MEADOW VIEW HEALTH & REHABILITATION
For profit - Corporation
120 Beds
MO OP HOLDCO, LLC
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
0/100
#422 of 479 in MO
Photo by Meadow View Health & Rehabilitation
Photo by Meadow View Health & Rehabilitation
Photo by Google Street View
1 / 5 photos
Last Inspection: May 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Meadow View Health & Rehabilitation has received a Trust Grade of F, indicating significant concerns and a poor overall reputation. It ranks #422 out of 479 facilities in Missouri, placing it in the bottom half of nursing homes in the state, and is #7 out of 8 in Cass County, meaning there is only one local option that is rated better. The facility's trend is improving, with a decrease in issues from 10 in 2024 to just 1 in 2025, but it still has a long way to go. Staffing is rated 2 out of 5 stars, with a turnover rate of 60%, which is average but could impact care continuity. Notably, the facility has faced serious incidents, including a resident going missing after being sent to an appointment unaccompanied and another resident being exploited for personal gain by a staff member, highlighting significant weaknesses in oversight and resident safety.
- Trust Score
- F
- In Missouri
- #422/479
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 60% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $17,136 in fines. Lower than most Missouri facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 28 minutes of Registered Nurse (RN) attention daily — below average for Missouri. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 54 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 12%
Review needed
10 → 1 violations
★☆☆☆☆
1.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★☆☆
3.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 10 issues
2025: 1 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Missouri average (2.5)
Significant quality concerns identified by CMS
Staff Turnover: 60%
13pts above Missouri avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $17,136
Below median ($33,413)
Minor penalties assessed
Chain: MO OP HOLDCO, LLC
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (60%)
12 points above Missouri average of 48%
The Ugly 54 deficiencies on record
2 life-threatening 6 actual harm
May 2025
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
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure resident shower rooms were kept clean, maintained and free fro...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure resident shower rooms were kept clean, maintained and free from build-up of black mold like/grime on the lower corner of the shower wall and shower floor tile located on 200 hallway; failed to ensure shower room was maintained and showed missing base board shower tiles and missing tile on memory care floor of the shower room and missing tile in the shower itself. This practice potentially affected all resident residents who used those shower rooms. The facility census was 82 residents.
Review of the facility's undated Daily Cleaning of Guidelines showed:
-The facility were complete regular inspect the shower room for signs of mold (often appearing as black, brown, or green stains), mildew and clogs.
-If mold or mildew return after cleaning report to maintenance immediately.
Review of copy Infection Prevention Rounds Maintenance Department check list dated 12/2021 showed:
-Insure integrity of caulking and tiles in shower stall is maintained as evidence by: in good repair, clean, no evidence of mold or mildew.
1. Observation on 5/29/25 at 9:40 A.M. of 200-hallways showed an unknown resident being escorted into the shower room by facility care staff.
Observation on 5/29/25 at 10:36 A.M. of the memory care shower room showed:
-An unknown resident was just escorted out the shower room.
-The room had large section of missing floor tile.
-Had build up grim in the corners shower room and shower stale.
Observation on 5/29/25 at 10:50 A.M. of the shower room [ROOM NUMBER] hallway showed:
The shower in the right side lower right corner, had exposed building stud and with missing tile or baseboard.
-The back right lower corner floor tile and wall tile had black like mold substance build up noted.
-Slight musty smell to the room.
-The resident toilet was not clean old brown substance splatter on inside of the toilet bowl.
During an interview on 5/29/25 at 10:30 A.M. Shower Aide B said:
-He/she cleans and disinfects the shower after each resident use.
-Housekeeping would be responsible for deep cleaning of the shower rooms.
-He/she not aware any black mold like or grim buildup in 500 hallway showers room.
During an interview on 5/29/25 at 10:36 A.M. Certified Medication Technician (CMT) B said:
-He/she was not aware any mold like substance in the 500-hallway shower room.
-He/she thought mold had been reported in the 200-hallway shower room.
During an interview on 5/29/25 at 11:00 A.M. Housekeeper B said:
-He/she was aware of possible black like mold build up in some of the resident's showers and in one resident room shower noted under shower mat.
-He/she has not been instructed to clean deep clean the shower rooms.
During an interview on 5/29/25 at 2:50 P.M. Registered Nurse (RN ) A said:
-He/she was aware of the black mold like substance/ grim in the 200-hallway shower room.
-The room had a musty odor noted.
-He/she had not reported the concern to housekeeping or maintenance.
During interview on 5/29/25 at 4:00 P.M. Maintenance Director said:
He/she was not aware of missing tile or expose wall materials in the shower rooms.
-Housekeeping would be responsible for the daily deep cleaning of the shower rooms and inspection for any mold or grim build up in the that room.
-Facility staff would be responsible for reporting any missing tile or shower room maintenance needed to the maintenance team.
-He/she would be responsible for checking the building eye wash station for any issue.
-He/she had just been notified of resident's room [ROOM NUMBER], shower floor having black grim mold buildup under a shower mat.
During an interview on 5/29/25 at 4:40 P.M. Administrator said:
-He/she would expect the nursing, bath aids, CNA's and housekeeping to notify administration staff of any mold, missing tiles or repairs need in shower rooms or any resident living area.
-He/she would expect housekeeping staff and maintenance staff to ensure the shower rooms are monitored and maintained for cleanness and in good repair.
Complaint # MO 00253529
Sept 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
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure one sampled resident (Resident #1) with limited range of motion (ROM) received restorative therapy services to prevent further decre...
Read full inspector narrative →
Based on interview and record review, the facility failed to ensure one sampled resident (Resident #1) with limited range of motion (ROM) received restorative therapy services to prevent further decrease in his/her ROM out of 10 sampled residents. The facility census was 91 residents.
Review of the facility's policy titled Restorative Nursing Services dated July 2017 showed:
-Residents would receive restorative nursing care as needed to promote optimal safety and independence.
-Restorative nursing care consisted of nursing interventions that may or may not be accompanied by formalized rehabilitative services.
-Residents may be stared on restorative nursing program upon admission, during the course of stay, or when discharged from rehabilitative care.
-A restorative goal may have included maintaining his/her dignity and self-esteem.
1. Review of Resident #1's face sheet showed he/she admitted to the facility with the following diagnoses:
-Person injured in unspecified motor vehicle accident.
-Fusion of the spine (a surgery performed that joins two or more vertebra (any of the bony or cartilaginous segments that make up the spinal column) together), cervical region (the neck region of the spine).
-Unspecified displaced fracture (when the pieces of the bone move so much a gap forms around the fracture) of sixth cervical vertebra.
-Unspecified displaced fracture of seventh cervical vertebra.
-Unspecified fracture of the thoracic (T- middle section of spine)7-T8 vertebra.
Review of the resident's Restorative Nursing Instruction Form dated 6/11/24 showed:
-The resident was to receive restorative nursing three times a week.
-The resident was to receive active assisted range of motion (AAROM- performed when the patient/resident needs assistance with movement from an external force because of weakness, pain, or changes in muscle tone) to his/her lower extremities.
-The goals of the program were:
--Improve sitting tolerance and balance.
--Maintain functional level.
Review of the resident's Annual Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 8/17/24 showed:
-The resident was cognitively intact.
-The resident had full functional range to his/her upper extremities.
-The resident had full functional range to his/her lower extremities in ROM.
-The resident was fully dependent (helper does all of the effort, resident does none of the effort to complete the activity) for the following:
--Eating.
--Oral hygiene.
--Toileting hygiene.
--Showering/bathing.
--Upper body dressing.
--Lower body dressing.
--Putting on/off footwear.
--Personal hygiene.
--Rolling left and right.
--Going from a sitting to lying position.
--Going from a lying position to sitting on the side of the bed.
--Chair to bed transferring.
--Tub/Shower transferring.
-The resident had zero days of restorative nursing in which active ROM (the ROM that can be achieved when opposing muscles contract and relax, resulting in joint movement) or passive ROM (ROM that is achieved when an outside source exclusively causes movement of a joint and is usually the maximum ROM that a joint can move) in the seven days look back period.
Review of the resident's care plan dated 9/4/24 showed:
-The resident had an Activities of Daily Living (ADLs) self-care performance deficit related to limited mobility due to quadriplegia (paralysis that affects all a person's limbs and body from the neck down).
-The resident had quadriplegia related to his/her spinal injury with a goal for the resident to maintain optimal status and quality of life within limitations.
Review of the resident's response history for the task Restorative Program dated 8/13/24 through 9/5/24 showed:
-The resident only received ten minutes of restorative therapy during that time period.
-The task had been documented as not applicable (N/A) 10 times out of 12 opportunities.
During an interview on 9/9/24 at 10:54 A.M. the resident said:
-He/She was supposed to get ROM exercises from the facility's Restorative Aide.
-He/She had not received any restorative therapy in the last three months.
-He/She thought the reason why he/she was not receiving his/her restorative therapy was due to staffing issues.
-He/She had benefited from the restorative therapy.
During an interview on 9/9/24 at 1:23 P.M. Certified Medication Technician (CMT) A said he/she was unsure of what therapy services the resident was supposed to receive.
During an interview on 9/9/24 at 1:50 P.M. Licensed Practical Nurse (LPN) A said:
-The resident used to receive restorative therapy.
-He/She thought there might have been an insurance problem and that was why the resident was no longer on restorative therapy services.
During an interview on 9/9/24 at 2:00 P.M. the Director of Nursing (DON) and Administrator said:
-There was a binder that held the orders for all residents currently on a restorative program.
-The Administrator thought that residents were re-evaluated for restorative therapy monthly.
-He/She thought the resident did not have an active order for restorative therapy.
During an interview on 9/9/24 at 2:08 P.M. Certified Occupational Therapist Assistant (COTA) A said:
-The Restorative Nursing Instruction Form indicated the resident had an active order for restorative therapy.
-The facility had just hired a new Restorative Aide.
-The therapy department was responsible for recommending restorative therapy services.
-Restorative therapy was still beneficial to the resident.
-Residents were re-evaluated for restorative therapy every three months.
-The resident would be re-evaluated for restorative therapy on 9/11/24.
During an interview on 9/9/24 at 2:15 P.M. CMT A said:
-He/She had not been trained on performing restorative therapy.
-He/She had charted not applicable (NA) on the restorative program task because the task was not applicable to him/her.
-He/She was unsure how long the facility had been without a Restorative Aide.
During an interview on 9/9/24 at 2:21 P.M. LPN A said he/she thought the facility had been without a Restorative Aide for a couple months.
During an interview on 9/9/24 at 2:24 P.M. the Assistant Director of Nursing (ADON) said:
-The facility had been without a Restorative Aide for a month.
-He/She was unsure of who would be responsible for completing the restorative therapy during the absence of a Restorative Aide.
-When N/A was documented on a task that indicated the task was not completed.
-He/She was unsure of who was responsible for ensuring the restorative therapy was being completed.
During an interview on 9/9/24 at 2:33 P.M. the DON and Administrator said:
-The facility had been without a Restorative Aide since July or August.
-A Certified Nursing Assistant (CNA)/CMT could perform restorative therapy.
-The ADON was responsible for over-seeing the documentation and completion of the restorative therapy.
NOTE: After the interview was conducted it was clarified that the facility had been without a Restorative Aide from 7/10/24 until the present.
MO00241400
May 2024
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain a physician order for the setting of the low a...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain a physician order for the setting of the low air loss mattress (LAL - a mattress designed to distribute weight over a broad surface and help prevent skin breakdown. It has continuous air flow through tiny holes on the mattress surface) for one sampled resident (Resident #77) who had developed a Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. It may also present as an intact or open/ruptured blister) out of 18 sampled residents. The facility resident census was 88 residents.
Review of the facility's Pressure Ulcer (PU)/Skin Breakdown - Clinical Protocol policy, revised April, 2018 showed the physician will order pertinent treatments, including pressure reduction surfaces and identify medical interventions related to wound management.
1. Review of Resident #77's admission Record showed the resident was readmitted to the facility on [DATE] with diagnoses that included dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses).
Review of the physician's Orders Summary Report (OSR) showed LAL mattress on at all times. Settings at resident's comfort. Check comfort level and functioning status every shift and as needed for skin integrity, starting 3/4/24.
Review of the resident's current Skin Integrity Care Plan, initiated 9/15/23 and showed:
-LAL mattress as ordered, initiated 3/4/24.
-An opened area was classified as pressure on 5/17/24.
-There was no information on how the resident's LAL mattress was to be set.
Review of the resident's Electronic Medical Record (EMR) showed the resident's most recent weight was 130.8 pounds on 5/3/24.
Review of the resident's Weekly Wound Assessment, dated 5/17/24 showed:
-A Stage II PU was identified on 5/17/24 on the resident's coccyx (small triangular bone at the base of the spine) measuring 1.8 centimeters (cm) long, 0.7 cm wide and 0.2 cm deep, red in color with no drainage or odors.
-Turn resident every two hours, continue LAL mattress as ordered, cushion in resident's chair while up, vitamins and wound care as ordered. Physician notified.
-No LAL mattress setting was specified.
Review of the physician's OSR on 5/21/24 showed:
-LAL mattress on at all times. Settings at resident's comfort. Check comfort level and functioning status every shift and as needed for skin integrity, starting 3/4/24.
-The order had not been changed once the resident developed a PU to specify a LAL mattress setting.
Review of the resident's Significant Change Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 5/20/24 showed the resident:
-Was severely cognitively impaired.
-Was receiving hospice services (medical care focused on comfort and quality of life for a person approaching end of life).
-Was at risk for PUs.
-Had one Stage II PU.
-Had a pressure reducing device for his/her bed and wheelchair.
Observation on 5/19/24 at 11:35 A.M. showed:
-The resident was lying on his/her right side in bed.
-The resident appeared thin and frail.
-The resident's LAL mattress was set to 200 pounds.
-The LAL adjustment device had 130 pounds as one possible setting.
Observation on 5/20/24 at 10:33 A.M. showed:
-The resident was lying in bed.
-The resident's LAL mattress was set at 200 pounds.
During an interview on 5/22/24 at 11:12 A.M. Certified Medication Technician (CMT) A said:
-The resident had a PU for about three weeks. He/She had a LAL mattress before acquiring the PU.
-Direct care staff were responsible for repositioning the resident every two hours.
-The CMTs and Certified Nurse Assistants (CNAs) didn't touch the LAL settings and he/she hadn't been trained on appropriate settings.
Observation on 5/23/24 at 9:30 A.M. showed:
-The resident was lying in bed.
-The resident's LAL mattress was set at 200 pounds.
During an interview on 5/23/24 at 11:20 A.M. the Wound Nurse said:
-The physician and his/her Nurse Practitioner (NP) assessed the resident's PU and he/she did the resident's wound treatments.
-He/She monitored LAL mattress settings for all residents when doing wound treatments, but he/she didn't document anywhere when settings were checked.
-He/She wasn't sure if hospice checked the resident's LAL mattress settings when they visited.
-The resident's physician's orders show his/her LAL mattress should be set for comfort. Once the resident developed a PU the mattress should have been set according to his/her weight.
During an interview on 5/23/24 at 12:37 P.M. the Assistant Director of Nursing (ADON) said:
-If a PU develops or gets worse the LAL mattress could be too hard or too soft. The LAL mattresses should be at the setting closest to the resident's weight. If a resident's weight is half-way between two settings the LAL mattress can be set up or down.
-The CMT should check the settings every shift. The LAL mattress settings should be on the physician's orders and there should be an order to check the resident's LAL mattress. CMTs wouldn't necessarily know they should check the settings by weight if the order doesn't show it should be set according to weight.
-The CMTs don't adjust the settings, but they should tell the charge nurse or the wound nurse when the mattress isn't set according to weight.
-The resident was unable to communicate, except by grimacing, if the LAL mattress was comfortable.
-The mattress should be set as close as possible to 130 pounds for the resident.
During an interview on 5/23/24 at 1:01 P.M. LPN B said:
- If an order showed a LAL mattress was to be set for comfort the residents could tell staff how they wanted it set. He/She asked residents if they want the mattress alternating or static. He/She had been taught if a resident had a PU staff were to set it alternating and not on static.
-He/She hadn't received any training at the facility on setting LAL mattresses.
-The nurse had to document on the Treatment Administration Record (TAR) that they checked the mattress.
-He/She wasn't sure how staff knew how to set the LAL mattresses if the order showed it was to be set according to comfort.
-If the resident weighed half-way between two weight settings staff could set the mattress to the setting up or down from their weight. Any resident who had a PU should have the LAL mattress set according to their weight.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure accurate documentation of refusal of enteral fe...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure accurate documentation of refusal of enteral feeding via feeding tube called Percutaneous endoscopic gastrostomy (is a surgery to place a feeding tube also called a PEG or G-tube) and physician order for total amount caloric formula to be given in a 24 hour period, for one sampled resident (Resident #4) who's at risk for weight loss due to decline health, refusal of treatment and cares out of 18 sampled residents. The facility resident census of 88 residents.
Review of the facility Policy for Medication Orders revised on 11/2014 showed:
-Enteral feedings orders: when recording orders for enteral tube feedings, specify the type of feeding, amount, frequencies of the feeding and rationale if as needed.
-The order should always specify the amount of flushing following the feeding.
Review of the facility Enteral Tube feeding via a Pump revised on 11/2018 showed:
-Document the average fluid intake per day.
-If the resident refused procedure or enteral feeding document the reason why and intervention taken.
-Report to supervisor if the resident refuses procedures.
1. Review of Resident #4's admission Face Sheet showed the resident had diagnosis of:
-Gastrostomy (is a surgical procedure used to insert a tube, often referred to as a G-tube, through the abdomen and into the stomach.)
-Protein-Calorie Malnutrition (is the state of inadequate intake of food).
-Dysphagia (difficult to swallowing).
-Adult Failure to thrive (is a decline in older adults that manifests as a downward spiral of health and ability).
Review of the resident's Nutrition Assessment Note dated 2/13/24 showed:
-Had recent new diagnosis of Protein-Calorie Malnutrition, G-tube, Dysphagia, Diabetes Mellitus, Failure to thrive.
-readmission noted, resident back on enteral feedings as he/she used to be.
-Oral diet advanced to pureed but resident was not eating well and has a history of refusing pureed food.
-Therapy orders noted, including speech therapy for Dysphagia. Weight down 4.8 pounds in one month, 15.5 pounds in six months, within ideal body weight. Recent weekly weights reviewed.
-Blood Sugar are generally less than 200 on return.
-Would change enteral regimen to Glucerna 1.2 at 80 milliliters (ml) per hour(hr) times 20 hr per day with no change to water flushes.
-Will monitor weight/intake/enteral tolerance moving forward.
`
Review of the resident's Care plan initiated on 2/20/24 showed:
-The resident required tube feeding related to Dysphagia, failure to thrive and poor intake.
-Discuss with resident/family/care givers any concerns about tube feeding.
Review of the resident Quarterly MDS dated [DATE] showed:
-Was severely cognitive impairment.
-Required tube feeding and altered mechanical diet while a resident at the facility.
-His/her weight at time of assessment was 155 pounds.
-Was dependent on facility staff for all cares.
Review of the resident's Nutrition Task (amount eaten) from 5/1/24 to 5/21/24 showed:
-The resident had meal intake of 37 out 63 opportunities documented at 0-25% of meal eaten.
-The resident had meal intake of 7 out 63 opportunities documented at 26%-50% of meal eaten.
-The resident had meal intake of 3 out 63 opportunities documented at 51%-75% of meal eaten.
-He/she had refused meal 13 out of 63 opportunity.
Review of the resident's nursing note dated 5/16/24 at 7:36 A.M. showed:
-A late entry note: dated 5/15/24 at 5:00 P.M., the resident hollering in his/her room, demanded to be unhooked from his/her PEG tube feeding stating I don't want this, get this off of me while pulling at his/her PEG tube in distress.
-Resident was assisted out of bed to dining room at that time.
-Notified social services of his/her distress and verbalization of not wanting his/her feeding per tube.
Review of the resident's nursing note dated 5/16/24 at 12:53 P.M. showed the nurse had notified the resident's nurse practitioner, about the resident's ongoing refusal at time for tube feeding and/or medications/general decline and routine refusal to eat pureed food. Order received for hospice (end of life) to consult/notified social services.
Review of the resident's nursing note dated 5/17/24 at 3:06 P.M. showed:
The resident continued to refuse tube feeding to be re-administered.
-He/she said, no and repeatedly says don't put nothing in there referring to his/her peg tube.
-Was unable to even flush the peg tube due to resident's agitation when he/she even touched the resident's peg tube.
-The resident also refused both breakfast and lunch, he/she would attempt to have the resident to eat dinner.
-Was told in change of shift report the doctor was already aware and a hospice care consult was pending.
Review of the resident's nursing note dated 5/18/24 at 3:09 P.M. showed:
- An enteral feed order every shift for hydration and to flush the peg tube with 250 cubic centimeters (cc) water every four hours.
-The resident was refusing anything to be put into peg tube including just water.
Review of the resident's Treatment Administration (TAR) dated from 5/1/24 to 5/31/24, showed:
-Enteral Feed every shift for nutrition Glucerna 1.2 to run at 85 ml/hr continuous time 20 hours off tube feeding from 10:00 A.M. to 2:00 P.M. (initial order was dated 4/18/24).
-Enteral feed every shift for hydration, Flush tube with 250 cc's water every four hours (order dated 2/7/24).
-Had documented on 5/16/24 at 6:30 A.M. code 9 and nursing initial, which meant to see progress note for tube feeding and water flushes.
-Had documented 5/16/24 at 6:30 P.M. had code 2 which meant resident refused tube feeding and water flushes.
-Had documented on 5/17/24, 5/18/24, had code 2 and nursing initial. Resident refused tube feeding and water flushed.
-Had documented on 5/19/24 and 5/20/24 a check mark and nursing initials of the tube feeding and water flushed were given.
Review of the resident's Orders - Administration Note dated 5/19/24 at 11:21 A.M. showed:
-Order to shut tube feeding off one time a day for overload.
-The resident was not allowing tube feeding to be infused at this time and stated don't put anything in that tube.
Observation and interview on 5/20/24 at 11:00 A.M., the resident showed:
-His/Her enteral feeding pump in the resident room was not running or connected to the resident.
-Had no formula bottle or bag hung on tube feeding pole/pump.
-The resident said he/she not getting tube feeding at this time.
Review of the resident's Orders - Administration Note dated 5/20/24 at 1:39 P.M. showed:
-A physician's order to shut the tube feeding off one time a day for overload.
-The resident continued to refuse his/her tube feed.
Review of the resident's Physician Order Sheet (POS) dated 5/21/24 showed:
-Enteral Feed every shift for hydration, Flush tube with 250 cc's water every four hours (order dated 2/7/24).
-On 5/21/24 an order for Enteral Feeding be placed on hold.
--Enteral Feed every shift for nutrition Glucerna 1.2 to run at 85 ml/hr continuous time 20 hours. The tube feeding turned off from 10:00 A.M. to 2:00 P.M. (initial order was dated 4/18/24).
-New order dated 5/21/24, nursing staff were to check feeding tube placement prior to administering medications or feeding.
--1. Current measurement for resident feeding tube was one centimeter (cm) between skin & bumper. If area between skin & bumper was more than finger width wide or two inches, notify physician.
--2. Residual (amount of formula left in the tube) check if 250 ml-500 ml, take measures to reduce risk of aspiration. If more than 500 ml, notify physician. Monitor residual every shift.
-NOTE: There were no physician's order's for recommended amount of tube feeding formula intake in a 24 hour and order for monitoring/documentation of caloric intake.
Review of resident nurse's note dated 5/21/24 at 12:40 P.M. showed:
-The resident's tube feeding was placed on hold until further notice due to refusals.
-Hospice was to consult.
-Nursing staff will continue with meals by mouth although intake was declining.
-The resident family member aware of the resident refusal.
Review of the resident's Order-Administration Note dated 5/21/24 at 11:31 A.M. showed:
-An order to shut off tube feeding one time a day for overload.
-The resident was refusing tube feeding states If you put that in, I will pull it out. I do not want it.
Review of the resident's Care plan revision on 5/21/24 showed the resident refusing to eat and refusing to allow tube feeding.
Observation and interview on 5/21/24 at 1:11 P.M. showed:
-The resident was in a low bed in his/her room.
-No meal tray in room.
-Had tube feeding pole and pump at bedside. Did not have tube feeding bottle hung or running.
During an interview on 5/21/24 at 1:12 P.M., Certified Nursing Assistant (CNA) G said:
-The resident was only staying up in his/her wheelchair for 30 minutes at a time.
-He/she not aware if the tube feeding was running at this time.
-The resident was declining in his/her health.
-He/she had a meal tray for the resident, but he/she did not want to eat.
-The meal tray was taken away.
Observation of the resident at 05/22/24 at 8:20 A.M., showed:
-The resident was in a low bed.
-The tube feeding pump not running, and no formula was hung at that time.
Observation and interview on 5/22/24 at 10:00 A.M., of the resident tube feeding and site showed:
-Registered Nurse (RN) A enter the resident room washed hand soap and water.
-The resident had agreed to have PEG tube site checked and to provide water flush through the feeding tube.
-RN A check PEG tube for residual, obtained a clear thick creamy substance from tube.
-He/she flushed the feeding tube with water.
-The resident said he/she would agree to have formula via pump connected.
-RN A said he/she needed to verify order, since tube feeding was placed on hold at that time.
-The resident was able to make his/her needs and wishes known, but difficulty understand him/her at times.
-RN A cleaned PEG site with Normal saline, then dried with gauze pad, then applied clean split 4 x 4.
-Resident denied any pain at this time.
During an interview on 5/23/24 at 9:49 A.M., with the resident said:
-He/she ate breakfast that morning and was up in wheelchair in dining area.
-He/she did have tube feeding per pump yesterday afternoon.
3. During an interview on 5/21/24 at 1:15 P.M., Licensed Practical Nurse (LPN) A said:
-The resident had a hospice evaluation and waiting on family response for approval of services.
-He/she was refusing his/her tube feeding and meals at times.
-The resident had a declined in health, with a short life expected.
-The resident's family members were aware of the resident's declining health, refusal of cares and meals.
During an interview on 5/22/24 at 8:00 A.M., Assistant Director of Nursing (ADON) said:
-Review of the resident TAR with ADON.
-When the resident had refusal of tube feeding and water flushes, he/she would expect nursing staff to code as refusal and document in the resident's nursing note.
-A check mark on TAR would indicate as treatment or medication were given as ordered or treatment completed.
-He/she had received an order to place tube feeding on hold 5/21/24, due to the resident's refusal of tube feeding and water flushes.
-On the TAR, if a check marked and nursing initial then would have meant tube feeding was given, but the resident had been refusing tube feedings and flushes. He/she and other nursing staff should had coded the resident refusal of tube feeding on the TAR and include a nursing note.
-He/she would expect nursing staff to documented refusal of tube feeding accurately and correctly.
-Nursing staff should report to the physician the resident refusal of tube feeding and document notification in the resident's nursing notes.
-The resident's family member was aware of his/her refusal of cares, tube feeding and medication.
-The facility recently obtained a physician order for hospice evaluation and care.
-The facility does not document or monitor the total amount of formula that was administered each shift.
During an interview on 5/22/24 at 9:42 A.M., RN A said:
-The resident had been refusing tube feedings.
-The resident had really did not want tube feeding since beginning, the family requested the resident be on tube feedings.
-The water flushing had also been refused by the resident.
During an interview on 5/23/24 at 12:13 P.M., RN A said he/she would document in the TAR if feedings were completed and if refused coded as refusal and complete a progress note for refusal and any action taken.
During an interview on 5/23/24 at 2:48 P.M., Regional Nurse and ADON said:
-The acting DON was out of facility for part of the survey.
-He/she would expect a physician order to include recommended intake amount and recorded per shift and would expect nursing staff to document the amount formula received each shift.
-He/she would expect to have accurate documentation and coding for administered and refusal for treatment/feeding in the resident TAR and progress notes.
-He/she would expect nursing staff to notify the resident physician of the resident refusal tube feeding and cares, and complete progress notes of the of the notification.
-He/she would expect the CNA to document in the resident oral meal intake or refusal of meals under the CNA Meal Task section.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to puree (to make food into a paste or a thick liquid suspension which is made from finely ground cooked food) turkey into a smoo...
Read full inspector narrative →
Based on observation, interview and record review, the facility failed to puree (to make food into a paste or a thick liquid suspension which is made from finely ground cooked food) turkey into a smooth texture that was not stringy. This practice potentially affected three residents with pureed diets. The facility census was 88 residents.
1. Review of the recipe for pureed turkey showed:
- Place turkey roasts in oven at a temperature of 375 ºF (degrees Fahrenheit) and roast for 3-4 hours. [NAME] until an internal temperature of 165 ºF was reached.
- Remove from oven and allow turkey breast to rest for 15 minutes prior to carving.
- Hold at 135 ºF or greater, for service.
- For pureed step do the following: Remove the desired number of servings and add nutritive liquid such as milk, broth etc. Blend until desired consistency. Add approved thickener to achieve desired consistency if needed.
Observation on 5/19/24 from 12:57 P.M. through 1:00 P.M., showed the following:
- DC A did not have the recipe book open.
- Dietary [NAME] (DC) A placed 3 servings of (3-4 ounces per serving) into the food processor and added broth and he/she pureed the turkey servings and the broth together.
- After pureeing the turkey servings with the broth, DC A placed the mixture into a pan and placed that pan on the steam table without tasting the mixture for texture.
Observation on 5/19/24 at 1:00 P.M., during a taste test of the pureed turkey the texture of the pureed turkey did not have a smooth texture and consistency.
During an interview on 5/19/24 at 1:58 P.M., the Dietary Director (DD) tasted the pureed turkey and said the pureed turkey was a bit stringy.
During an interview on 5/19/24 at 2:01 P.M., the DD said he/she required the cooks to taste the pureed foods.
During a phone interview on 5/29/24 at 10:58 A.M., the Consultant Registered Dietitian (RD) said:
-He/she has been the Consultant RD to that facility for at least 10 years.
-He/she expected the cooks for that meal to taste the puree food
-He/she expected the cook that day to taste the pureed food 100 %.
He/she usually planned in-services for the dietary staff at least quarterly, but those do not always occur, due to dietary staff turnover and scheduling issues.
Realistically, in-services happen at least twice per year.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain the floors free from a heavy buildup of dust ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain the floors free from a heavy buildup of dust and debris in the following resident rooms 208, 207, 302, 300, 601, 510, 500 Hall shower room, 607, 405, 410, 409, 407, 401; failed to maintain the fans free of a heavy buildup of dust in the following resident rooms 302, 301; and failed to maintain ceiling vents free of a heavy buildup of dust in the following resident rooms 405 and the 500 Hall shower room . This practice potentially affected at least 30 residents who resided in or used those areas. The facility census was 88 residents.
1. Review of the undated Housekeeping Route sheet (a sheet which showed the steps to clean the resident rooms), showed:
7-Step room cleaning:
1. Pull Trash.
2. Dust horizontal surfaces.
3. Sanitize high traffic areas.
4. Spot clean walls.
5. Sweep floors under and behind furniture and beds.
6. Damp mop floors under and behind furniture and beds.
7. Wipe down beds.
8. Sanitize high touch areas such as call lights, bed remotes light switches etcetera (etc.)
2. Observations with the Maintenance Director (MD) and the Regional Maintenance Person on 5/21/24, showed:
- At 10:15 A.M., there was a heavy buildup of dust on the floor of resident room [ROOM NUMBER].
- At 10:17 A.M., there was a heavy buildup of dust on the floor of resident room [ROOM NUMBER].
- At 10:37 A.M., there was a crack in the shower chair in the 200 Hall shower room.
- At 10:51 A.M., there was a buildup of debris on the floor and the there was a buildup of dust on the fan blades in resident room [ROOM NUMBER].
- At 10:52 A.M. there was a buildup of grime on the floor in resident room [ROOM NUMBER].
- At 10:53 A.M., there was a buildup of grime on the floors in resident room [ROOM NUMBER].
- At 11:00 A.M., there was a buildup of dust and hair between the bed and the wall in resident room [ROOM NUMBER].
- At 11:05 A.M., there was a buildup of dust on the fan in resident room [ROOM NUMBER].
- At 12:44 P.M., there was a buildup of grime on the floor next to the bed in resident room [ROOM NUMBER].
- At 1:05 P.M., there was a buildup of debris on the floor behind the nightstand in resident room [ROOM NUMBER].
- At 1:09 P.M., there were many sugar packets, food crumbs and empty coffee creamer containers on the floor behind the 600 Hall nurse's station.
- At 1:18 P.M., there was a buildup of crumbs on the floor in resident room [ROOM NUMBER].
- At 1:37 P.M., there was a buildup of dust on the ceiling vent in the restroom of Resident room [ROOM NUMBER].
- At 1:39 P.M., there was a buildup of grime and debris in under the bed and next to the bed in resident room [ROOM NUMBER].
- At 1:42 P.M., there was a buildup of grime between the bed and wall in resident room [ROOM NUMBER].
- At 1:51 P.M., there was a buildup of food debris under the bed in resident room [ROOM NUMBER].
- At 1:53 P.M., there was a layer of dust between the bed and the wall in resident room [ROOM NUMBER].
- At 1:56 P.M., there was a buildup of dust ad debris on the floor in resident room [ROOM NUMBER].
3. Review of Resident #47's quarterly Minimum Date Set (MDS-a federally mandated assessment tool completed by the facility for care planning) dated 3/22/24, showed the resident was cognitively intact.
During an interview on 5/21/24 at 11:02 A.M., the resident said the housekeepers do not get behind his/her bed as he/she noticed a lot of debris between his/her bed and the wall in his/her room.
4. Review of Resident #5's quarterly MDS dated [DATE], identified the resident as cognitively intact.
During an interview on 5/21/24 at 1:54 P.M., the resident said the housekeeping department did not have enough staff to clean his/her room regularly.
5. Observation on 5/22/24 at 12:37 P.M., with the Housekeeping Supervisor showed a buildup of grime and hair along the wall in room [ROOM NUMBER].
During an interview on 5/21/24 at 12:47 P.M., the Housekeeping Supervisor said there were only three housekeepers at that time and the housekeepers felt rushed to get to every room.
During an interview on 5/21/24 at 1:10 P.M., Certified Medication Technician (CMT) B said the housekeepers do not get a chance to clean behind the nurse's station very often.
During an interview on 5/22/24 at 12:39 P.M. the Housekeeping Supervisor said the dust and debris were present on the floor of resident room [ROOM NUMBER], because there were only three housekeepers on staff and they feel rushed to get to every room and may not do as thorough as a job in cleaning each room.
During an interview on 5/23/24 at 1:04 P.M., Housekeeper A said:
- He/she did not have enough time to clean the resident rooms because they were short staffed.
- The housekeepers do their best to clean all the rooms.
- He/she did not have enough time to move the beds and he/she can get under the beds as best he/she can, when the residents do not have a lot of stuff under the beds.
6. Observations with the MD and the corporate Maintenance Person on 5/21/24, showed:
-At 1:34 P.M., there was a buildup of dust on the ceiling vent in the 500 Hall shower room.
-At 1:37 P.M., there was a buildup of dust on the ceiling vent in the restroom of Resident room [ROOM NUMBER].
During an interview on 5/21/24 at 1:35 P.M., the MD said he/she did not know how long the ceiling vent in the shower room had dust inside of it.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a system in place for monitoring shower/bathing...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a system in place for monitoring shower/bathing related to Activities of Daily Living (ADL's- grooming, bathing, hygiene), and to ensure baths or showers were provided at as scheduled for five sampled residents (Resident #6, #32, #58, #76, and #85) out of 18 sampled residents. The facility census was 88 residents.
Review of undated facility policy entitled Bath, Shower/tub showed:
-The purpose was to promote cleanliness, provide comfort to the resident and observe the condition of the resident's skin.
-Complete bathing per residence preference (shower or bath).
-Document the time the shower/tub bath was performed.
-Document the name and title of the individual(s) who assisted the resident with shower/tub bath.
-Document all assessment data.
-Document how the resident tolerated the shower /tub bath.
-Document if the resident refused shower/tub bath, the reason(s) why and the interventions taken.
-Document the signature and title of the person who recorded the data.
-Notify the supervisor if the resident refused the shower/tub bath.
-Report other information in accordance with facility policy and professional standards of practice.
1. Review of Resident #32's admission record showed the resident was admitted to the facility on [DATE] with a diagnosis of Cerebral Palsy (a congenital disorder of movement, muscle tone, or posture).
Review of the resident's bathing documentation from the Electronic Medical Record (EMR) dated 3/2024 showed:
-The resident received a shower on 3/8/24, 3/11/24 and 3/12/24 and was totally dependent on staff.
-The resident received a bed/towel bath on 3/21/24 and was totally dependent on staff.
-The resident was scheduled for a shower/bath twice a week and received four baths out of eight opportunities.
Review of the resident's bathing documentation from the EMR dated 4/2024 showed:
-The resident received a shower on 4/2/24, 4/12/24, 4/18/24 and was totally dependent.
-The resident was scheduled for a shower/bath twice a week and received three shower/baths out of nine opportunities.
Review of the resident's annual Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 4/20/24 showed the resident:
-Had severe cognitive impairment.
-Required staff to perform all the activities for bathing and showering.
Review of the resident's bathing documentation from the EMR from 5/1/24 through 5/21/24 showed:
-The resident received a shower on 5/14/24 and was totally dependent.
-The resident was scheduled for a shower/bath twice a week and received one shower/bath out of six opportunities.
Review of the resident's Skin Monitoring Comprehensive Shower Review sheets 5/1/24-5/21/24 showed:
-A signed shower sheet for 5/14/24 and 5/17/24 that did not show if a bath or shower was given was not signed by the Certified Nurse's Aide (CNA) just signed by the charge nurse.
-A signed shower sheet for 5/21/24 that does not show if a bath or shower was given and was signed by the CNA, but not signed by the charge nurse.
-The resident was scheduled for a shower/bath twice a week and received three shower/baths out of five opportunities.
-No other shower sheets were received.
Review of the resident's care plan revised on 5/2/24 showed the resident required total assistance for bathing/showering.
Observation on 5/20/24 at 10:18 A.M. showed the resident had greasy hair that was combed.
2. Review of Resident #58's admission record showed the resident was admitted to the facility on [DATE] with a diagnosis of quadriplegia (paralysis of all four limbs).
Review of the resident's bathing documentation from the EMR dated 3/2024 showed:
-The resident received a shower on 3/7/24, 3/14/24, 3/18/24, 3/21/24, and 3/25/24 and was totally dependent on staff.
-The resident was scheduled for a shower/bath twice a week and received five shower/baths out of eight opportunities.
Review of the resident's bathing documentation from the EMR dated 4/2024 showed:
-The resident received a shower on 4/11/24, 4/15/24, and 4/22/24 and was totally dependent.
-The resident was scheduled for a shower/bath twice a week and received three shower/baths out of nine opportunities.
Record review of the resident's quarterly MDS dated [DATE] showed the resident:
-Was severely cognitively impaired.
-Required staff to perform all the activities for bathing and showering.
Review of the resident's care plan revised on 4/16/24 showed:
-The resident required total assistance for bathing/showering.
-The resident's family preferred to do to the resident bed baths.
-The care plan did not state when staff were supposed to give baths.
Review of bathing documentation from the EMR from 5/1/24 through 5/21/24 showed no baths/showers were given.
Review of the resident's Skin Monitoring Comprehensive Shower Review sheets dated 5/2024 showed:
-The resident's family member gave the resident a bath on 5/11/24 and 5/20/24 signed by the charge nurse.
-The resident was scheduled for a shower/bath twice a week and received two shower/baths out of six opportunities.
During and interview on 5/20/24 at 9:30 A.M., the resident's family member said:
-He/She preferred the resident to have a bed bath instead of a shower.
-He/She preferred to do the bathing, but expected the facility to do the bathing when he/she could not.
3. Review of Resident #76's admission record showed the resident was admitted to the facility on [DATE] with a diagnosis of quadriplegia.
Review of the resident's admission MDS dated [DATE] showed the resident:
-Was cognitively intact.
-Required staff to perform all the activities for bathing and showering.
Review of the resident's bathing documentation from the EMR dated 4/2024 showed:
-The resident received a shower on 4/22/24 and was totally dependent on staff.
-The resident was scheduled for a shower/bath twice a week and received one shower/baths out of five opportunities.
Review of the resident's Skin Monitoring Comprehensive Shower Review sheet for 4/2024 showed:
-The resident received a bath/shower on 4/23/24 signed by the CNA, but the form did not show if the resident received a shower or bath and was not signed by the charge nurse.
-This was the only shower sheet provided by the facility.
Review of the resident's care plan dated 5/1/24 showed the resident was totally dependent on staff to provide a bed bath/shower twice weekly and as necessary.
Review of bathing documentation from the EMR from 5/1/24 through 5/21/24 showed:
-The resident received a shower on 5/2/24 and was totally dependent.
-The resident was scheduled for a shower/bath twice a week and received one shower/baths out of five opportunities.
During an interview on 5/19/24 at 12:08 P.M. the resident said that no baths had be given to him/her in over 20 days.
Review of the resident's Skin Monitoring Comprehensive Shower Review sheet for 5/2024 showed:
-The resident received a bath/shower on 5/21/24 signed by the CNA, but the form did not show if the resident received a shower or bath and was not signed by the charge nurse.
-This was the only shower sheet provided by the facility.
6. Review of Resident #6's admission Face Sheet showed the resident admitted to the facility with diagnosis of quadriplegia.
Review of the resident's Care Plan 6/29/21 showed:
-The resident has an ADL self-care performance deficit related to quadriplegia.
-During resident showers/bathing care staff were to check nail length, trim and clean on bath day and as necessary. Report any changes to the nurse.
-The resident requires total assistance from care staff for bathing/showers.
Review of the resident's Quarterly MDS dated [DATE] showed:
-The resident was cognitively intact.
-Required total assistance of facility staff for bathing and showers.
-He/she had impairment of both upper and lower extremities.
Review of the resident's electronic CNA Bathing Task dated 4/2024 showed the resident had documentation that he/she was given a shower 7 out 10 opportunities.
Review of the resident's Skin Monitoring: Comprehensive CNA Shower Review sheet for 4/1/24 to 4/30/24 showed.
-Had no documentation of nail care was provided.
-The resident had documented on shower sheet showed he/she was given eight showers out of 10 opportunities.
Review of the resident's Skin Monitoring: Comprehensive CNA Shower Review sheet for 5/1/24 to 5/23/24 showed:
-Had documentation of a shower given on 5/1/24.
-Had no written Skin Monitoring: CNA shower sheet were completed from 5/8/24 to 5/20/24.
-The resident had documented on a shower sheet showed he/she was given one shower out seven opportunities.
Review of the resident's electronic CNA task report for 5/2024 showed the resident:
-Documented had been given a shower on 5/13/24 and 5/15/24.
-The resident had bathing documented showed he/she was given a shower two out seven opportunities.
Observation and interview on 5/19/24 at 11:30 A.M., the resident said:
-The CNAs were not clipping the resident's fingernails and toe nails.
-Observation of the resident's fingernails were slightly long.
During an interview on 5/20/24 at 10:45 A.M. the resident said:
-He/she was supposed get showers on Monday and Thursday and was not receiving showers.
-He/she had not received a shower that morning.
-He/she had refused a shower one time when care staff came in at 6:00 A.M. to take him/her to shower room.
-He/she washed his/her own hair in the morning at his/her bedside.
During an interview on 5/20/24 at 10:54 A.M., CNA D said:
-He/she was only working until 2:30 P.M. that day.
-He/she was not sure what residents were scheduled for shower/baths that day.
-Observation showed the CNA D went into the shower room and obtain the resident's shower schedule.
-Resident #6 was listed under Monday and Thursday as his/her shower days.
During interview 5/22/24 at 5:28 A.M., CNA E said:
-Resident # 6 requires total assistance with cares from facility staff.
-The resident had made complaints to staff related not getting baths as schedule.
-He/she had seen the resident not well groomed upon coming on for shift.
-The resident would request bucket of water to be able to wash his/her hair while in bed. The CNA would assist the resident at that time.
-He/she had notified the day shift care staff that the resident was requesting a shower.
During an interview on 5/22/24 at 6:50 A.M., CNA B said:
-He/she would complete a Skin Monitoring Comprehensive CNA Shower sheet for resident had received a shower and if refused would write resident refused and number of times offered shower that day.
-He/she would document on CNA shower sheet care provided to include hair washed and nails clipped.
-The electronic record under Task the CNA would document bath given or refused.
-He/she would normally complete the Skin Monitoring: shower sheet form, which would include skin monitoring section.
-If resident refused a shower, he/she would document on shower sheet and have the resident signed the shower sheet form.
During an interview on 5/22/24 at 7:07 A.M., with CNA F said:
-Each CNA for that hall would complete the resident's shower assigned to the CNA that day.
-He/she would complete the skin/shower sheet and give to the nurse for review.
-He/she would notify the nurse if resident the refused showers or if found any skin issue during showers.
-He/she would have the resident sign shower sheet showing the resident had refused the shower.
-He/she would inform the charge nurse of resident refusal of care or new skin issue.
-The DON would review the resident shower sheets.
During an interview on 5/22/24 at 10:47 A.M., CNA D said:
-He/she would complete handwritten shower sheets and document the shower in the resident's EMR.
-He/she was not aware of any resident left alone shower room.
-Staff were stay with the resident while in shower for safety issue.
During an interview on 5/23/24 at 12:13 P.M., Registered Nurse (RN) A said:
-CNA would verbally inform him/her any skin changes or if resident had refused a shower or care.
-He/she was not aware who assigned the resident shower or were CNA were to document showers given.
-He/she had not received or reviewed resident shower sheets.
-He/she not aware of Resident #6 complaint of not getting showers.
7. During an interview on 5/23/24 at 9:23 A.M., CNA A said:
-Residents were supposed to get showers/baths two times a week.
-Realistically the residents rarely get bathed twice a week.
-Residents would hopefully get a shower/bath at least every two weeks to a month.
-The lack of showers was due to lack of staff. There were only two CNAs assigned for the three halls.
-When a resident refused a shower or bath, he/she would tell the charge nurse after trying to reeducate the resident on the importance of the shower/bath if the resident still refused.
-The bathing charting used to be done on the computer, but now on shower sheets were started about two weeks ago.
During an interview on 5/23/24 at 9:28 A.M., CNA B said:
-When a resident refused showers/baths he/she would try to reeducate the resident on the importance and chart the refusal in the computer or on a shower sheet and inform the charge nurse.
-Residents were supposed to get a shower/bath twice a week, but it would usually be one bath every two to three weeks for the residents.
-There was usually not enough staff to do showers twice a week in his/her opinion.
-There was usually only two CNA's for the three halls no bath aide.
During an interview on 5/23/24 on 9:34 A.M., CNA C said:
-Residents would get showered/bathed depending on the staffing schedule.
- Residents were showered/bathed at least once every week to every two weeks.
-The facility had no shower/bath aid full time.
-Two CNAs cannot work the hall provide cares, answer call lights and give baths.
-The shower/bath charting used to be done in the EMR but now was done on paper charting.
-When a resident refused a shower/bath he/she would inform the charge nurse.
During an interview on 5/23/24 at 9:40 A.M., RN A said:
-Residents were to be shower/bathed two to three times a week.
-Residents were being showered/bathed maybe once a week.
-He/she was unsure why, but felt it was because the facility did not have a full time bath aide.
-When a resident refused a shower/bath and was told this by the CNA he/she would find out why and the reason and then educate.
- When resident still refused a shower/bath he/she would chart the refusal and education that was given in the chart.
-He/She might not chart first refusal but defiantly the second and consecutive refusals.
-When the resident's preferences were identified he/she would put this information in the residents care plan.
-The shower/bath charting was done in the EMR as a task but now it was done on paper.
During an interview on 5/23/24 at 2:50 P.M., Assistant Director of Nursing (ADON) said:
-Shower/Bathing was discovered to be an problem and a performance improvement plan (PIP) was started in March.
-Documentation for shower and baths was done in the computer, but there was an issue with the computer, so it was changed to a paper process then.
-The charge nurse was to ensure the bathing sheets were being done.
-The charge nurse reviewed bath sheets and then signed them.
-The charge nurses would give the signed shower sheets to the ADON who reviewed them for skin issues.
-When a resident refused a shower. A shower sheet was still filled out with refusal written on it.
-The resident was supposed to sign the refusal shower/bath sheet if the resident was able.
-When a resident had multiple refusals the ADON would talk with resident and find out why and see if a compromise could made to make the resident willing to get the shower/bath.
-It was easier to track refusals and when multiple refusals happen with the shower/bath sheets versus the computer.
-Prior to the PIP there was no system in place to track showers/baths.
-The expectation was for residents to get showers/baths was minimal shower/bath twice a week.
-He/she felt that if had been more than three weeks since a resident had a shower/bath it was an issue.
-The computer charting system did not flag if showers/baths were not done there was no report the system could generate.
-This was why it was decided to go back to the shower/bath sheets so the showers/baths would be tracked.
-The process for a refusal was when a resident refused a bath/shower the CNA reported this to the charge nurse then the charge nurse would approach and try to reschedule the shower/bath.
-The charge nurse would then sign the shower sheet and follow up on the bath/shower.
-There had been a lot of change in staff so tracking of the showers/baths had not been consistent.
-The facility had a bath aide and he/she used to track and reschedule residents for showers/baths he/she was then making up for missed showers/baths.
-He/She had left the facility about a month ago and the facility has not been able to hire a new bath aide.
-When a shower/bath was missed it should be charted in the progress notes and the reason why it was and the education provided.
-Residents should have received showers/baths at least twice weekly.
MO00236026, MO00235049 and MO00236223
4. Review of Resident #85's admission Face Sheet showed the resident was admitted to the facility on [DATE] with diagnosis of traumatic brain injury (TBI - damage to the brain resulting from external mechanical force).
Review of the resident's ADL Care Plan dated 12/21/23 showed the resident required extensive assistance by one staff with showering twice weekly as necessary.
Review of the resident's Quarterly MDS dated [DATE] showed the resident:
-Was severely cognitively impaired.
-Required substantial/maximal assistance of facility staff for bathing and showers.
-Was frequently incontinent of urine and occasionally incontinent of bowel.
Review of the resident's undated shower schedule showed the resident was scheduled for showers on Tuesdays and Fridays.
Review of the resident's electronic CNA Bathing Task dated 3/2024 showed:
-The resident received showers on 3/1/24, 3/15/24, 3/21/24 and 3/26/24.
-On 3/5/24, 3/12/24, and 3/29/24 the resident did not receive a shower or bath. There was no documentation why these showers were missed.
-The resident received four out of nine showers.
Review of the resident's electronic CNA Bathing Task dated 4/2024 showed:
-The resident showered on 4/2/24, 4/5/24 and 4/17/24.
-There was no shower as scheduled on 4/9/24, 4/12/24, 4/19/24, and 4/30/24. There was no documentation why he/she did not receive a shower.
-The resident received five out of nine showers.
Review of the resident's Skin Monitoring: Comprehensive CNA Shower Review Sheets for 4/2024 showed:
-He/she showered on 4/22/24, and 4/25/24. He/She refused a shower on 4/29/24, but there was no documentation why or if the resident had an opportunity to make up the shower. The resident did not sign the shower sheet acknowledging he/she refused the shower.
-The resident received five out of nine showers.
Review of the resident's Skin Monitoring Comprehensive CNA Shower Review sheets for 5/1/24 through 5/21/24 showed:
-The resident had a shower on 5/9/24. No other showers were given.
-The resident received one out of six showers scheduled for the three week period.
During an interview on 5/20/24 at 12:22 P.M., the resident said:
-He/She was not getting showers twice weekly as scheduled and had gone as long as two or three weeks before getting them.
-He/She had accidents and sometimes urinated before staff could get him/her to the toilet. The accidents made him/her smell.
-He/She needed help getting onto a shower chair and taking a shower. It was hard to get staff help for showers and staff never offered him/her a shower for any that were missed.
During an interview on 5/22/24 at 10:10 A.M. the resident's responsible party said:
-The resident sometimes urinated on himself/herself.
-The resident required staff assistance with ADLs.
During an interview on 5/22/24 at 11:08 A.M. Certified Medication Technician (CMT) A said the resident was incontinent every day. The resident just couldn't hold his/her urine and staff couldn't always toilet him/her in time.
During an interview on 5/23/24 at 3:16 P.M. CMT C said:
-All residents were scheduled to be showered twice weekly. The shower schedule was located at the nurses' desk and was available to all nursing staff.
-If a resident refused his/her shower staff were supposed to tell the charge nurse and the Director of Nursing (DON).
-The resident was partly incontinent, so showers for him/her were important.
-Staff used to document showers on the residents' electronic CNA Bathing Task form, but some staff weren't filling it out like they were supposed to.
-Staff were recently asked to do shower documentation on the shower (Skin Monitoring: Comprehensive CNA Shower Review) sheets.
-Shower sheets should be completed for every shower given or refused.
-Showers should be given as scheduled.
-The resident sometimes refused to shower and staff had to sweet talk him/her into taking a shower.
-He/She didn't know why there was missing documentation of all the resident's scheduled showers, but there should be documentation showing all the resident's showers.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to cook broccoli florets so they would not be mushy; fail...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to cook broccoli florets so they would not be mushy; failed to follow the recipe for pureed (cooked food, that has been ground, pressed, blended or sieved to the consistency of a creamy paste or liquid) broccoli, so the broccoli would be palatable; and failed to maintain room trays at the 600 Hall and the 300 Hall at or close to 120 ºF (degrees Fahrenheit) at the time of service. This practice potentially affected at least 13 residents. The facility census was 88 residents.
1. Review of the recipe for pureed broccoli florets, dated 9/1/15, showed:
- Steam broccoli 15-25 minutes until tender.
- Drain broccoli, in large mixing bowl, and toss broccoli with margarine and season with salt and pepper.
- Transfer to service pans and hold at a temperature of 135 ºF or greater.
- Puree step: Remove desired number of servings and add nutritive liquid such as milk or broth. Blend until desired consistency.
- Add approved thickener to achieve desired consistency if needed.
Observation during a taste test on 5/19/24 at 10:33 A.M., showed the broccoli had a mushy and overcooked texture.
Observation on 5/19/24 at 12:00 P.M., showed the following:
- Dietary [NAME] (DC) A made pureed broccoli.
- DC A added water to the mixture.
- DC A had no recipe book open.
During a taste test on 5/19/24 at 12:05 P.M., the pureed broccoli tasted bland.
During an interview on 5/19/24 at 12:07 P.M., DC A said the pureed broccoli was more bland, after he/she tasted the pureed broccoli.
Review of the recipe with DC A showed that he/she should have added broth to the pureed mixture instead of just water.
During an interview on 5/19/24 at 2:33 P.M., the Dietary Director (DD) said:
-DC A had been training for only a couple of weeks.
-He/she expected the dietary staff to taste the pureed food for temperature and taste.
-He/she expected facility staff to use the recipe book when making pureed recipes.
During an interview on 5/19/24 at 2:36 P.M., DC A said:
- He/she thought he/she was trained.
- The other cook (DC B) he/she did not tell him/her about using the broth instead of water for the pureed broccoli.
2. Observation on 5/19/24 from 1:05 P.M. through 1:34 P.M., showed the following:
- At 1:05 P.M., the food cart arrived at the 600 Hall.
- There were 12 residents in the 600 Hall dining room.
- None of the food trays inside the cart, had covers on them.
- Certified Medication technician (CMT A) and the Marketing director started serving the residents.
- With 5 more trays in the cart, the state surveyor checked the temperature of the test tray and the following temperatures were recorded:
-Sliced turkey was 95.2 ºF, the mashed sweet potatoes were 93.3 ºF and the broccoli was 93.7 ºF.
During an interview on 5/19/24 at 1:34 P.M., CMT A said no one from the dietary department had come to the 600 Hall to check temperatures of the room trays.
3. Observation on 5/19/24 at 2:19 P.M. showed the following temperatures of a tray that was served on the 300 Hall with two residents left to serve showed the following temperatures: Sliced turkey was 93.9 ºF, the mashed sweet potatoes were 97.4 ºF and the broccoli was 95.5 ºF.
Record review of Resident #39's annual Minimum Date Set (MDS-a federally mandated assessment tool completed by the facility for care planning) dated 5/12//24 showed the resident was cognitively intact.
During an interview on 5/22/24 at 12:51 P.M., Resident #39 said:
- At almost every meal, the food was cold.
- About two out of every three days, the meals were cold.
- People who eat in the dining room get their meals delivered to them hot.
- It makes him feel like less of a person because the residents who ate in the dining room get hot food.
Record review of Resident #3's significant change MDS dated 5/9//24, identified the resident as cognitively intact.
During an interview on 5/22/24 at 12:56 P.M, Resident #3 said:
- The food was cold at times when it was delivered to his/her room.
- Turkey was offered on one day and the flavor was OK, but the food temperature was cold, so he/she did not like it.
Record review of Resident #83's quarterly MDS dated [DATE], identified the resident as cognitively intact.
During an interview on 5/22/224 at 1:03 P.M., Resident #83 said:
-The room trays were cold every day said the room trays are cold every day.
-On 5/22/24, the food was served warm, but usually it was cold.
- During breakfast meals, the eggs were usually cold.
- He/she has received warm milk in the past if the food the food was late.
During a phone interview on 5/28/24 at 2:11 P.M., the Dietary Director said:
- He/she was working on temperature logs.
- He/she liked the facility staff to measure the temperatures of the foods when they cook the foods, again about halfway through the service and close to the end of service.
- He/she did not have any processes for checking temperatures of meals when those meals got to a resident or a certain hall.
- He/she only knew of a few complaints from residents about the food being cold.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0923
(Tag F0923)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure there was negative airflow in the restrooms of the following r...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure there was negative airflow in the restrooms of the following resident rooms: 106, 102, 210, 209, 206/204, 205, 311/309, and 302/304. This practice potentially affected at least 20 residents who resided in those rooms. The facility census was 88 residents.
**Note: Air flow was tested by holding one piece of tissue paper to the ceiling vent. If the paper was drawn up then negative air flow was present; if the paper was not drawn to the ceiling vent, then negative airflow was absent.
1. Observations with the Maintenance Director and the Regional Maintenance Person on 5/21/24, showed:
-At 9:52 A.M., there was not any negative airflow from the restroom vent of resident room [ROOM NUMBER].
-At 9:57 A.M., there was not any negative airflow from the restroom vent of resident room [ROOM NUMBER].
-At 10:04 A.M., there was not any negative airflow from the restroom of resident room [ROOM NUMBER].
-At 10:11 A.M., there was not any negative airflow from the restroom of resident room [ROOM NUMBER].
-At 10:18 A.M., there was not any negative airflow from the shared restroom of resident rooms 206/204.
-At 10:21 A.M., there was not any negative airflow from the shared restroom of resident rooms 205.
-At 10:39 A.M., there was not any negative airflow from the shared restroom of resident rooms 311/309. and
-At 10:51 A.M., there was not any negative airflow from the shared restroom of resident rooms 302/304.
During a telephone interview on 5/29/24 at 5:08 P.M., the Maintenance Director said:
-When he/she investigated the issue regarding the ventilation he/she was not sure if it was something related to electrical wiring.
-Some fans needed a bigger motor.
-The issues which affected the fans not providing negative airflow, was a little different for each hall.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure sufficient staffing numbers to consistently provide timely A...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure sufficient staffing numbers to consistently provide timely Activities of Daily Living (ADL - dressing, grooming, bathing, eating, and toileting) assistance for two sampled residents (Resident #77 and Resident #69) out of 18 sampled residents and ADL-dependent residents on the [NAME] Side of the building and to ensure adequate weekend staffing as reflected on the Payroll Based Journal data (PBJ- a report that provides staffing dataset information submitted by nursing homes on a quarterly basis) for the fourth quarter of 2023 (July 1 - September 30, 2023) and first quarter of 2024 (October 1 - December 31, 2023) which had the potential to affect all residents. The census was 88 residents.
Review of the facility's Staffing policy, revised October, 2017 showed:
-The facility provided sufficient numbers of staff with the skills and competencies necessary to provide care and services for all residents according to identified resident care needs and facility assessments.
-Daily direct care staffing information was submitted to the Centers for Medicare and Medicaid Services (CMS) PBJ system on the schedule specified by CMS but no less than quarterly.
-Concerns relative to facility staffing should be directed to the Administrator or his/her designee.
Review of the facility's Hospitality Assistant (HA) Job Description, undated showed:
-The HA was responsible for providing non-nursing, non-direct care, and ancillary services under the direction of the nurse supervisor.
-Has assisted nursing staff by making beds, passing ice and water, passing linens, answering call lights, passing meal trays, distributing laundry, cleaning and organizing equipment, reporting resident and family concerns to the supervisor, stocking rooms with health care items, and non-hands-on care to residents.
1. Review of the facility's PBJ Staffing Data Report for Fiscal Year (FY) Quarter Four 2023 (July 1 - September 30, 2023) showed excessively low weekend staffing for the quarter.
Review of the facility's PBJ Staffing Data Report for FY Quarter One 2024 (October 1 - December 31, 2023) showed excessively low weekend staffing for the quarter.
2. Review of the Facility Assessment Tool, dated 5/2/24, showed:
-An average daily census of 95 residents.
-Seventy residents required some to total assistance from staff for dressing.
-Seventy residents required some to total assistance from staff for bathing.
-Seventy residents required some to total assistance from staff for toileting.
-Seventy residents required some to total assistance from staff for transferring.
-Sixty residents required some to total assistance from staff for eating.
3. Review of the working staff schedules, dated 5/15/24 through 5/21/24 showed:
-The facility had three distinct staffing areas. The [NAME] Side consisted of three halls. The East Side consisted of two halls and there was a Special Care Unit (SCU - locked unit for residents with cognitive impairments who were at risk for wandering and/or needed dementia-specific cares).
-There were twelve, eight, and four-hour shifts shown on the schedule.
