CARMEL HILLS WELLNESS & REHABILITATION
For profit - Limited Liability company
194 Beds
EL DORADO NURSING AND REHABILITATION
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
16/100
#357 of 479 in MO
Photo by Esther Kaplan
Photo by Esther Kaplan
Photo by Patient Point
1 / 5 photos
Last Inspection: November 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Carmel Hills Wellness & Rehabilitation has received a Trust Grade of F, indicating significant concerns about the quality of care provided. It ranks #357 out of 479 facilities in Missouri, placing it in the bottom half of nursing homes statewide, and #27 out of 38 in Jackson County, meaning there are better local options available. While the facility is showing signs of improvement, as the number of issues decreased from 27 in 2024 to 9 in 2025, it still has a concerning history with 84 total issues found, including serious incidents like a resident being transferred improperly, leading to a fall without proper assessment, and delays in responding to critical changes in another resident's condition. Staffing is rated poorly with a turnover rate of 59%, which is average for Missouri, and there are $20,787 in fines, suggesting some compliance issues. On a more positive note, the facility does have good quality measures, with RN coverage that is average, meaning residents may have some consistent medical oversight.
- Trust Score
- F
- In Missouri
- #357/479
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 59% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ○ Average
- $20,787 in fines. Higher than 69% of Missouri facilities. Some compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 16 minutes of Registered Nurse (RN) attention daily — below average for Missouri. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 84 deficiencies on record. Higher than average. Multiple issues found across inspections.
16/100
Bottom 26%
Review needed
27 → 9 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★★☆
4.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 27 issues
2025: 9 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
1-Star Overall Rating
Below Missouri average (2.5)
Significant quality concerns identified by CMS
Staff Turnover: 59%
13pts above Missouri avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $20,787
Below median ($33,413)
Minor penalties assessed
Chain: EL DORADO NURSING AND REHABILITATIO
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (59%)
11 points above Missouri average of 48%
The Ugly 84 deficiencies on record
1 life-threatening 1 actual harm
May 2025
7 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
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 failed to notify the legal guardian of one discharged resident (Resident #6),...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the legal guardian of one discharged resident (Resident #6), in a timely manner (usually within 24 hours) after the resident passed away. The facility also failed to notify the facility's Business Office Manager (BOM) in a timely manner, which caused the business office to cash a check sent by the legal guardian's office to the facility, 14 days after the resident passed away out of 19 sampled residents. The facility census was 143 residents.
On 5/21/25 the Administrator were notified of the past noncompliance that occurred on 3/26/25. All staff were educated on the notification policy. The deficiency was corrected on 4/22/25.
Review of the Facility's policy entitled Change of Condition Notification revised 6/20, showed:
-Purpose: To ensure residents, family, legal representatives, and physicians are informed of changes in the residents' condition in a timely manner.
-Definition: An Acute Change of Condition (ACOC) is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains, Clinically important means a deviation that without intervention, may result in complications or death.
-Members of the Interdisciplinary Team (IDT) are expected to report and document signs and symptoms that might represent an ACOC.
The facility will promptly inform the resident, consult with the resident's Attending Physician, and notify the resident's legal representative when the resident endures a significant change in their condition caused by, but not limited to:
-Family Notification: The licensed Nurse will notify the resident, he resident's responsible party or the family/surrogate decision makers of any changes in the resident's condition as soon as possible.
--Documentation: A licensed Nurse will document the following:
--Date, time and pertinent details of the incident and the subsequent assessment in the nursing notes.
--The time the attending physician was contacted, the method by which he/she was contacted, the response time and whether orders were received.
--The time the family/responsible person was contacted.
1. Review of Resident #6's admission record printed on 5/16/25, showed he/she admitted on [DATE] with the following diagnosis:
-Unsteadiness on his/her feet.
-Alzheimer's disease (a progressive neurological disorder that primarily affects the brain, causing memory loss, thinking problems, and behavioral changes) with late onset; need for assistance with personal care.
-Hyperlipidemia (a condition where there are elevated levels of fats (lipids) in the blood).
-The resident's legal guardian was the Public Administrator's Office and was listed as the first contact.
Review of the resident's Progress Notes dated 3/26/25, showed:
-At 9:07 A.M. The resident was actively dying. Comfort medications only. There was no documentation of notification of the legal guardian.
-At 10:15 A.M., The hospice (end of life care) Case Manager was at the facility with Comfort Medications. The resident's relative was at the bedside of the resident. There was no documentation of notification of the legal guardian.
-At 11:02 A.M., The pulse and respirations quietly ceased at 10:57 A.M., with the resident's relative and the hospice nurse at the bedside of the resident. There was no documentation of notification of the legal guardian.
-At 12:10 P.M., the Post Mortem provide by the hospice nurse. The body was released to the funeral home transportation at this time. Death report was faxed to the local County Medical Examiner. There was no documentation of notification of the legal guardian.
Review of a check dated 4/3/25, showed a check from the legal guardian was made payable to the facility for $1,580.09.
Review of the deposit sheet dated 4/9/25 and the batch report (a report which showed a batch of checks which were processed into the facility's account) dated 4/9/25, showed the check from the legal guardian was processed on 4/9/25, 14 days after the resident passed away.
During an interview on 5/14/25 at 9:24 A.M., the Business Office Manager (BOM) said:
-He/she was on vacation from 3/12/25 through 4/1/25.
-Therefore, he/she did not find out the resident passed away until 21 days after he/she returned to duty at the facility.
-He/she notified the corporate business office on 4/23/25 that the legal guardian needed a refund because the resident passed away.
During a phone interview on 5/14/25 at 12:04 P.M., the legal guardian said the following:
-The office of the legal guardian was not notified of the Resident's death.
-He/she expected his/her office within 24 hours after a ward (a person, for whom a guardian has been appointed by a court or who has become directly subject to the authority of that court) of that office has passed away, because the Office of the legal guardian has to notify Medicaid, Social Security, and Medicare because the ward may have been recipient of some of that aide.
-The resident was on hospice (a program that gives special care to people who are near the end of life and have stopped treatment to cure or control their disease).
-The methods of contacting him/her were the main office phone number, the after-hours number, his/her e-mail, and his/her work phone.
-The process of notifying the guardian's office, if the Deputy Legal Guardian, were not there, would be let the clerical person know there was a death of one of the wards and the phone call would be transferred to another deputy Legal Guardian.
-It was not until 4/22/25, that his/her assistant was informed the resident had passed away when his/her assistant went to the facility to do a monthly visit of their wards at that facility.
-The facility did not submit any paperwork
During a phone interview on 5/14/25 at 3:04 P.M., the Deputy Legal Guardian's Assistant said the following:
-He/she went to the facility on 4/22/25 for a monthly visit and stated he/she wanted to Resident #6.
He/she was directed to the business office.
-At the business office, he/she was told that Resident #6 passed away and the date that Resident #6, passed away.
-He/she was very surprised to hear than one of the wards of the Legal Guardian's office had passed away.
-He/she did not hear about the resident's death, until she got to the facility. and
-No one in her office received a phone call from the facility regarding the death of the resident.
During an interview on 5/16/25 at 10:38 A.M., Licensed Practical Nurse (LPN) A said:
-He/she was the charge nurse for his/her unit the day the resident passed away.
-He/she had not notified the business Office the resident passed away.
-He/she did not notify the legal guardian's office because when Hospice was in the facility, Hospice was in charge of notify the family and legal guardians.
During an interview on 5/16/25 at 10:48 A.M., the Director of Nursing (DON) said hospice mentioned they notified the Legal Guardian's office.
During an interview on 5/16/25 at 11:38 A.M., Assistant Director of Nursing (ADON) A said:
-If a hospice staff member was in the facility when a death occurs, hospice was supposed to notify the Legal Guardian.
-He/she was told by a hospice staff member that a nurse from hospice notified the PA's office.
During an interview on 5/16/25 at 1:36 P.M., the Administrator said:
-The former Social Service Director (SSD) said he/she reached out by calling the Deputy Legal Guardian's mobile phone.
-He/she found out later that the SSD did not reach out to anyone at the Legal Guardian's Office.
-He/she found out in April 2025 that the Deputy Legal Guardian was not notified after the death of the resident.
-Based on his/her understanding of the situation, the BOM posted the checks into the accounts, without looking at the dashboard he/she was supposed to normally look at.
During a phone interview on 5/19/25 at 2:48 P.M., Hospice Licensed Practical Nurse (LPN) A said:
-On 3/25/25, he/she called the legal guardian and left a message for the legal guardian that the Resident was in the process of dying.
-The hospice Agency only does the notification to the legal guardian if there was no one at the bedside on the resident behalf and since the resident's relative was at the bedside, the hospice agency did not have to notify the legal guardian.
-The Facility should have notified the legal guardian.
MO00253155
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
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #5's Face Sheet showed the resident was admitted on [DATE], with diagnoses including diabetes, heart disea...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #5's Face Sheet showed the resident was admitted on [DATE], with diagnoses including diabetes, heart disease, stroke, high blood pressure and asthma.
Review of the resident's admission MDS dated [DATE], showed the resident:
-Was alert with significant confusion.
-Needed substantial assistance with transfers, mobility, bathing and dressing.
Review of the resident's Care Plan updated 2/13/25, showed the resident had impaired cognitive functioning, vision loss, was at risk for falls, was incontinent and had a self care deficit. Interventions showed the resident was dependent on staff for bathing and staff was to provide maximum assistance to the resident.
Review of the resident's bathing sheets from 3/24/25 to 5/8/25, showed the resident received bathing on the following dates:
-March-3/24/25
-April-4/2/25, 4/11/25, 4/18/25, 4/25/25
-May-5/1/25, 5/8/25
-Bathing for the resident was once per week.
Review of the resident's Medical Record showed there was no documentation showing the resident declined bathing.
During an interview on 5/16/25 at 11:01 A.M., showed Certified Medication Technician (CMT) A said:
-He/She worked with the resident and the resident had some cognitive impairment and needed total assistance for transfers.
-The resident needed total care, to include bathing and mobility assistance.
-The resident was supposed to receive bathing twice daily.
-They have bathing assistants but he/she was not sure if the resident received bathing twice every week while he/she was living there.
3. During an interview on 5/16/25 at 1:38 P.M., showed CMT B said:
-They try to have two bath aides to give the baths to residents.
-One of the bath aides worked consistently on Monday, Tuesday, Thursday and Friday and the other bath aide worked on the other days, but they do not have a bath aide on weekends.
-Both bath aides try to get as many baths completed as possible when they are here but they are giving baths to 90 or more people.
-Residents do not always get two baths weekly.
During an interview on 5/16/25 at 1:42 A.M., CNA A said:
-The bath aides were responsible for giving baths twice weekly.
-The primary bath aide gave baths four days weekly and they try to get as many baths as they can, but the resident's get at least one bath weekly.
-There were no bath aides working today.
-When the bath aides call in, the CNA staff try to get baths done as they are able and they complete the shower/bathing sheet and turn it in.
During an interview on 5/16/25 at 1:48 P.M. Registered Nurse (RN) A said:
-The bath aides were supposed to give each resident a bath/shower twice weekly.
-When the bath aide was not in the building, or was unable to give baths, the CNA staff was supposed to try to give the baths or make up the bath for the resident.
-He/She had not been in the facility for a few weeks, but the CNAs were expected to assist with giving baths so the residents get baths twice weekly.
-The bath aide had called in today and no baths had been given today.
During an interview on 5/16/25 at 1:51 P.M., Assistant Director of Nursing (ADON) A said:
-Residents were supposed to get baths/showers at least twice weekly.
-There were two bath aides on the long term care unit and one on the rehabilitation unit.
-There was no bath aide on the dementia unit and the CNA staff on the unit completed the baths weekly.
-All of the nursing staff were educated that if the bath aide was not there they were supposed to give baths/showers.
-He/She has also given baths/showers to residents
-They were trying to find additional staff to fill a bath aide position.
-Currently, residents were getting at least one bath per week, but not two.
-He/She did not believe the CNA staff were meeting their expectation because baths should be given on every shift and not by only the bath aide.
3. During an interview on 5/16/24 at 2:00 P.M., the Director of Nursing (DON) said:
- Assigned Restorative Aides (RA) and Bath Aides were over all responsible for offering and providing the resident a bath or shower two times a week.
-He/she would expect the CNA's and bath aides to ensure the resident was offered and received showers/bathing at least two times a week.
-He/she would expect the CNA's who were assigned to a specific hallway, to be responsible for ensuring the residents received scheduled baths/showers assigned for that day and the resident was kept well-groomed and clean.
-He/she would expect the shower sheet be completed by the staff who had provided the resident's shower/bath.
-He/she would expect the shower sheet to be reviewed by the charge nurse and signed as reviewed.
MO00252740 & MO00253115
Based on observation, interview and record review, the facility failed to follow their policy to ensure bathing was completed two times a week for two sampled residents (Resident's #9 & #5) out of 19 sampled residents. The facility resident census of 143 residents.
Review of the facility's undated Bathing/Shower Program policy showed:
-The resident will initially be placed on the schedule of two baths/showers per week, which may be adjusted to more or less often according to the resident's preference.
-Showers/baths will be available 24 hours per day as the resident request.
1. Review of resident #9's admission Record showed he/she had the following diagnosis:
-Absence of a right leg below the knee.
-Needs assistance with personal care.
Review of the resident's Quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 2/21/25 showed he/she:
-Had a moderate cognitive impairment.
-Was frequently incontinent of urine and frequently incontinent of bowel.
-Had no documentation related to rejection of cares noted.
Review of the resident's Activity of Daily Living (ADL'S) Care Plan revised on 2/13/25 showed:
-He/she has self care deficit related to a right below the knee amputation.
-He/she was dependent on facility staff for personal cares and bathing.
Review of the resident's Certified Nursing Assistant (CNA) Care Kardex (summary of how to care for the resident) showed the resident required assistance with bathing and personal.
Review of the resident's CNA Shower Sheet and Skin Condition reporting form from 4/1/25 to 4/29/25 showed:
-On 4/1/25 and 4/4/25, he/she had received a bath.
-On the week of 4/6/25 to 4/12/25, he/she received one bath on 4/11/25.
-On 4/15/25 he/she received a bath and none the rest of the week.
-No baths were recorded for the week of 4/20/25 to 4/26/25.
-On 4/29/25 he/she received a bath.
-The resident received five showers out of nine opportunities.
Review of the resident's CNA Shower Sheet and Skin Condition reporting form showed:
-On 5/2/25 documentation of a shower given and no skin issue noted.
-On 5/5/25, the staff did not indicate type bath or shower was given.
-On 5/8/25, the staff did not indicate type of bath or shower was given.
Observation and interview 5/14/25 at 10:25 A.M., the resident said:
-He/she was getting at least one bath a week.
-He/she had no lingering odors at that time of interview.
During an interview on 5/16/25 at 8:00 A.M., CNA B said:
-The facility has one or two bath aides assigned during the week to provide the residents baths/showers.
-If the facility does not have a bath aide assigned that day, then CNA staff assigned to each hall would be responsible for ensuring and completing their resident's scheduled shower that day.
-CNA staff who provide the shower for their assigned resident would be responsible for completing the shower sheets and they were to be reviewed by nursing staff.
During an interview on 5/16/25 at 10:55 A.M., CNA C said:
-The resident was able to make his/her care needs known.
-The residents were scheduled to have a bath or shower two times a week.
-The resident would normally receive bath/shower from the bath aides at least weekly, if not two times a week when bath aides are scheduled.
-The CNA's are also responsible for providing showers/baths to those residents assigned that day, if no bath aides were scheduled.
-He/she does not always have time to provide a shower/bath for the resident when a bath aide not available.
-The bath aide had called in sick today (5/16/25), so most likely those residents scheduled for baths today will not be completed.
-The staff providing the shower would be responsible for completing the shower sheet to include type of bathing provided.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one sampled resident (Resident #17) was supervi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one sampled resident (Resident #17) was supervised during smoking times. On 5/15/25 the resident was outside on the smoking patio when the wind came up and the resident's hair caught fire. Hospitality Aide B failed to report the smoking incident which resulted in a delayed burn treatment for the resident. The facility further failed to ensure resident electronic smoking materials were stored safely and not used in the facility for one sampled resident (Resident #9) who had a Electronic-cigarettes (also known as e-cigarettes/vape pen are battery-operated devices that heat a liquid and produce an aerosol) found in the resident bed, and also observed on bedside table, out of 19 sampled residents. The facility census was 143 residents.
Review of the Facility's Smoking by Resident Policy revised on 6/2020 showed:
-This policy applies to the use of both cigarettes and e-cigarettes.
-Smoking is not allowed anywhere inside the facility.
-Resident who choose to smoke will be assessed for their ability to smoke safely prior to being allowed to smoke in designated smoke areas.
-Resident will be allowed to smoke in designated smoking areas only.
-All smoking materials will be stored in a secure area to ensure they are kept safe.
-All smoking area session will be supervised by facility staff members.
Review of copy of undated Resident's Smoking Violation policy/Agreement showed:
-Smoking by resident will occur under the direct supervision of facility staff or delegated volunteer. The resident smoking care plan indicate type supervision needed.
-The resident will be assessed and evaluated for safe smoking and if can smoke independently or with supervision.
-Smoking supplies will be labeled with the resident name, room number and bed number, maintained by facility staff and stored in a suitable cabinet the kept lock at nursing station.
-If resident cognitively and physically able to secure all smoking materials, the facility may allow him/her to maintain his/her own tobacco or electronic cigarette product in a locked compartment.
-No resident will be allowed to maintain their own lighter fluid or matches.
Review of the facility undated guidelines for Hospitality Aid and All staff, resident smoking showed:
-Smoking materials locked up in the smoking cart. Resident should not have smoking material in possession.
Review of the Facility's policy entitled Change of Condition Notification revised 6/2020, showed:
-Purpose: To ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner.
-The facility will promptly inform the resident, consult with the resident's Attending Physician, and notify the resident's legal representative when the resident endures a significant change in their condition caused by an injury /accident,
The Licensed Nurse will notify the residents Attending Physician when there is an:
-Incident/accident involving the resident which results injury and has the potential for requiring physician intervention.
Review of the Facility's Smoking by Resident Policy revised on 6/2020 showed:
-Resident who choose to smoke will be assessed for their ability to smoke safely prior to being allowed to smoke in these smoke areas.
-All smoking area session will be supervised by facility staff members.
Review of copy of undated Resident's Smoking Violation policy/Agreement showed:
-Smoking by resident will occur under the direct supervision of facility staff or delegated volunteer. The resident smoking care plan indicate type supervision needed.
-The resident will be assessed and evaluated for safe smoking and if can smoke independently or with supervision.
Review of the facility undated guidelines for Hospitality Aid and All staff related to monitoring residents who smoke showed burns should be reported immediately to the nurse on duty.
Review of the Hospitality Aid job description revised 12/2023 showed:
-Monitor residents during smoking hours (in the facility designated smoke area). Chart and keeps track of cigarette counts for each resident, updates and organizes smoking book, log and storage.
-Identifies and correct safety hazards and reports safety concerns as required.
1. Record review of Resident #17's admission Record showed he/she had the following diagnoses:
-Cerebrovascular Accident (CVA, stroke a blockage in the one or more of the arteries supplying blood to the brain) affecting left non-dominant side.
-Nicotine Dependence-cigarettes.
-Chronic Obstructive Pulmonary Disease (COPD-a disease process that decreases the ability of the lungs to perform ventilation.)
-Bipolar (A disorder associated with episodes of mood swings ranging from depressive lows to manic highs).
-Lack of coordination.
-He/she was own responsible party.
Review of the resident's smoking care plan dated 11/19/24 showed:
-He/she had been advised of the facility smoking policy.
-The resident required supervision while smoking.
-Reassess the resident's smoking ability quarterly and after reported unsafe smoking practices.
Review of the resident's Annual Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning), dated 3/25/25 showed he/she:
-Was cognitively intact.
-He/she was able to understand others and make his/her needs known.
-Required supervision from staff for most cares.
-Used tobacco.
Review of the resident's Burn and Blister Incident Report from 5/15/25 at 11:00 A.M., showed:
-The report was documented and reported on 5/17/25.
-Nurse description: The resident received burns to his/her left ear while outside smoking. The resident stated the wind was blowing and the ashes from the end his/her cigarette blew in his/her hair and caught his/her hair on fire and burned his/her ear.
The resident said he/she had asked HA B not to report the incident to the nurse because he/she did not want to have to wear burn apron. HA B did not report this information to nursing, the Director of Nursing (DON) or to the Administrator. The resident did finally tell the nurse on 5/17/25 that he/she was burned three days ago, and his/her ear was hurting.
-Intervention were put in place at that time. All staff was educated on all incidents must be reported regardless of what the resident requests. The resident care plan has been updated to wear a burn apron when smoking and to braid his/her hair or ensure his/her hair is secured while smoking.
-On 5/18/25 root cause documented by DON showed: The incident was primarily due to environmental factors, specifically the wind conditions and an isolated failure by HA B to follow established oversight protocols.
-Reinforce of the facility policy that all incidents must be reported immediately.
-Regular training session for staff on safety protocols and incident reporting.
-Environmental assessments to mitigate risk associated with outdoor smoking areas.
Review of the resident's Weekly Skin Check dated 5/17/25 at 8:45 A.M. showed:
-He/she had new skin impairment of burn to his/her left ear.
-No detail description noted of the area burn.
Review of resident's Wound Assessment Detail Report dated 5/17/25 at 1:47 P.M. showed:
-The resident had a facility acquired burn injury to his/her left ear.
-The left ear tissue was deep purple with scant amount of drainage noted.
-The burn area measured length of 1.20 centimeters (cm) by width of 0.9 cm.
-Apply Silvadene ointment every shift.
Review of the resident's Physician Order Sheet (POS) dated 5/17/25 showed an physician order for Silvadene External Cream 1% (is a topical antibiotic used to prevent and treat infections in second- and third-degree burns) to apply cream to his/her left ear every shift for burn.
Review of the facility's Summary of Events date reported on 5/17/25 showed:
-Incidents happen on 5/15/25 at 11:00 A.M. in outside smoking area.
-On 5/15/25, the resident was outside smoking when the wind cause ashes from the end of his/her cigarette to blow into his/her hair, igniting his/her hair and resulting in a burn to his/her left ear.
-The resident chose not to report the incident immediately due to concerns about wearing a burn apron.
-HA B who was with the resident had not reported the incident per the resident's request.
-On 5/17/25, the resident informed the nurse about the burn, which had been causing him/her pain for three days. The DON, Administrator, and Primary Care physician (PCP) were notified immediately.
-Conclusion documented: The incident was primarily due to environmental factors, specifically the wind conditions and an isolated failure by HA B to follow established oversight protocols. This incident underscores the importance of strict adherence to safety protocols and environmental consideration in preventing accidents. The failure to report the incident promptly was an isolated case involving a staff member who did not follow the rules. Measure have been taken to prevent recurrence and ensure the safety and well-being of all residents.
Review of the resident's POS dated 5/19/25 showed a physician order for Doxycycline Hyalite (antibiotic It's used to treat a wide range of bacterial infections and also has anti-inflammatory properties) oral capsule 100 milligrams (mg) give one tab by mouth every 12 hours for the burn to his/her ear until 5/27/25.
Review of the resident's Medical Nurse Practitioner (NP) Note dated 5/19/25 at 3:10 P.M. showed:
-Reason for visit due to resident's burn to his/her left ear.
-Evaluation for follow-up of burns to the resident's left ear cause by a smoking incident.
-Exam showed the resident had a first-degree burn and second degree burn to his/her left ear.
-Started treatment for the burns with Silvadene cream and will start Doxycycline antibiotic prophylactic and will continue to monitor the resident.
-Wound care by nursing staff to monitor daily and call with adverse reaction.
-Monitor resident during smoking as per facility protocols.
Observation on 5/20/25 showed the resident's left ear had white cream on lower lobe and noted yellowish dried crusted drainage on the lower ear lobe.
Review of the resident's handwritten witness statement dated 5/17/25, documented and witness signature by License Practical Nurses (LPN) B showed the resident said:
-On 5/15/25, While out at the smoke area, he/she tried to light a cigarette.
-It was windy, and his/her hair caught fire.
-He/she and the roommate shouted for HA-B to bring the fire blanket.
-HA-B did not act very quickly and his/her roommate rubbed out the fire.
-He/she had pleaded with HA-B not to report the resident's fire, because he/she was afraid of consequences for the incident.
-On 5/17/25 he/she started to scratch his/her ear and now was painful.
-He/she was not aware he/she had a burn injury on his/her ear.
During an interview on 5/20/25 at 8:25 A.M., the resident said:
-On 5/15/25 in the afternoon (unsure time, after lunch) the resident was outside in smoke area.
-He/she was sitting with his/her roommate in the uncovered smoke area.
-He/she was not in visual site of HA-B, who inside the smoking covered carport area.
-It was very windy that day, he/she did not have his/her hair in a braid or ponytail, that day.
-He/she was trying to light his/her cigarette, when his/her hair had caught on fire.
-He/she was not aware that his/her hair was on fire until his/her roommate notice and tried to put the fire out him/herself while yelling for HA -B to assist and to grab the smoke blanket.
-HA-B came around the corner to assist his/her roommate put the fire out.
-He/she had begged HA-B not to report the fire incident to nursing staff.
-HA-B informed the resident he/she need to notify the nursing staff, but the resident did not want nursing staff to know because he/she did not want to have wear the safety smoke apron while smoking.
-He/she did not realize he/she burnt his/her left ear until two days later on 5/17/25, after he/she scratched his/her ear and broken a blister.
-On 5/17/25, LPN B found out about the smoking incident and did a skin assessment of the resident's left ear. LPN B had received orders for burn treatment, to apply burn ointment two times a day.
-He/she was educated by the DON on safe smoking to included prevention safety measure to include he/she was to ensure to place hair in braid or ponytail while smoking and he/she was required to wear the smoke apron while outside smoking.
Observation on 5/20/25 at 8:35 A.M., showed:
-The resident was wheeled himself/herself outside to the smoking area.
-He/she grabbed a smoke apron prior to exiting the facility.
-While outside, HA A assisted the resident with placement of the smoke apron.
-The resident had wheeled himself/herself over to place where the fire incident happened on 5/15/25.
-He/she was located outside the smoke carport area to right and sat by the open smoke area by the covered ashtray.
Record review of Resident's #11's (roommate) dated 4/11/25, showed he/she was cognitively Intact.
Review of Resident #11's handwritten undated witness statement showed:
-On 5/15/25, while out at the smoke area all of sudden Resident #17 was yelling for help that something was biting his/her ear.
-As, he/she turned around to look at the resident the left and right side of his/her hair was on fire as well as his/her left ear.
-He/she immediately started smacking Resident #17's head and yelling for help, specifically for the fire blanket.
-HA B came around the corner to see what was going on.
-HA B seemed to be confused as what to do.
-HA B told Resident #17 needed to report the incident.
-Resident #17 was afraid of the consequences.
-The resident's left the smoke area went back into their room.
During an interview on 5/20/25 at 10:04 A.M., Resident #11 said:
-On 5/15/25 in afternoon he/she and Resident #17 were outside smoking.
-The HA B was located inside the smoking carport area. HA B was not able to see them because they were out in courtyard area smoking.
-He/she heard Resident #17 yelling for help that something had stung his/her ear.
-He/she turned around and saw Resident #17's hair was inflamed with fire.
-He/she went over started hitting Resident #17's head to get the flames out.
-He/she was scared at that time.
-Resident #17 thought he/she was stung by a wasp but Resident #17's hair was on fire.
-He/she yelled for HA B to come to assist and bring the smoke blanket.
-His/her fingers were tingling after he/she slapped the fire out on Resident #17's head but he/she had no burns .
-No resident or staff were notified of what happened.
-He/she encouraged Resident #17 to call his/her daughter and tell the nursing staff about the burn.
-HA B flipped the resident's hair back but did not look at the resident's ear or skin.
-On 5/16/25 he/she noticed Resident #17 had blisters on his/her left ear.
-On 5/17/25 he/she told LPN B about the smoking incident and Resident #17 had a burn blister to his/her left ear.
Review HA B employee file on 5/20/25 showed:
-A Corrective Action Memo dated 5/17/25.
-Type of violation was insubordination.
-Employer stated the employee neglected to notify anyone of incident when a resident caught his/her hair on fire which resulted in a burn.
-The employee was suspended pending investigation.
Review of HA B handwritten witness statement dated 5/19/25 showed:
-He/she was outside on Thursday 5/15/25 in the smoke area.
-Resident #17 and Resident #11 were outside smoking with other unknown residents.
-Resident had called for HA-B to help Resident #17.
-He/she came around the corner of smoking carport, and sure enough Resident #17 hair was on fire.
-HA-B and Resident #11 assisted getting the fire out.
-Many times, he/she had told Resident #17 they needed to report the smoking incident to the nurse.
-Resident #17 did not want HA B to report smoking incident to the nurse.
-He/she should had reported the smoking incident but, he/she did not report the fire. He/she had written, was My fault, and he/she was sorry.
-He/she was notified by the DON on 5/17/25 related to the incident on 5/15/25 and did not complete a witness statement until 5/19/25.
During an interview on 5/20/25 at 8:10 A.M., HA A said:
-He/she worked as a smoke aid from 7:00 A.M. to 3:00 P.M.
-He/she was not working on 5/15/25 when smoke incident happened.
-He/she had worked on Friday 5/16/25 as a smoke aid and Resident #17 had his/her hair down that day and did not see the resident's left ear.
-He/she was not informed nor aware of any smoking incident that had happen on 5/15/25 until 5/17/25.
-On Saturday 5/17/25 he/she was completing his/her resident safety smoking check which include checking resident clothing for burn holes and burn on the resident hands and fingers from smoking.
-He/she would have notified the charge nurse immediately if noted any resident with clothes with burn holes or skin burns noted.
-On 5/17/25 Resident #17 was going out to smoke with his/her hair in a braid and that's when he/she notice Resident #17 had blisters on his/her left ear.
-He/she immediately asked Resident #17 what happen to his/her ear.
-Resident #17 said on Thursday 5/15/25, he/she and peers were out smoking while being supervised by HA B when his/her hair caught on fire trying to ash his/her cigarette.
-Resident #17 had asked HA B not to report his/her smoking/fire incident from 5/15/25 to nursing staff.
-He/she would immediately report any smoking incident immediately to charge nurse or administrative staff.
Review of Resident #18 Quarterly MDS dated [DATE] showed he/she was cognitively Intact.
During an interview on 5/20/25 at 8:13 A.M., Resident #18 said:
-He/she was outside smoking on 5/15/25 when the fire incident happened.
-He/she and HA B were under the smoking carport area.
-Resident #17 and Resident #11 were sitting outside to right of the carport out view by HA B.
-Resident #17's hair caught on fire, as heard Resident #11 yelling for HA B to get the smoke blanket.
-HA B went around to outside of the carport to see what had happened and the fire was already put out by Resident #11.
-He/she heard Resident #17 asking HA B not to report the smoking incident to nursing staff.
-He/she did not report the smoking incident from 5/15/25 to nursing staff.
During an interview on 5/20/25 at 9:40 A.M., Administrator said:
-He/she was not notified of the smoking incident occurred on Thursday 5/15/25 until Saturday 5/17/25.
-The facility started their smoking incident report and investigation on 5/17/25 to include obtaining witness statements from resident and staff and assessment of the resident.
-Resident #17 was assessed by LPN B and burn treatment order received on 5/17/25.
-Resident #17 did not require emergency medical treatment or hospitalization for burn care.
-HA B was suspended until further investigation for not reporting smoking incident immediately to nursing staff after it happen on 5/15/25.
-He/she would expect all facility staff to report any resident incident immediately to nursing staff and administrative staff.
During an interview on 5/20/25 at 11:56 A.M., LPN B said:
-On 5/17/25 HA A reported Resident #17 had a burn blister to his/her left ear from a smoking incident that happen on 5/15/25. The resident had scratched his/her ear was painful and had opened up the blister.
-Resident #17 said on 5/15/25 it was very windy and his/her hair had caught fire. Resident #17 and HA B did not report the smoking incident to nursing staff.
During an interview on 5/20/25 at 12:08 P.M., NP A said:
-On 5/17/25 he/she was notified by LPN B of the resident's smoking incident that happen on 5/15/25.
-On 5/17/25 the resident was examined and had a second degree/third degree burn to his/her left ear, the skin was broken open.
-He/she had ordered Silvadene cream 1% apply every shift.
-On 5/19/25 he/she ordered an antibiotic to be given due to increased risk for infection with burns.
-He/she would expect all facility staff to follow the policy of reporting any incident immediately to nursing staff or administrative staff member.
-He/she would expect the resident to follow the smoking policy related safe smoking.
During an interview on 5/20/25 at 1:30 P.M., DON said:
-He/she was notified on the morning of 5/17/25, that Resident #17 had a smoking incident on 5/15/25 that resulted in a burn to his/her left ear.
