resident #3:
Record review of Res #3 revealed a Care Plan dated [DATE] that read: At constipation risk r/t (in reference to) advanced age, impaired mobility, meds. Goal: Will have soft formed stool 2-3 x week (2-3 times per week) to next review [DATE] .Interventions: Observe & record frequency and amount of BM, Note any problem with consistency or color of BM, Encourage 100% fluid intake on meal tray, check bowel sounds prn, Observe for effectiveness of prn, Offer Prune Juice prn, Notify MD if needed, Administer meds as ordered (See MAR).
Record review of the medical record revealed Res #3 had no nursing progress notes written/recorded during the month of February 2023 addressing the constipation risk. There was one nursing progress note documented for the month of February dated [DATE] which did not address Res #3's ADL's or bowel program. No progress notes were documented for [DATE] by nursing staff. The ADL sheets for January and February 2023 for Res #3 were not documented by the CNAs' for every eight (8) hour shift seven (7) days per week.
Record review of Res #3 revealed that she had a Minimum Data Set (MDS) dated [DATE] that contained a Brief Interview of Mental Status (BIMS) score of 0 (Blank) which indicated that Res #3 was severely cognitively impaired.
Record review of the Face Sheet revealed Resident #3 was admitted to the facility on [DATE] with diagnoses that included Hemiplegia following cerebral infract affecting right dominant side; Constipation, unspecified; Senile degeneration of the brain.
Resident #4:
Interview with Res #4 on [DATE] at 1:10 PM, revealed that since she had been in the facility she had never been asked if she had had a bowel movement or what the consistency of her bowel movements were. Res #4 stated that she had never seen prune juice in the building and had never been offered a snack or juice of any type. Res #4 stated that she had never been offered a stool softener or a laxative. Res #4 stated that she had more issues with loose stools rather than with constipation. No one had talked to her about her bowel movements.
Record review of Res #4's Care Plan dated [DATE] revealed: Constipation has constipation risk r/t (in reference to) diverticulitis of the intestines, side effects of antipsychotic and antidepressant medications. Goal: Will have soft formed stool 2-3 x week (2-3 times per week) to next review [DATE]. Interventions: Administer meds as ordered, Record any problems with color or consistency of BM, Notify MD as needed, Encourage 100% fluid intake on meal tray, Check bowel sounds prn (as needed) , Encourage fluid intake, Offer Prune juice prn, Observe and record frequency and amount of BM, Observe for effectiveness of prn.
Record review of Res #4's Minimum Data Set (MDS) dated [DATE] contained a BIMS score of 14 which indicated that Res #4 was cognitively intact.
Record review of the Face Sheet revealed Res #4 was admitted to the facility on [DATE] with diagnoses that included Bipolar Disorder with mild depression; Chronic Obstructive pulmonary disease.
Record review of the medical record revealed there was no documentation submitted by the facility to indicate that the Care Plan of Res #4 had been followed for constipation and/or the bowel functioning of Res #4.
Resident #5:
In an interview and observation on [DATE] at 9:55 AM, Res #5 she stated that she had never been offered a stool softener or a laxative. She stated that a very few times she had been constipated and she had asked the nurse for Metamucil. Res #5 was unable to recall when the event occurred for the medication for constipation. Res #5 stated that she had more times that she had diarrhea or loose stools rather than constipation. She stated that she had never been offered Prune Juice and had never asked for Prune Juice.
Record review of Res #5's Care Plan dated [DATE] revealed: Constipation: I am at risk for constipation related to diuretic use, impaired mobility, medication side effects, opiate use. Goal: Will have soft formed stool 2-3 x week (2-3 times per week) by [DATE]. Interventions: Note any problem with consistency or color of BM, Encourage 100% fluid intake on meal tray, Check bowel sounds prn, Offer Prune juice prn (as needed) Administer my medication as per md orders, Observe & record frequency and amount of BM.
Record review of the [DATE] - [DATE] bowel function ADL sheet had Res #5 documented/recorded as having no bowel movements from [DATE]-[DATE] (three (3) consecutive days with no bowel movement). The ADL sheet had no BM's documented/recorded for Res #5 from [DATE]-[DATE] (three (3) consecutive days with no bowel movement). Record review of the February 2023 bowel function ADL sheet documented that Res #5 had no bowel movements (BM's) for the first three (3) days of February (February 1-3, 2023). Res #5 had no bowel movements (BM's) documented/recorded on the ADL sheet for the days of February 13, 2023-February 15, 2023 (three (3) consecutive days). There was no documentation in the medical records of Res #5 that the CNAs' had notified the licensed nurses (med cart nurse) about the bowel function of Res #5. There was no documentation in Res #5's medical record to indicate that the CNAs' had notified the cart nurse of no BM's for Res #5. There was no documentation provided by the facility to confirm that the nurses (cart nurses) had been monitoring the BM's of Res #5 during the months of January-[DATE].
Record review revealed that the Care Plan for Res #5 had not been implemented for Constipation.
Record review of the Face Sheet revealed Res #5 was admitted to the facility on [DATE] with diagnoses that included Acute heart disease of native coronary artery and Acute systolic (congestive) heart failure
Record review of the MDS dated [DATE] for Res #5 revealed BIMS score of 14 which indicated that she was cognitively intact.
Summary:
Record review of the ADL sheets for (5) of (5) sampled residents revealed that the BM's had not been appropriately documented/recorded on the ADL sheets by the CNAs' and there was no MAR documentation/recording of the BM's as per the facility policies and procedures. The nursing progress notes had not been documented for Resident #1 for the month of February 2023; and five (5) of five (5) residents nursing progress notes contained no information of ADL and/or BM functioning as outlined in the facility's policies and procedures for documenting BM functioning. The Care Plans for 5 of 5 Sampled Residents (Res #1; Res #2; Res #3; Res #4; and Res#5) had not been followed for bowel functioning /constipation risk, and ADL care. The medical record of Res #1 contained no monitoring of her BM's by the licensed nursing staff. As a result of neglecting to accurately and appropriately document/record the BM's of the residents led to Res #1 having un-treated serious constipation with led to a bowel impaction and hospital admission on [DATE] and ultimately led to the death of Res #1 at the hospital on [DATE]. The DON and the QA nurses (RN#3 and LPN#2) confirmed through interviews that Res #1 had not been properly monitored for BM's for [DATE]-February 2023 and that on [DATE] Res #1 suffered a bowel obstruction and was sent out to the hospital. Confirmed through record reviews and through interviews that Res #1's BM's were not monitored and the CNAs' and licensed nurses had neglected to monitor Res #1 which ultimately resulted in her death at the hospital on [DATE].
The facility provided an acceptable Removal Plan on [DATE]. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ:
Removal Plan:
On [DATE], Resident #1 began vomiting coffee ground emesis and was transferred to the hospital and expired at the hospital on [DATE]. The facility determined that Certified Nursing Assistants (CNAs') were documenting bowel movements inaccurately on the paper records. No one was assigned to check the CNAs documentation. The facility's failure likely placed residents who reside in the facility at risk for serious adverse outcomes. The administration must take immediate action to monitor staff actions to prevent likelihood of serious harm, impairment or death.
The State Survey Agency (SA) called Immediate Jeopardy (IJ) and provided the facility with IJ templates on [DATE] for neglect, failure to maintain accurate documentation, failure to implement care plans, and failure to provide residents with necessary treatments. The SA provided an IJ template on [DATE] for failure to administer the facility effectively.
All 88 residents were assessed for being at risk of no bowel movement. The Bowel Program policy to include the standing orders was initiated for residents identified at risk by Registered Nurse (RN#1), RN#2, RN#3, RN#4, and RN#5 on [DATE].
Certified Nursing Assistants (CNAs') that have worked were in-serviced on the Bowel Care Task documentation via the kiosk, to include whether they are continent, incontinent or colostomy as well as bowel characteristics of size and consistency with a prompt to notify nurse if stool is hard or watery. This in-service was conducted by Quality Assurance (QA) RN#2. This in-service began on [DATE]. Medication nurses that worked were in-serviced by Director of Nursing, RN#1, QA nurse RN#2 and Licensed Practical Nurse (LPN#1), in reference to checking the completion of documentation by the CNAs' per shift. This in-service began on [DATE]. No staff will be allowed to work until the in-service training has been completed.
CNAs' have documented bowel movements via the kiosk on [DATE]. 45 minutes prior to the end of each shift the medication nurse on each hall checked CNAs documentation for completion, beginning [DATE]. Medication nurses who have residents at risk initiated standing orders for no bowel movement protocol. The standing orders are as follows: If a resident goes 3 days with no bowel movement (BM) initiate the standing orders. Obtain vital signs, check abdomen for distention/pain. Auscultate bowel sounds. Administer Dulcolax suppository x 1 dose. Reassess resident. If no BM in 24 hours give fleet enema x 1 dose. Reassess resident. If no BM 30 minutes after enema, notify Medical Doctor (MD)/Nurse Practitioner (NP).
All staff that worked were in-serviced on the duty to report signs and symptoms of abuse and neglect immediately to their supervisor, who will report to the DON and Administrator. They were also in-serviced that it is the duty of anyone to report suspected abuse or neglect. This in-service was conducted by RN#1, RN#2 and LPN#1. This in-service began on [DATE] and no staff will be allowed to work until the in-service training has been completed. On Friday [DATE] and Monday [DATE] the Attorney General Office came to the facility and in-serviced all Administrative staff including the Administrator, DON, and facility staff on Abuse and Neglect.
CNAs' and License Practical Nurse's (LPN) and RN's that worked were in-serviced on the importance of reviewing and following resident care plans to prevent potentially serious outcomes. This in-service training was conducted by RN#1, RN#2, and LPN#1. This in-service was complete on 03//29/2023 for staff that worked and no staff will be allowed to work until the in-service training has been completed. All care plans related to residents at risk for constipation were reviewed by Minimum Data Set (MDS) assessment nurses on [DATE]. The standing orders were initiated for all residents identified at risk. All care plans have bowel interventions in place.