-The following nurse aide staffing was documented on the [NAME] Side:
--On 5/15/24 two Certified Nurse Assistants (CNAs) worked four hours each covering one Night shift from 10:30 P.M. to 6:30 A.M. Two HAs, were scheduled four hours each to cover the Night shift, but could not provide resident cares. There was not a second CNA scheduled for the Night shift.
--On 5/16/24 one CNA worked from 10:30 P.M. to 6:30 A.M. An HA was scheduled, but could not provide resident cares. There was not a second CNA scheduled for the Night shift hours.
--On 5/17/24 there was not a third CNA scheduled for the Day Shift. No staff was assigned bathing/showering responsibilities. On the Evening shift from 4:30 P.M. to 6:30 P.M. there was only one CNA scheduled.
--On 5/18/24 there was not a third CNA scheduled for the Day shift.
--On 5/19/24 there was not a third CNA scheduled for the Day shift.
--On 5/21/24 there was only one CNA scheduled from 7:30 P.M. to 10:30 P.M. Two other CNAs left at 7:30 P.M. An HA was scheduled from 6:30 P.M. to 10:30 P.M., but could not provide resident cares.
4. Review of Resident #77's Significant Change Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning), dated 5/20/24, showed the resident was:
-Diagnosed with Alzheimer's disease (a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception).
-Severely cognitively impaired.
-Dependent upon staff for eating, toilet hygiene, bathing, dressing, and transfers.
Observation on the SCU on 5/19/24 starting at 9:46 A.M. showed:
-Three residents were sitting in the common area/dining room. There was no staff in the area.
-A few minutes later Certified Medication Technician (CMT) A came out of a resident's room.
-At 9:55 A.M. Resident #77 was observed lying in bed.
During an interview on 5/19/24 at 10:15 A.M. CMT A said:
-He/She had been the only staff on the SCU since 7:00 A.M.
-The East Side nurse could help as needed for medical cares.
-There should always be two people on the SCU on the Day shift, but someone called in and he/she was by himself/herself.
-He/She thought an HA was coming in. The HA could help pass trays and restock linens and gloves, but couldn't do hands on cares with residents like feeding, transferring, or changing anyone who was incontinent, so he/she would need to do all the resident cares.
-There were 17 residents on the unit. Seven were incontinent and also needed help getting dressed. Two residents required cuing to toilet and two others required one-person staff assistance for transfers.
-Resident #77 transferred with a two-person mechanical lift. The resident hadn't gotten out of bed since there was nobody on the unit to help get him/her up. The resident also needed help repositioning in bed.
-Resident #77 needed to be fed so he/she raised the head of the bed to feed him/her breakfast. Two other residents needed cueing during meals, so he/she had to feed Resident #77 at a separate time.
Observation on 5/19/24 starting at 11:16 A.M. showed the Marketing Director entered the unit.
During an interview on 5/19/24 at 11:20 A.M. the Marketing Coordinator said:
-He/She came in on a Sunday because there was a new admission.
-He/She had current nurse aide certification and would be assisting on the SCU for as long as was needed.
Observation on 5/19/24 starting at 11:46 A.M. showed:
-CMT A and the Marketing Coordinator went into Resident #77's room.
-They were observed using the mechanical lift to get the resident out of bed.
Note: Review of the working staff scheduled showed a Certified Medication Technicians (CMT) and a CNA were scheduled to work the entire 6:30 A.M. to 2:30 P.M. shift. The schedule was not adjusted to show only one staff had provided resident cares from 7:00 A.M. to 11:15 A.M.
5. Review of Resident #69's quarterly MDS, dated [DATE], showed the resident:
-Had previously had a stroke.
-Had an upper body impairment on one side.
-Was cognitively intact.
-Required maximal assistance (staff does over half the effort) for showering and required moderate assistance to transferring into the shower or tub.
-Required cueing and/or steadying for toilet transfers.
During an interview on 5/20/24 at 9:44 A.M. Resident # 69 said:
-He/She needed help with transfers on and off the toilet.
-He/She had been left on the toilet for 25 minutes during the night shift.
-There wasn't any staff responding to the bathroom call light.
6. During an interview on 5/22/24 at 5:20 A.M. CMT D said:
-On the SCU a CMT and either an HA or CNA was usually scheduled during the Evening shift and a CMT or CNA was scheduled on the Night shift.
-An HA was sometimes left with the residents when he/she took a break. When residents got up during the night the HA was unable to toilet them or change them. If anyone needed any resident cares while the HA was alone on the SCU the East Side nurse had to leave that area unattended and provide the cares because the nurse was the only staff person scheduled on the East Side at night.
During an interview on 5/22/24 at 6:10 A.M. CNA H said:
-Several times there had just been a nurse, himself/herself, and one HA working the three [NAME] Side halls at night. The nurse had to pass medications as needed during the night. The HA wasn't supposed to help with incontinent cares, transfers, and dressing. There were times only he/she and a nurse worked the three halls.
-The 300 hall had 10 incontinent residents and another resident needed to be taken to the toilet during the night.
-Nine residents on the 200 hall were incontinent and one had to be taken to the toilet.
-On the 100 hall there were two incontinent residents.
-When he/she was the only CNA working he/she was unable to keep up with all the cares the residents needed during the night. He/She just did the best he/she could.
During an interview on 5/22/24 at 6:33 A.M. CNA B said:
-He/She sometimes worked the 6:30 P.M. to 11:00 P.M. hours if the facility was short staffed. There were times between those hours that he/she and the nurse were the only two staff.
-Thirteen residents on the 300 hall were sometimes or always incontinent and one resident needed to be taken to the toilet.
-Three residents on the 200 hall were always incontinent and one needed to be taken to the toilet.
-Two residents on the 100 hall were incontinent and one needed help getting off the toilet.
-Many times he/she had worked the 6:30 A.M. to 6:30 P.M. hours with only a nurse and two CMTs.
-Before meals the nurse was always busy getting the diabetics' blood sugar levels and giving insulin and the two CMTs were busy passing medications.
-The facility needed at least three CNAs on the [NAME] Side to do the three halls. It was too much for one CNA to get residents out of bed, changed if wet, and dressed for breakfast. The [NAME] Side was busy before the lunch and supper meal as well with only one CNA.
During an interview on 5/22/24 at 6:56 A.M. CNA D said:
-He/She did the [NAME] Side halls by himself/herself the previous night from 6:30 P.M. to 11:00 P.M. A nurse was also on the unit but had to pass medications leaving just him/her to do the cares part of the time.
-Some of the 100 hall residents could put on their call lights to let him/her know if they were wet.
-There were at least five residents on the 100 hall and at least five on the 200 hall who were incontinent and couldn't use their call lights or tell him/her if they were wet, so he/she had to check on them frequently.
During an interview on 5/23/24 at 9:23 A.M., CNA A said:
-Residents were supposed to gets showers or baths two times a week.
-Realistically the residents rarely got them twice a week.
-Residents would hopefully get a shower or bath at least every two weeks to a month.
-The lack of showers was due to a lack of staff. Often there were only two CNAs assigned for the three [NAME] Side halls.
During an interview on 5/23/24 at 9:28 A.M., CNA B said:
-Residents were supposed to get two showers/baths twice a week, but it would usually be two to three weeks with no baths for the residents.
-There was usually not enough staff to do showers twice a week.
During an interview on 5/23/24 on 9:34 A.M., CNA C said:
-Residents would get showered/bathed depending on staffing coverage.
-Residents were showered/bathed at least once every week to two weeks.
-The facility had no shower/bath aide full time.
-Two CNAs couldn't provide cares, answer call lights, and give baths on the three [NAME] Side halls.
During an interview on 5/23/24 at 9:40 A.M., Registered Nurse (RN) A said:
-Residents were to be showered/bathed two-three times a week.
-He/She was unsure how often residents were showered/bathed, but thought it was maybe once a week.
During an interview on 5/23/24 at 10:30 A.M. the Assistant Director of Nursing (ADON) said:
-He/She was responsible for the staffing assignment sheets which should accurately reflect the various nursing staff working on any given shift.
-Shifts were 6:30 A.M. to 2:30 P.M., 2:30 P.M. to 10:30 P.M. and 10:30 P.M. to 6:30 A.M.
-Minimum staffing on the [NAME] Side was:
--On the Day shift there should be one nurse, two Certified Medication Technicians (CMTs), and at least three Certified Nurse Assistants (CNAs), one of which was responsible for resident showers and the other two CNAs were responsible for care on the three resident halls.
--On the Evening shift there should be at least one nurse, two CMTs and two CNAs.
--On the Night shift there should be at least one nurse and two CNAs.
-Staffing on the two East Side halls should be:
--At least one nurse and one CMT or CNA on the Day shift.
--One nurse and one CMT on the Evening shift.
--One nurse on the Night shift.
-Minimal staffing on the SCU was:
--One nurse and two CNAs on the Day shift.
--One nurse or CMT and a CNA on the Evening shift.
--One CMT or CNA on the Night shift. If a CNA was working the hall the nurse from the East Side would assist with medications and medical needs.
-Weekends should be staffed the same as the weekdays on all shifts and all living areas, and as far as he/she knew they were.
-HAs were not allowed to do any resident cares such as transfers, incontinence cares, or feeding. They could make beds, keep the linen cart tidy, answer call lights and relay messages to the nurse or CNA, get ice for residents, wash wheelchairs and wipe trash bins.
During an interview on 5/28/24 at 3:56 P.M., the Administrator said:
-He/she was not aware that the facility triggered for low weekend staffing on the PBJ Staffing Data Report for two quarters.
-The facility used a third-party vendor for payroll who sent a summation with hours worked for each nursing category which was used for submitting PBJ data.
-He/She and the DON and ADON were responsible for addressing any known low nursing staff numbers.
MO00236223
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation and interview, the facility failed to maintain the floor under the refrigerator in the storage room, free of heavy dust buildup; failed maintain the sprinkler heads over the handw...
Read full inspector narrative →
Based on observation and interview, the facility failed to maintain the floor under the refrigerator in the storage room, free of heavy dust buildup; failed maintain the sprinkler heads over the handwashing sink and the food preparation, free of dust buildup on the sprinkler heads; failed to remove a buildup of grime from under the deep fat fryer; failed to maintain the gaskets (a mechanical seal which fills the space between two or more mating surfaces, generally to prevent leakage from or into the joined objects) of the walk-in freezer and the reach-in refrigerator across from the food preparation table in good repair; failed to maintain the ceiling vents in the kitchen free of a heavy buildup of dust; failed to maintain the handles of the food spatula in good repair; failed to maintain the nozzle of the upper spray wand of the dishwasher; failed to have a trash container dietary staff did not have to use their hands to open the lid every time they placed trash in the trash container; failed to maintain the bottled milk in the dining room at or close to a temperature of 41 ºF (degrees Fahrenheit); and failed to have enough spatulas available for use. This practice potentially affected 87 residents who ate food from the kitchen. The facility census was 88 residents.
1. Observations on 5/19/24 from 9:49 A.M. through 1:40 P.M., during the lunch meal preparation, showed:
- A buildup of dust and debris under the refrigerator in the storage room.
- The presence of dust on the sprinkler heads over the handwashing station and the food preparation table.
- A buildup of greasy grime under the deep fat fryer.
- A 24.5-inch (in.) section of the gasket of the reach-in refrigerator next to the food preparation table was held to the refrigerator door frame with black tape.
- A buildup of dust on the ceiling vent over the clean side of the automated dishwasher.
- A buildup of dust on the sprinkler head between the food preparation table and handwashing sink.
-A buildup of grime under the deep fat fryer.
The presence of food debris on the blade of the tabletop can opener.
- The handle of a spatula with melted areas which were not easily cleanable.
- An 18.5 in. section of gasket of the walk-in freezer was in disrepair.
- The presence of debris in the nozzle of the upper spray wand.
- Dietary staff had to use their hands to lift the lid of trash container and wash their hands every single time.
- Dietary [NAME] (DC) A pulled two hamburgers from a frying pan and placed into a pan to place on the steam table without checking the temperature of the burgers.
- The DD said the kitchen ran out of spatulas while he/she looked for a spatula to use when another one was being used for another process.
- A temperature check was conducted of the milk that served in the dining room by pouring a sample of milk into a glass and the temperature of the milk was 50 ºF.
During interviews on 5/19/24, the Dietary Director (DD) said the following:
- At 10:59 A.M., he/she said the gasket of the refrigerator across from the food preparation table was held together tape before he/she started employment in 11/2023.
- At 11:01 A.M., he/she said the freezer did not close properly because of the damaged gasket and the lever at the top did not operate the way it should.
- At 1:46 P.M., the DD said he/she had not checked the temperature of the milk in the bins in the different dining rooms and may have to use a different method keeping the milk at a cool temperature.
- At 2:24 P.M., the DD said he/she expected facility staff to sweep under the refrigerator in the storage room nightly.
- At 2:26 P.M. he/she expected dietary staff to scrub clean under the deep fat fryer weekly and to sweep and mop nightly.
- At 2:29 P.M., DD said it was his/her job to check on the spatula handles to ensure they were easily cleanable. He/she knew about the white handled one but not the black handled spatula.
- At 2:36 P.M., the DM said the dietary staff needed another trash container with a foot operated lid.
During an interview on 5/22/24 at 1:20 P.M., the DM said he/she expected the dietary cooks to check temps of potentially hazardous foods.
Aug 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0557
(Tag F0557)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to promote and enhance one sampled resident's (Resident #2) feelings o...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to promote and enhance one sampled resident's (Resident #2) feelings of self-worth and self-esteem, when Certified Nursing Assistant (CNA) A, was disrespectful and rude out of four sampled residents. The facility census was 93 residents.
On 8/14/23, the Administrator was notified of the past noncompliance which occurred on 8/1/23. The facility administration was notified on the same day of the incident and the investigations were started. Facility staff were educated on Dignity, Respect, and Abuse policy, resident intervention and behaviors before the start of the next shift. Resident care plans were updated. The deficiency was corrected on 8/1/23.
Review of the facility policy titled, Dignity, dated 2/2021 showed:
-Each resident shall be cared for in a manner that promoted and enhanced his/her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.
-Resident were treated with respect at all times.
-The facility culture supported dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs.
-Staff speak respectfully to residents at all times, including addressing the resident by his/her name of choice.
-Demeaning practices and standards of care that compromise dignity are prohibited.
-Staff were expected to promote dignity and assist residents; for example:
--Promptly responding to a resident's request for toileting assistance.
1. Review of Resident #2's face sheet showed the resident admitted to the facility on [DATE] with diagnoses that include:
-Post Traumatic Stress Disorder (PTSD-a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event).
-Severe Protein Calorie Malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat).
-Gun shot wound.
-Open wound to his/her right lower leg.
Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning), dated 6/13/23 showed:
-Brief Interview of Mental Status (BIMS) score of 15, which indicated that the resident was cognitively intact.
-Required one person physical assistance for transferring, personal hygiene and toileting.
-Required two person physical assistance for dressing.
Review of the resident's care plan dated 6/20/23 showed the resident was in the facility for short term healing from a traumatic event.
Review of the facility investigation dated 8/1/23 showed:
-The resident approached the Social Worker (SW).
-The resident said he/she needed to speak with the SW.
-The resident said he/she turned on the call light in the bathroom, CNA A walked in and he/she said he/she needed his/her behind wiped.
-CNA A wiped the resident's behind and as he/she was walking out of the bathroom said, you can do everything else but wipe your self.
-The resident said, excuse me, what did you say his/her insurance paid for him/her to be there.
-CNA A then said, his/her taxes paid for him/her to be there.
-The resident then said that he/she recorded everything, as CNA A was rude and hateful.
During an interview on 8/14/23 at 11:35 A.M.,the SW said:
-The resident stopped him/her in the hall and was wanting to speak with him/her in private.
-The resident played a recording from his/her phone.
-The recording was:
--CNA A said, you can do everything else but wipe yourself.
--Resident then said, excuse me, what did he/she say because his/her insurance paid for him/her to be there.
--CNA A said, His/her taxes paid for him/her to be there.
-The resident shared that he/she recorded the conversation as he/she knew CNA A was rude and hateful.
-The resident was very angry.
During an interview on 8/14/23 at 11:50 A.M.,the Director of Nursing (DON) said:
-CNA A denied any wrong doing.
-The resident had recorded the interaction on his/her phone.
-Multiple attempts were made to obtain statements from witnesses of the situation, but the other employees are reluctant to make statements.
-Verbal statement heard on the recording showed CNA A did in fact make the statements to the resident.
During an interview on 8/14/23 at 12:05 P.M.,the Administrator said:
-The resident was no longer at the facility.
-The resident had his/her discharge planned before the incident, to a facility closer to his/her home, across the state.
-He/she felt that this incident was a dignity issue.
-Other staff were reluctant to give witness interviews about the incident.
-When the resident played the recording from his/her phone, they felt as though this was a dignity issue.
During an interview on 8/22/23 at 2:00 P.M., the resident said:
-That was all behind him/her now, as he/she was in a different facility.
-When CNA A said that to him/her, it really made him/her mad and he/she felt bad.
-He/she had started recording CNA A because he/she knew that CNA A would be rude and hateful.
-He/she was glad that he/she recorded the conversation, because that wasn't right.
MO00222338
Mar 2023
2 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0602
(Tag F0602)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to protect Resident #500 from misappropriation of propert...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to protect Resident #500 from misappropriation of property and exploitation when Hospitality Aide (HA) A took advantage of the resident for personal gain, through use of emotional manipulation while employed at the facility. Hospitality Aide (HA) A befriended the resident in order to gain the resident's trust, took money from the resident for personal gain, and made plans to take the resident's truck while employed at the facility. After HA A left employment and received the truck, she ended the relationship with the resident, causing him/her to feel emotional harm including feelings of being hurt, angry, and violated. This deficient practice effected one out of seven sampled residents. The facility census was 86 residents.
Record review of the facility's Abuse Prevention Program, dated December 2016, showed:
-Residents have the right to be free from misappropriation of resident property and exploitation.
-The administration will protect residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual.
Record review of the facility's Employee Handbook, dated 2021, showed:
-Resident rights:
--The employee has an obligation to read materials provided about resident rights, understand what they mean, and sign a written Resident Rights acknowledgement that they understand them as a condition of employment.
--Resident rights include, but are not necessarily limited to:
---Freedom from abuse, neglect, exploitation, and misappropriation of property.
-Code of conduct:
--Provides guidance regarding required ethical and business conduct- which all employees are expected to read, be familiar with, and follow the principles, which include, but are not limited to:
---Refraining from any conduct which might violate the fraud and abuse laws.
---Avoiding questionable gifts from vendors or any gifts from residents and their families.
-Employee/Resident interactions:
--While giving efficient and friendly service to residents and families employees may get to know residents and there may be occasions where professional boundaries may be implicated.
--An employee may be offered a gratuity (gift, money, etc.) in appreciation for something done. Employees should courteously decline any individual gift and report the offered gift to supervisor.
--Employees may not solicit a gratuity under any circumstances.
--Under no circumstances may an employee borrow money from, give a loan to, or accept a loan, from a resident or the resident's family member.
-Termination:
--Some violations of policy or standards may warrant immediate discharge, including but not limited to:
---Theft or other criminal conduct, including toward a coworker, a resident, and/or the resident's family.
-Abuse and Neglect:
--Residents have right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, neglect, and/or misappropriation of property.
--Misappropriation means depriving, defrauding, or otherwise obtaining the real or personal property of a resident under applicable law and regulations.
Record review of the Power Point slide presentation (undated) employees watch during the orientation process showed:
-Code of conduct:
---Refraining from any conduct which might violate the fraud and abuse laws.
---Avoid questionable gifts from vendors or any gifts from residents and their families.
-Customer service:
--Be professional and courteous.
-Abuse and neglect:
--Misappropriation means depriving, defrauding, or otherwise obtaining the real or personal property of a resident under applicable law and regulations.
1. Record review of HA A's personnel file showed he/she hired as a HA on 12/1/22. Job duties included- assist in passing drinks, meals, answering call lights and notifying the Certified Nursing Assistant (CNA) or nurse of a resident's needs; does not perform any type of resident cares. On 12/1/22, he/she took a quiz related to abuse, which included:
- It is not ok to borrow money from a resident.
-Residents have the right to be free from verbal, sexual, physical, or mental abuse, neglect, corporal punishment and involuntary seclusion.
- Employees cannot accept money or gifts.
Record review of the facility Abuse and Neglect in-service documentation dated 1/23/23 and 2/3/23 showed HA A attended the in-services and answered questions related to content of the in-service.
Record review of Resident #500's admission Record showed the following diagnosis Major Depressive Disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), recurrent, unspecified.
Record review of phone texts between HA A and the resident showed:
On 1/20/23, HA A wrote:
-Awww and 3 heart emoji (An emoji is a picture or symbol embedded in text and used in electronic messages and web pages. The primary function of emoji is to fill in emotional cues otherwise missing from typed conversation) Love you [NAME] cakes.
On 1/21/23, HA A wrote:
-Good morning dear. Aww so sorry ur (your) world is getting turned upside down maybe not a bad thing tho (though). Mine is too as we speak. Everyone is clearing out and you are still holding strong [NAME]. I love you (heart face emoji) thanks for loving us.
-Is grandpas land liveable?or what is it. Always dreamed for like a good new car. But I will have like 4k soon so hopefully find a good one with that. I still fixing home situation now. I hope.
-Love you too. (Heart eyes face emoji.)
-I love you too hunny. Yes too long without seeing you. I miss you. (sad face, crying emoji, and 7 heart emoji) sweet dreams dear.
-Life is sure hard. I just want to live peaceful. Be happy. Calm and comfortable. Ot always worried about how I'm gonna make it or who's our (out) to hurt me.
-Awww. You mean a lot to me [NAME] cakes. Yes, you can be married to someone thru God. Doesn't have to be paperwork. I have never been married. But used to call the abusive one husband.
-On 1/22/23:
-The resident texted: I have the cash for you! I'll try and have my friends bring up my diesel to drive until you get your money or when. It's ford 350? Crew cab so there would be plenty of room for all 4 us. It's a bug TRUCK I like big Trucks oh ya. If you think you can drive we'll make it work I'll put your name as a driver I gave permission to drive. Ins co. (insurance company)
Pictures of the house in [NAME] city (resident sent two pictures of living area).
I had went thru house and remodeled it I love it and I love [NAME] city hope you will.
-HA A texted:
-Oh yes. I love big trucks I am good driver. Always drove big cars and vans. Used to pull a 19 ft trailer. Been walking for 3 years now because when I broke those windows and went to jail they took my license. Even tho (though) I was on foot. It was wrong and I couldn't fight it because I was in jail.
-I love you. Miss u (crying sad face, heart emoji). Still can't talk a whole lot at work cause they on me. But soon I will have you all to myself.
-And oh good cause I had to spend some cash on my medicine. Couldn't take the stress any longer so now im short. That will replace it so I don't get in trouble. Hanging in there best I can. U give me hope. I love you (resident's name). Glad to be your soulmate wifey.
-I trust you. What a wonderful man the Lord's sent for us. (heart and lip emoji)
-On 1/23/23, HA A texted:
-Good morning hunny (heart emoji)
-Awwww hunny. Don't be depressed. I love you. Today has been rough. Looking forward to seeing ur face tomorrow. Bright eyed to see me. How wonderful.
On 1/24/23:
-HA A texted: I'm coming don't say nothing about money or nothing. I will get it. People everywhere. LOL it's ok hunny I got the money but left your card cause u (you) had cash u said. There was people everywhere so I just had to be quick. I am on a transport. But I'll be back (2 heart emoji)
-The resident texted: The card is for you also. Pick up at your convenience please. You looked so pretty in the photo wow (emoji). No fair you get to see me but me see you no not fair!! Love you sweetheart! (2 heart emoji)
-HA A texted: So what's the card for? 80? For diapers lol
-The resident texted: Yes whatever you want 85 if you want just because I love you sweetheart sweet mommy (2 heart emoji)
-HA A texted: lol ok (a four digit pass code) I had to leave a bit early. But will bring ur card back tomorrow and say hi again. Im very depressed but trying to snap out of it. Yep it's (a four digit pass code) I found the message;
-The Resident said: I trust you. Remember I love you (2 heart emoji)
-On 1/25/23
-HA A texted: Darnnit. Really want to drop this card off with so I don't have to keep it another day. Just for here tho and I am on the other side. It is hard to get to ur room without being see but I'll try. Love you hunny. (2 red hearts) frustrated a bit but hanging in there. Ahng (Hang) in there too! (prayer hands emoji)
-The Resident texted: no proble (problem) with the ard (card) I could feel that you were upset, didn't risk getting in trouble (devil face emoji) I miss u but safe is better (2 heart emoji)
-On 1/26/23:
-HA A texted: Love u too. They moving (name of resident's roommate) out of ur room. I feel like they always watching me. Probably cause they are. Just talk work. (3 red heart emoji)
-Good night, hunny. I love you. (heart emoji)
-On 1/27/23:
-Good morning hunny (heart emoji) just getting up (kiss face emoji) u too. Hope to see u.
-Thanks so much for loving and caring about us (3 heart emoji) love you too.
-Sweet dreams hunny (heart emoji);
-On 1/28/23:
-HA A texted: Good morning [NAME] cakes. Have a good day (heart emoji);
-Good night hunny (sleeping face emoji) just been enjoying day off pretty good. (heart eyes emoji);
-On 1/29/23:
-The resident texted: Good morning sweetheart a big hug and kiss for you all. Was thinking about 2nd or 3rd week in February I may have to leave meadowview for a couple weeks before they operate on my shoulder if that's the case I'll drive up here so I can drive you around if you want. As soon as the house is empty you may move in, maybe you could pay me $200 a month for rent to help with expenses. Just think about it. It's the bed I could do! Wish I could do more for you. Your [NAME] cakes loves his sweet Angel Mommy very much (3 heart emojis and 4 lips emojis)
-HA A texted: Good morning hunny. Yes that sounds good. Keep me informed. Home in the cold with my little men today. Cleaning and playing. (3 heart emoji)
-On 1/30/23:
-HA A texted: Awww thank you hunny. I just met with caseworker and she said I do need to start working on somewhere else to go cause the daycare and housing keeps turning me down. I have until [DATE] and they not kicking me out but will meet every week after that until I find something else. Gotta start calling other shelters and programs and stuff. Keep me informed on truck and the house and stuff. Don't worry it will work out. Gotta call [NAME] City today and see about license and just duties duties.
-The resident texted: The truck is at the house I'll try and find out if house empty. When I find out I'll let you know. the truck is yours if you want. wound (would) $3500 work for you? If not then talk to me, love (heart emoji) sweet mommy it's [NAME] cakes.
-HA A texted: Oh thank goodness. Finally got one thing of good good news. Friday 1/27 my drivers license was reinstated What kind of truck is it? Year and stuff so I can take a look. How many miles on it;
-The resident texted: It is a 2003 ford f150 4.3 engine king cab, short box, has new tires brakes good all lights work. It is two tone gray 100119 . I put [NAME] flares and running boards interior is good no holes, plastic fish not cracked.
-The resident texted: I need to check my text before sending I'll pay my personal tax bill I have good ins (insurance) agent, cost about $70.00 a month fyi
-HA A texted: King cab means back seat space or no? I appreciate your sweet help so much [NAME] cakes little half doors with seats? Or 4 doors whole seats. Automatic transmission? No mechanical like engine transmission problems. A good truck. You would drive it to Washington?! Hahaha. Good miles too been dreaming of a car at 100K or less. Need a good ride for us so badly. And would you write gift on the title so I pay less taxes. Lol and yes. I will need to get insurance. Just regular insurance yay!!
-The resident texted: Little ½ doors up yes automatic transmission. Yes would drive any were. Less than 100k will costs 15kto 20k yes has a back seat has chrome side rails and a headache rack behind cab
-HA A texted: Yes I know it haha that's why it's always been my dream. But 100119 is good enough for me! Sounds great (thumbs up emoji) yes. I need to do that as long as it's a good running truck u believe will get me thru next 5 years or so
-So it looks like this kinda. With the cab and short butt. Do you think 2 of those carseats would bit in the back row? Kids not really supposed to be in front seat. Safer (picture of a Ford F-150 truck)
-The resident texted: I had new head gasket installed in May of last year I would trust as long as no drag racing. I need to get the exhaust welded at the y but I'll take of this for you yes. Last time I looked up blue book it was about $6000
-HA A texted: id the head gasket blow or you replaced it? No bent pistons and all that
LOL I'm almost a mechanic myself. No cracked block or nothing. (2 lip emoji)
-The resident texted: Nothing I would not do that to you!!! no my mechanic said this engine has a history of blowing gasket mine were almost blown, should be good to 600000 miles he said. Body is good no dents no accidents!! Oil filter changed every 2000 miles has up graded air filter. Has a bed liner also!!
-HA A texted: Awwww yay!!! I'm very excited. Thanks so much for caring about us.
-The resident texted: AC and heater work
-HA A texted: I love you so much (beating heart emoji) no one has truly been there for me like this. So the back seats are the little ones that fold right? Do you think the carseats will fit in the back
-The resident texted: You are the only one I would do this for!! Yes I think car seats will fit the seats don't fold a person can sit back there I keep telling you
-On 1/31/23:
-The resident texted: Good morning new truck owner. Ya! So glad this helps you out, all i want is to protect you and your boys and shower you with (heart emoji). I think you heal your self now with Gods help and some good loving from me! Hope to see your beautiful face today! I love you sweet mommy (3 heart emoji)
-The resident texted: I got price to replace exhaust. Will get it done my cost
-HA A texted: I love you sweet [NAME]. Good morning. (2 heart emoji)
-Unknown Date:
-The Resident texted: What did you think of your rings?
-HA texted: They are really pretty. (Heart face emoji)
-HA A texted: It's ok. Will get it to u. Yes Ill come to ur appointment. The card been the emergency plan until my new card gets here. Hope it hurries cause I got money like I cant spend. Lol stupid. GM. My card wont work for daycare lol ughh neither will urs. Fun. Ugh cant do nothing until my new card gets here . Okay. What time where is tomorrow. Yes Ill come visit with you (heart emoji); Struggling to stay happy or even know what to do. But trying.
-On 1/31/23, HA A texted:
-I love you sweet [NAME]. Good morning. (2 heart emojis);
-Your looking so good and healthy [NAME] today (kissy face emoji) love you;
-So excited (smiling face emoji)
-I'm still here just working. Love you you look happy and good today (content smiling face and heart emoji);
-Yes [NAME] cakes dollar general or work parking lot or something works just fine (3 heart emojis); yes I need to do the vehicle right away so I can get full time at work. They are thinking of renting the apt there for me for 3 months . So the truck helps me be able to do that in getting full time. Like as soon as I can drive I can get kids in daycare further with openings and work more (heart emoji and strong arm emoji) I am going to get my license valid Monday. Funds will be here soon (celebration hands emoji)
-Sweet dreams hunny.(2 heart emojis);
-On 2/1/23, HA A texted:
-Ok yes [NAME] cakes. All is sounding good. I will give you my information and you can see how much to add me to your insurance. I do liability and usually still 100. so maybe too much if you do full coverage. I will check into a couple too just for solo insurance. Get it figured out soon. So excited! I love you.
-I love you too! So much. Miss you hunny (2 heart emoji);
-Aww Love you too hunny. Sweet dreams. Very thankful to have you. (3 heart emoji);
-On 2/2/23, HA A texted:
-Good day honey.
-Trying to hang on but it comforts me knowing we have a place to go with a wonderful man that cares about us. For real. You mean a lot to me [NAME] cakes.
-I love you too.
-I love u too so blessed to have u in our lives. A great role model for my men.
-Thanks so much. I will take a ride out if I have to and get there. Be waiting for u. Don't know what I would do without my [Resident name] cakes hehehe
-Love you sweet dreams.
-On 2/4/23, HA A texted:
-Love you;
-Good night [NAME] cakes. Love you.
Record review of HA A's personnel file showed his/her last day worked was 2/3/23.
Record review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility staff for care planning), dated 2/4/23, showed:
-He/she was cognitively intact.
-His/her mood score a 7 on a scale of 7 out of 15, where 7 equaled the resident was moderately depressed.
--He/she felt down, depressed, or hopeless.
--He/she had difficulty in falling or staying asleep.
--He/she was tired little energy.
--He/she had trouble concentrating on things.
--He/she moved or spoke slowly that other people noticed or was fidgety.
During an observation and interview on 3/1/23 at 10:05 A.M., the resident rubbed his/her hands together and wiped a tear from his/her eyes. The resident said:
-HA A worked at the facility he/she was a tremendous con artist.
-HA A had went a to doctor's appointment with him/her in November 2022.
-The two of them seemed to have a lot in common.
-They started texting and it got interesting.
-The HA told him/her about his/her children and that he/she needed to borrow money to get medicine for them.
-He/She gave the HA his/her debit card and he/she pulled out $100 what was agreed on.
-The HA then said he/she needed to pay to get kids into day care.
-He/She agreed and let the HA have $200 which was all he had.
-The HA was supposed to buy the resident's truck.
-The HA was supposed to go to the town where he/she was from and get the keys to the truck from his/her landlord and the truck from his/her ex-spouse.
-The HA was also supposed to get the house key from the landlord to be able to move into it when his/her ex-spouse moved out.
-He/She said this was about six weeks ago.
-After HA A had the truck he/she drove up to see the resident and told him/her there was some problems with the truck.
-He/She told HA A he/she would knock the price down.
-He/she told HA A to give him/her $3,000 and use the $5,000 he/she reduced it to, to fix the truck.
-The shop the HA took the truck to wanted $3,000 to fix it.
-HA A sent the resident a Dear John text on 2/28/23 saying he/she just wanted to be friends due to their age differences and he/she was done with him/her.
-He/She bought HA A soulmate rings in November 2022.
-He/she had also bought the staff person a promise ring.
-The rings cost $50 each.
During an interview on 3/1/23 at 3:21 P.M., CNA B said:
-On Sunday 2/26/23, the resident had what looked like an engagement ring and a wedding ring on his/her bedside table.
-He/She thought the rings belonged to the resident and spouse since he/she had mentioned several times in past they were divorcing.
-The resident was crying and he/she assumed it was the resident's spouse's ring.
-He/She told the resident he/she shouldn't torture his/herself like this.
-He/She said something to the resident about the rings being his/her spouse's ring.
-The resident said no, it was not his/her spouse's ring it was supposed to be for a friend.
-The resident did not mention the friend's name.
During an interview on 3/2/23 at 1:47 P.M., Certified Medication Technician (CMT) B said:
-On 2/28/23, in the morning, the resident was broken hearted, disappointed, and disgruntled.
During an interview on 3/2/23 at 2:45 P.M., Licensed Practical Nurse (LPN) B said:
-The resident normally was alert and oriented times four, very polite and pretty much independent with his/her cares.
-On 2/28/23 in the morning the resident was normal, nothing out of the ordinary.
-By lunch the resident was sad, crying and upset.
-He/She found the resident with his/her call light cord around his/her neck and his/her face very dark red.
-Everybody had a feeling there was something between the resident and the HA, but where not sure what it was.
Record review of the Social Services Designee (SSD)'s written statement, dated 2/28/23, showed:
-At approximately 3:25 P.M., he/she went to the resident's room.
-When he/she entered the resident's room he/she was lying on his/her right side and appeared to be sobbing.
-He/she walked over to the resident and held his/her hand.
-He/She told the resident it was going to be ok.
-He/She sat with the resident until the police arrived.
-The police were talking to the resident and he/she handed his/her phone to the police officer.
-The police officer stated that it appeared that the resident was upset due to a person stating he/she wasn't in a relationship with the resident.
-The police officer stated it appeared that a person had been asking for money.
-The police officer asked if this person worked here.
-He/She stated the person was a former employee who hadn't worked in around a month.
-The police officer asked if he/she knew that the resident had given the person a truck.
-He/she stated the situation was shocking as nothing had ever been said.
Record review of the resident's Hospital Emergency Department Note, dated 2/28/23, showed:
-Resident admitted thoughts of self-harm, had plan, acted on the plan and self-inflicted trauma.
-He/she presented as crying and tearful.
-The resident reported HA A had texted him/her and wanted to be only friends. He/she had given HA $700 and a truck. He/she was upset and attempted to hang him/herself with the facility call light.
Record review of the facility investigation, dated 2/28/23, no time noted, showed:
-HA A had:
--Befriended the resident under false pretense.
--Led the resident to believe they were in a relationship.
--The resident had signed the title of his/her truck over to him/her.
During an interview on 3/1/23 at 9:40 A.M., the Hospital Behavioral Health Facility's Program Director said:
-The resident allegedly gave the staff person $700 and signed his/her truck over to the staff member.
-Now the staff member just wants to be friends.
During observation and interview on 3/1/23 at 10:39 A.M., the Hospital Behavioral Health Facility's Program Director said:
-The resident had allowed the program director to access his/her phone and copy the text messages between him/her and the staff person from the nursing facility from January 17, 2023 at 8:12 P.M., to February 28, 2023.
-The program director said:
--There was talk between the HA and the resident about using his/her credit card.
--A text message dated January 19, 2023 at 11:02 A.M., showed the HA left things in the resident's notebook in case he/she gets searched and that he/she needs the resident's debit card.
--A text message dated January 19, 2023 at 11:37 A.M., showed the HA will have to grab the resident's debit card the next time he/she is there.
During an interview on 3/2/23 at 11:51 A.M., CMT A said the resident told him/her:
-A person took his/her truck.
-He/She thought the person loved him/her and now he/she doesn't have a truck.
-HA A was the person.
-He/She said this is the first he/she had heard of this.
-HA A had told him/her at one time that he/she was buying a truck, but didn't say who it was from.
-HA A was staying in a homeless shelter and talked about all the improvements in his/her life and had got his/her taxes and a truck.
-He/she took the resident back to his/her room.
-The resident had calmed down and said he/she would be ok.
-He/She went to let the Assistant Director of Nursing (ADON) know about the information the resident just told him/her about.
-The ADON was on the phone, so he/she told the SSD.
During an interview on 3/1/23 at 3:44 P.M., the ADON said:
-On 2/28/23, the resident was crying when he/she was telling the police about the text messages on his/her phone about a person who got his truck and money.
During a phone interview on 3/3/23 at 10:10 A.M., HA A said:
-He/she left the faciity on his/her own and no longer worked there.
-He/she quit working at the facility on either 2/6/23 or 2/7/23.
-Resident #500 was a resident at the facility.
-He/She was the HA and answered call lights, took drinks and meals to the residents.
-He/She walked to work.
-Resident #500 had a truck for sale and offered to sell it to him/her due to his/her walking to work.
-The resident and his/her spouse were divorcing and both wanted to sell the truck.
-He/She was going to buy the truck and did buy the truck from the resident.
-Both the resident and his/her wife signed the truck over to him/her.
-He/She picked the truck up from the resident's spouse's house on 2/9/23.
-The resident then wanted to be together with him/her after he/she quit working at the facility.
-He/She had texted the resident only about his/her surgery and about getting the truck fixed before he/she bought it.
-He/She bought the truck unfixed and texted him/her about the suspension issues.
-He/She was paying the resident $1200 for the truck after the repairs are done.
-He/She got the keys and the truck title from the resident's spouse.
-The resident put him/her on his/her truck insurance until he/she gets his/her tax returns.
-Then he/she will title the truck and get insurance on it with the tax money.
-The resident offered to do all of this for him/her without his/her asking for anything.
-The resident was concerned about his/her struggles and his/her kids.
-The resident never gave him/her $700 or any other cash.
During an interview on 3/2/23 at 4:50 P.M., the Director of Nursing (DON) said it is not ok for employees to take money, gifts or have a relationship with a resident.
During an interview on 3/14/23 at 1:32 P.M., the resident said:
-He/she was still in the hospital.
-He/she had felt hurt, angry, and violated.
-On 2/28/23 after receiving HA A's text just wanted the hurt to go away.
-HA A had told him/her from the beginning that no one could know they were more than employee and patient or HA A would lose HA A's job.
-HA A had told him/her in the beginning he/she could be the parent HA A never had and the grandparent to HA A's children.
-The relationship had begun in December 2022, HA A had sent a picture of him/herself in front of the Christmas tree.
-HA A had kissed him/her on the head and on the cheek twice. HA A had hugged him/her.
-HA then needed help with money and HA A told him/her, I love you.
-HA A called him/her [NAME] cakes and he/she called HA A mama bug.
-HA A had accepted soulmate rings from him/her.
-HA said he/she would wear the rings around his/her neck.
-The relationship had changed or at least he/she thought it had.
-HA A would come and spend HA A's breaks when working at the facility and check in with him/her before leaving.
During an interview on 3/14/23 at 4:15 P.M., the Administrator said on 2/28/23:
-The resident was upset and crying.
-He/She did not know anything about the relationship until the police were talking to the resident and the resident told what had gone on between him/her and the HA.
During an interview on 3/15/23 at 1:01 P.M., the DON said:
-Did not work on 2/28/23.
-He/She didn't know about the resident giving truck to an ex-employee until the State surveyor came into the facility for investigation.
-It is not ok or appropriate for staff to take, accept money, gifts or have a relationship with a resident.
MO00214739 & MO00214746
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain a physician's order for and the cares for, and document the ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain a physician's order for and the cares for, and document the care of a Foley catheter (a tube with retaining balloon passed through the urethra into the bladder to drain urine); and failed to obtain orders for and the care of and to document care of a Colostomy (an alternative exit from the colon created to divert waste through a hole in the colon and through the wall of the abdomen) for one sampled resident (Resident #501) out of three sampled residents. The facility census was 86 residents.
Record review of the facility's Colostomy/Ileostomy (an alternative exit from the ileum [the last part of the small intestine] to divert waste through a hole in the wall of the abdomen) Care policy dated October 2010 showed:
-The purpose of care is to prevent exposure of the resident's skin to fecal matter.
-The following information should be recorded in the resident's medical record:
--The date and time care was provided.
--The name and title of the individual(s) who provided the care.
--Any breaks in the resident's skin, signs of infection (purulent discharge, pain, redness, swelling, temperature), or excoriation (wear off) of skin.
--How the resident tolerated the procedure.
Record review of the facility's Foley Catheter Insertion, Female Resident policy dated October 2010 showed:
-Verify that there is a physician's order for this procedure.
-Document the following:
--The date and time care was provided.
--The name and title of the individual(s) who provided the care.
--All assessment data (i.e., character, color, clarity, etc.) obtained during the procedure.
--The size of the Foley catheter inserted and the amount of fluid used to inflate the balloon.
--How the resident tolerated the procedure.
-Notify the physician of any abnormalities (i.e., bleeding, obstruction, etc.).
Record review of the facility's Catheter Care, Urinary policy dated September 2014 showed:
-The purpose is to prevent catheter-associated urinary tract infections (CAUTIs).
-Maintain an accurate record of the resident's daily output, per facility policy and procedure.
-Check the resident frequently to be sure he/she is not lying on the catheter and to keep the catheter and tubing free of kinks.
-Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended; rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised.
-The following information should be recorded in the resident's medical record:
--The date and time care was provided.
--The name and title of the individual(s) who provided the care.
--All assessment data obtained when giving catheter care.
Record review of the facility's Catheter-Urinary Catheter, Changing policy dated (no Month noted) 2016 showed:
-Indwelling urinary catheters will be changed based on assessment of the catheter for malfunction, infection or closed system compromise and not at arbitrary intervals, due to increased risk of infection and other urinary complications.
1. Record review of Resident #501's admission Record showed he/she was admitted on [DATE] with the following diagnoses:
-Chronic (persisting for a long time or constantly recurring) kidney disease (CKD- is a condition characterized by a gradual loss of kidney function over time) or End Stage renal Disease (ESRD-The kidneys have stopped working well enough to survive without dialysis or a kidney transplant).
-Diabetes Mellitus type II (condition that affects the way the body processes blood sugar [glucose]) with diabetic nephropathy (affects the kidneys' ability of removing waste products and extra fluid from the body).
-Chronic Candidiasis (infection caused by a yeast [a type of fungus]) of the genitalia.
-Hydronephrosis (swelling of a kidney due to a build-up of urine) with renal (kidney) and ureteral calculous (stones that have formed in the kidney and passed front the renal collecting system into the ureter) obstruction.
-Colostomy status.
-Sepsis (body's extreme response to an infection), unspecified organism.
Record review of the resident's Progress notes and Nurse's Notes for February 2023 showed no documentation of any cares for the resident's Foley Catheter or Colostomy.
Record review of the resident's Physician's Order Summary (POS) dated 2/1/23 showed:
-No order for a Foley Catheter, size of the catheter to be placed or amount of fluid to inflate the retaining balloon on the catheter.
-No order for the care of a Foley Catheter.
-No order for the care of a colostomy.
Record review of the resident's Nurse's Note dated 2/2/23 at 3:15 A.M, showed:
-The resident entered the facility by stretcher from a hospital.
-Had a Foley catheter with yellow mucus looking drainage
-Had a Colostomy.
Record review of the resident's Baseline Care Plan (written out plan for the care of the resident) dated 2/2/23 at 9:05 P.M., showed:
-Under bladder function that he/she had a catheter.
-Under bowel function he/she was not continent of bowel.
-Under medical conditions he/she had an ostomy.
--Did not specify the type of ostomy.
Record review of the resident's Skilled Note dated 2/3/23 showed the resident had a Foley catheter.
Record review of the resident's Physician's Progress Note dated 2/5/23 at 1:26 P.M., showed:
-Colostomy on 10/18.
Record review of the resident's Nutritional assessment dated [DATE] showed the resident had a Colostomy.
Record review of the resident's Progress Note dated 2/13/23 at 11:19 P.M., showed the resident was transported to the hospital for difficulty breathing.
Record review of the resident's Treatment Administration Record (TAR) dated 2/1/23 -2/28/23 showed:
-Change Foley catheter bag weekly on Sunday night for catheter care dated 2/12/23 and documented as completed on 2/12/23.
-Change Foley catheter as needed (PRN) for catheter care when blocked or dislodged dated 2/12/23. The order did not include the size of the catheter tube or the size of the balloon.
-Change catheter securement device every week, every 7 days dated 2/13/23 and documented as completed on 2/13/23
-Change catheter tubing and bag every month on the night shift dated 2/15/23 and documented as completed on 2/15/23.
-Change Foley catheter every night shift every 30 days for catheter care dated 2/15/23 and documented as completed on 2/15/23.
--NOTE: the resident had discharged from the facility to the hospital on 2/13/23 and had not returned to the facility as of 3/2/23.
-No orders or the resident's colostomy including directing staff how and how often to provide colostomy care.
-No orders for Foley catheter care including directing staff how often to cleanse the catheter insertion site.
During an interview on 3/2/23 at 11:48 A.M., Certified Nursing Assistant (CNA) C said:
-Cleans a Foley catheter tubing when doing peri care at least once a shift.
-He/She does not document Foley catheter care since it is just part of routine cares for a resident with a Foley catheter.
During an interview on 3/2/23 at 12:06 P.M., CNA A said:
-Cleans a Foley catheter tubing each shift when doing peri cares.
-He/She does not document Foley catheter care since it is just part of routine cares for a resident with a Foley catheter.
-Does not know much about this resident.
-Thinks the resident did not have much urine output he/she went to dialysis.
-The resident also had a colostomy bag.
-The colostomy bag sometimes would get loose on a side and have to be changed at least daily.
-The resident would call the staff if colostomy bag was leaking and needed to be changed.
-The CNA or nurse can change the colostomy bag.
During an interview on 3/2/23 at 3:25 P.M., Licensed Practical Nurse (LPN) D said:
-He/She would expect to have a doctor's order to have, and the care of a Foley catheter or a Supra pubic catheter (a hollow flexible tube that is used to drain urine from the bladder and inserted through the abdominal wall into the bladder) if a resident had one.
-He/She would also expect to have a doctor's order to have and the care of a colostomy.
-Orders should be on the Physician's orders and printed out on the TAR.
-The nurse charts on the TAR when cares are completed.
During an interview on 3/2/23 at 3:32 P.M., RN A said:
-Residents should have orders on the POS sheet if have they have a catheter or colostomy.
-Orders would be on the TAR for nurses to chart on.
-Would expect orders to be followed.
During an interview on 3/2/23 at 4:22 P.M., (LPN) D said:
-He/She found no physician orders for the resident for a Foley catheter and cares or for a colostomy and cares on the electronic chart.
-He/She found orders the Foley catheter and cares on the resident's electronic TAR.
-He/She did not find any orders for the resident's colostomy cares on the electronic TAR.
During an interview on 3/2/23 at 4:50 P.M., the Director of Nursing (DON) said:
-There should be an order for a Foley Catheter including the size of the catheter and of the balloon and when to change the Foley Catheter.
-There should be an order for the colostomy care.
-These should be documented on the TAR.
-The resident's Foley catheter and colostomy should be on his/her Care Plan.
-Nursing should get orders if there were no orders for the Foley or the colostomy.
-The nursing team and the Assistant Director of Nursing (ADON) should check for and be sure orders have been written.
MO00214046
Feb 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide an appropriate discharge for one sampled resident (Resident...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide an appropriate discharge for one sampled resident (Resident #81) out of three sampled residents for discharge out of a total of five sampled residents, when the facility discharged the resident to the hospital and refused to allow the resident to re-admit back to the facility even after the appeal process had been requested. The facility census was 88 residents.
Record review of the facility's Transfer or Discharge, Emergency policy, dated August 2018, showed:
-Emergency discharges may be necessary to protect the health and/or well-being of the resident(s).
-Residents will not be transferred unless:
--The discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility.
--The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident.
-If a resident exercised his/her right to appeal a discharge notice he/she would not be discharged while the appeal was pending, unless the failure to discharge would endanger the health or safety of the resident or other individuals in the facility.
-If the resident was discharged despite his/her pending appeal, the danger that failure to discharge would pose would be documented.
-Should it become necessary to make an emergency discharge to a hospital the facility would implement the following procedures:
--Notify the resident's physician.
--Notify the receiving facility that the transfer was being made.
--Prepare a transfer form to send with the resident.
-Notify the representative or other family member.
-The resident's medical record must be forwarded to the medical records office within 24 hours of the discharge.
Record review of the facility's Transfer or Discharge Notice, dated March 2021, showed:
-Discharge referred to the movement of a resident from a bed in one certified facility to a bed in another certified facility or other location in the community, when return to the original facility is not expected.
-Residents were permitted to stay in the facility and not be transferred or discharged unless the transfer was necessary for the resident's welfare and the resident's needs could not be met in the facility.
-Residents and/or representatives were notified in writing, at least 30 days prior to a transfer or discharge.
-The notice was given as soon as it was practicable but before the discharge if:
--The safety of individuals in the facility would be endangered.
--An immediate discharge was required by the resident's urgent medical needs.
-If a resident chose to appeal a discharge, the facility would not discharge the resident while the appeal was pending.
1. Record review of Resident #81's admission Record showed he/she was readmitted on [DATE] with the following diagnoses and information:
-Alcohol dependence with alcohol-induced persisting dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning and of decline in other mental abilities severe enough to interfere with daily functioning).
-Anxiety Disorder (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus).
-Schizoaffective Disorder (a mental health condition including schizophrenia [a chronic mental illness that interferes with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, and relate to others] and mood disorder [a group of mental health disorders that affect emotional state] symptoms), Bipolar (a form of mental illness associated with episodes of mood swings ranging from depressive lows to manic highs) type.
-Depressive Disorder (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living).
-Suicidal ideations.
-Had a Public Administrator (PA) a court appointed guardian).
Record review of Resident 81's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility staff for care planning), dated 12/29/22, showed:
-Cognition Brief Interview for Mental Status (BIMS) score of 99 unable to interview.
-Mood showed mild depression.
-Behavior showed:
--Had delusions (misconceptions or beliefs firmly held, contrary to reality).
--Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing) occurred one to three days.
--Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) occurred four to six days, but less than daily.
--Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, verbal/vocal symptoms like screaming, disruptive sounds) occurred one to three days.
--Refusal of evaluation or care (e.g., bloodwork, taking medications, Activities of Daily Living [ADL] assistance) that is necessary to achieve the resident's goals of health and well-being occurred 1 to 3 days.
Record review of the resident's behavior note, dated 1/25/23 at 7:07 P.M., showed:
-The resident was being aggressive towards other residents and staff.
-911 was called to discharge the resident to the hospital.
-The local police department and ambulance arrived.
-The resident continued to be agitated and combative with the police and ambulance crew.
-The resident was placed on the stretcher by the local police and ambulance crew and taken to the local hospital.
Record review of the resident's emergency discharge, dated 1/25/23, that was faxed to the local hospital emergency room (ER) from the facility Administrator showed:
-Pursuant to Federal and State regulations, this Notice was being provided as formal notification that the resident was being discharged from the facility (herein after facility) for the following reason(s):
--The discharge was necessary for the resident's welfare and the facility could not meet the resident's needs.
--The resident's clinical or behavioral status endangered the safety of individuals in the facility.
-The specific details in support of this reason(s) were:
--This was left blank.
-For additional assistance, contact the local Long-Term Care Ombudsman at:
--This information was left blank.
Record review of the facility's resident to resident abuse witness statement by the facility Social Service Director (SSD), dated 1/25/23, showed:
-Resident #81 was sent to the hospital for his/her combativeness on 1/25/23 about 5:45 P.M. towards Resident #500.
-Around 30 minutes after Resident #81 was transferred to the hospital the SSD received a phone call from an ER nurse stating the hospital was sending the resident back to the facility.
-The facility Administrator had informed the SSD that for safety of the facility residents, the resident would not be returning to the facility.
-The SSD called the hospital back to inform the facility would not be able to take the resident back.
Record review of the Long-Term Care Ombudsman Program Nursing Facility Transfer or Discharge Hearing Request, dated 2/1/23, showed:
-On 1/25/23 Resident #81 received a notice of the facility's intent to transfer or discharge the resident.
-The resident was requesting a hearing to appeal the nursing facility's decision.
Record review of the Missouri department of Health and Senior Services Appeals Unit, dated February 3, 2023, showed:
-Resident #81 as the petitioner.
-The facility as the respondent.
-Respondent's January 25, 2023, discharge notice failed to contain required information prescribed in the provisions of 19 CSR 30-82.050.
-Respondent's discharge did not meet the requirements for appropriate notice to discharge the Petitioner; therefore, Respondent's discharge was dismissed.
-Petitioner may remain at Respondent's facility.
-If Petitioner had been discharged , based upon the defective notice, Respondent was directed to proceed for Petitioner's return to Respondent's facility.
-Copies were sent to:
--Resident #81's PA.
--Long-Term Care Ombudsman.
--The facility Administrator.
During an interview on 2/7/23 at 1:39 P.M., the SSD said:
-On 1/25/23 about 6:15 P.M., 911 was called for an ambulance to transport Resident #81 to the hospital due to his/her combativeness and aggression towards another resident.
-The resident was discharged to the hospital.
-The hospital wanted to send the resident back to the facility.
-The facility Administrator and the Regional Director said the facility would not take the resident back.
-The resident was not returning due to his/her combativeness and aggression.
During a phone interview on 2/7/23 at 12:41 P.M., the Ombudsman said:
-He/she was notified on 2/1/23 by the hospital the resident had been sent to the Emergency Room.
-The resident was denied an inpatient psychiatric admission and was cleared to return to the facility.
-The hospital social worker informed him/her the facility was refusing to take the resident back.
-The facility had faxed an emergency discharge to the resident at the hospital.
-The emergency discharge did not have a discharge location, the correct appeal process, or the Ombudsman information in it.
-He/she contacted the resident's PA.
-The resident's PA did not receive a copy of the emergency discharge letter that was sent to the resident form the facility.
-The facility did not notify him/her of the resident's discharge.
-He/she did not receive a copy of the emergency discharge letter that was sent to the resident from the facility.
-He/she and the PA both sent in an appeal for the emergency discharge.
-He/she made multiple attempts to contact someone at the facility to speak to them about the appeal and needing to take the resident back.
-He/she was unsuccessful on four different attempts to contact the facility.
-On the fifth attempt to contact the facility he/she spoke with someone, but they would not take a message for the Administrator to return his/her call.
-He/she finally was able to speak to the Administrator about the emergency discharge letter not being completed properly and the appeal process.
-The Administrator told him/her the facility was not going to take the resident back.
-He/she informed the Administrator if the resident was not returned to the facility, the hospital had the obligation to file a complaint regarding the improper discharge of the resident to the hospital.
-The Administrator thanked him/her for the information, but made no indication the facility would take the resident back.
-On 2/3/23 he/she and the PA were notified of the dismissal of the emergency discharge letter, which indicated the letter was thrown out.
-On 2/6/23 the Administrator told him/her that the regulation was understood, but the team had decided they were not taking the resident back.
-The PA was in agreement the resident needed to be in a different facility, but he/she did not agree with the resident being discharged to the hospital and the facility having no intention of trying to find a different location for the resident to go to.
-The hospital understood the reason the facility was not taking the resident back, but it was an improper discharge and the facility made no effort and had no intention of helping find a new location for the resident.
-As of 2/7/23 the hospital was still trying to find new placement for the resident and no offer had been made by the facility to assist in that process.
During a phone interview on 2/8/23 at 10:16 A.M., Resident #81's PA said:
-He/she would expect to be notified by the facility when Resident #81 was transferred to the hospital.
-On an emergency discharge would expect the facility to find another placement since they had been trying to move the resident before.
-As the resident's guardian, he/she would provide consent for the location if a resident needed to be transferred. He/she would not be responsible for finding the alternate location.
-He/she was not notified of the resident's discharge on [DATE].
-He/she was contacted by the hospital on 1/26/23 and informed of the resident being at the hospital.
-He/she was told the resident was not allowed to return to the facility by the Ombudsman.
During an interview on 2/8/23 at 11:00 A.M., the Regional Director said:
-The facility was not taking the resident back due to his/her combativeness and aggressive behaviors.
MO00213134
MO00213546
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
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide an appropriate discharge notice with required information f...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide an appropriate discharge notice with required information for one sampled resident (Resident #81) out of three sampled residents for discharge out of a total of five sampled residents, when the facility discharged the resident to the hospital, and did not provide an appropriate discharge notice in writing to the resident's or resident's guardian. The facility census was 88 residents.
Record review of the facility's Transfer or Discharge, Emergency policy, dated August 2018, showed:
-Emergency discharges may be necessary to protect the health and/or well-being of the resident(s).
-Residents would not be transferred unless:
--The discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility.
--The safety of individuals in the facility was endangered due to the clinical or behavioral status of the resident.
-If a resident exercised his/her right to appeal a discharge notice he/she would not be discharged while the appeal was pending, unless the failure to discharge would endanger the health or safety of the resident or other individuals in the facility.
-If the resident was discharged despite his/her pending appeal, the danger that failure to discharge would pose would be documented.
-Should it become necessary to make an emergency discharge to a hospital the facility would implement the following procedures:
--Notify the resident's physician.
--Notify the receiving facility that the transfer was being made.
--Prepare a transfer form to send with the resident.
--Notify the representative or other family member.
--The resident's medical record must be forwarded to the medical records office within 24 hours of the discharge.
Record review of the facility's Transfer or Discharge Notice policy, dated March 2021, showed:
-Discharge referred to the movement of a resident from a bed in one certified facility to a bed in another certified facility or other location in the community, when return to the original facility is not expected.
-Residents were permitted to stay in the facility and not be transferred or discharged unless the transfer was necessary for the resident's welfare and the resident's needs could not be met in the facility.
-The resident and representative were notified in writing of the following information:
--The specific reason for the discharge.
--The effective date of the discharge.
--The location to which the resident was being discharged .
--An explanation of the resident's rights to appeal the discharge to the state including:
---The name, address, email and phone number of the entity which receives appeal hearing requests.
---Information about how to obtain, complete and submit an appeal request.
---How to get assistance completing the appeal process.
--The facility bed-hold policy.
--The name, address, and phone number of the Office of the State Long-Term Care Ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility).
--The name, address, and phone number of the state health department agency that had been designated to handle appeals of discharge notices.
-A copy of the notice was sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of discharge was provided to the resident and representative.
-Residents had the right to appeal a facility-initiated discharge through the state agency that handled appeals.
-If a resident chose to appeal a discharge, the facility would not discharge the resident while the appeal was pending.
-The reasons for the discharge were documented in the resident's medical record.
1. Record review of Resident #81's admission Record showed he/she readmitted on [DATE] with the following diagnoses:
-Alcohol dependence with alcohol-induced persisting dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning and of decline in other mental abilities severe enough to interfere with daily functioning).
-Anxiety Disorder (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus).
-Schizoaffective Disorder (a mental health condition including schizophrenia [a chronic mental illness that interferes with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, and relate to others] and mood disorder [a group of mental health disorders that affect emotional state] symptoms), Bipolar (a form of mental illness associated with episodes of mood swings ranging from depressive lows to manic highs) type.
-Depressive Disorder (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living).
-Suicidal ideations.
-Had a Public Administrator (a court appointed guardian).
Record review of Resident 81's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility staff for care planning), dated 12/29/22, showed:
-Cognition Brief Interview for Mental Status (BIMS) score of 99 unable to interview.
-Mood showed mild depression.
-Behavior showed:
--Had delusions (misconceptions or beliefs firmly held, contrary to reality).
--Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing) occurred one to three days.
--Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) occurred four to six days, but less than daily.
--Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, verbal/vocal symptoms like screaming, disruptive sounds) occurred one to three days.
--Refusal of evaluation or care (e.g., bloodwork, taking medications, Activities of Daily Living [ADL] assistance) that is necessary to achieve the resident's goals of health and well-being occurred 1 to 3 days.
Record review of the facility's resident to resident abuse witness statement by the facility Social Service Director (SSD), dated 1/25/23, showed:
-Resident #81 was sent to the hospital for his/her combativeness on 1/25/23 about 5:45 P.M. towards Resident #500.
-Around 30 minutes after Resident #81 was transferred to the hospital the SSD received a phone call from an emergency room (ER) nurse stating the hospital was sending the resident back to the facility.
-The facility Administrator had informed the SSD that for safety of the facility residents, the resident would not be returning to the facility.