-Root cause analysis of the smoking incident showed it was a windy day causing ash to fly into the resident's hair cause the fire. HA B, Resident #17 and Resident #11 did not report the smoking incident on 5/15/25 to nursing staff which delayed medical care for Resident #17's burn to left ear for two days.
2. Review of resident #9's admission Record showed he/she had the following diagnosis:
-Absence of right leg below the knee.
-Needs assistance with personal care.
-Uses tobacco.
Review of the resident's Plan of Care revised on 11/24/25 showed:
-The resident was dependent on tobacco.
-All facility staff were to notify the social services or Administrator immediately if it is a suspected resident had violated the facility smoking policy.
-NOTE: The resident's care plan did not show the resident vaped using a e-cigarette.
Review of the resident's Quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning), dated 2/21/25 showed he/she:
-Had a moderate cognitive impairment.
-Had no documentation related to rejection of cares noted.
-Uses tobacco.
Review of the resident's Safe Smoking Evaluation dated 2/28/25 showed:
-The resident smokes.
-He/she able to independently light smoking material safely.
-He/she was safe to smoke with minimal supervision.
-Had no documentation that smoking material was storage in the resident's room.
-The facility did not have a specific Safe Smoking Assessment for residents that use e-cigarettes.
Review of the resident's medical record on 5/20/25 showed no documentation that the resident used e-cigarettes or could store smoking material at bedside.
Observation and interview on 5/14/25 at 10:25 A.M., showed:
-The resident laid in his/her bed covered up with blankets. He/she was looking for his/her e-cigarette.
-He/she had found the square vape pen, the size of his/her palm of his/her hand, located under the resident's blankets.
-He/she does use the e-cigarettes while in his/her room most of the time.
-He/she requires assistance with transfer and was easier to just use e-cigarettes while in room.
Observation on 5/16/25 at 5:45 A.M. the resident showed:
-He/she was in bed with eyes closed.
-The e-cigarette was located on top of bedside table within the resident's reach.
Observation on 5/16/25 at 11:02 A.M., showed:
-The resident was sitting up in wheelchair.
-He/she had e-cigarette on bedside table, he/she asks for assistance reaching for the e-cigarette off the bedside table.
During an interview on 5/16/25 at 11:03 A.M., the resident said:
-He/she will go out to smoke some days, but he/she uses his/her e-cigarette while in his/her room.
-He/she did not have secure place to store vape pens.
During an interview on 5/14/25 at 12:35 A.M., Hospitality Aid (HA) A said:
-He/she has a list of residents that smoke, and the type of assistance needed.
-The resident does go outside to smoke, but does not go out to smoke every day.
-He/she noted the resident did use his/her e-cigarettes outside in smoke area.
During an interview on 5/16/25 at 7:55 A.M., HA A said:
-He/she not aware of any resident that uses e-cigarette while inside the facility.
-E-cigarettes should be use in supervised designated smoke areas only.
-All tobacco smoking material should be stored in the locked smoking cart.
-The resident that use e-cigarettes atre normally kept in the resident's room or carried with the resident.
-Most e-cigarette required to be charged.
-He/she not aware of any e-cigarette stored in the secured smoke material cart.
-He/she would notify the charge nurse of any resident not following safe smoking practices.
During interview on 5/16/25 at 8:00 A.M., Certified Nursing Assistant (CNA) B said:
-Residents were not to use e- cigarettes while inside the facility.
-He/she aware of several residents in the facility that keep e-cigarettes in their room.
-He/she aware of some the facility residents that have difficulty leaving their room will use a e-cigarette while inside the facility.
-The resident does have more than one e-cigarette in his/her room and does use it while in bed or up in wheelchair.
-He/she was not aware of the facility policy for the use of e-cigarettes.
During interview on 5/16/25 at 10:55 A.M., CNA C said:
-The resident does go outside to smoke but does have his/her own e-cigarette that he/she uses in his/her room. He/she keeps e-cigarette at bedside.
-The resident will leave the facility with family and does propel himself/herself outside around the facility.
-He/she was aware of other unknown residents on the hallway that do keep and use e-cigarettes at bedside.
During an interview on 5/16/25 at 11:45 A.M., Certified Medication Technician CMT) B said:
-He/she aware of the resident storing e-cigarettes on bedside table and do use e-cigarettes in the facility.
-Resident are aware they should not being using any smoking devices while in the facility.
During an interview on 5/16/25 at 11:55 A.M., Licensed Practical Nurse (LPN) B said:
-E-cigarettes and any other smoking material should not to be stored or keep in resident's room.
-He/she was not aware the resident had e-cigarettes at bedside and should not be using e-cigarette while inside the facility including resident's room.
-The facility smoking policy says no smoking material shall be kept in resident's rooms and no use of smoking items while inside the facility.
During an interview on 5/16/25 at 12:13 P.M., Administrator said:
-The facility aware ongoing issue with resident having e-cigarettes with nicotine only used in the facility.
-The facility staff and resident had been educated on use of e-cigarettes usage and other smoking material should not be kept in resident room.
-He/she would expect facility staff complete safety checks during cares to ensure no smoking materials left in resident room including e-cigarettes.
-He/she would expect facility staff to ask the resident to show the smoking material to staff and then request those smoking material be removed from resident room and place in secure smoking material cart.
During an interview on 5/16/25 at 12:13 P.M., Director of Nursing (DON) said:
-The resident smoking assessment were to be completed by social service upon admission, quarterly or if resident had smoking incident, includes the use of e-cigarettes.
-He/she was not aware the resident had e-cigarette and been using them while inside the facility.
-The residents were not allowed to use e-cigarettes while inside the facility.
-Residents are not allowed to keep smoking materials including e-cigarettes, stored in residents' rooms.
-He/she would expect facility staff to ensure that the resident smoking items are being turned into nursing staff for safe secure storage.
-He/she would expect all staff to ensure the resident only smoke in designated smoke areas.
MO00253115 & MO00254444
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 F0806
(Tag F0806)
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 offer substitutes and honor preferences for one sample...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to offer substitutes and honor preferences for one sampled resident (Resident #2) out of 19 sampled residents. The facility census was 143 residents.
Review of the facility's policy, Resident Preference Interview, revised December 2020 showed:
-Resident preferences will be reflected on the tray card and updated in a timely manner.
--If a preferred item is not available, a suitable substitute should be provided.
1. Review of Resident #2's admission record showed he/she was admitted [DATE] with diagnoses to include:
-Congestive heart failure (disorder that impairs the ability of the heart to fill with or pump a sufficient amount of blood throughout the body)
- 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)
-Anxiety Disorder (a psychiatric disorder causing feelings of persistent anxiety)
Review of the resident's Order Summary report for May 2025 showed he/she was on a regular diet with a fluid restriction of 2000 milliliters in a 24-hour period.
Review of the resident's care plan showed:
-He/She eats a heart healthy diet with regular consistency food and thin fluids.
--Monitor tolerance and acceptance of diet.
--Monitor, document, and report any signs and symptoms he/she appears concerned during meals.
During an interview on 5/14/25 at 9:59 A.M. the resident said:
-The facility has run out of food at times.
-He/She should be on a cardiac diet.
-The food was horrible.
-He/She liked fresh fruit and salads.
-He/She had to buy her own food.
-The facility was not offering alternatives.
-When he/she requested a chef salad she received a huge mound of mashed potatoes and gravy, approximately three helpings.
Interview on 5/14/25 at 1:09 P.M. the resident said:
-He/She was waiting his/her lunch tray.
-He/She had requested a chef salad from Certified Nursing Assistant (CNA) C.
-He/She was told there was no chef salad.
-He/She made a salad from his/her refrigerator.
Observation on 5/14/25 at 1:14 P.M. showed the resident received a lunch tray with chili and no salad. The resident refused the tray and asked staff to follow up on his/her requested salad. The meal ticket showed a chef salad but was marked out.
Review the resident's progress note dated 5/14/25 at 4:33 P.M. the Director of Nutritional Services showed:
-He/She spoke with resident after meal service to get an update on food preferences.
-The resident stated he/she would request a chef salad when he/she wanted one.
-The resident also said either lettuce or fresh cabbage as his/her base for salad was acceptable.
During and interview on 5/16/25 at 7:10 A.M. the resident said he/she discussed food preference again with the Dietician on 5/14/25 and a new Food Profile was completed.
During an interview on 5/16/25 at 9:53 A.M. the resident said:
-He/She did not get the chef salad again last night.
-He/She received enchiladas.
He/She had a colon issue and could not eat the food they serve.
During an interview on 5/16/25 at 10:00 A.M. the Dietary Manager said:
-Yes, we have lettuce.
-He/She went to the store to get some and some came on the truck.
-He/She was not aware resident did not get chef salad on 5/15/25 as requested for the evening meal.
-He/She would educate dietary staff.
During an interview on 5/16/25 at 11:24 A.M. the Administrator said:
-He/She expected residents to get diet requests within reason.
-Staff should offer alternative food choices.
-The always available food choice was too large and had food wasted so it was reduced.
-The facility had not run out of food.
-The facility had gone to the store to buy lettuce.
-He/She was not aware the resident did not get a chef salad.
MO00251558
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 F0809
(Tag F0809)
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 snacks were being offered on the long term care...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure snacks were being offered on the long term care unit consistently between meal times during the day and evening for two sampled residents (Resident #11 and #13) out of 19 sampled residents. The facility census was 143 residents.
Record review of the facility snack schedule showed facility snacks were supposed to be at 10:00 A.M., 2:00 P.M., and 7:00 P.M. daily.
1. Review of Resident #11's Face Sheet showed the resident was admitted on [DATE], with diagnoses including diabetes, high cholesterol, high blood pressure and cancer.
Review of the resident's annual Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 4/11/25, showed the resident:
-Was alert and oriented with no confusion.
-Ambulated with a walker and was able to eat with supervision only.
Observation and interview on 5/14/25 at 1:15 P.M., showed the resident was ambulatory in his/her room but also used a wheelchair. On the resident's dresser were a variety of snacks.
During an interview on 5/16/25 at 12:40 P.M., the resident said:
-He/she had snacks in his/her room that were his/her personal snacks (self-purchased).
-Dietary staff brought snacks to the nursing station up to three times daily but they don't always get the snacks on evenings.
-When snacks are delivered, some residents take a lot of the snacks and other residents don't get anything, depending on when they get to the nursing station after snacks were delivered.
-Snacks were not delivered this morning.
2. Review of Resident #13's Face Sheet showed the resident was admitted on [DATE], with diagnoses including heart failure, high cholesterol, diabetes and malnutrition.
Review of the resident's quarterly MDS dated [DATE], showed the resident:
-Was alert and oriented with no confusion.
-Ambulated with a walker and wheelchair and was able to eat with supervision only.
Observation on 5/14/25 at 10:41 A.M. showed the resident was laying in his/her bed watching television. There were beverages and graham crackers on his/her tray table that was next to his/her bed. The resident said he/she was able to ambulate independently but used a walker and wheelchair as needed. He/she was able to eat independently but usually ate all meals in his/her room.
During an interview on 5/16/25 at 11:50 A.M. the resident said:
-He/She received breakfast between 7:30-8:15 A.M., lunch between 12:30-1:30 A.M., dinner between 6-6:30 A.M.
-He/She ate independently.
-At 12:44 P.M., he/she kept his/her own snacks in his/her room.
-The snacks the facility passed out were placed at the nursing station between meals.
-Residents could go to the nursing station to get snacks, but staff did not pass snacks out.
-The dietary staff did not bring snacks to the unit on the evening shift/at bedtime.
Observation on 5/16/25 showed from 9:00 A.M. to 12:00 P.M., there were no snack trays brought to the long term care unit.
During an interview on 5/16/25 at 12:34 P.M., Certified Medication Technician (CMT) C said:
-Dietary staff usually brought snacks out to the nursing station between 10:00 A.M. and 11:00 A.M. after breakfast and before lunch.
-Dietary staff usually brought a variety of chips, fudge bars, peanut butter and jelly sandwiches, bananas and apples on the trays and residents came up to the nursing station to get snacks if they wanted them.
-He/She did not see dietary deliver any snacks this morning and he/she did not know why they were not brought out.
-He/She usually left work at 3:00 P.M. before the evening snacks were delivered and did not know if evening snacks were delivered.
During an interview on 5/16/25 at 12:35 P.M. Certified Nursing Assistant (CNA) D said:
-He/She worked during the week and on the weekends and snacks were usually brought out between 10:00 A.M. and 11: 00 A.M., and then again between 2:30 P.M. and 4:00 P.M. before dinner.
-Dietary staff brought out two snack trays and placed them at the nursing station.
-Dietary staff does not bring enough snacks for all of the residents to have a snack.
-They do not pass snacks out to the residents. The residents have to go to the nursing station to get a snack if they wanted one.
-For residents who are primarily in their room or who cannot come to the nursing station, if they want a snack the nursing staff will bring one to them.
-Some residents will take several snacks so they run out quickly.
-The Dietary staff don't always bring snacks at night and did not bring any snacks last night when he/she worked.
-Dietary staff did not bring snacks this morning before lunch today.
-It was not uncommon for the dietary staff to miss bringing snacks out to the nursing station because they have had several staff changes in the kitchen and they may not know they were supposed to bring snacks between meals.
During an interview on 5/16/25 at 12:37 P.M., CNA E said:
-He/She worked from 7:00 A.M. to 3:00 P.M. during the week and sometimes worked the evening shift.
-The dietary staff brought snacks between breakfast and lunch and again between lunch and dinner.
-When dietary staff brought snacks, they put them at the nursing station.
-The dietary staff did not bring snacks today.
-He/She worked last night until 7:30 P.M. and they did not bring the evening snacks.
-There are certain dietary staff who make sure they get the snacks when they are working but when those dietary staff are not working, they may not have the snacks delivered on evenings.
-They did not deliver snacks to the resident rooms, the residents usually came to get their own snacks.
-Residents who were unable to go to the nursing station could have staff bring their snack to them if they wanted a snack.
During an interview on 5/16/25 at 12:47 P.M., Dietary Aide A said:
-He/She was a newer employee and said he/she worked the evening shift.
-They were supposed deliver snacks to each unit twice during his/her shift at 2:00 P.M. and at 7:00 P.M.
-Each unit receives one tray of snacks and the long term care unit received two trays due to the number of residents on the unit.
-Once the dietary staff deliver the trays, the nursing staff pass the snacks out.
-He/She was not aware that the snacks were not brought to the long term care unit last night or this morning.
-If the nursing staff let them know they did not have the snacks delivered, they would bring snacks to the unit.
During an interview on 5/16/25 at 12:54 P.M., [NAME] A said:
-The schedule for snacks to be delivered to the unit are at 10:00 A.M., 2:00 P.M., and 7:00 P.M.
-He/She made sure snacks were passed out during the day shift at 10:00 A.M., and 2:00 P.M.
-He/She was not at the facility during the evening shift and did not know if snacks were passed out then.
-Each unit should get a tray of snacks (variety) and the long term care unit was supposed to receive to trays of snacks.
-They deliver the snack trays to the nursing station.
-He/She did not remember if snacks were passed out at 10:00 A.M. today because there was a lot going on in the kitchen.
-He/She would ensure that snacks would be passed out at 2:00 P.M.
During an interview on 5/16/25 at 1:00 P.M., the Dietary Manager said:
-Kitchen staff is to make and provide snacks at 10:00 A.M., 2:00 P.M., and 7:00 P.M.
-Snacks got missed today.
-Staff knows to pass snacks daily. Aides who usually work on the food side make snacks.
-Snack schedule times are posted in dining room.
During an interview on 5/16/25 at 2:00 P.M., Registered Nurse (RN) A said:
-Snacks are not provided daily per the schedule.
-He/She had not seen snacks provided for weeks.
During an interview on 5/16/25 at 2:13 P.M., the Assistant Director of Nursing (ADON) A said:
-Snacks were supposed to be offered to the residents three times daily.
-The Dietary staff brought the snack trays to each nursing station and residents could go to get their choice of snack and nursing staff also take snacks to those resident who are unable to obtain their own snack.
-They have had some issues with residents taking several snacks and there not being enough (running out) and that they were not always being passed three times daily.
-Dietary staff was getting better about bringing snacks out between meals.
MO00251977
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
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 ensure hot foods (vegetables on 5/14/25) and (French T...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure hot foods (vegetables on 5/14/25) and (French Toast on 5/16/25) were at or close to 120 ºF (degrees Fahrenheit) for two different meals. This practice potentially affected at least four residents (Residents #11, #3, #2 and #13) out of 19 sampled residents. The facility census was 143 residents.
Review of the facility's policy entitled Food Temperatures and revised on 12/20, showed:
- Purpose: To provide the nutrition services department with guidelines for food preparation and service temperatures.
- Policy: Foods prepared and served in the facility will be served at proper temperatures to ensure food safety.
- Procedure: Measuring Food Temperature
It is recommended to use a thermometer with a practical range of 0 ºF to 220 ºF.
- Wash, rinse, and sanitize a dial face, metal probe type thermometer with an alcohol wipe.
- Insert the thermometer into the center of the product.
- Allow time for stabilization. Wait until there is no movement for 15 seconds. Several readings may be required to determine hot and cold spots.
-Take the temperature of each pan product before serving.
- Resanitize the thermometer after each use.
1. Observation on 5/14/25 at 12:34 P.M., showed the vegetables on a test tray on the 100 Hall, had a temperature of 111.4 ºF, when the vegetables were checked for temperature.
During an interview on 5/14/25 at 12:51 P.M., Resident #11 (a resident who was assessed by the annual Minimum Data Set (MDS- a federally mandated assessment tool completed by the facility for care planning) dated 4/11/25, as cognitively intact, said his/her food is delivered cold sometimes.
Observation on 5/16/25 at 8:07 A.M., showed the temperature of the French Toast on a test tray for the 100 Hall was 106.3 ºF.
During an interview on 5/16/25 at 11:15 A.M., Resident #3 (a resident who was assessed as cognitively intact) by the annual MDS dated [DATE], said:
- He/she received cold food on 5 of 5 days.
- There was no difference amongst the meals ( breakfast, lunch or dinner) as to which ones were cold.
- When he/she ate lunch, both the entrée and the side items were cold.
During an interview on 5/16/25 at 11:21 A.M., Resident #2 (a resident who was assessed as cognitively intact) by the quarterly MDS dated [DATE], said:
-The food including the entrees was cold almost daily.
- Usually there was one staff member working to deliver trays on the halls where he/she resided on.
During an interview on 5/16/25 at 11:50 A.M., Resident #13 (a resident who was assessed as cognitively intact) by the quarterly MDS dated [DATE], said:
- Most of the time all the items were cold.
Sometimes, he/she requested the alternative menu.
-Many of the items on the alternative menus are delivered cold as well.
During an interview on 5/16/25 at 11:24 A.M., Resident #11 said:
- The food was delivered to his/her room cold at least 3 out of 5 days per week.
- Lunch was cold more often than other meals.
- There were not many staff who delivered room trays to the rooms.
During a phone interview on 5/22/25 at 3:38 P.M., the Dietary Manager said:
- Test trays are done by dietary staff 2-3 times per week.
- It was the last tray on the hall they chose for that day that was tested.
- If cold food food is found on a test tray, they keep the cooked food inside an oven until about 15 minutes before service.
- The dietary staff is then encouraged to check temperatures of the food on the steam table, and
- The dietary staff knows how to check temperatures, but he/she had to stay on them.
MO00252740 & MO00252293
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
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 sprinkler heads above the food preparation and food serving areas, free from dust and grease; maintain the oven mittens in good ...
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Based on observation and interview, the facility failed to maintain the sprinkler heads above the food preparation and food serving areas, free from dust and grease; maintain the oven mittens in good repair; maintain the drainage pipes, metal fixtures and walls under the dishwasher area, free of a buildup of grime and discarded dishes; ensure items (lemon juice and beef base), were refrigerated; maintain the handwashing sink free of obstructions; maintain hot foods ( pureed French Toast and regular French Toast) at or close to 135 ºF ( degrees Fahrenheit) at the steam table; to ensure that fresh fruits ( grapes) were washed prior to mixing them with the fruit salad for breakfast and to ensure Dietary Aide (DA) B use tongs or gloves while he/she handled French Toast from the steam table. This practice potentially affected 143 residents who received food from the kitchen. The facility census was 143 residents.
1. Observations on 5/14/25 at 12:17 P.M., during the lunch meal, showed:
- A buildup of grease and dust on the sprinkler heads and ceiling tiles over the food serving and food preparation areas.
- The presence of grime on the metal fixtures under the dishwasher and the walls behind the dishwasher.
- Two oven mittens with rips that were about two inches (in.)
- One bottle of lemon juice that was on the counter next to the microwave with a label which stated to refrigerate after opening.
2. Observations on 5/16/25 from 6:19 A.M. through 8:20 A.M., during the breakfast meal preparation showed:
- A buildup of dust and grease on the sprinkler heads and ceiling tiles over food preparation and food serving areas.
- The presence of grime on the metal fixtures and pipes under the dishwasher and the walls behind the dishwasher.
- The presence of a red tray, a gray cup, and a plastic glass that was under the dishwasher.
- The presence of a black speaker which laid right across the handwashing sink.
- Dietary Aide (DA) B slicing grapes to add to the fruit bowl mixture, without washing them.
- One bottle of lemon juice that was on the table next to the microwave that was not refrigerated
- Two containers of beef base on the same table as the soda dispenser that were not refrigerated.
During an interview on 5/16/25 at 7:35 A.M., Dietary [NAME] (DC) A said the mittens have been like that for 2-3 days.
Observation on 5/16/25 at 7:46 A.M., showed the pureed French Toast was 124.5 ºF on the steam table.
Observation on 5/16/25 at 7:53 A.M., showed the slices of French Toast which were not under the metal cover in the pan at the steam table, were between 104 ºF -- 107 ºF.
Observation on 5/16/25 at 8:22 A.M., showed DC B picked up a slice of French Toast with his/her bare hands after he/she was requested to taste the French Toast.
Observation on 5/16/25 at 8:23 A.M., showed the Dietary Manager (DM) told DC B to place gloves on and take a different slice.
During an interview on 5/16/25 at 8:42 A.M., DA C said he/she has worked at the facility for about 7 months and he/she remembered that the area under the dishwasher has only been cleaned twice.
During an interview on 5/16/25 at 8:46 A.M. the Maintenance Director said he/she had a work order that was dated 5/14/25 for cleaning behind the dishwasher and the dishrack table.
During an interview on 5/16/25 at 8:52 A.M., DA B said he/she was not trained to and did not know how to wash grapes before adding them to the fruit bowl.
During an interview on 5/16/25 at 9:10 A.M., the DM said he/she told the Maintenance Director about cleaning the dust and grease from the sprinkler heads and ceiling tiles on 5/16/25.
During an interview on 5/16/25 at 9:14 A.M., the DM said he/she expected the DAs to wash fruit before adding fruit to the fruit bowl.
MO00253234.
Jan 2025
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
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Refer to F550 Event ID ZSB9
Based on interview and record review, the facility failed to ensure the dignity of one sampled resident (Resident #104) out of 20 sampled residents. The facility census was...
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Refer to F550 Event ID ZSB9
Based on interview and record review, the facility failed to ensure the dignity of one sampled resident (Resident #104) out of 20 sampled residents. The facility census was 158 residents.
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 F0804
(Tag F0804)
Could have caused harm · This affected 1 resident
See F 804 Event ID ZSB9
This deficiency is uncorrected. For previous examples, refer to the Statement of Deficiency dated 11/25/24.
Based on observation, interview and record review, the facility fail...
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See F 804 Event ID ZSB9
This deficiency is uncorrected. For previous examples, refer to the Statement of Deficiency dated 11/25/24.
Based on observation, interview and record review, the facility failed to ensure hot foods on room trays were served at or close to 120 ºF (degrees Fahrenheit), on 1/15/25 during lunch and on 1/16/25 during breakfast. This practice potentially affected at least 60 residents who resided on the 100, 200, 300 and 400 Halls. The facility census was 158 residents.
Nov 2024
23 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure the dignity of one sampled resident (Resident #104) out of 20 sampled residents. The facility census was 158 residents.
Review of th...
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Based on interview and record review, the facility failed to ensure the dignity of one sampled resident (Resident #104) out of 20 sampled residents. The facility census was 158 residents.
Review of the facility's policy titled Privacy and Dignity dated June 2020 showed:
-The facility promoted resident care in a manner and an environment that maintains or enhances dignity and respect, in full recognition of each resident's individuality.
-The staff assisted with the residents in maintaining self-esteem and self-worth.
-Staff were to treat residents with respect including respecting their social status, speaking respectfully, and listening carefully.
-Staff were to focus on residents as individuals when they speak to them and address residents as individuals when providing care and services.
1. Review of Resident #104's admission Record showed he/she admitted to the facility with a diagnosis of legal blindness.
Review of the resident's Quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 12/16/24 showed the resident was cognitively intact.
Review of the resident's care plan dated 12/20/24 showed the resident was dependent on tobacco with the interventions to supervision while smoking.
Review of an Allegation of Staff to Resident Abuse Investigation completed by the facility on 1/11/25 showed:
-The incident involved the resident and Hospitality Aide (HA) B.
-The resident smoked cigarettes and due to his/her visual impairment, he/she was to wear a smoking apron (a fire retardant garment that protects the wearer from cigarette ash and debris) based of the recommendation of the smoking assessment completed 1/2/25.
-On 1/11/25 HA B observed the resident in the smoking area without his/her apron on.
-HA B knew that the resident needed to wear a smoking apron to ensure his/her safety.
-HA B then approached the resident and touched the back of the resident's head to get his/her attention and reminded him/her of the necessity to wear the apron while smoking.
-The resident had initially expressed that HA B had struck him/her.
-The facility removed HA B from all resident interactions.
-The nurse assessed the resident and found no signs of trauma or injury.
-The resident later clarified that the contact had not caused any injury or any mental anguish.
-The resident had not believed that HA B had touched him/her to willfully inflict injury.
-He/She stated that HA B should have just called his/her name.
-HA B had only intended to remind the resident to wear his/her apron and had no intent to harm the resident.
Review of the resident's written verbal statement collected from the resident by staff dated 1/11/25 showed:
-He/She had been out smoking and HA B hit him/her a couple of times in the back of the head.
-HA B had wanted him/her to come inside but he/she was not ready to go inside yet.
-HA B had not hurt him/her, HA B should not have hit him/her.
Review of an undated statement completed by HA B showed:
-He/She had touched the resident to let the resident know he/she had needed his/her smoking apron on while outside.
-The resident came in with him/her to get the resident's smoking apron and the resident went back outside.
-Everything seemed okay.
Review of a statement dated 1/11/25 completed by Registered Nurse (RN) A showed:
-The resident stated that HA B had walked up behind him/her and tapped him/her hard on the back of the head.
-The resident stated that it had not hurt him/her and felt that what HA B did was uncalled for and made him/her uncomfortable.
During an interview on 1/15/25 at 12:22 P.M. the resident said:
-HA B had hit him/her softly to the back of his/her head and neck area.
-HA B had told him/her that it was too cold and that he/she needed to go inside.
-He/She had told HA B that it was not too cold to be outside and then HA B became aggravated after that.
During an interview on 1/15/25 at 3:25 P.M. the resident said:
-He/She felt safe at the facility.
-The whole incident just made him feel embarrassed and HA B had made him/her feel like a kid.
During a phone interview on 1/17/25 at 11:18 A.M. HA B said:
-The resident had needed his/her smoking apron.
-He/She had gone to the bathroom and when he/she came back outside, the resident was already outside and was not wearing his/her smoking apron.
-The resident had told HA B that he/she was not smoking, so he/she did not need a smoking apron.
-The resident then proceeded to move closer to the other residents that were smoking.
-He/She then tapped the resident on the back of his/her head to get his/her attention.
-He/She had not hit the resident.
-He/She knew that he/she should not have tapped the resident in the back of the head and should have tapped the resident's shoulder instead.
-He/She was just not thinking at the time and would never intentionally hurt a resident.
During a phone interview on 1/17/25 at 2:28 P.M. Certified Nurses Aide (CNA) K said:
-He/She had been walking down the hall when he/she overheard a resident say that Resident #104 had been hit in the back of the head.
-He/She had not seen anything expect for HA B assisting the resident's in his/her wheelchair to get the resident to come inside.
-The resident had said you don't have to hit me in the back of the head like I am a kid.
-HA B should not have approached the resident how he/she had.
-The interaction between the resident and HA B made the resident feel embarrassed which indicated to him/her that HA B had showed the resident a lack of dignity.
During a phone interview on 1/21/25 at 8:06 A.M. Assistant Director of Nursing (ADON) A said:
-He/She was not sure what happened between HA B and the resident.
-HA B should not have touched the resident's back of head/neck area.
-He/She would have expected staff to have tapped the resident's shoulder to get his/her attention or to have brought over the smoking apron to the resident.
-The interaction was disrespectful towards the resident.
During a phone interview on 1/21/25 at 10:11 A.M. the Administrator said:
-The investigation determined the resident felt like his/her dignity was compromised.
-The incident between the resident and HA B was inappropriate because the resident did not want his/her back of head/neck area to be touched.
-He/She would have expected HA B to have gone in front of the resident to get his/her attention or to have touched him/her on the shoulder or hand.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to obtain a physician order for self-administration of medication at bedside and failed to evaluate and document the ability to ...
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Based on observation, interview, and record review, the facility failed to obtain a physician order for self-administration of medication at bedside and failed to evaluate and document the ability to self-administer medication for one sampled (Resident #96) out of 35 sampled residents. The facility census was 151 residents.
Review of the facility's policy titled Self-Administration of Medication dated August 2020 showed:
-If a resident desired to self-administer medications, an assessment was conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility during the care planning process.
-The results of the interdisciplinary team assessment of the resident skills and of the determination regarding bedside storage were recorded in the resident's medical record on the care plan.
-If the resident demonstrated the ability to safely self-administer medications, a further assessment of the safety of bedside medication storage was conducted.
1. Review of Resident #96's admission Record showed he/she admitted to the facility with the following diagnoses:
-Chronic Obstructive Pulmonary Disease (COPD-a disease process that decreases the ability of the lungs to perform ventilation).
-Pulmonary Fibrosis (a diseases in which the lungs become scarred over time).
Review of the resident's admission Minimum Data Set (MDS- federally mandated assessment instrument completed by facility staff for care planning) dated 10/16/24 showed the resident was cognitively intact.
Review of the resident's care plan dated 10/21/24 showed:
-The resident had altered respiratory status/difficulty breathing related to COPD but did not indicate the use of an inhaler.
-There was not focus or intervention related to the self-administration of medication.
Review of the resident's Physician Order Sheet (POS) dated November 2024 showed:
-A physician's order for ProAir HFA Inhalation Aerosol Solution (Albuterol Sulfate- used to prevent and treat wheezing, difficulty breathing, chest tightness, and coughing caused by lung diseases such as COPD) 108 (90 Base) micrograms (mcg)/ actuation (ACT), one puff inhale orally every six hours as needed for wheezing.
-No physician's order for the ability to self-administer any medication.
Observation on 11/19/24 at 2:09 P.M. of the resident's room showed an albuterol sulfate inhaler sitting by the resident's sink.
During an interview on 11/19/24 at 2:45 P.M. the resident said:
-He/She had been given the inhaler from an unknown staff member to keep in his/her room because he/she told staff that he/she only needed the inhaler whenever he/she was walking around the facility. -He/She was unsure of when the staff had given him/her the inhaler to keep in his/her room.
-The staff did not assess him/her to be able to self-administer the inhaler himself/herself.
During an interview on 11/19/24 at 2:51 P.M. Certified Medication Technician (CMT) B said:
-He/She was unsure if a self-administration assessment had been completed for the resident to use his/her inhaler.
-The Assistant Directors of Nursing (ADONs) were responsible for completing the self-administration assessments for residents to be able to self-administer medications.
-He/She was unaware that the resident had the albuterol inhaler in his/her room.
During an interview on 11/20/24 at 10:43 A.M. Registered Nurse (RN) A said:
-Residents were able to self-administer medications if they had an assessment for self-administration completed and a physician's order to do so.
-The resident did not have an order to be able to self-administer any medication.
-The inhaler should not have been kept in the resident's room due to the lack of the physician's order.
-Nurses were able to perform the self-administration of medication assessment and obtain a physician's order.
During an interview on 11/20/24 at 11:13 A.M. ADON A said:
-Residents were able to self-administer their own medication if an assessment for self-administration of medication was completed and a physician's order was in place to do so.
-If there was not an assessment in place, residents were not allowed to self-administer any medication and the staff were required to administer the medication.
-The resident did not have an order for self-administration for the inhaler.
-He/She would have expected the staff to notice the inhaler in the resident's room especially if it was on the resident's sink.
-He/She would have expected the staff to have taken the inhaler out of the resident's room if they had seen it in the resident's room or get a nurse to take the inhaler out of the room.