An emergency QA meeting was held on [DATE]. In attendance were the Administrator, DON/Infection Preventionist (IP), Assistant Director of Nursing, QA RN#2 and QA LPN#1, MDS RN#3 and MDS LPN#2, the Social Service Director and the Nurse Practitioner. Changes in CNAs charting from paper to kiosk was discussed. Staff in-service on constipation and standing orders were discussed and initiated by RN#2. It was decide to hire staff Development nurse.
An Emergency QA meeting was held on [DATE]. In attendance was the Medical Director, Administrator, DON/IP, QA RN#2, QA LPN#1, MDS LPN #2 and Accounts Manager. Immediate Jeopardy deficiencies and immediate Action Plan was discussed.
We allege the immediacy of the jeopardy was removed on [DATE] and the IJ was removed on [DATE].
VALIDATION:
On [DATE], the SA validated the facility had implemented the following measures to remove the Immediate Jeopardy (IJ). The Removal Plan was verified by staff interviews and record reviews of in-services and sign-in sheets.
On [DATE] the SA confirmed through interviews with DON (RN#1), interviews with the x2 QA nurses (RN#2 and LPN#1), interview with the ADON (RN#3), interview with the Wound Care Nurse (RN#4), and interview with MDS/Care Plan nurse (RN#5), and validated that the five (5) Registered Nurses assessed all 88 residents at risk of no bowel movements (BM's) and they initiated the Bowel Program policy and procedure for those residents that were identified.
The SA validated through interviews and record review of the in-service sign in sheets that eight (8) CNAs' working in the building on all three (3) shifts on [DATE] had attended in-service training beginning on [DATE] in reference of documentation of BM's in the kiosk. Interviews with six (6) RN's and five (5) LPN's confirmed that they had been in-serviced to supervise the CNAs' documentation and to check the kiosk documentation after the CNAs' had documented.
On [DATE] the SA confirmed through interviews that the CNAs' (CNAs#1, #2, #3, #4, #5, #6, #7, and CNAs#8) that they had begun digital documentation of the residents ADL's and BM's in the kiosk on [DATE]. Validated through interviews with five (5) LPN's and one (6) RN's that they were instituting the no bowel movement protocol. All interviewed licensed nurses confirmed that they would contact the NP or the MD if the no bowel movement protocol did not produce BM results.
The SA confirmed through interviews and record reviews with six (6) Registered Nurses (RN's), eight (8) CNAs', five (5) LPN's, and the facility Administrator that all facility staff had been in-serviced on Abuse and Neglect and all staff knew that any signs and symptoms of abuse would be reported immediately to their supervisors and to the DON and ADM. The ADM and the DON both confirmed and produced the sign in sheets for review for the Abuse and Neglect in-service that was conducted on Friday [DATE] and on Monday [DATE] presented by the AGO.
Confirmed through record review of in-services and through interview with RN#1, RN#2 and LPN#1 that they conducted in-service training of all staff that had worked on the importance of reviewing and following the care plans of all residents in order to prevent serious negative outcomes. Confirmed through interview with the two (2) MDS/Care Plan nurses (RN#5 and LPN#2) that all 88 resident care plans have bowel interventions in place.
The QA Nurse (RN#2) and (LPN#1) confirmed through interview that the facility conducted an Emergency QA committee meeting on [DATE] to discuss the bowel program and the documentation of BM's and that there would be changes in the documentation by the CNAs' to the new kiosk system rather than the paper documentation. The x 2 QA nurses confirmed through interview that a new Staff Development nurse had been hired and she had begun on [DATE] with in-servicing of facility staff. The ADM confirmed through interview that the QA meeting on [DATE] had all members in attendance except the MD and the ADM confirmed that the DON is the certified (IP).
The SA validated through interviews with the ADM that the facility QA committee had held a second QA committee meeting on [DATE] to discuss the deficiencies from the IJ and to discuss the Action Plan for removing the immediacy of the IJ. The ADM confirmed through interview that the QA meeting on [DATE] had all required members present including the MD and the IP.
Staff interviewed on [DATE] for Validations of the facility's Removal Plan were: eight (8) CNAs'; six (6) RN's; five (5) LPN's; one (1) Activities Director; one (1) facility ADM; and one (1) DON.
CRITICAL
(L)
📢 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
Quality of Care
(Tag F0684)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and policy and procedure reviews, the facility failed to implement the facilit...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and policy and procedure reviews, the facility failed to implement the facility's protocol for monitoring bowel functioning for five (5) of five (5) residents reviewed, Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5, which resulted in Resident #1 becoming ill with vomiting and stomach pain and transferred to the hospital on [DATE]. On [DATE], Resident #1 died at the hospital as a result of a bowel impaction/obstruction.
The facility's failure to render the care and services necessary to prevent constipation resulted in the death of Resident #1. The facility's failure to provide the care and services necessary to prevent constipation put all residents in the facility at risk for the likelihood of serious illness and death.
The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on [DATE] when Resident #1 began vomiting and complaining of stomach pain. Resident #1 was admitted to the local hospital on [DATE] with vomiting and stomach pain and died on [DATE] as a result of aspiration from vomiting due to a bowel impaction.
On [DATE] at 5:30 PM the SA notified the facility Administrator, and the Director of Nursing of the IJ and SQC and provided the facility with the IJ templates for F 600; F 609; F 656; F 684; and on [DATE] at 1:30 PM the SA provided IJ temple for F 835 to the facility. The facility submitted an acceptable Removal Plan on [DATE], in which the facility alleged that the immediacy of the Jeopardy was removed on [DATE]. 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. The scope and severity for CFR 483.25 (a) (1) Quality of Care (F 684) was lowered to an F while the facility monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements.
Findings include:
Record review of the facility policy and procedure titled: Bowel Program Policy, dated [DATE], revealed, Purpose: Monitoring of bowel movements are important to the general health and well being of the resident. Policy: A daily BM record will be monitored by the Charge Nurse on a daily basis. Should there be no BM of three consecutive days a Bowel Program will be initiated based on our Physicians standing orders. 1. Check abdomen for distention/pain. Auscultate bowel sounds. 2. Dulcolax suppository x (times) 1 dose. 3. If no BM in 24 hours give fleets enema x 1 dose. 4. If no BM after enema, notify MD/NP (Medical Doctor/Nurse Practitioner).
Review of the facility's policy and procedure titled: Activities of Daily Living (ADLs') dated 01/2008 Date Reviewed/Revised: [DATE] revealed: The facility will ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. The staff will provide care on a timely basis to promote and prevent avoidable changes in care.
Record review of the Certified Nursing Assistant Job Description, undated, revealed Objective: Assists nursing personnel in provision of basic care for residents and necessary unit tasks and functions in compliance with (Formal name of facility) policies and procedures, applicable health care standards and (Formal name of State Agency). Organization: The Certified Nurses Aide functions as a member of the health care team under the direction of the RN (Registered Nurse) or LPN (Licensed Practical Nurse) and reports to the Director of Nursing or ADON (Assistant Director of Nurses) in conformity with (Formal name of facility) and regulatory policy . Responsibilities: Assists patients in the following areas: .c. Toileting (bedpan, urinal, commode and/or toilet) . 2. Assists with feeding of residents. 3. Measuring and recording intake and output. 10. Accurate documentation of all ADLs' (Activities of Daily Living) by the end of each shift. Real time charting is required .17. Immediately report any changes in resident's condition or incidents to the Nursing Supervisor .
Interview on [DATE] at 12:00 PM with the Director of Nursing (DON) (RN#1) and the facility Administrator (ADM) revealed that the facility currently had a resident census of 88 residents and was licensed for 105 resident beds. The Certified Nursing Assistants (CNAs) documented the ADLs' for each resident at the end of each eight (8) hour shift. The DON stated that the nurses work 12 hour shifts and the CNAs work 8 hour shifts. The DON stated that the Activities of Daily Living (ADLs) care sheets were kept in a binder at the nursing stations and that they were accessible to all staff. The ADLs sheets were devised per the individual care plan of each resident. The ADLs sheets were the venue in which the care plans were followed and instituted for each resident. The DON stated that if something was not completed or a resident had issues, the CNAs report that to the Licensed Practical Nurses (LPN) medication cart nurses or to the Registered Nurse (RN) or Charge Nurse for the 7-3 and 3-11 shifts. The DON revealed that for over a year the CNAs charted manually on paper charts and on [DATE] the facility installed computers (Kiosk) systems that the CNAs now use to digitally chart on each resident at the end of each 8 hour shift. If a resident does not have a bowel movement (BM) during that shift, the CNAs was supposed to report the lack of BM to the Charge Nurse or to the medication cart nurses. BMs can only be reported once per shift in the digital system. On the manually (paper) system the CNAs documented the number of resident BMs during the shift. The ADM stated that Resident (Res) #1 had been sent out to the hospital and later passed away, but (Res #1) did not have an infection and did not have a known bowel issue; I was informed by the nurses that she (Res #1) was not dependent upon staff for toileting.
Interview on [DATE] at 3:30 PM, with the DON (RN#1) revealed that the facility did not have documentation to ensure that Bowel Movement (BM's) the Activities of Daily Living (ADLs) care had been implemented according to the residents care plans. DON stated We are not going to be able to provide for you what you are looking for. The CNAs did not document the Bowel Movements (BM's) on the ADLs sheets for the residents on each shift. The CNAs had been documenting manually on ADLs sheets for approximately one (1) year due to no computer/kiosk' system available to CNAs. They had been told to manually document the BMs on the ADLs sheets and if there had been no BM for that 8 hour shift they were instructed to tell the med cart nurse. The med cart nurse was supposed to check the resident and decide the appropriate method for the resident's BM per the Bowel policy and procedure. The nurses were supposed to document in the progress notes what they did and the results of the method for BMs. The DON stated that the nurses had not appropriately documented the BMs in the residents medical records. DON stated that the ADLs sheets had all been reviewed and an investigation completed by the facility's Quality Assurance (QA) nurses x 2, and there was no documentation of BMs on the ADLs sheets and no documentation that the nurses had been notified of residents' BMs. DON stated that they had no nursing notes and no documentation for Resident (Res) #1 stating that she had BMs prior to her admission to the hospital on [DATE]. DON said she thought that the med cart nurses were supervising the CNAs more closely, but they had not. DON stated that the Bowel policy and procedure had not been followed and the ADLs sheets had not been documented appropriately for each resident and the licensed nurses had not documented in the progress notes appropriately or often enough for each resident. DON stated the documented information needed for bowel movements on (Res #1) was not in the medical records.