-The SSD called the hospital back to inform them the facility would not be able to take the resident back.
Record review of Resident #81's emergency discharge, dated 1/25/23, that was faxed to the local hospital emergency room (ER) from the facility Administrator showed:
-Pursuant to Federal and State regulations, this Notice was being provided as formal notification that the resident was being discharged from the facility (herein after facility) for the following reason(s):
--The discharge was necessary for the resident's welfare and the facility could not meet the resident's needs.
--The resident's clinical or behavioral status endangered the safety of individuals in the facility.
-The specific details in support of this reason(s) were:
--This was left blank. There was nothing in this area.
-For additional assistance, you may contact the local Long-Term Care Ombudsman at:
--This information was left blank. The name, address, phone number were not documented.
Review of the emergency discharge notice showed:
- Written notice was not sent to the resident.
--The notice was not sent to any legally authorized representative of the resident and to at least one family member.
--Did not include the effective date of discharge.
--Did not include the resident's right to appeal the discharge notice to the director of the Department of Health and Senior Services or his/her designated hearing official within 30 days of the receipt of the notice.
--Did not include where the request for hearing should be sent.
--Did not include that filing an appeal would allow the resident to remain in the facility until the hearing was held unless a hearing official finds otherwise.
--Did not include the location to which the resident was being discharged .
--Did not include the name, address and phone number of the designated regional Long-Term Care Ombudsman office.
-- The resident was not given a copy of the discharge notice.
-- The resident's representative/guardian/PA was not given a copy of the discharge notice.
- The Ombudsman was not given a copy of the discharge notice.
Record review of the resident's appeal process notice, dated 2/3/23, showed the emergency discharge notice specifically failed to contain the following information:
-Written notice to the resident in a language and manner reasonably calculated to be understood by the resident. The notice must also be sent to any legally authorized representative or of the resident and to at least one family member. In the event that there is no family member known to the facility, the facility shall send a copy of the notice to the appropriate regional coordinator of the Missouri State Ombudsman's office.
-Effective date of transfer or discharge.
-The resident's right to appeal the transfer or discharge notice to the director of the Department of health and Senior Services or his/her designated hearing official within thirty (30) days of the receipt of the notice.
-That a request for hearing should be sent to: Department of Health and Senior Services Appeals unit (address provided, phone number and email provided).
-That filing an appeal would allow a resident to remain in the facility until the hearing was held unless a hearing official finds otherwise.
-The location to which the resident was being transferred or discharged .
-The name, address, and telephone number of the designated regional long term care ombudsman office.
During an interview on 2/7/23 at 1:39 P.M., the SSD said:
-On 1/25/23 about 6:15 P.M., 911 was called to transport Resident #81 to the hospital due to his/her combativeness and aggression towards another resident.
-The resident was discharged to the hospital.
-The hospital wanted to send the resident back to the facility.
-The facility Administrator and the Regional Director said the facility would not take the resident back.
-The facility was not taking the resident back.
-The charge nurse or someone in Administration could complete the discharge notice paperwork.
-On 1/25/23 he/she completed the emergency discharge notice and faxed it to the hospital.
-He/she knew what the notice should have included, but it was not included.
-He/She knew who should receive the notice, but it was not sent to them.
During a phone interview on 2/7/23 at 12:41 P.M., the Ombudsman said:
-He/she was notified on 2/1/23 by the hospital the resident had been sent to the Emergency Room.
-The resident was denied an impatient psychiatric admission and was cleared to return to the facility.
-The hospital social worker informed him/her the facility was refusing to take the resident back.
-The emergency discharge did not have a discharge location, the correct appeal process, or the Ombudsman information in it.
-He/she contacted the resident's Public Administrator (PA).
-The resident's PA did not receive a copy of the emergency discharge letter that was sent to the resident from the facility.
-The facility did not notify him/her of the resident's discharge.
-He/she did not receive a copy of the emergency discharge letter that was sent to the resident from the facility.
-He/she made multiple attempts to contact someone at the facility to speak to them about the appeal and needing to take the resident back.
-He/she finally was able to speak to the Administrator about the emergency discharge letter not being completed properly and the appeal process.
-The Administrator told him/her the facility was not going to take the resident back.
-On 2/3/23 he/she and the PA were notified of the dismissal of the emergency discharge letter, which indicated the letter was thrown out.
-He/she informed the Administrator of the letter being thrown out and the importance of assisting the hospital in finding a location for the resident to discharge to.
-The Administrator again thanked the Ombudsman for the information, but made no indication the facility would provide assistance in locating a place for the resident.
-On 2/6/23 the Administrator told him/her that the regulation was understood, but the team discussed and decided they were not taking the resident back.
During an interview on 2/8/23 at 10:16 A.M., Resident #81's PA said:
-He/she would expect to be notified by the facility when Resident #81 was transferred to the hospital on 1/25/23.
-He/she was not notified of the resident's discharge to the hospital until the hospital called and told him/her the resident was there.
-The hospital notified the on-call deputy PA on 1/26/23 that Resident #81 was there.
-He/she would have expected the facility to follow their procedures for transferring a resident to the hospital.
-He/she would expect the facility to find another placement if an emergency discharge was issued since they had been trying to move the resident before.
During an interview on 2/8/23 at 11:00 A.M., the Regional Director said the discharge paperwork that was sent to the hospital did not include the following information:
-The specific reason for the discharge.
-The effective date of the discharge.
-The location to which the resident was being discharged .
-An explanation of the resident's rights to appeal the discharge to the state including:
--The name, address, email and phone number of the entity which receives appeal hearing requests.
--Information about how to obtain, complete and submit an appeal request.
--How to get assistance completing the appeal process.
-The name, address, and phone number of the Office of the State Long-Term Care Ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility).
-The name, address, and phone number of the state health department agency that had been designated to handle appeals of discharge notices.
-The discharge notice was faxed to the hospital.
-He/she did not know why the discharge notice was not sent to the guardian/PA.
MO00213134
MO00213546
Jan 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Refer to *GIOQ13
This deficiency is uncorrected. For previous examples, refer to the statement of deficiencies dated 9/20/22 and...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Refer to *GIOQ13
This deficiency is uncorrected. For previous examples, refer to the statement of deficiencies dated 9/20/22 and 11/23/22.
Based on interview and record review, the facility failed to ensure one out of 10 sampled residents (Resident #410) was free from abuse. On 12/26/22, Resident #25 struck Resident #410 five to six times in the groin and/or lower abdomen with his/her elbow, causing Resident #410 pain to his/her groin and lower abdomen area. The facility census was 87 residents.
Record review of the facility's Recognizing Signs and Symptoms of Abuse/Neglect policy, dated January 2011, showed:
-Abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.
-Physical abuse was the use of physical force that may result in bodily injury, physical pain, or impairment. Physical abuse may include, but was not limited to acts of violence such as striking, hitting, beating, pushing, shoving, shaking, slapping, kicking, pinching, choking, hair-pulling, and burning.
Record review of the facility's Abuse Prevention Program policy/procedure, dated December 2016, showed administration will protect residents from abuse by anyone, other residents.
1. Record review of Resident #410's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 12/20/22, showed the resident:
-Was severely cognitively impaired.
-Had no behaviors directed towards others or other behaviors.
-Was resistive to cares one to three days out of the past seven.
-Had diagnoses that included:
--Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses).
--Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs).
--Anxiety disorder (a psychiatric disorder causing feelings of persistent anxiety).
Record review of Resident #25's admission Record showed he/she was admitted to the facility on [DATE] and had diagnoses that included:
-Traumatic brain injury (TBI - damage to the brain resulting from external mechanical force, such as rapid acceleration or deceleration, impact, blast waves, or penetration by a projectile).
-SynGap 1 related intellectual disability (a neurological disorder characterized by moderate to severe intellectual disability evident in early childhood with features of delayed speech development and motor skills and often seizures, hyperactivity and sensory processing problems).
-Schizoaffective disorder, depressive type (a mental condition that causes loss of contact with reality and mood problems).
-Restlessness and agitation.
-Psychosis (a mental state involving loss of contact with reality and causing deterioration of normal social functioning).
-Antisocial personality disorder (condition characterized by repetitive behavioral patterns that are contrary to usual moral and ethical standards and cause a person to experience continuous conflict with society).
-Intermittent Explosive Disorder (a chronic disorder involving repeated, sudden episodes of impulsive, aggressive, violent behavior and/or angry verbal outbursts in which reactions are grossly out of proportion to the situation).
Record review of Resident #25's Potential for Physical Aggression Care Plan, dated 4/2/22 and initiated 4/12/22 with updates, showed:
-The resident had potential to be physically aggressive related to Intermittent Explosive Disorder. The resident would hit staff, himself/herself, and other residents. He/She would throw objects, slide out of his/her wheelchair, and hit walls, doors and windows when upset.
-Interventions were first initiated 4/12/22 showing:
-Triggers for physical aggression were paranoia that others were talking about him/her.
-Behaviors were de-escalated by 1:1 reassurance.
-Staff will remove those individuals the resident feels are talking about him/her out of view by closing doors or putting up a shield so the resident can't see them.
-Interventions were re-iterated on 6/21/22 to provide 1:1 attention, reassurance, and attempts to calm the resident as the resident's behaviors were de-escalated by these interventions.
-On 6/27/22 the resident allegedly hit another resident.
-Staff were to keep the resident away from others when he/she was agitated and appeared aggressive towards others.
-The following information and intervention was added on 7/21/22:
--The resident hit another resident and was immediately separated from the other resident. He/She was given an as needed (pro re nata - PRN) medication for agitation and placed on 15 minute checks.
--Staff will not place the resident within arms' reach of others.
-On 9/3/22 an intervention was added to encourage the resident to remain in his/her room when agitated.
Record review of Resident #25's quarterly MDS, dated [DATE], showed the resident:
-Was severely cognitively impaired.
-Had fluctuating inattention and fluctuating disorganized thinking.
-The resident's mood assessment showed he/she was short-tempered and/or easily annoyed 12 to 14 days out of the past 14.
-Had physical behaviors directed towards others four to six days out of the past seven.
-Had verbal behaviors directed towards others one to three days out of the past seven.
-Had behaviors not directed towards others one to three days out of the past seven.
Record review of Resident #25's Psychiatric Periodic Evaluation, dated 10/14/22, showed the resident was seen for on-going medication management related to multiple severe psychiatric illnesses and had symptoms such as agitation and aggression related to intermittent explosive disorder and mood lability.
Record review of Resident#25's Potential for Physical Aggression Care Plan, updated 10/28/22, showed:
-The resident had an incident requiring him/her to be separated from another resident on 10/28/22.
-Medications were adjusted on 10/28/22 and a referral was sent to a psychiatric facility.
-On 11/16/22 the resident struck another resident passing in the hall and the residents were separated. Intervention to continue searching for placement options.
-On 12/5/22 the resident was moved away from the nurses' desk after hitting the computer.
-On 12/26/22 the resident was placed on 15 minute checks after hitting another resident.
-On 12/27/22 an intervention was added to keep the resident away from others when the resident agitated to the point he/she appeared aggressive towards others.
Record review of Resident #25's nurses' notes, dated 12/26/22 through 1/4/23, showed:
-There was no documentation of a resident to resident incident on 12/26/22 or that the resident's physician had been informed that the resident had been aggressive with another resident.
-The resident was discharged to a sister facility on 1/4/23.
Record review of the facility investigation, dated 12/29/22, showed:
-The following witness statements:
--A statement written by Certified Nurse Assistant (CNA) A, dated 12/26/22 showed at about 5:30 P.M. he/she told Resident #410 he/she had just finished using the phone about five minutes before and he/she needed to go back to his/her room and wait a while before using the phone again. Resident #410 started yelling at CNA A and Resident #25 started elbowing Resident #410 in the groin area. Certified Medication Technician (CMT) A took Resident #25 to his/her room and Resident #410 was told to go to his/her room by Registered Nurse (RN) A.
--A statement, taken by the Social Services Director (SSD) for Resident #410, dated 12/26/22, showed Resident #25 attacked him/her (Resident #410). The nurse was arguing with him/her about the phone. Resident #25 punched him/her in the stomach and below the stomach about five times total. Somebody pulled Resident #25 away from him/her. This was not the first time this had happened with Resident #25.
--A statement from CMT A, taken by the Director of Nursing (DON), dated 12/27/22 at 12:25 P.M., showed he/she (CMT A) was at the medication cart and Resident #25 was at the nurses' desk. He/She saw Resident #410 heading down the hall towards the nurses' desk. CNA A was on the 300 hall near the nurses' desk. RN A was at the end of the 200 hall using the laptop. He/She heard Resident #410 screaming. Then he/she heard CNA A tell Resident #25 to stop. He/She didn't witness any incident or know what happened, but removed Resident #25 from the situation and took him/her to his/her room to watch television. Resident #25 was calm and 15 minute checks were initiated.
--A statement from RN A, taken by the DON, dated 12/27/22 at 4:33 P.M., showed he/she (RN A) overheard Resident #410 say something about the phone, but could not hear what was said. He/She didn't see anything.
--There was no statement for Resident #25.
-The Investigation, dated 12/29/22, showed:
--On the evening of 12/26/22 at approximately 5:30 P.M., CNA A witnessed Resident #25 elbow Resident #410 in the groin area. Per written witness statements CNA A asked Resident #410 to wait to use the phone and Resident #410 started yelling at CNA A. Resident #25 started elbowing Resident #410 in the groin area. CMT A removed Resident #25 from the situation, taking him/her to his/her room. Resident #410 was then redirected to his/her room by RN A. Resident #25 was placed on 15 minute checks. The SSD obtained a witness statement from Resident #410 who stated the nurse was arguing with him/her (Resident #410) and Resident #25 attacked him/her (Resident #410), punching him/her in the stomach and below the stomach. Someone then pulled Resident #25 away from him/her (Resident #410) .
--A conclusion showed the allegation was verified by evidence collected during the investigation. Based on information gathered it appeared Resident #25 was experiencing the inability to rationalize the discussion/disagreement between CNA A and Resident #410. Resident #25 had a history of overprotectiveness toward female staff resulting in a display of frustration and aggression (behavior).
--Corrective action taken was to place Resident #25 on 15 minute checks to ensure safety of residents. Resident #25 was then moved to hourly checks once a pattern of safety was ensured after 48 hours.
Record review of Resident #410's nurses' notes, dated 12/26/22 through 1/4/23, showed there was no documentation the resident was involved in a resident to resident altercation on 12/26/22 or that the resident was examined by a nurse for injuries he/she might have sustained from being hit by another resident on 12/26/22.
During an interview on 1/5/23 at 11:19 P.M., Resident #410 said:
-He/she was at the front desk complaining to a nurse about something. He/She thought it was about using the phone. He/She and the nurse argued a small amount and Resident #25 started pounding him/her in the mid to lower stomach. Resident #25 might have hit him/her below the stomach, but he/she couldn't remember for sure. He/she was hit at least four or five times. It was unexpected and it startled and bothered him/her. Resident #25 hitting him/her wasn't right.
- He/she wasn't sure why Resident #25 hit him/her, but he/she argued with the nurse, not with Resident #25. Maybe Resident #25 thought he/she and the nurse were talking about him/her.
-That was not the first time he/she was hit by Resident #25. He/she was hit in the stomach before by Resident #25 several months ago.
-When he/she was hit approximately a week ago he/she didn't remember there being a bruise because of it, but he/she definitely noticed it. The areas hit hurt for about five minutes. It hurt a little bit after that, but not much, and he/she went about his/her normal daily activities the rest of the day.
During an interview on 1/5/23 at 12:00 P.M., CNA A said:
-On 12/26/22 at approximately 5:30 P.M., Residents #410 and #25 were in front of the nurses' station. Resident #25 was sitting in his/her wheelchair when Resident #410 walked up and stood about six or nine inches from Resident #25's right.
-Resident #410 was yelling about his/her phone, but he/she couldn't understand what the resident was saying about it. He/She (CNA A) was standing outside of the therapy room about 10 feet away from Resident #410 who was pointing a finger at him/her and continued yelling about two minutes or maybe three. Resident #25 hit Resident #410 about five or six times in the groin area with an upward movement of his/her (Resident #25's) elbow in quick succession. The punches were deliberate.
-Once Resident #25 started hitting Resident #410 he/she couldn't get to the residents in time to prevent Resident #410 from getting hit several times, because Resident #25 was hitting Resident #410 in quick succession.
-Resident #410 backed away, but still got hit with five or six elbow punches.
-He/she told Resident #25 he/she needed to stop. That was when CMT A came around the corner.
-CMT A wheeled Resident #25 to his/her room and RN A told Resident #410 to go to his/her room.
-He/she thought Resident #25 hit Resident #410 to try to make him/her stop yelling.
-He/she wrote a statement and gave it to the SSD who was still at the facility.
-He/she received abuse training in November or early December, 2022 and was told that physical abuse included hitting, punching, and throwing things at people. He/She wasn't sure if Resident #25's hitting Resident #410 was considered abuse, but the hits were intentional.
-He/she wasn't sure how hard Resident #410 was hit, but it didn't look like it was real hard, although Resident #410 did back away when Resident #25 was punching him/her.
During an interview on 1/5/23 at 1:00 P.M., CMT A said:
-On 12/26/22 he/she noticed Resident #410 walking towards the nurses' desk and out of his/her view. RN A was at the end of the 200 hall not far from the nurses' desk.
-At first he/she heard Resident #410 hollering. There was some back and forth interaction going on between CNA A and Resident #410, but he/she couldn't tell what they were saying because he/she was a ways from the nurses' station.
-He/she then heard CNA A scream for Resident #25 to stop.
-He/she hadn't seen anything, but heard the yelling.
-He/she came to the nurses' station where the residents were and took Resident #25 to his/her room and suggested he/she look at television. At the time he/she didn't know what Resident #25 had done, but focused on calming Resident #25.
-He/she thought Resident #25 was trying to protect CNA A. Resident #25 doesn't have the capacity to know when staff are in danger or not. He/she didn't know if Resident #25 was intentionally trying to hurt Resident #410, because he/she hadn't seen what happened.
-He/she received abuse training recently and was told physical abuse was any aggressive physical contact that was intentional such as hitting, kicking and scratching.
During an interview on 1/5/23 at 1:40 P.M., the SSD said:
-He/she was working the evening of 12/26/22 as a CMT.
-He/she took CNA A's statement and reported the incident to the DON and Administrator.
-It was a trigger for behaviors if Resident #25 thinks someone is being mean to female staff.
-He/she talked with Resident #25 right after the incident and Resident #25 said he/she thought Resident #410 was being mean to CNA A and then he/she hit Resident #410 intentionally.
-The resident was definitely angry with Resident #410 at the time.
-He/she asked Resident #25 if that was how he/she should handle things and Resident #25 said No.
-He/she asked Resident #25 if he/she was better than that behavior and the resident said Yes.
-Once Resident #25 was removed from the situation he/she had calmed down.
-The facility's abuse training defined physical abuse as any aggressive physical behavior that was intentional.
During an interview on 1/5/23 at 3:10 P.M. RN A said:
-He/she heard Resident #410 yelling at CNA A, but couldn't tell what the resident was saying. Resident #410 wanted to use the phone, but he/she told the resident they were starting to serve dinner and to use the phone after dinner.
-He/she was pushing the medication cart down the 200 hall when he/she heard Residents #410 and #25's voices raised, but couldn't tell what they were saying.
-Then he/she saw Resident #410 walk towards his/her room and Resident #25 was in his/her wheelchair. It was all quiet by that time.
-CNA A didn't tell him/her what he/she observed between Residents #410 and #25.
-CNAs are supposed to tell the charge nurse when a resident to resident or other incident happens.
-The on-coming nurse, LPN A, said he/she overheard Resident #410 say he/she was hit by Resident #25.
-He/she told LPN A he/she knew nothing about it.
-On his/her way home after his/her shift he/she received a text by one of the Assistant Director of Nurses (ADON) about the incident which caught him/her off guard.
-Since he/she didn't know Resident #410 was hit he/she did not check him/her for injuries.
-He/she didn't write a note about the incident or start an incident report because he/she didn't know Resident #410 was hit.
During an interview on 1/6/23 at 9:16 A.M., CNA A said:
-He/she thought RN A knew what happened because he/she was right there in a heartbeat when the incident happened.
-He/she told Resident #25 he/she had to stop and that was when RN A immediately came near the nurses' station. Since RN A came so quickly he/she assumed RN A knew what happened.
-He/she was supposed to report incidents to the charge nurse, but he/she thought RN A must have known what happened because he/she was near the nurses' station so he/she didn't report the incident to RN A.
-He/she gave his/her written statement to the SSD.
-Resident #25 was placed on 15 minute checks for at least a couple of days and one hour observations for a while after the incident happened.
During an interview on 1/6/23 at 9:25 A.M. the SSD said:
-He/she talked with Resident #410 within five minutes of him/her being hit and asked if he/she was hurt.
-Resident #410 lifted his/her shirt. He/She had a bruise on his/her side from a previous fall, but no redness to his/her abdomen.
-Resident #410 did not complain to him/her of his/her stomach or groin hurting and said he/she was just mad that he/she got hit and that Resident #25 had to stop hitting.
-Before 12/26/22 it had been several months since Resident #25 had hit Resident #410.
-He/she was able to get Resident #410 calmed down.
During an interview on 1/6/23 at 9:53 A.M., LPN A said:
-On 12/26/22 Resident #410 made two phone calls between 6:30 P.M. and 7:00 P.M. In both phone conversations he/she heard Resident #410 mention that Resident #25 hit him/her. Resident #410 didn't go into any details about what happened to whomever he/she was talking with on the phone.
-He/she asked RN A about Resident #410 being hit by Resident #25 and RN A denied knowing anything about it.
-He/she didn't ask Resident #410 about being hit or when he/she was hit and didn't ask Resident #410 where he/she had been hit.
-Resident #410 didn't complain of hurting anywhere the evening of 12/26/22.
-He/she didn't check Resident #410 for injuries because the resident didn't complain.
-He/she told the SSD what he/she overheard Resident #410 say when the resident was talking on the phone.
During an interview on 1/5/23 at 2:20 P.M., the Corporate Nurse Manager said:
-He/she received a call about the 12/26/22 incident.
-He/she was told Resident #410 was upset regarding the use of the phone.
-Staff thought Resident #25 was trying to protect the staff and ended up hitting Resident #410 as a result. Resident #25 can't rationalize in the moment. He/She just reacts.
-He/she thought the DON found the incident substantiated that Resident #25 hit Resident #410, but didn't know that it was substantiated for abuse.
-With Resident #25's TBI diagnosis, he/she didn't know if Resident #25 meant to hurt or abuse Resident #410.
During an interview on 1/6/23 at 1:57 P.M. ADON A said:
-Staff were told to follow their chain of command to report abuse.
-Nurses should always be informed of abuse and other resident incidents and the nurse should always check out a resident who has been hit for any possible injuries.
The DON who completed the investigation was unavailable for interview at the time of the investigation. As of 1/12/23 the DON had not returned the call.
MO00211738
Nov 2022
4 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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Refer to *GIOQ
This deficiency is uncorrected. For previous examples, refer to the statement of deficiencies dated 9/20/22.
Base...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Refer to *GIOQ
This deficiency is uncorrected. For previous examples, refer to the statement of deficiencies dated 9/20/22.
Based on interview and record review, the facility failed to develop and implement an effective system to ensure one cognitively impaired resident, who was assessed as high risk for elopement and had a history elopement, received the necessary supervision and oversight for his/her health and safety during an outside appointment. Facility staff failed to follow-up on staff concerns of the resident going to an outside appointment without assistance, resulting in the resident being sent out unaccompanied to an outside appointment and going missing from 11/17/22 until 11/23/22. This deficient practice affected one resident (Resident #408) out of 25 sampled residents. The facility census was 99 residents.
The Administrator was notified on 11/22/22 at 11:35 A.M., of the Immediate Jeopardy (IJ), which began on 11/17/22. The IJ was removed on 11/23/22 12:44 P.M. as confirmed by surveyor onsite verification.
Record review of facility policy Transportation, Dental Services, dated 2001 and revised 12/08, showed:
-The social service designee or charge nurse would notify the resident's representative, and inform them of the dental appointment.
-If the facility provided transportation, the social services designee and/or transportation staff person would be responsible for arranging the transportation through the business office.
-A member of the nursing staff or social services was to accompany the resident to the dental office- when the resident needed an escort.
1. Record review of Resident #408's Preadmission Screening and Resident Review (PASSAR), dated 9/29/13, showed the individual had substantial functional limitations in self-care, learning, and capacity for independent living.
-The resident was oriented to person and place, but forgetful of time.
-The resident thought process/cognitive status was irrelevant, had poor concentration, and poor judgement.
-The residents cognitive/intellectual functioning was that he/she could not make good judgements, could follow simple commands, could not follow complex directions, and could not stay on task or complete assignments.
-The resident exhibited memory impairment and disturbances in executive functioning.
-The resident needed supervision and reminders to do Activities of Daily Living (ADL - dressing, grooming, bathing, eating, and toileting).
-Long term nursing facility level of service was recommended.
Record review of the resident's Letter of Guardianship of an Incapacitated Person, dated 12/20/13, showed he/she was appointed a guardian.
Record review of the resident's annual Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning, dated 3/24/22, showed:
-Resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15.
-Showed the resident had a moderate cognitive impairment.
Record review of the resident's Progress Notes, dated 4/10/22 at 3:13 P.M., showed:
-The resident was taken outside to smoke.
-The resident walked away from the area.
-Resident was missing from the smoking area for five to eight minutes.
-A search of the facility property was started.
-The resident was found on the facility property hidden in the bushes.
-Resident was placed on the secured unit.
Record review of the facility's investigation, dated 4/10/22, showed:
-The resident was taken outside to smoke at 1:40 P.M. by a Certified Medication Technician (CMT).
-At 2:00 P.M. the CMT went back inside and left the resident outside.
-At 2:05 P.M. the CMT realized the resident was still outside, and went to go get the resident.
-When the CMT was outside the resident was not in the smoking area.
-The CMT looked around and could not find the resident.
-The CMT went back inside to get other staff to help in locating the resident.
-At 2:15 P.M. the Director of Nursing (DON) was notified of the missing resident. DON told the staff to call the police and notify the Administrator.
-2:20 P.M. the police were called.
-Police arrived and joined the staff in looking for the resident.
-At 4:30 P.M. the resident was located in a brush/tree covered area on the south side of the property. Emergency Medical Services were onsite and assessed the resident.
-The resident did not have any injuries.
-The resident was placed in his/her new room on the secured unit with the approval of his/her guardian.
-The resident said that he/she saw everyone looking for him/her, and that he/she would hide again.
-When the resident was asked why he/she walked away and hid the resident said Because I wanted to.
Record review of the resident's care plan, dated 4/10/22, showed:
-The resident was an elopement risk/wander related to that the resident walked away from smoking area into a heavy brush/tree covered area and prevented staff from being able to see him/her.
-The resident had prior trauma related to his/her diagnosis of Paranoid Schizophrenia, Major Depressive Disorder, Anxiety, and Bipolar. The resident had a long history of being a free spirit he/she stated he/she used to travel all over and was homeless by choice for a long while. The resident had periods of hallucinations and delusions, both visual and audio. He/She also stated that there was nothing wrong with him/her and he/she was completely normal, he/she did not have the crazy things the Doctors say he/she does.
-The resident was dependent on staff to met his/her emotional, intellectual, physical, and social needs due to his/her delusions and schizophrenia.
-The resident had limited physical mobility.
-The resident was alert and orientated by two to three, forgetful, inattention and disorganized thinking at times. The resident would fixate on something and obsess over it. The resident has had his/her Public Administrator (PA) since 2013 and would state the he/she just got his/her PA but he/she was still his/her own person and his/her PA did not make decisions for him/her.
-The resident had impaired communication and usually understood and had clear speech.
The resident was at risk for potential decline related to Alzheimer's, Major Depressive Disorder, Anxiety Disorder, Paranoid Schizophrenia, and Bipolar. At times he/she could be manipulative towards staff and peers, and attempted at times to work staff against other staff, until he/she got the answer that best suited him/her at the time.
-The resident had the potential to be verbally aggressive towards staff and peers.
-The resident had Paranoid Schizophrenia, Major Depressive Disorder, Bipolar Disorder, and dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses).
-The resident had an actual fall related to weakness, unsteady gait, poor balance, anemia, psychotropic medication (medication which affect psychic function, behavior, or experience)use, Alzheimer's disease, and pain at times.
-The resident has chronic pain related to other illnesses.
-The resident is at risk for impaired visual function related to Cataracts (a clouding of the normally clear lens of the eye).
Record review of the resident's Elopement Risk Evaluation, dated 9/20/22, showed the resident was a high risk to wander.
Record review of the resident's quarterly MDS, dated [DATE], showed:
-Resident had a BIMS score of 11 out of 15.
-Showed the resident had a moderate cognitive impairment.
-No wandering behaviors were exhibited.
Record Review of the resident's Progress Notes, dated 11/17/22 at 8:07 P.M., showed at 6:15 P.M. the charge nurse told Licensed Practical Nurse (LPN) E who wrote the note that the resident had a dental appointment that day at a local hospital clinic and the resident had not returned.
During an interview on 11/21/22 at 11:36 A.M., LPN E said:
-He/she did not believe the resident had ever gone to an appointment unescorted.
-The resident should have been escorted.
-No one notified the LPN that the outside transportation company had picked up the resident.
-He/she was unaware the resident had left for an appointment.
-He/she knew the resident had an outside appointment that day.
-The transportation person was the person who accompanied residents to appointments unless the resident needed a CNA to go with them.
-On the Transportation Sheet it was put no escort needed.
-There was no list at the nurse's station of who needed to be escorted.
-He/She was unaware the resident was an elopement risk, and no one told him/her of this fact.
During an interview on 11/21/22 at 2:50 P.M. LPN D said:
-He/she was working as a charge nurse the day the resident was sent to his/her appointment.
-The resident was very nervous that morning about getting his/her teeth pulled.
-The resident's paperwork was at the nurse's station.
-He/she was not the resident's charge nurse.
-He/she looked at the paperwork and noticed the transportation form showed the resident did not need an escort to the appointment.
-He/she talked about the resident going alone with another staff member, but was unsure who he/she talked to.
-He/she questioned the situation with the other staff member, but did not bring his/her concerns to the ADON.
-He/she questioned if the resident was allowed to leave the facility without an escort, but then figured ADON B had filled out the paperwork so it was fine if the resident went alone to the appointment.
-He/she had given the resident some mints to take with him/her to the appointment.
-The resident was in his/her wheelchair and went to wait by the front door for his/her ride to the appointment.
-He/she did not see the resident after that.
-An appointment like this usually took all day, so he/she did not question where the resident was.
-The resident was cognitively impaired and an elopement risk.
-He/she should always have an escort for all appointments.
During a follow-up interview on 11/21/22 at 2:55 P.M., CNA B said:
-Resident had an appointment that day.
-The resident was seen in the hallway that morning, and was told the transportation driver was going to be there in about 30 minutes.
-The resident's paperwork for the appointment was discovered at the nurse's station about 1:00 P.M.
-The Transportation Coordinator was notified of the found paperwork and took the paperwork.
-That afternoon he/she questioned where the resident was, this was about 4:00 P.M.
-The resident was just supposed to have had a tooth extracted, and he/she thought the resident should have been back.
-He/she told the charge nurse the resident was not back yet, and the charge nurse said to give it a bit longer.
-At about 5:00 P.M. the nurse called the hospital clinic to find out where the resident was.
During an interview on 11/21/22 at 3:10 P.M., Business Office Manager (BOM) A said:
-The outside transportation company driver came into the building.
-Two residents waited by the front door to go to appointments.
-The driver did not go to the nurse's station.
-The driver just got the residents and left the building.
During a phone interview on 11/21/22 at 5:01 P.M., Outside Transportation Driver A said:
-Before he/she left with the residents, he told a nurse that he/she was taking the residents, but he/she did not remember the name of the nurse.
-He/she was not given any paperwork for either resident.
-He/she did not handle any residents' paperwork, it was company policy that he/she did not handle any of the residents' paperwork, or ask any information about the appointments.
During an interview on 11/18/22 at 2:45 P.M., Certified Nursing Assistant (CNA) B said:
-The resident was unsafe to go outside unattended due to past behavior of walking off.
-The resident would seem alert and oriented in a short conversation, but a longer conversation showed the resident was not alert and oriented.
-The resident was good at fooling people that he/she was alert and oriented.
During an interview on 11/18/22 at 2:55 P.M., CNA A said:
-The resident was alert and oriented some days and some days not, it just depended on the day.
-Normally the resident went to all appointments with an escort.
-The resident was not safe to go to appointments alone.
-The resident was easily distracted and once outside would start to wander and was difficult to redirect and get back inside.
During an interview on 11/18/22 at 3:10 P.M., CNA C said:
-The resident was not oriented.
-The resident was an elopement risk.
-It would not be appropriate for resident to go to appointments unescorted, and if seen would inform the charge nurse of this.
-Resident had been seen looking for open/unlocked doors.
During an interview on 11/18/22 at 3:15 P.M., LPN C said:
-The resident was not alert and oriented.
-It would not be appropriate for resident to go out to appointments alone due to residents' elopement risk.
-The resident was easily distracted and once outside would start to wander and was difficult to redirect and get back inside,
-The resident was a high elopement risk.
-This LPN had known the resident for two years and the resident has gotten worse cognitively in that time.
-The resident had been out of the secured unit for about two months.
-The resident was a spur of the moment type of elopement risk, he/she was not exit seeking.
-If the LPN saw the resident going on appointment unescorted, he/she would inform the Director of Nursing (DON) or Assistant Director of Nursing (ADON).
During an interview on 11/21/22 at 8:30 P.M., LPN D said:
-He/she was unsure about resident #408 going out to appointments unescorted.
-The resident was alert and oriented at times, but also delusional at times.
-The resident was an elopement risk.
-The resident was not to be trusted to go outside alone.
-The ADON was responsible to ensure residents that need to be escorted are escorted.
-There nothing in the computer that designates if a resident needs an escort to outside appointments.
During an interview on 11/21/22 at 8:34 P.M., ADON said:
-It was not normal for the resident to go out to appointments unescorted.
-He/she was unsure how the resident went out unescorted this time.
-The Transportation Coordinator was responsible for ensuring the resident had an escort.
-The Transportation Coordinator did not drive the residents to appointments. -The facility contracted with an outside company, so the transportation person acted as the escort.
-The Transportation Coordinator would ask the charge nurses who needed an escort sometimes.
-The Transportation Sheet indicated if a resident needed an escort.
-There was nothing in the computer that showed which residents needed an escort.
-The resident was an elopement risk.
-The resident had to have supervision to go outside.
-If a nurse saw a problem with a resident not being escorted, then the nurse should let the DON or himself/herself know immediately.
During a phone interview on 11/21/22 at 9:04 A.M., Outside Transportation Company CEO said:
-The company did not provide escorts, that was the facility's responsibility.
-The company had an online portal that the facility fills out and inputs any special equipment that would be taken and if an escort was to be going.
-No escort was marked as going for this trip.
During an interview on 11/21/22 at 9:14 A.M., Public Administrator (PA) said:
-The resident had always been an elopement risk.
-It was his/her expectation that the resident would have had an escort when he/she went to appointments outside the facility.
-The resident was placed at the facility for his/her safety and oversight.
-The resident was cognitively impaired.
During an interview on 11/21/22 at 9:28 A.M., Corporate Nurse (CN) A said:
-The resident was an elopement risk.
-He/she was unsure why the resident was sent to an outside appointment unescorted.
-When the resident was sent out unaccompanied the Administrator, DON, and ADON should have been informed and known of this.
-This resident was cognitively impaired, had a complex medical history, and had hallucinations while still being medicated.
During an interview on 11/21/22 at 9:59 A.M. the Social Services Designee (SSD) said:
-He/she had been following up on the whereabouts of the resident.
-He/she had communication with the police department who stated the resident had been seen getting into an Uber on 11/17/22 leaving the hospital.
-That was all he/she knew at this time.
-The resident was an elopement risk and cognitively impaired.
-The resident should not have been sent to an appointment alone.
-The nurses were responsible for ensuring the resident had an escort to his/her appointment.
During an interview on 11/21/22 at 10:40 A.M., Transportation Coordinator said:
-He/she asked the charge nurse if a resident needed an escort if he/she was unsure if a resident needed an escort.
-He/She did not ask if this resident needed an escort because he/she thought this resident had gone out to appointments unescorted before.
-When he/she first took over the position, he/she requested a list of residents who needed to be escorted, but he/she had not received a list and that was four months ago.
-The resident had gone out alone before and returned.
-He/she was told before that the resident did not need an escort, but could not remember who told him/her this.
-He/she was not usually told of any special needs that the resident needed to include if the resident required an escort.
-He/she filled out the Transportation Sheet, and any questions he/she did not know, he/she would ask a charge nurse.
-He/she did not keep a list of residents that had gone out alone.
During an interview on 11/21/22 at 1:45 P.M., DON said:
-He/she was unfamiliar with the resident because he/she had just recently started at the facility in the position.
-It was his/her expectation that residents that had appointments, and what those residents needed that day would be discussed in the morning meeting.
-This was not happening at this time since he/she just started.
-The Transportation Coordinator made all the appointments for residents.
-The Transportation Coordinator did not have a list of residents that required escorts when the residents went out to appointments at that time.
On 11/21/22 at 3:08 P.M., a copy of the resident's paperwork that was found was requested from the Transportation Coordinator, and was told the paperwork was shredded. He/She did not keep resident's paperwork.
During a phone interview on 11/21/22 at 4:03 P.M., Outside Transportation Company Owner said:
-The company did not provide escorts to residents.
-It is company policy that any residents diagnosed with dementia was required to have an escort, and if no escort was present the resident was not taken and the appointment would have to be rescheduled when an escort was available.
-The facility was responsible to let the company know if a resident had a diagnosis of dementia through the online portal.
-On this transport the facility failed to notify the outside transportation company that the resident had a diagnosis of dementia.
MO002140047
NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A revisit will be conducted to determine if the facility is in substantial compliance with participation requirements.
At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).
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
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Refer to *GIOQ
This deficiency is uncorrected. For previous examples, refer to the statement of deficiencies dated 9/20/22.
Base...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Refer to *GIOQ
This deficiency is uncorrected. For previous examples, refer to the statement of deficiencies dated 9/20/22.
Based on observation, interview, and record review, the facility failed to ensure two sampled residents (Residents #81 and #11) were free from physical abuse when one sampled resident (Resident #25) out of 25 sampled residents, who had a known history of aggression, anger issues, yelling, and hitting other residents struck Resident #81 in the nose causing a nose bleed and resulting in the resident having to go to the emergency room (ER) after having symptoms of severe headache; and struck Resident #11 on the cheek and near his/her eye causing bruising. The facility census was 99 residents.
Record review of the facility's policy Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, dated April 2021, showed the resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives:
-Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone.
-Develop and implement policies and protocols to prevent and identify abuse or mistreatment of residents.
-Ensure adequate staffing and oversight/support to prevent burnout, stressful working situations and high turnover rates.
-Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems.
1. Record review of Resident #81's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning), dated 8/22/22, showed the resident:
-admitted to the facility on [DATE] with the following diagnoses:
--Dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning);
--Anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome);
--Depression (a constant feeling of sadness and loss of interest), and Schizophrenia (a chronic, severe mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality);
-no behaviors; and
-severe cognitive impairment.
2. Record review of Resident #11's quarterly MDS, dated [DATE], showed the resident had the following diagnoses:
--Dementia;
--Depression;
--Schizophrenia (a long-term mental disorder of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation);
-no behaviors; and
-severe cognitive impairment.
3. Record review of Resident #25's admission Record showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-Traumatic brain injury (TBI - damage to the brain resulting from external mechanical force, such as rapid acceleration or deceleration, impact, blast waves, or penetration by a projectile);
-SynGap 1 related intellectual disability (a neurological disorder characterized by moderate to severe intellectual disability evident in early childhood with features of delayed speech development and motor skills and often seizures, hyperactivity and sensory processing problems);
-Schizoaffective disorder, depressive type (a mental condition that causes loss of contact with reality and mood problems);
-Restlessness and agitation;
-Psychosis (a mental state involving loss of contact with reality and causing deterioration of normal social functioning);
-Antisocial personality disorder (condition characterized by repetitive behavioral patterns that are contrary to usual moral and ethical standards and cause a person to experience continuous conflict with society); and
-Intermittent Explosive Disorder (a chronic disorder involving repeated, sudden episodes of impulsive, aggressive, violent behavior and/or angry verbal outbursts in which reactions are grossly out of proportion to the situation).
Record review of the resident's Potential for Physical Aggression Care Plan, initiated 4/12/22, showed:
-The resident had potential to be physically aggressive related to Intermittent Explosive Disorder.
-The resident would hit staff, himself/herself, and other residents.
-He/She would throw objects, slide out of his/her wheelchair, and hit walls, doors and windows when upset.
-Triggers for physical aggression were paranoia that others were talking about him/her.
-Staff would remove those the resident feels are talking about him/her out of view by closing doors or putting up a shield so the resident can't see them.
-On 5/6/22 information and interventions were added showing:
--Triggers for physical aggression were paranoia that others were talking about him/her.
--Behaviors were de-escalated by one to one staff (1:1) reassurance.
--Anticipate needs.
--Staff will remove those the resident feels are talking about him/her out of view by closing doors or putting up a shield so the resident can't see them.
--Provide cues to alleviate anxiety such as giving feedback and encouraging the resident to seek out a staff member when agitated.
Record review of the resident's Preadmission Screening and Resident Review (PASRR) II (determines if the intellectual disability or serious mental illness of the individual can be met in a nursing facility or if the resident requires specialized services) dated 6/7/22, showed:
-Due to the resident's TBI he/she had problems with impulsive behaviors and anger control.
-His/her reported moods could be labile (rapid, exaggerated mood changes) and he/she struggled with expressing emotions appropriately.
-He/she needed assessment and implementation of a behavioral support plan, monitoring of behavioral symptoms, and provision of behavioral supports. The plan should show the level of supervision required to prevent harm to self or others. The plan should identify clear steps to manage the individual's behavior in a crisis situation, who to contact for assistance, and how staff will work together in a crisis.
Record review of the resident's Potential for Physical Aggression Care Plan showed:
-Interventions were re-iterated on 6/21/22 to provide one on one attention, reassurance, and attempt to calm the resident as the resident's behaviors were de-escalated by these interventions.
-On 6/27/22 the resident allegedly hit Resident #11. Staff were to keep the resident away from others when he/she was agitated and appeared aggressive towards others.
-On 7/21/22 the resident hit another resident. Staff were not to place the resident within arms reach of others.
Record review of the resident's quarterly MDS, dated [DATE], showed:
-severe cognitive impairment;
-fluctuating inattention and fluctuating disorganized thinking;
-mood assessment showed he/she was short-tempered and/or easily annoyed 12 to 14 days out of the past 14 days;
-physical behaviors directed towards others four to six days out of the past seven days;
-verbal behaviors directed towards others one to three days out of the past seven days; and
-behaviors not directed towards others one to three days out of the past seven days.
4. Record review of an Incident Report, dated 10/16/22, showed:
-Resident #25 hit Resident #11 on the left wrist and left an immediate blood bruise to Resident #11's left outer wrist.
-Resident #25 also hit a staff member and stated he/she was mad. Resident #25 was separated from the other residents.
-There were no predisposing environmental or physiological factors. Another resident was being given attention and staff was unable to give Resident #25 attention at the time.
Record review of Resident #25's Potential for Physical Aggression Care Plan showed no new interventions were implemented after 10/16/22 for increased monitoring or other measures to prevent the resident from harming other residents.
5. Record review of an Incident Report, dated 10/23/22 at 4:49 P.M., showed:
-Resident #25 was involved in a physical altercation with Resident #81.
-Resident #25 punched Resident #81 in the face and was punched in the face by Resident #81.
-The incident was witnessed.
-Resident #81 was oriented to person. Resident #25 was oriented to person and place.
-There were no predisposing factors.
Record review of the resident's Potential for Physical Aggression Care Plan showed information was added on 10/28/22 showing:
-On 10/23/22 Resident #25 had a resident to resident incident.
-No new measures were put into place after 10/23/22 to prevent further physical abuse in the future.
6. Record review of Resident #25's nurse's note, dated 10/25/22 at 3:44 P.M., showed:
-On 10/25/22 Resident #25 punched Resident #81 in the face, causing his/her right nostril to bleed.
-Resident #25 was taken to the therapy room and later to his/her room with the door open.
7. Record review of an Incident Report, dated 10/25/22 at 3:48 P.M., showed:
-Resident #25 was in his/her wheelchair and propelled himself/herself up to Resident #81, who was also sitting in a wheelchair, and hit Resident #81 with a closed fist in the nose. Resident #81's right nostril was bleeding.
-Resident #81 said This resident assaulted me.
-Resident #25 was oriented to self, place, and situation. Resident #81 was oriented to self.
-There were no predisposing situational factors.
-The physician, Assistant Director of Nursing (ADON) B, DON, and Resident #25's responsible party were notified.
-Certified Nursing Assistant (CNA) D's statement, undated, showed he/she was at the nurse's station on 10/25/22 and observed Resident #81 sitting in front of the nursing station when Resident #25 punched Resident #81 in the nose.
-Corporate Nurse A's statement, dated 10/25/22 and 10/26/22, showed:
--On 10/25/22 Resident #81 was assessed for injuries. A small amount of blood was noted on the resident's nose and fourth finger of his/her left hand which was cleaned up.
--On 10/26/22 Resident #81 reported neck pain and held his/her head slanted to the left. Orders were obtained to send the resident to the hospital. When asked why he/she thought his/her neck hurt Resident #81 responded I don't know; it just hurts, damn it.
Record review of Resident #25's Potential for Physical Aggression Care Plan showed no new measures were put into place to prevent further abuse after the 10/25/22 incident.
During an interview on 11/17/22 at 9:03 A.M. LPN F said:
-There had been an altercation in the afternoon between Resident #25 and Resident #81 about two to four weeks ago.
-He/she was on the 100 hall and heard yelling. He/she couldn't tell who yelled or what was being said.
-Resident #81 was in his/her Broda chair (tilt-in-space positioning chair) at the end of the 200 hall near the main hall and nurses' station. Resident #25 was beside Resident #81's Broda chair.
-A CNA told him/her Resident #25 punched Resident #81 in the nose.
-They separated Resident's #25 and #81 and he/she took Resident #25 into the therapy room.
-He/she assessed Resident #81 for injuries. Resident #81 had redness on the right side of his/her nose.
During an interview on 11/17/22 at 10:30 A.M., CNA D said:
-On 10/25/22, he/she was sitting at the nurses' station charting. He/She was talking with Resident #81 at the nurses' station about cars.
-Resident #25 came around the nurses' station. He/She thought Resident #25 was just going to wheel himself/herself right on by, but instead Resident #25 just punched Resident #81 on the side of his/her nose as he/she was rolling by. Resident #81 didn't do a thing to Resident #25. There was no warning whatsoever.
-He/she and LPN B separated the residents.
-Resident #25 was taken to the therapy room.
-Resident #81 was sent out the next day or two to the hospital because Resident #81 complained of a headache.
-If it seems like Resident #25 is aggravated, staff take him/her to the therapy room.
-During staff training three weeks ago staff were told to separate Resident #25 from others when he/she was agitated. The facility didn't tell staff what to do to prevent further instances.
During an interview on 2:12 P.M. CNA A said:
-He/she was working on 10/25/22.
-He/she saw Resident #81 bleeding from the nose around 10:30 A.M. or 11:00 A.M.
-A staff person was saying he/she saw Resident #25 hit Resident #81.
-Resident #81 was saying He/She hit me in my nose. I'm bleeding. So the incident had just happened.
-Staff moved Resident #25 somewhere away from Resident #81.
-They had a meeting recently and were told to separate residents after an altercation. Management told staff to try to keep Residents #25 and #81 apart. He/she didn't know why Resident #25 had a thing about Resident #81.
-Management did not say anything about how staff were to try to prevent further incidents between the two residents. Staff can't keep Resident #25 away from residents all the time.
-Resident #25 mostly picked on Residents #81 and #11.
-Resident #11 was very sweet and never picked on anyone.
During an interview on 11/17/22 at 2:35 P.M., LPN A said:
-On 10/25/22, he/she was at the nurses' station and heard staff say something.
-Resident #81 said Resident #25 hit or punched him/her in the nose.
-Blood was dripping down Resident #81's nostrils and LPN A grabbed a rag.
-They moved Resident #81 away from Resident #25 and took Resident #25 somewhere.
-The facility did some in-services. He/she couldn't recall what they told staff about resident to resident behaviors or abuse because they went over so many things.
-He/she didn't remember what they said about keeping Resident #25 away from other residents. They did say to keep a close eye on Resident #25.
-They didn't explain any specific interventions or methods to use to keep Resident #25 from hurting others.
During an interview on 11/17/22 at 3:45 P.M., CNA F said:
-On 10/25/22, he/she was coming from the dining room and when he/he came around the nurses' station he/she saw Resident #81 with a bloody nose.
-The nurse was assessing Resident #81 and staff took Resident #25 somewhere, maybe to his/her room.
-The facility did an in-service about resident to resident behaviors and abuse a few weeks back.
-They didn't take their masks off during the in-service so he/she didn't know what they said.
-They provided written literature that showed staff should separate residents if there was an altercation.
-Staff can't keep the residents separated all the time. Residents come and go.
-They did not get any specific training on what to do specifically to keep Resident #25 from hurting other residents.
-Resident #25 spent most of his/her time in the therapy room, but he/she wasn't sure why.
During an interview on 11/18/22 at 10:00 A.M., LPN B said:
-On 10/25/22 he/she was at the nurses' station charting. Resident #81 was sitting in his/her Broda chair in front of the therapy room and Resident #25 was coming from the 300 hall in his/her wheelchair heading towards the dining room.
-The next thing he/she knew, CNA D was standing in front of the nursing desk saying Resident #25 Resident just punched Resident #81.
-Resident #25 was taken to the therapy room and Resident #81 was moved.
-Staff cleaned Resident #81's bloody nose. The blood came down to his/her lip. Resident #81 said I was assaulted.
-Resident #81 was a little red on the left side of his/her nose. Resident #81 was moved to the memory care unit at the time or a day or two later.
-Staff were supposed to keep them apart from each other when Resident #25 was upset.
8. Record review of the facility's internal investigation, dated 11/16/22 showed the following written statements:
-LPN F's written statement, dated 11/16/22, showed:
--At approximately 10:00 A.M. on 11/16/22 he/she was in the doorway of a resident's room and heard yelling.
--He/she observed Resident #25 swing his/her right arm and fist towards Resident #11.
--The podiatrist was trying to get hold of Resident #25's arm.
--He/she took Resident #11 down the hall to assess him/her.
--The podiatrist told him/her that he/she saw Resident #25 punch Resident #11 in the right cheek after Resident #25 backed his/her wheelchair into Resident #11's wheelchair.
--A red area was noted on Resident #11's right cheek. Resident #11 denied pain. There was no swelling to the area.
Record review of the resident's Potential for Physical Aggression Care Plan showed no new measures were put into place to prevent further resident to resident abuse following the 11/16/22 incident.
During an interview on 11/17/22 at 8:15 A.M., LPN F said:
-He/she was the nurse working on 11/16/22.
-He/she was in the doorway of the room diagonal from the salon where the podiatrist was treating residents.
-Residents #25 and #11 were the only two residents in the hallway.
-He/she heard yelling, but couldn't make out what was said. He/She could hear both Resident #25's and the podiatrist's voice which sounded excited.
-The podiatrist had just finished with Resident #25 and came into the hallway.
-He/she saw Resident #25 punch out towards Resident #11's right cheek, but couldn't tell if Resident #25's fist made contact with Resident #11.
-The side of Resident #11's wheelchair was touching the back of Resident #25's wheelchair, because Resident #25 had backed up, hitting Resident #11's wheelchair.
-When the wheelchairs touched, Resident #25 immediately punched out towards Resident #11 with Resident #25's right hand.
-When he/she examined Resident #11's right cheek, he/she saw a red mark. Resident #11 said Resident #25 hit him/her pretty hard and Resident #11 then placed his/her hand on his/her right cheek. It was immediately red.
-The podiatrist told him/her he/she asked Resident #25 to hold on and not back up, but to let the podiatrist help back up Resident #25's wheelchair, but Resident #25 was determined to back his/her wheelchair up anyway. The podiatrist said he/she saw Resident #25's arm go out in a punch and saw it hit Resident #11 in the right cheek.
-He/she got in between the two residents.
-He/she interviewed Resident #25 about 10 or 15 minutes after the incident when he/she was calm. Resident #25 said Resident #11 ran into him/her and grabbed his/her wheelchair so he/she hit Resident #11, but he/she (LPN F) saw that Resident #11 did not hit or grab Resident #25's wheelchair.
-The incident happened around 10:00 A.M. The redness of Resident #11's face was gone by around noon. Resident #11 never said how it made him/her feel or if he/she was afraid of Resident #25.
Observation on 11/17/22 at 9:56 A.M., showed Resident #11 had very slight bruising to the right cheek and on the outside of his/her right eye, somewhat grayish in color with possible slight swelling.
During an interview on 11/17/22 at 9:57 A.M., Resident #11 said he/she didn't remember being hit the previous day or at any other times.
During an interview on 11/18/22 at 9:40 A.M., the podiatrist said:
-He/she was at the facility on 11/16/22. There were no staff supervising Residents #25 and #11.
-When the treatment ended, he/she told Resident #25 to wait for him/her to help Resident #25 back up, but Resident #25 refused to wait and bumped into Resident #11.
-There had been plenty of space for Resident #25 to move away and not be too close to Resident #11.
-Resident #25 swung his/her right arm multiple times attempting to hit Resident #11. Resident #25 made contact with Resident #11 two or maybe three times on the right side of Resident #11's face. (Note: The facility's Final Investigation Report, dated 11/21/21 for the 11/16/22 incident showed the podiatrist said Resident #25 made contact with Resident #11's face once.)
-Resident #11 had redness on his/her right cheek and outside of his/her right eye. He/she was very red. Resident #11's right eye was tearing. After being hit, Resident #11 covered his/her right eye.
-He/she pulled Resident #25's wheelchair towards himself/herself so Resident #25 wouldn't be so close to Resident #11 and told Resident #25 he/she needed to keep his/her hands to himself/herself.
-Resident #25 cursed and said Keep your hands to yourself.
-He/she hadn't noticed any staff around and yelled out Hey, you guys! Hey!
-LPN F showed up and said he/she had seen Resident #25 hit Resident #11, but was unable to immediately intervene, because he/she had been with another resident.
Record review of the Final Report, dated 11/21/22, for the 11/16/22 incident showed:
-On 11/21/22 at 10:15 A.M. the podiatrist was contacted who was the witness to the incident. The podiatrist's statement showed:
--He/she was treating Residents #25 and #11. He/She offered to back Resident #25 up, but Resident #25 would not wait for his/her help and bumped into Resident #11's wheelchair.
--Resident #25 started swinging his/her arm around and contacted Resident #11's right side of face one time. Resident #25 continued swinging a couple more times without success of contacting Resident #11 again.
--He/she grabbed Resident #25's wheelchair and pulled him/her away to create distance from Resident #11.
9. Observation on 11/17/22 at 2:27 P.M., showed:
-The Maintenance Manager could be heard yelling out Hey! Hey! Hey! Stop! and asking where he/she should take Resident #25.
-Staff were heard directing the Maintenance Director to take Resident #25 into the therapy room.
-The Maintenance Director was heard saying Resident #11 had just passed Resident #25 in the hallway and Resident #25 punched Resident #11 as Resident #11 was going by. Resident #11 hadn't done anything to Resident #25.
During an interview on 11/17/22 at 2:47 P.M., the Maintenance Director said:
-He/she came around the corner 15 or 20 minutes earlier on 11/17/22 and saw Resident #25 sitting outside the therapy room door.
-Resident #11 rolled his/her wheelchair within three feet of Resident #25 and Resident #25 just reached out with his/her good hand as if he/she had the intent to aggressively hit Resident #11. Resident #25 just had that look as if he/she might hit Resident #11. Resident #25's hand was probably eight to 10 inches from touching Resident #11's shoulder.
-That was when he/she yelled out Hey! Hey! Hey! Knock it off! and wheeled Resident #25 into the therapy room.
-Had he/she not seen it Resident #25 almost hit Resident #11 and yelled out there was a good likelihood that Resident #25 would have hit Resident #11.
-Resident #25 got close enough to Resident #11 he/she knew Resident #25 had some aggressive intent. Resident #25's wheelchair was almost touching Resident #11's wheelchair.
-He/She had not received any training on resident to resident behaviors and had no specific education on how to intervene to prevent Resident #25 from harming other residents.
During an interview on 11/17/22 at 4:02 P.M., CNA G said:
-They went over abuse and resident rights not long ago.
-After an incident staff are to remove residents from the situation and take them some place quiet where they can calm down and then report the altercation to the nurse.
-The nurse will do the incident note and staff are to write their statements.
-Resident #25 has verbal behaviors that can escalate to physical.
-He/she saw Resident #25 draw his/her hand back to punch Resident #11 because Resident #11 was sitting where Resident #25 thought was his/her spot. This was maybe three or less months ago.
-At the time he/she blocked Resident #25's punch by putting his/her hand out and got Resident #11 out of the line of fire.
-Staff had been told to keep Resident #25 away from Resident #81, but were not instructed to keep Resident #25 away from Resident #11.
During an interview on 11/17/22 at 4:15 P.M. CNA E said:
-Staff were in-serviced a couple of weeks ago about resident to resident incidents.
-Staff were told to keep Resident #25 away from other residents and to wheel Resident #25 elsewhere.
-Staff can't always tell ahead of time when Resident #25 is going to go after someone. He/She is pretty quick.
-Resident #25 might be having a conversation with another resident and he/she will just hit them.
-He/She saw Resident #25 punch Resident #11 on the wrist last month and leave a bruise. It was out of the blue.
-Resident #11 doesn't have behaviors. He/She is quiet and rolls himself/herself around.
-He/she had seen Resident #25 show his/her fist to Residents #81 and #11 within the past two to three months.
-He/She was at the facility when Resident #81 got the bloody nose, but didn't see him/her get hit.
-Resident #81 complained of a headache the day after he/she was hit. Resident #81 said his/her head felt terrible and was about to explode.
-Staff have had no training on what to do to prevent Resident #25 from hurting anyone. They mainly talked about what to do once an altercation or abuse happened.
Observation on 11/18/22 at 8:05 A.M., showed Resident #25 sitting by himself/herself at a dining table. Other residents were in the dining room. There were no staff in the dining room at the time, except for the Dietary Manager who was speaking with another resident.
During an interview on 11/18/22 at 10:00 A.M., the Social Services Designee (SSD) said:
-Triggers for the resident were someone bumping into his/her wheelchair, not having a soda immediately when he/she wants one, and other residents cussing around him/her.
-The resident had self-harm behaviors and was physically and verbally aggressive towards staff and other residents.
During an interview on 11/18/22 at 10:46 A.M., Assistant Director of Nursing (ADON) B said:
-On 11/16/22 LPN F came by his/her office to let him/her know Resident #25 just hit Resident #11 while they were waiting for the podiatrist and asked him/her to notify the DON and Administrator.
-On 10/26/22 Resident #81 was grabbing his/her head. The resident never complained of headaches so the resident was sent out to the ER because he/she could have had a concussion.
During an interview on 11/18/22 at 11:12 A.M., ADON A said:
-He/she helped with training staff on abuse/neglect and behaviors within the past couple of weeks. The training did not include preventing resident to resident abuse.
During an interview on 1/18/22 at 11:33 A.M. the DON said:
-Since he/she had been at the facility he/she was unaware of any resident having been put on 1:1 supervision or even on every 15 minute checks, but that should have happened for resident to resident aggression.
-Resident #25 should have a behavior care plan that effectively addresses his/her physically aggressive behaviors.
-The facility did some education on monitoring behaviors and ways to manage behaviors in general such as getting between residents, getting a nurse, separate residents, and letting other staff know more help is needed.
-There had been no education on what steps staff should take to prevent Resident #25 from harming other residents.
During an interview on 11/18/22 at 2:50 P.M. the Administrator said:
-The Interdisciplinary Team (IDT) was responsible for developing interventions after a resident to resident abuse investigation.
-He/she didn't know how much monitoring there had been of Resident #25's behaviors following resident to resident incidents.
-The facility generally used the therapy room to provide Resident #25 with attention. The room has glass and the nursing staff can look in.
MO00209989
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0742
(Tag F0742)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Refer to *GIOQ
Based on observation, interview, and record review, the facility failed to develop and implement interventions re...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Refer to *GIOQ
Based on observation, interview, and record review, the facility failed to develop and implement interventions related to supervision, self-harm, and aggression toward others for Resident #25, who showed no improvement in his/her ability to control expressions of anger over time. The facility failed to ensure psychiatric visits and supportive services were in place, and to have an individualized care plan based on Resident #400's needs related to suicidal ideations and multiple suicide attempts, crisis monitoring, social services interventions, and to arrange for ongoing mental health services to meet the resident's psychosocial needs. Lastly, the failed to ensure supportive services were in place and to have an individualized care plan based on Resident #14's needs including behavioral health counseling for mood management. This effected 3 out of 25 sampled residents. The facility census was 99 residents.
Record review of the facility's Behavioral Assessment, Intervention and Monitoring policy, revised 3/2019, showed:
-The facility would provide and residents would receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment.
-Behavioral health services would be provided by qualified staff who have the competencies and skills necessary to provide appropriate services and treatment.
-The Interdisciplinary Team (IDT) would thoroughly evaluate new or changing behavioral symptoms in order to identify the underlying causes and address and modifiable behaviors.
-The IDT would evaluate the behavioral symptoms of residents to determine the degree of severity, distress, and potential safety risks.
-The care plan would incorporate the findings.
-The interventions would be individualized and part of the overall care environment that supported physical function and psychosocial needs.