During an interview on 11/20/24 at 11:51 A.M. the Director of Nursing (DON) said:
-The resident did not have a self-administration assessment for his/her albuterol sulfate inhaler.
-The staff were unaware the resident did not have an assessment for self-administration of his/her inhaler and there was not a physician's order in place for the resident to keep the inhaler at bedside.
-He/She would have expected staff to notify the ADONs an assessment needed to be completed for the resident to be able to self-administer medication.
-The staff should have noticed the inhaler in the resident's room, especially if it was on the resident's sink and have taken it out of the resident's room.
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/or the resident's representative(s) of a tr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident and/or the resident's representative(s) of a transfer to a hospital, including the reasons for the transfer in writing for two sampled residents (Residents #137 and #109) out of 35 sampled residents. The facility census was 151 residents.
Review of the Facility's Transfer and Discharge Policy revised 06/2020 showed:
-The purpose of the policy was to ensure that residents are transferred and discharged from the facility in compliance with state and federal laws and to provide complete, safe, and appropriate discharge planning and necessary information to the continuing care provider.
-The facility may use Notice of Transfer/Discharge or another comparable form to provide the resident or his/her personal representative with advanced notice of transfer or discharge.
-When a resident is transferred/discharged , Social Services Staff include a copy of the written notice of transfer/discharge provided to the resident or his/her personal representative in the resident's medical record.
1. Review of Resident #137's admission Record showed:
-The resident was admitted to the facility on [DATE].
-The resident was re-admitted to the facility on [DATE].
Review of the resident's discharge Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 6/1/24, showed the resident was discharged to the hospital with his/her return anticipated.
Review of the resident's Electronic Medical Record (EMR) on 11/21/24 at 9:31 A.M., showed no transfer/discharge notice dated 6/1/24.
2. Review of Resident #109's admission Record showed:
-The resident was initially admitted to the facility on [DATE].
-The resident was re admitted to the facility on [DATE].
Review of the resident's discharge MDS dated [DATE], showed the resident was discharged to the hospital with his/her return anticipated.
Review of the resident's EMR on 11/21/24 at 11:14 A.M., showed no transfer/discharge notice dated 1/17/24.
3. During an interview on 11/21/24 at 1:53 P.M., Medical Records Staff said he/she could not locate a notice of transfer/discharge for Resident #137 or Resident #109 in the resident's medical records.
During an interview on 11/22/24 at 2:30 P.M., Registered Nurse (RN) B said:
-If a resident was transferred/discharged from the facility, the charge nurse was responsible for completing the notice of transfer/discharge.
-If a notice of transfer/discharge was completed on a resident, it would be uploaded and documented in the resident's electronic medical record by the charge nurse or the nurse manager.
-He/she was unaware of the process the facility used to ensure transfer notices were being completed.
During an interview with the Director Of Nursing (DON) on 11/25/24 at 11:10 A.M., said:
-The charge nurses or social services were responsible for completing the notice of transfer/ discharges.
- There should be documentation including details for reason of transfer, where, safe, and who was notified (physician, family) in the resident's medical record.
-If there was no documentation in the EMR of a notice of transfer for a resident, then he/she would say it was not completed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
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 a bed hold notification to a resident and/or the resident's...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a bed hold notification to a resident and/or the resident's representative upon transfer or discharge for two sampled residents (Resident #137 and #109) out of 30 sampled residents. The facility census was 151 residents.
Review of the facility's Bed Hold Policy dated 6/2020 showed:
-The purpose of the policy was to ensure that the resident and/or their representative was aware of the facility's bed hold policy, and that such policy complies with state and federal law and regulations.
-When a resident was admitted to the facility, the facility informed the resident or his/her personal representative in writing that the facility had a bed hold policy.
-The facility notified the resident or his/her representative, in writing, of the bed hold policy any time the resident was transferred to general acute care hospital even if the facility has not met the occupancy requirements.
-Upon notice to the resident or his/her personal representative, the licensed nurse (or designee) will document how the resident, or his/her personal representative was notified.
1. Review of Resident #137's admission Record showed:
-The resident was admitted to the facility on [DATE].
-The resident was re admitted to the facility on [DATE].
Review of the resident's discharge Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 6/1/24, showed the resident was discharged to the hospital with his/her return anticipated.
Review of the resident's electronic medical record on 11/21/24 at 9:31 A.M., showed no bed hold notice dated 6/1/24.
2. Review of Resident #109's admission Record showed:
-The resident was admitted to the facility on [DATE].
-The resident was re admitted to the facility on [DATE].
Review of the resident's discharge Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 1/17/24, showed the resident was discharged to the hospital with his/her return anticipated.
Review of the resident's electronic medical record on 11/21/24 at 11:14 A.M., showed no bed hold notice dated 1/17/24.
During an interview on 11/21/24 at 1:53 P.M., Medical Records Staff said he/she could not locate a bed hold notice for resident #137 or resident #109 in the resident's medical records.
During an interview on 11/22/24 at 2:30 P.M., Registered Nurse (RN) B said:
-If a resident was transferred/discharged from the facility, the charge nurse was responsible for completing the bed hold notice.
-If a bed hold notice was completed on a resident, it would be uploaded and documented in the resident's electronic medical record.
-He/she was unaware of the process that the facility used to ensure that bed hold notices were being completed.
During an interview with the Director Of Nursing (DON) on 11/25/24 at 11:10 A.M., said:
-The charge nurses were responsible for completing the notice of discharges.
-Once a bed hold notice was completed, it would be documented in the resident's electronic medical record.
-If there was no documentation in the electronic medical record of a bed hold notice for a resident, then he/she would say that it was not completed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS-a fed...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) for two sampled residents (Residents #14, #98) out of 35 sampled residents. The facility census was 151 residents.
A policy was requested and not received from the facility.
1. Review of Resident #14's admission Record showed he/she was admitted to the facility on [DATE] with the diagnosis of Need for Assistance with Personal Care.
Review of the resident's nursing Admission/readmission Evaluation dated 8/24/23 showed he/she had broken and/or carious teeth.
Review of the resident's Nutrition Assessment-Registered Dietician Evaluation dated 1/20/23 showed the resident has his/her own teeth in fair condition.
Review of the resident's Order Summary Report (OSR) showed a physician's order dated 4/30/24 may be seen and treated by a dentist.
Review of the resident's Annual MDS dated [DATE] showed:
-He/She had moderate cognitive deficits and required support of facility staff.
-He/she had no missing teeth or cavities.
Review of the resident's care plan on 11/22/24 10:39 A.M. failed to show the need for dental care.
During an interview on 11/19/24 at 10:25 A.M. the resident said he/she didn't have many teeth.
Observation on 11/19/24 at 10:25 A.M. of the resident's mouth showed:
-Multiple teeth missing on both upper and lower jaw.
-One tooth on the lower right side was loose and pointed towards the tongue.
-A buildup of a yellow substance was on the remaining teeth.
2. Review of Resident #98's admission Record showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-Chronic Obstructive Pulmonary Disease (COPD - a disease process that decreases the ability of the lungs to perform ventilation.)
-Chronic Respiratory Failure with hypoxia a condition where the lungs are unable to adequately exchange oxygen and carbon dioxide over a prolonged period, resulting in a persistently low levels of oxygen in the blood (Hypoxemia), which is a hallmark symptom of chronic respiratory failure; essentially, the body is not getting enough oxygen due to impaired lung function.
-Dependence on supplemental oxygen.
Review of the resident's nursing admission MDS completed by facility staff dated 7/31/23 showed:
-He/She was cognitively intact.
-He/she had no missing teeth or cavities.
-Did not use a BiPAP machine.
Review of the resident's Annual MDS completed by facility staff dated 6/4/24 showed:
-He/She was cognitively intact.
-Oral/Dental Status showed no problem with missing teeth or cavities.
-Failed to show usage of the BiPAP.
During an interview on 11/19/24 at 8:51 A.M. the resident said he/she had quite a few broken teeth or with cavities.
Observation of the resident's mouth on 11/19/24 at 8:51 A.M. showed:
-He/She had multiple teeth missing.
-He/She had teeth with sharp edges and blackened areas on multiple teeth.
During an interview on 11/21/24 at 9:39 A.M. the resident said he/she had the Bilevel Positive Airway Pressure (BiPAP-a type of noninvasive ventilation that helps you breathe) machine for approximately seven years.
Observation on 11/21/24 at 9:39 A. M showed he/she was currently utilizing the BiPAP machine.
During an interview on 11/25/24 9:14 A.M. MDS Coordinator A said:
-He/She gathered information for the MDS on interview of resident and staff, observation, the clinical record, and the daily clinical meeting.
-He/She was aware of #14's cavities.
-He/She was not aware Resident #98's broken and missing teeth.
-Dental issues should be coded on the MDS.
-The BiPAP machine should be coded on the MDS.
-
During an interview on 11/25/24 9:14 A.M. the MDS Coordinator B said:
-He/She gathered information for the MDS on interview of resident and staff, observation, the clinical record, and the daily clinical meeting.
-He/She was not aware if Resident #14 had teeth issues.
-He/She was not aware Resident #98's broken and missing teeth.
-He/She stated #98 had never complained about dental concerns.
-He/She said the BiPAP machine should be coded on the MDS.
During an interview on 11/25/24 9:44 A.M. Assist Director of Nursing (ADON) B said:
-He/She was not aware of missed BiPAP order.
-He/She expected the MDS to be accurate.
-He/She expected dental issues to be coded on the MDS.
-He/She expected a BiPAP machine to be coded on the MDS.
During an interview on 9/11/24 at 11:47 A.M. the Director of Nursing (DON) said:
-He/She would expect the MDS nurse to capture the documentation from the clinical chart.
-He/She would expect the MDS nurse to conduct his/her own assessments.
-He/She was not aware Residents #14 and #98 had missing and/or broken teeth or cavities.
-He/She expected a BiPAP machine to be coded on the MDS.
-He/She was aware Resident #98 had a BiPAP.
3. Review of Resident #109's admission Record showed:
-The resident was admitted to the facility on [DATE].
-The resident had a diagnosis of difficulty in walking.
Review of the resident's fall investigation dated 7/3/24 at 5:30 A.M., showed:
-The resident verbalized to the nurse that he/she fell while outside of the building smoking.
-The resident landed on his right elbow and arm when he/she fell.
-The resident was complaining of right shoulder and elbow pain at a 7 on a 0-10 pain scale.
-The resident had an egg sized abrasion on his/her right elbow.
-The nurse on duty ordered a 2-view x ray of the right shoulder and elbow.
Review of the resident's fall investigation dated 7/17/24 at 2:33 P.M., showed:
-The resident fell outside in the smoking area.
-The resident hit his/her outer left foot on the concrete curb.
Review of the resident's annual MDS dated [DATE] showed:
-The resident was cognitively intact.
-The resident had not had any falls in the facility since admission or the prior assessment.
During an interview on 11/22/24 at 2:17 P.M., Registered Nurse (RN) B said the MDS coordinator was responsible for updating the MDS assessments when a resident falls.
During an interview on 11/22/24 at 2:40 P.M., MDS coordinator A and MDS coordinator B said:
-They were responsible for updating the MDS assessments after a resident fall.
-The clinical team has morning meetings each morning and this is when falls with residents are discussed.
-They were both aware of the resident.
-They both denied having knowledge of the resident having any falls since admission.
-The two falls should have been coded on the MDS.
During an interview on 11/22/24 at 3:00 P.M., ADON A said:
-When a resident falls, the MDS should be updated to reflect the fall to help prevent future falls.
-The MDS coordinators were responsible for updating the MDS after a resident had a fall.
During an interview on 11/25/24 at 11:10 A.M., the DON said:
-The MDS coordinator was responsible for updating the MDS assessments after a resident fall.
-The MDS assessment should capture a resident's fall when the next assessment was completed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to address the residents' functional and health status, strengths and needs as related to dental services for two sampled residents, (Resident #14 and #98), failed to assess and care plan the usage of a Bilevel Positive Airway Pressure (BiPAP a non-invasive ventilation with two pressures settings, one for inhalation and one for exhalation, to assist with breathing) for one sampled resident, (Resident #98), and failed to assess and care plan two falls for one sampled resident (Resident #109) out of 35 sampled residents. The facility census was 151 residents.
Review of the facility policy Care Planning revised June 2020 showed:
-The purpose was to ensure the comprehensive person-centered care plan was developed for each resident based on individual assessed needs.
-The Facility's Interdisciplinary Team (IDT) would develop a comprehensive care plan for each resident in accordance with Omnibus Budget Reconciliation Act (OBRA) a United States federal law that was passed in 1987 and 1990 to improve the quality of care in long-term care facilities and nursing homes and Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) guidelines.
-The care plan serves as a course of action where the resident, resident's family and/or guardian or other legally authorized representative), resident's attending physician, and IDT work to help the resident move toward resident-specific goals that address the resident's medical, nursing, mental, and psychosocial needs.
-A licensed nurse would initiate the care plan, and the plan will be finalized in accordance with OBRA/MDS guidelines and updated as indicated for change in condition, onset of new problems, resolution of current problems, and as deemed appropriate by clinical assessment and judgment on an as needed basis.
-Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.
1. Review of Resident #14's undated admission Record Face Sheet showed he/she was initially admitted on [DATE] with the following diagnosis, Need for Assistance with Personal Care.
Review of the resident's nursing Admission/readmission Evaluation dated 8/24/23 showed he/she had broken and/or carious teeth.
Review of the resident's Nutrition Assessment -Registered Dietician Evaluation dated 1/20/24 showed:
-He/She was on a regular diet and regular consistency
-He/She had his/her own teeth in fair condition.
Review of the resident's Order Summary Report (OSR) showed a physician's order dated 4/30/24 may be seen and treated by a dentist.
Review of the resident's Annual MDS dated [DATE] showed:
-He/She had moderate cognitive deficits and required support of facility staff.
-Oral/Dental Status showed no problem with missing teeth or cavities.
-He/She required supervision and touching assistance for oral hygiene.
During an interview on 11/19/24 at 10:25 A.M. the resident said:
-He/She didn't have many teeth.
-His/Her teeth sometimes hurt.
Observation on 11/19/24 at 10:25 A.M. of the resident's mouth showed:
-Multiple teeth missing in the upper and lower jaw.
-One tooth on lower right side loose and pointed towards the tongue.
-Buildup of a yellow substance on the remaining teeth.
Review of the resident's current care plan on 11/22/24 at 10:39 A.M. showed no dental care needs were identified.
Review of the resident's Quarterly MDS dated [DATE] showed no issues with teeth.
2. Review of Resident #98's admission Record Face Sheet showed he/she was admitted on [DATE] with the following diagnoses:
-Chronic Obstructive Pulmonary Disease (COPD - a disease process that decreases the ability of the lungs to perform ventilation.)
-Chronic Respiratory Failure with hypoxia (a condition where the lungs are unable to adequately exchange oxygen and carbon dioxide over a prolonged period, resulting in a persistently low levels of oxygen in the blood (Hypoxemia), which is a hallmark symptom of chronic respiratory failure; essentially, the body is not getting enough oxygen due to impaired lung function).
-Dependence on supplemental oxygen.
Review of the resident's nursing Admission/readmission Evaluation dated 7/25/23 showed:
-He/She had her own teeth.
-The assessment question that stated broken or carious teeth was left blank.
Review of the resident's admission MDS dated [DATE] showed:
-He/She was cognitively intact.
-Oral/Dental Status showed no problem with missing teeth or cavities.
-No order for the utilization of the BiPAP.
Review of the resident's Annual MDS dated [DATE] showed:
-He/She was cognitively intact.
-Oral/Dental Status showed no problem with missing teeth or cavities.
-No order for the utilization of the BiPAP.
Review of the resident's OSR dated November 2024 showed:
-No order for dental to consult and evaluate.
-No order for the utilization of the BiPAP.
During an interview on 11/19/24 at 8:51 A.M. the resident said:
-His/Her teeth hurt sometimes.
-He/She had quite a few broken teeth or with cavities.
-He/She was supposed to get all teeth pulled.
-He/She had been on the BiPAP for approximately 7 years.
Observation of the resident's mouth on 11/19/24 at 8:51 A.M. showed:
-He/She had multiple teeth missing.
-He/She had teeth with sharp edges and blackened areas on multiple teeth.
Observation on 11/21/24 at 9:39 A. M showed he/she was currently utilizing the BiPAP.
During an interview on 11/25/24 at 9:14 A.M. MDS Coordinator A said:
-He/She gathered information for the MDS on interview of resident and staff, observation, the clinical record, and the daily clinical meeting.
-He/She was aware of Resident #14's cavities.
-He/She was not aware Resident #98 had broken and missing teeth.
-Dental issues should be captured on the MDS.
-A resident with dental issues should be care planned.
During an interview on 11/25/24 at 9:14 A.M. MDS Coordinator B said:
-He/She gathered information for the MDS on interview of resident and staff, observation, the clinical record, and the daily clinical meeting.
-He/She was not aware Resident #98 had broken and missing teeth.
-Resident #98 had never complained about dental concerns.
-The facility offered dental services.
-Dental issues should be captured on the MDS.
-A resident with dental issues should be care planned.
During an interview on 11/25/24 9:44 A.M. Assistant Director of Nursing (ADON) B said:
-He/She was not aware of Resident #98's missed BiPAP order.
-He/She expected the MDS to be correct.
-He/She expected dental issues to be captured on the MDS.
-He/She expected a BiPAP to be on the MDS.
-He/She expected dental issues and BiPAP to be care planned.
During an interview on 11/25/24 at 11:10 A.M. the Director of Nursing (DON) said:
-He/She expected the MDS nurse to capture the documentation from the clinical chart.
-He/She expected the MDS nurse to conduct his/her own assessments.
-He/She was not aware Residents #14 and #98 had missing and/or broken teeth or cavities.
-He/She expected dental concerns to be care planned.
-He/She expected a BiPAP to be on the MDS and care planned.
-He/She was aware Resident #98 had a BiPAP.
3. Review of the facility policy Fall Evaluation and Prevention dated 08/2020, showed:
-The purpose of the policy was to ensure the resident's environment remains as free of accident hazards as is possible, and that each resident receives adequate supervision and assistance to prevent accidents.
-The facility will evaluate residents for their fall risk and develop interventions for prevention.
-A resident should be evaluated for their fall risk; on admission/re admission to the home, following any changes of status, following a fall, and quarterly.
Review of the facility policy Care Planning, with no date, showed:
-The purpose of the policy was to ensure that a comprehensive person-centered care plan was developed for each resident based their individual needs.
-A licenses nurse will initiate the care plan, and the plan will be finalized and updated as indicated for change in condition, onset of new problems, resolution of current problems, and as deemed appropriate by clinical assessment and judgement on an as needed basis.
Review of Resident #109's face sheet, showed:
-The resident was admitted to the facility on [DATE].
-The resident had a diagnosis of difficulty in walking.
Review of the resident's fall investigation dated 7/3/24 at 5:30 A.M., showed:
-The resident verbalized to the nurse that he/she fell while outside of the building smoking.
-The resident landed on his right elbow and arm when he/she fell.
-The resident was complaining of right shoulder and elbow pain at a 7 on a 0-10 pain scale.
-The resident had an egg sized abrasion on his/her right elbow.
-The nurse on duty received an order for a 2-view x-ray of the right shoulder and elbow.
Review of the resident's fall investigation dated 7/17/24 at 2:33 P.M., showed:
-The resident fell outside in the smoking area.
-The resident hit his/her outer left foot on the concrete curb.
Review of the resident's psychiatric note dated 7/18/24, showed the resident's chief complaint was I am doing alright, I have foot pain from falling outside.
Review of the resident's quarterly MDS dated [DATE], showed:
-The resident was cognitively intact.
-The resident had not had any falls in the facility since admission or the prior assessment.
Review of the resident's care plan, revised 7/26/24, showed:
-No previous falls noted.
-No interventions for fall prevention noted.
Review of the resident's annual MDS dated [DATE], showed:
-The resident was cognitively intact.
-The resident had not had any falls in the facility since admission or the prior assessment.
During an interview on 11/20/24 at 9:38 A.M., the resident said:
-He/she fell twice outside a few months back.
-He/she continued to have pain in his/her right shoulder since the fall.
During an interview on 11/22/24 at 2:00 P.M., Certified Nurse Assistant (CNA) E said:
-The certified nurse assistants were made aware of when resident's fall from their charge nurse.
-He/she was familiar with the resident.
-He/she was not aware of the resident having any falls since admission.
During an interview on 11/22/24 at 2:17 P.M., Registered Nurse (RN) B said:
-The nurses were made aware when a resident fell from the electronic medical record.
-The charge nurse on duty at the time of a resident's fall was the one responsible for completing a fall investigation.
-He/she was familiar with the resident.
-He/she was not aware that the resident had any falls since admission.
-The MDS coordinator was responsible for updating the care plans when a resident fell.
During an interview on 11/22/24 at 2:40 P.M., MDS coordinator A and MDS coordinator B said:
-He/she was responsible for updating the MDS assessments after a resident fall.
-The clinical team had morning meetings each morning and this was when falls with residents were discussed.
-Both were aware of the resident.
-Both denied having knowledge of the resident having any falls since admission.
-The two falls should have been reflected in the updated MDS and care plan.
-Both were unaware of how the resident's two falls were overlooked.
During an interview on 11/22/24 at 3:00 P.M., ADON A said:
-When a resident fell, a risk management should be documented in the resident's medical record by the charge nurse.
-When a resident fell, the DON should be notified.
-He/she was familiar with the resident.
-He/she did recall one fall outside since the resident was admitted to the facility.
-He/she was unaware of who was responsible for completing the fall investigations.
-When a resident fell, the MDS and the care plan should be updated to reflect the fall to help prevent future falls.
-The MDS Coordinators were responsible for updating the MDS and care plans after a resident had a fall.
During an interview on 11/25/24 at 11:10 A.M., the DON said:
-The MDS coordinator was responsible for updating the MDS assessments and care plans after a resident fall.
-The MDS assessments were done quarterly and significant changes and care plans should be updated to reflect the MDS assessments.
-He/she would expect the MDS and care plan to reflect a resident who had two previous falls.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to update the care plan for an anticoagulant medication (a blood thinn...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to update the care plan for an anticoagulant medication (a blood thinning medication) for one sampled resident (Resident #110) out of 35 sampled residents. The facility census was 151 residents.
Review of the facility's Comprehensive Care Plans and Revisions policy dated 6/2020 showed:
-The care plan was to be prepared by an Interdisciplinary Team (IDT) and Nursing Staff.
-The Facility's IDT will develop a comprehensive care plan for each resident in accordance with OBRA and MDS guidelines.
-A comprehensive person-centered Care Plan must be completed within 7 days after the Comprehensive admission Assessment and must be periodically reviewed and revised by a team of qualified persons after each assessment, including the comprehensive and quarterly review assessments.
1. Review of Resident #110's admission Record showed the resident was admitted on [DATE], with a diagnosis of Peripheral Vascular Disease (PVD, is a circulatory condition that occurs when blood vessels outside of the brain and heart narrow, block, or spasm).
Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 10/8/24 showed the resident:
-Was cognitively intact.
-Was on an anticoagulant.
Review of the resident's Care Plan dated 10/15/24, showed:
-The resident has altered cardiovascular status of PVD.
-There was no anticoagulant care plan.
Review of the resident's Order Summary Report (OSR) showed the following physician ordered medication dated on 10/19/24: Rivaroxaban 20 milligrams (mg) daily by mouth in the evening.
During an interview on 11/25/24 at 9:44 A.M. the resident said he/she did receive an AC medication daily.
During an interview on 11/25/24 at 10:04 A.M., Licensed Practical Nurse (LPN) B said:
-He/she expected resident #110 to have AC medication addressed in his/her care plan.
-The MDS Coordinators were responsible for care planning.
During an interview on 11/25/24 at 10:29 A.M., MDS coordinator A and MDS coordinator B said:
-They were responsible for updating the residents' care plans.
-If a resident had an order for an AC, then the care plan should have addressed it.
-A care plan would have been created on the next assessment date when the medications were reviewed.
During an interview on 11/25/24 at 10:38 A.M., the Assistant Director of Nursing (ADON) B said he/she would had expected the resident's care plan to show that he/she was on an AC.
During an interview on 11/25/24 at 11:10 A.M., the Director of Nursing (DON) said:
-The MDS Coordinators were responsible for updating the care plans.
-The physician's orders should be monitored to ensure a care plan was created.
-He/she would expect care plans to be reviewed daily and updated as needed.
-He/she expected the resident to have an AC care plan.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0660
(Tag F0660)
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 document discharge planning prior to the resident's discharge from ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document discharge planning prior to the resident's discharge from the facility and failed to complete a discharge summary for one discharged resident (Resident #201) who was discharged to home out of four discharged records. The resident sample was 35. The facility census was 151 residents.
Review of the facility's Discharge Planning policy and procedure dated 8/2020, showed:
-Discharge Planning will start on the day the resident was admitted to the facility.
-If the Interdisciplinary team and the attending physician determine that the resident may soon be discharged , Social Service staff will coordinate the discussion of discharge with the Interdisciplinary team, the resident, and the resident's representative.
-Social Services staff will document the discharge planning, preparation, and the resident's post-discharge needs in the resident's electronic health record.
-Social Services staff will assist in developing the Discharge Summary and Discharge Care plan that is developed with the interdisciplinary team.
-A copy of the discharge summary and care plan will be maintained in the resident's medical record.
-A post-discharge plan of care will be provided to the resident/resident representative detailing the arrangements the facility has made to address the resident's needs post discharge.
1. Review of Resident #201's admission Record showed the resident was admitted to the facility on [DATE], with diagnoses including Leukoencephalopathy (a group of diseases that affect the white matter of the brain that can cause memory loss, muscle weakness, changes in behavior, language and vision changes), schizoaffective disorder (a mental health problem where you experience psychosis (hallucinations and delusions) as well as mood symptoms), bipolar disorder (a mental health condition that causes extreme mood swings), depression, and anxiety.
Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 8/9/24, showed the resident:
-The resident was alert and oriented with only minimal cognitive deficit.
-He/She had some loss of interests in doing things, feelings of depression, but had no behaviors of delusions, hallucinations, physical or verbal aggression, nor did he/she have any wandering or elopement behaviors during the look back period.
-Had no plan of discharge completed during the assessment and there was no plan for the resident to be discharged or to return to the community at this time.
Review of the resident's Care Plan dated 8/12/24, showed the resident used psychotropic medications related to Schizoaffective disorder, Bipolar disorder, and progressive leukoencephalopathy.
-The resident had a behavior of verbally asking staff and peers to have sex but has not physically touched anyone.
-Assist the resident to develop more appropriate methods of coping and interacting with staff and peers. Encourage the resident to express feelings appropriately.
-If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident.
-Minimize potential for the resident's disruptive behaviors by offering tasks which divert attention.
-Anticipate and meet The resident's needs.
-Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed.
-The care plan did not show any plans for discharge of the resident or seeking alternative placement based on discussions with the resident and/or responsible party.
Review of the resident's Psychiatric documentation showed:
-The resident was receiving weekly psychotherapy from 8/16/24 to 9/26/24.
-Documentation on 9/26/24 showed the therapist documented working with the resident on aggression/aggressive behaviors related to diagnoses.
-Notes did not show that the provider was working with the resident on transferring or a planned discharge from the facility (documentation showed there was prior discussion with family about transferring the resident closer to home 11/2023, but there was no current discussion documented in recent notes).
Review of the resident's Nursing Notes dated 10/22/24, showed:
-The nurse documented the resident was agitated and had behaviors of attempting to throw chairs, cursing and calling staff names. He/She was not redirectable despite several attempts. The nurse received a physician's order to send the resident the hospital for evaluation and treatment and made notifications to the resident's Power of Attorney and Director of Nursing (DON). The resident returned to the facility at 9:30 P.M. and was placed on one to one monitoring with no further incidents.
-There was no documentation showing the Social Worker had been contacting facilities for alternate placement/transfer of the resident or that there was a facility who was willing to accept the resident for placement. There was no documentation showing any active discharge planning.
Review of the resident's Social Service Notes on 10/22/24 showed:
-The Social Worker documented he/she spoke with a regional contact for a group of facilities that the resident could be transferred to and was informed that they had a bed available for the resident on the behavioral unit. The Social Worker documented he/she sent the referral and was waiting for confirmation and the facility would follow up to set up a time for an in-person assessment.
-There was no further documentation showing the Social Worker followed up with the resident or the resident's DPOA regarding a possible transfer of the resident. There was no documentation showing the current discharge plan for the resident.
Review of the resident's Nursing Notes showed:
-10/25/24 the nurse documented the resident had a confrontation with another resident that was observed by staff. The nurse notified the resident's DPOA, DON and Nurse Practitioner, who gave an order to send the resident out to the hospital for evaluation and treatment via ambulance.
-10/26/24 at 12:00 A.M., the resident returned to the facility and nursing staff placed him/her on one to one behavior monitoring with no further behaviors.
Review of the resident's Social Work Notes dated 10/26/24 showed:
-The Social Worker contacted the resident's DPOA and was informed they would be picking the resident up today (10/26/24) and he/she would not be returning to the facility. The Social Worker documented he/she notified the Administrator, DON and the Charge Nurse on the unit. The Social Worker documented he/she entered the physician's order to discharge the resident to home and send the resident with all his/her belongings and remaining medications to include 7 days of narcotics.
-There was no documentation showing the Social Worker informed the responsible party of the alternate placement that was found for the resident or of any aftercare services to be initiated for the resident. There was no documentation showing the Social Worker met with the resident's Interdisciplinary team regarding the plan to discharge the resident today and what aftercare services would be needed.
Review of the resident's Discharge Summary/Recapitulation Note dated 10/26/24 showed:
-The resident was discharged to home with his/her DPOA. The nurse documented he/she gave the resident's medications, medication sheet and face sheet to the resident's Power of Attorney. There was no additional information regarding the resident's discharge plan documented (follow up appointments or services provided).
During an interview on 11/22/24 at 12:04 P.M., with the Social Worker and the Regional Social Worker, the Social Worker said:
-He/She had been working at the facility for six weeks and was familiar with the resident and his/her behavioral concerns.
-He/She had met with the resident's responsible party about the resident's behaviors and needs and they had decided that the locked dementia unit was not the most adequate place for the resident, due to his/her youth and activities (socialization with peers). The responsible party said they understood that he/she should be on a locked unit but one with residents who were closer to the resident's age and interests.
They had also discussed trying to find a placement closer to the resident's family.
-He/She had started looking for alternate placement for the resident and had called several facilities prior to the resident having the recent behaviors.
-He/She had gotten a response back from a facility that had a bed available, but at the time, the resident had a behavior and was sent to the hospital for evaluation (on 10/22/24). When the resident came back to the facility, he/she was in process of notifying the responsible party that he/she found an alternative placement and the resident had another behavior and was sent back out to the hospital on [DATE].
-When the resident returned to the facility on [DATE], he/she notified the resident's DPOA and the Power of Attorney and family said they were going to discharge the resident to their home and they decided to come and take the resident home that day.
-He/She did not inform the resident's DPOA he/she had found a facility that was willing to accept the resident.
-Once he/she was notified the resident would be going home, he/she did not try to obtain and services or make any referrals for the resident for after care.
-The resident's DPOA and another family member came in and collected the resident's belongings and the nurse notified the Nurse Practitioner who gave orders to send the resident with his/her medications (for a week) and the resident's responsible party took the resident home.
-He/She did not document the facilities he/she had been contacting for alternate placement of the resident and only documented the note on 10/22/24 of his/her efforts to assist the family. He/she had not documented the conversations he/she had with the resident's DPOA regarding the resident's discharge planning.
-He/She did not write a summary of the resident's discharge in the resident's electronic record.
-The Regional Social Worker said the Social Worker should have been documenting any/all efforts and contacts he/she made regarding the resident's plans to transfer to another facility. If there had been discharge plans before this Social Worker arrived, it should have been documented in the Social Work notes. There should have been a discharge summary completed by the interdisciplinary team documented in the resident's medical record and the Social Worker should have documented his/her part of the discharge summary. He/she did not see any evidence of discharge planning or a discharge summary in the resident's medical record.
During an interview on 11/22/24 at 2:02 P.M., Licensed Practical Nurse (LPN) F said:
-The resident resided on the locked unit and had behaviors that they were managing but he/she began having more intensive behaviors due to his/her diagnoses and delusions.
-The resident's family wanted to find another placement for the resident because they said they wanted a placement that was more age appropriate for the resident with more age appropriate activities and peers.
-They were trying to find another placement for the resident leading up to the day the resident discharged .
-He/She was not aware of any facilities that had been contacted or if there had been ay that had accepted the resident for placement.
-On 10/26/24 he/she received a call stating the resident's family was coming to take the resident home and the resident's physician had already been notified and they received orders to send the resident home with his/her medications.
-He/She wrote down the resident's medication list and prepared medications for 7 days.
-The resident's Power of Attorney and another relative came in and boxed up all of the resident's belongings, he/she went over the resident's medication list with the resident's Power of Attorney and provided the medication list and the family took the resident home.