Resident #1:
Interview with the DON (RN#1) on [DATE] at 9:00 AM revealed that (Res #1) had been transferred to the hospital from the facility on [DATE] due to vomiting coffee ground looking substances (emesis) and for stomach pain. DON stated that Res #1 was diagnosed at the hospital on [DATE] with an impaction. The DON stated that on [DATE], Res #1 died of aspiration due to vomiting because of the bowel obstruction/bowel impaction. DON stated that the facility had no documentation that Res #1's BMs were appropriately monitored as per the facility policy and procedure and the nursing staff had not documented on the Medication Administration Record (MAR) or in the nursing notes that the BMs had been monitored. DON stated that the facility had not followed the care plan for Res #1 and the facility had not followed the policy and procedure for bowel movement programs. The DON stated that she had assumed that the med cart nurses had been monitoring and supervising the CNAs. DON stated that she should not have assumed, but she should have followed up and supervised the nursing staff more closely. The DON stated that the QA nurses x 2 had conducted an investigation of the incident with Res #1 and they had found that there was no documentation of BM monitoring for Res #1. The DON stated that the Quality Assurance (QA) nurses x 2, did all investigations and the written reports were given to the DON and to the facility (ADM). The DON stated that the facility had CNAs began ADLs, including BMs, documentation in the kiosk on [DATE]. DON stated that the CNAs and licensed nurses had failed to document and monitor the input and output of Res #1 which led to her hospital transfer and led to her death from an impaction.
Record review of the Care Plan for Res #1 dated [DATE] read: Constipation I have constipation risk r/t (in reference to) advanced age, impaired mobility, meds does not take laxative/stool softener regularly Risk for constipation/diarrhea. Will have soft formed stool 2-3 x week (2-3 times per week) to next review [DATE] Administer meds as ordered Monitor & record frequency and amount of BM Note any problem with consistency or color of BM Encourage 100% fluid intake pm meal tray check bowel sounds prn (as needed) Administer PRN med a/o (as ordered) Monitor for effectiveness of prn offer Prune Juice prn Notify MD if needed.
Record review of the facility's Care Tracker Documentation Record ADLs care sheets for [DATE] through [DATE] for Res #1 revealed the sheets were not appropriately documented for Res #1's BMs on each eight (8) hour shift. The input and output of Res #1 was not documented in accordance to the facility policies and procedures for each eight (8) hour shift by the CNAs, . From [DATE] through [DATE], Res #1 had no (zero) BM's documented/recorded on the ADLs care sheets. There was no documentation in Res #1's medical record to indicate that the CNAs had notified the licensed nurses that Res #1 had no BMs for eight (8) days. The CNAs had documented/recorded that Res #1 had three (3) BMs during the dates of [DATE] through [DATE]. The record review revealed that Res #1 had one (1) BM during the 3:00 PM-11:00 PM shift on [DATE]; on [DATE] there was one (1) BM recorded/documented by the CNAs for Res #1 on the 7:00 AM-3:00 PM shift; and on [DATE] the CNAs documented/recorded that Res #1 had one (1) BM during the 7:00 AM -3:00 PM shift. The record review revealed that the progress notes for [DATE] did not contain any documentation of Res #1's lack of BMs or that the licensed nurses had monitored the BMs of Res #1 or that Res #1 had received treatment and services for the lack of BMs during the month of [DATE].
Record review revealed there were four (4) progress notes in [DATE], and there were no progress notes documented/recorded for Res #3 during the month of February 2023. The ADLs care sheet dated February 1, 2023 through February 15, 2023 documented/recorded that Res #1 had no (zero) BMs from February 7, 2023 through February 15, 2023. The ADLs care sheet for Res #1 dated February 16, 2023 through February 28, 2023 documented/recorded that Res #1 had two (2) BMs during this time period one (1) BM recorded/documented during the 3:00 PM-11:00 PM shift on [DATE], and one (1) BM on [DATE] during the 7:00 AM-3:00 PM shift. Res #1 had no (zero) BMs documented/recorded on the ADLs care sheets from February 21, 2023 through February 28, 2023. The facility documentation that was provided for Res #1's BMs for February 21, 2023 through February 28, 2023, indicated that Res #1 had two (2) BM's recorded during a 13 day period. There was no progress notes in the medical record for Res #1 during the month of February 2023. The Medication Administration Record (MAR) did not document that Res #1 received bowel functioning treatment and services for the month of February 2023.
The record review of the Nurse Practitioner's (NP) progress note, dated [DATE] at 2:39 PM, revealed: Acute Visit [DATE] Chef Complaint: Nausea, vomiting coffee-ground emesis, and abdominal distention. The patient also has associated abdominal distention with some tenderness to palpation worse on left upper and lower quadrants. Patient symptoms started today this morning nothing making it better or worse. We will send patient to (name of hospital) for further evaluation and treatment.
Record review of the medical records from the hospital dated [DATE]-[DATE] for Res #1 revealed: Patient was admitted with consult to gastroenterology and general surgery. Patient was made NPO and evaluated by general surgery. Was not felt necessary to place NG tube but instead was given some measures in an attempt to relieve fecal impaction. She did have a small bowel movement. Patient found to have urinary tract infection and started on antibiotics. Discussion with family led to revelation patient wishes to be DO NOT RESUSCITATE/DO NOT INTUBATE. Unfortunately, shortly thereafter patient vomited as witnessed by nursing staff and as a result of aspiration had respiratory arrest and died. Cause of death Aspiration due to vomiting due to Small bowel obstruction. Time of death 1200 on 3 [DATE].
Interview on [DATE] at 12:00 noon with the facility Administrator (ADM) revealed that she had been the facility ADM for 1 year. The ADM stated that she had not received any reports from the QA nurses that the facility was responsible for the impaction of Res #1. The ADM stated that she had been told by the Nurse Practitioner (NP) that the hospital was to blame for Resident #1's death because they did not place an NG tube that was needed. ADM stated that she never knew that the facility had not monitored the BMs of Res #1 and was never was told of the bowel impaction of Res #1. The ADM stated that she was not a nurse and that she had been licensed as an ADM for approximately one (1) year. The ADM confirmed she was the one that instituted the new kiosk system on [DATE]. ADM confirmed that she had not reported the incident of Res #1's impaction because she was unaware that the facility had failed to monitor and document.
Interview on [DATE] at 2:15 PM with the DON (RN#1) revealed the facility knew on [DATE], when Res #1 died, that there was a problem with the monitoring of the BMs and that was why she had asked the Quality Assurance (QA) nurses to do an investigation. She stated that the written QA report was given to her and to the ADM by the QA nurses.
Interview on [DATE] at 2:50 PM with the Assistant Director of Nursing (ADON-RN#3) revealed that she had been working at the facility since [DATE]. She stated that no one had ever asked her to monitor the ADLs sheets or the charting of nursing staff. She stated that she had been working the unit on [DATE] when the NP had called for her to assess Res #1, who was vomiting. The ADON assessed and found Res #1 with coffee ground vomit on her clothing and on the floor. ADON stated that Res #1 was complaining of stomach pain and her stomach was distended. (ADON-RN#3) called 911 and stayed with the resident until the ambulance arrived to transfer Res #1. The ADON stated that she reported to the NP that Res #1 appeared to possibly have a GI bleed from the looks of the coffee ground vomit. ADON stated that she learned the next day that Res #1 had passed away at the hospital on [DATE], and that the hospital had reported that her death was due to an impaction/bowel obstruction. The ADON stated that the nurses should document in the progress notes each shift on the residents and should document in the progress notes when they give certain medications such as PRN's (as needed medications). The ADON stated that there were no documented nursing progress notes for the month of February 2023. The ADON stated that she did not know why the nurses had not documented progress notes for a month. The ADON stated that no one had asked her to monitor charts, and she had assumed that the DON was monitoring the ADLs sheets and the nursing progress notes.
Interview on [DATE] at 3:00 PM with the two (2) QA nurses RN#2 and LPN#1 revealed that they were asked by the DON(RN#1) to conduct an investigation of the incident involving (Res #1) and they gave a written report to the DON and also to the ADM, then they had an emergency QA meeting with all the committee members present to discuss the findings. They discovered that the CNAs had not documented on the ADLs sheets the BMs of the residents and the nursing staff had not documented what actions they took to monitor the ADLs. The QA nurses stated that the BMs of Res #1 had not been recorded on the ADLs sheets per their policy and procedure and the nurses had not documented in the progress notes for Res #1 during the month of February 2023.
Interview on [DATE] at 4:10 PM with the Administrator (ADM) she stated that she had no idea that Res #1 was impacted. All I was told was that Res #1 was sent out to the hospital because she was vomiting. I was told later by QA nurses that Res #1 only had seven (7) days that the BMs weren't recorded/documented. No one ever told me that was a problem. I trusted what the nurses said. The ADM stated that she had not read the hospital report for Res #1 and that the family of Res #1 was contacted and they did not raise any questions. The ADM stated that the AG's office came to the facility and in-serviced all staff on Abuse/Neglect. The ADM stated that she had called the Attorney General(AG) to come and in-service the staff because it was time for their annual Abuse/Neglect in-service.
At 8:20 AM on [DATE] Interviews and record reviews completed along with the former Administrator (ADM #2) and the current ADM. They confirmed that the ADLs sheets for Res #1 were not completed for BM's for at least the last 11 days in February 2023 and that there was no documented nursing notes/progress notes for the entire month of February 2023 regarding Res #1. They confirmed that the MAR's had no documented laxatives or stool softeners recorded for January-[DATE] for Res #1. They both confirmed that the Care Plan had not been followed for ADLs care and Constipation risk, and the facility policy and procedure for bowel programs had not been followed.