1. Record review of Resident #25's admission Record showed he/she was admitted to the facility on [DATE] and had diagnoses that include:
-Traumatic brain injury (TBI - damage to the brain resulting from external mechanical force, such as rapid acceleration or deceleration, impact, blast waves, or penetration by a projectile).
-SynGap 1 related intellectual disability (a neurological disorder characterized by moderate to severe intellectual disability evident in early childhood with features of delayed speech development and motor skills and often seizures, hyperactivity and sensory processing problems).
-Schizoaffective disorder, depressive type (a mental condition that causes loss of contact with reality and mood problems).
-Restlessness and agitation.
-Psychosis (a mental state involving loss of contact with reality and causing deterioration of normal social functioning).
-Antisocial personality disorder (condition characterized by repetitive behavioral patterns that are contrary to usual moral and ethical standards and cause a person to experience continuous conflict with society).
-Intermittent Explosive Disorder (a chronic disorder involving repeated, sudden episodes of impulsive, aggressive, violent behavior and/or angry verbal outbursts in which reactions are grossly out of proportion to the situation).
Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by staff for care planning), dated 4/8/22, showed the resident:
-Was severely cognitively impaired.
-Had fluctuating inattention.
-Had physical behaviors directed towards others one to three days out of the past seven.
-Had no verbal behaviors directed towards others.
-Had no other behaviors (e.g. hitting self, screaming, throwing objects) not directed at others.
Record review of the resident's Potential for Physical Aggression Care Plan, dated 4/2/22 and initiated 4/12/22, showed:
-The resident had potential to be physically aggressive related to Intermittent Explosive Disorder. The resident would hit staff, himself/herself, and other residents. He/she would throw objects, slide out of his/her wheelchair, and hit walls, doors and windows when upset.
-Interventions, initiated 4/12/22, showed:
--Analyze and document time of day, places, circumstances, and triggers for behaviors. Document what de-escalates behaviors.
--Administer medications as ordered.
-On 5/6/22 information and interventions were added showing:
--Triggers for physical aggression were paranoia that others were talking about him/her.
--Behaviors were de-escalated by one to one staff (1:1) reassurance.
--Anticipate needs.
--Staff will remove those the resident feels are talking about him/her out of view by closing doors or putting up a shield so the resident can't see them.
--Provide cues to alleviate anxiety such as giving feedback and encouraging the resident to seek out a staff member when agitated.
Record review of the resident's Preadmission Screening and Resident Review (PASRR) II (determines if the intellectual disability or serious mental illness of the individual can be met in a nursing facility or if the resident requires specialized services) dated 6/7/22, showed:
-The resident had an Intellectual Disability (when there are limits to a person's ability to learn at an expected level and function in daily life) or related condition and a substantiated dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and required nursing facility services.
-Due to the resident's TBI, he/she had problems with impulsive behaviors and anger control.
-His/Her reported moods could be labile (rapid, exaggerated mood changes) and he/she struggled with expressing emotions appropriately.
-He/she has a guardian to assist with major life and financial decisions and required 24 hour support.
-The resident needed assessment and implementation of a behavioral support plan, monitoring of behavioral symptoms, and provision of behavioral supports. Staff should identify precipitating factors which may exacerbate his/her volatile behaviors. A structured, low-stimulation environment should be provided. He/She will require continued psychiatric follow-up and medication management and periodic review of medications. Establish consistent routine, provide daily tasks/activities and assess and plan for the level of supervision required to prevent harm to self or others. The plan should identify clear steps to manage the individual's behavior in a crisis situation, who to contact for assistance, and how staff will work together in a crisis.
Record review of the resident's Potential for Physical Aggression Care Plan showed:
-Interventions were re-iterated on 6/21/22 to provide one on one attention, reassurance, and attempt to calm the resident as the resident's behaviors were de-escalated by these interventions.
-On 6/27/22 the following information and an intervention was added:
--The resident allegedly hit Resident #11.
--An intervention was put in place for staff to keep the resident away from others when he/she is agitated and appears aggressive towards others.
Record review of the resident's quarterly MDS, dated [DATE], showed the resident:
-Was severely cognitively impaired.
-Had fluctuating inattention.
-Had physical behaviors directed towards others four to six days out of the past seven days.
-Had verbal behaviors directed towards others one to three days out of the past seven days.
-Had behaviors not directed towards others one to three days out of the past seven days.
Record review of the resident's Potential for Physical Aggression Care Plan showed:
-The following information and intervention was added on 7/21/22:
--The resident hit another resident and was immediately separated from the other resident. He/She was given an as-needed (pro re nata - PRN) medication for agitation and placed on 15 minute checks.
--Staff will not place the resident within arms' reach of others.
-On 9/3/22 an intervention was added to encourage the resident to remain in his/her room when agitated.
-On 9/7/22 information was added that the resident's medication had been adjusted.
Record review of the resident's incident note, dated 9/28/22 at 2:18 P.M., showed:
-The resident was sitting at the nurses' station and became angry for unknown reasons and began hitting the wall behind him/her with his/her right elbow.
-His/her elbow became reddened and swelling was noted.
-The Nurse Practitioner (NP) was at the facility and assessed the resident.
-An X-ray was ordered and the resident's responsible party was notified.
-The note did not show what, or if any, intervention was implemented after this behavior started.
Record review of the resident's Potential for Physical Aggression Care Plan showed no new interventions had been added on or soon after the resident's self-harm behaviors of 9/28/22 to help prevent such behaviors in the future.
Record review of the resident's quarterly MDS, dated [DATE], showed the resident:
-Was severely cognitively impaired.
-Had fluctuating inattention and fluctuating disorganized thinking.
-The resident's mood assessment showed he/she was short-tempered and/or easily annoyed 12 to 14 days out of the past 14 days.
-Had physical behaviors directed towards others four to six days out of the past seven days.
-Had verbal behaviors directed towards others one to three days out of the past seven days.
-Had behaviors not directed towards others one to three days out of the past seven days.
Record review of the resident's nurses' note, dated 10/14/22 at 1:18 A.M., showed a Certified Nursing Assistant (CNA) notified the nurse about a bruise found on the resident's left upper thigh. The nurse looked at the bruise and observed three lines side by side which seemed to be newer bruising. When asked what happened, the resident said he/she punched his/her own thigh.
Record review of the resident's Psychiatric Periodic Evaluation, dated 10/14/22, showed:
-The resident was seen for on-going medication management related to multiple severe psychiatric illnesses and had symptoms such as agitation and aggression related to intermittent explosive disorder and mood lability.
-The resident had been hitting his/her own leg, but cannot identify why.
-The resident said he/she wanted something to keep in his/her lap so he/she can hit that instead of his/her own legs.
-Recommendation was for staff to offer a pillow or stuffed animal to keep in the resident's wheelchair.
-Offered education to staff.
-The staff needed to continue to offer activities, social events, and personal one on one time as staffing allows.
-Ensure regular physical activity as tolerated.
Record review of the resident's Potential for Physical Aggression Care Plan showed:
-No new interventions had been added on or soon after the resident's behaviors of 10/14/22 to prevent self-harm such as increased monitoring or other measures.
-The psychiatric recommendation for staff to offer Resident #25 a pillow to keep in the resident's lap was not incorporated into the resident's care plan.
Record review of the resident's behavioral note, dated 10/15/22 at 5:42 A.M., showed the resident was hitting himself/herself on the left leg and cussing throughout the shift. The resident was redirected, but reverted back to the behaviors. The resident was upset stating he/she had two televisions and was going to beat up his/her family member because he/she knew the family member took them. The resident had a working television in his/her room.
Record review of the resident's Potential for Physical Aggression Care Plan showed no new interventions had been added on or soon after the resident's behaviors of 10/15/22 to provide staff instruction for any increased monitoring needs or other measures to proactively prevent self-harm behaviors in the future.
Record review of the resident's behavioral note, dated 10/18/22 at 3:42 A.M., showed the resident was sitting in his/her room cussing and hitting the wall with his/her fists. The note did not describe how long the behaviors continued, or whether or not any interventions were implemented to decrease the behavior. It did not show if on-going monitoring was needed.
2. Record review of Resident #25's nurses' note, dated 10/25/22 at 4:01 P.M., showed:
-Resident #25 punched another resident in the face, causing the other resident's right nostril to bleed.
-Resident #25 was taken to the therapy room with the restorative aide and later to his/her room with the door open.
Record review of the internal investigation for Resident #25's Resident to Resident abuse investigation showed:
-An Incident Report, dated 10/25/22 at 3:48 P.M., showed:
--Resident #25 was in his/her wheelchair and propelled himself/herself up to Resident #81, who was also sitting in a wheelchair, and hit Resident #81 with a closed fist in the left side of his/her nose. Resident #81's right nostril was bleeding.
--Staff separated the two residents. Resident #25 was taken to the therapy room and sat with the Restorative Aide and later was taken to his/her room with the door left open.
--Resident #25 did not give a statement. Resident #81 said This resident assaulted me.
--Resident #25 was oriented to self, place and situation. Resident #81 was oriented to self.
--There were no predisposing situational factors.
--Resident #25 was recently started on Haldol (an antipsychotic medication (a group of psychoactive drugs (a drug or other agent that affects such normal mental functioning as mood, behavior, or thinking processes) commonly but not exclusively used to treat psychosis) 2 milligrams (mg) twice daily (BID).
Note: The incident report for 10/25/22 had been struck out by Corporate Nurse B with the reason given as incomplete documentation.
Record review of a nurses' note, dated 10/25/22 at 4:09 P.M., written by Corporate Nurse A, showed:
-There were no witnesses identified as having seen any hitting.
-Resident #25 denies hitting while the other resident states he/she was struck.
-Unable to determine who did what at this time.
-Resident #25 was separated from the situation and the other resident placed in another unit because the other resident cannot be kept in a unit near another resident who may have a history of aggression.
-Unable to determine who, if either in fact, was the aggressor.
Note: This note was inconsistent with the previous nurses' note written on 10/25/22 for Residents #25 and #81 and with the witness statements provided.
Record review of the internal investigation of 10/25/22 showed the following staff statements:
-CNA D's statement, undated, showed he/she was at the nurses' station on 10/25/22 and observed Resident #81 sitting in front of the nursing station when Resident #25 punched Resident #81 in the nose.
-A statement was obtained from Corporate Nurse A, dated 10/25/22 and 10/26/22 showing:
--On 10/25/22 Resident #81 was assessed for injuries. A small amount of blood was noted on the resident's nose and fourth finger of his/her left hand which was cleaned up.
--Resident #25 was also assessed on 10/25/22 and denied hitting anyone.
--On 10/26/22 Resident #81 reported neck pain and held his/her head slanted to the left. Orders were obtained to send the resident to the hospital. When asked why he/she thought his/her neck hurt Resident #81 responded I don't know; it just hurts, damn it.
-There were no further witness statements provided.
Further record review of the facility's Incident Summary, dated 10/25/22, completed by the Administrator and Corporate Nurse B, showed:
-On 10/25/22 at approximately 4:00 P.M. Resident #81 yelled He hit me. Resident #25 denied hitting Resident #81. Resident #81 had a little blood from his/her nose area that was dried and a little blood on his/her finger which looked like he/she picked his/her nose until he/she drew a little blood. Resident #81 was sent out to evaluate the nose bleed and no acute abnormalities were found.
-There was no redness or injury noted or actual witnesses.
-Resident #81 was a bipolar schizophrenic while Resident #25 had a TBI. Both residents have short memories and have behaviors. Both are mouthy to each other.
-Resident #81 was out of the dementia unit due to a previous fall and hip fracture, which was healing and the resident is walking again. Resident #81 was returned to the memory care unit to be able to wander freely and to separate the two residents.
-The IDT determined there was no evidence anyone hit anyone and it was most likely the two were mouthing each other.
Note: The Incident Summary contrasted with staff statements.
Record review of the resident's Potential for Physical Aggression Care Plan showed information was added on 10/28/22 showing:
-On 10/16/22 the resident's medications were evaluated and adjustments were made.
Record review of the resident's Psychiatric Periodic Evaluation, dated 11/2/22 showed:
-The resident was being seen for continued medication management for symptoms related to multiple severe psychiatric illnesses.
-Offered education to staff. A copy of his/her note was made available to clinicians participating in the resident's care.
-General recommendations included continuing to provide activities, social events and one-one time as staffing allows and ensure physical activity as tolerated.
-Resident to Staff Altercation recommendations included:
--Continue to monitor for agitation.
--Anger management education and counseling with psychologist.
--Work with psychological services to develop behavioral modification strategies.
--Reduce stimulation such as light and noise control and redirect the resident when he/she is in a position of high residential traffic.
Record review of the resident's Potential for Physical Aggression Care Plan showed none of the recommendations for counseling services and working with psychological services to develop behavioral modification strategies had been incorporated into the resident's care plan.
Record review of the resident's electronic record on 11/16/22 showed no documentation of counseling services with a psychologist.
Record review of the resident's Psychiatric Periodic Evaluation, date 11/16/22 showed:
-The resident was being seen for continued medication management for symptoms related to multiple severe psychiatric illnesses.
-General recommendations included continuing to provide activities, social events and one-one time as staffing allows and ensure regular physical activity as tolerated.
-Resident to Resident Altercation recommendations included:
--Anger management education and counseling with psychologist.
--Work with psychological services to develop behavioral modification strategies.
--Reduce stimulation with special attention paid to where the resident sits in relation to other residents.
--Every shift remind resident to avoid fighting just because people want to talk to him/her and get close.
During an interview on 11/17/22 at 10:30 A.M., CNA D said:
-On 10/25/22 he/she was sitting at the nurses' station charting. He/She was talking with Resident #81 at the nurses' station about cars.
-Resident #25 came around the nurses' station. He/She thought Resident #25 was just going to wheel himself/herself right on by, but instead Resident #25 just punched Resident #81 on the side of his/her nose as he/she was rolling by. Resident #81 didn't do a thing to Resident #25. There was no warning whatsoever.
-He/She and LPN B separated the residents. He/She thought it happened in the afternoon.
-Resident #25 was taken to the therapy room.
-Resident #81 was sent out the next day or two to the hospital because Resident #81 complained of a headache when he/she was sitting close to the nurses' station. He/She hadn't heard Resident #81 complain of a headache the day Resident #25 hit him/her.
-If it seems like Resident #25 is aggravated staff take him/her to the therapy room.
-Staff aren't doing anything to proactively prevent Resident #25 from hurting others until after Resident #25 becomes aggravated.
-If someone watched Resident #25 1:1 maybe it could prevent him/her from harming others.
-During staff training three weeks ago staff were told to separate Resident #25 from others when he/she is agitated. The facility didn't tell us what staff were to do, except for after he/she becomes agitated.
During an interview on 2:12 P.M. CNA A said:
-He/She was working on 10/25/22.
-He/She saw Resident #81 bleeding from the nose around 10:30 A.M. or 11:00 A.M.
-A staff person was saying he/she saw Resident #25 hit Resident #81.
-Resident #81 was saying He/She hit me in my nose. I'm bleeding, so the incident had just happened.
-Staff moved Resident #25 somewhere away from Resident #81.
-They had a meeting after the annual survey and were told to separate residents after an altercation. They told staff to try to keep Residents #25 and #81 apart. He/She didn't know why Resident #25 had a thing about Resident #81.
-They did not say anything about how staff were to try to prevent further incidents between the two residents. Staff can't keep Resident #25 away from residents all the time. Resident #11 comes out of his/her room. He/She was very sweet and never picked on anyone. Resident #25 just picks on Residents #81 and #11.
-The facility had never put Resident #25 1:1 with a staff person to his/her knowledge.
During an interview on 11/17/22 at 2:35 P.M. LPN A said:
-On 10/25/22 he/she was at the nurses' station squatting down to get his/her things before going home for the day. The incident happened around 3:00 P.M.
-He/She heard staff say something. Maybe they yelled Resident #25's name or said Hey, hey, hey. They said something like that.
-Resident #81 said about Resident #25 he hit me or he punched me in the nose or something to that effect.
-Blood was dripping down Resident #81's nostrils and he/she (LPN A) grabbed a rag.
-They grabbed Resident #81 away from Resident #25 and put Resident #25 somewhere.
-The facility did some in-services. He/She couldn't recall what they told them about resident to resident behaviors or abuse because they went over so many things.
-He/She didn't remember what they said about keeping Resident #25 away from other residents. They did say to keep a close eye on Resident #25.
-They didn't explain any specific interventions or methods to use to keep Resident #25 from hurting others.
During an interview on 11/17/22 at 3:45 P.M. CNA F said:
-On 10/25/22 he/she was coming from the dining room and when he/he came around the nurses' station he/she saw Resident #81 with a bloody nose.
-The resident were separated after the incident happened.
-The nurse was assessing Resident #81 and staff took Resident #25 somewhere, maybe to his/her room.
-The facility did an in-service about resident to resident behaviors and abuse a few weeks back.
-They didn't take their masks off during the in-service so he/she didn't know what they said.
-They provided written literature that showed they should separate residents if there was an altercation. anything about behaviors? No.
-Staff can't keep them separated all the time. Residents come and go.
-They did not get any specific training on what to do specifically to keep Resident #25 from hurting other residents.
-Resident #25 spent most of his/her time in the therapy room, but he/she wasn't sure why.
During an interview on 11/18/22 at 10:00 A.M. LPN B said:
-On 10/25/22 he/she was at the nurses' station charting. Resident #81 was sitting in his/her Broda chair in front of the therapy room and Resident #25 was coming from the 300 hall in his/her wheelchair heading towards the dining room.
-The next thing he/she knew CNA D was standing in front of the nursing desk saying Resident #25 Resident just punched Resident #81.
-Resident #25 was taken to the therapy room and Resident #81 was moved.
-Staff cleaned Resident #81's bloody nose. The blood came down to his/her lip. Resident #81 said I was assaulted.
-He/She didn't know why someone would have marked out his/her nursing note. The statement and note he/she wrote was accurate.
-CNA D and CNA E wrote their statements.
-Staff were supposed to keep them apart from each other when Resident #25 is upset.
-Resident #25 was never placed on 1:1, but we are supposed to try to keep the resident occupied.
3. Record review of the facility's internal investigation, dated 11/16/22 showed the following written statements:
-LPN F's written statement, dated 11/16/22 showed:
--At approximately 10:00 A.M. on 11/16/22 he/she was in the doorway of a resident's room and heard yelling.
--He/She observed Resident #25 swing his/her right arm and fist towards Resident #11.
--The podiatrist was trying to get ahold of Resident #25's arm.
--He/She took Resident #11 down the hall to assess him/her.
--The podiatrist told him/her that he/she saw Resident #25 punch Resident #11 in the right cheek after Resident #25 backed his/her wheelchair into Resident #11's wheelchair.
--A red area was noted on resident #11's right check. Resident #11 denied pain. There was no swelling to the area.
Further record review of the facility's internal investigation, dated 11/16/22 showed:
-At approximately 10:45 A.M. he/she was notified Resident #25 was upset by Resident #11 bumping into him/her. Resident #25 was cussing Resident #11 for hitting his/her wheelchair. Resident #25 denied hitting Resident #11. There were no witnesses to that.
-Staff separated the resident's.
-The podiatrist had left the building and a witness statement was not obtained.
-Later in the day on 11/16/22 LPN F's written statement showed he/she saw Resident #25 swing his/her right arm and fist toward Resident #11 and his/her statement contained hearsay, assuming what the podiatrist saw.
Record review of the Final Report, dated 11/21/22 for the 11/16/22 incident showed:
-On 11/21/22 at 10:15 A.M. the podiatrist was contacted who was the witness to the incident. The podiatrist's statement showed:
--He/She was treating Residents #25 and #11. He/She offered to back Resident #25 up, but Resident #25 would not wait for his/her help and bumped into Resident #11's wheelchair.
--Resident #25 started swinging his/her arm around and contacted Resident #11's right side of face one time. Resident #25 continued swinging a couple more times without success of contacting Resident #11 again.
--He/She grabbed Resident #25's wheelchair and pulled him/her away to create distance from Resident #11.
--A staff member took Resident #11 to his/her room and another took Resident #25 down the hall.
-Actions taken were Resident #25 was placed on 1:1 observation over the weekend with no further incidents between Residents #25 and #11. Appointment made for in-person counseling services scheduled for 11/22/22.
Record review of the resident's medical record on 11/21/22 showed no documentation of behavioral health counseling services had started by 11/21/22 or a social services supportive behavioral plan had been developed.
During an interview on 11/17/22 at 8:15 A.M., LPN F said:
-He/She was the nurse working on 11/16/22.
-He/She was in the doorway of the room cattycorner across from the salon where the podiatrist was treating residents.
-Residents #25 and #11 were the only two residents in the hallway.
-He/She heard yelling, but couldn't make out what was said. He/She could hear both Resident #25's and the podiatrist's voice which sounded excited.
-The podiatrist had just finished with Resident #25 and came into the hallway.
-He/She saw Resident #25 punch out towards Resident #11's right cheek, but couldn't tell if Resident #25's fist made contact with Resident #11.
-The side of Resident #11's wheelchair was touching the back of Resident #25's wheelchair because Resident #25 had backed up, hitting Resident #11's wheelchair.
-When the wheelchairs touched Resident #25 immediately punched out towards Resident #11 with Resident #25's right hand.
-When he/she examined Resident #11's right cheek he/she saw a red mark. Resident #11 said Resident #25 hit him/her pretty hard and Resident #11 then placed his/her hand on his/her right cheek. It was immediately red. He/She documented the reddened cheek in his/her statement, but not in either residents' e-record.
-The podiatrist told him/her he/she asked Resident #25 to hold on and not back up, but to let the podiatrist help back up Resident #25's wheelchair, but Resident #25 was determined to back his/her wheelchair up anyway. The podiatrist said he/she saw Resident #25's arm go out in a punch and saw it hit Resident #11 in the right cheek.
-He/She (LPN F) got in between the two residents. He/She took Resident #11 near the nurses' station and one of the aides took Resident #25 to his/her room.
-He/She interviewed Resident #25 about 10 or 15 minutes after the incident when he/she was calm. Resident #25 said Resident #11 ran into him/her and grabbed his/her wheelchair so he/she hit Resident #11, but he/she (LPN F) saw that Resident #11 did not hit or grab Resident #25's wheelchair.
During interview on 11/17/22 at 9:35 A.M. Corporate Nurse A said he/she was not in the building on 11/16/22 and didn't know why the Administrator showed him/her as a witness.
During an interview on 11/17/22 at 9:57 A.M. Resident #11 said he/she didn't remember being hit the previous day or at any other time and his/her cheek and side of his/her eye did not hurt.
During an interview on 11/18/22 at 9:40 A.M. the contracted podiatrist said:
-He/She was at the facility on 11/16/22. There were no staff supervising Residents #25 and #11.
-While he/she was treating Resident #25 the resident was telling him/her that he/she (Resident #25) brutalized his/her family member for sleeping with his/her spouse.
-When the treatment was ended he/she told Resident #25 to wait for him/her to help Resident #25 back up, but Resident #25 refused to wait and bumped into Resident #11.
-There had been plenty of space for Resident #25 to move away and not be too close to Resident #11.
-After Resident #25 hit Resident #11 Resident #25 said his/her family member was having sexual relations with his/her spouse and he/she wasn't going to let anyone else do that.
-Resident #25 swung his/her right arm several times attempting to hit Resident #11. Resident #25 made contact with Resident #11 two or three times on the right side of Resident #11's face. (Note: The facility's Final Investigation Report, dated 11/22/22 for the 11/16/22 incident showed the podiatrist said Resident #25 made contact with Resident #11 once.)
-Resident #11 had redness on his/her right cheek and outside of his/her right eye. He/She was very red. Resident #11's right eye was tearing. After being hit Resident #11 covered his/her right eye.
-He/She pulled Resident #25's wheelchair towards himself/herself so Resident #25 wouldn't be so close to Resident #11 and told Resident #25 he/she needed to keep his/her hands to himself/herself.
-Resident #25 cursed, then muttered Keep your hands to yourself.
-He/She hadn't noticed any staff around and yelled out Hey, you guys! Hey!
-LPN F showed up and said he/she had seen Resident #25 hit Resident #11, but was unable to immediately intervene because he/she had been with another resident.
4. Observation on 11/17/22 at 7:05 A.M. showed Resident #25 was up and dressed and sitting in his/her wheelchair near the nurses' station. Staff were moving around the unit and are not supervising or specifically focused on the resident.
Observation on 11/17/22 at 7:30 A.M. showed the resident was sitting alone at a dining room table. A number of other residents were in the dining room as well. Th
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
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Refer to *GIOQ
Based on observation, interview, and record review, the facility failed to thoroughly investigate allegations of ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Refer to *GIOQ
Based on observation, interview, and record review, the facility failed to thoroughly investigate allegations of resident abuse by not conducting interviews and/or obtaining statements from all witnesses and by not reviewing pertinent information from nursing notes and incident reports and using the information to determine if abuse occurred. This deficient practice affected two residents (Resident #81 and #11) out of 25 sampled residents. The facility census was 99 residents.
Record review of the facility's Abuse Investigation and Reporting policy, revised 7/2017, showed:
-The Administrator will ensure any further potential abuse is prevented.
-The individual conducting the investigation will, at minimum:
--Review completed documentation.
--Review the resident's medical record to determine events leading to incidents.
--Interview persons reporting the incident, any witnesses, the residents and their roommates as appropriate, alleged perpetrator, attending physician to determine the resident's cognitive function and medical condition, staff members on all shifts who have had contact with the resident during the incident, and other residents who might have been targeted/affected.
--Review all events leading up to the incident.
-The administration will protect residents from abuse by anyone, including but not limited to, other residents.
-The facility must establish means in which behaviors indicative of abuse may be identified and further investigated.
1. Record review of Resident #81's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning), dated 8/22/22, showed the resident:
-Was admitted to the facility on [DATE] with the following diagnoses:
--Dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning).
--Anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome).
--Depression (a constant feeling of sadness and loss of interest), and Schizophrenia (a chronic, severe mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality).
-Had no behaviors.
-Was severely cognitively impaired.
2. Record review of Resident #11's quarterly MDS, dated [DATE], showed the resident:
-Was readmitted to the facility on [DATE] with the following diagnoses:
--Dementia.
--Depression.
--Schizophrenia (a long-term mental disorder of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation).
-Had no behaviors.
-Was severely cognitively impaired.
3. Record review of Resident #25's admission Record showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-Traumatic brain injury (TBI - damage to the brain resulting from external mechanical force, such as rapid acceleration or deceleration, impact, blast waves, or penetration by a projectile).
-SynGap 1 related intellectual disability (a neurological disorder characterized by moderate to severe intellectual disability evident in early childhood with features of delayed speech development and motor skills and often seizures, hyperactivity and sensory processing problems).
-Schizoaffective disorder, depressive type (a mental condition that causes loss of contact with reality and mood problems).
-Restlessness and agitation.
-Psychosis (a mental state involving loss of contact with reality and causing deterioration of normal social functioning).
-Antisocial personality disorder (condition characterized by repetitive behavioral patterns that are contrary to usual moral and ethical standards and cause a person to experience continuous conflict with society).
-Intermittent Explosive Disorder (a chronic disorder involving repeated, sudden episodes of impulsive, aggressive, violent behavior and/or angry verbal outbursts in which reactions are grossly out of proportion to the situation).
Record review of the resident's Potential for Physical Aggression Care Plan, initiated 4/12/22 showed:
-The resident had potential to be physically aggressive related to Intermittent Explosive Disorder.
-The resident would hit staff, himself/herself, and other residents.
-He/She would throw objects, slide out of his/her wheelchair, and hit walls, doors and windows when upset.
-Triggers for physical aggression were paranoia that others were talking about him/her.
-Staff would remove those the resident feels are talking about him/her out of view by closing doors or putting up a shield so the resident can't see them.
Record review of the resident's quarterly MDS, dated [DATE] showed the resident:
-Was severely cognitively impaired.
-Had fluctuating inattention and fluctuating disorganized thinking.
-The resident's mood assessment showed he/she was short-tempered and/or easily annoyed 12 to 14 days out of the past 14 days.
-Had physical behaviors directed towards others four to six days out of the past seven days.
-Had verbal behaviors directed towards others one to three days out of the past seven days.
-Had behaviors not directed towards others one to three days out of the past seven days.
4. Record review of Resident #81's nurse's note, dated 10/25/22 at 3:44 P.M., showed:
-On 10/25/22 Resident #81 was punched in the face by another resident (Resident #25). Resident #81's right nostril was bleeding. The resident's nose was cleaned up.
-Resident #81 was encouraged to stay away from the other resident who hit him/her.
-Resident #81 stated He assaulted me.
Note: This note was struck out with a side note showing Incomplete documentation.
Record review of Resident #25's nurse's note, dated 10/25/22 at 4:01 P.M., showed:
-Resident #25 punched another resident in the face (Resident #81), causing the other resident's right nostril to bleed.
-Resident #25 was taken to the therapy room and later to his/her room with the door open.
Note: This note was struck out on 10/27/22 with a side note showing Incomplete documentation.
Record review of Resident #25's nurse's note, dated 10/25/22 at 4:09 P.M., written by Corporate Nurse B showed:
-There were no witnesses identified seeing any hitting.
-Resident #25 denied hitting the other resident. The other resident states he/she was struck.
-Unable to determine who did what at this time.
-Resident #25 was separated from the situation. The other resident was placed on another unit. It was found the other resident cannot be kept in a unit near a resident with a history of aggression.
-Unable to determine who was the aggressor, if either.
Record review of the facility's internal investigation, dated 10/25/22 showed:
-An Incident Report, dated 10/25/22 at 3:48 P.M., showed:
--Resident #25 was in his/her wheelchair and propelled himself/herself up to Resident #81, who was also sitting in a wheelchair, and hit Resident #81 with a closed fist on his/her nose. Resident #81's right nostril was bleeding.
--Resident #81 said This resident assaulted me.
--Resident #25 was oriented to self, place and situation. Resident #25 was oriented to self.
--There were no predisposing situational factors.
--The physician, Assistant Director of Nursing (ADON) B, Director of Nursing (DON), and Resident #25's responsible party were notified.
-Certified Nursing Assistant (CNA) D's statement, undated, showed he/she was at the nurse's station on 10/25/22 and observed Resident #81 sitting in front of the nursing station when Resident #25 punched Resident #81 in the nose.
-Corporate Nurse A's statement, dated 10/25/22 and 10/26/22, showed:
--On 10/25/22 Resident #81 was assessed for injuries. A small amount of blood was noted on the resident's nose and fourth finger of his/her left hand which was cleaned up.
--On 10/26/22 Resident #81 reported neck pain and held his/her head slanted to the left. Orders were obtained to send the resident to the hospital. When asked why he/she thought his/her neck hurt Resident #81 responded I don't know; it just hurts, damn it.
--There were no other witnesses interviewed and no other witnesses giving statement of knowledge of the incident.
-The Investigation summary, dated 10/25/22, with the Administrator's and Corporate Nurse B's name at the bottom showed:
--At approximately 4:00 P.M. Resident #81 yelled He hit me! Resident #25 said he/she didn't hit Resident #81.
--Resident #81 appeared to have a little blood in his/her nose area that was dried and a little on his/her finger which looked like he/she picked his/her nose until he/she drew blood.
--Resident #81 was sent out to evaluate that the nose bleed was not something more serious. Resident #81 returned with no acute abnormalities. No redness or injury noted.
--No actual witnesses.
--Resident #81 was a bipolar schizophrenic while Resident #25 has a TBI. Both residents have short memories and behaviors. Both are mouthy to each other.
--Resident #81 was out of the dementia unit due to a previous fall and hip fracture. His/Her fracture is healing and Resident #81 is walking again. Resident #81 was returned to his/her previous unit to be able to wander freely and also to add separation from Resident #25.
--The Interdisciplinary Team (IDT) determined there was no evidence anyone hit anyone and it was most likely the two were mouthing each other.
Note:
-All staff working on the unit at the time had not given a statement or been interviewed related to the incident.
-The conclusion there was no evidence Resident #81 was hit by Resident #25 contradicted with the witness statements the facility had and the original nurse's notes for Residents #25 and #81.
-There was no documentation of assessment of Resident #25's supervision needs or appropriate interventions to prevent Resident #25 from harming other residents.
Record review of Resident #81's nurse's note, dated 10/26/22 at 1:33 P.M., showed:
-Order to send Resident #81 to the emergency room (ER).
-Resident #81 had been complaining of a severe headache due to being hit in the nose the previous night.
-Wanted Resident #81 evaluated and treated.
Record review of Resident #81's hospital ER record, dated 10/26/22, showed:
-Orders for CT (computed tomography - several rotating X-ray images) scan of the head and facial bones.
-Reason for exam was the patient (Resident #81) was punched on 10/25/22 in the nose and/or mouth and has a right-sided headache.
-Findings of CT scans showed no acute abnormalities by radiologist readings.
-Diagnosis of contusion (bruising) of face.
During an interview on 11/17/22 at 9:03 A.M., Licensed Practical Nurse (LPN) F said:
-There had been an altercation in the afternoon between Resident #25 and Resident #81 about two to four weeks ago.
-LPN F was on the 100 hall and heard yelling. He/She couldn't tell who yelled or what was being said.
-Resident #81 was in his/her Broda chair (tilt-in-space positioning chair) at the end of the 200 hall near the main hall and nurses' station. Resident #25 was beside Resident #81's Broda chair.
-A CNA told him/her Resident #25 punched Resident #81 in the nose.
-They separated Resident's #25 and #81 and he/she took Resident #25 into the therapy room.
-He/She assessed Resident #81 for injuries. Resident #81 had redness on the right side of his/her nose.
During an interview on 11/17/22 at 10:30 A.M., CNA D said:
-On 10/25/22 he/she was sitting at the nurses' station charting. Resident #81 was sitting in front of the nurses' station and he/she was talking with Resident #81 about cars.
-Resident #25 came around the nurses' station. He/She thought Resident #25 was just going to wheel himself/herself right on by, but instead Resident #25 just punched Resident #81 on the side of his/her nose as he/she was rolling by. Resident #81 didn't do a thing to Resident #25. There was no warning whatsoever.
-He/She and LPN B separated the residents.
-Resident #25 was taken to the therapy room.
-Resident #81 was sent out the next day or two to the hospital because Resident #81 complained of a headache.
During an interview on 2:12 P.M., CNA A said:
-He/She was working on 10/25/22.
-He/She saw Resident #81 bleeding from the nose around 10:30 A.M. or 11:00 A.M.
-A staff person was saying he/she saw Resident #25 hit Resident #81.
-Resident #81 was saying He/She hit me in my nose. I'm bleeding, so the incident had just happened.
-Staff moved Resident #25 somewhere away from Resident #81.
During an interview on 11/17/22 at 2:35 P.M., LPN A said:
-On 10/25/22 he/she was at the nurses' station squatting down to get his/her things before going home for the day at around 3:00 P.M.
-He/She heard staff say something. Maybe they yelled Resident #25's name or said Hey, hey, hey. They said something like that.
-Resident #81 said about Resident #25 he/she hit me or he/she punched me in the nose or something similar.
-Blood was dripping down Resident #81's face and he/she (LPN A) grabbed a rag.
-They grabbed Resident #81 away from Resident #25 and put Resident #25 somewhere.
During an interview on 11/17/22 at 3:45 P.M., CNA F said on 10/25/22 he/she was coming from the dining room and when he/he came around the nurses' station he/she saw Resident #81 with a bloody nose.
During an interview on 11/18/22 at 10:00 A.M., LPN B said:
-On 10/25/22 he/she was at the nurses' station charting. Resident #81 was sitting in his/her Broda chair in front of the therapy room and Resident #25 was coming from the 300 hall in his/her wheelchair heading towards the dining room.
-The next thing he/she knew, CNA D was standing in front of the nursing desk saying Resident #25 Resident just punched Resident #81.
-Resident #25 was taken to the therapy room and Resident #81 was moved.
-Staff cleaned Resident #81's bloody nose. The blood came down to his/her lip. Resident #81 said I was assaulted.
-Resident #81 was a little red on the left side of his/her nose. Resident #81 was moved to the memory care unit at the time or a day or two later.
-He/She had no idea why his/her nurse's notes for Residents #25 and #81, written on 10/25/22, would have been struck out. He/She had been accurate in his/her description of what happened related to the resident to resident incident between Resident #25 and #81 on 10/25/22.
During an interview on 11/18/22 at 10:46 A.M., ADON B said:
-He/She realized two or three days after 10/25/22 that the nurse's notes written for Residents #25 and #81 had been struck out. LPN B had asked him/her why the notes had been struck out and said the notes did not contain incorrect information.
-He/She was unaware that a second note had been added to Residents #25 and #81's charts after the original notes had been written.
During an interview on 11/18/22 at 11:58 A.M., Corporate Nurse A said he/she struck out one of the notes written on 10/25/22 based on what he/she had been told by the Administrator about the incident.
During an interview on 1/18/22 at 11:33 A.M., the DON said he/she didn't know why the 10/25/22 notes had been struck out for Residents #25 and #81 or who would have struck them out.
5. Record review of Resident #25's nursing note, dated 11/16/22 showed:
-Staff member overheard commotion in hallway.
-Resident #25 pushed himself/herself back in his/her wheelchair and bumped his/her wheelchair into another resident's wheelchair.
-Staff member was able to redirect Resident #25.
Record review of the facility's internal investigation, dated 11/16/22 and completed by the Administrator showed:
-LPN F's written statement, dated 11/16/22 showed:
--At approximately 10:00 A.M. on 11/16/22 he/she was in the doorway of a resident's room and heard yelling.
--He/She observed Resident #25 swing his/her right arm and fist towards Resident #11.
--The podiatrist was trying to get a hold of Resident #25's arm.
--He/She took Resident #11 down the hall to assess him/her.
--The podiatrist told him/her that he/she saw Resident #25 punch Resident #11 in the right cheek after Resident #25 backed his/her wheelchair into Resident #11's wheelchair.
--A red area was noted on Resident #11's right cheek. Resident #11 denied pain. There was no swelling to the area.
-No other written witness statements were provided.
-The Administrator's report showed:
--At approximately 10:45 A.M. he/she was notified Resident #25 was upset by Resident #11 bumping into him/her. Resident #25 was cussing at Resident #11 for hitting his/her wheelchair. Resident #25 denied hitting Resident #11.
--There were no witnesses to that.
--Staff separated the resident's.
--A self-report was submitted to the State.
--The following witnesses were interviewed on 11/16/22 and all denied witnessing the incident: CNA D, CNA E, Corporate Nurse A, Social Services Designee, LPN F.
--The podiatrist had left the building and a witness statement was not obtained.
--Later in the day on 11/16/22 LPN F's written statement showed LPN F saw Resident #25 swing his/her right arm and fist toward Resident #11 and his/her statement contained hearsay, assuming what the podiatrist saw.
--As of 11/17/22 the Administrator found no evidence of abuse or neglect.
Record review of the Final Report, dated 11/21/22 for the 11/16/22 incident showed:
-On 11/21/22 at 10:15 A.M. the podiatrist was contacted who was the witness to the incident. The podiatrist's statement showed:
--He/She was treating Residents #25 and #11. He/She offered to back Resident #25 up, but Resident #25 would not wait for his/her help and bumped into Resident #11's wheelchair.
--Resident #25 started swinging his/her arm around and contacted resident #11's right side of face one time. Resident #25 continued swinging a couple more times without success of contacting Resident #11 again.
--He/She grabbed resident #25's wheelchair and pulled him/her away to create distance from Resident #11.
--A staff member took Resident #11 to his/her room and another took Resident #25 down the hall.
-The investigation Final Report showed actions taken were Resident #25 was placed on 1:1 observation over the weekend with no further incidents between Residents #25 and #11. Medications were reviewed. Follow up calls were made to other facilities for placement in a more appropriate facility for behaviors. Appointment was made for in-person counseling services.
Note:
-There was no final determination on 11/21/22 whether or not resident to resident abuse had taken place.
-The information provided by the podiatrist and LPN F and evidence of Resident #11's red cheek were not used in a final determination.
-There was no documentation of assessment for on-going increased supervision needs or other measures to prevent Resident #25 from harming other residents.
During an interview on 11/17/22 at 8:15 A.M. LPN F said:
-He/She was the nurse working on 11/16/22.
-He/She was in the doorway of the room catty corner across from the salon where the podiatrist was treating residents.
-Residents #25 and #11 were the only two residents in the hallway.
-He/She heard yelling, but couldn't make out what was said. He/She could hear both Resident #25's and the podiatrist's voice which sounded excited.
-The podiatrist had just finished with Resident #25 and came into the hallway.
-He/She saw Resident #25 punch out towards Resident #11's right cheek, but couldn't tell if Resident #25's fist made contact with Resident #11.
-The side of Resident #11's wheelchair was touching the back of Resident #25's wheelchair because Resident #25 had backed up, hitting Resident #11's wheelchair.
-When the wheelchairs touched, Resident #25 immediately punched out towards Resident #11 with Resident #25's right hand.
-When he/she examined Resident #11's right cheek, he/she saw a red mark. Resident #11 said Resident #25 hit him/her pretty hard and Resident #11 then placed his/her hand on his/her right cheek. It was immediately red.
-The podiatrist told him/her he/she asked Resident #25 to hold on and not back up, but to let the podiatrist help back up Resident #25's wheelchair, but Resident #25 was determined to back his/her wheelchair up anyway. The podiatrist said he/she saw Resident #25's arm go out in a punch and saw it hit Resident #11 in the right cheek.
-He/she got in between the two residents.
-He/She didn't interview any of the CNAs because none were in the hallway until after the incident happened.
-He/She filled out a written statement. It included what the podiatrist said he/she observed.
-He/She interviewed Resident #25 about 10 or 15 minutes after the incident when he/she was calm. Resident #25 said Resident #11 ran into him/her and grabbed his/her wheelchair so he/she hit Resident #11, but he/she (LPN F) saw that Resident #11 did not hit or grab Resident #25's wheelchair.
-The incident happened around 10:00 A.M. The redness of Resident #11's face was gone by around noon. Resident #11 never said how it made him/her feel or if he/she was afraid of Resident #25.
Observation on 11/17/22 at 9:56 A.M., showed Resident #11 had very slight bruising to the right cheek and on the outside of his/her right eye, somewhat grayish in color with possible slight swelling.
During an interview on 11/17/22 at 9:57 A.M., Resident #11 said he/she didn't remember being hit the previous day or at any other times.
During an interview on 11/18/22 at 9:40 A.M., the contracted podiatrist said:
-He/She was at the facility on 11/16/22. There were no staff supervising Residents #25 and #11.
-While he/she was treating Resident #25, the resident was telling him/her that he/she (Resident #25) brutalized his/her family member for sleeping with his/her spouse.
-When the treatment was ended, he/she told Resident #25 to wait for him/her to help Resident #25 back up, but Resident #25 refused to wait and bumped into Resident #11.
-There had been plenty of space for Resident #25 to move away and not be too close to Resident #11.
-After Resident #25 hit Resident #11, Resident #25 said his/her family member was having sexual relations with his/her spouse and he/she wasn't going to let anyone else do that.
-Resident #25 swung his/her right arm multiple times attempting to hit Resident #11. Resident #25 made contact with Resident #11 two or maybe three times on the right side of Resident #11's face. (Note: The facility's Final Investigation Report, dated 11/21/21 for the 11/16/22 incident showed the podiatrist said Resident #25 made contact with Resident #11's face once.)
-Resident #11 had redness on his/her right cheek and outside of his/her right eye. He/She was very red. Resident #11's right eye was tearing. After being hit, Resident #11 covered his/her right eye.
-He/She pulled Resident #25's wheelchair towards himself/herself so Resident #25 wouldn't be so close to Resident #11 and told Resident #25 he/she needed to keep his/her hands to himself/herself.
-Resident #25 cursed and muttered Keep your hands to yourself.
-He/She hadn't noticed any staff around and yelled out Hey, you guys! Hey!
-LPN F showed up and said he/she had seen Resident #25 hit Resident #11, but was unable to immediately intervene because he/she had been with another resident.
During an interview on 11/18/22 at 10:46 A.M. ADON B said:
-LPN F reported to him/her the podiatrist said he/she saw Resident #25 strike Resident #11.
-He/She (ADON B) reported to the Administrator what LPN F said.
6. During an interview on 10/18/22 at 10:46 A.M. ADON B said a thorough investigation included:
-Reporting immediately to the Administrator who is responsible for the investigation.
-Notifying the physician and residents' responsible parties.
-Getting statements and/or interviews from all possible witnesses.
-Assessing residents for injury.
-Investigation information should be thorough. All witness observations, assessments of injury and all other facts should be considered when determining whether or not abuse likely happened.
During an interview on 10/18/22 at 11:12 A.M. ADON A said:
-All allegations or observations of possible abuse must be reported immediately to the Administrator who is responsible for the investigation.
-Thorough investigations should include all possible witness statements, nursing notes, injury documentation, and facts related to events.
-The evidence gathered should be used to determine what happened for determining abuse.
-Interventions should be put in place that effectively prevent further abuse.
During an interview on 1/18/22 at 11:33 A.M. the DON said:
-Investigations should be thorough and include interviews with all staff who worked in the area and on the shift at the time of the incident.
-All possible instances of abuse should be reported to the Administrator who is responsible for completing a thorough investigation.
During an interview on 11/18/22 at 11:58 A.M. Corporate Nurse A said:
-For a thorough investigation the Administrator should use statements from all possible witnesses who might have knowledge of the incident. Information from staff should be accurate and witness statements and facts should be used in determining abuse.
-Reporting of incidents to the Administrator should happen immediately.
During an interview on 11/18/22 at 2:50 P.M., the Administrator said:
-A thorough abuse investigation included reporting to the Administrator through the chain of command all incidents of possible abuse, gathering as many facts as possible, looking at injury documentation, and interviewing all staff who might have knowledge of an incident.
-The IDT was responsible for investigating facts and developing interventions for a resident to resident abuse investigation. The IDT had determined there was no resident to resident abuse on 10/25/22 and 11/16/22.
-He/She was responsible for ensuring information was gathered and doing a final summary of the investigation.
-He/She was new to doing the investigations because the previous DON had been doing them before.
MO00209989
Sept 2022
26 deficiencies
1 IJ
CRITICAL
(J)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the environment remained free from accident ha...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the environment remained free from accident hazards by not assessing for safe smoking practices for one sampled resident (Resident #340) out of 19 sampled residents. The facility census was 95 residents.
Record review of facility's undated policy titled Smoking Policy and Acknowledgement showed:
-All residents must be supervised by a facility staff member or personal family member at the designated location.
-Smoke breaks were outside in a designated area.
-Facility staff member would only supervise smoke breaks at the designated times.
-The policy did not include a safe smoking assessment was to be performed for the resident who smoked or be assessed for any special equipment the resident needed while he/she smoked.
1. Record review of Resident #340's admission Record showed he/she was admitted on [DATE] with the following diagnosis Chronic Obstructive Pulmonary Disease (COPD - a disease process that decreases the ability of the lungs to perform ventilation).
Record review of the resident's quarterly Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff for care planning) dated 9/5/22 showed he/she:
-Was moderately cognitively impaired.
-Smoked.
Record review of residents undated care plan showed the resident:
-Was dependent on tobacco.
-Was educated on smoking risks and hazards.
-Was instructed on the facility policy for smoking.
During an interview on 9/12/22 at 2:25 P.M., the resident said he/she smoked and went out on the smoke breaks when the facility had them.
Record review of the resident's medical record on 9/14/22 showed there was no documentation that a safe smoking assessment had been completed.
Observation on 9/15/22 at 2:26 P.M. the resident was outside smoking with nine other residents.
During an interview on 9/16/22 at 9:18 A.M., Licensed Practical Nurse (LPN) A said:
-He/she was unsure how often a smoking assessment would be done.
-A smoking assessment should have been performed before the resident smoked for the first the time at the facility.
-He/She did not know who assessed the resident for safe smoking and filled out the assessment.
During an interview on 9/15/22 at 1:00 P.M., Registered Nurse (RN) A said:
-A safe smoking assessment would be completed on the resident before the resident ever smoked at the facility.
-The assessment would have covered if the resident would be able to perform the actions needed to smoke in a safe manner, or if any special equipment was needed.
During an interview on 9/20/22 at 12:04 P.M., the Director of Nursing (DON) said:
-It was his/her expectation that a safe smoking assessment would be done upon admission if a resident smoked.
-It was his/her expectation that a safe smoking assessment would be done prior to resident smoking at the facility.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one sampled resident (Resident #81) was free from abusive ac...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one sampled resident (Resident #81) was free from abusive acts when one sampled resident (Resident #25) who had a known history of aggression, anger issues, yelling, hitting and kicking other residents struck the resident in his/her face causing reddened areas to his/her left cheek, nose and the left side of his/her upper lip with a small amount of blood noted out of 19 sampled residents. The facility census was 95 residents.
Record review of the facility's policy Behavioral Assessment, Intervention and Monitoring policy revised 3/2019 showed:
-The facility would provide and residents would receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment.
-Behavioral health services would be provided by qualified staff who have the competencies and skills necessary to provide appropriate services and treatment.
-The Interdisciplinary Team (IDT) would thoroughly evaluate new or changing behavioral symptoms in order to identify the underlying causes and address and modifiable behaviors.
-The IDT would evaluate the behavioral symptoms of residents to determine the degree of severity, distress, and potential safety risks.
-The care plan would incorporate the findings.
-The interventions would be individualized and part of the overall care environment that supported physical function and psychosocial needs.
Record review of the facility's policy Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated April 2021 showed:
-The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives:
--Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone.
--Develop and implement policies and protocols to prevent and identify:
---Abuse or mistreatment of residents.
--Ensure adequate staffing and oversight/support to prevent burnout, stressful working situations and high turnover rates.
--Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems.
1. Record review of Resident #81's quarterly Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff for care planning) date 8/22/22 showed the resident:
-Was admitted to the facility on [DATE].
-Had diagnoses including broken hip, Dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), Anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), Depression (a constant feeling of sadness and loss of interest), and Schizophrenia (a chronic, severe mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality).
-Had no behaviors.
-Required extensive to total assistance with all cares.
-Used a wheelchair for mobility.
2. Record review of Resident #25's admission Record showed he/she was admitted to the facility on [DATE] and had the following diagnoses:
-Traumatic brain injury (TBI - damage to the brain resulting from external mechanical force, such as rapid acceleration or deceleration, impact, blast waves, or penetration by a projectile).
-SynGap 1 related intellectual disability (a neurological disorder characterized by moderate to severe intellectual disability evident in early childhood with features of delayed speech development and motor skills and often seizures, hyperactivity and sensory processing problems).
-Schizoaffective disorder, depressive type (a mental condition that causes loss of contact with reality and mood problems).
-Restlessness and agitation.
-Psychosis (a mental state involving loss of contact with reality and causing deterioration of normal social functioning).
-Antisocial personality disorder (condition characterized by repetitive behavioral patterns that are contrary to usual moral and ethical standards and cause a person to experience continuous conflict with society).
-Intermittent Explosive Disorder (a chronic disorder involving repeated, sudden episodes of impulsive, aggressive, violent behavior and/or angry verbal outbursts in which reactions are grossly out of proportion to the situation).
Record review of the resident's admission MDS dated [DATE] showed the resident:
-Was severely cognitively impaired.
-Had fluctuating inattention.
-Had physical behaviors directed towards others one to three days out of seven.
-Had no verbal behaviors directed towards others.
-Had no other behaviors not directed towards others (e.g. hitting self, screaming).
Record review of the resident's Preadmission Screening and Resident Review (PASARR) II (determines if the intellectual disability or serious mental illness of the individual can be met in a nursing facility or if the resident requires specialized services), reviewed on 6/7/22 by the Central Office Medical Review Unit (COMRU - reviews the DA 124 assessment forms for the PASARR) showed:
-The resident had an Intellectual Disability ( when there are limits to a person's ability to learn at an expected level and function in daily life) and a substantiated dementia ( chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) or related condition and required nursing facility services.
-Due to the resident's TBI he/she had problems with impulsive behaviors and anger control.
-His/her reported moods could be labile (rapid, exaggerated changes) and he/she struggles with expressing emotions appropriately.
-He/she has a guardian to assist with major life and financial decisions and requires 24 hour support.
-The resident needs assessment and implementation of a behavioral support plan, monitoring of behavioral symptoms, and provision of behavioral supports. Staff should identify precipitating factors which may exacerbate his/her volatile behaviors. A structured, low-stimulation environment should be provided. He/She will require continued psychiatric follow-up and medication management and periodic review of medications. Establish consistent routine, provide daily tasks/activities and assess and plan for the level of supervision required to prevent harm to self or others. The plan should identify clear steps to manage the individual's behavior in a crisis situation, who to contact for assistance, and how staff will work together in a crisis.
Record review of the resident's Potential for Physical Aggression Care Plan, updated on 6/21/22 showed:
-The resident's triggers for physical aggression were paranoia that others were talking about him/her.
-An intervention added on 6/21/22 showed the resident's behaviors were de-escalated by 1:1 attention and reassurance and attempts to calm him/her.
-The Care Plan did not include the assessment and implementation of a behavioral support plan, monitoring of behavioral symptoms, and provision of behavioral supports. Staff should identify precipitating factors which may exacerbate his/her volatile behaviors. A structured, low-stimulation environment should be provided. He/she will require continued psychiatric follow-up and medication management and periodic review of medications. Establish consistent routine, provide daily tasks/activities and assess and plan for the level of supervision required to prevent harm to self or others. The plan should identify clear steps to manage the individual's behavior in a crisis situation, who to contact for assistance, and how staff will work together in a crisis.
Record review of the resident's Behavioral Nurses' Notes for July, August, and September 2022 showed many notes were not detailed enough to help staff in fully assessing and addressing the resident's needs and behaviors. For instance many notes did not show:
-What precipitating factors contributed to the resident's behaviors.
-Whether or not the resident was asked what was upsetting him/her at the time of his/her agitation to help staff in identifying the resident's thought processes, or unmet emotional or physical needs that might trigger behaviors.
-What non-pharmacological interventions were used to try to de-escalate behaviors and whether or not they were successful.
-Whether or not the resident was able to calm down on his/her own or if interventions or cuing was needed to help the resident de-escalate.
-How long the resident's behaviors lasted.
Record review of the resident's electronic record (e-record) showed:
-There was no comprehensive evaluation of the resident's behaviors and no detailed plan to address the behaviors which had not decreased over time.
-The resident's Physical Aggression Care Plan did not show factors precipitating behaviors other than the resident thinking others were talking about him/her. The care plan did not address the resident's frustrations of being told he/she could not smoke, having to wait for food, or other observed frustrations the resident experienced and how staff were to address these.
-There was no documentation that staff were educated on how to manage and work with the resident's specific behaviors.
-There was no documentation showing how the facility was working with the resident's Guardian or psychiatrist to address the resident's behaviors.
-There was no documentation what role various disciplines like social services, nursing and activities could play in helping to address the resident's needs.
-There was no documentation the facility had evaluated trends related to the resident's behaviors such as:
--The time of day or shifts most behaviors took place.
--The specific employees working at the time of behaviors.
--The number of staff working when most of the behaviors took place.
--The most common precipitating factors triggering behaviors.
--Evaluations of the most and least successful interventions implemented.
--Periods of time when the resident had the fewest behaviors and circumstances surrounding those times (specific staff working, interventions being implemented, medications that were successful).
3. Record review of Resident #25's Incident Investigation, dated 9/3/22 showed:
-On 9/3/22 at 12:12 P.M. the resident was witnessed hitting another resident (Resident #81) in the face.
-The charge nurse notified the Director of Nursing (DON) and said the Rehabilitation Assistant (RA) was to assist the resident with lunch and when he/she didn't return quick enough the resident rolled his/her wheelchair next to the Resident #81 and hit him/her. The incident happened during lunch as the meal trays were being passed.
-The responsible parties for both residents and the physician were notified.
-The resident was sent to the hospital where the case manager was going to try to get him/her into a psychiatric evaluation hospital.
-The resident returned from the hospital.
--Staff were informed by the hospital he/she was not admitted because the resident couldn't be kept safe from other patients.
-Registered Nurse (RN) A said he/she was sitting at the nurses' station as the resident sat in his/her wheelchair on the 300 hall in front of the therapy gym waiting for the RA to return and assist him/her with his/her meal. The resident self-propelled toward the nurses' station and turned down 200 hall where the Resident #81 sat in his/her geriatric chair (Geri-chair) without signs of agitation or provocation. The resident hit Resident #81 with his/her half-opened hand because he/she was tired of waiting.
The RA's statement showed he/she was coming from the 200 hall toward the nurses' station when he/she saw the resident hit Resident #81 in the face and immediately moved the resident away from Resident #81 as the nurse checked him/her (Resident #81) for injuries.
-The resident said Resident #81 tried to kick him/her at which time RN A told the resident that was not what happened. Then the resident said Yeah, he/she took too long referring to the RA whom he/she was waiting on for assistance with his/her meal.
-Resident #81 was examined and was noted to have reddened areas to his/her left cheek, nose and the left side of his/her upper lip was slightly swollen with a small amount of blood noted.
-After the physician was notified an order was received to transport the resident to the hospital for psychiatric evaluation and treatment.
-Based on information gathered from interviews with staff and residents, it appeared the resident was unable to rationalize how much time it would take the RA to assist with hall trays before assisting him/her which created anxiety and frustration. As a result the resident displayed physical aggression (a behavior) to get the staff to respond to him/her.
-Intervention created for the physician to see the resident regarding his/her physical aggression and recent incident. New orders on 9/7/22 to discontinue Haldol and Clonazepam (generic for Klonopin, a benzodiazepine often used to treat depressive disorders) and start Xanax (an anxiolytic used to treat anxiety and panic disorders) 0.5 milligram (mg) three times daily and to increase Abilify (an antipsychotic medication which can decrease hallucinations (perceptions, such as hearing or seeing things which are not really there) and improve concentration) to 10 mg four times daily.
Record review of the resident's Potential for Physical Aggression Care Plan, updated 9/3/22 showed a new intervention that staff encourage the resident to remain in his/her room when agitated.
Record review of the resident's Nurses' Note dated 9/3/22 at 9:58 P.M. showed:
-The Certified Medication Technician (CMT) just told this nurse that the resident was threatening to come kick their ass because they were talking about him/her.
-The resident said he/she was going to kill them and [NAME] them into the ground.
During an interview on 9/15/22 at 9:39 A.M. the RA said:
-About 2 weeks ago he/she was mid-way down the 200 hall and saw the resident and another resident talking. The other resident said something and before he/she could reach him/her the resident had hit the other resident with his/her fist. The resident was not provoked by the other resident.
-He/she wasn't sure if the resident was hit on the mouth or how hard he/she was hit. The resident had been in the midst of talking when he/she was hit.
-The resident said he/she thought the other resident was talking bad about him/her. He/she assured the resident he/she wasn't.
-The resident was paranoid. He/she thought others were talking about him/her or people he/she liked quite often and would get upset and would raise a fist, yell out or start muttering.
-A lot of staff don't know how to handle the resident. He/she didn't tell the resident no. He/she would get the resident a soda or ask him/her to wait until later for something he/she wanted.
-The resident would hit his/her wheelchair or other surfaces when told no by staff. They sometimes talked to the resident like he/she was a kid. Some staff didn't know how to deal with him/her.
-The resident got upset when he/she couldn't have a cigarette or vape. His/her guardian wouldn't allow him to smoke or vape, but he/she wasn't sure why. He/she might burn himself/herself with a cigarette. The resident's right hand was shaky and he/she was inattentive. His/her left arm was contracted. He/she took the resident out when others smoke. Others tell the resident no when they take other residents out to smoke. The resident would tell him/her thanks for the smoke when he/she took him/her out even though he/she hadn't smoked.
-There had been no recent education about dealing with the resident's behaviors. The facility sometimes did inservices on individual resident behaviors, but he/she couldn't remember ever receiving education on the resident in particular.
-He/she heard about the resident being aggressive with others. The resident hit one of the CMT's in the head twice during one incident and he/she punched the evening night nurse and hit another resident.
-When he/she was told absolutely no he/she became upset and aggressive.
-That was why he/she kept the resident close to him/her during his/her shift.
-A lot of incidents happen during the evening and night shifts with the resident.
During an interview on 9/16/22 at 10:02 A.M. the resident said:
-He/she and the other resident were enemies.
-He/she didn't know how the incident started between him/her and the other resident.
-He/she couldn't remember what the other resident did to make him/her mad and couldn't remember what the other resident said.
-He/she didn't remember hitting the other resident.
-He/she probably thought the other resident was talking about the nurses. It made him/her mad when he/she thought someone was talking badly about the nurses.
-Sometimes he/she would hit the wall when he/she was upset.
-He/she wanted to smoke big time, but his/her guardian didn't want him/her to smoke.
-His/her guardian thought he/she owned him/her. It was because of COPD (Chronic Obstructive Pulmonary Disease - a disease process that decreases the ability of the lungs to perform ventilation) that he/she couldn't smoke. His/Her guardian thought the smoking would kill him/her, but it won't. It made him/her mad when he/she couldn't smoke.
-He/she thought he/she had hit one staff when they said he/she couldn't smoke and the nurse was going out to smoke.
-He/she probably tried to hit another resident as well, but he/she couldn't remember.
-He/she had a bad anger problem.
-He/she saw a psychologist or counselor who visited the facility during the week.
-When he/she was upset staff would try to get him/her in another spot where he/she could calm down which often helped, although sometimes he/she didn't want to go to another area.
During an interview on 9/16/22 at 10:49 A.M. CNA B said:
-The resident thought everyone was talking bad about him/her when they were talking about other things or talking bad about staff he/she liked.
-Usually the resident would cuss and bang his/her elbow, hand or head against the wall.
-Sometimes he/she would roll up to a person he/she was mad at.
-He/she was told by another CNA one time the resident hit another resident in the face maybe two months ago
-About a month ago in the dining room he/she saw the resident stick his/her foot in a resident face. It didn't touch his/her face. The resident just kind of sat there and didn't react. He/she didn't seem afraid. He/she took the resident out of the dining room and told the charge nurse about it. He/she sat with the resident near the nurse' station.