-The resident was happy to be leaving the facility.
-He/She remembered writing a discharge note, but he/she did not remember writing a summary, so if there was no summary in the resident's medical record then he/she did not do it.
During an interview on 11/25/24 at 11:10 A.M., the Director of Nursing (DON) said:
-The discharge plan was interdisciplinary and started at the resident's admission.
-The nurses complete the clinical part (medication disposition where they are going and what they need to send with the resident) and the Social Worker determines the safety of the resident's discharge and should include notes showing the aftercare services (if provided).
-He/She would expect to find documentation of the resident's discharge plan, discharge location, who was notified (physician family), transportation, disposition of medication and belongings upon discharge.
-There should be notes in the residents medical record that should include a progress note completed by the nurse and should be detailed and the Social Work note should be detailed as well regarding the discharge plan.
-Any interventions/efforts leading up to a planned discharge should have been documented thoroughly.
-He/She saw the resident's medical record and there was no documentation regarding discharge planning or discharge summary and this was not what he/she would expect it to look like.
During an interview on 12/3/24 at 419 P.M. The resident's DPOA said:
-The resident had been in the facility for almost a year and he/she was on a locked unit due to his/her behaviors and elopement risk.
-He/She expressed concerns regarding the resident's quality of life there and spoke with the facility team about the appropriateness of the resident remaining there(age, socialization with peers) and they decided that they would assist with trying to find another placement for the resident to better meet his/her needs.
-He/She was also independently looking for another placement for the resident closer to family and he/she made the facility staff aware of this.
-He/She had also spoken to the current Social Worker about the resident but no one had ever informed him/her of any progression regarding discharge planning.
-They had not kept him/her informed of who they had been contacting or any efforts they had made toward this goal.
-When he/she was contacted about the resident's behaviors on 10/22/24, no one told him/her that they had found a placement for the resident and when he/she was notified on 10/26/24 the resident had another behavior, he/she thought that he/she did not have another choice but to take the resident out of the facility.
-He/She took the resident to the hospital, not home, at the suggestion of staff in the facility due to his/her behaviors at the time.
-He/She was still looking for placement for the resident.
MO00244724
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to obtain treatment and monitoring orders for a head lace...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to obtain treatment and monitoring orders for a head laceration with staples for one sampled resident (Resident #45) out of 35 sampled residents. The facility census was 151 residents.
Review of the facility's Physician Orders policy revised on 6/2020 showed:
-The facility will ensure physician orders are complete and accurate.
-Medical records department will verify that physician order are complete, accurate and clarified as necessary.
-Physician order will include a description complete enough to ensure clarity of the physician plan of care.
1. Review of Resident #45's admission Record showed was admitting on 8/5/24 with diagnosis include History of Falls, 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).
Review of the resident's Annual Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 9/20/24, showed he/she:
-Was severely cognitively impaired and was able to make his/her needs known.
-Required assistance from staff for transfers and personal cares.
Review of the resident's Fall Injury Report dated 11/13/24 at 2:59 P.M., showed:
-The resident had sustained a laceration to the back of his/her head, that measured 3.8 centimeters (cm).
-He/she was bleeding from the laceration, bright red blood.
-Nursing staff applied a pressure bandage and called emergency medical response team.
-The resident taken to hospital for evaluation.
Review of the resident's Hospital Discharge summary dated [DATE] showed the resident:
-Had a scalp laceration with staples in place.
-Care staff were to monitor for signs and symptoms of infection.
-Call the doctor if the scalp laceration staples were to come apart or staples fall out before seven days or if the wound edges reopen.
Review of the resident's Fall Care Plan revised on 11/13/24 showed:
-The resident had an actual fall with minor injury after falling from standing position.
-He/she was sent to the hospital for an evaluation.
-Intervention include: The resident went to hospital for evaluation.
-Physical therapy would screen the resident for gait/safety awareness.
-There was no documentation regarding the head laceration or removal of the staples.
Review of the resident's Physician Order Sheet (POS) as of 11/13/24 showed no physician's orders regarding the laceration to the scalp or when the staples needed to be removed.
Review of the resident's Nurse Practitioner (NP) note dated 11/17/24 showed the resident was to be seen by the wound nurse for follow-up on head laceration injury.
Review of the resident's Physician Note dated 11/18/24 at 5:16: P.M., showed:
-The resident was being seen for evaluated for post fall, that resulted in emergency room visit.
-He/she observed and evaluated the resident's laceration to the back of scalp with staples intact.
-The wound care staff were to monitor the laceration.
-The resident's scalp had a laceration with bruises at the area and staples noted.
Review on 11/19/24 at 11:54 A.M. of the resident's medical record showed:
-The resident did not have a physician order for monitoring or care of the resident head laceration.
-Did not have a resident's physician order for the removal of the staples.
-Did not find documentation by wound nurse for monitoring, assessment of the resident's head laceration.
During an observation on 11/20/24 at 2:44 P.M., showed the resident had a head laceration with one staple in place, the laceration had a slight redden area.
2. During an interview on 11/21/24 at 11:53 A.M., Certified Nursing Assistant (CNA) F said he/she was not aware of any special care orders for the resident head laceration.
During an interview on 11/21/24 at 11:56 A.M., with Licensed Practical Nurse (LPN) G said:
-The resident did not have physician's orders for removal of the staples or care of head laceration.
-The wound nurse would have been responsible for oversite and monitor the resident's head laceration site.
-A that time, the resident only had one staple intact. The resident had been picking at the site and lost the staple.
-He/she would expect to have physician's order for care or monitoring of the laceration site.
-The hospital does not always send discharge summary or orders with the resident.
-Resident with staples were normally removed in 10 days with a physician order.
During an interview on 11/25/24 at 11:10 A.M., Director of Nursing (DON) said:
-He/she would expect a physician's order for monitoring and treatment of the resident head laceration.
-He/she would expect the physician's order to include when the staples were to be removed and any after care needed.
-He/she would expect the charge nurse to ensure to have review and transcribed any new physician order from the hospital to the resident POS and TAR.
-The charge nurse or wound care nurse would be responsible for documentation of the monitoring of the resident's head laceration wound/staples.
-He/she would expect to have a physician order transcribed to ensure have documentation by nursing staff for the monitoring and treatment of the resident head laceration.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to supervise, assess, and investigate a burn related to s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to supervise, assess, and investigate a burn related to smoking for one sampled resident (Resident #104) out of 35 sampled residents. The facility census was 151 residents.
Review of the facility's Incident Investigation policy revised in August 2020 showed:
-The purpose was to ensure the facility tracked incidents that take place at the facility to increase the quality of care provided to residents.
-The facility would have a licensed nurse fill out the Incident/Accident report as soon as possible.
-An incident included but was not limited to the following:
--Burns.
-In the event of an incident a licensed nurse or the individual who first encountered or witnessed an incident would complete the Incident/Accident report.
-As appropriate, interviews with staff members and other witnesses would be documented.
-The Director of Nursing (DON) and/or designee, would review the information and Incident log every month.
-The Director of Nursing and/or designee would submit the monthly Incident log to the Quality Assessment and Assurance (QAA) Committee.
1. Review of Resident #104's admission MDS dated [DATE] showed he/she was cognitively intact and required supervision and/or touching assistance with activities of daily living (ADLs).
Review of the resident's the Smoking assessment dated [DATE] showed the resident required direct supervision and required a fire-resistant smoking apron (a flame-retardant garment that protects the wearer from burns and hot ashes while smoking) while smoking.
Review of the resident's care plan revised 11/12/24 for smoking showed:
-The resident was dependent on tobacco.
-The resident would have minimized risk of injury from unsafe smoking practices.
-Interventions showed:
--Observe clothing and skin for signs of cigarette burns.
--The resident required supervision while smoking.
-Provide appropriate safety equipment:
--Smoking apron.
Observation on 11/19/24 at 2:34 P.M. showed:
-The resident was outside on the smoking patio.
-A staff member was outside but was not near by the resident.
-He/She had on a smoking apron
-He/She had a burn, approximately 2 centimeters (cm) by 1 cm on the back of his/her middle finger on his/her right hand.
During an interview on 11/19/24 at 2:34 P.M. the resident said:
-He/She burned his/her finger while smoking.
-He/She had neuropathy in his fingers (diabetic neuropathy damage to the nerves resulting in sensory loss in the extremities).
Review of the resident's Order Summary Report (OSR) on 11/22/24 showed no physician's orders to treat the resident's burn to the finger.
Review of the resident's medical record on 11/22/24 showed no incident report of the resident's burn to his/her finger.
During an interview on 11/22/24 at 12:39 P.M. Assistant Director of Nursing (ADON) B said:
-He/She could not find an incident report for the resident.
-He/She found no documentation in the nursing progress notes.
During an interview on 11/22/24 at 1:15 P.M. Hospitality Aide (HA) A said:
-He/She received smoking interventions from the Director of Nursing (DON) or the Administrator.
-He/She was aware of the burn to resident #104's finger.
-He/She did not remember when the incident occurred.
-He/She did not report the incident.
-He/She was aware the resident was to wear a smoking apron.
During an interview on 11/25/24 at 9:08 A.M. Licensed Practical Nurse (LPN) B said:
-The nurse, ADON, the DON and sometimes the Administrator would inform the staff of interventions.
-Once notified of an incident and/or burn, an incident report, a skin assessment, and a smoking assessment would be completed.
-Notifications would be made to DON, primary care physician (PCP), and to responsible party if required.
-He/She would educate the resident to have supervised smoking.
-He/She was unaware of the resident's burn to his/her finger.
During an interview on 11/25/24 at 9:44 A.M. ADON B said:
-The Infection Preventionist (IP) supervised smoking attendants and would inform staff of smoking interventions for residents.
-The IP met with staff for huddle daily at 3:00 P.M.
-The process when a burn happened would be to complete the incident report, assess the site, clean the wound, obtain a treatment order, notify the wound nurse, DON, Nurse Practitioner (NP) and put a progress note not into the clinical record.
-Interdisciplinary Team (IDT) would review and determine interventions if not already in place.
During an interview on 11/25/24 at 11:10 A.M. the DON said:
-He/She had just put in place the IP to supervise the HAs.
-He/She expected nurses and nurse managers to inform HAs of what interventions smokers required.
-He/She expected the HAs to notify the nurse immediately if an incident occurred.
-He/She was aware resident #104 had an intervention to wear an apron.
-He/She was not aware of the burn to the resident's finger.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure to obtain comprehensive physician order for a Suprapubic (S/...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure to obtain comprehensive physician order for a Suprapubic (S/P) catheter (a urinary bladder catheter inserted through the skin about one inch above the symphysis pubis) include type, size and care required and failed to ensure plan of care updated with the new Suprapubic catheter care and care of the stoma site for one sampled resident (Resident #15) out of 35 sampled resident. The facility census of 151 resident.
Review of the facility policy Physician Orders dated 6/2020, showed:
-The purpose of the policy was to ensure that all physician orders are completed and accurate.
-Documentation pertaining to physician's orders will be maintained in the resident's medical record.
-The licensed nurse receiving the physicians order will be responsible for documenting and implementing the order.
1. Review of Resident #15's admission Record showed the resident was admitted to the facility on [DATE] with the following diagnoses:
-Benign Prostatic Hyperplasia (a condition in which the prostate gland grows larger than normal, but the growth is not caused by cancer).
-Chronic kidney disease stage II (kidney disease indicates a mild loss of kidney function).
-Genitourinary-after care (A procedure that redirects urine flow from the kidneys to a bag outside the body).
Review of the resident's re-admission progress notes dated 10/10/24 at 6:29 P.M. showed:
-The resident was re-admitted to facility following a hospitalization due to blood in urine.
-The resident had a diagnosis of prostate cancer.
-A S/P catheter was placed on 10/9/24 at the hospital.
Review of the resident's admission assessment dated [DATE] showed:
-The resident had a S/P catheter.
-The catheter tubing size was 16.5 french (catheters are sized by a universal system that measures the diameter of the tube).
-There was no further information regarding the resident's newly placed S/P catheter.
Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 10/13/24, showed he/she:
-Was moderately cognitively impair able to make his/her needs known.
-Had an indwelling catheter.
Review of the resident's Physician Order Sheet (POS) 11/2024 showed:
-Physician's orders for his/her previous indwelling catheter (or Foley catheter, is a tube with retaining balloon passed through the urethra into the bladder to drain urine).
-Did not have any detailed physician's orders specifically for the resident's new S/P catheter, to include the care and monitoring of S/P catheter stoma site.
Review of the resident's care plan on 11/22/24 showed no information regarding the resident's S/P catheter.
2. During interview on 11/21/24 at 9:24 A.M., Certified Nursing Assistant (CNA) F said:
-The resident had a catheter leg drainage bag.
-The CNAs would only empty the resident's urine drainage bag.
-The nursing staff would complete supra pubic catheter care of stoma site (an opening on the abdomen that can be connected to your urinary system to allow urine to be diverted out of your body).
During an interview on 11/25/24 at 9:56 A.M., with Licensed Practical Nurse (LPN) G said:
-He/she would expect to have a physician's order to include the specific care, size and monitoring for the S/P catheter.
-He/she had been providing S/P catheter care without a physician order to include cleaning of the around the S/P stoma site.
-Would expect the S/P catheter to in his/her plan of care.
During an interview on 11/25/24 at 11:10 A.M., Director of Nursing (DON) said:
-He/she would expect to have completed physician's order to include location, size of catheter, any dressing changes schedule of the S/P catheter.
-He/she would expect the charge nurse ensure have transcribed physician's order to physician order sheet for the new S/P catheter.
-He/she would expect the resident's care plan S/P catheter including the size of the catheter and specific care required for a S/P catheter.
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 interview, and record review, the facility failed to ensure accurate documentation of refusal of enteral feeding via a ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure accurate documentation of refusal of enteral feeding via a Gastrostomy Tube also known as a feeding tube-surgical creation of a permanent opening into the stomach through the skin for the introduction of nourishment and fluids through a tube for one sampled resident (Resident #116) out of 35 sampled residents. The facility census was 151 residents.
Review of the facility policy Physician Orders dated 6/2020, showed:
-The purpose of the policy was to ensure that all physician orders are completed and accurate.
-Documentation pertaining to physician's orders will be maintained in the resident's medical record.
-The licensed nurse receiving the physicians order will be responsible for documenting and implementing the order.
A policy for enteral tube feeding was requested but not provided by the facility.
1. Review of Resident #116's admission Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 9/12/24, showed:
-The resident was admitted to the facility on [DATE].
-The resident was cognitively intact.
-The resident was at risk for malnutrition.
-The resident had difficulty swallowing.
-The resident was receiving enteral tube feedings on admission.
Review of the resident's care plan dated 9/13/24, showed:
-The resident had a diagnosis of dysphagia (difficulty in swallowing and/or feeding).
-The resident had a diagnosis of adult Failure To Thrive (FTT: A syndrome of weight loss, decreased appetite, poor nutrition, and inactivity).
-The resident's eating was dependent on enteral feedings.
-Note: There was no resident refusal of enteral feedings mentioned in the resident's care plan.
Review of the Physicians Order Sheet (POS) dated 10/2024, showed:
-Vital 1.5 400 ml bolus 4 times per day via PEG as tolerated (provide 1600 ml of formula).
-Routine water flush 240 ml 4 times per day via PEG. (provide 960 ml of free water).
Review of the resident's Treatment Administration Record (TAR) dated 10/1/24-10/31/24, showed:
-Enteral feed order every day shift, ordered 9/09/24.
-A physician's order to administer Jevity 1.5 Cal/Fiber oral liquid. Give 400 ml bolus 4 times per day via G-tube to provide 1600 milliliter (ml) of formula daily.
-Give feeding with 240 ml water bolus.
-14 of the 84 ordered enteral feeding opportunities were left blank.
-Note: 2 of the 14 blank opportunities were documented by the nursing staff as refusals by the resident.
-12 of the 14 blank opportunities showed no documentation of refused in the resident's electronic medical record.
Review of the nurses TAR dated 11/1/2024-11/21/2024, showed:
-A physician's order to administer Jevity 1.5 Cal/Fiber oral liquid. Give 400 ml bolus 4 times per day via G-tube to provide 1600 ml of formula daily.
-A physician's order to administer Vital 1.5 400 ml bolus 4 times per day via PEG tube.
-21 of the 68 ordered enteral feeding opportunities were left blank.
-Note: 0 of the 21 ordered enteral feeding blank opportunities were documented by the nursing staff as a refusal in the resident's electronic medical record.
During an interview on 11/22/24 at 2:17 P.M., Registered Nurse (RN) B said:
-The resident was supposed to receive enteral feeding four times per day.
-The resident went through a period of time where he/she was refusing the enteral feedings and/or requesting half of the order due to having diarrhea.
-When the resident refused his/her feedings, the nurse on duty at the time should have documented the refusal in the resident's electronic medical record.
-When the resident refused his/her feedings, the nurse should have went back and attempted to give the feeding an additional time and also documented that outcome in the resident's electronic medical record.
During an interview on 11/22/24 at 2:30 P.M., the resident said:
-He/she was only wanting half of his/her feedings for a while due to the feedings giving him/her diarrhea.
-He/she has not been refusing his/her enteral feedings lately.
-His/her diarrhea has subsided.
During an interview on 11/22/24 at 2:49 P.M., the Nurse Practitioner (NP) said:
-The resident refused many of his/her feedings for a while.
-He/she would have expected the nursing staff to document in the resident's medical record when the resident refused his/her enteral feedings.
-An empty spot in the resident's TAR and/or nurse administration record would indicate that the physicians order was not completed.
During an interview on 11/22/24 at 3:00 P.M., The Director of Nursing (DON) said:
-The charge nurses were responsible for implementing ordered enteral feedings to the resident.
-The resident went through a period where he/she was refusing some of his/her enteral feedings.
-He/she would expect the nurse to have documented in the resident's electronic medical record when the resident refused his/her enteral feedings.
-When the enteral feedings were implemented, the TAR and nurse administration record would have had the nurse's initials in the indicated box.
-When a box was left blank on a TAR and/or nurses TAR, it indicated that the enteral feeding was not completed.
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** 2. Review of Resident #97's admission Record showed the resident was admitted on [DATE], with a diagnosis of ESRD.
Review of th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #97's admission Record showed the resident was admitted on [DATE], with a diagnosis of ESRD.
Review of the resident's Annual MDS dated [DATE] showed the resident:
-Was cognitively intact.
-Had renal insufficiency, renal failure, or ESRD.
Review of the resident's POS dated 11/1/24 showed:
-Check and record weight pre and post dialysis two times a day every Monday, Wednesday, and Friday for Dialysis health maintenance.
-Dialysis Center on Monday, Wednesday, and Friday.
Review of the resident's Care Plan dated 10/14/24, showed:
-Received Dialysis related to renal failure.
-Had ESRD.
Review of the resident's Dialysis Communication Forms dated October 2024 showed:
-The resident had 13 Dialysis appointments scheduled for the month.
-The Dialysis communication forms were not completed 13 out of 13 times.
Review of the resident's Dialysis Communication Forms dated 11/1/24 to 11/22/24 showed:
-The resident had 10 scheduled Dialysis appointments.
-The Dialysis communication forms were not completed 10 out of 10 times.
During an interview on 11/25/24 at 10:15 A.M., RN A said:
-Before a resident would go to Dialysis the charge nurse would fill out a form of the resident's weight and vital signs (blood pressure, pulse) and send it with the resident to the Dialysis facility.
-The Dialysis facility would fill out the form and return it back with the resident.
-The forms were how the facility and the Dialysis facility communicated the resident's condition.
-The form should be filled out every time the resident went to Dialysis.
-The charge nurses were responsible for weights and vitals before and after the Dialysis treatment.
-The charge nurses would review the form when the resident returned from Dialysis.
During an interview on 11/25/24 at 10:38 A.M., Assistant Director of Nursing (ADON) B said:
-The charge nurse was responsible for completing the Dialysis communication form and would send it with the resident to the Dialysis center.
-When the resident returned from Dialysis the charge nurse was responsible for reviewing the communication form.
-No one was monitoring to ensure the form was returned and reviewed for changes.
-The charge nurse should take weights and vitals before and after the Dialysis treatment.
During an interview on 11/25/24 at 11:00 A.M. the resident said he/she was given the Dialysis communication form to take from the facility to the Dialysis facility sometimes.
During an interview on 11/25/24 at 11:10 A.M., the DON said:
-The Dialysis forms should be filled out for each date the resident received Dialysis.
-The charge nurse was responsible to weigh the resident and check their vital signs before and after the Dialysis treatment.
-The charge nurse was responsible for reviewing and monitoring the Dialysis communication forms.
Based on observation, interview and record review, the facility failed to follow physician's orders for assessing the resident's Dialysis (a procedure that removes waste products and excess fluid from the blood when the kidneys are unable to function properly) shunt (a surgically created connection between an artery and a vein that allows for direct access to the bloodstream for Dialysis) consistently, and failed to ensure Dialysis communication was received and documented after each Dialysis treatment for continuum of care, for two sampled residents (Resident #7 and #97) out of 35 sampled residents. The facility census was 151 residents.
Review of the facility's Dialysis Care policy dated June 2020, showed:
-The policy is to provide care for residents diagnosed with renal disease requiring ongoing dialysis treatments.
-The facility would be responsible for the overall care delivered to the resident, monitoring of the resident prior to and after the completion of each Dialysis treatment, providing for all non-Dialysis needs of the resident including during the time period when the resident was receiving Dialysis.
-The nursing staff, Dialysis provider staff, and the attending physician would collaborate on a regular basis concerning the resident's care as follows:
--Nursing staff would communicate pertinent information in writing to the Dialysis staff which may include:
---Any medication changes, changes in condition, and the resident's tolerance of Dialysis procedures.
--Nursing staff use Nurse Dialysis Communication Record or comparable form in the Electronic Medical Record (EMR) to convey information to the dialysis provider.
1. Review of Resident #7's Face Sheet showed the resident was admitted to the facility on [DATE], with cognitive impairment, diabetes, peripheral vascular disease (a chronic condition that occurs when blood vessels outside of the brain and heart narrow or become blocked), high blood pressure, communication deficit, and end stage renal failure (ESRD a medical condition where the kidneys have permanently lost their ability to function, requiring regular dialysis or a kidney transplant to survive).
Review of the resident's Treatment Administration Record (TAR) dated August 2024, showed the resident attended Dialysis every Tuesday, Thursday and Saturday. The nursing staff was to check the resident's shunt site for bruising bleeding and signs of infection twice daily. There were checkmarks showing the dates when the resident attended Dialysis and when the shunt site was checked. Documentation showed:
-There were 14 scheduled Dialysis visits during the month.
-The resident did not attend Dialysis on 8/3/24, 8/17/24 and 8/31/24.
-Nursing staff did not check the resident's shunt site as ordered on 8/2/24, 8/3/24, 8/4/24, 8/17/24, 8/26/24 and 8/31/24 when it was only checked as completed once daily.
Review of the resident's Nursing Notes dated 8/1/24 to 8/31/24 showed:
-The resident refused Dialysis on 8/17/24.
-The resident, once at Dialysis, refused treatment on 8/24/24.
Review of the resident's Documentation of Dialysis Communication from 8/1/24 to 8/31/24 showed on the document were areas for the facility nursing staff to document the resident's vital signs, location of his/her access site, whether there is a thrill (a vibration caused by blood flowing through the shunt) and bruit (a whooshing sound from blood flowing through the shunt) (monitoring) and if there was a dressing, any recent medication changes and if there were any change in condition prior to attending dialysis. There was an area for the Dialysis site to document on the form the resident's vital signs and weight, any lab results and dietary concerns, post Dialysis vital signs weights and any special instructions. At the bottom of the form was an area for Nursing Facility staff to document the resident's post Dialysis vital signs, location of the access site, whether there was a thrill and bruit completed, if there was a dressing any new orders and documentation of the assessment. Review of the documents showed on dates the resident went to dialysis:
-There were no Dialysis communication sheets documented from 8/1/24 to 8/10/24.
-Monitoring of thrill and bruit were not documented as completed prior to or after Dialysis on 8/10/24 and 8/20/24.
-Out of 14 Dialysis visits during the month there were no corresponding communication sheets for 11 dates.
Review of the resident's TAR dated September 2024, showed the resident attended Dialysis every Tuesday, Thursday and Saturday. It showed the nursing staff was to check the resident's shunt site for bruising bleeding and signs of infection twice daily. There were checkmarks showing the dates when the resident attended Dialysis and when the shunt site was checked. Documentation showed:
-There were 12 scheduled Dialysis visits during the month.
-The resident did not attend Dialysis on 9/14/24 and 9/28/24.
-Nursing staff did not check the resident's shunt site as ordered on 9/12/24 and 9/24/24 when it was only checked as completed once daily.
Review of the resident's Social Service Notes showed on 9/10/24 Social Services Worker (SSW) called the resident's family to discuss Hospice services. The resident continued to refuse Dialysis. The responsible party said he/she would notify their attorney so he/she could notify the courts that Hospice was being recommended. SSW advised that SSW would leave information about some Hospice providers with the business office for their review.
Review of the resident's Nursing Notes dated 9/1/24 to 9/30/24, showed:
-The resident, once at Dialysis, refused treatment on 9/7/24.
-The resident refused to go to Dialysis on 9/26/24.
Review of the resident's Documentation of Dialysis Communication from 9/1/24 to 9/30/24 showed on the document were areas for the facility nursing staff to document the resident's vital signs, location of his/her access site, whether there is a thrill and bruit (monitoring) and if there was a dressing, any recent medication changes and if there were any change in condition prior to attending Dialysis. There was an area for the Dialysis site to document on the form the resident's vital signs and weight, any lab results and dietary concerns, post Dialysis vital signs weights and any special instructions. At the bottom of the form was an area for Nursing Facility staff to document the resident's post Dialysis vital signs, location of the access site, whether there was a thrill and bruit completed, if there was a dressing any new orders and documentation of the assessment. Review of the documents showed on dates the resident went to Dialysis:
-Monitoring of thrill and bruit were not documented as completed prior to or after Dialysis on 9/14/24, 9/17/24, 9/21/24, and 9/26/24.
-Monitoring of thrill and bruit was not documented as completed after Dialysis on 9/3/24 and 9/21/24.
-Out of 12 Dialysis visits scheduled during the month, there were no communication sheets completed for six dates.
Review of the resident's TAR dated October 2024, showed the resident attended Dialysis every Tuesday, Thursday and Saturday. It showed the nursing staff was to check the resident's shunt site for bruising bleeding and signs of infection twice daily. There were checkmarks showing the dates when the resident attended Dialysis and when the shunt site was checked. Documentation showed:
-There were 11 scheduled Dialysis visits during the month through to 10/26/24.
-The resident did not attend Dialysis on 10/12/24.
-Nursing staff did not check the resident's shunt site as ordered on 10/1/24, 10/2/24, 10/3/24 and 10/4/24 (there was no documentation), 10/8/24, 10/11/24, 10 /12/24, 10/13/24 and 10/16/24 when it was only checked as completed once daily.
Review of the resident's Nursing Notes from 10/1/24 to 10/31/24 showed:
-The resident, once at Dialysis, refused treatment on 10/5/24 and 10/10/24.
-10/10/24 the resident refused to do Dialysis treatment while at the Dialysis center. Nurse at the center said if he/she was going to refuse, do not send the resident. Conversation with resident and education provided regarding Dialysis. Resident said he/she was not going to do Dialysis treatments. Spoke with SSW for meeting with the resident's Guardian. Spoke with family member yesterday and family was not receptive to education or situation of resident refusal of Dialysis.
Review of the resident's Documentation of Dialysis Communication from 10/1/24 to 10/31/24 showed on the document were areas for the facility nursing staff to document the resident's vital signs, location of his/her access site, whether there is a thrill and bruit (monitoring) and if there was a dressing, any recent medication changes and if there were any change in condition prior to attending Dialysis. There was an area for the Dialysis site to document on the form the resident's vital signs and weight, any lab results and dietary concerns, post Dialysis vital signs weights and any special instructions. At the bottom of the form was an area for Nursing Facility staff to document the resident's post Dialysis vital signs, location of the access site, whether there was a thrill and bruit completed, if there was a dressing any new orders and documentation of the assessment. Review of the documents showed on dates the resident went to Dialysis:
-Monitoring of thrill and bruit was not documented as completed after Dialysis on 10/5/24 and 10/15/24.
-There were no Dialysis communication sheets documented from 10/15/24 to 10/21/24.
-Out of 11 Dialysis visits scheduled during the month, there were no communication sheets documented for nine dates.
Review of the resident's Social Service Notes showed:
-10/10/24 SSW called and left voice mail for responsible party to return writers call regarding setting up a care plan meeting to discuss the resident refusing Dialysis after being sent to appointments as scheduled. The resident told the staff at the Dialysis treatment center that he/she would not be accepting treatment at all, and would continue to refuse treatment. Family/Guardian were saying they wanted him/her not to refuse and that this facility should keep sending him/her to Dialysis. Dialysis center was saying they could use that chair time if the resident was not going to accept treatment.
-10/18/2024 SSW held care plan conference with the resident's Guardian on phone. Resident continued to refuse Dialysis treatments and said he/she would not change his/her mind even if the facility continued to send him/her. Resident was also refusing medication for the last week. Hospice attended care plan and Guardian had decided to use Hospice services. They would be at the facility to complete paperwork on 10/21/24 and admit the resident to services. The resident would still go to Dialysis on Saturday 10/19/21 until he/she was completely admitted to Hospice.
Review of the resident's Significant Change Minimum Data Set (MDS a federally mandated assessment tool to be completed by facility staff for care planning) dated 10/28/24 showed the resident needed supervision for eating, moderate to maximum assistance for toileting, bathing and dressing; needed moderate assist for transfers and used a wheelchair for mobility.
-Received Dialysis treatments.
Review of the resident's Care Plan dated 10/28/24, showed the resident had Dialysis treatments three times weekly on Tuesday, Thursday and Saturday. It showed the location and contact information for the Dialysis treatment center. It showed the resident had a behavior problem related to frequently refusing Dialysis or having behavior problems when at Dialysis. Interventions showed nursing staff would:
-Anticipate and meet the resident's needs.
-Provide opportunity for positive interaction, attention. Stop and talk with him/her when passing by.
-Explain all procedures to the resident before starting and allow the resident time to adjust to changes.
-If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident.
-Will have no signs or symptoms of complications from Dialysis through the review date.
-Monitor/document/report as needed any sign or symptom of infection to access site (redness, swelling, warmth or drainage).
-Monitor/document/report as needed for signs or symptoms of renal insufficiency (changes in level of consciousness, changes in skin turgor, oral, changes in heart and lung sounds).
Review of the resident's Physician's Order Sheet (POS) dated November 2024, showed physician's orders for:
-Monitor left upper extremity shunt site for bruising, bleeding and signs/symptoms of infection. If bleeding noted, apply direct pressure until bleeding is controlled and notify physician for further directions (12/17/23).
-Upon return from Dialysis palpate shunt for thrill and listen for the bruit. Repeat twice within eight hours post Dialysis. If either was absent, notify the physician and document the findings, check thrill and bruit every shift routinely (12/17/23).
-Admit to Hospice services (10/21/24).
Review of the resident's Nursing Notes showed on 11/5/24 Dialysis vendor notified this nurse regarding follow up on the resident. Nurse informed Dialysis vendor the resident was currently on Hospice services at this time.
Observation and interview on 11/19/24 at 9:25 A.M., showed the resident was laying in bed with his/her call light within reach. He/She was not wearing a shirt and his/her Dialysis access site was on his/her upper left arm. There was no redness, bruising or sign of infection. The resident was alert and oriented and said:
-He/She did not go to Dialysis anymore because he/she was now on Hospice.
-He/She was educated on discontinuing Dialysis and the consequence of that choice and he/she did not want to go to Dialysis.
-He/She did not remember when his/her last visit to Dialysis was and said he/she did not remember if staff assessed his/her Dialysis site after Dialysis or daily.
During an interview on 11/25/24 at 9:36 A.M., showed Registered Nurse (RN) A said:
-They did not do anything with the resident's shunt now, they did not check it or monitor it.
-They stopped checking and monitoring the resident's shunt once he/she decided to no longer go to Dialysis and was placed on Hospice, but up until the resident started Hospice, they had been monitoring his/her shunt.
-They would check for the thrill and bruit and symptoms of infection and take his/her vital signs before and after Dialysis and document their findings on the Dialysis communication form.
-Usually, the Dialysis center would document their findings on the form and return it, and the nurse would then document the monitoring of the resident's shunt after Dialysis.
-For some time before the resident stopped Dialysis, he/she would go to Dialysis and then refuse treatment.
-There should have been documentation showing they checked the resident's shunt (thrill and bruit) before and after each Dialysis treatment and it should have been on the Dialysis communication form.
-They also were supposed to check the thrill and bruit twice daily and document it on the TAR, but they were primarily supposed to document on the Dialysis Communication Form and place the form in the resident's Dialysis book or scan it into the resident's medical record.