Interview on [DATE] at 10:25 AM, with the ADON-RN#3, revealed that after the death of Res #1 on [DATE] that the facility had a QA committee meeting to discuss the lack of documentation for the BMs of Res #1 and the lack of nursing progress notes. The facility also discussed the need to return to using the kiosk so the monitoring would be easier to track. The facility reinstated the CNA's kiosk system on [DATE]. The ADON-RN#3 stated that she would be responsible for monitoring the ADLs' through the week days and would do chart audits on the day shift 8:00 AM-3:00 PM Monday through Friday, and the weekend Charge Nurse would monitor the ADLs sheets on the weekends. The ADON stated that the facility did not have a Staff Development Nurse but was hiring one and she would also monitor charts.
Interviewed on [DATE] at 11:45 AM with Care Plan/MDS nurses, RN #5 and LPN#2, revealed they both confirmed that the care plans for Res #1 had not been followed and that the facility had a QA meeting immediately after Res #1 died on [DATE], and they learned at the QA meeting that Res #1 had died as a result of an impaction. They discussed at the QA meeting on [DATE] that the ADLs sheets had not been documented for bowel movements for Res #1 and that the nurses had not written nursing progress notes for Res #1 for over one (1) month. The Care Plan/MDS Nurses confirmed that the facility hired a new staff development nurse on [DATE] and she began in-services with all staff on [DATE].
Interview on [DATE] at 1:00 PM with the Resident Representative (RR) of Resident #1 revealed that she had been at the facility visiting Res #1 on [DATE] or [DATE] when Res #1 told her that her stomach was hurting. RR stated that (Res #1) had dementia and had some cognitive difficulties. I am positive that Res #1 reported not feeling well to the nurse, but I do not know who. RR did not witness the nurse evaluating Res #1. RR stated that the next day early in the morning at approximately 9:00 AM she was contacted by the facility that Res #1 was going to be transferred to the emergency room (ER) due to vomiting and stomach pain. RR met Res #1 at the hospital and stayed with her there. The hospital physician told RR that Res #1 had been vomiting due to a possible GI bleed and that they would run a test to see where the blood was coming from because she had vomit that looked like possible old blood was present somewhere. The hospital did the test and found that there was no GI bleed but that Res #1 had a bowel impaction and that was why she was vomiting. The next day, on [DATE], Res #1 passed away. RR stated that she had no Death Certificate as of yet but the hospital staff told her that the cause of death was due to an impaction. RR stated that she could not figure out how that could happen. RR stated that Res #1 was incontinent of bowel and bladder but at times she would ask to be assisted to the bathroom.
Interview on [DATE] at 2:00 PM with LPN#3 med cart nurse, revealed that she was the nurse for Res #1 everyday that Res #1 was living in the facility. LPN#3 confirmed that she worked days 7:00 AM-7:00 PM and she was never told that Res #1 was not having BMs. The CNAs did not report any negative findings to her for Res #1. LPN #3 also stated that she did not chart in Res #1's nursing notes because she was not aware of any findings that required documentation in the progress notes for Res #1. LPN #3 stated that she documented on the MAR when she gave Res #1 meds. LPN #3 stated that Res #1 was incontinent of bowel and bladder and that she (LPN #3) was told that Res #1 took herself to the toilet and was independent with toileting. LPN #3 stated that she would have given Res #1 a stool softener and followed the physician's orders had she been told by the CNAs that Res #1 had not had a BM within three (3) days. LPN #3 stated that it was the facility policy that if a resident had not had a BM in three (3) days then the CNA would report it to the med cart nurse. The CNA never reported to me that Res #1 had not had a BM. I was shocked to hear about what happened to Res #1. LPN#3 confirmed that she had never been told to monitor the CNA's ADLs sheets. She confirmed that she now knows to monitor the ADLs' and bowel movements (BMs) that the CNAs document in the kiosk. LPN #3 stated that the facility had been using the kiosk since the middle of March.
The nursing progress notes had not been documented for Resident #1 for the month of February 2023; and The medical record of Res #1 contained no monitoring of her BMs by the licensed nursing staff. As a result of neglecting to accurately and appropriately document/record the BMs of the resident led to Res #1 having untreated constipation with led to a bowel impaction and hospital admission on [DATE] and ultimately led to the death of Res #1 at the hospital on [DATE].
Resident #2:
Observation of Res #2 on [DATE] at 12:30 PM revealed that Res #2 was sitting in a wheelchair outside of her room. Res #2 was not interviewable.
Record review of Res #2's Care Plan dated [DATE] revealed: I am incontinent of bowel and bladder, I have a history of UTI' and E-coli. This is r/t (in reference to) my limited mobility with transfers and toileting and my decreased cognition. Please monitor me for s/s (signs and symptoms) of UTI. Provide me incontinence pads Assess me for symptoms of urinary tract infection. Provide me with good pericare after each incontinent episode Observe me for acute behavioral changes that may indicate UTI Evaluate my fluid intake and hydration status Notify my MD as needed. There was no Care Plan submitted by the facility that outlined the bowel functioning of Res #2.
Record review of Res #2 revealed a face sheet with an admission date of [DATE] and diagnoses of Hemiplegia following cerebral infraction affecting right dominant side; Dysphagia; Speech and language deficits; Contracture of muscle, right hand; dementia; Anxiety disorder; Anorexia; among other diagnoses. Record review revealed a Minimum Data Set (MDS) dated [DATE] that contained a Brief Interview of Mental Status (BIMS) score of 3 which indicated that Res #2 was severely cognitively impaired.
Record review of Res #2's ADLs sheet, dated [DATE] through [DATE], revealed documentation under the Bowel Function section as follows Res #2 had no BM's recorded for five (5) consecutive days for [DATE] through [DATE]. Res #2 had no BM's recorded/documented on the ADLs sheets for three (3) consecutive days from [DATE]-[DATE]; and Res #2 had no BM's recorded on the ADLs sheets for five (5) consecutive days of [DATE]-[DATE]. Res #2 had no progress notes documented/recorded in the medical record for the month of February 2023. Res #2 had one (1) progress note recorded for [DATE] and one (1) progress note recorded for [DATE]. No progress notes were recorded/documented for Res #2 pertaining to her ADLs care and services for [DATE]-[DATE].
Interview on [DATE] at 12:35 PM with CNA#1 revealed that she was the CNA for Res #2 on [DATE]. CNA#1 stated that Res #2 was wearing briefs and was incontinent of bowel and bladder. CNA#1 stated that she would record the bowel movements of the residents she worked with on each of her eight (8) hour shifts. At the end of the eight (8) hour shift if the resident had not had a BM in eight (8) hours the CNAs were to report that to the med cart nurse.
Resident #3:
Observation on [DATE] at 12:20 PM revealed that Res #3, was small and frail and was lying in fetal position on her right side. Res #3 was not interviewable.
Record review of Res #3 revealed that she had a Minimum Data Set (MDS) dated [DATE] that contained a Brief Interview of Mental Status (BIMS) score of 0 (Blank) which indicated that Res #3 was severely cognitively impaired. Res #3 had a face sheet that contained an admission date of [DATE] and diagnoses of Heart Failure; Hemiplegia following cerebral infract affecting right dominant side; Vascular Dementia; Hypertension; Depression; Constipation, unspecified; Senile degeneration of the brain; among other diagnoses.
Res #3 had no nursing progress notes written/recorded during the month of February 2023 addressing the constipation risk. There was one nursing progress note documented for the month of February dated [DATE] which did not address Res #3's ADLs' or bowel program. Res #3 had one (1) documented progress note dated [DATE] written by the social worker. No progress notes were documented for [DATE] by nursing staff. The ADLs sheets for January and February 2023 for Res #3 were not documented by the CNAs for every eight (8) hour shift seven (7) days per week.
Record review of Res #3 revealed a Care Plan dated [DATE] that read: At constipation risk r/t (in reference to) advanced age, impaired mobility, meds. Will have soft formed stool 2-3 x week (2-3 times per week) to next review [DATE]. Observe & record frequency and amount of BM, Note any problem with consistency or color of BM, Encourage 100% fluid intake on meal tray, check bowel sounds prn, Observe for effectiveness of prn, Offer Prune Juice prn, Notify MD if needed, Administer meds as ordered (See MAR).
Interview on [DATE] at 1:00 PM with CNA #2 she stated that she had been working at the facility as a CNA since [DATE]. She stated that when she completed a shift she documented in the kiosk at the end of each eight (8) hour shift the ADLs and the BMs. CNA #2 stated that she was assigned to work with Res #3 on [DATE] on the first (1st) shift. If a resident does not have a BM on the eight (8) hour shift it is reported to the med cart nurse. The med cart nurse was responsible for checking the resident after the CNA reported to them. CNA#2 stated that she documented on the ADLs sheets prior to [DATE]. CNA#2 stated that they documented on the ADLs sheets the BMs for residents on every shift. CNA #2 did not remember Res #1.
Resident #4:
Interview and Observation on [DATE] at 1:10 PM with Res #4, revealed that she was awake and alert and was a good historian. She stated that she had been living in the facility for a little over a year and was a retired Registered Nurse. Res #4 stated that the facility staff had been talking about the lady that died from an impaction for weeks. Res #4 stated the DON nor the ADM ever walk around and look, and they never go in and out of the residents rooms. Res #4 stated I am able to do most things for myself , I just have bad knees and have a need to be assisted with my meds at times. I go to the bathroom by myself, I toilet myself, I bath myself and do most all things for myself. I am aware that a person died from a bowel obstruction. Res #4 stated that since she had been in the facility she had never been asked if she had had a bowel movement or what the consistency of her bowel movements were. Res #4 stated that she had never seen prune juice in the building and had never been offered juice of any type. Res #4 stated that she had never been offered a stool softener or a laxative. Res #4 stated that she had more issues with loose stools rather than with constipation. Res #4 stated that she thought that the reason why the staff had never asked her about her bowel movements was because she was cognitive and she was continent and had no bowel issues.