-Usually staff just seat the resident near the nursing station after aggressive incidents.
During an interview on 9/16/22 at 11:08 A.M. CNA C said:
-He/she had seen the resident hit the wall, tables, and his/her chair when irritated. He/she wanted things right away. Any time the resident got aggravated he/she did this. Staff tried to find out what he/she was aggravated about.
-He/she didn't think the resident had control of his/her aggression.
-It helped the resident's behavior if staff offered to help him/her lay down in bed. He/She liked that and realized that helped him/her calm down.
-The resident wanted to smoke. It made him/her upset he/she couldn't.
-One time staff brought the resident outside with them when taking others outside to smoke because he/she liked to be outside. He/she was trying to rock hard to throw himself/herself out of his/her wheelchair. Staff had to bring the resident back inside.
-Today the resident went out with staff when others went out to smoke and he/she was fine. It just depends.
During an interview on 9/16/22 at 11:41 A.M. RN A said:
-It was just he/she and the RA who saw the the resident hit another resident on 9/3/22.
-The resident said the other resident made him/her mad, but never was able to explain why.
-He/She was at the nurses' station around 1:00 P.M. charting and the other resident was in the hallway near the nurses' station. The resident had anger management issues partly due to his/her TBI diagnosis and the resident said he/she had anger and impulse control issues before the TBI.
-The resident would throw a temper tantrum when not immediately getting his/her way and called staff names like bitch, whore, slut and says our butt stinks. He/She would swing out at and hit staff.
-To his/her knowledge the resident had only made physical contact with two residents. Staff tried to keep him/her separated from other residents for that reason.
-The RA would let him/her follow him/her around and would bring him/her into the physical therapy room where it was calm and quiet and keep him/her close to the nursing station.
-When provided one to one attention the resident was great with no problems, but the facility didn't have staff to provide one to one staffing for him/her 24 hours a day.
-On 9/3/22 the resident started down the 200 hall, He/She didn't hear anything the other resident said and the resident drew his/her arm back and hit the other resident with a closed fist on his/her lip, nose and left side of cheek. The other resident, with his/her dementia attempted to hit the resident back but he/she and the RA intervened before any other punches were thrown. The other resident had a scant amount of blood on his/her upper lip which was initially swelled that day.
-The resident swung and made contact with him/her once. It didn't really hurt. He/she didn't necessarily do an incident if he/she isn't hurt.
-The resident was not fully accountable due to his/her TBI.
-The resident thought everyone was talking about him/her and became very upset about that.
-Social Services had tried to get the resident in-patient psychiatric services and they told him/her they had no openings. After the 9/3/22 incident the facility put the resident on 15 minute checks for 72 hours. There was a 24 hour form for the 15 minute checks and the resident would have had it for 3 days.
-He/she was not here when the resident hit the other resident. They tried to get the resident into an in-patient psychiatric setting then as well. The SSD said there was no bed available.
-The resident would hit and punch himself/herself in the head, hit the wall and medication cart when upset.
-Frequently the resident became upset when he/she saw others go out to smoke because he/she knows he/she can't smoke due to his/her COPD.
-The resident's psychiatrist has been changing his/her medications.
During an interview on 9/19/22 at 10:30 A.M. the SSD said:
-The resident's behaviors were hitting and punching the walls periodically throughout the day.
-He/she was usually redirectable, but not always redirectable in the evenings.
-The resident had some recent behavioral medication changes.
-He/she had been in contact with the resident's guardian, but hadn't documented the calls.
-Most of the time he/she, the RA, or charge nurse had the resident with them.
-The resident saw psychiatrist routinely, but he/she couldn't find any of the psychiatrist's notes in his/her e-record.
-He/she had tried to discharge the resident to a facility that dealt more with behaviors and to get psychological evaluations and treatment, but had been unable to find any facility who would accept the resident and didn't think the resident was appropriate for the facility's setting due to the extent of the behaviors. He/She was unable to provide documentation showing what facilities and hospitals had been contacted.
-He/she had conversations with the resident about his/her behaviors, but had not documented the conversations or the resident's behavioral progress.
-He/she did not schedule regular meetings with the resident to discuss his/her mood and behaviors.
-No comprehensive root-cause analysis had been done related to the resident's behaviors.
During an interview on 9/20/22 at 10:46 A.M. the DON said:
-The resident doesn't always have control over his/her moods and would act out.
-He/she was normally redirectable.
-He/she didn't target any specific person.
During an interview on 9/20/22 at 12:00 P.M. the DON said:
-The facility had a psychiatrist who visited residents routinely.
-They discussed behaviors in clinical meetings and documented behaviors in notes.
-The IDT should try to determine the root cause of the resident's behaviors.
-If residents had on-going behaviors there should be a detailed plan with specific interventions and all staff should know the interventions.
-CNA's had access to care plans through the e-record.
-CNA's were educated through shift change meetings regarding residents' behavioral interventions.
MO00206506
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Quality of Care
(Tag F0684)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to identify, assess, monitor and treat non-pressure wound...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to identify, assess, monitor and treat non-pressure wounds to the right great toe, the right little toe, the right ankle, the right Achilles tendon (fibrous tissue that connects the calf muscles to the heel bone)) and multiple scabbed areas over the resident's bilateral shins resulting in the non-pressure wounds worsening over the 42 day delay before treatment started for one sampled resident (Resident #14); to ensure the charge nurse reviewed and followed up with lab results for a resident suspected of having Clostridium Difficile (C. Diff - an infection which typically occurs after use of antibiotic medications that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon); failed to ensure physician orders to treat the infection were obtained immediately and available for one sampled resident (Resident #31) which resulted in the resident having a new onset of stomach issues, loose, watery diarrhea stools that made him/her upset due to the uncontrolable strong smelling stools for seven days before treatment started; and to ensure two sampled residents (Resident #47 and Resident #68) were witnessed taking their medications out of 19 sampled residents. The facility census was 95 residents.
Record review of the facility's Wound Evaluations policy revised 9/2018 showed:
-The purpose of this procedure was to provide guidelines for the evaluation of current or new wounds.
-Evaluation of wounds would be performed on admission, weekly, and on discovery.
-Wound assessments may be completed by a facility nurse or an outside wound company.
-The wound assessment would identify the type of wound, size, wound bed, drainage, odor, infection, healing, the surrounding skin and pain.
-Evaluation results were communicated to the members of the care team through documentation, care plan meetings and care planning.
-Wounds would be observed during dressing changes.
Record review of the Missouri Certified Medication Technician, 2008 Revision manual showed:
-Hand the medication to resident with a glass of water if needed.
-Remain with resident until medication is swallowed.
1. Record review of Resident #14's admission Record showed he/she was admitted to the facility on [DATE] and had the following diagnoses:
-Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin).
-Cerebrovascular Accident (CVA, stroke), cerebral artery occlusion with infarct (a blockage in the one or more of the arteries supplying blood to the brain resulting in a stroke).
Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by staff for care planning) dated 3/24/22 showed the resident:
-Was cognitively intact.
-Did not have any wounds on his/her body.
Record review of the resident's quarterly MDS dated [DATE] showed the resident:
-Was cognitively intact.
-Did not have any wounds on his/her body.
Record review of the resident's Weekly Skin Check dated 6/30/22 showed the resident did not have any new wounds identified during this skin check.
Record review of the resident's Weekly Skin Check dated 7/7/22 showed the resident did not have any new wounds identified during this skin check.
Record review of the Resident's Comprehensive Certified Nurses Assistant (CNA) Shower Review Sheet dated 7/13/22 showed:
-The form was used for a visual assessment of the resident's skin while showering. Report any abnormal skin to the charge nurse immediately.
-There were no skin issues marked on the form for the resident's legs or feet.
Record review of the resident's Weekly Skin Check dated 7/14/22 showed the resident did not have any new wounds identified during this skin check.
Record review of the Resident's Comprehensive CNA Shower Review Sheet dated 7/15/22 showed there were no skin issues marked on the form for the resident's legs or feet.
Record review of the resident's Weekly Skin Check dated 7/21/22 showed the resident did not have any new wounds identified during this skin check.
Record review of the resident's Weekly Skin Check dated 7/28/22 showed the resident did not have any new wounds identified during this skin check.
Record review of the Resident's Comprehensive CNA Shower Review Sheet dated 8/3/22 showed the resident:
-Had scabs on the side of his/her right lower leg.
-Had scabs on the top of the right side of his/her right foot.
Record review of the resident's Weekly Skin Check dated 8/4/22 showed the resident:
-Did not have any new wounds identified during this skin check.
-NOTE: the scabs on the side of his/her right lower leg were not identified.
-NOTE: the scab on the top of the right side of his/her right foot were not identified.
Record review of the Resident's Comprehensive CNA Shower Review Sheet dated 8/4/22 showed:
-There were no skin issues marked on the form for the resident's legs or feet.
-NOTE: the scabs on the side of his/her right lower leg were not identified.
-NOTE: the scab on the top of the right side of his/her right foot were not identified.
Record review of the Resident's Comprehensive CNA Shower Review Sheet dated 8/8/22 showed the resident:
-Had scabs on the top of the right side of his/her right foot.
-NOTE: the scabs on the side of his/her right lower leg were not identified.
Record review of the resident's Weekly Skin Check dated 8/11/22 showed the resident:
-Did not have any new wounds identified during this skin check.
-NOTE: the scabs on the side of his/her right lower leg were not identified.
-NOTE: the scab on the top of the right side of his/her right foot were not identified.
Record review of the Resident's Comprehensive CNA Shower Review Sheet dated 8/12/22 showed the resident:
-Had scabs on the front of his/her right lower leg.
-Had an open area behind the right ankle.
Record review of the Resident's Comprehensive CNA Shower Review Sheet dated 8/16/22 showed:
-The resident had scabs on the front of his/her right lower leg.
-NOTE: the open area behind the right ankle was not identified.
Record review of the resident's Weekly Skin Check dated 8/18/22 showed:
-The resident did not have any new wounds identified during this skin check.
-NOTE: the scabs on the front of his/her right lower leg were not identified.
-NOTE: the open area behind the right ankle was not identified.
Record review of the Resident's Comprehensive CNA Shower Review Sheet dated 8/23/22 showed the resident:
-Had scabs on the front of his/her right lower leg.
-Had scabs on his/her right little toe.
-NOTE: the open area behind the right ankle was not identified.
Record review of the resident's Weekly Skin Check dated 8/25/22 showed:
-The resident did not have any new wounds identified during this skin check.
-NOTE: the scabs on the front of his/her right lower leg were not identified.
-NOTE: the open area behind the right ankle was not identified.
-NOTE: the scabs on his/her right little toe were not identified.
Record review of the Resident's Comprehensive CNA Shower Review Sheet dated 8/28/22 showed:
-The resident had scabs on the front of his/her right lower leg and left lower leg.
-NOTE: the open area behind the right ankle was not identified.
-NOTE: the scabs on his/her right little toe were not identified.
Record review of the Resident's Comprehensive CNA Shower Review Sheet dated 8/30/22 showed the resident:
-Had scabs on the front of his/her right lower leg.
-Had a scab on his/her great right toe and on the little toe.
-NOTE: the open area behind the right ankle was not identified.
-NOTE: the scabs on his/her left lower leg were not identified.
Record review of the resident's Weekly Skin Check dated 9/1/22 showed:
-The resident did not have any new wounds identified during this skin check.
-NOTE: the scabs on the front of his/her right lower leg were not identified.
-NOTE: the scabs on the front of his/her left lower leg were not identified.
-NOTE: the scabs on his/her right great toe were not identified.
-NOTE: the scabs on his/her right little toe were not identified.
Record review of the Resident's Comprehensive CNA Shower Review Sheet dated 9/2/22 showed the resident:
-Had scabs on the front of his/her right lower leg.
-Had a scab on his/her right great toe.
-NOTE: the scabs on the front of his/her left lower leg were not identified.
-NOTE: the scabs on his/her right little toe were not identified.
Record review of the Resident's Comprehensive CNA Shower Review Sheet dated 9/6/22 showed the resident:
-Had scabs on the front of his/her right lower leg.
-Had a scab on his/her right great toe.
-Had scabs on his/her left knee.
-NOTE: the scabs on the front of his/her left lower leg were not identified.
-NOTE: the scabs on his/her right little toe were not identified.
Record review of the resident's Weekly Skin Check dated 9/8/22 showed:
-The resident did not have any new wounds identified during this skin check.
-NOTE: the scabs on the front of his/her right lower leg were not identified.
-NOTE: the scabs on the front of his/her left lower leg were not identified.
-NOTE: the scabs on his/her right great toe were not identified.
-NOTE: the scabs on his/her right little toe were not identified.
-NOTE: the scabs on his/her left knee were not identified.
Record review of the Resident's Comprehensive CNA Shower Review Sheet dated 9/9/22 showed the resident:
-Had scabs on the front of his/her right lower leg.
-Had a scab on his/her right great toe.
-NOTE: the scabs on the front of his/her left lower leg were not identified.
-NOTE: the scabs on his/her right little toe were not identified.
-NOTE: the scabs on his/her left knee were not identified.
Observation on 9/13/22 at 12:41 P.M. showed:
-The resident was in his/her recliner with lower legs and feet exposed.
-The resident had multiple scabbed areas on the front of both lower legs up to the knees.
-Had wound/scabbed areas to his/her feet.
-Had a quarter sized wound on the right great out toe covered in eschar (a collection of dry, dead tissue within a wound).
--There was no documentation indicating eschar had been present.
--The staff were preparing to take the resident to the shower including Licensed Practical Nurse (LPN) F.
Record review of the Resident's Comprehensive CNA Shower Review Sheet dated 9/13/22 showed the resident:
-Had scabs on the front of his/her right lower leg.
-Had a scab on his/her right great toe.
--There was no documentation of eschar on the wound.
-Had scabs on his/her left knee.
-NOTE: the scabs on the front of his/her left lower leg were not identified.
-NOTE: the scabs on his/her right little toe were not identified.
Record review of the resident's Weekly Wound assessment dated [DATE] at 3:37 P.M. showed:
-A great right toe wound.
-Date of onset of wound was 9/13/22.
-The wound was facility acquired.
-The wound was 2.2 centimeters (cm) in length by 1.1 cm in width.
-The wound bed was eschar and deep red/black in color.
-The area around the wound was red.
-There was no drainage and no odor.
-The wound was a trauma with no drainage noted. The area around to wound had skin texture, temperature, and moisture were within normal limits.
-Apply skin prep (forms a film upon application to intact or damaged skin) and leave open to air.
-There was no other documentation related to other areas of the resident's feet and legs.
-There were no other wound assessments in the resident's electronic medical record.
-NOTE: this wound was identified on 8/30/22 as a scab with no redness on the skin around the wound.
Record review of the resident's Order Recap Report showed the following physician's orders dated 9/13/22:
-Apply A&D ointment (a protective barrier to seal out wetness) to bilateral lower extremities (lower legs) every day shift for skin integrity.
-Skin prep to right great toe eschar every shift for wound care.
Record review of the resident's care plan dated 9/14/22 showed:
-The resident had a wound on his/her right great toe and bilateral shins.
-Avoid scratching and keep hands and body parts from excessive moisture.
-Follow facility protocols for treatment of injury.
-Weekly treatment documentation to include measurements of each area of the skin and any other notable changes.
During an interview on 9/14/22 at 8:01 A.M. the Wound Nurse said:
-He/she was notified of the resident's wound on the right great toe by LPN F on 9/13/22.
-He/she was not aware of any wounds on the resident prior to 9/13/22.
-He/she measured the resident's great right toe wound and assessed the wound.
-He/she obtained physician's orders for the great right toe wound and the scratches on the legs.
-The great right toe area was red so he/she put a note in for the doctor to take a look at the toe due to redness around the wound.
-The toe was not warm to touch.
-The resident's physician should be able to assess the wound type today.
-He/she thought the wound was probably trauma because the resident moves around a lot.
-He/she did not think the wound was pressure related due to the resident not wearing shoes.
-The nurses were responsible for completing wound assessments weekly.
-The wound should have been identified with bath sheets or on a skin assessment.
-The CNAs should have reported to the nurse the resident had a wound.
-The nurse was then responsible to notify him/her the resident had a wound so he/she could haven assessed and obtained treatment orders.
-The wound has been there for a while and has not been assessed or treated.
-The resident's wounds should have been caught and documented on a skin assessment.
-It was a pretty significant wound and should have been noticed.
-He/she was responsible for measuring, assessing and documenting all wound reports.
-He/she was responsible for completing wound treatments.
Observation and interview on 9/14/22 at 10:02 A.M. showed:
-The resident's wounds were being assessed by the Wound Nurse.
-The resident stated his/her toe had been hurting for two days.
-The resident's right great toe wound was closed with a brown eschar over the wound bed. The wound measured 2.2 cm in length by 1.1 cm in width. The periwound (area around the wound) was slightly reddened, intact, and the redness extended down halfway down on the pad of the toe. The redness extended over the top side of the toe further than the nail bed.
-The resident's right heel was red with a small scab.
-The resident's right little toe had an area that was moist with yellow slough (necrotic/avascular tissue in the process of separating from the viable portions of the body & is usually light colored, soft, moist, & stringy) and eschar measuring 0.5 cm in length by 0.5 cm in width. The periwound had peeling skin.
-The right outer ankle had a wound that measured 3.1 cm in length by 1.1 cm in width with 25% slough and the rest of the area was eschar. The periwound area was starting to peel around the edges.
-The right heel was red in color.
-The right foot area had a wound over the Achilles tendon which measured 0.4 cm in length by 0.7 cm in width covered with brown eschar. The periwound area was red.
-The right ankle bone area had a wound that was 0.5 cm in length by 0.4 cm by 0.7 cm in width with 25% slough and the rest of the area was covered in eschar.
-The right lower leg had multiple scabbed areas 22 cm in length by 3.5 cm in width.
-The left leg had multiple scabbed areas 22 cm in length by 8.0 cm in width.
-The left knee had one distinct scabbed area 3 cm in length by 1.5 cm in width.
-The resident stated he/she obtained the wounds in prison from thrashing around and could not state how long the wounds had been on his/her legs.
-The Wound Nurse stated he/she had only obtained physician's orders for the right great toe and the scabbed areas on the lower legs. He/she had not assessed all of the areas on the resident's legs and should have done a better job on the wound assessment. The resident had a history of crawling on the floor and scratching himself/herself.
During an interview on 9/14/22 at 11:21 A.M. CNA C said:
-If scabbed areas or wounds were seen on a resident, he/she would report this to the charge nurse immediately.
-If he/she saw the wound care nurse he/she would also notify him/her.
-CNA D usually completed all the baths for the residents.
-When bathed, he/she documented skin issues on the bath sheet.
-The bath sheets were given to the charge nurse and he/she was not sure where they go after that.
-He/she put a pillow under the resident's heals today because the resident complained of pain to his/her heels.
-He/she did not notice any wounds on the resident's feet or legs today.
-He/she really did not look at the resident's legs or feet when he/she put the pillow under the resident's heels.
-He/she had reported to LPN F and to RN B the resident's heels were hurting.
During an interview on 9/14/22 at 11:31 A.M. CNA D said:
-He/she was the bath aide and completed all of the residents' baths.
-If he/she discovered wounds or skin issues, he/she would immediately report this to the charge nurse.
-He/she documented the skin issues on the resident's bath sheet (also called Comprehensive CNA Shower Review Sheet).
-He/she would document the wound/skin issues on the bath sheet and give it to a charge nurse.
-The charge nurse should review and sign the bath sheet, then it goes to the Assistant Director of Nursing (ADON) B.
-He/she bathed the resident twice a week.
-He/she had noticed the scabs on the resident's legs and the wound on the right big toe.
-He/she had been documenting the resident's wound and skin issues for weeks.
-He/she put it on the bath sheets and told the charge nurse each time including LPN F and Register Nurse (RN) B.
-He/she verbally told them because it was there for weeks, at least three weeks.
-Whoever the nurse was on this side it was reported immediately each time.
-He/she did the reporting and the nurses were responsible for following up.
-He/she kept telling the nurses because nothing was being done for the resident's wound and sin issues.
-He/she kept putting on bath sheet and letting the nurses know of the resident's wound and skin issues.
-The nurses were responsible for signing off on the bath sheet so they do see the wound and skin issues he/she had documented on the bath sheets for the resident.
During an interview on 9/14/22 at 11:32 A.M. CNA E said:
-He/she saw the resident's skin on 9/12/22 and the resident's right great toe had a quarter size black area.
-He/she thought the nurses were aware of the resident's wounds and skin issues.
-The resident's right great toe had the black area since June 2022.
-The resident scratched himself/herself.
-When he/she saw the resident scratch himself/herself, he/she would tell the resident he/she needed to stop scratching himself/herself, if the resident did not stop he/she would tell the licensed nurse the resident was scratching himself/herself.
-If he/she saw any new skin areas he/she had not seen before, he/she would tell the licensed nurse.
During an interview on 9/14/22 at 11:50 A.M. RN B said:
-If the CNAs discovered wounds, scabs, or skin issues, they were to report the issues to the charge nurse.
-If wounds and skin issues were discovered during a shower, the bath aide was responsible for documenting this on the bath sheet.
-Nurses were responsible for reviewing the bath sheets and sign the bath sheet when reviewed.
-Nurse should go in and assess any new issues and if it needed treatment he/she would notify the wound nurse if a wound was present.
-The bath sheets were then given to ADON B for review.
-Skin assessments were completed by nurses.
-All new skin issues and wounds should be reflected on the weekly skin check.
-The resident did not have any wounds or skin issues that he/she was aware of.
-The CNAs were very good at reporting new wound and skin issues.
-No staff have reported any wounds to him/her by CNA or bath aide.
-He/she could not recall if anyone reported wounds to feet or legs over the past weeks, not this week though.
-He/she had not seen any new wounds on the resident's legs and feet on his/her skin assessments he/she completed.
During an interview on 9/14/22 at 12:01 P.M. LPN F said:
-If a CNA or Bath Aide discover wounds or skin issues they should report this to a charge nurse immediately.
-The Bath Aide was responsible for documenting the issues on the residents' skin on the bath sheet.
-He/she would review and sign the bath sheet and look to see if skin issues were present.
-Skin assessments were completed by the nurses.
-The nurse would document any new skin issues on the skin assessment.
-He/she would notify the wound nurse of any new wounds.
-The wound nurse was responsible for assessing and treating the residents' wounds.
-The resident can turn himself/herself in bed.
-No identification of wounds were reported to him/her by the CNAs.
-The resident did pick at his/her lower legs.
-He/she had noticed any other wounds or skin issues except for the resident's toe yesterday when he/she assisted transferring the resident.
-He/she reported great right toe wound to the Wound Nurse.
-He/she did not notice any other wounds on the resident's legs or feet but the great right toe which had a big wound on it.
Observation and interview on 9/14/22 at 12:54 P.M. showed:
-The resident was up in his/her wheelchair in his/her room; his/her legs, feet and toes were uncovered.
-The resident's physician and the facility wound nurse were discussing the resident's right great toe.
-The resident's physician told the wound nurse he would order calcium alginate (dressings used on moderate to heavily exudative wounds during the transition from debridement to repair phase of wound healing), a venous ultrasound to produce images of the veins in the body. It is commonly used to search for blood clots, especially in the veins of the leg and an arterial Doppler (an ultrasound exam of the arteries in the arms or legs that can help evaluate whether there are blockages caused by plaque in the arteries).
-He/she said the resident's right great toe wound was a venous wound, not a pressure wound; all the other wound areas on the resident's legs were scratches, and the areas on the resident's right little toe and the over the resident's right Achilles tendon (fibrous tissue that connects the calf muscles to the heel bone) area were scratches.
During an interview 9/19/22 at 8:41 A.M. ADON B said:
-CNAs were responsible for letting the nurse know if a resident had wounds or skin issues.
-CNAs were responsible for documenting any wounds or skin issues on the bath sheet and charge nurse would sign off of the bath sheet after he/she reviewed it.
-The nurse was responsible for notifying the Wound Nurse of any new wounds.
-The Wound Nurse was responsible for assessing and treating the residents' wound.
-The Wound Nurse was responsible for obtaining physician's orders for the wounds.
-He/she received the bath sheets and housed them.
-He/she did not review the bath sheets because the nurses already reviewed them.
-Skin assessments were completed by the nurses and should be done weekly, and document any new skin or wound issues.
-When the resident's wounds and skin issues were brought to his/her attention by the Wound Nurse on 9/16/22, he/she reviewed the bath sheet and found the right great toe wound went back to mid-August.
-The staff had not told the wound nurse the resident had wounds.
-The bath sheets and the skin assessments should match up for the resident but do not.
-The wound was significant and had been on the resident for a while with no assessments, monitoring or treatments.
During an interview on 9/20/22 at 11:59 A.M. the Director of Nursing (DON) said:
-If a CNAs discover wounds or skin issues they were responsible for notifying the charge nurse.
-CNAs were to add the wound and skin issues to bath sheet
-The charge nurse was responsible for reviewing the bath sheet for wounds and skin issues and sign the bath sheet.
-Skin assessments were completed weekly by the charge nurses and all new areas should be documented.
-Skin assessments should match up with bath sheets with the condition of the resident's skin.
-Bath sheets were then given to ADON B and/or the Wound Nurse and should be reviewed for skin issues and wounds.
-The wound nurse was responsible for calling the physician to obtain orders to treat the wound.
-The wound nurse was responsible for assessing the wound and trying to determine what type of wound it was.
-The Wound Nurse would monitor and assess the wounds.
-If needed, the wound nurse would call wound care plus.
-The resident's wounds were not identified prior to 9/13/22.
-The resident's wounds should have been caught on the bath sheets and skin assessments. -The nurses should have notified the wound nurse of the resident's skin condition and wounds.
2. Record review of Resident #31's admission Record sheet showed he/she was admitted to the facility on [DATE] with a primary diagnosis of moderate protein-calorie malnutrition (when you are not consuming enough protein and calories. This can lead to muscle loss, fat loss, and your body not working as it usually would).
Record review of the resident's admission MDS, dated [DATE] showed the resident:
-Was severely cognitively impaired.
-Had fluctuating disorganized thinking.
-Required limited assistance with most Activities of Daily Living (ADL - dressing, grooming, bathing, eating, and toileting) and was totally dependent upon staff for toileting.
-Was always incontinent of both bowel and bladder.
-Had not been on an antibiotic within the past seven days.
Record review of the resident's progress notes, dated 8/15/22 to 9/19/22 showed no mention of the resident having diarrhea or of staff suspecting the resident to have C. Diff.
Record review of the resident's laboratory results, dated 9/8/22 showed:
-A stool sample was collected 9/7/22.
-Results on 9/8/22 showed the resident tested positive for C. Difficile Toxin [NAME] (indicates it is likely the person's diarrhea and related symptoms were due to toxin-producing C. Difficile, a bacteria present in the digestive tract) by nucleic acid amplification (a test used to detect the presence of C. Diff).
During an interview on 9/14/22 at 12:17 P.M. CNA A said:
-The resident was having diarrhea, usually after eating, and sometimes even after drinking.
-He/she told multiple charge nurses.
-The resident would cry because he/she was so sad about it. The fact he/she couldn't control the diarrhea bothered him/her. The resident said the smell bothered him/her and he/she knew it bothered others. Yesterday the resident had his/her first formed stool since he/she came to facility.
-His/Her feces had mucus in it last week.
-The resident was in isolation last week.
Record review of the resident's Physician Orders (PO), dated 9/16/22 showed:
-Vancomycin HCI (an antibiotic used to treat C. Difficile and certain other bacterial infections) capsule 125 milligrams (mg) by mouth four times a day every 10 days for C. Diff starting 9/15/22.
--NOTE: this order was written seven days after the results of the resident's stool sample were received, this was a delay in treatment of seven days.
-NOTE: the resident continued to have loose, watery stools during those seven days.
Record review of the resident's Medication Administration Records (MAR) for September 2022 showed:
-Vancomycin HCI 125 mg capsule 125 mg by mouth four times a day (at 9:00 A.M., 12:00 P.M., 5:00 P.M. and 9:00 P.M.) every 10 days for C. Diff starting 9/15/22. The order was discontinued on 9/17/22.
-The resident was not administered Vancomycin HCI 125 mg on the following dates and times:
--9/15/22 at 9:00 A.M. and 12:00 P.M.
--9/16/22 at 9:00 A.M., 12:00 P.M. and 5:00 P.M.
-Vancomycin HCI capsule 125 mg by mouth four times a day for C. Diff for 10 days starting on 9/17/22. The resident was administered the medication on:
-There were no orders for Vancomycin shown in the September, 2022 MAR prior to 9/15/22.
During an interview on 9/15/22 at 10:17 A.M. the resident said:
-He/she had stomach problems starting 1 1/2 to 2 weeks ago that included lots of gas and real watery diarrhea multiple times a day.
-Staff would know when it started because they help with his/her brief changes.
-Staff took a stool sample to see if it was contagious and they told him/her it was not contagious.
-He/she had not been put on any antibiotic.
-His/Her stools were still loose.
-The stomach issues were a new thing and were not typical for him/her.
During an interview on 9/16/22 at 10:38 A.M. CNA B said:
-Since the resident's admission he/she has had a little diarrhea off and on.
-He/she told the DON the resident had diarrhea two or more weeks ago and the resident had been on isolation for about one or two weeks.
During an interview on 9/19/22 at 9:04 A.M. LPN G said:
-He/she wasn't sure why it would take a week to get an antibiotic medication.
-Normally when someone was diagnosed with C. Diff they put them on an antibiotic right away.
-Once the lab results were back the nurse should immediately phone the physician to get an order.
-Depending on the time the lab results got back, the medication should be at the facility that day or at least by the time medications are delivered that night, whenever the next pharmacy delivery takes place. Normally, medications are delivered before 3:00 P.M.
-If results from the lab come in later that day there was one night pharmacy delivery and the medication should come by then. It should definitely be at the facility in less than 24 hours. -He/She thought the pharmacy might even do emergency deliveries but was not sure.
During an interview on 9/19/22 at 9:29 A.M. LPN B said:
-The nurse should call the doctor immediately upon positive C. Diff lab results to get an order.
-If the resident had tested positive for C. Diff they would likely be put on Vancomycin.
-Nurses should put the order in as soon as they get it and fax it to the pharmacy because the resident needed to start it right away.
-He/she thought the facility had Vancomycin in their emergency kit (e-kit) because most oral antibiotics were in there. (At this point LPN B checked the facility's list of medications that could be accessed from the e-kit and said Vancomycin was not on the list).
-Vancomycin should be available on the next pharmacy delivery. They deliver in the afternoon and on the evening or night shift.
-The medication should arrive within 24 hours or less.
During an interview on 9/19/22 at 10:00 A.M. LPN D said:
-Once lab results of positive C. Diff arrive the nurse should contact the physician immediately to get orders to start the resident on antibiotic therapy. They usually get orders for Vancomycin for C-Diff.
-The medication should be at the facility from pharmacy by early to mid-afternoon. If the lab results come back later in the day the medication should be here by the night run.
-Vancomycin was not in the facility's e-kit.
-An antibiotic order was entered into the computer system and goes directly to the pharmacy.
-If the lab results came back on 9/8/22 and the resident did not get an order for ABT until 9/15/22 it was probably
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0742
(Tag F0742)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to adequately assess, monitor, document and provide treat...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to adequately assess, monitor, document and provide treatment that includes ongoing appropriate interventions related to the resident's behaviors; to ensure monthly psychiatric visits were in the medical record and reviewed by the staff; to ensure supportive services were in place and to have an individualized care plan based on the resident's behaviors of two sampled residents (Resident #14 and #25) out of 19 sampled residents. The facility census was 95 residents.
Record review of the facility's policy Behavioral Assessment, Intervention and Monitoring policy revised 3/2019 showed:
-The facility would provide and residents would receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment.
-Behavioral health services would be provided by qualified staff who have the competencies and skills necessary to provide appropriate services and treatment.
-The Interdisciplinary Team (IDT) would thoroughly evaluate new or changing behavioral symptoms in order to identify the underlying causes and address and modifiable behaviors.
-The IDT would evaluate the behavioral symptoms of residents to determine the degree of severity, distress, and potential safety risks.
-The care plan would incorporate the findings.
-The interventions would be individualized and part of the overall care environment that supported physical function and psychosocial needs.
1. Record review of Resident #14's admission Record showed he/she was admitted to the facility on [DATE] and had the following diagnoses:
-Major depressive disorder with psychiatric symptoms (a mental disorder in which a person has depression along with loss of touch with reality).
-Insomnia (inability to sleep).
Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by staff for care planning) dated 3/24/22 showed the resident:
-Was cognitively intact.
-Did not have behaviors.
Record review of the resident's Nurses Notes dated 5/20/22 showed:
-The Certified Nursing Assistant (CNA) brought the resident to the nurses station.
-The resident was tearful and kicking his/her feet into the floor stating he/she was having withdrawals.
-The CNA reported the resident was talking to him/her and roommate stating he/she wanted to kill himself/herself.
-The resident stated he/she wanted to go to the hospital or he/she was going to kill himself/herself.
-The physician and family were notified.
-The resident was sent to the hospital for a psychiatric (relating to mental illness or its treatment) evaluation.
-The resident was sent back from the hospital saying the resident was not a harm to himself/herself and was not admitted for psychiatric services.
-The resident complained he/she did not want to return to the room he/she was in and wanted a different roommate.
-His/her roommate was mean to him/her.
-The resident was placed in a different room.
-The resident was appreciative of the room move and was resting without distress.
Record review of the resident's quarterly MDS dated [DATE] showed the resident:
-Was cognitively intact.
-Did not have behaviors.
Record review of the resident's Care Plan dated 7/29/22 showed the resident:
-Was at risk of falls related to lowering himself/herself to the floor for attention.
-Did not have a care plan that showed all the resident's behaviors, including attention seeking or making statements of harming him/herself.
Record review of the resident's Behavioral Note dated 7/22/22 showed:
-He/she received a call from the resident's family member stating the resident sent a text to him/her saying the resident was in pain.
-He/she went to check on the resident and the resident said he/she was not in pain.
Record review of the resident's Behavioral Note dated 8/2/22 showed:
-The resident had been crying since the writer was on duty.
-The resident wanted his/her family member to come take care of him/her.
-The resident needed help with charging his/her phone and the CNA went to assist.
-The resident was yelling that they were trying to poison him/her with medications and refused medications.
-The resident said he/she was being held against his/her will and needed his/her family member to come and get him/her.
-The resident was assisted with incontinence care, linen changes and laid down.
-The resident was sleeping.
Record review of the resident's Behavioral Note dated 8/7/22 showed:
-The resident was very emotional and crying this morning and refused his/her medications.
-The resident had called his/her family member and the family member would not answer the phone.
-The resident refused evening medications and was throwing his/her belongings out into the hallway.
-The staff asked the resident why he/she was throwing his/her belongings the resident said because his/her family member would not get up.
-The staff explained the resident's family member was not here.
Record review of the resident's Behavioral Note dated 8/10/22 showed:
-The resident was crying, upset, or arguing about different things all shift.
-Once the resident was afraid he/she would fall off his/her bed.
-The CNA went to sit with the resident to calm him/her down and the resident became angry stating if the CNA left he/she would cry rape.
-The resident was now crying and praying he/she was urinating more than usual and he/she was afraid.
-The staff offered to take the resident to the bathroom and the resident declined.
-The resident was not wet but was scared he/she might urinate.
-The resident continued to cry and repeat he/she was scared.
Record review of the resident's Behavioral Note dated 8/31/22 showed:
-The resident had been crying all during the shift.
-Staff had just left the room and the resident was in his/her wheelchair.
-The resident put himself/herself on the floor.
-The resident refused all medications this shift.
-The resident was assisted to the dining room for lunch.
Record review of the resident's Behavioral Note dated 8/31/22 showed:
-The resident was very tearful this morning stating they are trying to kill me.
-He/she offered reassurance to the resident that he/she was safe here.
Record review of the resident's Behavioral Note dated 8/31/22 showed the resident:
-Had been yelling since he/she came on shift.
-Stated the staff were not taking care of him/her.
-Wanted his/her family member to come take him/her home.
-Threw his/her food all over the floor then denied doing this when a CNA witnessed this.
-Threw his/her medications on the floor.
Observation on 9/14/22 at 10:02 A.M. showed:
-The resident was alert and laying in his/her bed.
-He/she said he/she had just gotten out of prison.
During an interview on 9/16/22 at 12:52 P.M. CNA B said:
-The resident had behaviors and said the staff worshiped Satan.
-The resident's family members did not come to see him/her often.
-He/she was not aware of any behavioral interventions.
-He/she believed the resident was depressed.
-The resident scratched at his/her legs.
-He/she would scream and yell and cry all day sometimes.
Record review of the resident's electronic medical record on 9/16/22 showed no Social Services Designee (SSD) notes or psychiatric notes.
Observation on 9/19/22 at 11:10 A.M. showed:
-The resident was in the dining room in his/her wheelchair.
-He/she was crying and speaking but could not be understood.
-He/she was crying with no staff consoling him/her.
-Multiple staff walked by the resident.
Observation on 9/19/22 at 12:20 P.M. showed:
-The resident continued sitting in his/her wheelchair in the dining room.
-He/she was crying with no staff consoling him/her.
-Another resident was across the room and was telling the resident to shut up and quit crying.
During an interview on 9/19/22 at 12:20 P.M. the SSD said:
-The resident was sometimes happy and sometimes he/she cried.
-He/she had been referred to psychiatric (mental health) due to his/her crying and mood.
--There were no psychiatric notes in the resident's e-chart (facility electronic medical record -EMR).
-He/she had not been told about the resident picking his/her skin.
-The resident's crying was constant and he/she would get upset and want to go to emergency room.
-He/she had not been documenting in the resident's progress notes related to his/her behaviors.
-He/she did talk to the resident but did not put notes in the resident's e-chart.
-He/she would just talk to the resident and try to calm him/her down.
-He/she did not do scheduled regular meetings with the resident related to his/her mood and behaviors.
-The resident had said he/she felt like he/she was just left at the facility.
-The resident was not that emotional when he/she first came to the facility.
-He/she had not referred the resident for behavioral health services.
-Psychiatric came to the facility monthly.
-He/she could not find notes related to psychiatric visits in the resident's e-chart.
-The resident was very easy to re-direct.
-No root cause analysis had been done related to the resident's behavior.
During an interview on 9/19/22 at 12:54 P.M. Licensed Practical Nurse (LPN) D said:
-The resident did not have behaviors when he/she first was admitted to the facility.
-He/she was not sure what happened with the resident.
-The resident yelled out a lot and if he/she checked on the resident, he/she said non-sensible things.
-He/she just tried to console the resident.
During an interview on 9/19/20 at 1:38 P.M., the MDS Coordinator said:
-The resident was admitted to the facility from a psychiatric hospital.
-The resident made up stories and would sit himself/herself on the floor; facility staff had talked about that.
-The resident had been seen by a psychiatrist but no notes had been given to the facility.
-The resident had no behavioral health services or counseling services.
-Facility staff had just talked about the resident but had not tried to determine the root cause of the resident's behaviors there had been no root cause analysis.
-Staff had not looked at the root cause of the resident's behavior to try to determine a plan to address the resident's behaviors.
-The SSD should have been visiting the resident to talk about the resident's mood and behavior and this should have been documented.
-The resident's care plan should have been updated to reflect the resident's current behaviors and interventions.
-He/she was responsible for updating the care plan.
During an interview on 9/20/22 at 12:00 P.M. the Director of Nursing (DON) said:
-Regarding resident behaviors, he/she expected staff, depending on the behavior to redirect the resident and provide diversion (activity that diverts the mind from concerns).
-The facility could have residents with behaviors seen by psychiatric for evaluation.
-The clinical team meets every morning regarding behaviors at the daily Resident Risk Meetings but the meetings were not documented.
-No behavioral health services were utilized for the resident, but this would be the SSD that would assist to council the resident.
2. Record review of Resident #25's admission Record showed he/she was admitted to the facility on [DATE] and had the following diagnoses:
-Traumatic brain injury (TBI - damage to the brain resulting from external mechanical force, such as rapid acceleration or deceleration, impact, blast waves, or penetration by a projectile).
-SynGap 1 related intellectual disability (a neurological disorder characterized by moderate to severe intellectual disability evident in early childhood with features of delayed speech development and motor skills and often seizures, hyperactivity and sensory processing problems).
-Schizoaffective disorder, depressive type (a mental condition that causes loss of contact with reality and mood problems).
-Restlessness and agitation.
-Psychosis (a mental state involving loss of contact with reality and causing deterioration of normal social functioning).
-Antisocial personality disorder (condition characterized by repetitive behavioral patterns that are contrary to usual moral and ethical standards and cause a person to experience continuous conflict with society).
-Intermittent Explosive Disorder (a chronic disorder involving repeated, sudden episodes of impulsive, aggressive, violent behavior and/or angry verbal outbursts in which reactions are grossly out of proportion to the situation).
Record review of the resident's admission MDS dated [DATE] showed the resident:
-Was severely cognitively impaired.
-Had fluctuating inattention.
-Had physical behaviors directed towards others one to three days out of seven.
-Had no verbal behaviors directed towards others.
-Had no other behaviors not directed towards others (e.g. hitting self, screaming).
Record review of the resident's Preadmission Screening and Resident Review (PASARR) II (determines if the intellectual disability or serious mental illness of the individual can be met in a nursing facility or if the resident requires specialized services), reviewed on 6/7/22 by the Central Office Medical Review Unit (COMRU - reviews the DA 124 assessment forms for the PASARR) showed:
-The resident had an Intellectual Disability ( when there are limits to a person's ability to learn at an expected level and function in daily life) and a substantiated dementia ( chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) or related condition and required nursing facility services.
-Due to the resident's TBI he/she had problems with impulsive behaviors and anger control.
-His/her reported moods could be labile (rapid, exaggerated changes) and he/she struggles with expressing emotions appropriately.
-He/she has a guardian to assist with major life and financial decisions and requires 24 hour support.
-The resident needed assessment and implementation of a behavioral support plan, monitoring of behavioral symptoms, and provision of behavioral supports. Staff should identify precipitating factors which may exacerbate his/her volatile behaviors. A structured, low-stimulation environment should be provided. He/She will require continued psychiatric follow-up and medication management and periodic review of medications. Establish consistent routine, provide daily tasks/activities and assess and plan for the level of supervision required to prevent harm to self or others. The plan should identify clear steps to manage the individual's behavior in a crisis situation, who to contact for assistance, and how staff will work together in a crisis.
Record review of the resident's Potential for Physical Aggression Care Plan, updated on 6/21/22 showed the resident's triggers for physical aggression were paranoia that others were talking about him/her. An intervention added on 6/21/22 showed the resident's behaviors were de-escalated by 1:1 attention and reassurance and attempts to calm him/her.
Record review of the resident's Nurses' Note dated 6/25/22 at 2:07 P.M. showed:
-At approximately 3:00 A.M. the resident started yelling and cursing down the hall. Staff assisted the resident to go to the bathroom.
-He/she was assisted to his/her wheelchair and taken to the nurses' desk at 5:00 A.M.
-A few minutes later the resident started to yell again and cursing at staff calling them bitches and punching anything close to him/her.
-Another resident down the hall started to yell and the resident started yelling if the other resident did not stop yelling he/she would come down and beat his/her ass. The resident would only be redirected a few minutes and start again yelling at staff and other resident and threatening to beat their ass. This continued until lunchtime.
-The resident was taken to the dining room to eat and started to yell to other residents and staff to shut the hell up and started to pound the table. The resident was taken out of the dining room to the therapy room to eat lunch. The resident was still unable to be redirected for more than a few minutes.
-A one-time order was received from the physician for Haloperidal (Haldol, an antipsychotic (a psychoactive drug (pertaining to a drug or other agent that affects such normal mental functioning as mood, behavior, or thinking processes) commonly but not exclusively used to treat psychosis) 5 milligrams (mg)/milliliter (ml) Intramuscularly (IM).
-At 1:00 P.M the medication was administered in the right deltoid (upper arm).
Record review of the resident's Potential for Physical Aggression Care Plan, updated on 6/27/22 showed a new intervention for staff to keep the resident away from others when agitated when he/she appears aggressive to others.
Record review of the resident's Nurses' Note dated 7/8/22 at 2:30 A.M showed:
-The resident began yelling at 1:15 A.M. down the hall from his/her room waking other residents.
-The CNA got the resident up and dressed so he/she wouldn't wake other residents.
-The nurse made and fed the resident a packet of oatmeal and one pudding cup.
Record review of the resident's quarterly MDS dated [DATE] showed the resident:
-Was severely cognitively impaired.
-Had fluctuating inattention.
-Had physical behaviors directed towards others four to six days out of seven.
-Had verbal behaviors directed towards others one to three days out of seven.
-Had other behaviors not directed towards others one to three days out of seven.
Record review of the resident's Incident Investigation, dated 7/21/22 showed:
-A statement from the CNA that he/she had been at the nurses' station when he/she saw the resident hit another resident when that resident was just sitting there. He/she immediately separated the two and then the DON came into the area.
-The other resident was sitting in his/her wheelchair at the nurses' station when a CNA witnessed the resident, who had been sitting next to him/her, became agitated and hit the other resident on the face/nose area with his/her right hand.
-The residents were immediately separated.
-The other resident said he/she didn't know why the resident hit him/her.
-There were no observable injuries.
-The resident said he/she was sorry and thought the other resident had been talking about him/her.
-The resident was given a pro re nata (PRN - as needed) medication (the investigation did not show what medication) for agitation and placed on 15 minute checks.
-The cause of the behavior was believed to be the resident's paranoia (symptoms of a chronic mental illness, characterized by persistent preoccupation with illogical delusions (false beliefs), usually of a persecutory, grandiose, or jealous nature) and not abuse.
-The investigation showed a new behavioral intervention beginning 7/21/22 for the resident to not be placed within arm's length of other residents.
-A Nursing Note dated 7/22/22 at 1:18 P.M. showed the resident continues on 15 minute checks and staff ensuring the resident sat away from other residents for safety. He/She was noted to have two episodes of agitation and was easily redirectable.
Record review of the resident's Potential for Physical Aggression Care Plan, updated 7/21/22 showed the resident hit another resident and was immediately separated from the other resident. He/she was given a PRN for agitation and placed on 15 minute checks. A new intervention was added that staff were not to place the resident within arm's length of other residents.
-Other interventions on the care plan included:
--Administer medications as ordered.
--Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document.
--Assess and anticipate the resident's needs related to food, thirst, toileting, and comfort level.
--Provide physical and verbal cues to alleviate anxiety, give positive feedback, assist the resident in verbalizing his/her source of agitation, encourage seeking out a staff member when agitated.
--Psychiatric consult as indicated.
--Staff to remove those the resident feels are talking about him/her out of view by closing doors.
Record review of the resident's Nurses' Note dated 7/22/22 at 10:54 P.M. showed:
-The resident was trying to start a fight with three different residents.
-When trying to redirect the resident he/she swung at the nurse.
-Nurse called the physician and got a one-time order for Haldol IM.
-IM medication was administered and effective.
Record review of the resident's Nurses' Note dated 7/24/22 showed:
-The resident was yelling and cussing at staff, accusing them of stealing his/her money.
-The resident then started hitting himself/herself in the stomach with his/her hand.
-No bruising at this time.
-Hitting his/her head on the wall.
Record review of the resident's Nurses' Note dated 7/24/22 at 5:57 P.M. showed:
-The resident propelled himself/herself to the dining room and started to go after another resident, saying the other resident stole his/her money.
-Staff took the resident out of the dining room and the resident was still yelling.
Record review of the resident's Nurses' Note dated 7/24/22 at 6:19 P.M. showed:
-The resident propelled himself/herself down the hallway while yelling, cussing and hitting his/her head, arm, and hand on the wall.
-Staff were unable to talk to the resident and calm him/her down.
-The resident was now sitting in the hallway eating.
Record review of the resident's Nurses' Note dated 7/26/22 at 5:59 A.M. showed:
-The resident was hitting himself/herself on the right upper thigh.
-No bruising at this time.
Record review of the resident's Nurses' Note dated 8/21/22 at 10:45 P.M. showed:
-The resident was sitting in front of the nurses' station and started to lean to the right and kept leaning until he/she turned over his/her wheelchair, saying he/she meant to turn over his/her chair.
-Range of Motion was assessed with no complaints of pain or discomfort.
-The resident had been hitting his/her head on the wall since the nurse came in at 6:30 P.M.
-Staff were unable to distract the resident.
-He/she continued to hit his/her head on the wall until he/she turned over the chair.
-He/she also hit his/her right arm and watch on the bedside table.
-The resident then asked if he/she broke it because he/she wanted to break it.
-The resident then took off his/her glasses, threw them on the floor, picked them back up and was bending them.
-This nurse asked him/her to please stop before he/she broke them and he/she said he/she wanted to break them.
-The resident got the lens out of his/her glasses frames.
-The resident was given Haldol IM at 9:01 P.M. for behaviors.
Record review of the resident's Nurses' Note dated 8/24/22 showed:
-The resident was seen by several people punching a Certified Medication Technician (CMT) because he/she pushed him/her away from the door as he/she was trying to get out to smoke.
-The resident wasn't allowed to smoke per his/her Guardian.
-The resident pushed the CMT twice in the forehead after being pushed from the door.
Record review of the resident's Nurses' Note dated 8/29/22 at 6:30 P.M. showed:
-The resident was in the dining room cussing and propelling himself/herself to the hallway when the resident stopped in front of the entrance door and started to kick the door, saying he/she was leaving.
-The nurse went to the door and pulled the resident backward and he/she took his/her right hand and hit the nurse in the right shoulder cussing at the nurse.
-The resident went to the wall and took the fire extinguisher off the wall and dropped it to the floor.
-The resident received Haldol IM at this time.
Record review of the resident's e-record further showed there were no social services notes or psychiatric notes.
Record review of the resident's Nurses' Note dated 9/14/22 at 3:21 A.M. showed:
-The resident went after another resident, but the CNA walked up before he/she punched the other resident and stopped the incident from happening.
-The resident was taken to the other side of the nurses' station and within an hour the resident went to bed.
-The resident woke up at 2:30 A.M. wanting to get up but was talked into staying in bed and trying to get some more rest.
During an interview on 9/16/22 at 10:49 A.M. CNA B said:
-The resident thought everyone was talking bad about him/her when they were talking about other things or talking bad about staff he/she liked.
-Usually the resident would cuss and bang his/her elbow, hand or head against the wall.
-Sometimes he/she would roll up to a person he/she was mad at.
-He/She was told by another CNA one time the resident hit another resident in the face maybe two months ago.
-About a month ago in the dining room he/she saw the resident stick his/her foot in a resident face. It didn't touch his/her face. The resident just kind of sat there and didn't react. He/she didn't seem afraid. He/She took the resident out of the dining room and told the charge nurse about it. He/She sat with the resident near the nurse' station.
-Usually staff just put the resident near the nursing station after aggressive incidents.
During an interview on 9/16/22 at 11:08 A.M. CNA C said:
-He/she had seen the resident hit the wall, tables, and his/her chair when irritated. He/She wanted things right away. Any time the resident got aggravated he/she did this. Staff tried to find out what he/she was aggravated about.
-He/she didn't think the resident had control of his/her aggression.
-It helped the resident's behavior if staff offered to help him/her lay down in bed. He/She liked that and realized that helped him/her calm down.
-The resident wanted to smoke. It made him/her upset he/she couldn't.
-One time staff brought the resident outside with them when taking others outside to smoke because he/she liked to be outside. He/She was trying to rock hard to throw himself/herself out of his/her wheelchair. Staff had to bring the resident back inside.
-Today the resident went out with staff when others went out to smoke and he/she was fine. It just depends.
During an interview on 9/19/22 at 10:30 A.M. the SSD said:
-The resident's behaviors were hitting and punching the walls periodically throughout the day.
-He/she was usually redirectable, but not always redirectable in the evenings.
-The resident had some recent behavioral medication changes.
-He/she had been in contact with the resident's guardian, but hadn't documented the calls.
-Most of the time he/she, the RA, or charge nurse had the resident with them.
-The resident saw psychiatrist routinely, but he/she couldn't find any of the psychiatrist's notes in his/her e-record.
-He/she had tried to discharge the resident to a facility that dealt more with behaviors and to get psychological evaluations and treatment, but had been unable to find any facility who would accept the resident and didn't think the resident was appropriate for the facility's setting due to the extent of the behaviors. He/She was unable to provide documentation showing what facilities and hospitals had been contacted.
-He/she had conversations with the resident about his/her behaviors, but had not documented the conversations or the resident's behavioral progress.
-He/she did not schedule regular meetings with the resident to discuss his/her mood and behaviors.
-No comprehensive root-cause analysis had been done related to the resident's behaviors.
Observation on 9/19/22 at 10:50 A.M. showed:
-The resident was outside the SSD's office yelling and banging his/her right foot on the floor requesting change for his/her bill.
-The SSD went to get the resident change from the business office and the resident calmed down.
Observation on 9/20/22 at 9:20 A.M. in the therapy room showed:
-The Certified Occupational Therapist Assistant (COTA) put a splint on the resident's hand and wrist.
-The resident yelled out and cussed at the COTA and then calmed without further incident.
During an interview on 9/20/22 at 9:39 A.M. CNA E said:
-The resident's speech became rapid and excessive and he/she became fidgety when agitated. Behaviors consisted of beating his/her arms and head against the wall and purposely trying to flip his/her wheelchair backwards.
-He/she had seen various residents make fun of the resident when he/she hit the wall. They would tell the resident it wasn't OK to keep hitting the wall or will tell him/her he/she will get sent out.
-He/she received no training on what to do in particular for the resident's behaviors, but he/she could ask the nurse what he/she was supposed to do.
-He/she just separated the resident when he/she became agitated and tried to talk with him/her.
During an interview on 9/20/22 at 10:46 A.M. the DON said:
-The resident doesn't always have control over his/her moods and would act out.
-He/she was normally redirectable.
-He/she didn't target any specific person.
During an interview on 9/20/22 at 12:00 P.M. the DON said:
-The facility had a psychiatrist who visited residents routinely.
-They discussed behaviors in clinical meetings and documented behaviors in notes.
-The IDT should try to determine the root cause of the resident's behaviors.
-If residents had on-going behaviors there should be a detailed plan with specific interventions and all staff should know the interventions.
-CNA's had access to care plans through the e-record.
-CNA's were educated through shift change meetings regarding residents' behavioral interventions.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident's wishes for advanced directives related to a D...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident's wishes for advanced directives related to a Do not Resuscitate (DNR a directive indicating that, in case of respiratory or cardiac failure, the resident or legal representative had directed that no cardiopulmonary resuscitation (CPR - a lifesaving technique involving hard, fast chest compressions and/or rescue breaths/oxygen supplementation used when someone's breathing or heartbeat has stopped) code statuses were communicated to direct care staff and the physician and were reflected on the Physician Order Sheet (POS) and Care Plan for one sampled resident (Resident #42) out of 19 sampled residents. The facility census was 95 residents.
Record review of the facility's Advanced Directives policy, revised 12-16-22 showed:
-Upon admission the resident will be provided with written information concerning the right to formulate an advanced directive (a written instruction, such as a living will (a document specifying a person's preference about measures used to prolong life when there is a terminal prognosis/situation) or durable power of attorney (DPOA - a document recognized by state law relating to the provisions of health care, delegating authority to a legal representative in the event the individual subsequently becomes incapacitated) if he or she chooses to do so. The written information provided by the facility will include a description of the facility's policies to implement advanced directives.
-Prior to or upon admission of a resident the social services director or designee will inquire of the resident about the existence of any written advanced directives.
-In accordance with current Omnibus Budget Reconciliation Act (OBRA) definitions and guidelines governing advanced directives, our facility has defined advanced directives as preferences regarding treatment options and include, but are not limited to:
--Advanced Directives.
--Do Not Resuscitate or other life sustaining treatments or methods are to be used.
-Information on whether or not the resident has executed an advanced directive shall be displayed prominently in the medical record.
-The interdisciplinary team will review annually with the resident his or her advanced directives to ensure that such directives are still the wishes of the resident.
1. Record review of Resident #42's admission Record sheet showed he/she was admitted to the facility on [DATE] and had diagnoses that included:
-Parkinson's Disease (a neurological disorder).
-Dysphagia (difficulty swallowing).
-Atrial Fibrillation (abnormal heart rhythm in the upper chambers of the heart).
-Sick Sinus Syndrome (heart rhythm problems due to the sinoatrial (sinus) node, which starts each heartbeat, not functioning properly).
-The resident was his/her own responsible party and there was no DPOA listed as a contact.
Record review of the resident's Outside the Hospital Do Not Resuscitate (OHDNR) Order form, signed by the resident on [DATE], showed the form was signed in the Attending Physician Signature (Mandatory) line and was not dated by the physician.
Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated [DATE] showed the resident was moderately cognitively impaired and had no disorganized thinking.
Record review of the resident's POS dated [DATE] showed the resident was a Full Code status beginning [DATE].
During an interview on [DATE] at 1:27 P.M. the resident said:
-He/she told a staff person that he/she wanted to be a DNR status upon his/her admission and that he/she wanted a particular family member to speak on his/her behalf if he/she couldn't.
-He/she is his/her own responsible party and his/her family was aware of his/her wishes.
During an interview on [DATE] at 11:35 A.M. the Business Office Manager (BOM) said:
-He/she went over Advanced Directive information upon a resident's admission, including their right to choose a DPOA and asked them if they wanted to be a Full Code or DNR status on the day of admission when he/she went over their rights. This was part of the resident's admission process and the information was included in the admission paperwork packet residents were given. He/she explained to the newly admitted resident what advanced directives entailed.
-He/she would let the resident know they could change their code status at any time.
-The Social Services Designee (SSD) also periodically went over the code status with the resident once they were admitted to the facility and also answered resident questions related to advanced directives and their code status.
-He/she would let the Director of Nursing (DON) and Assistant Director of Nursing (ADON) B know what code status the resident/resident's representative chose and they entered the information into the resident's electronic record (e-record).
-Nurses took care of obtaining orders for the resident's code status.
-The MDS Coordinator would put the resident's code status on their care plan.
-The admission packet contained the OHDNR sheet and he/she had the resident sign it upon admission if that was their wish. He/She gave the OHDNR sheets to the SSD. He/She thought the signed OHDNR form got faxed to the physician in order to get the DNR order.
-The resident's code status should be the same on the POS and the care plan.
During an interview on [DATE] at 12:32 P.M. Certified Nurse Assistant (CNA) A said:
-If CNA's found a resident unconscious they would get the nurse who could access the resident's code status from their e-record.
-CNA's wouldn't know the residents' code statuses and he/she didn't know if they had access to the information on the e-record.
-If a resident was a Full Code status (CPR was to be performed if the resident was to stop breathing or his/her heart stopped beating) the nurse should do CPR. If the resident's code status was DNR he/she wasn't sure if the nurse would do CPR.
During an interview on [DATE] at 10:37 A.M. Licensed Practical Nurse (LPN) B said:
-The residents were asked upon admission what code status they wanted to be and were asked to sign the OHDNR sheet if that was what they wanted.
-Nurses look at the admission Record sheet to find the resident's code status.
-He/she looked at the resident's e-record and said the resident was a Full Code status.
During an interview on [DATE] at 9:39 A.M. Registered Nurse (RN) A said:
-He/she had most of the residents' code statuses memorized.
-They were on the resident's Medication Administration Records (MAR), POS, admission Record sheet and Code Status Care Plan. All of those sources of information should match. There was no way for all of them not to match.
-He/she could get a report that had everyone's code status as well.
-The resident was a Full Code status.
During an interview on [DATE] at 10:13 A.M. ADON A said:
-The ADON's put the resident's code status on their orders.
-If the resident had requested a DNR status, the POS should not show Full Code.
During an interview on [DATE] at 12:00 P.M. the DON said:
-The BOM or ADON B verified the resident's code status wishes upon admission. The code status should be put on the POS and the physician notified.
-The SSD obtained and maintained the residents' Advanced Directives and code statuses and these were reviewed at the residents' care plan meetings.
-The POS and care plan should match and reflect the resident's code status wishes.
-If the resident signed an OHDNR sheet the POS and care plan should show DNR.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility to failed to notify the resident's physician when there was a missed medicati...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility to failed to notify the resident's physician when there was a missed medication and when blood sugars continued to be elevated for one sampled resident (Resident #3) out of 19 sampled residents. The facility census was 95 residents.
Record review of facility policy titled Change in a Resident's Condition or Status revised February 2021 showed:
-The facility would promptly notify the resident, his/her attending physician, and the resident representative of a change in the resident's medical/mental condition and/or status.
-The nurse would notify the resident's attending physician when that had been:
-A need to alter resident's medical treatment significantly.
-Significant change in the resident's physical condition.
-A significant change of condition is major decline in the resident's status that:
-Would not normally resolve itself without intervention by staff of by implementing standard disease related clinical interventions.
-Impacted more than one area of resident's health status.
-Required interdisciplinary review and/or revision to the care plan.
1a. Record review of Resident #3's admission record showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-Cellulitis (an infection of deep skin tissue), unspecified.
-Type 1 Diabetes Mellitus (the pancreas doesn't make insulin or makes very little insulin. Insulin helps blood sugar enter the cells in the body for use as energy. Without insulin, blood sugar can't get into cells and builds up in the bloodstream) without complications.
Record review of the resident's Order Summary Report dated September 2022 showed an order for Vancomycin Solution Reconstituted 750 milligram (mg) Use 750 mg intravenously every 24 hours for Cellulitis in both legs for 14 Days started 8/31/22.
Record review of the resident's September 2022 Treatment Administration Record (TAR) showed he/she had two missed doses of Vancomycin (a bacterial antibiotic used against resistant strains of streptococcus and staphylococcus) on 9/5/22 and 9/8/22.
Record review of the resident's Progress Notes dated 9/5/22 showed no notes as to why the medication was missed, and no notification to the doctor of the missed medication.