During an interview on 11/25/24 at 11:10 A.M., the Director of Nursing (DON) said:
-He/She would expect the Dialysis communication form to be filled out completely on each day the resident attended Dialysis.
-The nurses should complete and document vital signs and check the resident's thrill and bruit on the resident before and after the Dialysis treatments.
-The most accurate documentation should be found in the resident's medical record.
-Even if Resident #7 refused treatments, once he/she returned from Dialysis, the nurses should have continued to monitor the thrill and bruit, check for signs and symptoms of infection and document their findings on the Dialysis communication form.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident's physician responded with a rationale to the p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident's physician responded with a rationale to the pharmacist's recommendation for a Gradual Dose Reduction (GDR) of the resident's psychotropic medications (drugs which affect psychic function, behavior, or experience) on the Drug Regimen Review (DRR) for one sampled resident (Resident #137) out of 35 sampled residents. The facility census was 151 residents.
Review of the facilities Medication Management policy dated August 2020, showed:
-In order to optimize the therapeutic benefit of medication therapy and minimize or prevent potential adverse consequences, facility, the attending physician/prescriber, and the consultant pharmacist perform on going monitoring for appropriate, effective, and safe medication use.
-When selecting medications and non-pharmacological interventions, members of the interdisciplinary team participate in the care process to identify, assess, address, advocate, for, monitor, and communicate the resident's needs and changes in condition.
-If a resident is admitted on an antipsychotic medication or the facility initiates antipsychotic therapy, the facility should attempt a GDR in two separate quarters within the first year unless clinical contraindicated. After the first year, a GDR must be attempted annually.
-A GDR is considered contraindicated if the continued use is in accordance with relevant current standards of practice and the physician documents clinical rationale for why any additional attempted dose reduction would impair the resident's function, increase distressed behavior, or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder.
1. Review of Resident #137's admission Record, showed:
-The resident was admitted to the facility on [DATE].
-The resident had a diagnosis of Bipolar (formerly called manic depression, is a mental health condition that causes extreme mood swings).
-The resident had mild cognitive impairment.
-The resident had a diagnosis of depression (a common and serious mental disorder that negatively affects how you feel, think, act, and perceive the world).
-The resident had a diagnosis of insomnia (a sleep disorder in which you have trouble falling and/or staying asleep).
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 4/18/24, showed:
-The resident had a diagnosis of depression.
-The resident was taking an antipsychotic (a group of psychoactive drugs (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) medication.
-A GDR had not been completed on the resident's antipsychotic medication.
-A GDR had not been documented by a physician as being contraindicated.
-Note: The MDS did not reflect that the resident had bipolar disorder, as mentioned on the admission record.
Review of the resident's care plan dated 4/20/24, showed:
-The resident used psychotropic medications related to behavior management.
-The resident was at high risk for side effects from psychotropic medications.
-The resident should be monitored for side effects and effectiveness of psychotropic medications.
Review of the resident's Consultant Pharmacist Recommendation to Physician dated 10/15/24, showed:
-The resident had been taking Aripiprazole (Abilify an antipsychotic medication used to treat mental health conditions bipolar disorder) 15 milligram (mg) every day since 4/15/24 without a GDR.
-The pharmacist recommended reducing the dose of Aripiprazole to 10 mg every day.
-The physician responded with no.
-The physician did not give a rationale for his/her response to the recommendation.
Review of the resident's Physician Order Sheet (POS) dated 11/13/24, showed:
-Aripiprazole Oral Tablet 15 mg. Give 1 tablet by mouth one time per day for bipolar disorder.
-Trazadone (antidepressant) Oral Tablet 100 mg. Give 0.5 tablet by mouth at bedtime for
Sleep.
During an interview on 11/22/24 at 2:30 P.M., Registered Nurse (RN) B said:
-He/she was unaware of the facility policy or the facility process for medication reviews and GDR's.
-He/she was unaware of who in the facility took care of the GDR request from the pharmacist.
-He/she had not done any GDR request in a long time.
During an interview on 11/22/24 at 3:00 P.M., Assistant Director of Nursing (ADON) A said:
-The Director of Nursing (DON) was responsible for medication reviews and ensuring that the GDR's were completed.
-When a GDR was completed, it should be documented in the resident's Electronic Medical Record (EMR).
-If a physician did not complete a GDR that was recommended by the pharmacist, the physician should have documented a rationale as to why the GDR was not completed.
During an interview on 11/25/24 at 11:10 A.M., the DON said:
-The pharmacy reviewed the medication carts and medication records and then sent GDR recommendations to himself/herself.
-He/she was responsible for printing off the GDR recommendations and discussing them with the physician.
-He/she would enter a progress note in the resident's EMR and change orders as needed once a decision was made about a GDR recommendation.
-He/she would expect the physician to document a rationale if a GDR recommendation was not initiated.
-He/she would expect all rationales from GDR's to be documented in a resident's EMR.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
2. Review of the facility policy titled Insulin Administration, dated September 2014, showed:
-The type of insulin should have been verified prior to administration to ensure it corresponded with the ...
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2. Review of the facility policy titled Insulin Administration, dated September 2014, showed:
-The type of insulin should have been verified prior to administration to ensure it corresponded with the physician order.
-The nurse was to notify the DON or physician of any discrepancies.
Review of Resident #120's POS, dated 11/19/24, showed an order for Fiasp (Insulin Aspart with Niacinamide) 17 units subcutaneously (under the skin into fatty tissue) with meals for Diabetes Mellitus.
Observation on 11/18/24 at 12:16 P.M., showed:
-RN A did not have a computer or immediate access to the resident's medical record.
-RN A opened the medication cart and retrieved a multi-dose vial of Insulin Lispro with no resident identifiers on the vial.
-RN A measured 17 units of the Insulin Lispro and, without verifying the accuracy of the order, administered the insulin to the resident.
During an interview on 11/18/24 at 2:18 P.M., RN A said the resident should have received Fiasp instead of the Insulin Lispro.
Review of the resident's medical record on 11/19/24, showed no documentation or follow up of the medication error of the resident receiving Insulin Lispro instead of Fiasp.
During an interview on 11/19/24 at 1:27 P.M., the DON said:
-He/She would not expect a resident to receive an Insulin other than what was ordered.
-He/She would expect Insulin to be given from a vial that was marked with the resident's name.
-He/She would expect staff to verify physician orders from the resident's medical record before administering a medication.
Based on observation, interview, and record review, the facility failed to ensure a medication error rate under five percent for one sampled resident (Resident #96). The medication error rate was eight percent. The facility census was 151 residents.
1. Review of Resident #96's face sheet showed he/she admitted to the facility with the following diagnoses:
-Chronic Obstructive Pulmonary Disease (COPD-a disease process that decreases the ability of the lungs to perform ventilation).
-Pulmonary Fibrosis (a diseases in which the lungs become scarred over time).
Review of the resident's admission Minimum Data Set (MDS- federally mandated assessment instrument completed by facility staff for care planning) dated 10/16/24 showed the resident was cognitively intact.
Review of the resident's Physician Order Sheet (POS) dated November 2024 showed an order for Symbicort (a medication used to treat COPD) Inhalation Aerosol 160-4.5 micrograms (mcg)/actuation (act), two puffs inhale orally two times a day for COPD.
Observation on 11/18/24 at 9:36 A.M. of medication administration completed by Certified Medication Technician (CMT) A showed he/she documented the resident received his/her dose of Symbicort but had not watched the resident take the medication or given the medication to the resident for him/her to take.
During an interview on 11/18/24 at 9:48 A.M. CMT A said he/she would not have done anything differently during the medication pass.
During an interview on 11/19/24 at 2:09 P.M. the resident said he/she was unaware that he/she had an order for the Symbicort, and the inhaler had not been given to him/her on 11/18/24.
During an interview on 11/19/24 at 2:51 P.M. CMT B said:
-CMT's were responsible for giving scheduled inhaler administration to the residents.
-The CMT should not have just documented that the resident received the medication without verifying that the resident took it or gave it to the resident himself/herself.
During an interview on 11/20/24 at 10:43 A.M. Registered Nurse (RN) A said:
-CMT's were responsible for administering scheduled inhalers.
-CMT's were to watch the resident take the inhaler or assist in the administration of the inhaler.
-The CMT should not have documented that the resident received his/her Symbicort.
During an interview on 11/20/24 at 11:13 A.M. Assistant Director of Nursing (ADON) A said:
-CMT's were responsible for administering scheduled inhalers.
-The CMT should have given the inhaler for the resident to take or assisted in the administration of the inhaler.
-The CMT should not have documented that the resident received his/her Symbicort because he/she had not administered the medication.
During an interview on 11/20/24 at 11:51 A.M. the Director of Nursing (DON) said:
-CMT's could administer scheduled doses of inhalers.
-The CMT should have watched the resident take the inhaler or assisted in the administration of the inhaler.
-The CMT should not have documented that the resident received his/her Symbicort because he/she had not administered the medication.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure residents were free from significant medication errors when staff administered the incorrect insulin (a synthetic hormo...
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Based on observation, interview and record review, the facility failed to ensure residents were free from significant medication errors when staff administered the incorrect insulin (a synthetic hormone used to lower blood glucose levels) for one sampled resident (Resident #120) out of 35 sampled residents. The facility census was 151 residents.
Review of the facility's Insulin Administration policy dated September 2014 showed:
-The type of insulin should have been verified prior to administration to ensure it corresponded with the physician's order.
-The nurse was to notify the Director of Nursing (DON) or physician of any discrepancies.
1. Review of Resident #120's Annual Minimum Data Set (MDS, a federally mandated assessment tool completed by facility staff for care planning) dated 9/20/24 showed the resident had a diagnosis of Type II Diabetes Mellitus (a condition in which the body is unable to use insulin appropriately).
Review of the resident's Physician Order Summary (POS), dated 11/19/24, showed an order for Fiasp (Insulin Aspart with Niacinamide) 17 units subcutaneously (under the skin into fatty tissue) with meals for Diabetes Mellitus (a disease affecting the body's usage of natural insulin).
Review of the resident's Care Plan, dated 9/23/24, showed:
-The resident used insulin for diabetes.
-Staff were to administer diabetes medication (insulin) as ordered by the doctor.
Observation on 11/18/24 at 12:16 P.M., showed:
-Registered Nurse (RN) A was using the nurse medication cart to check glucose levels and administer insulin.
-RN A did not have a computer or immediate access to the resident's medical record.
-RN A opened the medication cart and retrieved a multi-dose vial of Insulin Lispro with no resident identifiers on the vial.
-RN A said this must belong to the resident, measured 17 units of the Insulin Lispro and, without verifying the accuracy of the order, administered the insulin to the resident.
During an interview on 11/18/24 at 2:18 P.M., RN A said the resident should have received Fiasp instead of the Insulin Lispro.
Review of the resident's medical record showed no documentation or follow up of the medication error.
During an interview on 11/19/24 at 1:27 P.M., the DON said:
-He/She would not expect a resident to receive an insulin other than what was ordered.
-He/She would expect insulin to be given from a vial that was marked with the resident name.
-He/She would expect staff to verify physician orders from the resident's medical record before administering a medication.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
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 routine and emergency dental services to meet ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure routine and emergency dental services to meet the needs of residents were offered to two sampled residents, (Residents #14 and #98) out of 35 sampled residents. The facility census was 151 residents.
Review of the facility's undated Dental Services policy showed:
-Refer and/or assist residents to obtain dental services as indicated for routine and emergency dental care including making appointments for the residents, if needed or requested and arrange transportation to and from the dentist's office.
--Routine services include but are not limited to:
---Annual inspections.
---Dental cleaning, fillings, and x-ray as needed.
---Minor dental plate adjustments.
---Smoothing of broken teeth.
--Emergency dental services include but are not limited to:
---Acute or intolerable pain in teeth, gums, palate.
---Broken, damaged teeth, or dentures.
1. Review of Resident #14's admission Record showed he/she was admitted to the facility on [DATE] with the diagnosis of Need for Assistance with Personal Care.
Review of the resident's nursing Admission/readmission Evaluation dated 8/24/23 showed he/she had broken and/or carious (cavities) teeth.
Review of the resident's Nutrition Assessment Registered Dietician Evaluation dated 1/20/24 showed:
-He/She was on a regular diet and regular consistency.
-He/She had his/her own teeth in fair condition.
Review of the resident's Order Summary Report (OSR) showed a physician's order dated 4/30/24, that the resident may be seen and treated by a dentist.
Review of the resident's Annual Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated 8/28/24 showed:
-He/She had moderate cognitive deficits and required support of facility staff.
-He/She had no missing teeth or cavities.
-He/She performed oral care with supervision and/or touching assistance by staff.
Observation on 11/19/24 at 10:25 A.M. of the resident's mouth showed:
-Multiple teeth missing in the upper and lower jaw.
-One tooth on the lower right side was loose and pointed towards the tongue.
-A buildup of a yellow substance on the remaining teeth.
During an interview on 11/19/24 at 10:25 A.M. the resident said:
-He/She was unsure the last time he/she had seen a dentist.
-He/She had not seen a dentist since admission.
-He/She didn't have many teeth.
-Sometimes his/her teeth hurt, but he/she was able to eat a regular diet.
Review of the resident's current care plan showed no mention of the resident requiring a need for dental care.
Review of the resident's Quarterly MDS dated [DATE] showed no missing teeth or cavities.
2. Review of Resident #98's admission Record showed he/she was admitted on [DATE].
Review of the resident's nursing Admission/readmission Evaluation dated 7/25/23 showed:
-He/She had his/her own teeth.
-The assessment question that stated broken or carious teeth was left blank.
Review of the resident's care plan dated 8/1/23 showed staff were to monitor oral hygiene and notify MD of abnormal findings or concerns. Refer to a dentist as indicated.
Review of the resident's Annual MDS dated [DATE] showed:
-He/She was cognitively intact.
-Oral/Dental Status showed no problem with missing teeth or cavities.
Review of the resident's dental evaluation dated 6/25/24 showed:
-Tooth #25 was now a root tip.
-Missing teeth included #1, 2, 5, 6, 10, 13, 14, 15, 16, 17, 18, 19, 29, and 32.
-He/She had root tips on #7, 8, 9, 11, 12, 20, 25, 30, and 31.
-Doctor of Dental Surgery (DDS) recommended full mouth extraction of remaining natural teeth.
-The resident wanted teeth extracted and wanted to get dentures.
During an interview on 11/21/24 at 9:39 A.M. the resident said:
-His/Her teeth hurt sometimes.
-He/She was supposed to get all teeth pulled.
Observation of the resident's mouth on 11/21/24 at 9:39 A. M showed:
-He/She had multiple teeth missing.
-He/She had teeth with sharp edges and blackened areas on multiple teeth.
3. During an interview on 11/21/24 9:36 A.M. the Social Worker (SW) said:
-The facility had a provider for dental care.
-The dental provider came frequently, approximately every other month.
-He/She would receive a list from the dental provider with the residents' names for the next visit.
-He/She said nursing would be informed of new admissions or changes that needed to be addressed.
-He/She was not aware Resident #14 had missing teeth or had not seen a dentist.
-He/She said #14 had not been seen by a dentist.
-He/She said #98 had seen the dentist in 6/2024 but could not find paperwork and would have to request the information from dental provider.
During an interview on 11/25/24 at 9:14 A.M. MDS Coordinator A said:
-He/She gathered information for the MDS on interview of resident and staff, observation, the clinical record, and the daily clinical meeting.
-He/She said he/she was aware of #14's cavities.
-He/She was not aware Resident #98's broken and missing teeth.
-He/She stated dental issues would be captured on the MDS and be care planned.
During an interview on 11/25/24 at 9:16 A.M. MDS Coordinator B said:
-He/She gathered information for the MDS on interview of resident and staff, observation, the clinical record, and the daily clinical meeting.
-He/She was not aware Resident #98's broken and missing teeth.
-He/She stated Resident #98 had never complained about dental concerns.
-He/She stated the facility offered dental services.
-He/She stated dental issues would be captured on the MDS and be care planned.
During an interview on 11/25/24 9:44 A.M. Assistant Director of Nursing (ADON) B said:
-He/She would expect a resident with multiple teeth missing and/or caries to be seen by the dentist.
-He/She said he/she would notify the SW of new residents or residents with issues to add to the schedule.
-He/She expected dental documentation/recommendations to be provided by end of day before the dentist leaves.
-The recommendations went to the SW and would give to the appropriate ADON for processing.
-He/She expected a resident would be seen by a dentist within one month.
-A referral for teeth extraction would be scheduled within one week after the dental provider recommended the resident have his/her teeth pulled.
During an interview on 11/25/24 11:10 A.M. the Director of Nursing (DON) said:
-The facility had a dental provider.
-He/She expected a resident with multiple missing teeth or with caries on admission would be seen by dental.
-He/She expected the dental evaluation to be available to the facility within a day or two.
-The SW followed up on dental recommendations.
-He/She expected a new resident would be seen within 30 days.
-Residents could be sent out for emergency dental services.
-He/She was not aware Resident #14 had missing teeth.
-He/She was not aware of Resident #98's broken, missing, and carious teeth.
-He/She expected a resident with multiple missing teeth on admission would be seen by dental.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure pneumococcal pneumonia vaccines (a vaccine to protect agains...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure pneumococcal pneumonia vaccines (a vaccine to protect against pneumococcal disease caused by the bacteria Streptococcus pneumoniae) were offered, administered, or documented for one sampled resident (Resident #95) and failed to ensure an influenza vaccine (an annual vaccine to protect against the influenza virus) was offered, administered, or documented for one sampled resident (Resident #48) out of five residents sampled for vaccination provision. The facility census was 151 residents.
Review of a facility policy titled Pneumococcal Disease Prevention, dated June 2020 showed:
-Residents that reside in nursing homes are recommended to have the pneumococcal vaccine.
-Residents would be assessed for and offered pneumococcal vaccinations.
-Any vaccine refusals or administrations would be documented in the residents' medical record.
-Any consent or refusal would be documented in the resident record.
Review of an undated facility policy titled Influenza Prevention and Control showed:
-Residents would be offered the influenza immunization during flu season.
-Any consents or refusals would be documented in the resident record.
-The vaccine administration would be documented in the medical record of the resident.
Review of the Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccine Timing for Adults, revised 10/26/24, showed the CDC recommended pneumococcal vaccination for adults [AGE] years old and older.
Review of the CDC influenza vaccine guidelines, dated 10/3/24, showed the CDC recommended influenza vaccines for everyone 6 months and older each flu season (October through April) with everyone being ideally vaccinated by the end of October.
1. Review of Resident #95's admission Record showed:
-The resident was older than [AGE] years old.
-The resident had an admission date of 9/24/24.
-Risk factors of infectious respiratory infections including a diagnosis of respiratory failure and use of a tracheostomy (an implanted device used to assist in getting air into the lungs).
Review of the resident's immunization report showed:
-No evidence of pneumococcal vaccination administration dates.
-The report lacked documentation of education, consent or refusal and administration of the pneumococcal vaccine for which the resident was recommended per the CDC.
2. Review of Resident #48's admission Record showed.
-The resident had an admission date of 12/6/22.
Review of the resident's immunization report showed:
-No evidence of influenza vaccination administration dates.
-The report lacked documentation of education, consent or refusal and administration of the influenza vaccine.
During an interview on 11/19/24 at 9:29 A.M., the Infection Preventionist (IP) said:
-Residents should have been screened for pneumococcal immunizations on admission.
-Influenza vaccines should have been offered to all residents eligible to receive it.
-The facility had already offered the influenza vaccine to current residents.
-All administered immunizations should have been documented in the resident medical record.
-Any refusals should have been signed and documented in the resident's medical record.
-Residents that were recommended pneumococcal vaccines should have been offered the vaccine by the facility.
-He/She was responsible for ensuring resident's vaccine status along with refusals were documented and they were offered recommended vaccines.
During an interview on 11/19/24 at 1:27 P.M., the Director of Nursing (DON) said:
-Residents should have been screened for pneumococcal immunizations on admission.
-Residents should be offered the influenza vaccine annually.
-All administered immunizations should have been documented in the resident medical record.
-Any refusals should have been signed and documented in the resident's medical record.
-Residents that were recommended vaccines should have been offered the vaccines by the facility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to provide education to the resident or the resident's representative and obtain signed consent or refusal of the Coronavirus Disease 2019 (CO...
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Based on interview and record review, the facility failed to provide education to the resident or the resident's representative and obtain signed consent or refusal of the Coronavirus Disease 2019 (COVID-19), and failed to administer recommended vaccines for three sampled residents (Residents #71, #93 and #95) out of five sampled residents. The facility census was 139 residents.
Review of the Centers for Disease Control (CDC) Clinical Considerations for COVID-19 Vaccines, dated 10/31/24, showed:
-Unvaccinated residents (residents who did not receive a multidose vaccine series) should receive a two dose vaccine series.
-The Moderna COVID-19 vaccine is a two-dose initial vaccine series with recommended boosters thereafter.
1. Review of Resident #71's medical record showed:
-An admission date of 2/12/24.
-A single dose of Moderna COVID-19 vaccine administered 10/27/23.
-No other COVID-19 vaccine doses.
-No evidence of a COVID-19 vaccine being offered or administered by the facility.
-No signed consent or refusal for the COVID-19 vaccine.
-No evidence of COVID-19 vaccine education provided to the resident or resident ' s representative.
2. Review of Resident #93's medical record showed:
-An admission date of 2/3/24.
-A single dose of Moderna CO3. VID-19 vaccine administered 1/31/24.
-No other COVID-19 vaccine doses.
-No evidence of a COVID-19 vaccine being offered or administered by the facility.
-No signed consent or refusal for the COVID-19 vaccine.
-No evidence of COVID-19 vaccine education provided to the resident or resident's representative.
3. Review of Resident #95's medical record showed:
-An admission date of 9/24/24.
-No COVID-19 vaccination history.
-No evidence of a COVID-19 vaccine being offered or administered by the facility.
-No signed consent or refusal for the COVID-19 vaccine.
-No evidence of COVID-19 vaccine education provided to the resident or resident ' s representative.
During an interview on 11/19/24 at 9:29 A.M., the Infection Preventionist (IP) said:
-He/she was responsible for ensuring the completion of COVID-19 vaccinations for residents.
-Vaccine history was reviewed on admission, including the state vaccine registry.
-The facility would offer the vaccine to residents able to consent and send letters to the medical representatives of those who were not.
-Residents that were recommended the COVID-19 vaccine should have received the vaccine.
-The facility was trying to catch up on offering the vaccine to residents.
During an interview on 11/19/24 at 1:27 P.M., the Director of Nursing (DON) said:
-The IP was tasked with infection control, including ensuring the completion of the COVID-19 vaccinations of residents.
-The IP responsible for ensuring the resident ' s received education, the facility obtained a signed consent, administered the COVID-19 vaccine as appropriate and documented the resident's COVID-19 vaccination status in the medical record.
-He/she would expect education, signed consents, vaccination administration information and the offering of the COVID-19 vaccination as appropriate to be completed and documented by the facility.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of Resident #14's admission Record showed he/she was admitted on [DATE] with the following diagnoses:
-Acute and chron...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of Resident #14's admission Record showed he/she was admitted on [DATE] with the following diagnoses:
-Acute and chronic respiratory failure with hypoxia (Respiratory failure occurs when the lungs have difficulty exchanging oxygen and carbon dioxide with the blood, resulting in hypoxia (low oxygen) or hypercapnia (high carbon dioxide) .
-Chronic respiratory failure.
-Chronic Obstructive Pulmonary Disease.
Review of the resident's OSR orders dated 05/05/24 showed the following physician's orders:
-Oxygen at 3 liters via nasal cannula continuously or to keep O2 sat greater than 90%.
-Oxygen tubing to be changed weekly, label each component with date and initials every Sunday.
Review of the resident's annual MDS dated [DATE] showed the resident:
-Was moderately cognitively impaired.
-Was on oxygen.
Review of the resident's care plan on 11/19/24 showed:
-Administer oxygen therapy as ordered.
-Change tubing per protocol.
Observation on 11/19/24 at 10:35 A.M. showed:
-The concentrator was noted with dirt and debris on it and the external filter had a buildup of dust.
-No bag was observed for the resident to take off the nasal cannula and place in a bag when he/she left the room.
Observation on 11/20/24 at 9:07 A.M. showed:
-The oxygen concentrator had dirt and debris on it and the filter had a buildup of dust.
-There was no oxygen bag for when resident went outside to smoke or left the room.
Observation on 11/21/24 at 8:48 A.M. showed the oxygen concentrator was on and the nasal cannula was draped across the top drawer of nightstand.
Observation on 11/21/24 at 12:38 P.M. showed the oxygen concentrator remained on and noted with dirt and debris on it and the external filter had a buildup of dust. The nasal cannula was draped across top drawer of nightstand not bagged.
Observation on 11/25/24 at 10:34 A.M. showed:
-The oxygen concentrator was noted with dirt and debris on it and the external filter had a buildup of dust.
-The resident returned to his/her room and retrieved the nasal cannula from the top drawer of nightstand.
6. Review of Resident #98's admission Record showed he/she was initially admitted on [DATE] with the following diagnoses:
- Chronic Obstructive Pulmonary Disease
-Chronic respiratory failure
-Dependence on supplemental oxygen.
Review of the resident's Annual MDS dated [DATE] showed:
-He/She was cognitively intact.
-Did not show the usage of oxygen or the BiPAP.
Review of the resident's OSR dated 6/23/24 showed the following physician's orders:
-Oxygen and nebulizer tubing change weekly, label each component with date and initials weekly on Sunday.
-Did not show an order for the BiPAP machine, how and when to use, clean, and for the storage.
Review of the resident's nursing admission MDS dated [DATE] showed:
-He/She was cognitively intact
-He/She was on oxygen.
-Did not show the usage of the BiPAP.
Observation on 11/21/24 at 9:39 A.M. showed he/she was lying on her bed and had the BiPAP mask over his/her mouth.
Observation on 11/21/24 at 12:44 P.M. showed:
-The resident with oxygen on via nasal cannula attached to the concentrator.
-An oxygen tank in an cylinder cart by dresser with the oxygen tubing wrapped around the top by the handle and not dated or bagged.
-The BiPAP was set on the dresser with tubing and mask laid over the machine and not bagged.
-The concentrator was noted with dirt and debris and external filter had a buildup of dust.
Interview on 11/22/24 at 12:10 P.M. with Certified Nursing Assistant (CNA) A said:
-The nurses change the oxygen tubing.
-The nurses clean the filters.
-Oxygen tubing was to be put in a bag when not in use.
-He/She was aware Resident #98 used a BiPAP machine.
-He/She did not but store the mask when not in use.
7. During an interview on 11/21/24 at 10:26 A.M., Certified Medication Technician (CMT) C said:
-They have plastic bags they use to store oxygen nasal cannulas, face masks and other respiratory in and they usually put them on the oxygen concentrator or beside the breathing treatment machine.
-The bags should be labeled and dated and the nasal cannulas, face masks and any oxygen equipment should be stored in the bags when the equipment is not being used.
-Usually the oxygen tubing, humidifier bottles and face masks are changed out on Tuesdays and Thursdays on the night shift by the night shift CMTs and they also label and date the equipment and bags.
-Nursing staff round every two hours and if they know a resident is on oxygen, they should be checking to ensure the resident's oxygen equipment is stored in the bags if it was not in use.
-The bag should be labeled with resident name and with date when tubing was change.
During an interview on 11/22/24 at 2:12 P.M. CMT D said:
-The nurse or resident would take off the nasal cannula.
-Oxygen tubing was supposed to be stored in a bag when not in use.
-The night shift nurses changed the tubing once a week and as needed.
-Central Supply staff or the oxygen provider would clean the concentrators and filters.
During an interview on 11/25/24 at 9:08 A.M. with Licensed Practical Nurse (LPN) B said:
-Oxygen tubing was to be changed weekly on night shift.
-There would be an order for oxygen.
-There would be an order for changing the tubing.
-Central Supply staff would clean the concentrators and filters.
-There may not be an order for cleaning concentrators and filters since central supply did it himself/herself.
-The respiratory specialist would enter the order for when to use, clean, store the BiPAP.
-The oxygen tubing and BiPAP mask should be in bag when not in use.
During an interview on 11/25/24 at 9:33 A.M. the Central Supply Manager said:
-The night nurses were to change and date oxygen tubing weekly and as needed.
-The oxygen tubing/BIPAP mask was to be stored in a bag when not in use.
-The CNA, the nurse, or any staff could place tubing or mask in the bag.
-The nurse would clean filters when oxygen tubing was changed.
-The CNA would clean the concentrators.
-The Infection Control Preventionist was responsible for monitoring the process of oxygen tubing and storage.
During an interview on 11/25/24 at 9:44 A.M. Assistant Director of Nursing (ADON) B said:
-The night nurses were responsible to change and date oxygen tubing.
-That the ADONs monitored that oxygen tubing was changed and dated.
-The oxygen tubing was to be placed in plastic bag when not in use.
-The central supply staff cleaned the concentrators and filters.
-The ADONs would audit the process.
-He/She expected there would be an order to change tubing and clean filters weekly.
During an interview on 11/25/24 at 11:10 A.M. the Director of Nursing (DON) said:
-Oxygen tubing, nasal cannulas, masks, tracheostomy tubing, BIPAP machines and supplies should be in a bag labeled and dated.
-He/She expected a physician's order for the concentrators, BIPAPs, and filters to be cleaned.
-He/She expected oxygen tubing to be dated and bagged when not in use.
-The Infection Preventionist (IP) was responsible to change oxygen tubing, but nurses could also change.
-The Infection Control Preventionist was responsible for making rounds and following up with the nurses for education on when equipment should be changed.
-The nurses should check for dates when they provided a breathing treatment.
-He/She expected the CNA to wipe down concentrator before giving to a resident.
-He/She expected filters to be cleaned by nurses.
-Oxygen equipment and supplies were usually changed at night.
-The nursing staff should be checking to ensure the oxygen equipment is stored in bags as they are in an out of the resident's rooms, and during cares.
8. Review of Resident #116's POS dated 9/10/24, showed:
-Tracheostomy care every shift, two times per day and as needed.
Review of the resident's admission form dated 9/12/24, showed:
-The resident was admitted to the facility on [DATE].
-The resident was cognitively intact.
-The resident had a diagnosis of respiratory failure (a serious condition that makes it difficult to breathe on your own. Respiratory failure develops when the lungs can't get enough oxygen into the blood).
-The resident received tracheostomy care daily.
Review of the resident's care plan dated 9/13/24, showed:
-The resident had potential for impairment to skin integrity.
-The resident had altered respiratory status and difficulty breathing related to chronic respiratory failure, tracheostomy, and oxygen dependent.
Review of the resident's Treatment Administration Record (TAR) dated 9/1/24-9/30/24, showed:
-A physician's order for tracheostomy care every shift, two times per day and as needed.
-Two of the 43 ordered tracheostomy care opportunities were left blank.
Review of the resident's TAR dated 10/1/24-10/31/24, showed:
-A physician's order for tracheostomy care every shift.
-Eight of the 62 ordered tracheostomy care opportunities were left blank.
Review of the resident's TAR dated 11/1/24-11/18/24, showed:
-A physician's order for tracheostomy care every shift, two times per day and as needed.
-Three of the 36 ordered tracheostomy care opportunities were left blank.
During an interview on 11/22/24 at 2:17 P.M. RN B said:
-The resident had a physician's order to get tracheostomy care twice daily.
-When a nurse performed tracheostomy care, the nurse documented implementation of the order in the resident's medical record.
-If tracheostomy care was completed, the TAR would reflect the nurse's initials.
-If a box on the TAR was blank, that would indicate that the tracheostomy care was not performed.
During an interview on 11/22/24 at 3:00 P.M., ADON A said:
-The resident had a physician's order to get tracheostomy care daily.
-He/she performed the tracheostomy care on the resident when he/she worked the floor.
-When tracheostomy care was done, the nurse that performed the care should have documented it being done.
-When tracheostomy care was completed, the box on the TAR would have the nurse's initials.
-A blank box on a resident's TAR would indicate that a physician's order was not completed.
During an interview with the DON on 11/25/24 at 11:10 A.M., said:
-The charge nurses provided tracheostomy care.
-The nurse managers and the ADON monitor to ensure physician's orders are completed.
-He/she would expect nurses to document in the TAR when tracheostomy care was completed.
-If there were blank areas in a resident's TAR, the tracheostomy cares were not done.
-He/she would expect the nurse to document in the resident's medical record a rationale as to why a tracheostomy care was not completed.
4. Review of Resident #19's admission Face Sheet showed had diagnosis of COPD.
Review of the resident's Annual MDS dated [DATE] showed he/she:
-Was cognitively intact.
-Was able to understand others and make his/her needs known.
-Required assistant for staff for all cares and transfer.
-Did not have documentation related to the use of oxygen (O2).
Review of the resident's care plan revised on 10/24/24 showed;
-The resident had chronic lung disease related to COPD.