Interview on [DATE] at 1:40 PM with CNA #3 revealed that she had worked the third shift 11:00 PM -7:00 AM since 2018 prior to today and yesterday. She stated that the third shift checked the residents every 2 hours and changed those that needed changing. She stated that if a resident did not have a BM during the 8 hour shift the CNAs reported it to the med nurse. CNA #3 stated that they report the BMs on the ADLs sheets in the kiosk since [DATE] and before that they wrote the BMs on the ADLs sheets every 8 hour shift. CNA #3 stated that they manually recorded the BMs on the ADLs sheets for over a year because the kiosk were broken.
Record review of Res #4's Care Plan dated [DATE] revealed: Constipation has constipation risk r/t (in reference to) diverticulitis of the intestines, side effects of antipsychotic and antidepressant medications. Will have soft formed stool 2-3 x week (2-3 times per week) to next review [DATE]. Administer meds as ordered, Record any problems with color or consistency of BM, Notify MD as needed, Encourage 100% fluid intake on meal tray, Check bowel sounds prn (as needed) , Encourage fluid intake, Offer Prune juice prn, Observe and record frequency and amount of BM, Observe for effectiveness of prn.
Record review of Res #4's Minimum Data Set (MDS) dated [DATE] contained a Brief Interview of Mental Status (BIMS) score of 14 which indicated that Res #4 w[TRUNCATED]
CRITICAL
(L)
📢 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 most or all residents
⚠️ Facility-wide issue
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, job description reviews, interviews, and policy and procedure reviews, the facility admini...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, job description reviews, interviews, and policy and procedure reviews, the facility administration failed to identify the staff's failure to monitor residents bowel movements and provide treatment and services to prevent avoidable changes in residents medical conditions as evidenced by the lack of documentation or the inaccurate documentation of five (5) of five (5) sampled residents bowel movement regimens. Resident (Res) #1, #2, #3, #4 and #5. This failure had the potential to affect all residents.
The facility's failure to provide administrative oversight and supervision to prevent Res #1's constipation resulted in the ultimate death of Resident #1. The facility's failure to provide the care and services necessary to prevent constipation put all residents in the facility at risk, and in a situation likely to cause serious injury, serious impairment, serious harm or death.
The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on [DATE] when Res #1 began vomiting and complaining of stomach pain. Res #1 was admitted to the local hospital on [DATE] with vomiting and stomach pain and died on [DATE] as a result of aspiration from vomiting due to a bowel impaction.
On [DATE] at 5:30 PM the SA notified the facility Administrator, and the Director of Nursing of the IJ and SQC and on [DATE] at 1:30 PM the SA provided IJ template for F835 to the facility. The facility submitted an acceptable Removal Plan on [DATE], in which the facility alleged that the immediacy of the Jeopardy was removed 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 483.70 (a) (1) Administration (F835) was lowered from an L' to a F, while the facility developed a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements.
Findings include:
Record review of the facility's policy and procedure titled Reporting Alleged Violations with a revision date of [DATE] revealed, Policy: The purpose of this policy is to ensure that all alleged violations involving . neglect .are reported immediately to the administrator of the facility and to other state officials in accordance with State Law through established procedures (including to the State survey and certification agency) .Compliance Guidelines: 2. If the alleged violation involves abuse or results in serious bodily injury it must be reported immediately but no later than 2 hours after the allegation is made . Neglect: Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness .
Record review of the facility policy and procedure titled Abuse Neglect and Exploitation/Misappropriation Policy with a revision date of [DATE] revealed It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress
Record review the facility policy titled Recognizing Signs and Symptoms of Abuse, Neglect, Exploitation/Misappropriation with a revision date of [DATE] revealed . Signs of Physical Neglect: Improper use/ administration of medication; Inadequate provision of care
Record review of the facility policy and procedure titled: Bowel Program Policy dated [DATE] revealed, Purpose: Monitoring of bowel movements are important to the general health and well being of the resident. Policy: A daily BM record will be monitored by the Charge Nurse on a daily basis. Should there be no BM of three consecutive days a Bowel Program will be initiated based on our Physicians standing orders. 1. Check abdomen for distention/pain. Auscultate bowel sounds. 2. Dulcolax suppository x (times) 1 dose. 3. If no BM in 24 hours give fleets enema x 1 dose. 4. If no BM after enema, notify MD/NP (Medical Doctor/Nurse Practitioner).
Record review of a written statement dated [DATE] and signed by the Administrator revealed I, __________(Proper name of Administrator) have not been issued a job description as Administrator at (Proper name of facility).
Record review of the Job Description for the Director of Nursing, undated and unsigned revealed the facility job description titled Director of Nursing undated and unsigned revealed Job Summary: Administer all areas in the Nursing Department. This includes patient care, personnel management, and material management. Ensure that license requirements are met. Responsible for: 1. Staff education and performance 2. Staff supervision 3. Setting the standard for patient care. 4. Compliance with state and federal regulations to include . Care Plans, and patient records .
Interviews on [DATE] at 12:00 PM, with the Director of Nursing (DON) and the facility Administrator (ADM) revealed that the facility currently had a resident census of 88 residents and was licensed for 105 resident beds. The DON stated that the Care Tracker Documentation Record Activities of Daily Living (ADL) care sheets were kept in a binder at the nursing stations and that they were accessible to all staff. The Certified Nursing Assistants ( CNAs) documented the ADL's for each resident at the end of each eight (8) hour shift. The ADL sheets were developed per the individual care plan of each resident. The ADL sheets were the venue in which the care plans are followed and instituted for each resident. The DON confirmed that there were two (2) care plan nurses working in the facility on [DATE]. The DON stated that if something was not completed or a resident had issues the CNAs report that to the Licensed Practical Nurses (LPN) medication cart nurses or to the Registered Nurse (RN) or Charge Nurse for the 7-3 and 3-11 shifts. The DON stated that the nurses work 12 hour shifts and the CNAs work 8 hour shifts. The DON revealed that for over a year the CNAs charted manually on paper charts. If a resident does not have a bowel movement (BM) during that shift the CNAs report that to the Charge Nurse or to the medication cart nurses. On the ADL sheets, the CNAs could record the number of BM's during the shift, that the resident had. DON stated that she had not reported any incidents of Neglect/Abuse to the State and that the ADM was responsible for all reporting to the State. The ADM stated that Resident #1 (Res) had been sent out to the hospital and later passed away. But (Res #1) did not have an infection and did not have a known bowel issue, I was informed by the nurses that she (Res #1) was not dependent upon staff for toileting. ADM stated that she had not reported any Neglect/Abuse to the State Agency (SA) in the past three months (Jan-[DATE]).
In an interview on [DATE] at 3:30 PM with the DON, she stated that the facility did not have documentation to ensure that the Activities of Daily Living (ADL) care and Bowel Movement (BM's) had been implemented according to the residents care plans. The DON stated We are not going to be able to provide for you what you are looking for. The CNAs did not document the Bowel Movements (BM's) on the ADL sheets for the residents on each shift. The CNAs have been documenting manually on ADL sheets for approximately one (1) year due to no computer/kiosk' system available to CNAs. They had been told to manually document the BM's on the ADL sheets and if there had been no BM for that 8 hour shift they were instructed to tell the med cart nurse and the med cart nurse was to check the resident and decide the appropriate method for the resident's BM per the Bowel policy and procedure. The nurses were to document in the progress notes what they did and the results of the method for BM's. She stated that the nurses had not appropriately documented the BM's in the residents medical records. The DON stated that the ADL sheets had all been reviewed and an investigation completed by the Quality Assurance (QA) nurses and there was no documentation of BM's on the ADL sheets and no documentation that the nurses had been notified of no BM's for the residents. DON stated that they had no nursing notes and no documentation for Res #1 that she had BM's prior to her admission to the hospital on [DATE]. DON thought that the med cart nurses were supervising the CNAs more closely, but they had not. DON stated that the Bowel policy and procedure had not been followed and the ADL sheets had not been documented appropriately for each resident and the licensed nurses had not documented in the progress notes appropriately or often enough for each resident . She stated the documented information needed for bowel movements on (Res #1) was not in the medical records.
During an interview at 9:30 AM on [DATE], the ADM stated that the cooperate office did not have a job description for her as Administrator and she was unable to provide the responsibilities of the ADM. ADM documented on facility letterhead a statement that she was unable to provide a job description for the facility Administrator (ADM).
Resident #1:
Record review of the Nurse Practitioner's (NP) progress note date [DATE] at 2:39 PM revealed: Acute Visit [DATE] Chief Complaint: Nausea, vomiting coffee-ground emesis, and abdominal distention. The patient also has associated abdominal distention with some tenderness to palpation worse on left upper and lower quadrants. Patient symptoms started today this morning nothing making it better or worse. We will send patient to (name of hospital) for further evaluation and treatment.
Record review of the medical records from the hospital dated [DATE]-[DATE] for Res #1 revealed: Patient was admitted with consult to gastroenterology and general surgery. Abdominal Computerized Tomography (CT) scan findings were consistent with small bowel obstruction, fecal impaction and stercoral colitis without bowel perforation. Large amounts of stool throughout the rectum. History and Physical Reports revealed positive left-sided abdominal tenderness. The patient was made NPO (nothing by mouth) and evaluated by general surgery. Was not felt necessary to place NG tube but instead was given some measures in an attempt to relieve fecal impaction. Discussion with family led to revelation patient wishes to be DO NOT RESUSCITATE/DO NOT INTUBATE. Unfortunately, shortly thereafter patient vomited as witnessed by nursing staff and as a result of aspiration had respiratory arrest and died. Cause of death Aspiration due to vomiting due to small bowel obstruction. Time of death 1200 on 3 [DATE].