Record review of the resident's Progress Notes dated 9/8/22 showed no notes as to why the medication was missed, and no notification to the doctor of the missed medication.
1b. Record review of the resident's blood sugars dated 9/1/22 to 9/13/22 showed:
-The normal range for blood sugars was 60 milligram (mg)/deciliter (dL) to 100 mg/dL.
-On 9/1/22 at 8:39 A.M. his/her blood sugar was 260.0 mg/dL.
-On 9/1/22 at 1:32 P.M. his/her blood sugar was 260.0 mg/dL.
-On 9/1/22 at 5:54 P.M. his/her blood sugar was 364.0 mg/dL.
-On 9/2/22 at 8:07 A.M. his/her blood sugar was 248.0 mg/dL.
-On 9/2/22 at 11:40 A.M. his/her blood sugar was 234.0 mg/dL.
-On 9/2/22 at 4:52 P.M. his/her blood sugar was 266.0 mg/dL.
-On 9/3/22 at 4:49 P.M. his/her blood sugar was 132.0 mg/dL.
-On 9/4/22 at 7:31 A.M. his/her blood sugar was 311.0 mg/dL.
-On 9/4/22 at 12:34 P.M. his/her blood sugar was 378.0 mg/dL.
-On 9/4/22 at 5:24 P.M. his/her blood sugar was 339.0 mg/dL.
-On 9/5/22 at 8:25 A.M. his/her blood sugar was 291.0 mg/dL.
-On 9/5/22 at 12:22 P.M. his/her blood sugar was 197.0 mg/dL.
-On 9/5/22 at 6:01 P.M. his/her blood sugar was 178.0 mg/dL.
-On 9/6/22 at 7:40 A.M. his/her blood sugar was 154.0 mg/dL.
-On 9/6/22 at 12:22 P.M. his/her blood sugar was 178.0 mg/dL.
-On 9/6/22 at 4:54 P.M. his/her blood sugar was 219.0 mg/dL.
-On 9/7/22 at 8:10 A.M. his/her blood sugar was 180.0 mg/dL.
-On 9/7/22 at 12:30 P.M. his/her blood sugar was 129.0 mg/dL.
-On 9/7/22 at 4:48 P.M. his/her blood sugar was 235.0 mg/dL.
-On 9/8/22 at 8:21 A.M. his/her blood sugar was 212.0 mg/dL.
-On 9/8/22 at 12:33 P.M. his/her blood sugar was 202.0 mg/dL.
-On 9/8/22 at 5:06 P.M. his/her blood sugar was 202.0 mg/dL.
-On 9/9/22 at 7:25 A.M. his/her blood sugar was 177.0 mg/dL.
-On 9/9/22 at 12:17 P.M. his/her blood sugar was 187.0 mg/dL.
-On 9/9/22 at 6:08 P.M. his/her blood sugar was 243.0 mg/dL.
-On 9/10/22 at 8:45 A.M. his/her blood sugar was 385.0 mg/dL.
-On 9/10/22 at 8:46 A.M. his/her blood sugar was 385.0 mg/dL.
-On 9/10/22 at 12:36 P.M. his/her blood sugar was 307.0 mg/dL.
-On 9/11/22 at 6:29 P.M. his/her blood sugar was 195.0 mg/dL.
-On 9/12/22 at 8:04 A.M. his/her blood sugar was 194.0 mg/dL.
-On 9/12/22 at 1:20 P.M. his/her blood sugar was 255.0 mg/dL.
-On 9/12/22 at 4:50 P.M. his/her blood sugar was 252.0 mg/dL.
-On 9/13/22 at 8:35 A.M. his/her blood sugar was 283.0 mg/dL.
-On 9/13/22 at 11:57 A.M. his/her blood sugar was 223.0 mg/dL.
-There were no physician order for parameters to monitor the resident's blood sugar and when to notify the doctor of an elevated blood sugar.
2. During an interview on 9/16/22 9:40 A.M., Licensed Practical Nurse (LPN) C said:
-When a resident's blood sugars run routinely in 200 and 300 you would notify the resident's physician, the nurse on the next shift, Director of Nursing (DON), and the Assistant Director of Nursing (ADON).
-When a medication was missed the nurse would call pharmacy, notify the DON, the resident's physician and inform them there was a missed medication.
-He/she would then document a missed dose in the progress notes and a note about any new orders received.
-The nurse would then notify the responsible party.
-If a medication was given there would a checkmark or some notion in the TAR, and the space would not be blank.
-If a space was blank it meant the medication was not given.
During an interview on 9/15/22 at 1:00 P.M., Registered Nurse (RN) A said:
-The doctor would have been notified if an intravenous medication like Vancomycin was missed, and that would be significant.
-When a medication was missed the nurse would notify the doctor, and then a note would be made in the resident's progress notes to record what the doctor was informed and if the doctor gave any new orders.
-When a resident's blood sugar was over 150 for three consecutive readings the doctor would be informed.
-Blood sugar control was very important with a resident with an infection.
During an interview on 9/20/22 at 12:04 P.M., the DON said:
-When the TAR was blank it was assumed the medication was not given.
-It was his/her expectation that the doctor would be notified of missed medications.
-It was his/her expectation that a progress note would also be documented about the missed medication to include any new orders given.
- It was his/her expectation that when a resident's blood sugars were elevated and stayed elevated that the doctor would have been notified of the elevated blood sugars and this would be charted in the progress notes.
MO00207430
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all alleged violations of resident abuse were reported to th...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all alleged violations of resident abuse were reported to the State immediately or no later than two hours after the allegation was made for an incident of abuse involving two out of 25 sampled residents. Resident #25 was witnessed punching Resident #81, resulting in a bloody nose requiring an emergency room (ER) visit. The facility census was 99 residents.
Record review of the facility's Abuse Investigation and Reporting policy, revised 7/2017, showed staff are required to immediately report any incident, allegation, or suspicion of potential abuse, neglect, exploitation, and misappropriation of resident property, mistreatment or a crime against a resident.
1. Record review of Resident #81's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning), date 8/22/22, showed the resident:
- admitted to the facility on [DATE];
-diagnoses including Dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), Anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), Depression (a constant feeling of sadness and loss of interest), and Schizophrenia (a chronic, severe mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality);
-Had no behaviors;
-Required extensive to total assistance with all cares; and
-Had severe cognitive impairment.
2. Record review of Resident #25's admission Record showed he/she was admitted to the facility on [DATE] and had the following diagnoses:
-Traumatic brain injury (TBI - damage to the brain resulting from external mechanical force, such as rapid acceleration or deceleration, impact, blast waves, or penetration by a projectile);
-SynGap 1 related intellectual disability (a neurological disorder characterized by moderate to severe intellectual disability evident in early childhood with features of delayed speech development and motor skills and often seizures, hyperactivity and sensory processing problems).
-Schizoaffective disorder, depressive type (a mental condition that causes loss of contact with reality and mood problems);
-Restlessness and agitation;
-Psychosis (a mental state involving loss of contact with reality and causing deterioration of normal social functioning);
-Antisocial personality disorder (condition characterized by repetitive behavioral patterns that are contrary to usual moral and ethical standards and cause a person to experience continuous conflict with society); and
-Intermittent Explosive Disorder (a chronic disorder involving repeated, sudden episodes of impulsive, aggressive, violent behavior and/or angry verbal outbursts in which reactions are grossly out of proportion to the situation).
Record review of the resident's Potential for Physical Aggression Care Plan, initiated 4/12/22, showed the resident had potential to be physically aggressive related to Intermittent Explosive Disorder. The resident would hit staff, himself/herself, and other residents. He/She would throw objects, slide out of his/her wheelchair, and hit walls, doors and windows when upset.
Record review of the resident's quarterly MDS, dated [DATE], showed the resident:
-Was severely cognitively impaired.
-Had fluctuating inattention and fluctuating disorganized thinking.
-The resident's mood assessment showed he/she was short-tempered and/or easily annoyed 12 to 14 days out of the past 14 days.
-Had physical behaviors directed towards others four to six days out of the past seven days.
-Had verbal behaviors directed towards others one to three days out of the past seven days.
-Had behaviors not directed towards others one to three days out of the past seven days.
3. Record review of the facility's internal abuse investigation, dated 10/25/22 showed:
-Record review of the 10/25/22 abuse investigation nurses' note for Resident #81, dated 10/25/22 at 3:44 P.M. showed:
-Resident #81 was punched in the face by another resident. The right nostril on Resident #81 was bleeding. Resident #81's nose was cleaned up.
-Resident #81 was encouraged to stay away from the other resident who hit him/her.
-Resident #81 stated he/she was assaulted.
Record review of a nurses' note for Resident #25, dated 10/25/22 at 4:01 P.M., showed:
-Resident #25 punched another resident in the face (Resident #81), causing the other resident's right nostril to bleed.
-Resident #25 was taken to the therapy room with the restorative aide and later to his/her room with the door open.
Record review of the resident to resident internal investigation Incident Report, dated 10/25/22 showed:
-Resident #81 was in his/her wheelchair facing the 100 hall when Resident #25 moved his/her wheelchair up to Resident #81 and punched Resident #81 in the nose with a closed fist.
-Resident #81 said This resident assaulted me.
-Resident #81's nose was cleaned up.
-Resident #81 was oriented to person.
-Staff separated the two residents.
-Resident #25 was asked to stay away from the other resident.
-Resident #25 was taken to the therapy room and sat with the Restorative Aide.
-Resident #25 was oriented to person, place and situation.
-There were no predisposing factors related to the incident.
-The physician, Assistant Director of Nursing (ADON) B, Director of Nursing (DON) and Resident #25's responsible party were notified.
-Certified Nurses Aide (CNA) D's statement, undated, showed:
--He/she was at the nurses' station on 10/25/22 and observed Resident #81 sitting in front of the nursing station when Resident #25 punched Resident #81 in the nose.
-A statement was obtained from Corporate Nurse A, dated 10/25/22 and 10/26/22 showing:
--On 10/25/22 Resident #81 was assessed for injuries. A small amount of blood was noted on the resident's nose and fourth finger of his/her left hand which was cleaned up.
--Resident #25 was also assessed on 10/25/22 and denied hitting anyone.
--On 10/26/22 Resident #81 reported neck pain and held his/her head slanted to the left. Orders were obtained to send the resident to the hospital. When asked why he/she thought his/her neck hurt Resident #81 responded I don't know; it just hurts, damn it.
-Review of the facility's Incident Summary, dated 10/25/22, completed by the Administrator and Corporate Nurse B, showed:
--On 10/25/22 at approximately 4:00 P.M. Resident #81 yelled he/she hit me. Resident #25 denied hitting Resident #81. Resident #81 had a little blood from his/her nose area that was dried and a little blood on his/her finger.
--Resident #81 was sent out to evaluate the nose bleed and no acute abnormalities were found.
--There was no redness or injury noted or actual witnesses.
--Both residents have short memories and have behaviors.
--The Interdisciplinary Team (IDT) determined there was no evidence anyone hit anyone and it was most likely the two were mouthing each other.
-There was no documentation the incident was reported to the State Agency (SA).
(Note: This IDT's determination conclusion is in direct conflict with witness statements).
During an interview on 11/17/22 at 8:15 A.M. Licensed Practical Nurse (LPN) F said:
-He/she reported the following information to ADON B who said he/she would let the DON and Administrator know:
--On 10/25/22 Resident #81 was in his/her Broda chair (tilt-in-space positioning chair) at the end of the 200 hall near the main hall and nurses' station. Resident #25 was beside Resident #81's Broda chair.
--A CNA told him/her Resident #25 punched Resident #81 in the nose.
--They separated Resident's #25 and #81 and he/she took Resident #25 into the therapy room.
--He/She assessed Resident #81 for injuries. Resident #81 had blood and redness on the right side of his/her nose.
During an interview on 11/17/22 at 10:30 A.M., CNA D said:
-He/she reported immediately to the charge nurse the following information:
--On 10/25/22 he/she was sitting at the nurses' station charting. He/She was talking with Resident #81at the nurses' station about cars.
--Resident #25 came around the nurses' station. He/She thought Resident #25 was just going to wheel himself/herself right on by, but instead Resident #25 just punched resident #81 on the side of his/her nose as he/she was rolling by. Resident #81 didn't do a thing to Resident #25. There was no warning whatsoever.
--During staff training staff were told to separate Resident #25 from others when he/she is agitated. The facility didn't tell staff what they were to do to prevent abuse.
--Staff were told to report abuse to the charge nurse who reported to the DON who reported to the Administrator. The Administrator reported to the SA.
During an interview on 2:12 P.M., CNA A said:
-He/she was working on 10/25/22.
-He/she saw Resident #81 bleeding from the nose around 10:30 A.M. or 11:00 A.M.
-He/she didn't report it to the charge nurse because he/she already knew and was with Resident #81.
-A staff person was saying he/she saw Resident #25 hit Resident #81.
-Resident #81 was saying He/She hit me in my nose. I'm bleeding so the incident had just happened.
During an interview on 11/17/22 at 2:35 P.M., LPN A said:
-He/she had actually seen the incident on 10/25/22 because he/she was at the nurses' station squatting down to get his/her things before going home for the day. The incident happened around 3:00 P.M.
-He/she was working as a Certified Medication Technician (CMT) that day and LPN B was aware and on the unit at the time.
-He/she heard staff say something. Maybe they yelled Resident #25's name or said Hey, hey, hey. They said something like that.
-Resident #81 said about Resident #25 he/she hit me or he/she punched me in the nose or something to that effect.
-Blood was dripping down Resident #25's mustache and he/she grabbed a rag.
-They grabbed Resident #81 away from Resident #25 and put Resident #25 somewhere.
-The facility told staff they were to immediately report suspicion of abuse up the chain of command and the Administrator contacted the SA if he/she thought there might be abuse.
During an interview on 11/17/22 at 3:45 P.M., CNA F said:
-On 10/25/22 he/she was coming from the dining room and when he/he came around the nurses' station he/she saw Resident #81 with a bloody nose.
-The residents were separated after the incident happened.
-He/she didn't report the incident to the charge nurse, because the nurse was assessing Resident #81 while staff took Resident #25 somewhere, maybe to his/her room.
-The facility did an in-service about resident to resident behaviors and abuse a few weeks back.
-They didn't take their masks off during the in-service so he/she didn't know what they said.
-They provided written literature that showed they should separate residents if there was an altercation.
-There was nothing in the in-service about reporting abuse allegations.
During an interview on 11/17/22 at 4:15 P.M., CNA E said:
-He/she had seen Resident #25 hit another resident before, but had not seen the incident on 10/25/22.
-Staff have had no training on what to do to prevent Resident #25 from hurting anyone. They mainly talked about what to do once an incident happened.
-CNAs were supposed to report suspicion of abuse to the charge nurse.
During an interview on 11/18/22 at 10:00 A.M., LPN B said:
-On 10/25/22 he/she was at the nurses' station charting. Resident #81 was sitting in his/her Broda chair in front of the therapy room and Resident #25 was coming from the 300 hall in his/her wheelchair heading towards the dining room.
-The next thing he/she knew CNA D was standing in front of the nursing desk saying Resident #25 Resident just punched Resident #81.
-Resident #25 was taken to the therapy room and Resident #81 was moved to the memory care unit that day or within a day or two.
-Staff cleaned Resident #81's bloody nose. The blood came down to his/her lip. Resident #81 said I was assaulted.
-Resident #81 was a little red on the left side of his/her nose.
-Staff are supposed to keep Resident #25 and #81 apart from each other when Resident #25 is upset.
-Staff had received education a couple of weeks ago about resident to resident abuse. They were mainly told to keep residents apart from each other. Charge nurses were to immediately notify the DON, Administrator, physician, and involved resident's family or responsible party.
During an interview on 11/18/22 at 10:46 A.M., the ADON B said:
-The Administrator is responsible for reporting suspicions of abuse to the State.
During an interview on 11/18/22 at 11:12 A.M., ADON A said:
-When possible abuse happens the charge nurse should notify the DON immediately who notifies the Administrator immediately.
-The Administrator must report possible abuse to the State.
During an interview on 1/18/22 at 11:33 A.M., the DON said:
-Staff should report possible abuse to the charge nurse immediately who immediately reports to him/her as the DON. He/She reported to the Administrator immediately.
-The Administrator was responsible for reporting possible abuse to the State.
-The incident on 10/25/22 should have been reported to the State because Resident #25 hit Resident #81.
During an interview on 11/18/22 at 2:50 P.M., the Administrator said:
-The charge nurse reports incidents to the DON who reports to the Administrator.
-The IDT concluded both residents had behaviors and they did not think there was sufficient evidence for abuse. They were responsible for coming up with appropriate interventions related to their conclusions.
-He/she was responsible for either reporting abuse to the State or delegating someone to do so. The former DON had been completing the abuse investigations and reporting to the State and he/she was new to doing it.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to thoroughly investigate allegations of resident abuse ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to thoroughly investigate allegations of resident abuse by not conducting interviews and/or obtaining statements from all witnesses and by not reviewing pertinent information from nursing notes and incident reports and using the information to determine if abuse occurred. This deficient practice affected two residents (Resident #81 and #11) out of 25 sampled residents. The facility census was 99 residents.
Record review of the facility's Abuse Investigation and Reporting policy, revised 7/2017, showed:
-The Administrator will ensure any further potential abuse is prevented.
-The individual conducting the investigation will, at minimum:
--Review completed documentation.
--Review the resident's medical record to determine events leading to incidents.
--Interview persons reporting the incident, any witnesses, the residents and their roommates as appropriate, alleged perpetrator, attending physician to determine the resident's cognitive function and medical condition, staff members on all shifts who have had contact with the resident during the incident, and other residents who might have been targeted/affected.
--Review all events leading up to the incident.
-The administration will protect residents from abuse by anyone, including but not limited to, other residents.
-The facility must establish means in which behaviors indicative of abuse may be identified and further investigated.
1. Record review of Resident #81's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning), dated 8/22/22, showed the resident:
-Was admitted to the facility on [DATE] with the following diagnoses:
--Dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning).
--Anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome).
--Depression (a constant feeling of sadness and loss of interest), and Schizophrenia (a chronic, severe mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality).
-Had no behaviors.
-Was severely cognitively impaired.
2. Record review of Resident #11's quarterly MDS, dated [DATE], showed the resident:
-Was readmitted to the facility on [DATE] with the following diagnoses:
--Dementia.
--Depression.
--Schizophrenia (a long-term mental disorder of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation).
-Had no behaviors.
-Was severely cognitively impaired.
3. Record review of Resident #25's admission Record showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-Traumatic brain injury (TBI - damage to the brain resulting from external mechanical force, such as rapid acceleration or deceleration, impact, blast waves, or penetration by a projectile).
-SynGap 1 related intellectual disability (a neurological disorder characterized by moderate to severe intellectual disability evident in early childhood with features of delayed speech development and motor skills and often seizures, hyperactivity and sensory processing problems).
-Schizoaffective disorder, depressive type (a mental condition that causes loss of contact with reality and mood problems).
-Restlessness and agitation.
-Psychosis (a mental state involving loss of contact with reality and causing deterioration of normal social functioning).
-Antisocial personality disorder (condition characterized by repetitive behavioral patterns that are contrary to usual moral and ethical standards and cause a person to experience continuous conflict with society).
-Intermittent Explosive Disorder (a chronic disorder involving repeated, sudden episodes of impulsive, aggressive, violent behavior and/or angry verbal outbursts in which reactions are grossly out of proportion to the situation).
Record review of the resident's Potential for Physical Aggression Care Plan, initiated 4/12/22 showed:
-The resident had potential to be physically aggressive related to Intermittent Explosive Disorder.
-The resident would hit staff, himself/herself, and other residents.
-He/She would throw objects, slide out of his/her wheelchair, and hit walls, doors and windows when upset.
-Triggers for physical aggression were paranoia that others were talking about him/her.
-Staff would remove those the resident feels are talking about him/her out of view by closing doors or putting up a shield so the resident can't see them.
Record review of the resident's quarterly MDS, dated [DATE] showed the resident:
-Was severely cognitively impaired.
-Had fluctuating inattention and fluctuating disorganized thinking.
-The resident's mood assessment showed he/she was short-tempered and/or easily annoyed 12 to 14 days out of the past 14 days.
-Had physical behaviors directed towards others four to six days out of the past seven days.
-Had verbal behaviors directed towards others one to three days out of the past seven days.
-Had behaviors not directed towards others one to three days out of the past seven days.
4. Record review of Resident #81's nurse's note, dated 10/25/22 at 3:44 P.M., showed:
-On 10/25/22 Resident #81 was punched in the face by another resident (Resident #25). Resident #81's right nostril was bleeding. The resident's nose was cleaned up.
-Resident #81 was encouraged to stay away from the other resident who hit him/her.
-Resident #81 stated He assaulted me.
Note: This note was struck out with a side note showing Incomplete documentation.
Record review of Resident #25's nurse's note, dated 10/25/22 at 4:01 P.M., showed:
-Resident #25 punched another resident in the face (Resident #81), causing the other resident's right nostril to bleed.
-Resident #25 was taken to the therapy room and later to his/her room with the door open.
Note: This note was struck out on 10/27/22 with a side note showing Incomplete documentation.
Record review of Resident #25's nurse's note, dated 10/25/22 at 4:09 P.M., written by Corporate Nurse B showed:
-There were no witnesses identified seeing any hitting.
-Resident #25 denied hitting the other resident. The other resident states he/she was struck.
-Unable to determine who did what at this time.
-Resident #25 was separated from the situation. The other resident was placed on another unit. It was found the other resident cannot be kept in a unit near a resident with a history of aggression.
-Unable to determine who was the aggressor, if either.
Record review of the facility's internal investigation, dated 10/25/22 showed:
-An Incident Report, dated 10/25/22 at 3:48 P.M., showed:
--Resident #25 was in his/her wheelchair and propelled himself/herself up to Resident #81, who was also sitting in a wheelchair, and hit Resident #81 with a closed fist on his/her nose. Resident #81's right nostril was bleeding.
--Resident #81 said This resident assaulted me.
--Resident #25 was oriented to self, place and situation. Resident #25 was oriented to self.
--There were no predisposing situational factors.
--The physician, Assistant Director of Nursing (ADON) B, Director of Nursing (DON), and Resident #25's responsible party were notified.
-Certified Nursing Assistant (CNA) D's statement, undated, showed he/she was at the nurse's station on 10/25/22 and observed Resident #81 sitting in front of the nursing station when Resident #25 punched Resident #81 in the nose.
-Corporate Nurse A's statement, dated 10/25/22 and 10/26/22, showed:
--On 10/25/22 Resident #81 was assessed for injuries. A small amount of blood was noted on the resident's nose and fourth finger of his/her left hand which was cleaned up.
--On 10/26/22 Resident #81 reported neck pain and held his/her head slanted to the left. Orders were obtained to send the resident to the hospital. When asked why he/she thought his/her neck hurt Resident #81 responded I don't know; it just hurts, damn it.
--There were no other witnesses interviewed and no other witnesses giving statement of knowledge of the incident.
-The Investigation summary, dated 10/25/22, with the Administrator's and Corporate Nurse B's name at the bottom showed:
--At approximately 4:00 P.M. Resident #81 yelled He hit me! Resident #25 said he/she didn't hit Resident #81.
--Resident #81 appeared to have a little blood in his/her nose area that was dried and a little on his/her finger which looked like he/she picked his/her nose until he/she drew blood.
--Resident #81 was sent out to evaluate that the nose bleed was not something more serious. Resident #81 returned with no acute abnormalities. No redness or injury noted.
--No actual witnesses.
--Resident #81 was a bipolar schizophrenic while Resident #25 has a TBI. Both residents have short memories and behaviors. Both are mouthy to each other.
--Resident #81 was out of the dementia unit due to a previous fall and hip fracture. His/Her fracture is healing and Resident #81 is walking again. Resident #81 was returned to his/her previous unit to be able to wander freely and also to add separation from Resident #25.
--The Interdisciplinary Team (IDT) determined there was no evidence anyone hit anyone and it was most likely the two were mouthing each other.
Note:
-All staff working on the unit at the time had not given a statement or been interviewed related to the incident.
-The conclusion there was no evidence Resident #81 was hit by Resident #25 contradicted with the witness statements the facility had and the original nurse's notes for Residents #25 and #81.
-There was no documentation of assessment of Resident #25's supervision needs or appropriate interventions to prevent Resident #25 from harming other residents.
Record review of Resident #81's nurse's note, dated 10/26/22 at 1:33 P.M., showed:
-Order to send Resident #81 to the emergency room (ER).
-Resident #81 had been complaining of a severe headache due to being hit in the nose the previous night.
-Wanted Resident #81 evaluated and treated.
Record review of Resident #81's hospital ER record, dated 10/26/22, showed:
-Orders for CT (computed tomography - several rotating X-ray images) scan of the head and facial bones.
-Reason for exam was the patient (Resident #81) was punched on 10/25/22 in the nose and/or mouth and has a right-sided headache.
-Findings of CT scans showed no acute abnormalities by radiologist readings.
-Diagnosis of contusion (bruising) of face.
During an interview on 11/17/22 at 9:03 A.M., Licensed Practical Nurse (LPN) F said:
-There had been an altercation in the afternoon between Resident #25 and Resident #81 about two to four weeks ago.
-LPN F was on the 100 hall and heard yelling. He/She couldn't tell who yelled or what was being said.
-Resident #81 was in his/her Broda chair (tilt-in-space positioning chair) at the end of the 200 hall near the main hall and nurses' station. Resident #25 was beside Resident #81's Broda chair.
-A CNA told him/her Resident #25 punched Resident #81 in the nose.
-They separated Resident's #25 and #81 and he/she took Resident #25 into the therapy room.
-He/She assessed Resident #81 for injuries. Resident #81 had redness on the right side of his/her nose.
During an interview on 11/17/22 at 10:30 A.M., CNA D said:
-On 10/25/22 he/she was sitting at the nurses' station charting. Resident #81 was sitting in front of the nurses' station and he/she was talking with Resident #81 about cars.
-Resident #25 came around the nurses' station. He/She thought Resident #25 was just going to wheel himself/herself right on by, but instead Resident #25 just punched Resident #81 on the side of his/her nose as he/she was rolling by. Resident #81 didn't do a thing to Resident #25. There was no warning whatsoever.
-He/She and LPN B separated the residents.
-Resident #25 was taken to the therapy room.
-Resident #81 was sent out the next day or two to the hospital because Resident #81 complained of a headache.
During an interview on 2:12 P.M., CNA A said:
-He/She was working on 10/25/22.
-He/She saw Resident #81 bleeding from the nose around 10:30 A.M. or 11:00 A.M.
-A staff person was saying he/she saw Resident #25 hit Resident #81.
-Resident #81 was saying He/She hit me in my nose. I'm bleeding, so the incident had just happened.
-Staff moved Resident #25 somewhere away from Resident #81.
During an interview on 11/17/22 at 2:35 P.M., LPN A said:
-On 10/25/22 he/she was at the nurses' station squatting down to get his/her things before going home for the day at around 3:00 P.M.
-He/She heard staff say something. Maybe they yelled Resident #25's name or said Hey, hey, hey. They said something like that.
-Resident #81 said about Resident #25 he/she hit me or he/she punched me in the nose or something similar.
-Blood was dripping down Resident #81's face and he/she (LPN A) grabbed a rag.
-They grabbed Resident #81 away from Resident #25 and put Resident #25 somewhere.
During an interview on 11/17/22 at 3:45 P.M., CNA F said on 10/25/22 he/she was coming from the dining room and when he/he came around the nurses' station he/she saw Resident #81 with a bloody nose.
During an interview on 11/18/22 at 10:00 A.M., LPN B said:
-On 10/25/22 he/she was at the nurses' station charting. Resident #81 was sitting in his/her Broda chair in front of the therapy room and Resident #25 was coming from the 300 hall in his/her wheelchair heading towards the dining room.
-The next thing he/she knew, CNA D was standing in front of the nursing desk saying Resident #25 Resident just punched Resident #81.
-Resident #25 was taken to the therapy room and Resident #81 was moved.
-Staff cleaned Resident #81's bloody nose. The blood came down to his/her lip. Resident #81 said I was assaulted.
-Resident #81 was a little red on the left side of his/her nose. Resident #81 was moved to the memory care unit at the time or a day or two later.
-He/She had no idea why his/her nurse's notes for Residents #25 and #81, written on 10/25/22, would have been struck out. He/She had been accurate in his/her description of what happened related to the resident to resident incident between Resident #25 and #81 on 10/25/22.
During an interview on 11/18/22 at 10:46 A.M., ADON B said:
-He/She realized two or three days after 10/25/22 that the nurse's notes written for Residents #25 and #81 had been struck out. LPN B had asked him/her why the notes had been struck out and said the notes did not contain incorrect information.
-He/She was unaware that a second note had been added to Residents #25 and #81's charts after the original notes had been written.
During an interview on 11/18/22 at 11:58 A.M., Corporate Nurse A said he/she struck out one of the notes written on 10/25/22 based on what he/she had been told by the Administrator about the incident.
During an interview on 1/18/22 at 11:33 A.M., the DON said he/she didn't know why the 10/25/22 notes had been struck out for Residents #25 and #81 or who would have struck them out.
5. Record review of Resident #25's nursing note, dated 11/16/22 showed:
-Staff member overheard commotion in hallway.
-Resident #25 pushed himself/herself back in his/her wheelchair and bumped his/her wheelchair into another resident's wheelchair.
-Staff member was able to redirect Resident #25.
Record review of the facility's internal investigation, dated 11/16/22 and completed by the Administrator showed:
-LPN F's written statement, dated 11/16/22 showed:
--At approximately 10:00 A.M. on 11/16/22 he/she was in the doorway of a resident's room and heard yelling.
--He/She observed Resident #25 swing his/her right arm and fist towards Resident #11.
--The podiatrist was trying to get a hold of Resident #25's arm.
--He/She took Resident #11 down the hall to assess him/her.
--The podiatrist told him/her that he/she saw Resident #25 punch Resident #11 in the right cheek after Resident #25 backed his/her wheelchair into Resident #11's wheelchair.
--A red area was noted on Resident #11's right cheek. Resident #11 denied pain. There was no swelling to the area.
-No other written witness statements were provided.
-The Administrator's report showed:
--At approximately 10:45 A.M. he/she was notified Resident #25 was upset by Resident #11 bumping into him/her. Resident #25 was cussing at Resident #11 for hitting his/her wheelchair. Resident #25 denied hitting Resident #11.
--There were no witnesses to that.
--Staff separated the resident's.
--A self-report was submitted to the State.
--The following witnesses were interviewed on 11/16/22 and all denied witnessing the incident: CNA D, CNA E, Corporate Nurse A, Social Services Designee, LPN F.
--The podiatrist had left the building and a witness statement was not obtained.
--Later in the day on 11/16/22 LPN F's written statement showed LPN F saw Resident #25 swing his/her right arm and fist toward Resident #11 and his/her statement contained hearsay, assuming what the podiatrist saw.
--As of 11/17/22 the Administrator found no evidence of abuse or neglect.
Record review of the Final Report, dated 11/21/22 for the 11/16/22 incident showed:
-On 11/21/22 at 10:15 A.M. the podiatrist was contacted who was the witness to the incident. The podiatrist's statement showed:
--He/She was treating Residents #25 and #11. He/She offered to back Resident #25 up, but Resident #25 would not wait for his/her help and bumped into Resident #11's wheelchair.
--Resident #25 started swinging his/her arm around and contacted resident #11's right side of face one time. Resident #25 continued swinging a couple more times without success of contacting Resident #11 again.
--He/She grabbed resident #25's wheelchair and pulled him/her away to create distance from Resident #11.
--A staff member took Resident #11 to his/her room and another took Resident #25 down the hall.
-The investigation Final Report showed actions taken were Resident #25 was placed on 1:1 observation over the weekend with no further incidents between Residents #25 and #11. Medications were reviewed. Follow up calls were made to other facilities for placement in a more appropriate facility for behaviors. Appointment was made for in-person counseling services.
Note:
-There was no final determination on 11/21/22 whether or not resident to resident abuse had taken place.
-The information provided by the podiatrist and LPN F and evidence of Resident #11's red cheek were not used in a final determination.
-There was no documentation of assessment for on-going increased supervision needs or other measures to prevent Resident #25 from harming other residents.
During an interview on 11/17/22 at 8:15 A.M. LPN F said:
-He/She was the nurse working on 11/16/22.
-He/She was in the doorway of the room catty corner across from the salon where the podiatrist was treating residents.
-Residents #25 and #11 were the only two residents in the hallway.
-He/She heard yelling, but couldn't make out what was said. He/She could hear both Resident #25's and the podiatrist's voice which sounded excited.
-The podiatrist had just finished with Resident #25 and came into the hallway.
-He/She saw Resident #25 punch out towards Resident #11's right cheek, but couldn't tell if Resident #25's fist made contact with Resident #11.
-The side of Resident #11's wheelchair was touching the back of Resident #25's wheelchair because Resident #25 had backed up, hitting Resident #11's wheelchair.
-When the wheelchairs touched, Resident #25 immediately punched out towards Resident #11 with Resident #25's right hand.
-When he/she examined Resident #11's right cheek, he/she saw a red mark. Resident #11 said Resident #25 hit him/her pretty hard and Resident #11 then placed his/her hand on his/her right cheek. It was immediately red.
-The podiatrist told him/her he/she asked Resident #25 to hold on and not back up, but to let the podiatrist help back up Resident #25's wheelchair, but Resident #25 was determined to back his/her wheelchair up anyway. The podiatrist said he/she saw Resident #25's arm go out in a punch and saw it hit Resident #11 in the right cheek.
-He/she got in between the two residents.
-He/She didn't interview any of the CNAs because none were in the hallway until after the incident happened.
-He/She filled out a written statement. It included what the podiatrist said he/she observed.
-He/She interviewed Resident #25 about 10 or 15 minutes after the incident when he/she was calm. Resident #25 said Resident #11 ran into him/her and grabbed his/her wheelchair so he/she hit Resident #11, but he/she (LPN F) saw that Resident #11 did not hit or grab Resident #25's wheelchair.
-The incident happened around 10:00 A.M. The redness of Resident #11's face was gone by around noon. Resident #11 never said how it made him/her feel or if he/she was afraid of Resident #25.
Observation on 11/17/22 at 9:56 A.M., showed Resident #11 had very slight bruising to the right cheek and on the outside of his/her right eye, somewhat grayish in color with possible slight swelling.
During an interview on 11/17/22 at 9:57 A.M., Resident #11 said he/she didn't remember being hit the previous day or at any other times.
During an interview on 11/18/22 at 9:40 A.M., the contracted podiatrist said:
-He/She was at the facility on 11/16/22. There were no staff supervising Residents #25 and #11.
-While he/she was treating Resident #25, the resident was telling him/her that he/she (Resident #25) brutalized his/her family member for sleeping with his/her spouse.
-When the treatment was ended, he/she told Resident #25 to wait for him/her to help Resident #25 back up, but Resident #25 refused to wait and bumped into Resident #11.
-There had been plenty of space for Resident #25 to move away and not be too close to Resident #11.
-After Resident #25 hit Resident #11, Resident #25 said his/her family member was having sexual relations with his/her spouse and he/she wasn't going to let anyone else do that.
-Resident #25 swung his/her right arm multiple times attempting to hit Resident #11. Resident #25 made contact with Resident #11 two or maybe three times on the right side of Resident #11's face. (Note: The facility's Final Investigation Report, dated 11/21/21 for the 11/16/22 incident showed the podiatrist said Resident #25 made contact with Resident #11's face once.)
-Resident #11 had redness on his/her right cheek and outside of his/her right eye. He/She was very red. Resident #11's right eye was tearing. After being hit, Resident #11 covered his/her right eye.
-He/She pulled Resident #25's wheelchair towards himself/herself so Resident #25 wouldn't be so close to Resident #11 and told Resident #25 he/she needed to keep his/her hands to himself/herself.
-Resident #25 cursed and muttered Keep your hands to yourself.
-He/She hadn't noticed any staff around and yelled out Hey, you guys! Hey!
-LPN F showed up and said he/she had seen Resident #25 hit Resident #11, but was unable to immediately intervene because he/she had been with another resident.
During an interview on 11/18/22 at 10:46 A.M. ADON B said:
-LPN F reported to him/her the podiatrist said he/she saw Resident #25 strike Resident #11.
-He/She (ADON B) reported to the Administrator what LPN F said.
6. During an interview on 10/18/22 at 10:46 A.M. ADON B said a thorough investigation included:
-Reporting immediately to the Administrator who is responsible for the investigation.
-Notifying the physician and residents' responsible parties.
-Getting statements and/or interviews from all possible witnesses.
-Assessing residents for injury.
-Investigation information should be thorough. All witness observations, assessments of injury and all other facts should be considered when determining whether or not abuse likely happened.
During an interview on 10/18/22 at 11:12 A.M. ADON A said:
-All allegations or observations of possible abuse must be reported immediately to the Administrator who is responsible for the investigation.
-Thorough investigations should include all possible witness statements, nursing notes, injury documentation, and facts related to events.
-The evidence gathered should be used to determine what happened for determining abuse.
-Interventions should be put in place that effectively prevent further abuse.
During an interview on 1/18/22 at 11:33 A.M. the DON said:
-Investigations should be thorough and include interviews with all staff who worked in the area and on the shift at the time of the incident.
-All possible instances of abuse should be reported to the Administrator who is responsible for completing a thorough investigation.
During an interview on 11/18/22 at 11:58 A.M. Corporate Nurse A said:
-For a thorough investigation the Administrator should use statements from all possible witnesses who might have knowledge of the incident. Information from staff should be accurate and witness statements and facts should be used in determining abuse.
-Reporting of incidents to the Administrator should happen immediately.
During an interview on 11/18/22 at 2:50 P.M., the Administrator said:
-A thorough abuse investigation included reporting to the Administrator through the chain of command all incidents of possible abuse, gathering as many facts as possible, looking at injury documentation, and interviewing all staff who might have knowledge of an incident.
-The IDT was responsible for investigating facts and developing interventions for a resident to resident abuse investigation. The IDT had determined there was no resident to resident abuse on 10/25/22 and 11/16/22.
-He/She was responsible for ensuring information was gathered and doing a final summary of the investigation.
-He/She was new to doing the investigations because the previous DON had been doing them before.
MO00209989
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident and the resident's representative in writing of...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident and the resident's representative in writing of a discharge including the reason for the transfer for one sampled resident (Resident #90) out of three sampled closed records. The facility census was 95 residents.
1. Record review of Resident #90's admission Record showed the resident:
-Was admitted to the facility on [DATE] with a diagnosis of lung cancer.
-Was at the facility for a rehabilitation stay.
Record review of the resident's Discharge Instructions for Care form dated 8/1/22 showed the resident was being discharged to home.
Record review of the resident's Progress Notes on 9/19/22 showed no information regarding a discharge transfer notice being given to the resident.
During an interview on 9/20/22 at 9:24 A.M. Registered Nurse (RN) B said:
-He/she completed the nursing part of the discharge including discharge medications.
-He/she was not aware of a transfer/discharge letter that needed to be given to the resident upon discharge.
During an interview on 9/20/22 at 9:30 A.M. Assistant Director of Nursing (ADON) A said the nurses were responsible for providing the transfer/discharge letter to the resident at the time of discharge.
During an interview on 9/20/22 at 9:34 A.M. the Social Service Designee (SSD) said the nurses were responsible for providing the transfer/discharge letter to the resident at the time of discharge.
During an interview on 9/20/22 at 11:59 A.M. the Director of Nursing (DON) said:
-The SSD was responsible for notifying the charge nurse when a resident discharged .
-The nurses were responsible for providing the transfer/discharge letter to the resident at the time of discharge.
-There was a standard letter that was in the residents' electronic medical record.
A policy was requested but no policy was received regarding transfer/discharge notices.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, the facility failed to ensure the follow through of the Pre-admission Screening and Resident ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, the facility failed to ensure the follow through of the Pre-admission Screening and Resident Review (PASARR) recommendations and integrate the recommendations into the care plan for one sampled resident (Resident #90) out of 19 sampled residents. The facility census was 95 residents.
Record review of the facility's Behavioral Assessment, Intervention and Monitoring policy revised 2019 showed the Level II PASARR report would be used when conducting the resident assessment and developing the care plan.
1. Record review of Resident #90's admission Record showed he/she was admitted to the facility on [DATE] and had the following diagnoses:
-Anxiety Disorder (a psychiatric disorder causing feelings of persistent anxiety).
-Major depressive disorder (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living).
-Bipolar disorder (a mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks).
Record review of the resident's Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) dated 5/29/22 showed the resident:
-Was moderately cognitively impaired.
-Was independent with transfers and used a wheelchair for mobility.
-Did not have any behaviors.
Record review of the resident's Level 2 PASARR dated 7/3/22 showed:
-The resident had the following diagnoses:
--Anxiety disorder.
--Major depressive disorder.
--Bipolar disorder.
--Obsessive Compulsive Disorder (OCD-a personality disorder characterized by excessive orderliness, perfectionism, attention to details, and a need for control in relating to others).
--Panic Disorder: (characterized by a sudden wave of fear or discomfort or a sense of losing control even when there is no clear danger or trigger).
--Mild Intellectual disability (ID-is characterized by below-average intelligence or mental ability and a lack of skills necessary for day-to-day living).
-The resident did not have a history of aggressive behaviors or suicidal thoughts.
-The resident could follow simple directions and express his/her needs and wants.
-The resident could not follow complex directions, stay on task, or complete assigned tasks.
-The resident enjoyed daily activities of watching television, music and group activities.
-The resident was physically dependent on staff for to administer medications and could not self-administer medications.
-Was appropriate for long-term care placement.
-Required the facility to provide:
--Medication therapy and monitoring: psychiatric care and medication management, medication management, monitoring for adverse side effects of medications, monitoring of therapeutic effect in managing mental health including laboratory services, address refusal and implement plan to manage resident refusals of medications, provide education/training in drug therapy management.
--Structured environment: provide personal space, provide for sensory supports, maintain environment with low stimulation, with a minimum of visual/auditory distractions, provided consistent routines with daily activities, assess and plan for the level of supervision required to prevent harm to self or others, provide instructions on resident's level of understanding.
--Activities of Daily Living (ADL's-activities related to personal care) program: develop a program for grooming, dressing, personal hygiene, toileting, nutrition needs. Money management, bathing, and maintenance of own living environment.
--The resident initially received rehabilitation therapy and the staff needed to implement an ADL program to increase independence.
Record review of the resident's care plan on 9/14/22 showed:
-The care plan was completed 2/18/22 with no further updated dates.
-There was no documentation of the PASARR care plan with all information contained in the resident's Level II PASARR.
During an interview on 9/20/22 at 8:18 A.M. the Business Office Manager (BOM) said:
-He/she would help track PASARR's and get them signed by the physician.
-He/she would track the residents' PASARR's then give them to the MDS Coordinator for the nursing side and care planning.
-The MDS Coordinator was responsible for care planning and implementing the PASARR.
During an interview on 9/20/22 at 9:19 A.M. the MDS Coordinator said:
-He/she did get electronic mail with the completed Level II PASARR's when done.
-He/she did not add the information to the resident's care plan or implement the PASARR information.
-He/she did not know the process for adding to the care plan or implementing the Level II PASARR information.
During an interview on 9/20/22 at 11:59 A.M. the Director of Nursing (DON) said:
-The PASARR was to be integrated into a personalized care plan related to the resident's needs.
-The MDS Coordinator was responsible for integrating the information from the Level II PASARR into the care plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the resident and/or his/her representative with a copy of t...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the resident and/or his/her representative with a copy of the baseline care plan for one sampled resident (Resident #341) out of 19 sampled residents. The facility census was 95 residents.
Record review of the facility policy Care Plans-Baseline revised December 2016 showed:
-A baseline care plan to meet the resident's immediate needs would be developed for each resident within 48 hours of admission.
-The interdisciplinary team would review the health practitioner's orders and implement a base line care plan that met the resident's immediate care needs.
-The baseline care plan would be used until staff conducted the comprehensive assessment and developed an interdisciplinary person-centered care plan.
-The resident and his/her representative would be provided a summary of the baseline care plan.
1. Record review of Residents #341's admission record showed he/she was admitted to the facility on [DATE].
Record review of the resident's medical record showed no documentation of a signed baseline care plan.
Record review of resident's admission Progress Notes dated 9/1/22 at 7:00 P.M. showed:
-He/she was assessed with no significant finding.
-He/she had no complaints and denied pain.
-The baseline care plan was not mentioned.
-No documentation that baseline care plan was given to the resident.
Record review of Progress Notes dated 9/2/22 to 9/13/22 showed no documentation a baseline care plan was developed or given to the resident and/or the resident's representative.
During an interview on 9/12/22 at 10:57 A.M., the resident said
-No staff had given him/her a copy of the baseline care plan.
-No staff had given a copy of the baseline care plan to his/her family.
During an interview on 9/15/22 at 1:15 P.M., Licensed Practical Nurse (LPN) B said the baseline care plan was to be given to the resident or his/her representative upon admission and it was to be documented in the progress notes.
During an interview on 9/15/22 at 1:29 P.M., LPN C said the baseline care plan was to be given to the resident or responsible party and charted in the nurse's notes that it was given.
During an interview on 9/20/22 at 12:04 P.M., the Director of Nursing (DON) said:
-The baseline care plans would be done between 24-48 hours.
-It would be given to the resident or resident representatives.
-It would be documented in the computer charting system.
-The nurse would give the resident or resident's representative a copy and have the original signed.
-The signed baseline care plan would be scanned into the computer charting system.
-Medical records was responsible for scanning the document into the computer charting system.
-Once scanned it would be found in the document section of the computer charting system.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0661
(Tag F0661)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a recapitulation of stay was completed; to have a clear disc...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a recapitulation of stay was completed; to have a clear discharge plan after a rehabilitations stay, and to document the disposition of belongings upon discharge for one sampled resident (Resident #90) out of three sampled closed records. The facility census was 95 residents.
Record review of the facility's policy Discharge Summary and Plan revised 12/2016 showed:
-When the facility anticipated a resident discharge to a private residence, a discharge summary and post-discharge plan would be developed.
-The discharge summary would include a recapitulation of the resident's stay at the facility and a final summary of the resident's status upon discharge.
1. Record review of Resident #90's admission Record showed the resident:
-Was admitted to the facility on [DATE] with a diagnosis of lung cancer.
-Was at the facility for a rehabilitation stay.
Record review of the resident's Discharge Instructions for Care form dated 8/1/22 showed:
-The resident was being discharged to home.
-Under medications showed see list.
-The resident was independent with Activities of Daily Living (ADL's-walking, bathing, dressing).
-No diet orders and home health orders were documented on the form.
-No documentation regarding disposition of belongings.
Record review of the resident's Transfer/Discharge Report dated 8/1/22 showed:
-The resident's admission Record sheet with diagnoses, allergies, admission date, insurance information, primary contact information, and allergies.
-This was signed by the resident.
Record review of the resident's electronic medical record on 9/19/22 showed no information regarding the resident's discharge, a recapitulation of the resident's stay, and the disposition of the resident's belongings.
During an interview on 9/20/22 at 9:24 A.M. Registered Nurse (RN) B said:
-He/she completed the nursing part of the discharge including discharge medications.
-The nurses were responsible for completing a summary note in progress notes upon discharge including disposition of belongings.
-He/she was not sure who completed the recapitulation of the resident's stay.
During an interview on 9/20/22 at 9:30 A.M. Assistant Director of Nursing (ADON) A said:
-He/she was not aware of a recapitulation of stay or who was responsible for completing this upon discharge.
-The Social Services Designee (SSD) was responsible for discharge planning.
During an interview on 9/20/22 at 9:34 A.M. the SSD said:
-He/she was not sure what a recapitulation of stay was or who was responsible for completing this.
-He/she had set up home health for the resident upon discharge but he/she did not document anything related to the resident's discharge plan.
-He/she should have documented the details of the resident's discharge.
During an interview on 9/20/22 at 11:59 A.M. the Director of Nursing (DON) said:
-Nurses were responsible for writing discharge notes upon the resident's discharge which should include the disposition of belongings.
-The nurses were responsible for completing a recapitulation of the resident's stay.
-The SSD was responsible for completing the discharge planning including home health and documenting this in the resident's progress notes.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide an ongoing resident-centered activities progra...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide an ongoing resident-centered activities program that provided daily meaningful involvement in activities of choice and included opportunities for individual expression, creativity, enjoyment, success and a sense of belonging and enhanced the physical, cognitive, and emotional well-being for two sampled residents (Residents #81 and #25) who could benefit from daily 1:1 and/or small group activities out of 19 sampled residents. The facility census was 95 residents.
Record review of the facility's Activity Evaluation policy, revised June, 2018 showed:
-An activity evaluation is conducted as part of the resident's comprehensive assessment that reflects the choices and interests of the resident and is used to develop an individual activities care plan. The resident's lifelong interests, spirituality, life roles, goals, strength, needs and activity pursuit patterns and preferences are included in the evaluation.
-The activities director is responsible for completing and/or delegating the completion of the activities component of the comprehensive assessment.
-The activity evaluation and activities care plan identify if the resident is capable of pursuing activities independently or if supervision and assistance is needed.
Record review of the facility's Activity Programs policy, revised June, 2018 showed:
-Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident.
-The activities program is ongoing and includes facility-organized group activities and independent and assisted individual activities that promote:
--Self-esteem.
--Comfort.
--Pleasure.
--Education.
--Creativity.
--Success.
--Independence.
-Activities are not necessarily limited to the formal activities being provided only by activities staff.
-All activities are documented in the resident's medical record.
1. Record review of Resident #81's Administration Record showed he/she was initially admitted to the facility on [DATE] and had diagnoses that included:
-Intertrochanteric fracture of right femur (fracture at the top portion of the thigh bone), diagnosed 6/27/22.
-Anxiety Disorder (a psychiatric disorder causing feelings of persistent anxiety).
-Schizoaffective Disorder, Bipolar Type (a mental condition that causes loss of contact with reality and mood problems).
Record review of the resident's Significant Change Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 7/7/22 showed:
-The resident's hearing was adequate without hearing aids and his/her vision was adequate without corrective lenses.
-The resident was severely cognitively impaired and had fluctuating inattention and fluctuating disorganized thinking.
-The resident required extensive assistance to total dependence from staff for most Activities of Daily Living (ADL - dressing, grooming, bathing, eating, and toileting).
-The resident utilized a wheelchair, was not steady during transfers, and had a lower extremity impairment on one side.
-The resident was diagnosed with dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses).
Record review of the resident's Preferences for Customary Routine and Activities assessment, dated 7/7/22 showed it was somewhat to very important that the resident:
-Be able to use the phone in private.
-Listen to music.
-Keep up with the news.
-Go outside for fresh air, weather permitting.
-Have snacks between meals.
Record review of the resident's Activities Participation Notes dated 7/7/22 to 8/9/22 showed the resident did not have documentation of participating in activities on the following dates:
-7/7/22 to 7/14/22.
-7/16/22 to 7/31/22.
-8/6/22 to 8/7/22.
-8/9/22.
Record review of the facility activity schedule dated September, 2022 showed:
-There were two activities scheduled Monday through Friday in the mornings and two scheduled for the afternoons which were appropriate for residents with moderately good attention span (such as Bingo, table games, arts/crafts, and group exercises).
-Saturday activities were table games and activity packs and a 2:00 P.M. movie.
-On the Memory Care unit there were two activities scheduled in the morning and two in the afternoon of a simpler nature (e.g. music, sensory activities, toss games and reminiscing).
Observations on the Long Term Care (LTC) unit on 9/13/22 between 9:30 A.M. and 11:50 A.M. and from 1:30 P.M. to 2:20 P.M. showed:
-The resident's Geri-chair (a reclining chair used for positioning and comfort or to prevent a resident from rising) was located at the end of the 200 hall facing the nurses' station in the reclined position.
-At no time was the resident engaged in any activities or conversation.
Observation on 9/14/22 at 9:05 A.M. showed:
-The resident was placed at the end of the 200 hall in a reclined position after finishing breakfast in the dining room.
-The staff member walked away after placing the resident's Geri-chair at the end of the hall.
During an interview on 9/14/22 at 9:13 A.M. the resident was alert and responsive when spoken to and maintained good eye contact and said he/she liked to eat, fish, and paint.
Observations on 9/14/22 between 9:13 A.M. and 11:30 A.M. showed:
-The resident remained at the end of the 200 hall with the Geri-chair in the reclined position facing the nurses' station.
-Had no activity or social involvement.
-Multiple staff frequently walked past the resident and did not interact with him/her or engage the resident in any activity.
Observation on 9/15/22 between 9:09 A.M. and 10:00 A.M. showed:
-The resident was sitting reclined in his/her Geri-chair at the end of the 200 hall across from the nursing desk following breakfast.
-He/she was not engaged in any activity or conversation during this time.
During an interview on 9/15/22 at 10:05 A.M. the Restorative Aide (RA) said:
-He/she wasn't sure what the activities department did besides Bingo which was led by either activities staff or residents.
-He/she couldn't say he/she had ever seen the activities department doing anything with the resident since he/she had been on the LTC unit following his/her hip fracture a couple of months or so back.
-He/she hadn't seen the resident engaged in any 1:1 or group activities.
Observation on 9/16/22 at 12:11 P.M. showed:
-The resident in the hallway near the nursing desk, slumped down in his/her Geri-chair with the chair reclined.
-Staff passed by frequently, but did not chat with the resident or engage him/her in any activity.
Observation on 9/16/22 at 1:29 P.M. showed:
-Staff wheeled the resident back at the end of 200 hall after finishing his/her lunch and left him/her in the reclined position.
-The resident had no visual, auditory or other stimulation.
During an interview on 9/16/22 at 1:44 P.M. the resident said he/she liked:
-Classic rock and would like to hear it more.
-Social activities when food was offered.
-Pitching horseshoes.
-NOTE: During the interview the resident was focused, alert and smiled.
During an interview on 9/16/22 at 2:08 P.M. Certified Nurse Assistant (CNA) E said:
-Before the resident was hospitalized for a fractured hip a few months ago he/she resided on the Memory Care unit. When he/she was readmitted following hip surgery the resident was placed on the LTC unit.
-While on the Memory Care unit the resident liked to fix stuff. For example, there was a wobbly table and the resident folded a piece of paper to stabilize the table so it wouldn't wobble.
-The resident would talk with staff for hours all day long about whatever came to his/her mind.
-He/She liked to talk about the navy, animals, and being outside.
-If the weather was nice he/she would go outside.
-He/she liked to eat snacks and eat when activities staff brought popcorn to the unit.
During an interview on 9/19/22 at 8:20 A.M. the Activities Director said:
-The resident liked country music. He/she could tell that by the way the resident's face lit up when he/she played it using his/her (the Activities Director's) cell phone. If the resident can't hear it he/she used Blue Tooth so the music was clearer and the volume could be controlled better.
-The resident liked to talk about his/her job. It sounded like he/she was in construction type work and that he/she drove a truck and was some sort of a boss.
-The resident loved to visit and would always talk. That seemed like his/her favorite thing.
-He/she sometimes gave the resident a manicure while they visited.
-He/she didn't know how often the resident got outside and he/she had never taken the resident out.
During an interview on 9/19/22 at 10:10 A.M. Registered Nurse (RN) A said:
-He/she had not seen the resident involved in activities since he/she had been on the LTC unit, except once when the RA gathered supplies for baskets to hand out to residents. He/She had seen the resident assist the RA in making baskets for the other residents. Each basket contained hand sanitizer, tooth paste, a tooth brush, word searches, water, and a bag of cookies. He/She noticed the resident was entertained and engaged when doing the 1:1 activity with the RA.
-The resident can articulate and was social upon approach.
-The resident most definitely would enjoy going outside and would probably like an activity like hitting at a ball.
2. Record review of Resident #25's admission Record sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-Intellectual disability (below average intelligence and life skills functioning).
-Schizoaffective disorder, depressive type (a mental condition that causes loss of contact with reality and mood problems).
-Restlessness and agitation.
-Contracture (an abnormal, usually permanent, condition of a joint, characterized by flexion and fixation), left wrist.
-Psychosis (a mental state involving loss of contact with reality and causing deterioration of normal social functioning).
-Intermittent explosive disorder (repeated, sudden episodes of impulsive aggressive behavior or verbal outburst grossly out of proportion to the situation).
-Foot drop (weakness or paralysis of muscles involved in lifting the front part of the foot).
-Cognitive communication deficit (impairment in thought organization, problem solving and safety awareness).
Record review of the resident's Preferences for Customary Routine and Activities assessment, dated 4/8/22 showed it was somewhat to very important for the resident to:
-Be able to use the phone in private.
-Listen to music.
-Keep up with the news.
-Go outside for fresh air, weather permitting.
-Have snacks between meals.
-Have books, newspapers and magazines to read.
-Do things with groups of people.
-Engage in favorite activities.
-Participate in religious services.
Record review of the resident's quarterly MDS, dated [DATE] showed:
-The resident's hearing was adequate without hearing aids and his/her vision was adequate with corrective lenses.
-The resident was severely cognitively impaired and had fluctuating inattention.
-The resident required limited assistance from staff for most ADL's.
-The resident utilized a wheelchair, was not steady during transfers, and had an upper and lower extremity impairments on one side.
Record review of the resident's Activities Participation Notes dated 7/1/22 to 9/12/22 showed the resident did not have documentation of participating in activities on the following dates:
-7/1/22 to 7/9/22.
-7/11/22 to 7/14/22.
-7/16/22.
-7/18/22 to 7/19/22.
-7/21/22 to 8/1/22.
-8/6/22 to 8/7/22.
-8/9/22 to 8/18/22.
-8/20/22 to 8/24/22.
-8/26/22 to 8/28/22.
-8/30/22 to 9/1/22.
-9/3/22 to 9/7/22.
-9/10/22 to 9/12/22.
Observation throughout the day on 9/12/22 to 9/15/22, 9/19/22 and 9/22/22 in the morning and afternoon showed:
-The resident almost continuously was seeking out 1:1 staff attention from the RA, Assistant Director of Nursing (ADON) A, Therapy staff, and the Social Services Designee (SSD).
-During non-meal times (9:00 A.M. to 12:00 P.M. and 1:15 P.M. to 2:30 P.M.) the resident was not actively engaged in activities.
During an interview on 9/15/22 at 9:39 A.M. the RA said:
-He/she sometimes took the resident outside when he/she took other residents out to smoke.
--Other staff tell the resident he/she can't go out when residents are taken outside to smoke because the resident's guardian does not want him/her to smoke.
-He/she had never seen any 1:1 activities with the resident.
-The resident liked Bingo, but didn't like morning exercises.
-He/she got the resident a ninja punching bag and set him/her up with a puzzle.
-The resident did well with individual activities.
During an interview on 9/15/22 at 1:48 P.M. the resident said:
-Activities didn't leave him/her things to do.
-It made him/her feel unhappy when he/she didn't have something to do.
-He/she hadn't been to social activities for a long time except for Bingo, but would like to be involved.
-He/she liked throwing games and would like throwing a NERF football or kicking a ball outside.
-He/she wanted to go outside as often as the residents who smoke.
During an interview on 9/19/22 at 8:36 A.M. the Activity Director said:
-The resident loved to play Bingo and Farkle and would participate in Sittercise once in a while.
-He/she would laugh and joke around while playing Farkle.
-He/she had conversations with the resident but was not good about documenting them.
-The resident told him/her he/she liked heavy metal music. He/she had never presented that to the resident.
-The resident was better in a group setting because he/she got side-tracked easily when engaged in 1:1 activities. He/She would observe his/her environment rather than focus on a conversation. In groups the resident was focused on activities.
-Every once in a while he/she would have to ask the resident to calm down during activities and then he/she was fine.
--The resident might be in middle of a game and say Shit, shit, shit and become agitated.
-He/she had never taken the resident outside.
-He/she had been at the facility for six months and did activity assessments quarterly and annually.
-He/she documented resident participation in activities participation notes on a daily basis.
-Most vulnerable residents or those with physical and cognitive limitations responded to music. He/she also brought them activities packets consisting of word searches, Sudoku, crosswords, and mazes and he/she visited with the residents when he/she delivered the puzzle packets.
-Currently there was only one Activity Aide who worked with him/her on Mondays and Tuesdays.
During an interview on 9/19/22 at 9:12 A.M. Licensed Practical Nurse (LPN) B said:
-The resident can't go out and smoke per his/her guardian's request.
-Sometimes the RA would take the resident outside, but not very often.
-There was not a group of residents going outside on a daily basis that doesn't smoke.
During an interview on 9/20/22 at 12:00 P.M. the Director of Nursing (DON) said:
-The Activities Department was responsible for ensuring activities of interest were offered daily to each resident.
-For residents who had difficulty participating in most group activities, the Activities department should provide 1:1 or small group activities that better meet their individual needs.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure physician orders were followed for pressure-red...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure physician orders were followed for pressure-reducing boots for one sampled resident (Resident #81) who had a Pressure Injury (PI - localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) out of 19 sampled residents. The facility census was 95 residents.
Record review of the National Pressure Injury Advisory Panel (NPIAP) definition of a Deep Tissue Injury showed:
-A Deep Tissue Injury (DTI) was defined as intact or non-intact skin with localized area of persistent non-blanchable (skin that does not turn white when pressed) deep red, maroon, or purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin coloration changes. This injury results from intense and/or prolonged pressure and shear forces (resistance, such as gravity, between the patient and a surface like a bed or chair) at the bone-muscle interface.
-The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss.
-If the necrotic tissue, subcutaneous tissue (layer closest to the muscle), granulation tissue (tissue that fills in when a wound is healing), fascia (a thin layer of tissue surrounding and holding organs, blood vessels, nerve fibers, bone and muscles in place), muscle, or other underlying structures are visible, this indicates a full thickness pressure injury.
Record review of the facility's Pressure Ulcers (Injury)/Skin Breakdown - Clinical Protocol, revised April, 2018, showed:
-The physician will help identify medical interventions related to wound management.
-The physician will order pertinent wound treatments, including pressure-reduction surfaces.