-The nursing staff were to monitor the resident for sign and symptoms of shortness of breath.
-Note: He/she did not have a care plan for use of oxygen.
Review of the resident's POS dated 11/1/24 to 11/21/24 showed:
-Oxygen flow rate of 2 Liter per minute (LPM) per Nasal Cannula. Titrate oxygen to keep oxygen saturation (O2 SATs, which is a measure of how much oxygen is in your blood) above 90%, as needed for Shortness of Breath (SOB).
-Albuterol Sulfate Nebulization Solution 3 ml inhaled orally via a nebulizer machine every four hours as needed for shortness of breath, ordered on 11/23/24.
Observation on 11/18/24 at 12:02 P.M., the resident's room showed:
-An O2 concentrator with an uncovered nasal cannula tubing coiled on top of the O2 concentrator machine.
-The nebulizer mask was on the dresser not stored in a plastic bag.
Observation on 11/19/24 at 9:13 A.M., of the resident room showed he/she had O2 and nebulizer tubing not covered at that time.
During interview 11/19/24 at 9:18 A.M., the resident said:
-He/she had used O2 and nebulizer treatment when had respiratory infection.
-He/she was not currently using O2 or the nebulizer.
Observation on 11/20/24 at 10:15 A.M., of the resident room showed:
-He/she had the O2 tubing left uncovered on top his/her O2 concentrator.
-The nebulizer mask was uncovered on his/her bedside table.
Observation on 11/21/24 at 10:40 A.M. of the resident room showed:
-He/she had uncovered O2 tubing coiled on top the oxygen concentrator machine.
-His/her nebulizer mask was uncovered on the bedside table.
-There were no dates on the oxygen tubing or nebulizer mask and tubing.
-No bags were in the areas to place the mask or tubing in when not in use.
Based on observation, interview and record review, the facility failed to ensure suction and oxygen equipment were kept covered to prevent cross contamination for one sampled resident (Resident #95) who had a tracheostomy (a surgically created hole, also called a stoma, in your windpipe, also known as your trachea. This hole allows air to pass into your windpipe); failed to ensure oxygen face masks and nasal cannulas (a medical device that provides supplemental oxygen to patients through two prongs that sit inside the nostrils) were covered for two sampled resident (Resident #126 and Resident #19) who had respiratory concerns; failed to ensure necessary respiratory care related to oxygen tubing and/or a bilevel positive airway pressure (BiPAP a non-invasive ventilation with two pressures settings, one for inhalation and one for exhalation, to assist with breathing) tubing, and mask bagged when not in use and the concentrators external filters to be free of buildup of dust for two residents (Resident #14 and #98); and failed to follow physician orders for tracheostomy care on one sampled resident (Resident #116) out of 35 sampled residents. The facility census was 151 residents.
Review of the facility's Physician Order policy dated 06/2020, showed:
-The purpose of the policy was to ensure that all physicians orders were complete and accurate.
-Documentation pertaining to the physician's order would be maintained in the resident's medical record.
Review of the facility's policy Tracheostomy-Care of dated 06/2020, showed:
-The purpose of the policy was to ensure airway patency by keeping the tube free from mucous buildup and to maintain mucous membrane and skin integrity.
-Tracheotomy care would be performed as ordered by the attending physician.
-No information regarding storage of equipment.
Review of the facility's Oxygen Administration policy revised 06/2020 showed the oxygen items would be stored in a plastic bag when not in use at the resident's bedside to protect the equipment from dust and dirt when not in use.
1. Review of Resident #95's Face Sheet showed the resident was admitted on [DATE], with diagnoses including respiratory failure, sleep apnea (a sleep disorder that causes breathing to repeatedly stop or become shallow during sleep), heart failure, and tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck. A person with a tracheostomy breathes through a tracheostomy tube inserted in the opening).
Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 9/27/24, showed the resident:
-Was alert and oriented without confusion.
-Had coughing or choking during meals.
-Received oxygen therapy, suctioning and tracheostomy care.
Review of the resident's Physician's Order Sheet (POS) dated [DATE], showed physician's orders for:
-High Humidity Tracheostomy Collar: at 28 percent, every shift for shortness of air, change in condition (9/24/24).
-Change oxygen tubing and set, including drainage bag every night shift every 7 days for shortness of air, change in condition (9/24/24).
-Change disposable inner cannula size 5 every day shift for shortness of air, change in condition and as needed (9/24/24).
-Keep at bedside for emergency use: a disposable ambu bag (a device used to provide respiratory support to patients in emergency and non-emergency situations), a back up complete tracheostomy set and suction machine (9/24/24).
Review of the resident's Care Plan dated 9/24/24, showed the resident had a tracheostomy due to impaired breathing. Interventions showed staff should:
-Give humidified oxygen as prescribed.
-Keep extra tracheostomy tube and obturator (a thin, rigid, and curved rod that helps guide the outer cannula into the trachea) at bedside. If tube is coughed out, open stoma (an artificial opening made into a hollow organ, especially one on the surface of the body leading to the gut or trachea) with hemostat (a tool used to control bleeding).
Observation on 11/18/24 at 11:22 A.M., showed there was a nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) on a dresser against the wall. The face mask was uncovered, sitting beside the machine. Next to it was the resident's humidifier machine that showed an undated/unlabeled humidifier bottle containing a clear fluid. The mask and tubing that were connected to it was laying on the surface uncovered. Beside the humidifier machine was the resident's suction machine and the tubing was coiled around the machine and was uncovered.
Observation on 11/19/24 at 9:40 A.M., showed the resident's suctioning machine was sitting on a dresser beside the resident's bed and the tubing and mask was uncovered. There was a humidifier machine that was across from his/her bed on a dresser. The humidifier bottle was unlabeled/undated and the tubing and mask were uncovered. There was a nebulizer on the dresser and the face mask was sitting next to the humidifier machine uncovered.
Observation and interview on 11/19/24 at 1:40 P.M., showed the resident's nebulizer was across from the resident's bed and the face mask was uncovered, the resident's humidifier machine was on a dresser across from the resident's bed and the tubing and mask was still uncovered and the suction machine tubing was coiled up and around the machine and was also uncovered.
During an interview on 11/22/24 at 10:37 A.M., the Infection Control Preventionist said:
-The resident's humidifier mask and tubing and the resident's suction tubing should both be in a plastic bag.
-He/She would have to discard the current masks and tubing and replace them since they were exposed.
-Whenever they use any oxygen equipment they should store it in a bag after use and the suction tubing should be replaced.
2. Review of Resident #126's Face Sheet showed the resident was admitted to the facility on [DATE] with diagnoses including respiratory failure, sleep apnea and Chronic Obstructive Pulmonary Disease (COPD- a group of lung diseases that damage the airways and air sacs, making it difficult to move air in and out of the lungs).
Review of the resident's POS dated [DATE] showed the following physician's orders:
-Oxygen at 3 liters per minute via nasal cannula continuously every shift and as needed (10/3/23).
-Bilevel positive airway pressure (BIPAP-a machine that helps people breathe by delivering pressurized air into their airways)in BIPAP mode at bedtime and as needed for COPD and shortness of air (4/22/24).
-Change nebulizer tubing, mask and holding bag and date new tubing per protocol and as needed (every week) every evening shift on Wednesday (7/3/23).
-Change oxygen tubing weekly, label each component with date and initials every evening shift every Wednesday (7/3/23).
Review of the resident's quarterly MDS dated [DATE] showed the resident:
-Was alert and oriented without confusion.
-Used oxygen therapy. It did not show the resident used BiPAP therapy.
Review of the resident's Care Plan dated 11/14/24, showed the resident had altered respiratory status/difficulty breathing related to respiratory failure, COPD, obstructive sleep apnea, and hypoventilation (a condition where breathing is too slow or shallow, which prevents the body from getting enough oxygen and getting rid of enough carbon dioxide).
Observation on 11/18/24 at 10:56 A.M., showed in the resident's room, on the resident's nightstand was a nebulizer machine with a mask on top of it that was uncovered, the re was a BIPAP machine sitting beside it with a face mask that was laying on top of it that was uncovered, and there was an oxygen concentrator sitting beside his bed on the floor. The nasal cannula and tubing was draped around the concentrator, also uncovered. The humidifier bottle was not labeled or dated and there was no bag or covering for any of the oxygen equipment observed. On the vanity was a portable oxygen container that had a nasal cannula and tubing that was wrapped around it uncovered.
Observation on 11/19/24 at 9:35 A.M., showed on his/her nightstand was his/her nebulizer machine. The face mask was laying on top of the machine uncovered. The portable oxygen machine was sitting on the vanity with the oxygen tubing and nasal cannula coiled around the machine uncovered.
Observation and interview on 11/21/24 at 9:47 A.M. showed:
-On the vanity was a portable oxygen machine without any tubing attached. On the nightstand beside his/her bed was his/her nebulizer and his/her BIPAP machine. The face masks for both machines were sitting on top of the machines uncovered. The oxygen concentrator was on the floor next to his/her bed and it was on and running. The nasal cannula and tubing were laying on his bed linen, uncovered. The resident said that he/she had just removed his/her nasal cannula. He/She said:
-He/She wore his/her BIPAP every night and the nursing staff have never provided any covering for his/her BIPAP face mask.
-He/She usually took the BIPAP mask off and placed it on the nightstand beside his bed.
-Nursing staff replaced the mask and tubing when he/she requested it.
-He/She used his/her portable oxygen when he/she goes out of the building or during showers. Staff have never given him/her a covering/bag for the oxygen tubing or nasal cannula.
-He/She had breathing treatments as needed and there was no covering for the face mask for his/her breathing treatment machine, so he/she usually laid it on top of the machine or on the dresser.
-He/She had a lot of respiratory issues and was unaware that nursing staff was supposed to provide him/her with any bag or covering for any of his oxygen equipment to prevent cross contamination.
3. During an interview on 11/21/24 at 10:26 A.M., Certified Medication Technician (CMT) C said:
-They have plastic bags they use to store oxygen nasal cannulas, face masks and other respiratory in and they usually put them on the oxygen concentrator or beside the breathing treatment machine.
-The bags should be labeled and dated and the nasal cannulas, face masks and any oxygen equipment should be stored in the bags when the equipment is not being used.
-Usually the oxygen tubing, humidifier bottles and face masks are changed out on Tuesdays and Thursdays on the night shift by the night shift CMTs and they also label and date the equipment and bags.
-Nursing staff round every two hours and if they know a resident is on oxygen, they should be checking to ensure the resident's oxygen equipment is stored in the bags if it is not in use.
During an interview on 11/25/24 at 9:42 A.M., Registered Nurse (RN) A said:
-All oxygen supplies to include face masks, oxygen tubing, nasal cannulas should be stored in a bag when not in use.
-Central supply provides the bag and the night shift change out the supplies and they are to provide the bags in each resident room.
-The nursing staff who go in and out of the rooms daily are supposed to check to ensure the bag is in the room and the oxygen supplies are stored in the bag.
-With residents who are more independent and able to remove their oxygen masks they should check to see if the masks are in the bag when not in use and remind the resident to put it in the bag when they remove it.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
6. Observation on 11/18/24 at 1:58 P.M., a medication cart for the 500 hall showed:
Expired medication on the cart included:
-Docusate (a stool softener) liquid, expired 8/2024.
-Pro-stat (a liquid pr...
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6. Observation on 11/18/24 at 1:58 P.M., a medication cart for the 500 hall showed:
Expired medication on the cart included:
-Docusate (a stool softener) liquid, expired 8/2024.
-Pro-stat (a liquid protein supplement), with an opened date of 5/15/24 and manufacturer instructions printed on the bottle to discard three months after opening.
- Iron supplement liquid, expired 8/2024.
-Pro-stat, expired 2/2024.
-Meclizine (a nausea medication), expired 3/2024.
Other medications noted to be stored or labeled incorrectly included:
-Insulin Lispro multi dose vial with no resident identifier.
-Albuterol inhaler with no date or resident identifier.
-A medication cup with several partially dissolved pills and a pink gel sitting in a medication drawer of the cart.
7. During an interview on 11/18/24 at 2:18 P.M., Registered Nurse (RN) A said:
-He/She would expect expired medications to be removed from the cart.
-He/She would expect all medications to be labeled appropriately with a resident name.
-He/She did not know what medications were partially dissolved in the medication cup or when they were placed on the medication cart.
During an interview on 11/19/24 at 1:27 P.M., the Director of Nursing (DON) said:
-He/She would not expect expired medications to be kept on the medication cart.
-He/She would expect medications to be labeled appropriately.
-He/She would expect proper storage of all medications.
During an interview on 11/19/24 at 2:54 P.M. CMT B said:
-The CMT and nurse carts were checked about three times a week.
-He/She thought the facility policy was for the CMT and nurse carts to be checked once a week.
-CMTs were responsible for checking the CMT carts for expired medications and the appropriate storage and labeling of medications.
-Nurses were responsible for checking the nurse carts for expired medications and the appropriate storage and labeling of medications.
-The Assistant Directors of Nursing (ADONs) were responsible for ensuring completion of the CMT carts and nurse carts checks for expired medications and the appropriate storage and labeling of medications.
-All medications including inhalers and nasal sprays needed to be stored in their own container.
-He/She was aware that the Flonase and Advair had been stored in the same container.
-The Flonase and Advair had been sent to the facility that way and he/she never asked for a new container for the Flonase.
-Expired medications should not be in any cart that holds medications.
-If expired medications were found in any medication cart, then the medication should be removed and thrown away/destroyed.
- The CMTs and nurses were responsible for going through the medication storage rooms to check for expired medications and the appropriate storage and labeling of medications.
-The ADONs were responsible for ensuring completion of the medication storage room checks.
-The ADONs were responsible for checking the medication storage rooms for expired medical supplies.
-Expired medical supplies should not be stored in the medication storage rooms and should be removed and disposed of appropriately.
During an interview on 11/20/24 at 10:47 A.M. Registered Nurse (RN) A said:
-The staff who get into the medication carts should be checking expiration dates of medications every time they are in the cart and pulling medications out of the cart.
-The nursing supervisors were responsible for checking the CMT and nurse carts for expired medications and the proper storage and labeling of medication.
-All medications including nasal sprays and inhalers should be stored in their own container.
-The Lidocaine 1% vial should not be used if the label was illegible or ripped off.
-The Lidocaine 1% vials were not multi-use vials and were supposed to be labeled for a specific resident.
-The Lidocaine 1% vial needed to be removed from the cart and appropriately disposed of.
-Expired medications should not be in any medication carts and should be removed from the carts and appropriately disposed of.
-Nurses and nursing supervisors were responsible for checking the medication storage rooms for expired medications/supplies and the appropriate storage and labeling of medications.
-Nursing supervisors were responsible for ensuring the checks were getting completed.
-Expired medical supplies should not be stored in medication storage rooms and should be removed and appropriately despised of.
-Any staff who use the thickened liquid cartons should be checking for expiration anytime the carton is used.
-The staff should have noticed that the thickened liquid cartons had expired and should have thrown them away after they had expired.
-The Tuberculin PPD solution should have been stored in its original container.
-If the open date of the Tuberculin PPD solution was illegible, the staff should have appropriately disposed of the vial.
During an interview on 11/20/24 at 11:19 A.M. ADON A said:
-Anyone who were able to access medication carts were responsible for checking them for expired medications and the appropriate storage and labeling of medications.
-This included CMTs, nurses, and nurse managers.
-The nurse managers were responsible for ensuring the completion of the checks and it was normally completed once a week.
-The medication storage rooms were also checked once a week for expired medications/medical supplies and was completed by the nursing managers.
-Expired medications should never be stored in medication carts and if found they should be removed and appropriately disposed of.
-All medications including nasal sprays and inhalers needed to be stored in their own container.
-Lidocaine 1% vials were not multi-use vial and usually labeled with the designated resident's name.
-The Lidocaine 1% vial should have been labeled and stored in its original container.
-The staff should have removed the Lidocaine 1% vial and appropriately disposed of it.
-Expired medical supplies should not be stored in medication storage rooms.
-Any expired medical supplies found should be removed and be appropriately disposed of.
-The dietary staff were the staff who usually opened the cartons of thickened liquids and would be responsible for the appropriate labeling of the cartons.
-The nurses and dietary staff were able to check expiration dates of the thickened liquid cartons.
-The expired thickened liquid cartons should have removed and thrown away.
-The Tuberculin PPD solution should not have been outside of its original container.
-If the Tuberculin PPD solution open date could not be read and the original container could not be found then the vial should be removed and appropriately disposed of.
During an interview on 11/20/24 at 11:57 A.M. the Director of Nursing (DON) said:
-The medication carts should be checked daily for expired medications and the appropriate storage and labeling of medications.
-The ADONs were responsible for completing a weekly audit of the medication carts and ensuring all expired medications were removed from the cart and all medications in the cart were appropriately stored and labeled.
-All medications should be stored in their own container including nasal sprays and inhalers.
-The Lidocaine 1% vial should have been labeled with the resident's name and stored in its own container.
-The Lidocaine 1% should have been removed form the nurse cart and appropriately disposed of since the label had been ripped off.
-Anyone who enters the medication storage rooms can check for expired medications/supplies and the appropriate storage and labeling of medications.
-The ADONs were responsible for ensuring the completion of medication storage rooms checks.
-Expired medical supplies should not be stored in medication storage rooms and any expired medical supplies should be removed and appropriately disposed of.
-If the thickened liquid carton comes from the kitchen, then the dietary staff would be responsible for checking the expirations dates.
-Once the thickened liquid cartons were opened and stored in nursing areas, then nursing staff would be responsible for checking the expiration dates.
-The night nurses were responsible for checking the medication room refrigerators and they would be the ones responsible for ensuring that everything stored in the fridge was not expired and stored/labeled appropriately.
-The Tuberculin PPD solution should not have been stored outside of its original container.
Based on observation, interview and record review, the facility failed to ensure the appropriate storage and labeling of medications throughout the facility's medication carts and medication storage rooms. This deficient practice had the potential to affect all residents within the facility. The facility census was 151 residents.
Review of the facility's policy titled Storage of Medications dated August 2020 showed:
-Nurses were not to transfer medications from one container to another or return partially used medication to the original container.
-All medications dispensed by the pharmacy were to be stored in the pharmacy container with the pharmacy label.
-Outdated, contaminated, or deteriorated medications and those in containers that were cracked, soiled, or without secure closures were to be immediately removed from inventory, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order existed.
-Expirations dates (beyond-use dates) of dispensed medications should be determined by the pharmacist at the time of dispensing.
-The nurse would check the expirations date of each medications before administering it.
-All expired medications would be removed from the active supply and destroyed in accordance with facility policy, regardless of amount remaining.
1. Observation on 11/18/24 at 1:59 P.M. of the Certified Medication Technician (CMT) cart for 300 hall showed a Fluticasone Propionate Nasal Spray (Flonase- used to treat allergies and non-allergic nasal symptoms) and a Fluticasone Propionate and Salmeterol (Advair- used to treat asthma (a condition in which a person's airways become inflamed, narrow, swell, and produce extra mucus, which makes it difficult to breathe) or Chronic Obstructive Pulmonary Disease (COPD- a disease process that decreases the ability of the lungs to perform ventilation) stored in the same box.
2. Observation on 11/18/24 at 2:07 P.M. of the nurse cart for 100/200 hall showed:
-A vial of Lidocaine 1% (typically used to cause numbness or loss of feeling for patients having certain medical procedures) half-used, outside of its original container, with a label that appeared to have been ripped off.
-A bottle of Dakin's solution (used to prevent and treat skin and tissue infections) that expired October 2024.
3. Observation of on 11/18/24 at 2:17 P.M. the medication storage rooms on the Long-Term Care (LTC) side of the facility showed:
-A box of liquid skin preparation (prepares damaged or intact skin for attachment sites, tapes, films, and adhesive dressings) that expired 5/17/24.
-12 Dermaview II transparent film wound dressings with label (a moisture-vapor permeable transparent dressing that aids in the prevention of bacterial contamination) that expired 5/6/23.
-Two boxes of Curad oil emulsion dressings (a dressing that is ideal for lightly draining wounds including minor burns, lacerations, and abrasions) that expired on 7/7/2024.
-A carton of thickened water that had been opened on 6/21/24 and had expired on 10/22/24.
-A carton of thickened cranberry cocktail that had been opened on 7/4/24 and had expired on 11/14/24.
-A Tuberculin purified protein derivative (PPD) (Aplisol- used in a skin test to help diagnose tuberculosis (TB- a serious infectious bacterial disease that mainly affects the lungs) stored in the fridge outside of its original container and unreadable open date.
-An intravenous (IV) administration set that expired on 10/27/24.
-Two needleless connectors that expired on 9/13/23.
-A foley catheter (a device that drains urine from the bladder into a collection bag) insertion tray that expired on 9/29/24.
4. Observation on 11/18/24 at 3:15 P.M. of the CMT cart for 100 hall showed a bottle of liquid iron supplement that expired in September 2024.
5. During an interview on 11/19/24 at 2:54 P.M. CMT B said:
-The CMT and nurse carts were checked about three times a week.
-He/She thought the facility policy was for the CMT and nurse carts to be checked once a week.
-CMTs were responsible for checking the CMT carts for expired medications and the appropriate storage and labeling of medications.
-Nurses were responsible for checking the nurse carts for expired medications and the appropriate storage and labeling of medications.
-The Assistant Directors of Nursing (ADONs) were responsible for ensuring completion of the CMT carts and nurse carts checks for expired medications and the appropriate storage and labeling of medications.
-All medications including inhalers and nasal sprays needed to be stored in their own container.
-He/She was aware that the Flonase and Advair had been stored in the same container.
-The Flonase and Advair had been sent to the facility that way and he/she never asked for a new container for the Flonase.
-Expired medications should not be in any cart that holds medications.
-If expired medications were found in any medication cart, then the medication should be removed and thrown away/destroyed.
- The CMTs and nurses were responsible for going through the medication storage rooms to check for expired medications and the appropriate storage and labeling of medications.
-The ADONs were responsible for ensuring completion of the medication storage room checks.
-The ADONs were responsible for checking the medication storage rooms for expired medical supplies.
-Expired medical supplies should not be stored in the medication storage rooms and should be removed and disposed of appropriately.
During an interview on 11/20/24 at 10:47 A.M. Registered Nurse (RN) A said:
-The staff who get into the medication carts should be checking expiration dates of medications every time they are in the cart and pulling medications out of the cart.
-The nursing supervisors were responsible for checking the CMT and nurse carts for expired medications and the proper storage and labeling of medication.
-All medications including nasal sprays and inhalers should be stored in their own container.
-The Lidocaine 1% vial should not be used if the label was illegible or ripped off.
-The Lidocaine 1% vials were not multi-use vials and were supposed to be labeled for a specific resident.
-The Lidocaine 1% vial needed to be removed from the cart and appropriately disposed of.
-Expired medications should not be in any medication carts and should be removed from the carts and appropriately disposed of.
-Nurses and nursing supervisors were responsible for checking the medication storage rooms for expired medications/supplies and the appropriate storage and labeling of medications.
-Nursing supervisors were responsible for ensuring the checks were getting completed.
-Expired medical supplies should not be stored in medication storage rooms and should be removed and appropriately despised of.
-Any staff who use the thickened liquid cartons should be checking for expiration anytime the carton is used.
-The staff should have noticed that the thickened liquid cartons had expired and should have thrown them away after they had expired.
-The Tuberculin PPD solution should have been stored in its original container.
-If the open date of the Tuberculin PPD solution was illegible, the staff should have appropriately disposed of the vial.
During an interview on 11/20/24 at 11:19 A.M. ADON A said:
-Anyone who were able to access medication carts were responsible for checking them for expired medications and the appropriate storage and labeling of medications.
-This included CMTs, nurses, and nurse managers.
-The nurse managers were responsible for ensuring the completion of the checks and it was normally completed once a week.
-The medication storage rooms were also checked once a week for expired medications/medical supplies and was completed by the nursing managers.
-Expired medications should never be stored in medication carts and if found they should be removed and appropriately disposed of.
-All medications including nasal sprays and inhalers needed to be stored in their own container.
-Lidocaine 1% vials were not multi-use vial and usually labeled with the designated resident's name.
-The Lidocaine 1% vial should have been labeled and stored in its original container.
-The staff should have removed the Lidocaine 1% vial and appropriately disposed of it.
-Expired medical supplies should not be stored in medication storage rooms.
-Any expired medical supplies found should be removed and be appropriately disposed of.
-The dietary staff were the staff who usually opened the cartons of thickened liquids and would be responsible for the appropriate labeling of the cartons.
-The nurses and dietary staff were able to check expiration dates of the thickened liquid cartons.
-The expired thickened liquid cartons should have removed and thrown away.
-The Tuberculin PPD solution should not have been outside of its original container.
-If the Tuberculin PPD solution open date could not be read and the original container could not be found then the vial should be removed and appropriately disposed of.
During an interview on 11/20/24 at 11:57 A.M. the Director of Nursing (DON) said:
-The medication carts should be checked daily for expired medications and the appropriate storage and labeling of medications.
-The ADONs were responsible for completing a weekly audit of the medication carts and ensuring all expired medications were removed from the cart and all medications in the cart were appropriately stored and labeled.
-All medications should be stored in their own container including nasal sprays and inhalers.
-The Lidocaine 1% vial should have been labeled with the resident's name and stored in its own container.
-The Lidocaine 1% should have been removed form the nurse cart and appropriately disposed of since the label had been ripped off.
-Anyone who enters the medication storage rooms can check for expired medications/supplies and the appropriate storage and labeling of medications.
-The ADONs were responsible for ensuring the completion of medication storage rooms checks.
-Expired medical supplies should not be stored in medication storage rooms and any expired medical supplies should be removed and appropriately disposed of.
-If the thickened liquid carton comes from the kitchen, then the dietary staff would be responsible for checking the expirations dates.
-Once the thickened liquid cartons were opened and stored in nursing areas, then nursing staff would be responsible for checking the expiration dates.
-The night nurses were responsible for checking the medication room refrigerators and they would be the ones responsible for ensuring that everything stored in the fridge was not expired and stored/labeled appropriately.
-The Tuberculin PPD solution should not have been stored outside of its original container.
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
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 ensure residents were provided food that was at a safe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were provided food that was at a safe and appetizing temperature for three sampled residents (Residents #109, #91 and #139) out of 35 sampled residents. The facility census was 151 residents.
Review of the facility's Food Temperature policy, dated December 2020, showed:
-The purpose of the policy was to prove the nutrition services department with guidelines for food preparation and service temperatures.
-Food prepared and served in the facility would be served at proper temperatures to ensure food safety.
-Acceptable serving temperatures were: Above or equal to 135-degree Fahrenheit (F) for; eggs, vegetables, potatoes, pasta, meats, casseroles, and entrees.
-If temperatures do not meet applicable serving temperatures, reheat the product to a temperature of 164-degree F for hot foods for 15 seconds.
-If temperatures are not acceptable levels and cannot be corrected in time for meal services, an appropriate substitution should be implemented.
-Do not put food on the tray line until 30 minutes prior to meal services.
-Heated hot plates may be used to maintain warm temperatures.
1. Review of Resident #109's admission Record, showed the resident was admitted to the facility on [DATE].
Review of the resident's annual MDS (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 10/24/24, showed the resident was cognitively intact.
During an interview on 11/20/24 at 9:49 A.M., the resident said:
-He/she ate most all meals in his/her room and was served room trays.
-His/her food was always served cold.
-He/she did not eat many meals, due to the temperature of the served food being unappetizing.
-He/she had complained about the cold food to the nurses and dietary staff many times.
Observation on 11/20/24 at 1:00 P.M., showed:
-Staff handed out the first room tray.
-Room trays were all stacked on a rolling cart.
Observation on 11/20/24 at 1:35 P.M., showed:
-Staff brought the resident's room tray in to his/her room.
-The resident said his/her food was not warm.
-The resident's ham was 100-degree F.
-The resident's baked potatoes was 114 degree F.
-The resident's steamed carrots were 101-degree F.
During an interview on 11/21/24 at 8:52 A.M., the resident said:
-His/her breakfast was cold.
-He/she was served, scrambled eggs, toast, and oatmeal.
-He/she did not eat his/her breakfast due to unappetizing temperatures.
2. Review of Resident #91's admission Record, showed the resident was admitted to the facility on [DATE].
Review of the resident's admission MDS dated [DATE], showed the resident was cognitively intact.
During an interview on 11/20/24 at 10:30 A.M., the resident said:
-He/she ate in his/her room and was served room trays.
-He/she was often served cold food.
-He/she refused to eat many of his/her meals due to unappetizing serving temperatures.
-He/she had reported the cold temperatures to the nurses.
During an interview on 11/22/24 at 10:47 A.M., the resident said he/she did not eat his/her breakfast that morning due to the temperature of the food served being cold.
3. Review of Resident #139's admission Record, showed the resident was admitted to the facility on [DATE].
Review of the resident's admission MDS dated [DATE], showed the resident was cognitively intact.
During an interview on 11/21/24 at 9:09 A.M., the resident said:
-He/she ate in his/her room and was served room trays.
-He/she many times was served cold food.
-His/her breakfast was barely warm on that day and he/she was served oatmeal and scrambled eggs.
Observation on 11/21/24 at 12:37 P.M., showed residents on the hall were getting served drinks.
Observation on 11/21/24 at 12:43 P.M., showed residents on the hall were getting served appetizers and desserts.
Observation on 11/21/24 at 1:01 P.M., showed:
-Residents on the hall were getting served lunch room trays.
-Room trays were all stacked on a rolling cart.
Observation on 11/21/24 at 1:11 P.M., showed:
-Staff brought the resident's room tray in to his/her room.
-The resident said his/her food was not warm.
-The resident's peas were 100-degrees F.
-The resident's mashed potatoes were 120-degrees F.
-The resident's Salisbury steak was 120-degrees F.
4. During an interview on 11/22/24 at 2:00 P.M., Certified Nurse Assistant (CNA) E said:
-It generally took about 7-8 minutes to get all of the food trays passed per hall.
-He/she had received complaints from residents about the food not being warm.
-He/she had reported the resident complaints to the Director of Nursing (DON).
-He/she tried to offer alternatives when the food was not to the residents liking.
-He/she had never witnessed a staff member monitoring food temperatures on any of residents room trays.
-He/she was unaware of the food temperature policy.
During an interview on 11/22/24 at 2:30 P.M., Registered Nurse (RN) A said:
-It generally took around 5 minutes for room trays to be passed in a hall.
-He/she had residents complain about the food temperature.
-He/she notified the kitchen staff when the residents had a food complaint.
-He/she often warmed the food up for the residents due to the food being served cold.
During an interview on 11/22/24 at 3:00 P.M., Assistant Director of Nursing (ADON) A said:
-Room trays were passed to the residents in their room within 5 minutes of coming from the kitchen.
-He/she had received complaints from residents about food temperatures.
-He/she would expect a residents room tray to meet the facility's temperature policy.
-He/she had spoken to the kitchen manager about the room temperature complaints.
-He/she had filed grievances on the residents behalf for cold food.
During an interview on 11/25/24 at 9:00 A.M., Dietary Manager said:
-The dining room was served before the room trays were served.
-The 100-200-300-400 halls all had a hotbox for room trays.
-The 600-700 halls were served from the steam table directly.
-The 500 hall was served from the main dining room steam table and the trays were taken to the residents, one or two at a time, to maintain temperatures.
-He/she monitored the room tray temperatures.
-He/she checked the room tray temperatures daily, rotating the meal.
-He/she walked the facility and ensured room trays were being passed timely.
-He/she had not heard of any resident concerns regarding the temperatures of the food trays.
-He/she had heard resident complaints that were being served last.
-Note: Observation above showed all of the room trays being passed at once from a rolling cart.
During an interview on 11/25/24 at 11:10 A.M. the Director of Nursing (DON) said:
-100-400 hall room trays were served from a dietary hotbox.
-500 hall room trays were served from a rolling cart.
-He/she was unaware of the facility policy for room tray temperatures.
-He/she was unaware of who was responsible for monitoring room tray temperatures.
-He/she was aware that there had been concerns voiced regarding the room tray temperatures.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8. Review of Resident #72's admission Record showed he/she initially admitted to the facility 12/24/19 with the following diagno...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8. Review of Resident #72's admission Record showed he/she initially admitted to the facility 12/24/19 with the following diagnoses:
-Gastrostomy (surgical creation of a permanent opening into the stomach through the skin for the introduction of nourishment and fluids through a tube).
-Need for assistance with personal care.
Review of the resident's care plan with a start date of 12/24/19 showed:
-The problem of required tube feeding for nutritional needs related to history of 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).
-He/She was to have Nothing By Mouth (NPO).
-Activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting) care plan showed a problem the resident was dependent to complete ADLs. The resident was dependent with dressing, bathing, incontinence, and transfers.
-The care plan did not show EBP precautions with cares.
Review of the resident's Significant Change MDS dated [DATE] showed:
-He/She was severely cognitively impaired and required total support from staff.