In an interview with the DON on [DATE] at 9:00 AM, revealed that Res #1 had been admitted to the hospital from the facility on [DATE] due to vomiting coffee ground looking substances (emesis) and for stomach pain. Res #1 was diagnosed at the hospital on [DATE] with an impaction and on [DATE] Res #1 died of aspiration due to vomiting because of the bowel obstruction/bowel impaction. DON stated that the facility had no documentation that Res #1 's BM's were appropriately monitored as per the facility policy and procedure and the nursing staff had not documented on the Medication Administration Record (MAR) or in the nursing notes that the BM's had been monitored. DON stated that the facility had not followed the care plan for Res #1 and the facility had not followed the policy and procedure for bowel movement programs. The DON stated that she felt responsible because she had assumed that the med cart nurses had been monitoring and supervising the CNAs. DON stated that she should not have assumed she should have followed up and she should have supervised the nursing staff more closely. DON stated that the Cans and licensed nurses had neglected to document and monitor the input and out put of Res #1 which led to her hospital transfer and ultimately led to her death from an impaction. The DON confirmed that the CNAs' and the licensed nurses had not been adequately supervised and their documentation monitored for implementing the plan of care for each resident.
Record review of the facility's Care Tracker Documentation Record ADL care sheets for January-[DATE] were reviewed for Res #1 and they were not appropriately documented for Res #1's BM's on each eight (8) hour shift. The input and out put of Res #1 was not appropriately documented on each eight (8) hour shift by the CNAs, in accordance to the facility policies and procedures. From [DATE]-[DATE] Res #1 had no (zero) BM's documented which confirms that Resident #1 went eight (8) days without having a BM. There was no documentation in the medical record of Res #1 to indicate that the CNAs had notified the licensed nurses that Res #1 had no BM's for eight (8) days. The CNAs had documented that Res #1 had three (3) BM's during the dates of [DATE]-[DATE]. The record review revealed that Res #1 had one (1) BM during the 3:00 PM-11:00 PM shift on [DATE]; on [DATE] there was one (1) BM recorded on the 7:00 AM-3:00 PM shift; and on [DATE] the CNAs documented (1) BM during the 7:00 AM -3:00 PM shift. The record review revealed that the progress notes for [DATE] did not contain any documentation that spoke to Res #1's lack of BM's, that the licensed nurses had monitored the BM's of Res #1 or that Res #1 had received treatment and services for the lack of BM's during the month of [DATE]. The ADL care sheet dated February 1, 2023-February 15, 2023 documented/recorded that Res #1 had no (zero) BM's from February 7, 2023-February 15, 2023. The ADL care sheet for Res #1 dated February 16, 2023-February 28, 2023 documented/recorded that Res #1 had two (2) BM's during this time period (one (1) BM recorded/documented during the 3:00 PM-11:00 PM shift on [DATE], and one (1) BM on [DATE] during the 7:00 AM-3:00 PM shift). Res #1 had no (zero) BM's documented/recorded on the ADL care sheets from [DATE]-[DATE]. The facility documentation that was provided for Res #1's BM's for [DATE]-[DATE] indicated that Res #1 had two (2) BM's recorded during a 13 day period. There was no progress notes in the medical record for Res #1 during the month of February 2023.
Record review of the Medication Administration Record (MAR) did not document that Res #1 received bowel functioning treatment and services for the month of February 2023.
In an interview on [DATE] at 12:00 PM, with the facility Administrator (ADM) revealed that she had been licensed and the facility ADM for 1 year. She stated that she never knew that the facility had not monitored the BM's of Res #1 and never was told of the bowel impaction of Res #1. The ADM stated that she was not a nurse and that she was still learning the ropes. ADM confirmed that she had not reported the incident of Res #1's impaction because she was unaware that the facility had failed to monitor and document the BM's. ADM stated that she was unaware that the lack of documentation of bowel movements was neglect.
In an interview on [DATE] at 2:15 PM, with the DON, she stated that they knew on [DATE] when Res #1 died, that there was a problem with the monitoring of the BM's and that was why she had asked the Quality Assurance (QA) nurses to do an investigation. She stated that the written QA report was given to her and to the ADM by the QA nurses.
Interview on [DATE] at 2:50 PM, with the Assistant Director of Nursing (ADON-RN#3) revealed that she had been working at the facility since [DATE]. She stated that no one had ever asked her to monitor the ADL sheets or the charting of nursing staff. ADON stated that the nurses should document in the progress notes each shift on the residents and should document in the progress notes when they give certain medications such as PRNs (as needed medications). ADON stated that there were no documented nursing progress notes for the month of February 2023 and that this was not a standard of practice. The ADON stated that she did not know why the nurses had not documented progress notes for a month. She stated that no one had asked her to monitor charts. The ADON stated that she had assumed that the DON was monitoring the ADL sheets and the nursing progress notes.
Interview on [DATE] at 3:00 PM, with the two (2) QA nurses, RN#2 and LPN#1, revealed that they were asked by the DON to conduct an investigation of the incident involving (Res #1) and they gave a written report to the DON and she gave it to the ADM. They discovered that the CNAs had not documented on the Care Tracker Documentation Record ADL sheets the BM's of the residents and the nursing staff had not documented what actions they took to monitor the ADL's. The QA nurses stated that the BM's of Res #1 had not been recorded on the ADL sheets per their policy and procedure and the nurses had not documented in the progress notes for Res #1 during the month of February 2023. Resident #1 was sent out to the hospital on [DATE] for vomiting and then Resident #1 died on [DATE].
In an interview on [DATE] at 4:10 PM, with the Administrator (ADM) she stated that she had no idea that Res #1 was impacted. All I was told was that Res #1 was sent out to the hospital because she was vomiting. I was told later by QA nurses that Res #1 only had seven (7) days that the BM's weren't documented. No one ever told me that was a problem, I'm not a nurse. I trusted what the nurses said. ADM stated that she had not read the hospital report for Res #1. ADM stated that the family of Res #1 was contacted and they did not raise any questions. ADM stated that this past Monday and last Friday the Attorney General's office came to the facility and in-serviced all staff on Abuse/Neglect. ADM stated that she had called the Attorney General(AG) to come and in-service the staff because it was time for their annual Abuse/Neglect in-service. ADM stated that she did not ask them to come do the in-service as a result of any incidents at the facility.
At 8:20 AM on [DATE], interviews and record reviews were completed along with the former Administrator (ADM #2) and the current ADM. They confirmed that the ADL sheets for Res #1 were not completed for BM's for at least the last 11 days in February 2023 and that there was no documented nursing notes/progress notes for the entire month of February 2023 regarding Res #1. They confirmed that the MAR's had no documented laxatives or stool softeners recorded for January-[DATE] for Res #1. They both confirmed that the Care Plan had not been followed for ADL care and Constipation risk and the facility policy and procedure for bowel programs had not been followed. (ADM#2) stated that she learned a long time ago that if it was not written down in the medical records it did not happen.
Resident #2:
Record review of Res #2's Care Tracker Documentation Record ADL sheet dated [DATE]-31, 2023 revealed many days of missing documentation under the Bowel Function section. Res #2 had no BM's recorded for five (5) consecutive days for [DATE]-[DATE]. Res #2 had five (5) BM's recorded/documented on the ADL sheets for February 1, 2023-February 15, 2023. Res #2 had no BM's recorded/documented on the ADL sheets for three (3) consecutive days from [DATE]-[DATE], and no BM's recorded on the ADL sheets for five (5) consecutive days of [DATE]-[DATE]. No progress notes were documented for Res #2 pertaining to her ADL care and services for [DATE]-[DATE].
Record review of Res #2 revealed a Face Sheet with an admission date of [DATE] and diagnoses of Hemiplegia following cerebral infraction affecting right dominant side, Dysphagia, and dementia, among other diagnoses.
Record review revealed a Minimum Data Set (MDS) dated [DATE] that contained a Brief Interview for Mental Status (BIMS) score of 3 which indicated that Res #2 was severely cognitively impaired.
Resident #3:
Record review of the Care Tracker Documentation Record ADL sheets for January and February 2023 for Res #3 were not documented by the CNAs' for every eight (8) hour shift seven (7) days per week as outlined in the CNAs' Job Description.
Record review revealed Res #3 had no nursing progress notes written/recorded during the month of February 2023 addressing the constipation risk.
Record review of Res #3 revealed that she had a MDS dated [DATE] that contained a BIMS score of 0 (Blank) which indicated that Res #3 was severely cognitively impaired.
Record review of Res #3's Face Sheet revealed an admission date of [DATE] and diagnoses of Heart Failure; Hemiplegia following cerebral infract affecting right dominant side; Constipation, unspecified; Senile degeneration of the brain; among other diagnoses.
Resident #4:
Interview and Observation on [DATE] at 1:10 PM with Res #4, revealed that she was awake and alert and was a good historian. She stated that she had been living in the facility for a little over a year and was a retired Registered Nurse. Res #4 stated that since she had been in the facility she had never been asked if she had had a bowel movement or what the consistency of her bowel movements were. No one had talked to her about her bowel movements.
Record review of Res #4's Care Tracker Documentation Record revealed bowel functioning was not addressed by the staff for [DATE] - [DATE].
Record review of Res #4's MDS dated [DATE] contained a BIMS score of 14 which indicated that Res #4 was cognitively intact.
Record review revealed Res #4 had a Face Sheet with an admission date of [DATE] and diagnoses of Chronic Obstructive pulmonary disease; and Gastro-escophageal reflux disease; among other diagnoses.
Resident #5:
In an interview and observation on [DATE] at 9:55 AM, with Res #5 revealed that she wears briefs and has been incontinent of bowel and bladder. Res #5 stated that she has to have the assistance of staff for all her ADL's. Res #5 stated that the CNAs' change her briefs for her on a regular basis.
Record review of the [DATE] - [DATE] Care Tracker Documentation Record bowel function ADL sheet had Res #5 documented/recorded as having no bowel movements from [DATE]-[DATE] (three (3) consecutive days with no bowel movement). The ADL sheet had no BM's documented for Res #5 from [DATE]-[DATE] (three (3) consecutive days with no bowel movement). There was no documentation in Res #5's medical record to indicate that the CNAs' had notified the med cart nurse of no BM's for Res #5.