1. Record review of Resident #81's admission Record sheet showed he/she was originally admitted to the facility on [DATE] with the following diagnoses:
-Severe protein calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function).
-Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses).
Record review of the resident's Physician Order Sheet (POS) dated July 2022 showed an order for a Pressure Relief Ankle Foot Orthosis (PRAFO - a device that is worn on the calf and foot similar to a boot and is often used for patients that spend the majority of their time in bed to prevent pressure injuries from developing on the back of the heel or for patients who are ambulatory) to both feet, every shift for pressure prevention starting 7/12/22.
Record review of the resident's Significant Change Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff for care planning) dated 7/7/22 showed the resident:
-Was severely cognitively impaired.
-Required extensive to total assistance from one to two staff with Activities of Daily Living (ADL - dressing, grooming, bathing, eating, and toileting), including needing extensive assistance of one staff with dressing.
-Had no pressure injuries.
-Was at risk for pressure injuries.
-Had no skin issues marked.
-Had a pressure reducing wheelchair and bed.
Record review of the resident's Deep Tissue Injury Care Plan, dated 7/12/22 showed:
-The resident was to wear PRAFO boots as directed.
-Receive treatments as ordered.
-Identify causative factors and eliminate where possible.
Record review of the resident's Weekly Wound Assessment, dated 7/14/22 showed:
-The resident had a right medial heel partial thickness blister with no drainage with an onset date of 7/12/22 measuring 4.0 centimeters (cm) long, 5.3 cm wide and 0 cm deep.
-The periwound (skin surrounding a wound) texture, moisture, color and temperature were within normal limits and did not exhibit signs or symptoms of infection.
-Treatment was skin prep and PRAFO boot daily.
Record review of the resident's outside wound care company's physician assessment and progress notes, dated 7/14/22 showed:
-Wound #1 was a right medial heel partial thickness new blister measuring 4.0 cm x 5.3 cm with no measurable depth with an area of 21.2 square (sq) cm. No drainage noted. Periwound skin texture, color, moisture and temperature were normal and did not exhibit signs of infection.
-Recommendations to start skin prep daily and leave open to air (OTA). Ensure edges surrounding skin were painted as well.
-Recommend PRAFO boot to right lower extremity.
-Discussed with facility staff the importance of off-loading, pressure relief and PRAFO boot to right lower extremity. Plan of care discussed with the resident.
Record review of the resident's electronic medical record showed there were no other outside wound care company assessments or progress notes after 8/1/22.
Record review of the resident's POS dated September 2022 showed PRAFO boots to both of his/her feet every shift for pressure prevention, starting 7/12/22.
Record review of the resident's Treatment Administration Record (TAR), dated September, 2022 showed:
-PRAFO boots to both his/her feet every shift for pressure prevention starting 7/12/22.
-From 9/1/22 through 9/19/22 staff documented the resident wore PRAFO boots on the day and night shifts.
Observations on 9/13/22 intermittently between 9:30 A.M. and 11:50 A.M. showed:
-The resident sitting in his/her Geri chair (a reclining chair used for positioning and comfort or to prevent a resident from rising) facing the nurses' station at the end of the 200 hall.
-He/she was not wearing a PRAFO boot or any other type of pressure-relieving boots, on either foot.
-Several nursing employees walked past the resident and were at the nurses' station and none of them put pressure-relieving boots on the resident.
Observations on 9/13/22 from 1:30 P.M. to 2:30 P.M. showed:
-The resident sitting in his/her Geri chair facing the nurses' station at the end of the 200 hall.
-He/she was not wearing a PRAFO boot or any other type of pressure-relieving boots, on either foot.
-Several nursing employees walked past the resident and were at the nurses' station and none of them put pressure-relieving boots on the resident.
Observation on 9/14/22 intermittently between 9:05 A.M. and 12:10 P.M. showed:
-Between 9:05 A.M. and 11:30 A.M. the resident was sitting in his/her Geri-chair at the end of the 200 hall facing the nurses' station and was not wearing a PRAFO or other pressure-relieving boots.
--Several staff members walked past the resident and were at the nurses' station and none put pressure-relieving boots on the resident.
-At 12:07 P.M. the resident was at the dining room table with both feet on the floor wearing non-skid socks.
--He/she was not wearing pressure-relieving boots.
-At 12:09 P.M. two padded heel protection boots were observed on the floor against the wall near the foot of the resident's bed.
--There were no PRAFO or other heel protection boots visible in the room.
Observations on 9/15/22 intermittently between 9:00 A.M. and 10:00 A.M. showed:
-The resident was in his/her Geri-chair at the end of the 200 hall and was not wearing a PRAFO or other pressure relieving boots.
-Multiple staff passed by him/her and were at the nursing station and did not put on his/her boots.
Observations on 9/16/22 intermittently between 9:45 A.M. and 12:11 P.M. showed:
-The resident sitting in his/her Geri-chair at the end of the 200 hall with no PRAFO or other pressure-relieving boots.
-Staff passing by the resident did not assist the resident in putting on his/her boots.
-At 11:04 A.M. padded heel protection boots were observed on the floor in the resident's room against the wall near the foot of the resident's bed.
During an interview on 9/16/22 at 9:51 A.M. Registered Nurse (RN) A said:
-An aide noticed the resident's PI while getting him/her dressed and told him/her about it.
-He/she did a skin assessment and identified the new area as a suspected DTI.
-The resident should be wearing the soft-sided boots at all times for pressure relief, but he/she ends up eventually kicking them off.
-He/she tried to make sure they were on at least the right heel since the resident won't off-load with a pillow.
During an interview on 9/16/22 at 11:22 A.M. Certified Nurse Assistant (CNA) C said:
-The resident always complains about his/her right heel.
-He/she will tell staff to be careful with his/her right foot when staff provided his/her cares.
-The resident wore soft, padded boots on both feet when he/she was in bed.
-He/she didn't know if the resident was supposed to wear pressure relieving boots during the day.
-The resident moved his/her feet a lot during the day and he/she wasn't sure the boots would work when the resident was out of bed.
Observation on 9/16/22 at 1:20 P.M. showed:
-Staff wheeling the resident out of the dining room and setting his/her Geri-chair at the end of the 200 hall.
-The resident was not wearing pressure-relieving boots and the employee did not offer to get his/her boots and put them on the resident before walking away.
Observations on 9/19/22 intermittently throughout the morning and early afternoon showed:
-The resident was not wearing PRAFO or other pressure relieving boots.
-No staff offered to help him/her put them on or attempted to encourage him/her to wear them.
During an interview on 9/20/22 at 10:17 A.M. Assistant Director of Nursing (ADON) A said he/she expected staff to put the resident's padded boots on and encourage him/her to wear them.
During an interview on 9/20/22 at 12:00 P.M. the Director of Nursing (DON) said:
-If a nursing staff member noticed a wound they should let the nurse know about it.
-CNA's report skin issues on bath sheets and the charge nurse did weekly skin assessments to document skin changes and to identify any new issues.
-The wound nurse did the wound assessment and determined the type of wound and communicated with the outside wound care physician.
-CNA's were educated by the charge nurse about the use of PRAFO and other pressure-relieving boots.
-If a resident had orders for PRAFO boots all nursing staff should encourage the resident to wear them.
-Staff should put the pressure-relieving boots on when residents were dependent upon staff to wear them.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who required dialysis (process of c...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who required dialysis (process of cleansing the blood by passing it through a special machine - necessary when the kidneys were not able to filter the blood) receives ongoing assessments of the dialysis site, accurate description of resident's the dialysis site, and ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for one sampled resident (Resident #341) out of 19 sampled residents. The facility census was 95 residents.
Record review of facility policy Hemodialysis (process of cleansing the blood by passing it through a special machine - necessary when the kidneys are not able to filter the blood) Access Care policy revised September 2010 showed:
-Central dialysis catheters (type of access used for Hemodialysis. Catheters are placed under the skin and into a large central vein, preferably the internal jugular veins. Catheters are meant to be used for a short period of time until a more permanent type of dialysis access has been established) for Hemodialysis are generally inserted in the neck, chest or groin area.
-Central dialysis catheters are to catheters that exited from an insertion site.
-The catheters are short and made from heavy thick rubber.
-There was clamps on the catheters.
-The following would be documented:
-Location of the dialysis catheter.
-Condition of the dressing.
-Any reports from the dialysis facility.
1. Record review of Resident #341's admission Record showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-Chronic kidney disease, stage 3 unspecified (kidneys had mild to moderate damage, and they were less able to filter waste and fluid out of the blood. This waste would build up in the body and began to harm other areas, such as high blood pressure, anemia and problems with bones. This buildup of waste was called uremia).
-Dependence on Renal (Kidney) dialysis.
Record review of the resident's Order Summary Report showed:
-Renal diet was ordered for the resident.
-Pre-dialysis assessment was to be completed and taken to the dialysis center every Monday, Wednesday, and Friday.
-Nurse was to provide a copy of the Pre-Dialysis Assessment to the resident to take to the dialysis center every Monday, Wednesday, and Friday.
-Post-dialysis assessment was to be completed every Monday, Wednesday, and Friday.
-Resident was to attend dialysis every Monday, Wednesday, and Friday at the dialysis center chair time was 5:45 A.M.
-No orders for site care and type of access the resident had.
-No orders for the frequency of how often the dialysis site was to be monitored.
Record review of resident's comprehensive care plan dated September 2022 showed:
-The resident would have immediate intervention should any signs or symptoms of complications from dialysis occurred through the review date.
-The nurse would check and change dialysis site dressing daily at access and document this in the computerized medical record.
-Assess the dialysis access site every shift and notified the physician of abnormalities.
-Encourage the resident to go for the scheduled dialysis appointments.
-Resident received dialysis three times weekly.
Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) dated 9/8/22 showed he/she:
-Was cognitively intact.
-Received dialysis while at the facility.
Record review of the resident's Pre-Dialysis assessment dated [DATE] showed:
-The resident had an arteriovenous fistula (AV) (connection that's made between an artery and a vein for dialysis access).
-The AV fistula location had not changed.
-The AV fistula had an audible bruit (turbulent blood flow through the blood vessel) and a palpable thrill (a vibration felt in the blood vessel) present.
-There was no bleeding.
-There were no signs of infection.
Record review of the resident's Post-Dialysis assessment dated [DATE] showed:
-The resident had an AV fistula.
-The AV fistula location had not changed.
-The AV fistula had an audible bruit and a palpable thrill present.
-There was no bleeding.
-There were no signs of infection.
Observation on 9/12/22 at 1:00 P.M. of the resident showed:
-He/she was sitting in a wheelchair after dialysis.
-He/she had a dialysis catheter that exited from the right side of his/her chest with a clean, dry, intact dressing.
-His/Her arms showed no AV fistula.
During an interview on 9/12/22 at 1:00 P.M., the resident said:
-He/she has no dialysis sites in his/her arms.
-He/she only had the dialysis access through the catheter in his/her chest.
-He/she had no AV fistula.
Record review of the resident's Pre-Dialysis assessment dated [DATE] showed:
-The resident had an AV fistula.
-The AV fistula location had not changed.
-The AV fistula had an audible bruit and a palpable thrill present.
-There was no bleeding.
-There were no signs of infection.
Record review of the resident's Post-Dialysis assessment dated [DATE] showed:
-The resident had an AV fistula.
-The AV fistula location had not changed.
-The AV fistula had an audible bruit and a palpable thrill present.
-There was no bleeding.
-There were no signs of infection.
During an interview on 9/14/22 at 9:20 A.M. Licensed Practical Nurse (LPN) B:
-Was asked to find the dialysis communication forms that were completed at the dialysis center and returned to the facility.
-He/she was unable to produce the forms.
-He/she said the Director of Nursing (DON) might be able to find them.
During an interview on 9/14/22 at 9:23 A.M. the DON:
-Was asked to find the dialysis communication forms that were sent with the resident to the dialysis center and returned for the past week
-He/she was unable to produce the forms.
During an interview on 9/15/22 at 1:15 P.M., LPN B said:
-He/she did not know what dialysis access the resident had.
-He/she did not know what documentation should be sent with the resident, and what documentation would be brought back from dialysis.
-He/she did not know where the dialysis communications forms were kept once the resident returned from dialysis.
-He/she did not know what should be assessed for a resident with dialysis access.
-He/she had not been given any special or refresher training for what was expected when caring for a resident with dialysis.
-When he/she filled out the Pre/Post-Dialysis Assessment he/she did not know what the assessment was asking and just copied the previous assessment.
During an interview on 9/15/22 at 1:29 P.M., LPN C said:
-The resident had an AV fistula shunt.
-The AV fistula was on the right upper arm.
-Dialysis access should be assessed every shift and should be charted in the computerized medical record for the resident.
-He/she would expect the resident to have orders for what type of site and what was to be monitored.
-Orders to monitor for the signs and symptoms of infection and bleeding of the dialysis access site.
-The site needed to be monitored for infection because if it was infected it was a medical emergency.
-He/she had assessed the resident's site and it was not infected and it was not bleeding.
-He/she did not know what a thrill and bruit were but marked it since previous post assessment had it charted in the resident's computerized medical record.
-It had been some time since the facility had a dialysis resident and there was no refresher training given.
-He/she did not know where the dialysis communications forms were kept when the resident returned from the dialysis center.
During an interview on 9/16/22 at 9:20 A.M., LPN A said:
-He/she did not know what type of dialysis access the resident had.
-The dialysis the site would be assessed prior to and after dialysis, but the site would be looked at every time staff were in the room.
-The dialysis site would be assessed every day.
-The dialysis site would be assessed for signs of infection and bleeding
-There would be orders for dressing changes, when the site was to be assessed, and when resident went to dialysis.
-The nurse would assess the AV fistula for a thrill and bruit.
-A dialysis catheter did not have a thrill and bruit.
-When a resident went to dialysis staff would send a list of allergies, any new medications orders, admission Record, Physician Order Summary, and medications that were given that morning with the resident.
-When the resident returned from dialysis the nurse would receive any paperwork sent back from the dialysis facility.
-The nurse expected to have a dialysis communication form with weights, amount fluid removed and any new orders, but the dialysis facility was not always sending the form back.
-He/She did not know where the dialysis communications forms were kept that were sent back from the dialysis center.
-The nurse charted on the Pre/Post-Dialysis Assessment what he/she thought the resident had, and he/she did not know what differences were in dialysis access sites.
-The nurse thought that since the site had no issues and was not bleeding it must have had a thrill and bruit.
-He/she had not received any training, from the facility, on the expectations the facility had of care of a resident with dialysis access was expected to receive.
During an interview on 9/20/22 at 12:04 P.M., DON said:
-It was his/her expectation that a nurse would know the type of dialysis access a resident had.
-It was his/her expectation that the nurses would know how to assess the dialysis access.
-It was his/her expectation that if the nurse did not know what type of dialysis access the resident had and how to assess it the nurse would have found another nurse and have it explained to him/her or would have come to him/her.
-A dialysis access site that was in the arm was an AV fistula.
-A dialysis access site that was in the chest was a dialysis catheter.
-A dialysis catheter wound not have a thrill or bruit assessed or charted because a dialysis catheter cannot have a thrill for bruit.
-It was the expectation that staff have training to be able to care for the resident's needs.
-There was no training given on dialysis catheters.
-In the orders there would be an order with what type of dialysis access a resident had and how often the dialysis site would be assessed.
-A dialysis site would be monitored daily for infection, drainage and depending on the access a thrill and bruit, and it would be charted on an assessment in the computerized medical record.
-When a resident went to dialysis the pre-dialysis assessment was sent with the resident along with dialysis communication form and when resident returned the nurse would do the post-dialysis assessment.
-When the dialysis communication form was not returned with the resident the nurse should call the dialysis center and requested it.
-The dialysis assessment should be accurate to what type of dialysis access the resident had.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent (%). Out of 25 observed medication opportunities, two errors occurred during insulin (Insulin is a hormone that lowers the level of glucose (a type of sugar) in the blood) administration resulting in an error rate of 8%. The facility census was 95 residents.
Record review of the facility Insulin Administration policy revised September 2014 showed:
-Onset of action is the characteristic of how quickly a type of insulin reaches the bloodstream and begins to lower blood glucose (sugar).
-Rapid-acting insulin has an onset of 10 to 15 minutes.
Record review of the facility Administering Medications policy revised April 2019 showed:
-Medication administration times are determined by resident need and benefit, not staff convenience.
-Factors that are considered for administration times included enhancing the optimal therapeutic effect of the medication.
-References including manufacturer's instructions or user's manuals are available at the nurse's station or are kept with the devices.
Record review of www.humalog.com ©Lilly USA, LLC 2021 showed:
-Humalog KwikPen is a small, lightweight pen that's prefilled with mealtime insulin.
-Humalog (Insulin Lispro) is a fast-acting insulin-it helps control the blood sugar spikes that happen naturally when you eat.
-Humalog injection starts acting fast, inject Humalog within 15 minutes before or right after you eat a meal.
Record review of https://www.novo-pi.com/novolog.pdf revised 10/2021 showed:
-Novolog starts acting fast.
-You should eat a meal within 5 to 10 minutes after you take your dose of Novolog.
1. Record review of Resident #21's admission Record showed:
-He/she was admitted to the facility on [DATE].
-He/she had a diagnosis of diabetes (a disease in which blood sugar levels are too high).
Record review of the resident's Order Summary Report showed the following physician's order dated 6/27/21:
-Humalog Kwik-Pen Solution Pen-injector 100 unit/milliliter (ml), inject as per (in accordance with) sliding scale (the progressive increase in the pre-meal or nighttime insulin dose, based on pre-defined blood glucose ranges).
-If blood sugar is 150 - 200 give Humalog 2 units.
Observation on 9/14/22 at 7:15 A.M. showed:
-Licensed Practical Nurse (LPN) A completed the resident's blood sugar monitoring; the resident's blood sugar was 160.
-LPN A then administered 2 units of Humalog insulin to the resident.
Observation and interview on 9/14/22 at 8:21 A.M. showed:
-The resident and his/her roommate were in their room and were alert and oriented.
-Both resident's said the resident's breakfast room tray arrived around 8:00 A.M.
--NOTE: the resident's breakfast tray arrived 45 minutes after the resident's insulin was administered.
2. Record review of Resident #35's admission Record showed:
-He/she was admitted to the facility on [DATE].
-He/she had diagnosis of diabetes.
Record review of the resident's Order Summary Report showed the following physician's order dated 6/27/21 Novolog Solution 100 units/ml, inject 30 units before meals and at bedtime.
Observation on 9/14/22 at 7:22 A.M. showed LPN A administered the resident's NovoLog 30 units.
Observation and interview on 9/14/22 at 8:18 A.M. showed:
-The resident was alert and oriented.
-He/she said his/her breakfast arrived in his/her room about 8:00 A.M.
--NOTE: the resident's breakfast tray arrived 38 minutes after the resident's insulin was administered.
3. Observation on 9/14/22 showed room trays left the kitchen at 8:05 A.M., over 40 minutes after the residents' insulin's were administered.
4. During an interview on 9/16/22 at 2:29 P.M., LPN A said he/she administers rapid acting insulin 30 to 45 minutes before a resident's meal.
During an interview on 9/22/22 at 12:00 P.M., the Director of Nursing (DON) said:
-Resident's rapid acting insulin's could be given 30 minutes before a meal.
-He/she had not checked the manufacturer's information for rapid acting insulin recently.
-The facility policy was to give rapid acting insulin's 30 minutes before a meal.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents were free of significant medicat...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents were free of significant medication errors by ensuring Intravenous (IV) medications were administered as ordered for one sampled resident (Resident #3) out of 19 sampled residents. The facility census was 95 resident's
Record review of policy titled Administering Medications revised April 2019 showed:
-The Director of Nursing (DON) supervised and directed all personnel who administered medications and/or related functions.
-Medications were administered in accordance with the prescriber's orders, and included any required time frames.
-Medication errors were documented, reported, and reviewed by the Quality Assurance Performance Improvement (QAPI) team.
Record review of facility policy titled Administered Medications by IV push revised March 2022 showed:
-Reported to physician, supervisor, and on coming shift any results, problems, or complications that occurred during the medication administration.
1. Record review of Resident #3's admission Record showed he/she was admitted to the facility on [DATE] with the following diagnosis:
-Cellulitis (an infection of deep skin tissue), unspecified.
-Type 1 Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin) without complications.
Record review of the resident's Treatment Administration Record (TAR) dated September 2022 showed missed doses of Vancomycin (a bacterial antibiotic used against resistant strains of streptococcus (type of bacteria that can cause strep throat) and staphylococcus (group of bacteria that cause a multitude of diseases) on 9/5/22 and 9/8/22.
During an interview on 9/16/22 9:40 A.M., Licensed Practical Nurse (LPN) C said:
-When a medication was missed the nurse should notify the Director of Nursing (DON) and physician and inform both there was a missed medication.
-He/she should then document a missed dose in the progress notes and a note about any new orders received.
-The nurse should then notify the resident's responsible party.
-On the TAR if a medication was given there would a checkmark or some notion and the space would not be blank.
-If a space was blank it meant the medication was not given with no reason charted.
During an interview on 9/15/22 at 1:00 P.M., Registered Nurse (RN) A said:
-The physician should have been notified if an IV medication like Vancomycin was missed, and that would be significant.
-When a medications was missed the nurse should notify the physician and DON, and then a note should be made in the progress notes to record that the physician was informed and if the physician gave any new orders.
During an interview on 9/20/22 at 12:04 P.M., the DON said:
-When the TAR was blank it was assumed the medication was not given.
-It was his/her expectation that the physician would be notified of missed medications.
-It was his/her expectation that a progress note would also be documented about the missed medication to include any new orders given.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to promote dignity and self-worth for three sampled resid...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to promote dignity and self-worth for three sampled residents (Resident #14, #44 and #81) out of 19 sampled residents. The facility census was 95 residents.
Record review of the facility Resident rights policy revised 12/2016 showed the resident had the right to be treated with kindness, respect, and dignity.
1. Record review of Resident #14's admission Record showed he/she was admitted to the facility on [DATE] and had the following diagnoses:
-Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin).
-Cerebrovascular Accident (CVA, stroke), cerebral artery occlusion with infarct (a blockage in the one or more of the arteries supplying blood to the brain resulting in a stroke).
Record review of the resident's Care Plan dated 5/17/22 showed the resident:
-Was independent with eating.
-Needed limited assistance with dressing.
Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 6/24/22 showed the resident:
-Was cognitively intact.
-Needed extensive assistance with transfers.
-Needed limited assistance of staff with dressing.
-Needed set up assistance with eating.
-Used a wheelchair for mobility.
Observation on 9/12/22 at 10:40 A.M. showed:
The resident was in his/her bed and was wearing a hospital gown.
-The resident had his/her right breast fully exposed and could be seen from the hallway.
-A staff member walked by with a medication cart, stopped at the room, and did not close the door or assist the resident.
Observation on 9/12/22 at 12:46 A.M. showed the resident was in his/her bed and was wearing a hospital gown.
Observation on 9/13/22 at 12:28 P.M. showed he resident was in his/her room in a recliner and was wearing a hospital gown.
During an interview on 9/13/22 at 12:29 P.M. the resident said:
-The staff just leave him/her in the recliner and do not get him/her dressed.
-He/she would like to have clothes on and not a hospital gown.
-He/she did not feel good not being dressed in his/her own clothing.
Observation at 9/13/22 at 12:33 P.M. of the resident having a conversation with a staff member showed:
-A staff member brought the resident's lunch to his/her room.
-The resident said he/she felt horrible and less than equal.
-He/she wanted to be up, dressed, and eat in the dining room.
Observation and interview on 9/14/22 at 8:20 A.M. showed the resident:
-Had a blue shirt on and no pants.
-Said he/she had to sleep in the shirt last night.
-Said the staff never got him/her dressed.
Observation on 9/15/22 at 8:59 A.M. showed the resident was in his/her bed in a hospital gown.
Observation and interview on 9/16/22 at 12:46 P.M. showed:
-The resident was dressed in regular clothing in the dining room eating independently.
-The resident said he/she was happy to be up, dressed and eating a meal in the dining room.
During an interview on 9/16/22 at 12:52 A.M. Certified Nursing Assistant (CNA) B said:
-The resident always wanted to be dressed.
-If you put a hospital gown on the resident, he/she would take it off.
-He/she did not have pajamas for the resident so he/she would use a hospital gown.
-He/she had not tried to obtain pajamas for the resident.
-If the resident was exposed the door needed to be shut.
During an interview on 9/19/22 at 9:06 A.M. CNA A said:
-The resident should not be in a hospital gown.
-The resident had pajamas to wear at night.
-Residents wearing hospital gowns was a dignity issue.
-Having a breast exposed with the door open was a dignity issue.
Observation on 9/19/22 at 9:22 A.M. showed the resident was in his/her room in bed in a hospital gown.
During an interview on 9/19/22 at 9:47 A.M. CNA C said:
-He/she was unaware why the resident was wearing hospital gowns.
-When he/she worked with the resident, he/she would get him/her dressed.
-The staff were probably using hospital gowns due to being lazy.
-The hospital gowns were easier to put on residents.
-The resident should not have been left with his/her breast exposed to the hallway.
-The staff that walked by should have assisted the resident.
During an interview on 9/19/22 at 12:12 P.M. the Social Services Designee (SSD) said:
-All residents should be in their own clothes, and not wearing hospital gowns.
-The resident did not like to wear hospital gowns and always wanted to be dressed in his/her own clothing.
-The resident should not have been left with his/her breast in view of the hallway.
-The staff should have assisted the resident.
-These were dignity issues.
During an interview on 9/19/22 at 12:54 P.M. Licensed Practical Nurse (LPN) D said:
-The CNAs should be dressing the residents in regular clothing and not hospital gowns.
-The resident should not have been left exposed to the hallway with his/her breast visible.
During an interview on 9/20/22 at 11:59 A.M. the Director of Nursing (DON) said if a resident was exposed, the staff should shut the door.
2. Record review of Resident #44's admission Record showed he/she was admitted to the facility on [DATE] and had a diagnosis of Anxiety Disorder (a psychiatric disorder causing feelings of persistent anxiety).
Record review of the resident's care plan dated 1/23/21 showed the resident was independent with eating.
Record review of the resident's quarterly MDS dated [DATE] showed the resident:
-Was cognitively intact.
-Was independent with Activities of Daily Living (ADL's-personal care to take care of oneself).
During an interview on 9/16/22 at 1:37 P.M. the resident said he/she never received his/her lunch and was going to the kitchen to ask for lunch.
During an interview on 9/16/22 1:41 P.M. the resident said:
-He/she went to the kitchen to get lunch and the Dietary Manager (DM) said he/she needed to ask a CNA about his/her lunch.
-The resident said he/she was pissed and just wanted lunch.
-The resident was visibly upset.
-The DM approached the resident by the nurses station.
-The DM came swiftly up to the resident and waived a dietary card at the resident and said you did not order lunch today in an aggressive manner.
-The resident said he/she had ordered lunch for today.
-The DM said the lunch menu portion of the card was marked out and he/she had not ordered lunch for today.
-The DM was aggressive towards to resident and leaning in towards the resident during this conversation.
-The resident requested a double portion of macaroni and cheese and the DM said he/she would get the food for the resident.
Observation and interview on 9/16/22 at 1:48 P.M. the resident said:
-The resident was in his/her room eating macaroni and cheese.
-The DM was very aggressive towards him/her and did not speak to him/her with dignity.
-This was how the DM treated him/her all the time.
-The DM had treated him/her worse in the past.
-He/she had an issue like this in the past and was not given food when requested.
During an interview on 9/19/22 at 12:12 P.M. the Social Services Designee (SSD) said:
-The resident should have received the meal when he/she asked for the meal.
-The resident should not have been questioned about the meal or talked to in an aggressive manner.
During an interview on 9/20/22 at 11:59 A.M. the Director of Nursing (DON) said:
-If a resident did not receive their meal, they should be able to get the meal from dietary staff.
-The resident's meal ticket would show the diet order.
-The dietary staff just should have given the meal to the resident.
-The dietary staff should not have been aggressive or argumentative with the resident.
3. Record review of Resident #81's admission Record sheet showed he/she was originally admitted to the facility on [DATE] with diagnoses that included severe protein calorie malnutrition (inadequate intake of calories from proteins, vitamins, and minerals) and dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses).
Record review of the resident's MDS dated [DATE] showed the resident:
-Was severely cognitively impaired.
-Required extensive to total assistance from one to two staff with ADL's including needing extensive assistance of one staff with dressing.
Record review of the resident's undated care plan showed the resident needed extensive assistance from staff with dressing.
Observation on 9/19/22 at 8:38 A.M. showed:
-The resident was in a broda chair (a specialized wheelchair for positioning).
-The resident was in a hospital gown eating breakfast on a tray table.
-Multiple staff and residents were walking by the resident.
Observation on 9/19/22 at 8:52 A.M. showed:
-The resident was in a broda chair.
-The resident was in a hospital gown eating breakfast on a tray table.
-Multiple staff and residents were walking by the resident.
During an interview on 9/19/22 at 8:57 A.M. CNA C said:
-The resident was already by the nurses station dressed in a hospital gown when he/she came in this morning.
-The resident had clothes in his/her room.
During an interview on 9/20/22 at 10:19 A.M. Assistant Director of Nursing (ADON) A said:
-The staff should have dressed the resident before bringing him/her out of the room.
-The resident should not be dressed in a hospital gown.
During an interview on 9/20/22 at 11:59 A.M. the DON said:
-Hospital gowns should not be used for residents.
-If a resident did not have pajamas, the facility staff could go shopping for the resident or call the family to obtain clothing.
-The staff could go to laundry and use unclaimed clothing items.
-Hospital gowns should not be used for convenience.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents received services in the facilit...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents received services in the facility with reasonable accommodation of residents needs and preferences to create a home-like environment by serving meals on Styrofoam plates or container and serving beverages in Styrofoam cups for six sampled residents (Resident #3, #340, #14, #44, #84 and #72) out of 19 sampled residents. The facility census was 95 residents.
Record review of facility policy entitled Homelike Environment revised February 2021 showed:
-Residents were provided with a safe, clean, comfortable and homelike environment.
-Staff provided person-centered care that emphasized the residents' comfort, independence and personal needs and preferences.
-The facility staff and management maximized, to the extent possible, the characteristics of the facility that reflected a personalized, homelike setting.
-The facility staff and management minimized, to the extent possible, the characteristics of the facility that reflected a depersonalized, institutional setting.
1. Record review of Resident #3 admission Record showed he/she was admitted to the facility on [DATE] with the following diagnosis:
-Cellulitis (an infection of deep skin tissue), unspecified.
-Type 1 Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin) without complications.
-Chronic Kidney disease (also called chronic kidney failure, involves a gradual loss of kidney function. Your kidneys filter wastes and excess fluids from your blood, which are then removed in your urine).
-Muscle weakness (generalized).
-Anemia, unspecified (a decrease in hemoglobin in the blood to levels below the normal range).
-Essentials hypertension (high blood pressure).
Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 9/4/22 showed he/she was cognitively intact.
Observation on 9/12/22 at 12:17 P.M. of the resident showed:
-Lunch was brought in to the resident's room.
-The meal was in a Styrofoam take out container.
-Plastic ware was also brought into the room.
During an interview on 9/12/22 12:17 P.M., the resident said:
-All meals were served in Styrofoam take out containers with plastic utensils, and Styrofoam cups.
-He/she did not get real plates and silverware.
-It was not a home-like feel with meals.
During an interview on 9/12/22 at 12:17 P.M., Certified Nursing Assistant (CNA) E said all meals were served on Styrofoam containers.
2. Record review of Resident #340 admission Record showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-Liver cell , carcinoma (cancer).
-Unspecified Cirrhosis of Liver (a chronic disease of the liver marked by degeneration of cells, inflammation, and fibrous thickening of tissue. It is typically a result of alcoholism or hepatitis).
-Unspecified protein-calorie malnutrition.
-Insomnia (sleep disorder that can make it hard to fall asleep, hard to stay asleep, or cause you to wake up too early and not be able to get back to sleep), unspecified.
-Gastroesophageal reflux disease (back-up of stomach acid/heartburn)without Esophagitis (inflammation of the Esophagus).
Record review of the resident's admission MDS dated [DATE] showed he/she had moderate cognitive impairment.
Observation on 9/14/22 at 8:29 A.M. showed the resident was served breakfast in his/her room in a Styrofoam take out container with a Styrofoam drink cup with a lid on it.
During an interview on 9/16/22 at 9:34 A.M., Licensed Practical Nurse (LPN) A said:
-Meals were served on Styrofoam.
During an interview on 9/16/22 at 9:54 A.M., the resident said:
-The use of Styrofoam for meals makes it not feel like a home.
-He/she felt bad because it was a very bad environmental polluter.
-He/she believed it was not needed.
3. Record review of Resident #14's admission Record showed he/she was admitted to the facility on [DATE] and had the following diagnoses:
-Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin).
-Cerebrovascular Accident (CVA, stroke), cerebral artery occlusion with infarct (a blockage in the one or more of the arteries supplying blood to the brain resulting in a stroke).
Record review of the resident's admission MDS dated [DATE] showed the resident was cognitively intact.
Record review of the resident's Care Plan dated 5/17/22 showed the resident was independent with eating.
Observation and interview on 9/13/22 at 12:33 P.M. showed:
-The resident was served lunch in his/her room.
-The lunch meal was served in a Styrofoam container, the cups were Styrofoam and the utensils were plastic.
-The resident said he/she was never served meals on a regular plate, regular cups, or received silverware at meals. He/she felt horrible and less than an equal.
4. Record review of Resident #44's admission Record showed he/she was admitted to the facility on [DATE] and had a diagnosis of Anxiety Disorder (a psychiatric disorder causing feelings of persistent anxiety).
Record review of the resident's care plan dated 1/23/21 showed the resident was independent with eating.
Record review of the resident's quarterly MDS dated [DATE] showed the resident:
-Was cognitively intact.
-Was independent with Activities of Daily Living (ADL's-personal care to take care of oneself).
Observation on 9/12/22 at 12:13 P.M. showed:
-The resident was in his/her room.
-Was served his/her lunch meal in a Styrofoam container, the cups were Styrofoam and the utensils were plastic.
During an interview on 9/15/22 at 9:12 A.M. the resident said:
-He/she always received all meals on Styrofoam.
-He/she bet the staff did not eat on Styrofoam at home.
-The staff did not care anything about him/her.
5. Record review of Resident #84's admission Record showed he/she was admitted to the facility on [DATE].
Record review of the resident's quarterly MDS dated [DATE] showed:
-He/she was cognitively intact.
-He/she had no behavioral symptoms.
During an interview on 9/13/22 at 1:02 P.M. the resident said:
-This was the first meal when residents were served beverages in regular cups.
-Always before all residents were served in Styrofoam cups at meals.
-To him/her that showed they did have regular cups and staff did not use the regular cups because they did not want to do the dishes.
During an interview on 9/16/22 at 10:52 A.M. the resident said:
-He/she did not like the Styrofoam plates, food containers and cups; it made him/her feel like a child.
-When he/she was a child the children got paper or Styrofoam and the adults got regular plates and regular cups and glasses.
6. Record review of Resident #72's admission Record showed he/she was admitted to the facility on [DATE].
Record review of the resident's annual MDS dated [DATE] showed:
-He/she was cognitively intact.
-He/she had no behavioral symptoms.
During an interview on 9/16/22 11:01 A.M. the resident said:
-He/she did not like being served food on Styrofoam.
-He/she never ate off Styrofoam at any other place he/she had ever been until he/she came to live at the facility.
-Food was served on Styrofoam all the time.
7. During an interview on 9/19/22 at 10:36 A.M., Dietary Aid (DA) A said:
-Styrofoam was used for two to three months during the COVID (a new disease caused by a novel (new) coronavirus) outbreaks.
-During meals two weeks ago the facility used Styrofoam.
-Styrofoam was used for hall trays and cups with plastic utensils.
-Styrofoam containers were not very homelike, but plates were.
During an interview on 9/19/22 at 10:40 A.M., [NAME] A said:
-The facility used Styrofoam due to a COVID outbreak.
-Styrofoam was also used due being short staffed.
-Staffing was short in dietary and nursing.
-Styrofoam cups, plates, and plastic utensils were used off and on.
-There had been times when the [NAME] was the only staff in the kitchen.
-Administration had put out ads to get more staff.
-When Styrofoam was used it was not home environment like plates were.
-The Styrofoam used was like a takeout package.
During an interview on 9/19/22 at 10:45 A.M. the Dietary Manager said:
-Styrofoam was used on the 500 hall because the residents were on quarantine.
-Styrofoam was used for all residents because the kitchen had to wait to get the ok for plates.
During an interview on 9/20/22 12:04 P.M., the Director of Nursing (DON) said:
-Styrofoam might have not created a homelike environment.
-The disposable items were used during the COVID outbreak.
-The last outbreak of COVID was 8/4/22.
-Styrofoam should not still be in use.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Record review of Resident #3 admission Record showed he/she was admitted to the facility on [DATE] with the following diagnos...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Record review of Resident #3 admission Record showed he/she was admitted to the facility on [DATE] with the following diagnosis:
-Cellulitis (an infection of deep skin tissue), unspecified.
-Type 1 Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin) without complications.
-Chronic Kidney disease (also called chronic kidney failure, involves a gradual loss of kidney function. Your kidneys filter wastes and excess fluids from your blood, which are then removed in your urine. )
-Muscle weakness (generalized)
-Anemia, unspecified (a decrease in hemoglobin in the blood to levels below the normal range)
-Essentials hypertension (high blood pressure)
Record review of the resident's quarterly MDS dated [DATE] showed he/she was cognitively intact.
During an interview on 9/12/22 at 12:17 P.M., CNA E said:
-Milk was not offered at lunch only at breakfast and dinner.
-Milk was not on the drink cart for lunch.
-Residents cannot get seconds of a meal.
-If seconds were requested by staff, the dietary staff yelled at him/her.
During an interview on 9/15/22 12:2 P.M., the resident said:
-He/she did not get enough to eat with meals.
-He/she had asked for seconds and was told by staff that the facility did not do seconds.
-He/she did not want to go back to regular portion size, and wanted to stay on larger portion size.
-He/she told both the nurse and SSD of desire to stay on larger portions sizes.
-He/she was placed back on regular portion size.
Observation on 9/19/22 at 8:31 A.M. showed the resident had to ask the nurse for butter, jelly, salt, and pepper for breakfast. The resident had received scramble eggs and biscuit for breakfast with no condiments.
7. During an interview on 9/16/22 at 9:34 A.M., LPN A said:
-Milk was not offered with lunch.
-If a resident asked for it, staff could go to the kitchen and request it and they might give it to you, but more than likely the kitchen would tell whoever asked for the milk no.
-A resident could ask for seconds, the nurse would have to go to the kitchen and request it, and the kitchen might give it out, if everyone had been fed and if there were left overs.
-Seconds for a meal was rarely available.
-If residents were still hungry after meals, the nurse had to make a peanut butter and jelly sandwich.
-When staff asked for extra food from the kitchen, kitchen staff would yell at the staff that requested the extra food.
-There was an always available menu, but the food was not always available.
-The snacks for residents were mainly junk food.
During an interview on 9/16/22 at 12:52 P.M. CNA B said:
-The residents could not have milk with lunch.
-If they ask for milk with lunch he/she told them we do not serve milk with lunch and offered them something else.
-He/she could not give them any milk for lunch.
-He/she did not know why.
-The cart was usually gone off the floor and we could not do rounds for second drinks.
-If he/she asked the dietary staff for more lemonade if he/she ran out while passing the drinks on the hall the dietary staff would say no.
-He/she could not give residents beverages in between meals.
-He/she could not get any drinks after dinner on the evening shift.
-There was no hydration station for the residents in the evening and nights, only water from the sink.
-If they chose to eat a cheeseburger when asked the previous day, they could not get anything else for lunch but what they requested.
-The resident could not change their mind on the meal choice.
During an interview on 9/19/22 at 9:06 A.M. CNA A said:
-The residents could only have milk with meals, only breakfast but not lunch.
-The kitchen refused to give milk for lunch.
-All dietary staff tell you that.
-If he/she asked for coffee or other beverages in between meals, the dietary staff yelled at him/her.
-He/she could only get tap water and no beverages other than meals.
-No drink carts or always available drinks were provided in between meals or in the evening or night time.
-If a resident chose a certain meal and received the meal, did not like it, the resident could not get the alternate meal.
-The dietary staff would only give them a peanut butter and jelly sandwich.
-The residents were not allowed to change their mind about the meal they wanted.
-Residents can get seconds if there was extra food made which was seldom.
-Residents cannot get special requests for meals.
-The facility had no snacks at all during the day.
During an interview on 9/19/22 at 9:47 A.M. CNA C said:
-The residents could not have milk with lunch.
-Several residents asked for milk during the lunch meal.
-If he/she asked for milk the dietary staff would say no and were not pleasant.
-There were no beverages out for residents in between meals.
-The residents could only have tap water.
-The residents would chose the meal they wanted to day before.
-They were not allowed to change their mind.
-They have the main dish or alternate of a hot dog, hamburger, or grilled cheese.
-They can only get what they signed up for, if they change their mind when the meal was served the resident could not have something different.
-The dietary staff would say the residents did not order this and they refused to give the resident a different item for lunch or dinner.
During an interview on 9/19/22 at 10:36 A.M., Dietary Aid (DA) A said:
-When drink carts go out staff and/or residents could get more drinks.
-Hydration stations were set up at 10:00 A.M. and left out until the evening shift left at 8:30 P.M.
-Could not say if they have an official alternate hot meal for breakfast.
-When the CNA's passed drinks the residents could have the large water cups filled up with the drinks.
-At times the facility did not always have enough pitchers to use.
-Milk was only served with breakfast and dinner.
-The kitchen did not send out milk at lunch.
-The coolers were not large enough to have enough milk for breakfast, lunch, dinner, and to make food with.
-They might run out of milk if it was offered with lunch.
-When the CNA's came to the kitchen and asked for milk it would be sent out with the CNA.
-If a resident wanted another meal, the resident could get a meal off the always available menu.
-Residents could always ask for seconds.
-Residents could have seconds if there was any extra available.
-When a meal was missed the resident could get a meal off the always available menu.
-When an alternate meal was ordered the resident would still get all the rest of the meal that was on the menu with the alternate meal.
-When a resident needed a larger portion it was communicated on the top of the meal ticket.
-The portion size would be doubled.
-When a resident wanted seconds and there was extra food leftover resident could have seconds.
-The meals were cooked with 5 to 10 additional servings, for seconds, after all the residents had been fed.
During an interview on 9/19/22 at 10:40 A.M., [NAME] A said:
-Milk could be gotten anytime, but it was only sent out on drink carts for breakfast and supper per the menus.
-The facility follows the dietician's menus.
-Beverages were set out at 10:00 A.M. along with snacks.
-Coffee, tea, water, and flavored water was out in the dining room all day until after dinner.
-Drinks were pulled down around 7:30 P.M.
-There was no access to beverages after 8:00 P.M.
-Meal tickets were filled out by the residents for what the resident wanted to eat, and if the residents wanted something else there was an alternate menu.
-The only hydration station was in the main dining room if you want something, and staff had to come from the units to the main dining room.
-There was no official alternate meal for breakfast.
-There was a hot meal alternate for both dinner and lunch
-If a resident was hungry and wanted something to eat the resident just needed to come to the kitchen and ask.
-All nurses' stations had peanut butter jelly sandwiches for overnight.
-When meals were cooked the kitchen made eight to ten extra servings that covered seconds.
-The facility made about one or two extra puree meals.
-When Styrofoam was used it was not home environment like plates were.
-Filling resident's water pitchers with drinks from the drink cart was discouraged due to cups might have touched the spout.
-All CNA's needed to do was ask the kitchen and they could get more drinks.
During an interview on 9/19/22 at 10:45 A.M. Dietary Manager (DM) said:
-There was no alternate hot meal for breakfast.
-If residents did not like something they got for dinner the resident could get an alternate meal always.
-The always available menu was also available.
-Milk was served at breakfast and dinner but all the resident had to do was ask for it at lunch.
-Milk was not on the menu for lunch.
-The dietician company the facility used made up the menus.
-Beverages/drinks carts go out at 7:00 A.M. and hydration station is set up at 10:00 A.M.
-Hydration station was torn down around 8:30 P.M.
-The residents had water and ice on the floor.
-If a resident signed up for a meal and the resident decided they did not want it the resident just had to ask for another meal and the resident could get it.
-The meals were cooked with five to ten extra servings for seconds.
-All a resident had to do was ask for seconds and the resident could have them.
-Resident #3 could get seconds whenever he/she wanted.
-Fresh fruit was always available.
-If it was on the menu and the resident wanted it, all the resident had to do was ask for it.
-If they ran out of beverages on the beverage cart, staff could get more, all the staff had to do was tell the kitchen.
-Residents could fill his/her big cup up if the resident wanted to fill the cup up.
During an interview on 9/19/22 at 12:12 P.M. the SSD said:
-He/she had complaints from different residents due to not enough food and not able to get extra portions.
-If the resident was still hungry they could not get second portions.
-The residents could not have milk with lunch.
-The residents could not have reasonable access to beverages in between meals, in the evening or at night.
-The beverages were put up after dinner around 7:30 P.M. to 8:00 P.M.
-Different CNA's have asked for second portions for the residents and the kitchen door gets shut on them.
-The residents were not allowed to have second portions.
During an interview on 9/19/22 at 12:54 P.M. LPN D said:
-The residents cannot have second portions.
-If a resident had an order for large portions all he/she was going to get was an extra half piece of sausage.
-No extra cereal allowed by dietary.
-No second beverages were allowed and no milk was allowed at lunch at all.
-If the staff ask for milk, the staff were yelled at by the DM.
-If the residents do not like the meal, the resident could not get an alternate meal.
-The DM would yell at staff if second portions were asked for and tell the staff that was all the resident would get and nothing more.
-He/she bought and kept sandwich supplies here for the residents because he/she could not get anything from the kitchen if a resident was still hungry.
-He/she provided sandwiches to the residents when they were hungry.
-When the drink cart was out of beverages on a hall, he/she could not get more beverages, and nothing else could be given to the residents.
-When the DM was here, he/she avoided asking for anything because the DM would yell at the staff and were told no.
-If the DM was not here, the Dietary Aides would give us what the resident asked for.
During an interview on 9/19/22 at 1:38 P.M. the MDS Coordinator said:
-He/she brought snacks from home to give to the residents.
-The residents were not allowed to have second portions with meals.
-They were only offered the alternate meal the day before but when they got their food they were not allowed to change to a different meal.
-The residents had to eat what they got.
-There were no beverages in the evenings or during the night.
During an interview on 9/20/22 at 11:59 A.M. the DON said:
-The residents should be able to get second portions at meals if wanted.
-There should be an alternate meal at breakfast.
-The residents should be able to get reasonable choices of beverages at all meals.
-The residents should be able to have coffee, milk, tea, lemonade at all meals and reasonable choices in evening and night for drinks.
-Staff do not have access to the kitchen at night to get snacks or beverages.
-The residents should be able to change their mind at a meal and get an alternate meal.
-When a resident ordered large portions they should get more food than a regular portion.
-Residents should have large portions if the doctor agreed the resident could have more.
-Always available menu means you could have it anytime.
-The resident should get the rest of the ordered meal when the alternative was ordered.
-The residents should be assisted with getting up, getting dressed, and brought to the dining room for meals.
-The residents should be dressed and up, not left in bed.
4. Record review of Resident #14's admission Record showed he/she was admitted to the facility on [DATE] and had the following diagnoses:
-Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin).
-Cerebrovascular Accident (CVA, stroke), cerebral artery occlusion with infarct (a blockage in the one or more of the arteries supplying blood to the brain resulting in a stroke).
Record review of the resident's Care Plan dated 5/17/22 showed the resident:
-Was independent with eating.
-Needed limited assistance with dressing.
Record review of the resident's quarterly MDS dated [DATE] showed the resident:
-Was cognitively intact.
-Needed the extensive assistance with transfers.
-Needed the limited assistance of staff with dressing.
-Needed set up assistance with eating.
-Used a wheelchair for mobility.
Observation on 9/12/22 at 10:40 A.M. and 12:46 A.M. showed the resident was in his/her bed and was wearing a hospital gown.
Observation on 9/13/22 at 12:28 P.M. showed he resident was in his/her room in a recliner and was wearing a hospital gown.
During an interview on 9/13/22 at 12:29 P.M. the resident said:
-The staff just leave him/her in the recliner and do not get him/her dressed.
-He/she would like to have clothes on and go to the dining room.
-He/she was very social and liked to be around others.
-He/she would ask to go to the dining room and get dressed but no one would assist.
-He/she did not feel good not being dressed in his/her own clothing.
Observation and interview at 9/13/22 at 12:33 P.M. showed:
-A staff member brought the resident lunch to his/her room.
-The resident stated he/she felt horrible and less than equal.
-He/she wanted to be up, dressed, and eat in the dining room.
Observation and interview on 9/14/22 at 8:20 A.M. showed:
-The resident was in his/her room in bed.
-The resident was eating breakfast on an over the bed table.
-The resident had two pancakes, bacon, a bowl of frosted flakes, and one cup of orange juice.
-The resident had a blue shirt on and no pants.
-The resident stated he/she did not get any milk for his/her cereal. He/she had asked for the milk and was told they did not have any. He/she had been placed in the blue shirt after a bath yesterday and no one changed him/her. He/she had to sleep in the shirt last night. The staff never get him/her dressed or take him/her to the dining room. He/she was very social and liked to be around others.
Observation and interview on 9/14/22 at 8:43 A.M. showed:
-The resident had eaten his/her pancakes, bacon and drank his/her orange juice.
-The resident was eating the dry frosted flakes with his/her hand.
-He/she stated the frosted flakes were very dry and wished he/she had milk.
Observation and interview on 9/16/22 at 12:46 P.M. showed:
-The resident was dressed in regular clothing in the dining room eating independently.
-The resident stated he/she was happy to be up, dressed and eating a meal in the dining room.
During an interview on 9/16/22 at 12:52 A.M. Certified Nurses Assistant (CNA) B said:
-The resident always wanted to be dressed and go to the dining room.
-He/she always wanted to get up an out of bed.
-The resident should have been up, dressed and taken to the dining room when requested.
-When the resident asked for milk the staff member should have come back with milk.
-The resident should not have had to eat dry cereal.
-This was a reasonable request.
Observation and interview on 9/19/22 at 9:22 A.M. showed:
-The resident was in his/her room in bed in a hospital gown.
-He/she had wanted to go to breakfast this morning and get dressed but no one would help him/her.
During an interview on 9/19/22 at 12:12 P.M. the Social Services Designee (SSD) said:
-The resident liked to get up and did not refuse to get up.
-The resident should always be dressed in regular clothing and assisted when he/she wanted to get up.
-The resident always wanted to eat in the dining room.
-He/she liked to be with other and was very social.
During an interview on 9/19/22 at 12:54 P.M. Licensed Practical Nurse (LPN) D said the staff should be getting the resident up and dressed when he/she wanted to get up.
5. Record review of Resident #44's admission Record showed he/she was admitted to the facility on [DATE] and had a diagnosis of Anxiety Disorder.
Record review of the resident's care plan dated 1/23/21 showed he/she was independent with eating.
Record review of the resident's quarterly MDS dated [DATE] showed the resident:
-Was cognitively intact.
-Was independent with Activities of Daily Living (ADL's-personal care to take care of oneself).
Observation and interview during the initial tour on 9/12/22 at 12:13 P.M. showed:
-The resident was in his/her room.
-A staff member was serving drinks to the resident's room.
-The resident asked for milk with lunch.
-The staff member said milk was not on the lunch cart and he/she could not have milk with lunch.
-After the staff member left, the resident said he/she wanted milk with lunch and no residents were allowed to have milk with lunch.
During an interview on 9/15/22 at 9:12 A.M. the resident said:
-He/she bet the staff could have a glass of milk when they wanted it.
-He/she wanted milk for lunch.
-The staff do not care about him/her and they make him/her feel terrible the way he/she was treated.
-He/she could not get beverages in between meals, in the evening or at night.
-He/she should be able to have something to drink other than tap water.
Based on observation, interview and record review, the facility failed to promote the right to self-determination and choices by not providing access to food when hungry and/or reasonable access to beverages for seven sampled residents (Residents #12, #21, #87, #14, #44, #3, and #4); and to assist with getting out of bed, getting dressed, and taken to the dining room when requested for one sampled resident (Resident #14) out of 19 sampled residents. This potentially effected all facility residents who were able to consume beverages and food provided by the facility kitchen. The facility census was 95 residents.
Record review of the facility Resident Rights policy revised December 2016 showed the following rights:
-A dignified existence.
-Be treated with respect, kindness and dignity.
-Self-determination.
Record review of the facility Dignity policy revised February 2021 showed:
-Each resident shall be cared for in a manner that promotes and enhances his/her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.
-The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values, and beliefs.
-Residents are provided with a dignified dining experience.
1. Record review of Resident #12's admission Record showed he/she admitted to the facility on [DATE] with the following diagnoses:
-Recurrent stroke.
-Depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).
-Anxiety(a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome).
Record review of the resident's progress note dated 7/3/22 showed:
-The resident was upset that he/she did not receive a dinner (supper) meal tray.
-The licensed nurse went to the kitchen to ask dietary staff if they had sent a tray for this resident and if they had not then please send one.
-The kitchen staff then replied, I'll find out.
-This nurse then returned to the nurse's station to tell the resident the kitchen staff were checking to see what was going on with his/her meal tray.
-Some time had passed and this resident was getting more agitated that he/she did not have a tray.
-The dietary staff stated they did not have a meal tray for the resident.
-Another 10 minutes passed and the resident was very upset.
Record review the resident's progress note dated 7/3/22 showed:
-The licensed nurse phoned the Director of Nursing (DON) regarding the situation (the resident not receiving a dinner tray).
-While the nurse was on the phone with the DON, he/she went to the kitchen and asked for the resident's meal tray.
-Dietary staff said they had not made the resident a meal tray and that they had asked the resident earlier if he/she wanted a tray and the resident had said no at that time.
-While on the phone with the DON, this nurse relayed to the dietary staff that the DON was requesting a meal tray for the resident to which the dietary staff stated he/she would just go get my boss.
-The licensed nurse went to the resident and asked him/her what kind of food he/she wanted and told the resident the DON was going to order him/her some food from a food take out delivery service; the resident said he/she did not then care about food and just wanted to leave the facility.
-Per the DON's instruction staff escorted the resident outside and stayed with him/her.
-The resident was provided soda and a pizza to eat while staff remained with him/her outside.
Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 8/31/22 showed:
-He/she had unclear speech, was usually understood and understood others.
-Was severely cognitively impaired.
-Had no behavioral symptoms.
During an interview on 9/20/22 at 11:40 A.M. the DON said:
-He/she did not recall a lot about what had occurred with the resident's meal tray on 7/3/22.
-He/she did remember a call from the charge nurse and did not remember speaking to the dietary manager on the phone about the resident's meal tray.
-He/she got a pizza delivered to the facility for the resident.
-He/she could not say if the resident would not have become upset had he been provided food by the dietary staff.
During an interview on 9/20/22 at 12:00 P.M. the DON said:
-He/she expected dietary staff to help the resident get food for the resident.
-He/she could not say if the resident would not have become upset had he/she been provided food by the dietary staff on 7/3/22.
2. Record review of Resident #21's annual MDS dated [DATE] showed:
-He/she was admitted to the facility on [DATE].
-He/she was cognitively intact.
During an interview on 9/19/22 at 8:46 A.M. the resident said:
-He/she wanted staff to fill up his/her large water cup with lid and straw with ice tea at lunch time and the staff would not fill up the cup and would only give him/her a small cup of ice tea.
-This made him/her mad.
-Staff were rude to the residents.
-Resident's should be able to get tea.
-Staff said they could not give residents more tea because they would run out of tea but all they have to do is get another pitcher of tea, staff are rude about it and it happens all the time.
3. Record review of Resident #87's quarterly MDS dated [DATE] showed:
-He/she was admitted to the facility on [DATE].
-He/she was cognitively intact.
During an interview on 9/19/22 at 8:46 A.M. the resident said:
-He/she wanted staff to fill up his/her large water cup with lid and straw with ice tea at lunch time and the staff would not fill up the cup and would only give him/her a small cup of ice tea.
-Staff would not fill up her cup with ice tea.
-He/she felt like the staff were treating him/her like he/she was a child and it made him/her mad.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure the Employee Disqualification List (EDL), Criminal Background Checks (CBC) and Nurse Aide (NA) Registry checks were completed to ens...
Read full inspector narrative →
Based on interview and record review, the facility failed to ensure the Employee Disqualification List (EDL), Criminal Background Checks (CBC) and Nurse Aide (NA) Registry checks were completed to ensure potential employees did not have a Federal Indicator (FI - a marker given to a potential employee who has committed abuse, neglect, or misappropriation of property against residents) in accordance with the state and federal regulation prior to hire on four out of ten employees sampled. The facility census was 95 residents.
Record Review of the Missouri Revised Statute Chapter 660, Section 660.317 showed, prior to allowing any person who has been hired as a full time part time or temporary position to have contact with any patient or resident, the provider shall, or in the case of temporary employees hired through or contracted for an employment agency, the employment agency shall prior to sending a temporary employee to a provider:
-Request a criminal background check as provided in section 43.540, RSMo. Completion of an inquiry to the highway patrol for criminal records that are available for disclosure to a provider for the purpose of conducting an employee criminal records background check shall be deemed to fulfill the provider's duty to conduct employee criminal background checks pursuant to this section.
-Make an inquiry to the department of health and senior services whether the person is listed on the employee disqualification list as provided in section 660.315.
Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised April 2021 showed:
-The staff were to conduct new employee background checks and not knowingly employee or otherwise engage any individual:
--Who had been found guilty of abuse, neglect, exploitation, or misappropriation of property.
1. Record review of Employee C's employee file showed:
-The employee was hired on 9/5/22 as a hospitality aide.
-The CBC, EDL check, and NA Registry were completed on 9/6/22.
-The background checks were not completed prior to hire.
Record review of Employee D's employee file showed:
-The employee was hired on 4/18/22 as a Dietary Assistant (DA).
-The NA registry check was completed on 4/19/22.
-The background check was not completed prior to hire.
Record review of Employee H's employee file showed:
-The employee was hired on 10/2/21 as a Certified Nursing Assistant (CNA).
-The CBC, EDL check, and NA Registry were completed on 7/2/22.
-The background checks were not completed prior to hire.
Record review of Employee I's employee file showed:
-The employee was hired on 1/5/22 as a Licensed Practical Nurse (LPN).
-The NA registry check was completed on 9/15/22.
-The background check was not completed prior to hire.
During an interview on 9/16/22 at 11:30 A.M. the Human Resources Manager said:
-He/she was responsible for completing employee background checks.
-The employee would come in, fill out and application and interview all at the same time.
-The employee was hired right then by whatever department manager was interviewing the employee.
-The employee left here hired on that day.
-After the employee was hired, he/she would complete all of the background checks that were required.
-He/she was not aware the background checks were required to be requested prior to hire.
During an interview on 9/20/22 at 11:59 A.M. the Director of Nursing (DON) said:
The Human Resource Manager was responsible for completing background checks.
-All background checks were to be requested prior to hire.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that Comprehensive Care Plan meetings were held on admission...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that Comprehensive Care Plan meetings were held on admission and quarterly and to the extent practicable, the participation of the resident and the resident's representative(s), and an explanation was not included in the residents medical record why the participation of the resident and residents representative was determined to impractical for the development of the resident's care plan for three sampled residents (Resident #3, #68, and #84) out of 19 sampled residents. This potentially effected all facility residents who could participate in care plan meetings. The facility census was 95 residents.
Record review of facility policy titled Care Planning-Interdisciplinary Team revised September 2013 showed:
-The facility's care planning/interdisciplinary team was responsible for the development of an individualized comprehensive care plan for each resident.
-A comprehensive care plan was developed within seven days of completion of the resident assessment.
-The resident, the resident's family and/or the resident's legal representative/guardian or surrogate were encouraged to participate in the development and revisions to the resident's care plan.
-Every effort would be made to have care plan meetings scheduled at the best time of the day for the resident and family.
-The comprehensive, person-centered care plan was developed within 7 days of the completions of the required comprehensive assessment.
-Assessments of the residents were ongoing and care plans were revised as information about the residents' condition changed.
-The interdisciplinary team must have reviewed and updated the care plan:
--When there had been a significant change in the resident's condition.
--When the desired outcomes were not met.
--When the resident had been readmitted to the facility from a hospital stay; and
-At least quarterly, in conjunction with the required quarterly Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning).
-The resident had the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals would be documented in the resident's clinical record in accordance with the established policies.
1. Record review of Resident #3 admission Record showed he/she was admitted to the facility on [DATE] with the following diagnosis:
-Cellulitis (an infection of deep skin tissue), unspecified.
-Type 1 Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin) without complications.
-Chronic Kidney disease (also called chronic kidney failure, involves a gradual loss of kidney function. Your kidneys filter wastes and excess fluids from your blood, which are then removed in your urine. )
-Muscle weakness (generalized)
-Anemia, unspecified (a decrease in hemoglobin in the blood to levels below the normal range)
-Essentials hypertension (high blood pressure)
Requested a copy of the care plan meeting notes and the facility failed to provide them.
Record review of the resident's quarterly MDS dated [DATE] showed he/she was cognitively intact.
During an interview on 9/12/22 12:24 P.M., the resident said:
-He/she never had a Care Plan meeting since being admitted to the facility.
-He/she would have liked to have a care plan meeting and had gone over the plan of care for himself/herself.
During an interview on 9/14/22 at 8:10 A.M., the MDS Coordinator said:
-The resident would have had two to three care plan meetings scheduled.
-There have not been any care plan meetings at the facility.
-There were no care plan meetings charted in the resident's progress notes.
-Care plan meetings were to be done upon admission, quarterly, annually and anytime there was a significant change in resident's condition.