-He/She had a gastrostomy tube (G Tube).
-He/She was dependent for incontinent care, hygiene, shower/bathing, transferring, and dressing.
Review of the resident's POS dated November 2024 showed:
-Enteral Feed order as needed. (1/13/20).
-Enteral Feed Order every 24 hours as need for tube feeding (enteral) Complete tube site care with warm water and soap. (12/24/19).
-Enteral Feed Order every day and night shift check and record residuals every shift. Hold feeding for 1 hour if greater than 100 Milliliters (mls). Contact physician if residual exceeded 100 mls for three consecutive checks. (1/13/20).
-Enteral Feed order every day and night shift check tube placement before initiation of formula and medication administration. (1/13/20).
-Enteral Feed Order every day and night shift for tube feeding complete tube site care with warm water and soap. (12/24/19).
-Enteral Feed order every night shift change syringe tube feeding administration set up and graduate. (1/13/20).
-Enteral Feed Order NPO, administer Osmolite (nutrition that provides complete, balanced nutrition for long- or short-term tube feeding) 1.5 at 40 mls per hour nocturnally (at night) for 12 hours as tolerated (from 7:00 P.M. to 7:00 A.M.) to provide 480 mls of formula. Routine water flush 30 mls an hour during duration of enteral feeding (12 hours) and routine flush 150 mls at start and completion of enteral feed. (9/62/24).
-Elevate head of bed (HOB) at 30 to 45 degrees at all times during feeding and for at least 30 to 40 minutes after the feed had stopped. (1/13/20).
-Flush G Tube with 45 to 60 mls before and after administration of medications. (1/25/23).
-There was not an order for Enhanced Barrier Precautions with cares.
Observation on 11/18/24 at 11:04 A.M. showed there was no sign on the resident's door for EBP.
Observation on 11/20/24 at 12:53 P.M. showed LPN B:
-Had the bedside table set up with supplies for G Tube site care and flush.
-Spoke to resident and explained the procedure.
-Performed hand hygiene at sink and donned gloves.
-ADON B entered room and asked resident if it would be ok to observe care.
-The head of bed was up at a 30-degree angle.
-He/She left the room and reentered and performed hand hygiene and donned new gloves.
-He/She obtained the syringe and pulled back 20 mls air. LPN B then cleaned the G Tube hub and placed syringe into hub and expelled the air with stethoscope close to G Tube site to check for placement.
-He/She then pulled back on the syringe plunger to assess residual. No residual noted.
-He/She pulled water into the syringe and pushed the water into the G Tube hub.
-He/She thanked resident. Rinsed syringe and graduate and set them out to dry upside down.
-He/She gathered trash, removed gloves, and performed hand hygiene.
-He/She put on gloves and removed trash from the room then returned, removed gloves and performed hand hygiene again.
-LPN B did not put on a gown for EBP.
-No sign for EBP noted on the door.
During an interview on 11/20/24 at 1:02 P.M. LPN B said this was how he/she completed a G Tube flush and care daily.
Observation on 11/25/24 10:12 A.M. of the resident's door showed no EBP signage and no PPE cart observed on the hall.
9. Review of Resident #40's admission Record showed he/she initially admitted to the facility 11/21/18 with the following diagnoses:
-Quadriplegia (paralysis of all four extremities and usually the trunk)
-Methicillin Resistant Staphylococcus Aureus (MRSA - a type of bacteria that is resistant to many antibiotics) infection as the cause of diseases classified elsewhere.
-Need for assistance with personal care.
-Neuromuscular dysfunction of the bladder/neurogenic bladder (a disorder of urinary bladder control due to damage to the spinal cord or to the nerves supplying the bladder).
-Pressure ulcer ((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) of the left buttock (the two round fleshy parts that form the lower rear area of a human trunk), Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.)
-Pressure ulcer of the right buttock, stage IV.
Review of the resident's care plan dated 12/24/19 showed:
-Resident had a history of chronic wounds r/t quadriplegia, History of osteomyelitis and pressure ulcers, immobility, muscle wasting and atrophy, presence of suprapubic catheter, presence of colostomy, generalized muscle weakness, contracture unspecified joint, protein calorie malnutrition, noncompliance with offloading and treatments. Resident had current pressure Ulcers. (5/26/24).
--Keep the bed as flat as possible to reduce shear. The resident preferred to be repositioned with two staff. (10/18/19).
--While repositioning at routine intervals use positioning wedge and heel suspension
boots to promote offloading (10/18/19).
-Resident had an ADL self-care performance deficit related to Quadriplegia.
--Bed mobility: Dependent assistance.
--Transfer: Dependent via Hoyer with 2 staff.
--Dressing: Dependent assistance.
--Toilet use: Dependent assistance.
--Personal hygiene: Dependent assistance.
--Bathing: Dependent assistance. (10/31/18)
-The care plan did not address EBP with any cares provided.
Review of the resident's POS dated November 2024 showed:
-Catheter care as needed. (10/2/19).
-Catheter care every day and night shift. (10/2/19).
-Catheter size: 18 French with 30 cubic centimeters (cc) bulb for neuromuscular dysfunction of the bladder. (3/13/21)
-Change catheter monthly on the 15th. (2/21/22)
-Hibiclens soap to be applied to entire body, buttock, peri area, and suprapubic catheter site with showers 2 to 3 times a week. (3/25/24)
-Treatment to left posterior hip cleanse wound with wound cleanser, pat dry, apply collagen powder to wound bed, apply calcium alginate to wound bed, cover with super absorbent dressing every Monday, Wednesday and Friday and as needed if dressing becomes soiled or comes off. (10/17/24)
-Treatment to right buttock cleanse with wound cleanser, pat dry, apply calcium alginate and cover with foam dressing every day shift and as needed. (10/31/24)
-No order noted for EBP.
Observation on 11/19/24 at 12:03 P.M. did not show EBP precautions on the resident's door.
Observation on 11/21/24 at 10:03 A.M. of catheter care performed by LPN B showed:
-He/She had set up the tray with supplies of 4x4s opened and sprayed with cleanser and a clean split 4x4.
-He/She entered and explained procedure to resident.
-He/She performed hand hygiene and put on gloves, then moved bedside table and removed gloves and performed hand hygiene.
-He/She emptied the catheter with the graduate then emptied contents.
-He/She removed gloves and performed hand hygiene and put on new gloves.
-The resident lowered the head of the bed so LPN B could perform catheter care.
-He/She removed gloves and performed hand hygiene and put on new gloves.
-He/She cleansed the suprapubic at drain site circle around opening with 2 separate 4x4s then dried and applied split 4X4 to site and secured with tape.
-He/She removed gloves and performed hand hygiene and put on new gloves.
-He/She pulled the trash and removed gloves and performed hand hygiene, then placed new gloves on and removed trash from room.
-He/She returned to room performed hand hygiene and placed new trash liner.
-He/She performed hand hygiene again before leaving the room.
-No gown was utilized for EBP precautions.
During an interview on 11/21/24 at 10:19 A.M. LPN B said:
-The procedure was the same as he/she performed daily.
-EBP was if there was MRSA in the wound.
-Staff had received training on EBP.
Observation on 11/22/24 at 2:34 P.M. of wound care provided by LPN D showed:
-He/She cleaned the bedside table.
-He/She came in the room in a gown with a tray with a box of gloves and placed items on the cleaned bedside table.
-He/She performed hand hygiene at the sink and turned water off with paper towel and put on gloves.
-ADON B entered to assist with holding the resident with gloves on and pulled foley bag and set catheter bag on the bed.
-CNA B entered room performed hand hygiene and donned gloves.
-ADON B and CNA B rolled resident to his/her right side so LPN D could remove the old treatments.
-He/She removed the treatment to the right and left buttocks.
-He/She removed gloves and performed hand hygiene and put on new gloves.
-He/She cleansed and placed new treatment to left buttock, performed hand hygiene, then put on new gloves then proceeded to the right buttock wound. He/She cleansed wound, and skin prepped the surrounding area applied alginate and bordered foam.
-He/She removed gloves and performed hand hygiene.
-He/She put on clean gloves and rolled the dirty chux and linens under resident to be removed.
-He/She performed hand hygiene and put on clean gloves and placed clean linen and chux under resident and rolled resident to complete the linen change pulled resident up in bed and reposition according to resident's preference with wedge placed to right side of buttocks.
-CNA B emptied catheter bag performed hand hygiene and left the room.
-CNA B returned with clean towel for under the television and new sheet for resident.
-He/She pulled trash and placed new liner for trash can.
-ADON B removed gloves and perform hand hygiene.
-He/She removed gown and gloves and performed hand hygiene.
-ADON B and CNA B were not in a gown as they assisted with care.
During an interview on 11/22/24 at 3:03 P.M. LPN D said:
-The treatment was completed as he/she would do daily if resident allowed.
-He/She said he/she just started wearing a gown.
Observation on 11/22/24 at 3:03 P.M. showed no EBP sign on the resident's door.
Observation on 11/25/24 10:12 A.M. of the resident's door showed no EBP signage and no PPE cart observed on the hall.
Observation on 11/25/24 at 10:28 A.M. showed CNA G in resident's room putting on gloves with no gown to provide care and empty catheter. The door was open, and curtain partially pulled.
During an interview on 11/25/24 at 10:35 A.M. CNA G said he/she did not wear a gown with resident care.
10. During an interview on 11/25/24 at 9:33 A.M. the Central Supply staff said:
-He/She supplied PPE for residents on EBP.
-He/She would be made aware of residents that required EBP through the daily Standup meeting or from a nurse for a new admission.
During an interview on 11/25/24 9:44 A.M. ADON B said:
-Residents with an open wound, catheter, or ostomy would be on EBP.
-Staff would be notified of residents on EBP by a sign on door, the Infection Preventionist (IP) would talk to staff at shift change, and during staff meetings.
-EBP procedure was that staff were to put on PPE before care then remove PPE and perform hand hygiene before leaving the room.
-He/She said a cart with PPE was placed in the hallways.
-The IP placed signs on the doors.
During an interview on 11/25/24 11:10 A.M. the DON said:
-EBP was just rolled out to the facility.
-The IP nurse had just started.
-Residents with tracheotomies, extensive wounds, gastrostomy, and catheters would be on EBP.
-Staff would receive training from IP.
-He/She said the facility had not been using EBP.
12. Review of Resident #116's admission MDS dated [DATE], showed:
-The resident was admitted to the facility on [DATE].
-The resident was cognitively intact.
-The resident had a diagnosis of respiratory failure (a serious condition that makes it difficult to breathe on your own. Respiratory failure develops when the lungs can't get enough oxygen into the blood).
-The resident received tracheostomy care daily.
Observation on 11/18/24 at 11:00 A.M., showed:
-No sign outside of the resident's door identifying the room as needing EBP.
-No PPE outside or inside the room.
-The resident was lying in bed in the supine (on back) position.
-The resident's tracheostomy was clean and intact.
During an interview on 11/18/24 at 11:05 A.M., the resident said:
-The staff did not use gowns or a mask when they were performing tracheostomy care on his/her tracheostomy.
-The staff did not put on a gown or a mask when performing any other cares for the resident.
Observation on 11/20/24 at 1:10 P.M., showed:
-Tracheostomy care was performed by ADON A .
-ADON A sanitized hands, applied gloves, and performed tracheostomy care and suctioning.
-ADON A did not wear a gown or a mask during the tracheostomy care and suctioning.
Observation on 11/21/24 at 9:43 A.M., showed:
-CNA E sanitized his/her hands and entered the resident's room to complete cares.
-CNA E exited the resident's room and sanitized hands.
-CNA E did not wear a gown during personal cares.
During an interview on 11/22/24 at 2:00 P.M., CNA E said:
-He/she was familiar with the resident and worked with the resident often.
-He/she did not wear gowns or mask when completing resident cares.
-He/she has never witnessed other staff members using gowns or gloves when interacting with the resident.
-He/she was unaware of what EBP was until yesterday.
During an interview on 11/22/24 at 2:17 P.M., RN B said:
-He/she was familiar with the resident.
-He/she works with the resident often.
-He/she just started using EBP today when giving the resident cares.
-He/she was unaware of the need for EBP with vulnerable resident's until today.
-He/she had not used EBP when giving cares to the resident before today.
During an interview on 11/22/24 at 3:00 P.M., ADON A said:
-He/she was familiar with the resident.
-He/she sometimes worked the floor as a charge nurse and gave resident cares.
-He/she did not use EBP while giving resident cares to the resident.
-The facility started education on EBP this week.
During an interview on 11/25/24 at 11:10 A.M. the DON said:
-EBP was just rolled out to the facility.
-Residents with tracheotomies, extensive wounds, gastrostomy, and catheters would be on EBP.
-Staff would receive training from the infection preventionist regarding EBP.
-He/She said the facility had not been using EBP.
2. Review of the facility's policy titled Personal Protective Equipment dated June 2020 showed hands were to be washed before and after glove usage.
Review of the facility's policy titled Blood Glucose Monitoring dated June 2020 showed:
-Staff were to wash their hands and put on gloves before performing the test.
-Staff were to remove their gloves and wash their hands after completing the procedure.
-The policy did not include the use of a barrier for placing supplies during the test.
Review of the facility's undated policy titled Hand Hygiene showed:
-Facility staff were to wash hands with soap and water in between glove changes.
-Facility staff were to use alcohol-based hand hygiene products:
--Immediately upon entering a resident occupied area regardless of glove use.
--Immediately upon exiting a resident occupied area regardless of glove use.
--Before moving from one resident to another in a multi-bedroom or procedure area regardless of glove use.
--After removing PPE and before moving to another resident in the same room or exiting the room.
-The use of gloves did not replace hand hygiene procedures.
Review of the facility's undated policy titled Medication Administration showed staff were to wash hands before and after medication administration.
Review of Resident #84's face sheet showed he/she admitted to the facility with the following diagnoses:
-Displaced Trimalleolar (ankle) Fracture of Left Lower Leg.
-Diabetes Mellitus (DM II- 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).
Review of the resident's Physician Order Sheet (POS) dated November 2024 showed:
-An order for blood glucose monitoring.
-An order for Hydrocodone-Acetaminophen Oral Tablet (pain medication) 5-325 milligrams (mg), give one tablet by mouth every four hours as needed for pain.
-An order for Novolog Injection Solution (Insulin Aspart- a short acting insulin) 100 unit/milliliters (ml), inject 20 units subcutaneously (situated or applied under the skin) before meals for DMII.
Observation on 11/19/24 at 8:39 A.M. of the resident's medication administration, blood glucose test, and insulin administration completed by Licensed Practical Nurse (LPN) A showed:
-LPN A did not sanitize his/her hands prior to the medication pass.
-He/She put on gloves and then got his/her keys out of his/her pocket and unlocked the medication cart.
-He/She then removed his/her gloves and walked away from the cart without sanitizing his/her hands.
-He/She returned to the medication cart and put on new gloves without sanitizing his/her hands.
-He/She sanitized the glucometer (glucose meter- a medical device used to determine the approximate concentration of glucose in the blood), set the glucometer down on a barrier, then removed his/her gloves.
-He/She then entered the resident's room to give the resident his/her pain medication and washed his/her hands before exiting the room.
-He/She walked out of the room and applied new gloves.
-He/She unlocked the medication cart and removed the other supplies needed for the blood glucose test.
-He/She then entered the resident's room with the same pair of gloves on and performed the blood glucose test.
-During the test LPN A placed the glucometer on the resident's bedside table without using a barrier.
-He/She removed his/her gloves and exited the resident's room.
-He/She returned to the medication cart and put on new gloves without sanitizing his/her hands.
-He/She then unlocked the medication cart and touched multiple different bags that held insulin pens in order to find the resident's insulin.
-He/She needed to get the resident a new insulin pen and removed his/her gloves without sanitizing his/her hands after the removal.
-He/She left the medication cart and walked to the medication room to get the resident a new insulin pen.
-Once LPN A was back at the medication cart, he/she did not sanitize his/her hands prior to getting a needle for the insulin pen out of the medication cart.
-He/She sanitized the insulin pen hub and placed the needle on the insulin pen without using gloves.
-He/She then put on new gloves without sanitizing his/her hands and walked into the resident's room to administer the insulin.
-He/She administered the insulin, removed his/her gloves, and walked out of the resident's room.
3. Review of Resident #132's face sheet showed he/she admitted to the facility with a diagnosis of DM II.
Review of the resident's POS dated November 2024 showed:
-An order for blood glucose monitoring before meals and at bedtime.
-An order for Humalog Injection Solution (Insulin Lispro- a short acting insulin), inject 15 units subcutaneously with meals for DM II.
Observation on 11/19/24 at 9:05 A.M. of the resident's blood glucose test and insulin administration completed by LPN A showed:
-LPN A transported the resident via his/her wheelchair to the medication cart.
-He/She put on gloves without sanitizing his/her hands.
-He/She performed the blood glucose test on the resident.
-The glucometer read an error and LPN A needed to re-perform the test.
-He/She grabbed new supplies from the cart with the same gloves and performed the test again.
-He/She then removed his/her gloves, sanitized his/her hands, removed the resident's insulin from the cart and put on new gloves.
-He/She removed insulin from the resident's insulin vial and administered the resident's insulin.
-He/She removed his/her gloves and did not sanitize his/her hands before continuing the resident's medication pass.
During an interview on 11/19/24 at 9:14 A.M. LPN A said:
-He/She would not have done anything differently during the medication administration, blood glucose tests, and insulin administrations for either resident.
-He/Should would normally perform hand hygiene after each glove removal.
-There was not a specific reason as to why he/she had not done that during the observation.
-He/She would normally sanitize his/her hands before and after any type of resident care including medication administration, when going from task to task during resident care, and after glove removal.
4. During an interview on 11/20/24 at 10:55 A.M. RN A said:
-Hand hygiene was to be performed before and after each resident during medication pass.
-The nurse should not have worn gloves when gathering supplies at the cart and going into the cart and should not have worn them into Resident #84's room.
-The nurse had not performed hand hygiene correctly throughout Resident #84's care.
-The nurse should have sanitized his/her hands before gloves were put on and taken off.
-The nurse should have placed a clean barrier between the resident's bedside table and the glucometer during the blood glucose test.
-The nurse should have removed his/her gloves before going into the resident's room.
-Upon entering the resident's room, the nurse should have sanitized his/her hands and put on new gloves before performing the blood glucose test.
-The nurse had not performed appropriate hand hygiene during Resident #132's care.
-The nurse should have sanitized his/her hands after touching the resident's wheelchair.
-The nurse should have removed his/her gloves, sanitized/washed his/her hands, and put on new gloves before redoing the resident's blood glucose test.
-Gloves were not a substitute for hand hygiene.
During an interview on 11/20/24 at 11:36 A.M. ADON A said:
-He/She expected staff to perform hand hygiene before and after each medication pass.
-He/She expected staff to perform hand hygiene before entering and after exiting resident rooms.
-Gloves were not a replacement for hand hygiene.
-LPN A did not perform appropriate hand hygiene during Resident 84's and Resident #132's care.
-LPN A should have washed/sanitized his/her hands after each glove removal and before putting on gloves.
-LPN A should not have worn gloves into Resident #84's room.
-LPN A should not have kept the same pair of gloves on to redo Resident #132's blood glucose test.
-LPN A should have removed his/her gloves, washed his/her hands, and put on new gloves before re-performing Resident #132's blood glucose test.
-LPN A should have placed a barrier on Resident #84's bedside table during Resident #84's blood glucose test.
During an interview on 11/20/24 at 12:07 P.M. the DON said:
-He/She expected staff to sanitize their hands between each resident during medication pass.
-Gloves were not a substitution for hand hygiene.
-Staff were expected to wash/sanitize their hands before and after glove use.
-Staff were expected wash/sanitize their hands before and after any resident care.
-Staff were expected to wash/sanitize their hands when entering and exiting resident rooms.
-LPN A had not performed appropriate hand hygiene during Resident #84's and Resident #132's care.
-LPN A should not have worn gloves into Resident #84's room.
-LPN A should have placed a barrier down between Resident #84's bedside table and the glucometer.
-Gloves were not to be worn when accessing non-medical supplies.
-LPN A should not have worn the same gloves after Resident #132's first blood glucose test.
-LPN A should have removed his/her gloves, washed his/her hands, and put on new gloves when he/she performed Resident #132's blood glucose test again.
11. Review of Resident #19's admission Face Sheet showed he/she had the following diagnosis:
-Chronic Obstructive Pulmonary Disease (COPD, prevents airflow to the lungs, causing breathing problems).
Review of the resident's Annual MDS dated [DATE] showed he/she:
-Was cognitively intact.
-Was able to understand others and make his/her needs known.
-Required assistance from staff for all cares and transfers.
Observation on 11/20/24 at 10:15 A.M., of the resident's perineal care (peri-care to the area between the anus and the exterior genitalia) showed:
-ADON B and CNA H and CNA J entered the resident room placed gloves on hands.
-CNA H provided peri care. He/she placed cleansing wipe on bed, lowered the resident brief and began personal care.
-He/she pulled a wipe out with his/her gloved hand and grabbed the body cleanser and sprayed the resident's frontal area.
-CNA H used the same gloved hands to assist the resident to turn towards the wall.
-With the same gloved hands CNA H cleaned the resident's bottom.
-With the same unclean gloves, CNA H then grabbed the barrier cream and applied the cream to the resident's bottom area.
-CNA H placed the wipes and cleanser back onto the side table.
-Did not have a barrier for soiled items.
-CNA H removed the resident's soiled brief and then removed soiled gloves.
-CNA J placed a clean brief on the resident and placed the Hoyer sling under the resident.
During an interview on 11/20/24 at 11:18 A.M., CNA H and CNA J said:
-He/she should perform hand hygiene with each glove change and from a dirty to clean process.
-CNA H was not aware he/she should have changed gloves prior to applying barrier cream.
-He/she should have removed gloves and performed hand hygiene prior to applying barrier cream.
-CNA's were not aware of potential of cross contamination of supplies when placed on bed and when soiled gloves were used to handle care items.
During an interview on 11/20/24 at 11:18 A.M., ADON B said:
-He/she would expect the CNA's to change gloves from a dirty process to clean process.
-The CNA's with clean gloves should provide the wipes and spray for the CNA who was completing care process.
-Should have had a barrier for supplies to prevent cross contamination.
-He/she would expect care staff to perform hand hygiene upon enter of the resident room between gloves changes and from a dirty to clean process.
During an interview on 11/25/24 at 11:10 A.M., the DON said:
-He/she would expect hand hygiene between every resident, before and after care, from a dirty to clean process and between glove changes.
-He/she would expect clean gloved hands prior to obtaining supplies to prevent cross contamination.
Based on observation, interview, and record review, the facility failed to properly screen new employees for Tuberculosis (TB a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) for five sampled new employees (Employee F, G, H, I, and J,) out of ten sampled new employees. This practice had the potential to affect all residents, employees, and visitors to the facility; the facility failed to ensure appropriate hand hygiene, glove usage, and barrier placement was appropriately used during medication administration, blood glucose (sugar) test, and insulin (a hormone produces in the pancreas which regulates the amount of glucose in the blood) administration for one sampled resident (Resident #84) and for one supplemental resident (Resident #132) out of five supplemental residents; failed to ensure enhanced barrier precautions (EBP-an infection control method that uses personal protective equipment (PPE-clothing or equipment that protects the wearer from injury or the spread of infection or illness) to reduce the spread of multidrug-resistant organisms) were used and failed to use handwashing/sanitizing to prevent cross contamination when providing care for six sampled residents (Resident #95, #84, #72, #19, #40, and #116) out of 35 sampled residents; The facility census was 151 residents.
Review of 19 Code of State Regulations (CSR) 20-20.100 TB testing for residents and workers in long-term care facilities, paragraph three, showed:
-All new long-term care facility employees who work ten or more hours per week should have the first of two TB skin tests (TST) within one month prior to starting employment in the facility.
-The results of the TSTs should be read within 48-72 hours from administration.
-If the initial TST result is zero to nine millimeters (mm) induration, the second test should be administered as soon as possible within three weeks after employment begins, unless documentation is provided indicating a two-step TST was completed in the past and at least one subsequent annual test within the past year.
Review of the facility's Employee TB Screening and Interpretation of TST's policy revised 6/2020 showed:
-After a TST test was administered, the TST test must be read within 48 to 72 hours by a qualified nurse or health practitioner in mm of induration.
1. Review of Employee F's employee file showed:
-The employee was hired on 5/9/24 as a Certified Medication Technician (CMT).
-The first step TB test was administered 5/9/24 and read as 0 millimeter (mm). There was no date showing when the TST was read.
-The second step TB test was administered 5/20/24 and read as 0 mm. There was no date showing when the TST was read.
Review of Employee G's employee file showed:
-The employee was hired on 6/7/24 as a Registered Nurse (RN).
-The first step TB test was administered 6/7/24 and read as 0 mm. There was no date showing when the TST was read.
-The second step TB test was administered 6/20/24 and read as 0 mm. There was no date showing when the TST was read.
Review of Employee H's employee file showed:
-The employee was hired on 8/16/24 as a Licensed Vocational Nurse (LVN).
-The first step TB test was administered 8/2/24 and read as 0 mm. There was no date showing when the TST was read.
-The second step TB test was administered 8/12/24 and read as 0 mm. There was no date showing when the TST was read.
Review of Employee I's employee file showed:
-The employee was hired on 9/4/24 as a Certified Nursing Assistant (CNA).
-The first step TB test was administered 9/4/24 and read as 0 mm. There was no date showing when the TST was read.
-The second step TB test was administered 9/13/24 and read as 0 mm. There was no date showing when the TST was read.
Review of Employee J's employee file showed:
-The employee was hired on 10/23/24 as a Cook.
-The first step TB test was administered 10/23/24 and read as 0 mm. There was no date showing when the TST was read.
-The second step TB test was administered 11/1/
Oct 2024
1 deficiency
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
Deficiency F0602
(Tag F0602)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure one sampled resident's (Resident #1) narcotics were secure when 47 pills of Oxycodone (a narcotic pain medication) were noted as mis...
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Based on interview and record review, the facility failed to ensure one sampled resident's (Resident #1) narcotics were secure when 47 pills of Oxycodone (a narcotic pain medication) were noted as missing on 9/11/24 out of three sampled residents. The facility census was 159 residents.
On 10/16/24 the administrator was notified of the past noncompliance which occurred on 9/11/24. On 9/11/24 the Administrator was notified of missing Oxycodone from the licensed nursing cart. The staff was educated on narcotic count and handling, and changed the policy for removing empty cards from all narcotic lock boxes on 9/11/24. The deficiency was found to be corrected on 9/11/24.
Review of the facility's Storage of Controlled Substances Policy dated 8/2020 showed:
-Medications classified by the Drug Enforcement Agency (DEA) as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility in accordance with federal, state, and other applicable laws and regulations.
-The Director of Nursing (DON), in collaboration with the consultant pharmacist, maintains the facility's compliance with federal and state laws and regulations in the handling of controlled substances.
-Only authorized licensed nursing and pharmacy personnel have access to controlled substances.
-Schedule II through V medications and other medications subject to abuse or diversion are stored in either a permanently affixed, double locked compartment separate from all other medications or in accordance with state regulations.
-If a key system is used, the medication nurse on duty maintains possession of the key to controlled substance storage areas.
-Back-up keys to all medication storage areas, including those for controlled substances, are kept the DON or designee.
-A controlled substance accountability record is prepared by the pharmacy/facility for all Schedule II, III, IV, and V medications, including those in the emergency supply.
-Unless otherwise indicated in a facility policy and/or as required by state regulations, the following will be performed:
--At each shift change, or when keys are transferred, a physical inventory of all controlled substances is conducted by two licensed personnel and is documented.
-Any discrepancy in controlled substance counts is reported to the DON immediately and/or in accordance with the facility policy.
-The DON or designee investigates and makes every reasonable effort to reconcile all reported discrepancies.
-The administrator, consultant pharmacist, and/or DON determine whether other actions are needed.
-The medication regimen of residents using medications that have such discrepancies are reviewed to assure the resident has received all medications ordered and the goal of therapy is met.
-Current controlled substance accountability records are kept in the Medication Administration Record (MAR) or a designated book.
-Completed accountability records are submitted to the DON and kept on file for five years at the facility or in accordance with facility policy and state regulations.
Review of the facility's Discrepancies, Loss and/or Diversion of Medications Policy dated 8/2020 showed:
-All discrepancies, suspected loss, and/or diversion of medications, irrespective of drug type or class, are immediately investigated and report filed.
-A thorough search is conducted in all drug storage areas, the resident's room, and any other locations where medications may have been used/placed during medication administration in an attempt to locate any missing container or medication supply.
-Any corrective action that the DON deems appropriate should be taken.
-Appropriate agencies required by state regulation will be notified.
1. Review of the facility Delivery Manifest dated 9/7/24 showed:
-Oxycodone/APAP (acetaminophen) 5-325 milligram (mg) tab, 20 tablets for Resident #1.
-Signed by facility staff as received from pharmacy on 9/7/24 at 2:45 P.M.
-The narcotic count sheet for this delivery could not be located.
Review of the facility Delivery Manifest dated 9/8/24 showed:
-Oxycodone/APAP 5-325 mg tab, 30 tablets for Resident #1.
-Signed by facility staff as received from pharmacy on 9/8/24 at 2:11 P.M.
-The narcotic count sheet for this delivery could not be located.
Review of Resident 1's admission Record showed the resident was admitted with diagnoses including breast cancer and chronic pain.
Review of the resident's Order Summary Report dated for September 2024 showed an order for Oxycodone-Acetaminophen Oral Tablet 5-325 mg, give two tablets by mouth every six hours as needed for pain.
Review of the resident's Treatment Administration Record (TAR) dated for September 2024 showed an order for Oxycodone/APAP 5-325 administered on 9/11/24.
During an interview on 10/1/24 at 10:30 A.M., the DON said:
-He/She was notified by Licensed Practical Nurse (LPN) A immediately when the Oxycodone was noted to be missing.
-He/She began an investigation immediately.
-He/She determined the medication as well as the count/sign-out sheets for the medication was missing.
-During a thorough search of the facility, the Assistant Director of Nursing (ADON) located the empty medication cards in the shred box at the nurse's station.
During an interview on 10/10/24 at 2:29 P.M., LPN B said:
-He/She counted the cards (against the shift to shift log) with LPN A on 9/11/24 and there were no cards missing at that time.
-The facility contacted him/her on 9/11/24 in reference to the resident's Oxycodone missing.
-He/She denied knowing what happened to the resident's Oxycodone.
-At no time was more than one nurse able to access the narcotics lock box.
-The only time there was two nurses able to access narcotics was during count at shift change.
-He/She did resign his/her position at the facility.
During an interview on 10/10/24 at 3:22 P.M., LPN A said:
-He/She was aware of the Oxycodone received into the facility between 9/7/24 and 9/8/24.
-When he/she counted with LPN B the count appeared to be correct and did not realize the count sheets for 9/7/24 and 9/8/24 were missing.
-The sheets for the resident's Oxycodone were not in the count book when he/she and LPN B counted at shift change.
-When the resident requested the medication for pain, he/she noticed the Oxycodone for the resident was not in the narcotic lock box.
-He/She recalled the medication being in the narcotic box three to four days prior when he/she worked last.
-He/She immediately reported the medication missing to the DON.
During an interview on 10/10/24 at 4:12 P.M. the ADON said:
-He/she located the empty cards of Oxycodone in the shred box at the nurse's station.
-He/She was not able to locate the count sheets sent from pharmacy for the Oxycodone.
-He/She was unable to locate the shift to shift log.
-There was a set of master keys to all narcotics lock boxes secured in the DON office, only accessible by the DON.
-LPN B refused to give a statement in reference to the missing medication and resigned instead.
During an interview on 10/16/24 at 2:09 P.M. LPN C said:
-He/She last counted the resident's Oxycodone with LPN B during shift change on 9/10/24 at approximately 7:00 P.M.
-The narcotic sheets for the Oxycodone delivered on 9/7/24 and 9/8/24 were there at that time.
-There was no way the resident could have taken all the Oxycodone from 9/10/24 through 9/11/24.
-When he/she returned to work the facility had already discovered the Oxycodone missing.
-There were prior complaints by residents stating they had not gotten narcotic pain medications on overnight shifts when LPN B worked, but the narcotics had been signed off by LPN B.
-He/She reported his/her concerns to the ADON.
-He/She did not know what happened to the resident's Oxycodone.
During an interview on 10/16/24 at 2:18 P.M., the DON said:
-He/She was responsible for monitoring the narcotic logs and adherence to policy.
-The ADON was responsible for daily checks of the narcotic logs.
-He/She expected staff to keep accurate records of all narcotics and ensure narcotics are secured in the facility for each resident in accordance with state and federal regulation.
-He/She provided additional education immediately and implemented a policy that all empty cards remain in the lock box until signed out by the ADON or DON.