Record review of the February 2023 Care Tracker Documentation Record bowel function ADL sheet recorded/documented that Res #5 had no bowel movements (BM's) for the first three (3) days of February (February 1-3, 2023). Res #5 had no bowel movements (BM's) documented/recorded on the ADL sheet for the days of February 13, 2023-February 15, 2023 (three (3) consecutive days). There was no documentation in the medical records of Res #5 that the CNAs' had notified the licensed nurses (med cart nurse) about the bowel function of Res #5. There was no documentation provided by the facility to confirm that the med cart nurses had been monitoring the BM's of Res #5 during the months of January-[DATE].
Record review for Res #5 revealed that she had a Face Sheet revealed a re-admission date of [DATE]. Res #5 had diagnoses of Acute heart disease of native coronary artery; Acute systolic (congestive) heart failure; History of falling; among other diagnoses.
Record review revealed Res #5's MDS dated [DATE] contained a BIMS score of 14 which indicated that she was cognitively intact.
Summary:
Record review of the ADL sheets for (5) of (5) sampled residents revealed that the BM's had not been appropriately documented/recorded on the ADL sheets by the CNAs' and there was no MAR documentation/recording of the BM's as per the facility policies and procedures. The nursing progress notes had not been documented for Resident #1 for the month of February 2023; and five (5) of five (5) residents nursing progress notes contained no information of ADL and/or BM functioning as outlined in the facility's policies and procedures for documenting BM functioning. The Care Plans for 5 of 5 Sampled Residents (Res #1; Res #2; Res #3; Res #4; and Res#5) had not been followed for bowel functioning /constipation risk, and ADL care. The medical record of Res #1 contained no monitoring of her BM's by the licensed nursing staff. As a result of neglecting to accurately and appropriately document/record the BM's of the residents led to Res #1 having un-treated serious constipation with led to a bowel impaction and hospital admission on [DATE] and ultimately led to the death of Res #1 at the hospital on [DATE]. The DON and the QA nurses (RN#3 and LPN#2) confirmed through interviews that Res #1 had not been properly monitored for BM's for [DATE]-February 2023 and that on [DATE] Res #1 suffered a bowel obstruction and was sent out to the hospital. Confirmed through record reviews and through interviews that Res #1's BM's were not monitored and the CNAs' and licensed nurses had neglected to monitor Res #1 which ultimately resulted in her death at the hospital on [DATE].
The facility provided an acceptable Removal Plan on [DATE]. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ:
Removal Plan:
On [DATE], Resident #1 began vomiting coffee ground emesis and was transferred to the hospital and expired at the hospital on [DATE]. The facility determined that Certified Nursing Assistants (CNAs') were documenting bowel movements inaccurately on the paper records. No one was assigned to check the CNAs documentation. The facility's failure likely placed residents who reside in the facility at risk for serious adverse outcomes. The administration must take immediate action to monitor staff actions to prevent likelihood of serious harm, impairment or death.
The State Survey Agency (SA) called Immediate Jeopardy (IJ) and provided the facility with IJ templates on [DATE] for neglect, failure to maintain accurate documentation, failure to implement care plans, and failure to provide residents with necessary treatments. The SA provided an IJ template on [DATE] for failure to administer the facility effectively.
All 88 residents were assessed for being at risk of no bowel movement. The Bowel Program policy to include the standing orders was initiated for residents identified at risk by Registered Nurse (RN#1), RN#2, RN#3, RN#4, and RN#5 on [DATE].
Certified Nursing Assistants (CNAs') that have worked were in-serviced on the Bowel Care Task documentation via the kiosk, to include whether they are continent, incontinent or colostomy as well as bowel characteristics of size and consistency with a prompt to notify nurse if stool is hard or watery. This in-service was conducted by Quality Assurance (QA) RN#2. This in-service began on [DATE]. Medication nurses that worked were in-serviced by Director of Nursing, RN#1, QA nurse RN#2 and Licensed Practical Nurse (LPN#1), in reference to checking the completion of documentation by the CNAs' per shift. This in-service began on [DATE]. No staff will be allowed to work until the in-service training has been completed.
CNAs' have documented bowel movements via the kiosk on [DATE]. 45 minutes prior to the end of each shift the medication nurse on each hall checked CNAs documentation for completion, beginning [DATE]. Medication nurses who have residents at risk initiated standing orders for no bowel movement protocol. The standing orders are as follows: If a resident goes 3 days with no bowel movement (BM) initiate the standing orders. Obtain vital signs, check abdomen for distention/pain. Auscultate bowel sounds. Administer Dulcolax suppository x 1 dose. Reassess resident. If no BM in 24 hours give fleet enema x 1 dose. Reassess resident. If no BM 30 minutes after enema, notify Medical Doctor (MD)/Nurse Practitioner (NP).
All staff that worked were in-serviced on the duty to report signs and symptoms of abuse and neglect immediately to their supervisor, who will report to the DON and Administrator. They were also in-serviced that it is the duty of anyone to report suspected abuse or neglect. This in-service was conducted by RN#1, RN#2 and LPN#1. This in-service began on [DATE] and no staff will be allowed to work until the in-service training has been completed. On Friday [DATE] and Monday [DATE] the Attorney General Office came to the facility and in-serviced all Administrative staff including the Administrator, DON, and facility staff on Abuse and Neglect.
CNAs' and License Practical Nurse's (LPN) and RN's that worked were in-serviced on the importance of reviewing and following resident care plans to prevent potentially serious outcomes. This in-service training was conducted by RN#1, RN#2, and LPN#1. This in-service was complete on 03//29/2023 for staff that worked and no staff will be allowed to work until the in-service training has been completed. All care plans related to residents at risk for constipation were reviewed by Minimum Data Set (MDS) assessment nurses on [DATE]. The standing orders were initiated for all residents identified at risk. All care plans have bowel interventions in place.
An emergency QA meeting was held on [DATE]. In attendance were the Administrator, DON/Infection Preventionist (IP), Assistant Director of Nursing, QA RN#2 and QA LPN#1, MDS RN#3 and MDS LPN#2, the Social Service Director and the Nurse Practitioner. Changes in CNAs charting from paper to kiosk was discussed. Staff in-service on constipation and standing orders were discussed and initiated by RN#2. It was decide to hire staff Development nurse.
An Emergency QA meeting was held on [DATE]. In attendance was the Medical Director, Administrator, DON/IP, QA RN#2, QA LPN#1, MDS LPN #2 and Accounts Manager. Immediate Jeopardy deficiencies and immediate Action Plan was discussed.
We allege the immediacy of the jeopardy was removed on [DATE] and the IJ was removed on [DATE].
VALIDATION:
On [DATE], the SA validated the facility had implemented the following measures to remove the Immediate Jeopardy (IJ). The Removal Plan was verified by staff interviews and record reviews of in-services and sign-in sheets.
On [DATE] the SA confirmed through interviews with DON (RN#1), interviews with the x 2 QA nurses (RN#2 and LPN#1), interview with the ADON (RN#3), interview with the Wound Care Nurse (RN#4), and interview with MDS/Care Plan nurse (RN#5), and validated that the five (5) Registered Nurses assessed all 88 residents at risk of no bowel movements (BM's) and they initiated the Bowel Program policy and procedure for those residents that were identified.
The SA validated through interviews and record review of the in-service sign in sheets that eight (8) CNAs' working in the building on all three (3) shifts on [DATE] had attended in-service training beginning on [DATE] in reference of documentation of BM's in the kiosk. Interviews with six (6) RN's and five (5) LPN's confirmed that they had been in-serviced to supervise the CNAs' documentation and to check the kiosk documentation after the CNAs' had documented.
On [DATE] the SA confirmed through interviews that the CNAs' ([TRUNCATED]
Sept 2019
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected 1 resident
Based on observation, staff interviews, resident interview, and review of the facility policy, the facility failed to resolve a grievance concerning a missing item for one (1) of 21 sampled residents,...
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Based on observation, staff interviews, resident interview, and review of the facility policy, the facility failed to resolve a grievance concerning a missing item for one (1) of 21 sampled residents, Resident #61.
Findings include:
Review of the facility policy entitled Resident and Family Grievance dated 8/6/2019 revealed, Prompt efforts to resolve include facility acknowledgment of a complaint/grievance and activity working toward resolution of that complaint/grievance 12) The facility will make prompt efforts to resolve a grievance.
During an interview on 9/17/2019 at 2:00 PM, Resident #61 reported she had been missing her green bedspread for a month. She stated she reported to housekeeping at that time the blanket went missing.
In an interview on 09/19/19 at 8:30 AM, Social Worker #1 stated Resident #61's family member had told her about the missing bedspread, but she could not remember when she had told her. Later that day Social Worker #1 provided a grievance written on 9/17/2019.
In an interview, 09/19/19 09:45 AM, the Administrator stated when a resident brings up a concern in the Resident Council meeting, the Activity Director brings it up in the morning meeting. The Social worker then looks for the missing items and if she finds the item, she does not always write a grievance.
In an interview on 09/19/19 at 10:15 AM, Certified Nursing Assistant #1 stated Resident #1 had a green blanket that had been missing over a week and a half.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based on Staff Interview, Record Review, and Facility Policy Review, the facility failed to prevent the use of unnecessary medication for one (1) of seven (7) residents reviewed for unnecessary medica...
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Based on Staff Interview, Record Review, and Facility Policy Review, the facility failed to prevent the use of unnecessary medication for one (1) of seven (7) residents reviewed for unnecessary medications, Resident #48. Resident #48 was given medication for the diagnosis of Schizophrenia, after admission, with no prior history of this mental illness.
Findings include:
The facility's policy, Use of Psychotropic Drugs, not dated, noted the indications for initiating, as well as the use of non-pharmacological approaches, will be determined by: The indications for use of any psychotropic drug will be documented in the medical record. 2.3 Pre-admission screening and other pre-admission data shall be utilized for determining indications for use of medications ordered upon admission to the facility. 2.4 For psychotropic drugs that are initiated after admission to the facility, documentation shall include the specific condition as diagnosed by the physician. 2.4.1 Psychotropic medications shall be initiated only after medical, physical, functional, psychosocial, and environmental causes have been identified and addressed.