-Care plan meetings were to be done after the scheduled MDS was done.
-The Social Services Designee (SSD) scheduled the care plan meetings and filled out the care plan meeting form and it would have covered who attended, what was discussed, and what was to be changed in the care plan.
-The SSD gave the care plan meeting form back to the MDS Coordinator.
-He/she reviewed the Care Plan meeting form, then would give it to medical records to be scanned into the residents computerized medical record.
-He/she would have expected this to be done within a day or two after Medical Records received the care plan meeting form.
During an interview on 9/19/22 at 8:53 A.M., the SSD said:
-Care plan meetings were held on Wednesday or Thursday each week.
-Care plan meetings are determined by the MDS calendar.
-Care plan meetings were not documented in the resident's progress notes.
-The meeting was done and the care plan meeting form was signed by all who attended the meeting, and was given back to the MDS Coordinator for review.
-The care plan meeting sheets were then scanned into the resident's computerized medical record.
-He/she did not remember when the resident had a care plan meeting.
-The resident's care plan had a revision date and that was when the meeting would have been held.
-He/she was unable to retrieve any care plan meeting forms for the resident.
2. Record review of Resident #68's admission Record showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-Schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves).
-Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).
-Anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome).
-Stimulant dependence (a chronic, progressive disease characterized by significant impairment that is directly associated with persistent and excessive use of a substance that affects the mind).
-Alcohol abuse (to consume excessive amounts of alcohol).
Record review of the resident's quarterly MDS dated [DATE] showed:
-He/she was cognitively intact.
-He/she had no mood indicators.
-He/she had no hallucinations (perceptual experiences in the absence of real external stimuli) and no delusions (misconceptions or beliefs that are firmly held, contrary to reality).
-He/she had no behavioral symptoms.
Record review of the resident's electronic-chart (EMR - electronic medical record) dated 10/2/21 through 9/16/22 showed no progress notes or other documentation showing the resident was invited to attend and participate in his/her comprehensive and quarterly care plan meetings.
During an interview on 9/12/22 at 10:20 A.M. the resident said he/she had not been invited to his/her care plan meetings.
3. Record review of Resident #84's admission Record showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-High blood pressure.
-Diabetes (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin).
Record review of the resident's quarterly MDS dated [DATE] showed he/she was cognitively intact.
During an interview on 9/12/22 the resident said he/she had not been invited to a care plan meeting in the past six months he/she had lived at the facility.
4. During an interview on 9/20/22 at 12:04 P.M., the Director of Nursing (DON) said:
-Care plans and care plan meetings were to be coordinated between the MDS Coordinator and the SSD.
-Care plan meetings were held quarterly.
-There was a form in the computerized charting program that was utilized.
-Medical records scanned the care plan meeting form into the computerized medical record.
-The form addressed who attended the meeting, what was discussed in the care plan meeting, and any changes that would be made to the care plan.
-The time frame from care plan meeting to the form being scanned into the system was usually 24-48 hours.
-The care plan would be created and updated to reflect the current condition of the resident.
-The care plan was reviewed quarterly and was updated and signed in the computerized medical record.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Record review of Resident #3 admission Record showed he/she was admitted to the facility on [DATE] with the following diagnos...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Record review of Resident #3 admission Record showed he/she was admitted to the facility on [DATE] with the following diagnosis:
-Cellulitis (an infection of deep skin tissue), unspecified.
-Type 1 Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin) without complications.
-Chronic Kidney disease (also called chronic kidney failure, involves a gradual loss of kidney function. Your kidneys filter wastes and excess fluids from your blood, which are then removed in your urine).
-Muscle weakness (generalized)
-Anemia, unspecified (a decrease in hemoglobin in the blood to levels below the normal range).
-Essentials hypertension (high blood pressure).
Record review of the resident's progress notes dated 8/30/22 at 6:12 P.M. showed the resident returned from the hospital.
Record review of hospital discharge instructions dated 8/30/22 showed the following physician's order to continue taking Tramadol (an opioid pain medication used to treat moderate to moderately severe pain) 50 mg by mouth every eight hours as needed for moderate to severe pain.
Record review of the resident's Order Summary Report dated 8/30/22 showed:
-Acetaminophen extra strength tablet 500 mg give two tablets by mouth every six hours as needed for pain/temperature.
-No other pain medication was ordered for the resident.
Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 9/4/22 showed he/she:
-Was cognitively intact.
-Had occasional pain.
During an interview on 9/13/22 at 12:32 P.M., the resident said:
-He/she did not have pain medications besides Acetaminophen for the entire month.
-He/she did not have Tramadol given since he/she returned from the hospital.
-He/she has told the nurses repeatedly that his/her pain was not controlled with just Acetaminophen.
-He/she said no other as needed pain medication had been ordered for him/her.
During an interview on 9/15/22 at 12:24 P.M. the resident said his/her pain was still not controlled.
During an interview on 9/15/22 at 1:00 P.M., Registered Nurse (RN) A said:
-The resident occasionally complained of pain.
-When pain medication was given it would be re-evaluated for effectiveness.
-He/she believed the pain medication the resident had was Tramadol.
-Discharge instructions would have reflected current mediation needs along with any medications that were changed.
-When the resident returned from the hospital the physician would be contacted and the discharge medications would be gone over to see if the physician agreed with them and would have ordered the medications.
-Medication discharge orders from the hospital would be expected to be ordered at the facility and continued for the resident.
-If the physician did not want a medication ordered from the hospital a progress note would be charted with the rational.
-When current ordered pain medication was not effective the doctor would be contacted and informed and new orders received.
-The resident's Tramadol medication should have been continued and given to the resident when he/she came back from the hospital.
During an interview on 9/20/22 at 12:04 P.M., Director of Nursing (DON) said:
-It was his/her expectation that a resident's pain would be controlled.
-It was his/her expectation that hospital discharge orders would be communicated to the resident's physician, orders written, and medications continued at the facility.
-It was his/her expectation that hospital discharge orders that the resident's physician did not want to continue would have a progress note charted with a rational for not continuing the medication.
Based on interview and record review, the facility failed to ensure Acetaminophen (an over the counter pain medication) orders were clarified to include parameters (a numerical or other measurable factor) for maximum dose per day for four sampled residents (Resident #68, #37, #72 and #84); and to ensure the pain medication order was confirmed and continued upon admission to the facility for one sampled resident (Resident #3) out of 19 sampled residents. The facility census was 95 residents.
Record review of the facility Acute Condition Changes - Clinical Protocol policy, revised March 2018 showed:
-The physician and nursing staff would review the details of any recent hospitalization.
-The physician would help identify medications and medication combinations that were associated with adverse consequences that could cause significant changes in condition.
Record review of the facility Administering Medication's policy, revised April 2019 showed:
-If a medication dosage was believed to be excessive for a resident, or a medication had been identified as having potential adverse consequences for the resident or was suspected of being associated with adverse consequences, the person preparing or administering the medication would contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns.
Record review of https://www.tylenol.com/safety-dosing/dosage-for-adults showed:
-To help encourage the safe use of Acetaminophen, the makers of TYLENOL® in 2011 lowered the maximum daily dose for single-ingredient Extra Strength Tylenol (Acetaminophen) products sold in the U.S. to 3 grams (gm = 1,000 milligrams - mg).
1. Record review of Resident #68's admission Record showed:
-He/she was admitted to the facility on [DATE].
-He/she had a diagnosis of fracture of right femur (thigh bone).
Record review of the resident's electronic medical record physician's orders showed:
-Acetaminophen Tablet 325 mg, give 2 tablets by mouth every 4 hours as needed for general discomfort.
--There was no notation to not exceed 3 gm in 24 hours, dated 8/3/24.
---The total 24 hour possible dose administration on this medication was 3.900 gm (3900 mg).
-Hydrocodone (a narcotic pain medication)-Acetaminophen Tablet 10-325 mg, give 1 tablet by mouth three times a day for pain.
--There was no notation to not exceed 3 gm in 24 hours.
---The total 24 hour total dose administration of this medication was .975 gm (975 mg).
-Acetaminophen tablet Extended Release 650 mg, give one tablet by mouth every 12 hours as needed for pain, dated 9/15/22.
--There was no notation to not exceed 3 gm in 24 hours.
---The total 24 hour dose administration of this medication was 1.3 gm (1300 mg).
-The total 24 hour possible dose administration of Acetaminophen was 6.175 gm (6,175 mg) without instruction to not exceed 3 gm in 24 hours.
2. Record review of Resident #37's admission Record showed:
-He/she was admitted to the facility on [DATE].
-He/she had a diagnoses of high blood pressure and diabetes.
Record review of the resident's electronic medical record physician's orders showed Hydrocodone-Acetaminophen Tablet 5-325 mg, give one tablet by mouth three times a day for pain without a parameter to not exceed 3 grams of Acetaminophen in all medications in 24 hours.
3. Record review of Resident #72's admission Record showed:
-He/she was admitted to the facility on [DATE].
-He/she had a diagnoses of peripheral neuropathy (nerve damage in the hands, feet and arms that causes tingling or numbness to more serious effects, such as burning pain).
Record review of the resident's electronic medical record physician's orders showed:
-9/15/22 Acetaminophen ER Tablet Extended Release 650 mg, give 1 tablet by mouth every 12 hours as needed for pain.
--There was no parameter to not exceed 3 grams of Acetaminophen in 24 hours.
---The total 24 hour dose administration for this medication was 1.3 gm (1300 mg).
-12/29/21 Hydrocodone-Acetaminophen Tablet 10-325 mg, give 1 tablet by mouth three times a day for pain.
--There was no parameter to not exceed 3 grams of Acetaminophen in 24 hours.
---The total 24 hour dose administration for this medications was .975 gm (975 mg).
-Acetaminophen ER Tablet Extended Release 650 mg, 1 tablet every 12 hours as needed for pain, dated 9/15/22.
--There was no parameter to not exceed 3 grams of Acetaminophen in 24 hours.
---The total 24 hour possible dose administration for this medications was 1.3 gms (1300 mg).
-The total 24 hour possible dose administration of Acetaminophen was 3.575 gm (3,575 mg) without instruction to not exceed 3 gm in 24 hours.
4. Record review of Resident #84's admission Record showed:
-He/she was admitted to the facility on [DATE].
-He/she had a diagnoses of high blood pressure and diabetes.
Record review of the resident's electronic medical record physician's orders showed:
-Hydrocodone-Acetaminophen Tablet 5-325 mg Give 2 tablet by mouth every 6 hours as needed for right shoulder pain, dated 4/5/22 without a parameter to not exceed 3 grams of acetaminophen in all medications in 24 hours.
5. During an interview on 9/20/22 at 10:17 A.M. Licensed Practical Nurse (LPN) A said:
-Total dosage of Acetaminophen in 24 hours should be no more than 3 grams.
-Some resident's medication orders for Acetaminophen and all medications containing Acetaminophen did not have the parameter for no more than 3 grams in 24 hours.
-He/she did not know why all resident's did not have instruction to not exceed 3 grams in 24 hours on all their Acetaminophen containing medications.
During an interview on 9/20/22 at 12:00 P.M. the Director of Nursing (DON) said:
-All medications with Acetaminophen should have a parameter to not exceed 3 gm in 24 hours in all medications.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the staffing levels were adequate to meet the n...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the staffing levels were adequate to meet the needs of the residents based on their acuity; and to ensure staffing levels were adequate to get residents dressed, out of bed, and to meals for two sampled resident (Resident #14 and #81) out of 19 sampled residents. This deficient practice potentially affected all residents who needed assistance with Activities of Daily Living(ADL's-dressing, transfers eating, mobility). The facility census was 95 residents.
Record review of the facility's staffing policy dated 10/2017 showed:
-The facility provided sufficient numbers of staff with the skills and competency necessary to provide care an services for all residents in accordance with resident care plans and facility assessment.
-Staffing numbers and the skill requirements of direct care staff were determined by the needs of the residents based on the plan of care.
Record review of the facility's Facility Assessment Tool, updated 4/15/22 showed:
-The facility assessment should serve as a record for staff and management to understand the reasoning and decisions made regarding staffing.
-The average daily census was 95 residents.
-The resident population included those diagnosed with a wide range of psychiatric and medical diseases and conditions and physical and cognitive disabilities that required complex medical care and management.
-Resident nursing services needs included management of medical conditions for assessment, early identification of problems, and management of medical and psychiatric symptoms and conditions.
-Four nurses with administrative duties were needed daily to meet resident needs.
Record review of the facility's Resident Census and Conditions of Residents dated 9/12/22 showed:
-The facility had a census of 95 residents.
-ADL's-personal care needs of the residents showed:
--Bathing: 65 residents needed the assistance of one to two staff members and 7 were totally dependent on staff.
--Dressing: 48 residents needed the assistance of one to two staff members and 20 were totally dependent on staff.
--Transferring: 28 residents needed the assistance of one to two staff members and 12 were totally dependent on staff.
--Toilet use: 35 residents needed the assistance of one to two staff members and 15 were totally dependent on staff.
--Eating: 7 residents needed the assistance of one to two staff members and 4 were totally dependent on staff.
1. Record review of Resident #14's admission Record showed he/she was admitted to the facility on [DATE] and had the following diagnoses:
-Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin).
-Cerebrovascular Accident (CVA, stroke), cerebral artery occlusion with infarct (a blockage in the one or more of the arteries supplying blood to the brain resulting in a stroke).
Record review of the resident's Care Plan dated 5/17/22 showed the resident:
-Was independent with eating.
-Needed limited assistance with dressing.
Record review of the resident's quarterly minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 6/24/22 showed the resident:
-Was cognitively intact.
-Needed extensive assistance with transfers.
-Needed limited assistance of staff with dressing.
-Needed set up assistance with eating.
-Used a wheelchair for mobility.
Observation on 9/12/22 at 10:40 A.M. and 12:46 P.M., showed the resident was in his/her bed and was wearing a hospital gown.
Observation on 9/13/22 at 12:28 P.M. showed he resident was in his/her room in a recliner and was wearing a hospital gown.
During an interview on 9/13/22 at 12:29 P.M. the resident said:
-The staff just leave him/her in the recliner and do not get him/her dressed.
-He/she would like to have clothes on and go to the dining room.
Observation on 9/19/22 at 9:04 A.M. showed:
-The resident was in his/her bed wearing a hospital gown.
-Certified Nurses Aide (CNA) A was in the room with the resident.
-The resident asked to get and get dressed.
-CNA A said he/she would try to help the resident as soon as possible as soon as another staff member was available to help.
During an interview on 9/19/22 at 9:06 A.M. CNA A said:
-There were only two CNA's working 100/200/300 hall.
-This was normal to only have two CNA's for the halls.
-He/she did not have time to get the residents up, dressed and to breakfast due to staffing levels.
-Many of the residents did not get up last week at all due to not enough staff, including Resident #14.
-He/she had taken the residents to the dining room that needed to be monitored during meals.
-One resident had to be placed by the nurses station while eating because he/she was a fall risk and needed to be monitored.
2. Record review of Resident #81's admission Record sheet showed he/she was originally admitted to the facility on [DATE] with the following diagnoses:
-Severe protein calorie malnutrition (inadequate intake of calories from proteins, vitamins, and minerals).
-Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses).
Record review of the resident's quarterly MDS dated [DATE] showed the resident:
-Was severely cognitively impaired.
-Required extensive to total assistance from one to two staff with ADL including needing extensive assistance of one staff with dressing.
Record review of the resident's undated care plan showed the resident:
-Needed extensive assistance from staff with dressing.
-Required set up assistance with eating.
Observation on 9/19/22 at 8:38 A.M. showed:
-The resident was in a broda chair (a specialized wheelchair for positioning).
-The resident was in a hospital gown eating breakfast on a tray table.
Observation on 9/19/22 at 8:52 A.M. showed:
-The resident was in a broda chair.
-The resident was in a hospital gown eating breakfast on a tray table.
During an interview on 9/19/22 at 9:06 A.M. CNA A said:
-There were not enough staff to get the resident dressed and to the dining room.
-He/she placed the resident by the nurse's station to watch him/her while eating.
-The resident needed to be monitored at all times because he/she was a fall risk and there were no staff in the dining room to monitor the resident.
3. During an interview on 9/19/22 at 9:47 A.M. CNA C said:
-There were only two CNA's on 100/200/300 hall.
-There were not enough staff to meet the needs of the residents.
-There were five residents in the dining room because they could not get all the residents up and dressed.
-This happened a lot with CNA staffing.
-He/she had worked all three halls by himself/herself before.
-He/she was the only CNA scheduled to work day shift on these halls tomorrow.
During an interview on 9/19/22 at 12:54 P.M. Licensed Practical Nurse (LPN) D said:
-Residents were not getting up for breakfast because there were not enough CNA's to get the residents dressed, up, and to the dining room.
-The day shift only had two CNA's for 100/200/300 hall.
-The CNA's tried to get as many residents up as possible.
-Staffing for CNA's was an issue and the residents' needs could not be met.
During an interview on 9/19/22 at 2:01 P.M. the Director of Nursing (DON) said:
-He/she was responsible for scheduling staffing.
-On 100/200/300 halls he/she tried to staff three CNA's with a minimum of two CNA's on the day shift, two to three CNA's on the evening shift and night shift.
-Sometimes, he/she was not able to staff CNA's at that level.
-On the memory care unit he/she tried to staff one CNA on the day shift.
--He/she did not staff a CNA on the evening and night shift.
--He/she used an LPN and Certified Medication Technician (CMT) on the evening and night shift.
-The East hall had more independent residents so there were two CNA's for day and evening shift and one CNA for night shift.
During an interview on 9/20/22 at 10:39 A.M. the Administrator said:
-Staffing levels were based on the facility assessment and basic parameters of the building.
-The staff was based on acuity and the needs of the residents.
-The DON was responsible for staffing and scheduling.
-He/she believed three CNA's was enough to meet the needs of the residents on 100/200/300 halls.
During an interview on 9/20/22 at 11:59 A.M. the DON said:
-The staffing should be based on the residents' care needs.
-The facility had a CNA shortage.
-The residents' Activity of Daily Living were not being met.
MO00207430
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were not subjected to unnecessary psychotropic med...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were not subjected to unnecessary psychotropic medications (drugs which affect psychic function, behavior, or experience); to ensure pro re nata (PRN, as needed or indicated) antipsychotic medications (a group of drugs affecting mental functioning such as mood, behavior, or thinking processes, commonly used to treat psychosis) were not prescribed for more than 14 days; to ensure an oral medication was ordered to try a lower dose of medication for behaviors; and to ensure non-pharmacologic interventions were implemented prior to administering PRN Intramuscular (IM) antipsychotic medication for two sampled residents (Resident #25 and #14); and to ensure documentation showed monitoring of behaviors and response to medications for one sampled resident (Resident #68) out of 19 sampled residents. The facility census was 95 residents.
Record review of the facility's Antipsychotic Medication Use policy, revised December, 2016 showed:
-Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and review.
-Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective.
-In the case of an emergency situation (an acute onset or exacerbation of symptoms or immediate threat to the health or safety of a resident or others) the use of antipsychotic medications must meet the following additional requirements:
--The acute treatment period is limited to seven days or less.
--A clinician, in addition to the interdisciplinary team must evaluate and document the situation within seven days to identify any contributing and underlying causes of the acute psychiatric condition and verify the continuing need for antipsychotic medication.
--Pertinent non-pharmacological interventions must be attempted unless contraindicated and documented following the resolution of the acute psychiatric situation.
-For enduring psychiatric conditions antipsychotic medications will not be used unless behavioral symptoms are, amongst other circumstances, not sufficiently relieved by non-pharmacological interventions.
-Residents will not receive PRN doses of psychotropic medications unless that medication is necessary to treat a specific condition that is documented in the clinical record.
-PRN orders for antipsychotic medications will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of that medication.
1. Record review of Resident #25's admission Record showed he/she was admitted to the facility on [DATE] and had the following diagnoses:
-Restlessness and agitation.
-Psychosis (a mental state involving loss of contact with reality and causing deterioration of normal social functioning).
-Intermittent Explosive Disorder (a chronic disorder involving repeated, sudden episodes of impulsive, aggressive, violent behavior and/or angry verbal outbursts in which reactions are grossly out of proportion to the situation).
Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 4/8/22 showed:
-He/she was severely cognitively impaired.
-He/she had no indicators of mood problems.
-He/she had one to three episodes of physical behaviors towards others.
-He/She took antipsychotic medications daily on a routine schedule only.
-He/She also took antianxiety and antidepressant medications.
Record review of the resident's Physician Order Sheet (POS), dated 6/4/22 showed Haloperidol (Haldol - an antipsychotic medication) tablet 1 milligram (mg). Give 2 mg by mouth every 12 hours as needed (PRN - pro re nata) for aggressiveness starting 5/31/22 and discontinuing 6/6/22.
Record review of the resident's Medication Administration Record (MAR) showed Haloperidol 2 mg was administered on 6/4/22 at 10:10 P.M.
Record review of the resident's medication monitoring sheet, dated June, 2022 showed:
-Behavior monitoring for targeted behaviors of hitting, pinching, slapping, agitation related to diagnosis of schizoaffective disorder.
-If behavior was noted on your shift please make nurses' note saying what the behavior was and any and all interventions performed to reduce behavior. Every shift for monitoring.
-The day shift documented there were no behaviors on 6/4/22.
Record review of the resident's Behavioral Nurses' Notes for 6/4/22 showed there was no documentation of any resident behaviors and no documentation that any PRN medication was administered on 6/4/22.
Record review of the resident's POS, dated 6/12/22 showed:
-Haloperidol tablet 1 mg. Give 2 mg by mouth every 12 hours as needed for schizoaffective disorder starting 6/6/22 and discontinuing 6/27/22.
-NOTE: The facility failed to ensure the PRN antipsychotic medication order did not exceed 14 days.
Record review of the resident's MAR dated June 2022 showed Haloperidol 2 mg was administered:
-On 6/12/22 at 12:00 P.M.
-On 6/22/22 at 3:57 P.M.
-On 6/27/22 at 5:01 A.M.
-NOTE: There was no documentation of the medication being administered on 6/25/22 at 1:00 P.M.
Record review of the resident's medication monitoring sheet, dated June 2022 showed:
-No behavior was documented for 6/12/22.
-On 6/22/22 and 6/27/22 behaviors were indicated by a Y for yes.
Record review of the resident's Behavioral Nurses' Notes dated 6/12/22 to 6/25/22 showed:
-On 6/12/22 at 1:49 P.M. multiple times throughout this shift the resident had been heard and seen punching the walls and nurses' station, saying he/she was pissed off because he/she couldn't smoke. Staff explained numerous times that until he/she was given permission by his/her guardian, he/she would not be able to smoke. Later in the shift the resident was sitting in the hallway and began pounding his/her head on the wall behind him/her. The Certified Nursing Assistant (CNA) intervened and took the resident into the therapy gym where he/she was able to calm down. The resident began cursing around the 1:30 P.M. smoke break, but the resident was easier to calm down at the time.
-NOTE: The note did not mention that a PRN medications for behaviors had been administered. The note did not mention any non-pharmacologic intervention except for when the CNA took the resident to the therapy gym.
-There was no documentation of any resident behaviors and no documentation that any PRN medication was administered on 6/22/22 in the notes.
-A note written on 6/25/22 at 2:07 P.M. showed at approximately 3:00 A.M. the resident started yelling and cursing down the hall. Staff assisted the resident to use the bathroom. He/She was assisted to his/her wheelchair and taken to the nurses' desk at 5:00 A.M. A few minutes later the resident started to yell again and cursing at staff calling them bitches and punching anything close to him/her. Another resident down the hall started to yell and the resident started yelling if the other resident did not stop yelling he/she would come down and beat his/her ass. The resident would only be redirected a few minutes and start again yelling at staff and other resident and threatening to beat their ass. This continued until lunch time. The resident was taken to the dining room to eat and started to yell to other residents and staff to shut the hell up and started to pound the table. The resident was taken out of the dining room to the therapy room to eat lunch. The resident was still unable to be redirected for more than a few minutes. A one-time order was received from the physician for Haloperidal 5 mg/ml IM.
--At 1:00 P.M. the medication was administered in the right deltoid (upper arm).
--- he note does not show non-pharmacological interventions attempted prior to administering the IM medication except when the resident was taken to the therapy room. This administration does not show up on the June, 2022 MARS.
Record review of the resident's physician orders dated for 6/25/22 showed his/her physician ordered Haloperidol 5 mg/mL, inject 1 mg IM one time only for agitation for one day starting 6/25/22. The resident did not have a by-mouth medication ordered to try a lower dose of medication for behaviors.
Record review of the resident's Behavioral Nurses' Note dated 6/27/22 showed:
-Another resident reported being struck by the resident by his/her right hand.
-The two were separated.
-The resident said the other resident was lying and he/she didn't hit him/her.
-NOTE: There was no documentation the resident received a PRN medication for behaviors, what non-pharmacological interventions used, or how effective the PRN was.
Record review of the resident's physician orders dated for 7/16/22 showed his/her physician ordered Haloperidol 5 mg/ mL, inject 5 mg IM one time only for aggression for one day starting 7/16/22. The resident did not have a by-mouth medication ordered in July, 2022 to try a lower dose of medication for behaviors.
Record review of the resident's MAR dated July, 2022 showed Haloperidol 5 mg/mL. Inject 5 mg IM was administered on 7/16/22 at 10:51 A.M.
Record review of the resident's behavior monitoring for targeted behaviors sheet showed the resident had behaviors on 7/16/22 and 7/25/22, but not on 7/22/22.
Record review of the resident's Behavioral Nurses' Notes dated 7/16/22 showed no documentation of any behavioral episodes and no documentation PRN Haloperidol was administered.
Record review of the resident's physician orders dated for 7/22/22 showed his/her physician ordered Haloperidol 5 mg/mL, inject 1 ml IM one time only related to restlessness and agitation until 7/22/22.
Record review of the resident's MAR for July, 2022 showed Haloperidol 5 mg/mL was administered on 7/22/22 at 11:46 P.M.
Record review of the resident's Nurses' Note dated 7/22/22 at 10:54 P.M. showed:
-The resident was trying to start a fight with three different residents.
-When trying to redirect the resident he/she swung on the nurse.
-Nurse called the physician and got a one-time order for Haldol IM.
-IM medication was administered and effective.
-NOTE: There was no documentation to show what other non-pharmacologic interventions were used in attempting to redirect the resident.
Record review of the resident's physician orders dated 7/25/22 showed his/her physician ordered Haloperidol 5 mg/mL, inject 1 ml IM one time only for agitation related to schizoaffective disorder starting 7/25/22. There was no stop date for the medication and the resident did not have an oral medication ordered to try a lower dose of medication for behaviors.
Record review of the resident's MAR dated July, 2022 showed Haloperidol 5 mg/mL was administered on 7/25/22 at 10:12 A.M.
Record review of the resident's medication monitoring sheet, dated July, 2022 showed the resident had behaviors on 7/25/22.
Record review of the resident's Behavioral Nurses' Notes dated 7/25/22 showed no documentation of any behavioral episodes and there was no documentation PRN Haloperidol was administered.
Record review of the resident's POS dated August, 2022 showed his/her physician ordered Haloperidol 5 mg/ ml, inject 1 ml IM for agitation related to schizoaffective disorder, depressive type and intermittent explosive disorder starting 7/25/22. There was no stop date for the order. The resident did not have a by-mouth medication ordered in August, 2022 to try a lower dose of medication for behaviors.
Record review of the resident's MAR dated August, 2022 showed Haloperidol 5 mg/ml was administered on 8/19/22 at 7:07 P.M., 8/21/22 at 9:01 P.M., 9/28/22 at 9:36 A.M. and 9/30/22 at 6:01 P.M.
Record review of the resident's Behavior Monitoring sheets showed no behaviors for any dates the PRN Haloperidol was administered.
Record review of the resident's Nurses' Note dated 8/21/22 at 10:45 P.M. showed:
-The resident was sitting in front of the nurses' station and started to lean to the right and kept leaning until he/she turned over his/her wheelchair, stating he/she meant to turn over his/her chair.
-Range of Motion was assessed with no complaints of pain or discomfort.
-At 9:01 P.M. Haldol IM was given for behaviors.
-The resident has been hitting his/her head on the wall since the nurse came in at 6:30 P.M.
-Staff unable to distract the resident. He/She continued to hit his/her head on the wall until he/she turned over the chair.
-He/She also hit his/her right arm and watch on the bedside table.
-The resident then asked if he/she broke it because he/she wanted to break it.
-The resident then took off his/her glasses, threw them on the floor, picked them back up and was bending them.
-This nurse asked him/her to please stop before he/she broke them and he/she stated he/she wanted to break them.
-The resident got the lens out of his/her glasses frames.
-The resident was given Haldol IM at 9:01 P.M.
-NOTE: There was no documentation to show what, if any, non-pharmacological interventions were attempted prior to administering the PRN antipsychotic.
Record review of the resident's Nurses' Note dated 8/29/22 at 6:30 P.M. showed:
-The resident was in the dining room cussing and propelling himself/herself to the hallway when the resident stopped in front of the entrance door and started to kick the door, stating he/she was leaving.
-This nurse went to the door and pulled the resident backward and he/she took his/her right hand and hit this nurse in the right shoulder cussing at the nurse.
-The resident went to the wall and took the fire extinguisher off the wall and dropped it to the floor.
-The resident received Haldol IM at this time.
-NOTE: There was no documentation to show if any non-pharmacological interventions were attempted prior to administering the PRN antipsychotic. The MAR did not show that PRN Haloperidol was used. The Behavior Monitoring sheet did not show the resident had behaviors related to symptoms of schizoaffective disorder.
During an interview on 9/16/22 at 11:41 A.M. Registered Nurse (RN) A said:
-The resident didn't have anything ordered he/she could use for behaviors other than Haldol IM.
-The physician could have PRN orders written for antipsychotics for 2 weeks.
-He/She wasn't sure if there was a stop date on the resident's orders.
--He/she looked at the resident's orders and said the Haldol IM did not have a stop date.
-Nurses were supposed to look for a stop date.
-The physician should know the requirements of having a stop date.
During an interview on 9/19/22 at 9:12 A.M. Licensed Practical Nurse (LPN) B said:
-The resident had orders for PRN Haldol IM which was an antipsychotic medication.
-He/she did not know the policy related to antipsychotic medications.
-The resident had been on PRN antipsychotics a long time.
-He/she assumed nurses would need to try non-pharmacologic interventions before administering an antipsychotic or psychotropic medication and that nurses might need to give a non-IM PRN for behaviors prior to trying the IM medication.
2. Record review of Resident #14's admission Record showed:
-He/she was admitted to the facility on [DATE].
-He/she had a diagnosis of major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), with psychotic symptoms (a mental disorder in which a person has depression along with loss of touch with reality).
Record review of the resident's Order Recap Report for orders dated 5/1/22 to 9/30/22 showed his/her physician ordered:
-Haldol 5 mg/ml, inject 5 mg intramuscularly (IM) every 24 hours as needed for agitation, hysteria (ungovernable emotional excess) related to major depressive disorder recurrent, severe with psychotic symptoms for 10 days, dated 5/4/22.
-Haloperidol 5 mg/ml, inject 5 mg IM every 24 hours as needed for agitation, hysteria related to major depressive disorder recurrent, severe with psychotic symptoms dated 9/1/22 and without an end date.
Record review of the resident's quarterly MDS dated [DATE] showed:
-He/she was cognitively intact.
-He/she had no indicators of mood problems.
-He/she had no behavioral symptoms, including no hallucinations (perceptual experiences in the absence of real external stimuli) and no delusions (misconceptions or beliefs that are firmly held, contrary to reality).
Record review of the resident's MAR dated 9/2022 showed the resident received IM Haldol on 9/5/22.
During an interview on 9/19/22 at 12:54 P.M. LPN D said:
-He/she was working when the resident received the Haldol injection, which the resident received one time; the resident had been yelling all day long for hours and staff had tried to console him/her.
-There was no documentation in the resident's medical record for the use of the resident's Haldol injection.
-Interventions prior to the use of Haldol injection had not been documented.
-Interventions should have been attempted prior to the use of Haldol injection.
-The Haldol injection should have been used as a last resort.
-There was no place to document interventions that were tried prior to administering a PRN medication for behaviors.
-The resident did not have a by mouth medication ordered to try a lower dose of medication for behaviors.
During an interview on 9/19/20 at 1:38 P.M., the MDS Coordinator said behavior medications should start with low doses.
During an interview on 9/20/22 at 12:00 P.M. the DON said:
-Regarding resident behaviors, he/she expected staff, depending on the behavior to redirect the resident and provide diversion (activity that diverts the mind from concerns).
-If a meeting was held that reviewed the root cause of the use of Haldol injection, it would be documented in the resident's progress notes.
-Medications for behaviors should have a diagnosis for use of the medication.
-If new order staff would try to start low (use a low dose) with the medication.
-IM Haldol would be used when behaviors could not be redirected.
-He/she was not sure if other medications were tried with the resident prior to injection of Haldol.
-Prior to giving as needed medications for behaviors there needed to be some form of redirection or diversion.
-Resident behaviors should be documented on Treatment Administration Record (TAR) and there should have been a progress note when an IM medication was given.
-For as needed (PRN) behavior medications, the resident's behaviors, non-pharmacological (non-medication) interventions and responses to the medication should be documented in the residents' progress notes.
3. Record review of Resident #68's admission Record showed:
-He/she was admitted to the facility on [DATE].
-He/she had diagnoses of Schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), depression, anxiety, stimulant dependence, (a chronic, progressive disease characterized by significant impairment that is directly associated with persistent and excessive use of a substance that affects the mind) and alcohol abuse.
Record review of the resident's quarterly MDS dated [DATE] showed:
-He/she was cognitively intact.
-He/she had no mood indicators.
-He/she had no hallucinations (perceptual experiences in the absence of real external stimuli) and no delusions (misconceptions or beliefs that are firmly held, contrary to reality).
-He/she had no behavioral symptoms.
Record review of the resident's electronic medical record (EMR) physician's orders on 9/13/22 showed orders for the following psychoactive medications (any substance that has an effect on the mind or behavior).:
-Diazepam (medication used to relieve anxiety and control agitation), 5 mg tablet, give 0.5 tablet by mouth two times a day related to other stimulant dependence and alcohol abuse.
-Aripiprazole (medication that works in the brain to treat schizophrenia and mood disorders), 5 mg, give two tablets once daily related to schizophrenia).
-Mirtazapine (antidepressant medication, 30 mg, give one tablet at bedtime for depression.
-Celexa (antidepressant medication) 10 mg, give two tablets one time a day.
-NOTE: There was no instruction regarding documenting of the resident's physical, mental, behavioral, and/or psychosocial signs, symptoms, or related causes to assist in determining the resident's continued need for the medications or indicators for the resident's need for the current dose of medications including Diazepam, Aripiprazole, Mirtazapine and Celexa.
During an interview on 9/20/22 at 9:45 A.M. LPN A reviewed the resident's EMR and said there was no monitoring in place in the resident's physician's order and MAR for monitoring of the resident's behavior/symptoms related to his/her Diazepam, Aripiprazole, Mirtazapine, and Celexa.
During an interview on 9/20/22 at 12:00 P.M. the DON said:
-For new orders for psychoactive medications, the facility would try to start low (use a low dose).
--For PRN behavior medications, the resident's behaviors, non-pharmacological interventions and responses to the medication should be documented in the residents' progress notes.
-All antidepressant, antianxiety antipsychotic medications should have behavioral and side-effect monitoring.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0800
(Tag F0800)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #3 admission Record showed he/she was admitted to the facility on [DATE] with the following diagnos...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #3 admission Record showed he/she was admitted to the facility on [DATE] with the following diagnosis of Type 1 Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin) without complications.
Record review of the residents care plan dated 5/10/22 showed the resident had a nutritional problem or potential problem and was at risk for malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat) with interventions place.
Record review of the resident's Order Summary Report (OSR) dated September 2022 showed he/she had a diet order for a controlled carbohydrate (any of a large group of organic compounds occurring in foods and living tissues and including sugars, starch, and cellulose), no added salt, regular texture and thin liquids dated 8/30/22.
Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 9/4/22 showed he/she:
-Was cognitively intact.
-Was independent with meals.
-Had no swallowing disorders.
During an interview on 9/12/22 at 12:13 P.M. the resident said:
-He/she was not able to get an alternate breakfast meal.
-He/she did not always like the breakfast meal.
-He/she tried to get an alternate meal but was told there was not alternate breakfast meals.
During an interview on 9/16/22 at 9:34 A.M., Licensed Practical Nurse (LPN) A said there were no alternate breakfast meals available.
During an interview on 9/19/22 at 8:30 A.M., Certified Nurses Assistant (CNA) A said there were no alternative hot meals offered for breakfast.
Based on observation, interview, and record review, the facility failed to ensure that residents had sufficient alternate food choices at breakfast including one sampled resident (Resident #3) out of 19 sampled residents. This deficient practice potentially affected all residents who ate food from the kitchen. The facility census was 95 residents.
Record review of the facility's Frequency of Meals policy revised 7/2017 showed alternate meals would be offered to residents who choose to eat non-traditional or outside of scheduled meal times.
1. Record review of the facility's undated Spring/Summer Menu Cycle showed:
-The breakfast meal was outlined daily with food and beverages.
-There was no alternate meal listed for breakfast.
Record review of the facility's untitled, undated, alternate menu showed:
-The alternate meal choices were lunch and dinner items.
-There were no breakfast items listed for daily alternatives.
During an interview on 9/19/22 at 10:35 A.M. Dietary Aide (DA) A said he/she was not aware of any alternate breakfast items or alternate meal at breakfast for the residents.
During an interview on 9/19/22 at 10:51 A.M. [NAME] A said there was one main meal for breakfast but no alternate breakfast menu.
During an interview on 9/19/22 at 11:07 A.M. the Dietary Manager (DM) said:
-There was no alternate breakfast menu or choices for the resident.
-He/she followed the menus.
Oct 2019
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Employment Screening
(Tag F0606)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to request a Criminal Background Check (CBC) prior to hiring one sampled employee (Employee C), and to check the Certified Nurse Aide (CNA) Re...
Read full inspector narrative →
Based on interview and record review, the facility failed to request a Criminal Background Check (CBC) prior to hiring one sampled employee (Employee C), and to check the Certified Nurse Aide (CNA) Registry, used to determine if an individual had a Federal Indicator (shows abuse, neglect or misappropriation of property occurred while the individual was employed as a CNA in a Medicaid and/or Medicare federally certified facility, which prohibits the individual from working in a certified facility) prior to hiring one sampled newly hired employee (Employee D), out of five sampled employees. The facility hired 46 employees since the last annual survey. The facility census was 82 residents.
Record review of the facility's policies showed no policy was provided related to new employee background checks.
1. Record review on 10/11/19 of Employee C's personnel record showed:
-He/She was hired 2/19/19; and
-His/her CBC was requested 2/20/19, after the date of hire.
2. Record review on 10/11/19 of Employee D's personnel record showed:
-He/she was hired 8/23/19; and
-A CNA Registry check was not completed prior to hiring.
3. During an interview on 10/10/19 at 12:37 P.M., the Human Resources Manager (HRM) said:
-There was no other information to show a CBC was requested before hiring Employee C;
-He/she did not know why the CBC was requested late; and
-He/she could not find a CNA registry check for Employee D, but would get it done.
During an interview on 10/11/19 at 3:56 P.M. the Director of Nursing (DON) and the Corporate Nurse said:
-He/she would have expected all newly hired employees to have had their CBC done prior to being hired and
-Each department manager was responsible for following up on pre-employment background checks.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident and the resident's representative(s) in writing...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident and the resident's representative(s) in writing of a transfer to a hospital, including the reasons for the transfer and to provide the Ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) a copy of the notification for two sampled residents (Residents #13 and #55) out of 18 sampled residents. The facility census was 82 residents.
Record review of the Facility's Transfer or Discharge, Emergency Policy dated as Revised December 2018 showed:
-Residents will not be transferred unless:
--The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility;
-Notify the representative (sponsor) or other family member;
-Provide the transfer letter to the resident and/or Power of Attorney (POA- a person previously identified to make decisions for an individual in the event of inability to make wishes known) if applicable at the time of discharge or as soon as practicable;
-Place a copy of the letter in the resident record and
-Notify the Ombudsman of the discharge per the Ombudsman direction.
1. Record review of Resident # 13's Electronic Health Record (EHR) showed he/she was admitted of 6/27/19 with the following diagnoses:
-Paraplegia (loss of movement of both legs and generally the lower trunk);
-Neuromuscular Dysfunction of Bladder (a disorder of urinary bladder control due to damage to the spinal cord or to the nerves supplying the bladder);
-History of Urinary Tract Infections (UTI-an infection in any part of the urinary system-kidneys, ureters, bladder and urethra) and
-History of Deep Venous Thrombosis (DVT-blood clot in the blood vessel) and Embolism (obstruction of an artery).
Record review of the resident's Nurses Notes dated 7/11/19 at 1:57 P.M., showed:
-The resident's Physician was notified of a critical International Normalized Ratio (INR lab result used to monitor how well the blood-thinning medication (anticoagulant) is working to prevent blood clots] and
-Received an order to send the resident to the hospital.
Record review of the resident's Nurses Notes dated 7/11/19 at 2:13 P.M., showed he/she left the facility to go to the hospital.
Record review of the resident's medical record showed:
-No documentation of a letter of transfer/discharge was sent to the resident's responsible party and
-No notification sent to the Ombudsman.
Record review of the resident's Nurses Notes dated 7/16/19 at 9:52 P.M., showed he/she returned to the facility.
2. Record review of Resident # 55's EHR showed he/she was admitted of 1/24/11 with the following diagnosis of Malignant Neoplasm (cancerous tumor) of the lip, oral cavity, and the pharynx (the membrane-lined cavity behind the nose and mouth connecting them to the esophagus (connects the throat to the stomach).
Record review of the resident's Annual Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility staff for care planning) dated 3/12/18 and Quarterly MDS dated [DATE] and 9/6/19 showed the resident had a Percutaneous Endoscopic Gastrostomy Tube (PEG Tube, also known as a G-Tube- a tube placed into the stomach through the abdominal wall to provide feeding/nutrition when not able to take orally).
Record review of the resident's Nurses Notes dated 7/31/19 at 11:51 P.M., showed:
-The resident was shaky, and sweaty;
-The G-Tube site had a rust tinged color drainage;
-The resident's Physician was notified and orders were received;
-The resident's oxygen saturation dropped to 70%;
-The resident was gurgling;
-The resident's face beginning to have a purple tint around eyes and nose;
-Oxygen was applied to the resident and
-The resident was transferred at 10:10 P.M. to hospital.
Record review of resident's medical record showed:
-No documentation of a letter of transfer/discharge was sent to the resident's responsible party and
-No notification sent to the Ombudsman.
Record review of the resident's Nurses Notes dated 8/5/19 at 8:52 P.M., showed that the resident returned to the facility.
3. During an interview on 10/10/19 at 2:15 P.M., the Director of Nursing (DON) said he/she was not sure if a resident's responsible party was notified by letter when the resident was transferred to the hospital.
During an interview on 10/10/19 at 2:29 P.M., the Social Service Director (SSD) said he/she:
-Does the letters of discharge with a bed hold policy and
-Had not been sending a letter to the family member/responsible party when the resident was their own person.
During an interview on 10/11/19 at 11:29 A.M., the SSD said:
-He/She sends a list to the Ombudsman at the beginning of each month for the previous month of all residents who were transferred or discharged from the facility;
-These two residents should have been on the list sent to the Ombudsman and
-He/she rechecked the list and also the EHR and the two resident's names were not on the list sent to the Ombudsman.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide services according to accepted standards of c...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide services according to accepted standards of clinical practice by pre-pouring medications during a medication pass for one unidentified resident and one supplemental resident (Resident #54) out of 6 sampled residents. The facility census was 82 residents.
Record review of the policy titled Safer Practice Notice, dated March 26, 2015 showed:
-Pre-pouring medication was the process of preparing medication in advance;
-The medication was to be stored until administered to the resident; and
-A review into patient/resident harm events had discovered that pre-pouring medications was unacceptable because the medications could not be accurately compared to the Medications Administration Record (MAR).
1. Record review of Resident #54's Face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-High blood pressure;
-Dementia (a group of thinking and social symptoms that interferes with daily functioning);
-Bipolar (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs); and
-Chronic obstructive pulmonary disease (COPD a group of lung diseases that block airflow and make it difficult to breathe).
Observation on 10/9/19 at 5:45 A.M., of the medication pass on 500 hallway with Licensed Practical Nurse (LPN) B showed:
-The resident's medication was in the top drawer of the medication cart in a medicine cup and
-One Oxycodone (a narcotic pain medication) five milligram (mg) pill was to be taken orally three times a day (was already popped into a medication cup before start of the medication pass).
2. Observation on 10/9/19 at 5:50 A.M. of the medication pass on 500 hallway with LPN B showed:
-An unidentified resident had two medications in his/her medication cup;
-The unidentified resident's medication was in the top drawer of the medication cart;
--LPN B identified the medications as Levothyroxine (used when the thyroid does not produce enough hormone) 50 microgram (mcg) pill to be taken once a day, and Omeprazole (used to treat heartburn) 20 mg pill to be taken once a day; and
-The medications were already popped into a medication cup before the start of the medication pass.
During an interview on 10/9/19 at 5:55 A.M. LPN B said:
-He/she should not pop the residents medications out of the containers;
-The resident's medications should be done individually not set up before the medication pass; and
-He/she knew better than to do that.
During an interview on 10/9/19 at 6:00 A.M. Certified Medication Technician (CMT) A said:
-The medications should be given to each resident after it is checked and
-You would never pre-set all the medications before the medication pass.
During an interview on 10/11/19 at 1:15 P.M. LPN A said:
-Each resident should be given their medications one at a time; and
-You don't pop all the pills before you start.
During an interview on 10/11/19 at 1:40 P.M. Registered Nurse (RN) A said:
-You give each resident their medication after you double check it;
-You should never set the resident's medication up before you start the medication pass; and
-It was wrong to do that.
During an interview on 10/11/19 at 4:00 P.M. the Director of Nursing(DON) said:
-He/she would not expect his/her staff to pre-set the medications for the medication pass; and
-The medications would be given to each resident individually after the nurse has verified it.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure pain medication was administered in a manner consistent with professional standards of practice by not making sure the resident's Me...
Read full inspector narrative →
Based on interview and record review, the facility failed to ensure pain medication was administered in a manner consistent with professional standards of practice by not making sure the resident's Medication Administration Record (MAR) and controlled medication records matched for one sampled resident (Resident #46), out of 18 sampled residents. The facility census was 82 residents.
1. Record review of Resident #46's Electronic Health Record (EHR) showed he/she was admitted to the facility 2/6/18 with diagnoses included chronic pain (pain that persists).
Record review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 8/24/19, showed he/she:
-Was cognitively intact;
-Was independent with activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting);
-Had an indwelling catheter (a tube passed through the urethra into the bladder to drain urine);
-Received as needed (PRN) and scheduled pain medication as well as non-pharmacological interventions;
-Had pain almost constantly that interfered with sleep at night and daily activities and
-Took opioid pain medication.
Record review on 10/8/19 of the resident's current care plan, dated 8/28/19, showed:
-He/she had chronic back pain and pain in other areas related to his/her history of fractures and other health concerns;
-The presence of daily severe pain limited his/her participation in activities;
-The resident's choice was to call for staff assistance only if he/she felt he/she needed it and
-Staff was to administer medications as ordered, monitor, and document side effects and effectiveness.
Record review of the resident's Physician's Order Sheet (POS) for October 2019 showed the following controlled medications:
-Oxycontin Tablet extended release (ER) 12 Hour Abuse-Deterrent 30 milligrams (mg), including the following instructions related to this medication:
--Give one 30 mg tablet by mouth (PO) every 12 hours for pain related to chronic pain syndrome;
--Do not give this med with PRN Oxycodone 20 mg at the same time; administer one hour in between doses;
-Oxycodone Hydrochloride (HCL - a common salt used to formulate medication) Tablet 20 mg, including the following instructions related to this medication:
--Give one tablet PO every 4 hours PRN for pain;
--Do not give within 1 hour of scheduled Oxycontin 30 mg;
--The start date was 10/3/19; and
-Morphine Sulfate (Concentrate) Solution 20 mg/milliliters (ml), including the following instructions related to this medication:
--Give one ml orally every 6 hours PRN for severe pain and
--The start date was 6/19/19.
Record review on 10/10/19 of the resident's October 2019 MAR showed he/she received the following controlled medications:
-An Oxycodone HCL 20 mg Tablet, PRN, 33 times between 10/3/19 and 10/10/19 at 11:20 A.M. and
-Morphine Sulfate Solution 20 ml, PRN, 18 times between 10/1/19 and 10/7/19.
Record review on 10/10/19 of the resident's Controlled Drug Record for Oxycodone HCL 20 mg Tablet, PRN, showed the resident received the controlled medication 38 times between 10/3/19 and 10/10/19 at 11:20 A.M.
Record review on 10/10/19 of the resident's Controlled Drug Record for Morphine Sulfate Solution 20 ml, PRN, showed the resident received the controlled medication 24 times between 10/1/19 and 10/7/19.
During an interview on 10/10/19 at 2:45 P.M. the Assistant Director of Nursing (ADON) said he/she could provide copies of controlled drug records for requested sampled residents.
During an interview on 10/10/19 at 3:16 P.M., the ADON said the controlled medication records should match the controlled medications on the MAR.
During an interview on 10/11/19 at 3:56 P.M., the Director of Nursing (DON) said he/she would expect the controlled drug records and the MAR to match.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to provide the correct Notice of Medicare Non-Coverage form (NOMNC, form CMS 10123) for three sampled residents (Residents #8, #71 and #235) w...
Read full inspector narrative →
Based on interview and record review, the facility failed to provide the correct Notice of Medicare Non-Coverage form (NOMNC, form CMS 10123) for three sampled residents (Residents #8, #71 and #235) who discharged from Medicare part A services, and to provide verification of a timely delivery of Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) and NOMNC for one resident (Resident #71) who was discharging from Medicare Part A services when his/her benefit days were not exhausted, out of three sampled residents. The facility census was 82 residents.
Record review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C-09-20), dated 1/9/09 showed the following:
-The NOMNC, form CMS-10123 is issued when all covered Medicare services end for coverage reasons and
-The SNFABN provides an estimated cost of items or services in case the beneficiary had to pay for them him/herself or through other insurance they may have.
Record review of the undated Form Instructions for the NOMNC CMS-10123 showed the NOMNC must be delivered at least two calendar days before Medicare coverage services end.
Record review of the facility's Business Office Policies and Procedures related to
SNF Notices of Medicare Non-Coverage Determination revised April 2012, showed:
-During the in-patient stay, the beneficiary or the person acting on his/her behalf is advised in writing at least two days prior to covered services ending or prior to discharge that the beneficiary no longer requires covered services;
-If unable to deliver the Beneficiary Notice personally to a person acting on behalf of a beneficiary, telephone the person on the same day it is known the services are not covered (minimum of two days prior to services ending); document the telephone contact, and issue a written notice on the same date;
-If unable to reach the person acting on behalf of the beneficiary, a minimum of two telephone attempts are completed and documented prior to mailing the written notice. In this case the date of notice is the date the beneficiary or their authorized representative signs (or refuses to sign) the notice, not the date the provider initiated the notice;
-All Beneficiary Notices with a cover letter are mailed using Certified Return Receipt Requested if unable to personally deliver the notice;
-Document date mailed, attach postage receipt to notice and attach the return receipt when received back;
-Maintain all Beneficiary Notices in the resident financial and medical files and
-Document telephone contact for Beneficiary Notices.
1. Record review of Resident #8's notification of non-coverage related to Medicare A showed the notification was not on the official Notice of Medicare Non-Coverage form (NOMNC, form CMS 10123).
2. Record review of Resident #71's notification of non-coverage related to Medicare A showed the notification was not on the official Notice of Medicare Non-Coverage form (NOMNC, form CMS 10123).
Record review of Resident #71's SNF Beneficiary Protection Notification Review sheet showed:
-The resident's last day of Part A Service was 9/23/19; and
-The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted.
Record review on 10/10/19 at 2:03 P.M. of the resident's SNFABN showed:
-Beginning on September 24, 2019 you may have to pay out of pocket for this care if you do not have other insurance that may cover these costs (room and board, and therapy);
-The reason Medicare may not pay: the resident's highest level of functioning had been reached for that skilled stay;
-The boxes to be checked for choosing an appeal option for the resident were not checked;
-The notice was not signed and dated by the resident or an authorized representative; and
-There was no Certified Return Receipt Requested receipt attached to the notice and
-There was no documentation of phone calls or the date the notice was mailed.
3. Record review of Resident #235's notification of non-coverage related to Medicare A showed the notification was not on the official Notice of Medicare Non-Coverage form (NOMNC, form CMS 10123).
4. During an interview on 10/10/19 at 1:40 P.M. the Business Office Manager said:
-He/she had always used the form he/she was currently using, but it was not the form from CMS, NOMNC Form CMS 10123; and
-A signature verifying the resident or representative has been notified of the ending Medicare Part A Services ending, should be obtained no less than two days prior to the services ending.
During and interview on 10/11/19 at 3:56 P.M., the Director of Nursing (DON) and the Corporate Nurse said:
-During morning meetings the Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) Coordinator would give Social Services staff the information regarding residents who's Medicare A Services were ending; and
-Social Services staff would be responsible for making sure notices were out 72 hours prior to the resident's Medicare A services ending.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a baseline care plan to the resident and their representati...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a baseline care plan to the resident and their representative for two sampled residents (Residents #17 and #71) out of 18 sampled residents, and two supplemental residents (Residents #33 and #10). The facility census was 82 residents.
Record review of the facility's Baseline Care Plan policy, dated December 2016, showed:
-A baseline care plan would be developed within 48 hours of the resident's admission and
-The resident and their representative would be provided a summary of the baseline care plan.
1. Record review of Resident #17's electronic health record (EHR) showed he/she was admitted to the facility on [DATE], and his/her diagnoses included Dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities).
Record review of the resident's care plan showed no documentation that a summary of the resident's baseline care plan was provided to the resident and his/her responsible party.
Record review of the resident's progress notes showed no documentation that a summary of the resident's baseline care plan was provided to the resident or his/her responsible party.
2. Record review of Resident #71's entry tracking form showed he/she was admitted to the facility on [DATE].
Record review of the resident's baseline care plan dated 7/2/19 showed no documentation that the baseline care plan or a summary of the baseline care plan was provided to the resident and their representative.
Record review of the resident's interdisciplinary notes dated 7/2/19 to 7/5/19 showed no documentation that the baseline care plan or a summary of the baseline care plan was provided to the resident and their representative.
During an interview on 10/8/19 at 9:45 A.M., the resident's representative said the facility did not go over the resident's plan of care within the first few days of the resident's admission and did not provide him/her with a baseline care plan or a summary of the baseline care plan.
3. Record review of Resident #33's entry tracking form showed he/she was admitted to the facility on [DATE].
Record review of the resident's baseline care plan dated 8/5/19 showed no documentation that the baseline care plan or a summary of the baseline care plan was provided to the resident and their representative.
Record review of the resident's interdisciplinary notes dated 8/5/19 to 8/11/19 showed no documentation that the baseline care plan or a summary of the baseline care plan was provided to the resident and their representative.
4. Record review of Resident #10's entry tracking form showed he/she was admitted to the facility on [DATE].
Record review of the resident's baseline care plan dated 7/14/19 showed no documentation that the baseline care plan or a summary of the baseline care plan was provided to the resident and their representative.
Record review of the resident's interdisciplinary notes dated 7/14/19 to 7/18/19 showed no documentation that the baseline care plan or a summary of the baseline care plan was provided to the resident and their representative.
5. During an interview on 10/10/19 at 10:11 A.M., the Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) Coordinator said:
-The nurses do the baseline care plan assessment form;
-The baseline care plan is probably not being given to the resident or the family and
-He/she should print out the baseline care plan the next day.
During an interview on 10/10/19 at 12:50 P.M., the Social Worker said he/she does not provide the resident and their representative with the baseline care plan.
During an interview on 10/11/19 at 9:32 A.M., Licensed Practical Nurse (LPN) A said:
-The nurses complete the baseline care plan assessment;
-He/she does not print out the baseline care plan and
-He/she does not give the baseline care plan to the resident or their representative.
During an interview on 10/11/19 at 3:55 P.M., the Director of Nursing (DON) said the MDS Coordinator was responsible for giving the baseline care plan to the resident and their representative.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
2. Observation on 10/9/19 at 6:00 A.M. of the Memory care unit CMT cart with CMT A showed:
-Memantine (a prescription medication used with Donepezil to treat Alzheimer's Disease) a five mg (per day) b...
Read full inspector narrative →
2. Observation on 10/9/19 at 6:00 A.M. of the Memory care unit CMT cart with CMT A showed:
-Memantine (a prescription medication used with Donepezil to treat Alzheimer's Disease) a five mg (per day) bottle was opened without an opened date written on it;
-Donepezil (a prescription medication to treat Alzheimer's Disease) a five mg bottle (to be taken at bedtime) was opened without an opened date written on it;
-Valporic Acid (a prescription medication used to treat seizures, bipolar manic episodes, and migraine headaches) a 250 mg/5 milliliter (ml) bottle was opened without an opened date written on it;
-A dirty (used) syringe was attached to the bottle (used to give the liquid medicine);
-Batteries were in the same compartment (a locked narcotics drawer) as prescription medications and
-A resident's gait belt (his/her name was on it) was in the same compartment as the residents' prescription medications.
During an interview on 10/9/19 at 6:15 A.M., CMT A said:
-He/she did not know why the batteries were in with the medications;
-The batteries were not a size used for anything that was used on the medication cart;
-He/she did not know why a resident's gait belt was in with the medications and
-He/she thought all of the medications should have had a date that they were opened written on them.
During an interview on 10/11/19 at 1:15 P.M. Licensed Practical Nurse (LPN) A said:
-The medications should be dated if they were opened and
-There should not be anything but medications in the medication cart.
During an interview on 10/11/19 at 1:40 P.M. Registered Nurse (RN) A said:
-There should not be anything else on the medication cart but medications and supplies and
-If a medication bottle or vial was opened there should be a date on it as to when it had been opened.
During an interview on 10/11/19 at 4:00 P.M. the Director of Nursing (DON) said:
-He/she would not expect to find medications that were opened without an opened date written on the bottle;
-He/she would not expect to find batteries if they were not used for something on the cart (such as a glucometer - to test the resident's blood sugar) and
-He/she would not expect to find a resident's gait belt on the medication cart.
Based on observation, interview, and record review, the facility failed to ensure medications were stored, labeled, and dated correctly for two sampled medication carts out of four sampled medication carts by not ensuring that the residents' prescription medications had opened dates written on them and by not ensuring personal belongings were not store in the medication drawers. The facility census was 82 residents.
Record review of the facility's policy, Administering Medications, dated December 2012 showed:
-The expiration date on the medication label must be checked prior to administering; and
-When opening a multi-dose container the date opened shall be recorded on the container.
Record review of the facility's policy, Medication Storage and Labeling, dated February 2017 showed:
-Medications and biologicals in medication rooms and carts would be maintained in a clean condition;
-Medications and biologicals in medication rooms and carts would be maintained in a sanitary condition and
-Multi-dose vials which have been opened should be dated.
1. Observation on 10/9/19 at 8:06 A.M., showed the Certified Medication Technician (CMT) B administering to one resident:
-Linzess 290 milligrams (mg) by mouth (PO) daily for constipation with a pharmacy reorder for after 10/19/19, with no open date on the bottle and
-Hair, skin, and nails supplement, one capsule PO daily with the resident's name on it and no opened date.
During an interview on 10/9/19 at 8:10 A.M., CMT B said that all opened containers of medications should be dated as when it was opened.
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: 2 life-threatening violation(s), 6 harm violation(s). Review inspection reports carefully.
- • 54 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $17,136 in fines. Above average for Missouri. Some compliance problems on record.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: Trust Score of 0/100 indicates significant concerns. Thoroughly evaluate alternatives.
✓ Report will be sent to your email
About This Facility
What is Meadow View Health & Rehabilitation's CMS Rating?
CMS assigns MEADOW VIEW HEALTH & REHABILITATION an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Missouri, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Meadow View Health & Rehabilitation Staffed?
CMS rates MEADOW VIEW HEALTH & REHABILITATION's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 60%, which is 13 percentage points above the Missouri average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.
What Have Inspectors Found at Meadow View Health & Rehabilitation?
State health inspectors documented 54 deficiencies at MEADOW VIEW HEALTH & REHABILITATION during 2019 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 6 that caused actual resident harm, and 46 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Meadow View Health & Rehabilitation?
MEADOW VIEW HEALTH & REHABILITATION is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by MO OP HOLDCO, LLC, a chain that manages multiple nursing homes. With 120 certified beds and approximately 83 residents (about 69% occupancy), it is a mid-sized facility located in HARRISONVILLE, Missouri.
How Does Meadow View Health & Rehabilitation Compare to Other Missouri Nursing Homes?
Compared to the 100 nursing homes in Missouri, MEADOW VIEW HEALTH & REHABILITATION's overall rating (1 stars) is below the state average of 2.5, staff turnover (60%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Meadow View Health & Rehabilitation?
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 you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the facility's high staff turnover rate, and the below-average staffing rating.
Is Meadow View Health & Rehabilitation Safe?
Based on CMS inspection data, MEADOW VIEW HEALTH & REHABILITATION has documented safety concerns. Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Missouri. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Meadow View Health & Rehabilitation Stick Around?
Staff turnover at MEADOW VIEW HEALTH & REHABILITATION is high. At 60%, the facility is 13 percentage points above the Missouri 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 Meadow View Health & Rehabilitation Ever Fined?
MEADOW VIEW HEALTH & REHABILITATION has been fined $17,136 across 1 penalty action. This is below the Missouri average of $33,250. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Meadow View Health & Rehabilitation on Any Federal Watch List?
MEADOW VIEW HEALTH & REHABILITATION is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.