Review of current Physician's orders, revealed Resident #48 had orders for Seroquel 25 milligram (mg) at bedtime.
In an interview on 9/19/19 at 12:48 PM, the Pharmacy Consultant stated Resident #48 did not have a diagnosis of Schizophrenia on admission orders, nor was she taking Seroquel 25 milligram (mg) daily at bedtime.
In an interview on 09/19/19 at 1:33 PM, the Director of Nursing (DON) stated she was not sure why a diagnosis of Schizophrenia was added after Resident #48 was admitted .
In an interview on 09/19/19 at 2:41 PM, Licensed Practical Nurse (LPN) #1/ Minimum Data Set (MDS) Nurse, confirmed the Quarterly MDS on 6/24/19, does not list Schizophrenia as a diagnosis. She also confirmed Resident #48 did not have a baseline Care Plan to address the diagnosis of Schizophrenia, and if is listed as a diagnosis, there should be a care plan for it.
In an interview on 09/19/19 at 2:51 PM, the Medical Director and Resident #48's Primary Care Physician (PCP) stated that he was unable to find where the initial diagnosis of Schizophrenia came from for Resident #48. The PCP stated on review the progress notes from two (2) separate hospital progress notes, revealed no diagnosis of Schizophrenia prior to admission. The PCP stated the progress notes from a local hospital on 1/14/19, also did not reveal a diagnosis of Schizophrenia. The PCP confirmed he wrote a diagnosis of Labeled as Schizophrenic, but stated, I did not necessarily agree with that.
During an interview on 09/19/19 at 3:15 PM, the DON confirmed the Pre-admission Screening Resident Review (PASRR) Level II, dated 7/17/19, revealed Resident # 48 did not have sufficient documentation to support a diagnosis of Schizophrenia or Mental Illness, and did not have evidence of the need for Seroquel.
In an interview on 09/19/19 at 3:47 PM, Resident #48 stated she had never had a diagnosis of Schizophrenia. Resident #48 stated years ago when she was having family problems, a doctor told her she was upset because all women are neurotic. Resident #48 denied ever having other psychiatric concerns prior to admission.
A review of the admission Physician Orders for Resident #48, dated 2/1/19, revealed no diagnosis that included Schizophrenia, and no orders for Seroquel.
The facility admitted Resident #48 on 3/26/19, with the diagnoses which included: Acute Respiratory Failure with Hypoxia, Congestive Heart Failure, and Type 2 Diabetes Mellitus.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0577
(Tag F0577)
Could have caused harm · This affected multiple residents
Based on resident interviews, observations, and facility statement/policy, the facility failed to ensure residents were aware of the location and availability of the most recent survey results, this a...
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Based on resident interviews, observations, and facility statement/policy, the facility failed to ensure residents were aware of the location and availability of the most recent survey results, this affected four (4) of five (5) residents who attended the Resident Council group meeting, who complained they were unaware of the location of the survey results.
Findings include:
Review of the facility statement/policy, dated 9/19/19, revealed the facility posts the location of the State Survey Book on the bulletin board in the front hallway.
During the Resident Council meeting on 9/17/2019 at 2:00 PM, four (4) of five (5) residents complained they were unaware of the location of the survey results.
On 09/19/19 at 8:30 AM, interview with Social Worker #1 revealed she did not know where the survey results were posted in the facility.
The survey results were observed on 9/19/2019 at 8:35 AM, posted in the far corner of the activity room, which is not always readily accessible (such as a lobby or other area frequented by most residents, visitors or other individuals) where individuals wishing to examine survey results do not have to ask to see them. The notice was posted on the board Located in our activity Department you will find a copy of our most recent State Board of Health Survey Results, with a lot of other information. This was not in the front hallway.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected multiple residents
Resident #3
Review of Resident #3's yearly MDS, with the ARD date of 7/30/2019, revealed the MDS was not submitted to CMS until 9/17/19, and should have been completed and submitted by 7/30/19.
Resi...
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Resident #3
Review of Resident #3's yearly MDS, with the ARD date of 7/30/2019, revealed the MDS was not submitted to CMS until 9/17/19, and should have been completed and submitted by 7/30/19.
Resident #6
Review of Resident #6's Quarterly MDS, with the ARD date of 8/9/2019, revealed the MDS was not transmitted to CMS until 9/19/2019, which is more than 14 days past the due date.
During an interview on 09/19/19 at 05:10 PM, RN #1 confirmed the MDS's were late. The nurse said they printed out the assessment summary and noticed they had missed four (4) MDS's that had not been submitted. The nurse said she submitted the MDS's on 9/18/2019 for Residents #1, #7, #3 and #6.
Based on Record Review, Staff Interview, and facility policy Review, the facility failed to transmit the Minimum Data Set (MDS) in a timely manner for four (4) of four (4) residents reviewed for MDS transmission, of 24 sampled residents reviewed, Residents #1, #3, #6, and #7.
Findings Include:
Review of a signed statement on facility letterhead, dated 9/19/19, and signed by the Administrator, revealed the facility followed the Resident Assessment Instrument (RAI) Manual guidelines for submitting the MDS.
Record Review of the Resident Assessment Instrument (RAI) Manual, used by the facility for policy requirements, revealed the Transmittal requirements. Within 14 days after a facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System, including the following: (i) admission assessment, Annual assessment, Significant change in status assessment, Significant correction of prior full assessment, Significant correction of prior quarterly assessment, Quarterly review, A subset of items upon a resident's transfer, reentry, discharge, and death, Background (face-sheet) information, for an initial transmission of MDS data on resident that does not have an admission assessment.
Resident #1
Record Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 7/8/2019, revealed the MDS was not transmitted to Centers for Medicare & Medicaid Services (CMS) until 9/18/2019.
Resident #7.
Record Review of Resident #7's MDS, with an ARD of 8/1/2019, revealed the MDS was not transmitted to CMS until 9/18/2019.
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 Observation, Staff Interview, Record Review, and Facility Policy review, the facility failed to prevent the possible spread of infection by not cleaning Blood Pressure cuffs during medication...
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Based on Observation, Staff Interview, Record Review, and Facility Policy review, the facility failed to prevent the possible spread of infection by not cleaning Blood Pressure cuffs during medication Administration two (2) of four (4) Medication Pass Observations.
Findings Include:
Record Review of the facility's policy titled, Infection Control Policy with an effective date of 1/1/07, revealed it is the policy of this facility to maintain an infection control program as follows: designed to provide a safe, sanitary, comfortable environment to help prevent the development and transmission of disease and infection.
Observation on 9/18/2019 at 4:51 PM, of a medication pass with Licensed Practical Nurse (LPN) #3, revealed the nurse failed to clean the blood pressure cuff between resident contact of Residents #62 and #66.
During an interview on 9/19/2019 at 2:58 PM, LPN #3 confirmed she pulled the cuff out of her pocket and failed to clean the blood pressure cuff in between both residents, Resident #62 and Resident #66.
During interview on 9/19/2019 at 3:30 PM, the Director of Nursing (DON) confirmed the nurse should not put the blood pressure cuff in her pocket. The DON also said the nurse should clean the blood pressure cuff after each use, between residents.
A review of the facility's face sheet revealed the facility admitted Resident #62 on (12/14/2016), with diagnoses, which included Hypertension, Atrial Fibrillation, and Chronic Obstructive Pulmonary Disease .
A review of the facility's face sheet revealed the facility admitted Resident #66 on (5/10/2013), with diagnoses, which included Diabetes Mellitus, Hypertension and Major Depressive Disorder.
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?"
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 6 life-threatening violation(s), Special Focus Facility, 2 harm violation(s), $450,136 in fines, Payment denial on record. Review inspection reports carefully.
- • 32 deficiencies on record, including 6 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $450,136 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 is on CMS's Special Focus list for poor performance. Consider alternatives strongly.
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About This Facility
What is Lakeview Nursing Center's CMS Rating?
LAKEVIEW NURSING CENTER does not currently have a CMS star rating on record.
How is Lakeview Nursing Center Staffed?
Staff turnover is 59%, which is 12 percentage points above the Mississippi average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.
What Have Inspectors Found at Lakeview Nursing Center?
State health inspectors documented 32 deficiencies at LAKEVIEW NURSING CENTER during 2019 to 2025. These included: 6 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 2 that caused actual resident harm, 23 with potential for harm, and 1 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Lakeview Nursing Center?
LAKEVIEW NURSING CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 105 certified beds and approximately 83 residents (about 79% occupancy), it is a mid-sized facility located in GULFPORT, Mississippi.
How Does Lakeview Nursing Center Compare to Other Mississippi Nursing Homes?
Compared to the 100 nursing homes in Mississippi, LAKEVIEW NURSING CENTER's staff turnover (59%) is significantly higher than the state average of 46%.
What Should Families Ask When Visiting Lakeview Nursing Center?
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?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the facility's high staff turnover rate.
Is Lakeview Nursing Center Safe?
Based on CMS inspection data, LAKEVIEW NURSING CENTER has documented safety concerns. Inspectors have issued 6 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility is currently on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes nationwide). The facility has a 0-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 Lakeview Nursing Center Stick Around?
Staff turnover at LAKEVIEW NURSING CENTER is high. At 59%, the facility is 12 percentage points above the Mississippi average of 46%. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Lakeview Nursing Center Ever Fined?
LAKEVIEW NURSING CENTER has been fined $450,136 across 4 penalty actions. This is 12.0x the Mississippi average of $37,580. 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 Lakeview Nursing Center on Any Federal Watch List?
LAKEVIEW NURSING CENTER is currently on the Special Focus Facility (SFF) watch list. This federal program identifies the roughly 1% of nursing homes nationally with the most serious and persistent quality problems. SFF facilities receive inspections roughly twice as often as typical nursing homes. Factors in this facility's record include 6 Immediate Jeopardy findings and $450,136 in federal fines. Facilities that fail to improve face escalating consequences, potentially including termination from Medicare and Medicaid. Families considering this facility should ask for documentation of recent improvements and what specific changes have been made since the designation.