During an interview on 10/16/24 at 3:13 P.M., the Regional Nurse Consultant said:
-He/She used the shift to shift log to conduct his/her investigation.
-Based on his/her investigation, the medications came up missing after LPN B had access to the cart.
-It was determined there were approximately 47 Oxycodone missing.
-He/She was not aware the empty cards were located in the facility shred box at the nurse's station.
-The count sheets to the missing Oxycodone were never located.
MO00241972
Jun 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
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 staff failed to provide an appropriate immediate discharge letter for one sam...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to provide an appropriate immediate discharge letter for one sampled resident (Resident #5) out of nine sampled residents. The facility census was 160 residents.
Record review of the facility's policy for Transfer and Discharge revised 10/24/22 showed:
-The purpose of the policy was to ensure that residents were transferred and discharged from the facility in compliance with state and federal laws and to provide complete, safe, and appropriate discharge planning and necessary information to the continuing care provider.
-In a situation where the facility initiated a discharge while the resident was in the hospital following an emergency transfer, the facility must have had evidence that the resident's status at the time the resident sought to return to the facility (not at the time the resident was transferred for acute care) met one of the criteria for discharge outline in the policy.
-The resident had the right to return to the facility pending an appeal of any facility-initiated discharge unless the return would endanger the health or safety of the resident or other individuals in the facility and the facility was to document the danger that the failure to transfer or discharge the resident would have posed.
1. Review of Resident #5's facility admission Record showed he/she was admitted on [DATE] with the following diagnoses:
-Spinal stenosis- (narrowing of the spinal canal)
-Type II 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)
-History of drug abuse.
Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff and used for care planning) dated 4/5/24 showed he/she:
-Was cognitively intact.
-Had no history of negative behaviors.
-Required only supervision for all self-cares and mobility.
Review of the resident's Nurse's Notes dated 6/13/24 at 3:44 P.M., showed:
-The resident's behavior had increased and he/she had an altercation with his/her roommate.
-The resident was sent to the hospital for evaluation.
Review of the resident's Notice of Transfer or discharge date d 6/13/24 showed:
-The resident was issued a discharge to a hospital.
-The reason for discharge was the resident's behavior became increasingly aggressive, including medication refusal, staff confrontations, and belligerence.
-The resident showed homicidal threats directed towards his/her roommate, involving menacing actions with a belt.
-On 6/13/24 the facility Administrator and Corporate Nurse spoke with the hospital nurse who stated the resident had been assessed by the hospital physician who determined the resident was at his/her cognitive baseline, with no acute changes.
-Due to the ongoing threats compromising resident safety, the facility discharged the resident to the hospital and did not agree to re-admit him/her.
During an interview on 6/14/24 at 6:48 A.M., Hospital Employee said:
-The resident was brought to the hospital for a psychiatric evaluation.
-The resident was cleared and determined ready to send back to the facility, an unknown facility nurse said the resident could not come back.
-The Administrator was contacted and said the resident could not come back, the facility had done an emergency eviction.
During an interview on 6/27/24 at 2:50 P.M., the Ombudsman said:
-He/she had gotten a copy of the Emergency Discharge for the resident.
-He/she noted the disposition was a hospital which was not correct.
During an interview on 6/27/24 at 3:15 P.M., the Facility Administrator said:
-He/she told the hospital nurse that the resident had threatened to kill his/her roommate, holding up a belt with a buckle stating he/she was going to beat and strangle him/her.
-The resident had luckily been stopped by staff in time to stop the resident from harming anyone.
-The resident continued to threaten staff and residents.
-It was his/her understanding that if a resident was an active threat to other residents residing in the facility, he/she could make the determination to deny re-admission to the facility from the hospital and that he/she could make the hospital the disposition of the resident.
-He/she could not have found appropriate placement for the resident within the short amount of time he/she had.
-The resident had never shown this type of behavior before, so they were not prepared in the facility to safely handle the resident's care and keep everyone safe.
-He/she expected the hospital to place the resident in a psychiatric setting until the resident was back at his/her baseline and no longer threatening.
MO00237584
Feb 2024
2 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from accidents for two sam...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from accidents for two sampled residents (Resident #1 and #3) out of six sampled residents. On 1/5/24 about 10:15 P.M., Certified Nurse Assistant (CNA) A transferred Resident #1 without using the Hoyer lift (a mechanical means to transfer a resident) from the wheelchair to the bed. During the transfer CNA A realized it was not safe to continue and lowered the resident to the floor. CNA A and CNA B then transferred the resident from the floor to bed by placing their arms under the resident's arms, one on each side and lifting the resident up. They did not use a gait belt or mechanical lift to transfer the resident back to his/her bed. Facility staff did not report the fall or assess the resident after the fall. The resident had an increase in yelling behavior throughout the night and was noted as not very responsive to questions being asked, pale in color, and yelling out in pain when turned from side to side during changing the next morning. The resident was also found to have bruising on their left upper arm and chest. The resident was sent to the hospital for further assessment. It was found the resident had extensive swelling in the left knee, left ankle, left posterior thigh and right hamstring, and multiple fractures in the left knee/femur. The hamstring bruising was a source of blood loss. The resident had a hemoglobin (the protein contained in red blood cells that is responsible for delivery of oxygen to the tissue) of 6 and required 5 units packed red blood cells and surgical intervention. The facility also failed to ensure they knew the location and status of one resident (Resident #3) and to coordinate safe transportation when on 1/9/24 the resident was left sitting in the hospital lobby all night after a dialysis appointment. The facility census was 154 residents.
The Administrator was notified on 1/31/24 at 1:50 P.M., of an Immediate Jeopardy (IJ) which began on 1/5/24. The IJ was removed on 1/7/24, as confirmed by surveyor onsite verification.
Review of the facility's Transfer Policy, dated 6/1/2020, showed:
-To provide the form of transfer best suited to the residents' needs and to maintain resident safety during the transfer.
-A licensed nurse and/or Director of Rehabilitation Services assess and determine lifting and transfer requirements and the procedure used for each resident.
-The procedure is recorded in the resident's Care Plan.
-Residents must be lifted or transferred according to the determined procedure.
-Residents who require assistance in transferring will be transferred using a gait/transfer belt or with a lift.
-Nursing staff are trained to use good body mechanics, knowing the proper procedure, and properly operating assistive devices.
-Mechanical lift procedures are used on any resident unable to independently pivot or transfer.
Review of the facility's Fall Policy, dated 8/1/2020, showed:
-To ensure that the resident's environment remains as free of accident hazards as is possible, and that each resident receives adequate supervision and assistance to prevent accidents.
-A fall is defined as a sudden, uncontrolled, unintentional, downward displacement of the body to the ground.
-Upon a fall, stay with the resident and send another staff member to notify a licensed nurse.
-The resident should not be moved until the licensed nurse has assessed the resident's condition.
-The assessment should include level of consciousness, position, possible injuries, pain, vital signs, swelling, bruising, alignment, and range of motion.
-The resident's physician and responsible party will be notified.
-After each fall a licensed nurse will complete a Post-Fall Assessment & Investigation and document in a detailed progress note.
-Document all falls on the 24-hour report, notification of physician and responsible party.
1. Review of Resident #1's admission Record showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-Cognitive Communication Deficit (having trouble reasoning and making decisions while communicating, remembering their conversations and experiences and trouble responding in an appropriate or socially acceptable manner).
-Parkinson's disease (a chronic disease characterized by a fine slowly spreading tremor, muscle weakness, muscle stiffness and a peculiar gait).
-Dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain).
-Contractures (an abnormal usually permanent condition of a joint, characterized by flexion and fixation) of left & right ankles and left & right knees.
-Osteoarthritis (a degenerative disease of the bone and Joint) of knee, unspecified.
Review of the resident's Care Plan, revised on 3/24/23, showed:
-Focus:
--Had self-care performance deficit related to post-polio syndrome, Parkinson's disease, and stroke.
-Interventions:
--He/she was dependent assist by two staff for bed mobility, transfers, dressing and bathing.
-Focus:
--He/she uses opioid pain medication related to chronic pain.
-Goal:
--Will be free of any discomfort or adverse side effects from pain medication.
-Interventions:
--Administer pain medications as ordered by physician.
--Monitor/document side effects and effectiveness every shift.
--Monitor for increased falls.
-Focus:
--He/she was at risk for alterations in comfort related to chronic pain and decreased mobility.
-Interventions:
--Anticipate the resident's need for pain relief and respond immediately to any complaint of pain.
--Monitor/document for side effects of pain medications.
--Monitor/record/report to nurse any signs or symptoms of non-verbal pain, changes in breathing, vocalization (grunting, moaning, yelling out or silence), mood/behavior changes (more irritable, restless, aggressive,squirmy, or constant motion), eyes (wide open/narrow, slits/shut, glazed, tearing, or no focus), Face (sad, crying, worried, scared, clenched teeth or grimacing), and body (tense, rigid, rocking, curled up, or thrashing).
--Provide the resident with reassurance that pain is time limited.
--Encourage to try different pain relieving methods (positioning, relaxation therapy, progressive relaxation, bathing, heat and cold application, muscle stimulation, ultra-sound).
-The care plan did not identify the resident need or use of a Hoyer lift.
Review of the resident's undated Card-X (a resource for care staff that gives a brief overview of each resident and updated as needed) that was generated by the care plan showed:
-He/she was dependent for transfer via Hoyer lift by two staff.
-Bed mobility was extensive assist by two staff.
Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment tool used by facilities for care planning), dated 12/6/23, showed:
-He/she was cognitively intact.
-Was able to make self understood and understand others.
-His/her lower extremities were impaired on both sides.
-He/she used a mechanical lift for transfers.
-Dependent on staff for sit to lying, lying to sitting, chair/bed to chair and cannot sit to stand.
-No pain frequency assessed.
-Had as needed pain medication.
-No non-medical interventions for pain received.
-No opiods given for pain.
Review of the resident's Order Summary Report dated 1/1/24 to 1/31/24, showed:
-No physician order for the use of a Hoyer lift for transfers.
-Pain monitoring every shift for pain.
-Hydrocodone-Acetaminophen Oral Tablet 5-325 milligrams (mg), give one tablet by mouth every 4 hours as needed for moderate to severe pain, started 5/9/23.
-Tylenol (Acetaminophen) Tablet, give 650 mg by mouth every 4 hours as needed for pain related to pain in left knee, not to exceed three grams (gms) of Acetaminophen in 24 hours, started 9/26/22.
-Voltaren External Gel 1% (Diciofenac Sodium) Topical, apply to both knees topically two times a day for pain, Apply 4 gms, not to exceed 16 gms per knee or 32 gms in 24 hours.
Review of the resident's Skilled Evaluation Note, dated 1/4/24 at 9:50 A.M., showed:
-He/she was alert and oriented to person and place.
-He/she had impaired balance.
-He/she had paralysis.
Review of the resident's Behavior Note, dated 1/7/24 at 00:07 A.M., showed:
-On 1/5/24 the resident sat by the nurse's station in his/her wheelchair and requested pain medication for his/her chronic right knee pain.
-No new issues with the resident's knee noted at 9:30 P.M. on 1/5/24.
-At 10:15 P.M. on 1/5/24 the resident verbalized pain medication was effective.
-Resident was transferred to bed by CNA A at 10:30 P.M. on 1/5/24.
-Resident had increased yelling after getting into bed which is a behavior that is related to the resident's dementia.
-Upon entering his/her room to check on him/her, he/she would just stare at Licensed Practical Nurse (LPN) A and stopped yelling.
-When asked what the problem was, he/she would not respond.
-No signs or symptoms of pain or discomfort noted when checking on him/her, reminded him/her to use the call light if he/she needed LPN A.
-LPN A checked on the resident throughout the night, when entering the room, he/she would stop yelling.
-This occurred multiple times throughout the night.
-LPN A would inquire if he/she was in pain or discomfort and he/she would smile and not answer the question.
-He/she had documented history of yelling out at night for no reason for doing so when assessed by LPN A.
-He/she had dementia and history of exhibiting this type of behavior during late evening and night.
-LPN A offered emotional support and encouraged him/her to use his/her call light which was kept within reach.
-LPN A also offered drinks and snacks for comfort and was assessed for pain and discomfort every time which he/she did not have when LPN A went into room.
Review of written statements by CNA C and CNA D, dated 1/6/24, showed:
-Around 8:30 A.M., CNA C heard the resident yelling out, so he/she and CNA D went to see what the resident needed.
-They proceeded to get the resident up, when they noticed he/she was not very responsive to questions being asked.
-The resident was pale in color and was yelling out in pain when turned from side to side during changing.
- They asked the resident several times if he/she was having pain, but the resident could not tell them if he/she was in pain.
-The resident was Hoyer lifted into his/her wheelchair and was still moaning.
-The resident was asked again about pain with no response.
-CNA C went and got the Assistant Director of Nursing (ADON) while CNA D stayed with the resident.
-CNA D changed the resident's shirt and that is when the bruising on the resident left upper arm and chest were noticed.
-The ADON took over the care of the resident at that time.
Review of the resident's Behavior Note, dated 1/6/24 at 7:24 A.M., showed:
-Resident screamed for 10 hours of the shift, increased when he/she was put to bed by CNA A.
-Resident had no pain or discomfort noted.
-LPN A checked on him/her several times throughout the night.
-He/she was just sitting in bed with eyes closed screaming and yelling.
Review of the resident's Nurse's Note, dated 1/6/24 at 10:14 A.M., showed:
-ADON was alerted by CNA C and CNA D the resident was not baseline and had bruising to the left arm that was spreading across his/her chest.
-Physician was called and received an order for STAT chest X-ray.
-Resident was put on oxygen via nasal cannula for low oxygen level and low blood pressure.
-Communicated with Nurse Practitioner (NP) and received an order to send resident to the hospital for evaluation and treatment.
-Resident left the facility at 9:58 A.M. via Emergency Medical Services (EMS) in route to the hospital.
Review of the resident's Treatment Administration Record (TAR), dated 1/1/24 to 1/31/24, showed:
- No pain medications was given to the resident on the night of 1/5/24 or on 1/6/24.
Review of the resident's emergency room and Hospital notes, dated 1/6/24, showed:
-Resident arrived by EMS on 1/6/24 at 10:45 A.M., from the facility.
-The resident's injuries were described as traumatic injuries of unknown source.
-He/she was non-ambulatory.
-He/she arrived having altered mental status, moaning, writhing and crying out in pain.
-He/she had significant bruising to the left upper chest and shoulder and center of his/her chest, and noted to have bruising to right anterior (front) chest which was tender and painful.
-He/she had swelling in his/her left knee, left ankle hematoma (a collection of blood outside of the blood vessel), left posterior (back) thigh and had a large right proximal (center) hamstring (a group of three muscles that run along the back of the thigh from hip to below the knee) hematoma 9 centimeter (cm) x 8 cm.
-Hemoglobin was 6.0., (normal range is 12 to 16).
-Radiology showed no chest fractures.
-He/she had multiple comminuted supracondylar fractures (a break to the lower part of this bone) left knee/femur.
-The hamstring hematoma was an avulsion injury (bone attached to tendon/ligament gets pulled away from the main part of the bone) which was the source of the blood loss.
-He/she required 5 units PRBC (Packed Red Blood Cells) and surgical intervention.
Review of the facility investigation, dated 1/6/24, showed:
-On 1/6/24 at 10:14 A.M., ADON was alerted by CNA C the resident was exhibiting a deviation from his/her baseline cognitive state.
-He/she needed repeated stimuli to awaken, had low blood pressure and oxygen levels.
-ADON immediately applied oxygen on the resident.
-Further assessment revealed the resident had dark purple bruising on his/her left upper arm extending to his/her left breast area accompanied by trace swelling.
-ADON notified the physician and received an order to send the resident to the hospital for evaluation and treatment.
-CNA A had attempted to transfer the resident by him/herself and had lowered the resident to the floor on 1/5/24.
-LPN A noted no new issues with the resident's knee at 9:30 P.M. on 1/5/24.
-At 10:15 P.M. on 1/5/24 the resident verbalized pain medication was effective that was given for resident chronic pain in both knees.
-Resident was transferred to bed by CNA A at 10:30 P.M. on 1/5/24. CNA A placed his/her arm under the resident's left arm and lifted the resident up. CNA A said that was how he/she transferred the resident 6 to 7 months ago when he/she worked at the facility. He/she said the resident had gained some weight and he/she could not hold the resident up and lowered him/her to the floor.
-During the transfer CNA A realized it was not a safe to continue and lowered the resident to the floor. No gait belt, Hoyer, or Sit to Stand was used in the transfer.
-CNA A was able to get assistance from CNA B and together they placed their arms under the resident's arms, one on each side and lifted the resident up off the floor and into bed. No gait belt, Hoyer, or Sit to Stand was used to transfer the resident from the floor back to the bed.
-Neither of the CNAs informed LPN A about lowering the resident to the floor, because they did not believe it was a fall since he/she was lowered to the floor.
-The resident sustained a fracture to his/her left knee from being lowered to the floor by CNA A, as the resident had a contracted left knee and was lowered to the floor with pressure on his/her left knee.
-It was ascertained the resident suffered a left knee fracture during the descent to the floor, exerting undue pressure on his/her already contracted left leg, compounded by preexisting comorbidities and the bruising under his/her left arm area was a result from being transferred off the floor into bed by the CNAs.
During an interview on 1/23/24 at 2:30 P.M., CNA A said:
-He/she had worked at the facility before and had only been back at the facility for three days.
-He/she used to transfer the resident by holding onto the resident's arm to help steady the resident.
-He/she figured he/she could transfer the resident just like he/she had in the past.
-The care plan had not identified any new way to transfer the resident. He/she transferred the resident the same way he/she transferred the resident six to seven months ago when last working with the resident.
-Staff are supposed to look at the resident's card-x as well to know how to transfer residents.
-The resident had gained some weight and he/she could not hold the resident up, so he/she lowered the resident to the floor.
-He/she then left the resident's room to get CNA B to help lift the resident up off the floor and into bed.
-The resident did not have a Hoyer pad under him/her, so CNA A figured the resident still transferred the same way he/she did six months ago.
-He/she did not think it was necessary to notify the nurse of lowering the resident to the floor.
-He/she did not think if was a reportable incident since he/she lowered the resident. He/she did not know it was considered fall.
Review of a written statement by CNA B, dated 1/6/24, showed:
-He/she worked on the 1/5/24 evening shift on the 400 hall.
-CNA A asked him/her for help.
-He/she went to help CNA A with the resident.
-The resident was on the floor next to the bed, feet in front of him/her.
-CNA A stated that he/she had alerted LPN A and needed help putting the resident in bed.
-He/she assisted CNA A with putting the resident in bed.
-He/she used the resident's pants and lifted with one hand in the front and one hand in the back on the right side of the resident.
-Once the resident was back in the bed, he/she left the room, because CNA A said he/she was able to finish cares on the resident.
During an interview on 1/23/24 at 2:13 P.M., CNA B said:
-He/she was working a different hall when CNA A came and asked him/her for help transferring the resident.
-He/she went to the resident's room and saw the resident on the floor.
-He/she asked CNA A if LPN A said it was okay to get the resident up off the floor.
-CNA A said LPN A said it was alright to get the resident up, so they both lifted the resident off the floor by each one taking a side and arm without using a lift or gait belt.
-The resident was a Hoyer lift to transfer, but there was no sling under the resident or in the resident's wheelchair to lift the resident up.
-CNA A said the Care Plan card-x did not indicate the need for a lift or gait belt. He/she did not look at the care plan themselves.
-He/she asked CNA A if she had notified LPN A about lowering the resident to the floor and CNA A said yes, LPN A said it was ok to lift the resident up off the floor.
Review of written statement by LPN A, dated 1/6/24, showed:
-He/she worked on 1/5/24 from 7:00 P.M. to 7:00 A.M., as the charge nurse for the 300/400 halls.
-The resident was at the nurse's station in his/her wheelchair and asked for pain medication for chronic right knee pain.
-The resident was transferred to bed by staff.
-The resident noted to increase yelling and when asked what the problem was, he/she would not respond, no signs/symptoms of pain or discomfort noted when checking on the resident .
-He/she checked on the resident throughout the night, when entering the room the resident would stop yelling. This occurred multiple times during the night.
-He/she would ask the resident if he/she was in pain or discomfort, the resident would just smile and not answer any of the questions.
-At no time during his/her shift was he/she notified of the resident being lowered to the floor or having a fall.
During an interview on 1/24/24 at 8:20 A.M., LPN A said:
-He/she had given the resident pain medication for his/her chronic pain before he/she was put to bed.
-He/she was not notified by CNA A or CNA B the resident was lowered to the floor, he/she would have expected the staff to notify him/her if that occurred.
-To his/her knowledge the resident was put to bed without any problems.
-When the resident would yell out, he/she would help the resident and he/she would quit yelling.
-He/she checked on the resident for chronic pain several times during the night when he/she was yelling out and it was not normal.
-The resident never said he/she was in pain when checking on him/her.
-He/she only assessed the resident for pain before the resident was put to bed.
-He/she did not turn on the resident's room light when he/she would got to the resident' room, because the resident had a big television that was always on.
-He/she did not see any color change in the resident's skin and did not see any signs or symptoms of pain when he/she went into the room.
-He/she did not do a skin assessment, because the resident was not due for a skin assessment.
-CNA A was the staff member who checked the resident to see if he/she needed his/her brief changed during the night.
-CNA A never said anything about the resident having a change in condition.
-The resident's right leg was contracted straight and would not bend and the left leg moved around and was not contracted.
-The resident was not able to stand and pivot due to weakness in the left leg.
-The resident was a Hoyer lift transfer and it should have been on the care plan card-x.
-He/she did not know the resident was lowered to the floor until the administrator called him/her during the investigation.
During an interview on 1/30/24 at 2:55 P.M., CNA D said:
-CNA C and CNA D were covering the 300 Hall the day shift when he/she heard the resident moaning.
-He/she asked the resident if he/she was ready to get up for breakfast.
-The resident did not respond, just moaned.
-CNA D and CNA C changed the resident's brief and the resident did not say anything about pain or even moan during rolling from side to side.
-The resident was pale in color in his/her face and was not at his/her normal baseline.
-CNA C went to notify the nurse of the resident's change in condition.
-CNA D went to change the resident out of his/her gown and that was when CNA D noticed all the bruising to the resident's left upper arm, left side, and chest.
-CNA D asked the resident if the bruising hurt and the resident did not respond.
-The resident would yell out when in pain or he/she would tell staff when in pain.
-It was not normal behavior for the resident to yell out.
-He/she can find how a resident was to transfer on the care plan and card-x for all residents.
-Max assist means Hoyer lift with two staff.
-Hoyer pad stays with the resident after a transfer.
During an interview on 1/30/24 at 3:11 P.M., CNA C said:
-The resident was not his/her normal self on the morning of 1/6/24.
-The resident was very picky on how he/she got ready for the day and would tell staff it they were not doing something to his/her liking.
-He/she did not say anything to CNA C or CNA D that morning, he/she would just moan.
-CNA C had worked with the resident for several years and the resident was able to tell staff when he/she needed assistance or was in pain.
-He/she notified the nurse the resident was pale in color in his/her face and was not answering questions when asked.
-When CNA C returned with the nurse is when he/she saw the bruising on the resident's left arm, side and chest.
During an interview on 1/30/24 at 3:26 P.M., the ADON said:
-He/she was working the floor when CNA C notified the nurse of the resident's change in condition.
-The resident was already sitting in his/her wheelchair when he/she arrived to the resident's room.
-He/she did not notice any signs or symptoms of pain.
-He/she was more worried about the bruising on the resident's left arm, side, and chest.
-He/she did not assess the resident's lower half of the body.
-The resident had very low blood pressure and his/her oxygen level low.
During an interview on 1/16/24 at 4:46 P.M., the Administrator said:
-The resident should have been transferred by the Hoyer lift as ordered by the physician and care plan card-x.
-LPN A should have been notified of the resident being lowered to the floor.
-The resident should have never been moved until LPN A assessed him/her for injuries.
-A gait belt or the Hoyer lift should be used to assist a resident up off the floor if no injuries are found.
During an interview on 1/17/24 at 12:53 P.M., the resident's Nurse Practitioner (NP) said:
-CNA A and/or CNA B should have notified LPN A the resident was lowered to the floor so LPN A could assess the resident for injuries.
-The resident yelling out for 10 hour was not the resident's baseline.
-LPN A should have notified him/her about the change in the resident's behavior.
-He/she was not notified of the resident being lowered to the floor, until the next morning.
-He/she gave an order to send the resident to the hospital for evaluation and treatment.
-He/she would expect the facility staff to notify him/her or the physician of any changes in the residents.
During an interview on 1/30/24 at 2:20 P.M., CNA E said:
-The resident was a two person Hoyer transfer at all times.
-The resident would yell instead of using his/her call light. Once the resident's needs were met the resident would not yell out until he/she needed help again.
During an interview on 1/30/24 at 2:25 P.M., CNA F said:
-The resident was a Hoyer lift when transferring.
-Resident could use the call light when he/she needed assistance.
-He/she could notify staff if he/she was in pain.
-The resident would yell instead of using his/her call light. Once the resident's needs were met the resident would not yell out until he/she needed help again.
During an interview on 1/30/24 at 2:32 P.M., the MDS Director said:
-The resident had been a Hoyer lift for sometime.
-The care plan and card-x would list how the resident was to transfer and how many staff were required for the transfer.
-How a resident transfers was not in the clinical orders, but is on the care plan from the MDS.
-As a resident's condition changes items will be added or deleted from the care plan.
2. Review found no transportation policy.
Review of Resident #3's admission Record showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses:
-End stage renal disease with dialysis (is when the kidneys have a decline in function to the point that the kidneys can no longer function on their own).
-Chronic Obstructive Pulmonary disease (COPD) (is a chronic inflammatory lung disease the causes obstructed airflow from the lungs).
-Diabetes Mellitus (a disease in which the body's ability to produce or respond to the insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine).
-Major Depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest).
-High blood pressure.
-Heart failure (the heart does not pump blood as well as it should).
Review of the resident's Order Summary Report, MAR & TAR dated 1/1/24, showed:
-Resident to receive hemodialysis on Tuesday, Thursday, and Saturday.
-Chair time is 11:00 A.M.
-Transportation to pick up resident every day shift on Tuesday, Thursday, and Saturday.
-PM medications were Baclofen 5 mg tablet for muscle spasms, Carvedilol 25 mg tablet for high blood pressure, Insulin Glargine 10 units for diabetes, Insulin Aspart 8 units for diabetes. Review showed these medications were not given on 1/9/24.
-AM medications were Allopurinol 100 mg tablet for end stage renal disease, Aspirin 81 mg for prophylaxis (action taken to prevent disease), Gabapentin 300 mg capsule for pain, Sertraline 25 mg for depression, Carvedilol 25 mg for high blood pressure, and Insulin Aspart 8 units for diabetes. Review showed these medications were not given as on 1/10/24.
Review of the resident's Nurse's Note, dated 1/9/24 at 12:20 P.M., showed:
-The resident went to dialysis as scheduled.
-Call received from dialysis center after he/she arrived and start of dialysis, nurse stated that he/she coded and was sent to the ER.
Review of the resident's hospital visit summary dated 1/9/24, showed the resident went to the ER on [DATE] at 11:11 A.M. and discharged back to dialysis on 1/9/24 at 12:40 P.M. He/she received IV Normal Saline 500 ml for hypotension or fluid hydration.
Review of the resident's Nurse's Note, dated 1/10/24 at 8:30 A.M., showed:
-The resident came back to the facility at 8:00 A.M.
-He/she was alert, no complaints of pain or discomfort, skin was dry and intact no concerns currently.
-NP notified of his/her return to the facility.
During an interview on 1/17/24 at 2:15 P.M., the resident said:
-He/she went to dialysis via transportation on 1/9/24 chair time 11:00 A.M.
-He/she was taken to what he/she thought was the ER and given fluids for dehydration.
-He/she then went back to the chair for dialysis.
-After dialysis was over, the clinic nurse took the resident to wait for his/her ride back to the facility.
-The ride never came, and he tried to call the facility several times with no one answering the phone.
-He/she fell a sleep in the hospital lobby and woke up about 3:30 A.M.
-He/she decided if he/she wanted to get back to the facility he/she needed to call UBER for a ride.
-He/she arrived back to the facility around 8:00 A.M. on 1/10/24.
-He/she did not receive his/her evening medications or any supper on 1/9/24.
During an interview on 1/16/24 at 4:30 P.M., LPN B said:
-He/she received a call from an unknown staff person at dialysis the resident had a rapid response, but was never told when the resident would be returning to the facility.
-He/she assumed rapid response meant the resident had coded at dialysis and was sent to the ER.
-He/she never called dialysis or the hospital afterward to check on the resident or if the resident was ready to return.
-He/she told LPN A the resident had coded and was at the ER.
During an interview on 1/24/24 at 8:20 A.M., LPN A said:
-The facility takes the resident to dialysis and picks up the resident from dialysis.
-If the resident goes to the ER from dialysis, then the ER at the hospital is responsible for the resident's return to the facility.
-The facility transportation driver leaves around 3:00 P.M. daily.
-An outside transportation company will bring the resident back to the facility or the ambulance might bring a resident back to the facility.
-ER nurse is to set up the resident's transportation back to the facility.
During an interview on 1/24/24 at 1:14 P.M., Dialysis Social Worker said:
-The resident usually arrives at dialysis around 10:30 A.M. for chair time at 11:00 A.M.
-He/she was done with dialysis at 2:30 P.M.
-Pick up time is 2:45 P.M. to 3:00 P.M. for ride back to the facility.
-A dialysis nurse called the facility for the resident to be transported back to the facility, he/she could remember the facility was specifically called when the resident was finished with dialysis.
-Facility informed the nurse that UBER Health would be picking up the resident.
-The nurse stayed with Resident #3 while waiting for transportation to pick up the resident.
-After awhile the nurse called the facility again to see when transportation was going to show up.
-Around 2:30 or 3:00 P.M., facility said transportation should be at dialysis anytime to pick up the resident.
-The nurse had to go and help other clients and left the resident in the main lobby.
-The resident did not feel good at dialysis and a rapid response was called and the resident was given fluids for dehydration.
-The resident never coded or went to the
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
Resident Rights
(Tag F0550)
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 one of six sampled residents (Resident #1) received timely a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of six sampled residents (Resident #1) received timely assistance in obtaining a hearing device for communication. The facility census was 154 residents.
Review of Resident #1's admission Record showed:
-Was admitted to the facility on [DATE] with the following diagnosis;
-Cognitive Communication Deficit (having trouble reasoning and making decisions while communicating, remembering their conversations and experiences and trouble responding in an appropriate or socially acceptable manner).
Review of the resident's Care Plan, revised on 3/24/23, showed:
-Focus:
--Had a communication problem related to hearing deficit.
-Goal:
--Will be able to make basic needs known on a daily basis through the review date of 12/6/23.
-Interventions:
--Anticipate and meet needs.
--Allow adequate time to respond, repeat as necessary, do not rush, and request clarification from the resident to ensure understanding.
--Face when speaking, make eye contact, turn off television/radio to reduce environmental noise, ask yes/no questions if appropriate, use simple brief, consistent words/cues and use alternative communication tools as needed.
--Discuss with resident/family concerns of feelings regarding communication difficulty.
--Ensure hearing aids are placed in both ears.
--Speak on an adult level, speaking clearly and slower than normal.
--Validate resident's messages by repeating aloud.
Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment tool used by facilities for care planning), dated 12/6/23, showed:
-He/she was cognitively intact.
-Was able to make self understood and understand others.
-Hearing adequate with hearing aids.
Review of the resident's Order Summary Report dated 1/1/24 to 1/31/24, showed the night nurse must ensure resident's hearing aids are taken from the resident and stored in their box in the top drawer of the nurse's cart. The A.M. nurse must put hearing aids in the resident's ears every A.M. Found in a box in the top drawer of the nurse's cart, every morning and at bedtime for loss prevention.
Review of the resident's Treatment Administration Record (TAR), dated 1/1/24, showed the following:
-No hearing aids were applied the mornings of 1/1/24 & 1/6/24;
-1/2/24 - 1/5/24 showed code 9 (see progress note), but no progress notes were documented in medical record.
-At bedtime the TAR showed 1/1/24 - 1/5/24 no hearing aids were removed and on 1/6/24 showed staff documented yes (resident was in the hospital at this time).
During an interview on 1/16/24 at 4:46 P.M., the Administrator said:
-The resident was sent to the hospital in November 2023 and the resident only returned with the blue hearing aid.
-The red hearing aid was missing.
-The hospital was contacted to see if the red hearing aid had been found. It was not found.
-The blue hearing aid was cracked and did not work.
-The family was notified of the missing and broken hearing aids.
-Family picked up the broken hearing aid to get it fixed. Not sure of the date.
-Contact had been made with the family about the hearing aids and when the facility could expect to get the hearing aids for the resident. No time frame was given.
During an interview on 1/30/24 at 2:01 P.M., Licensed Practical Nurse (LPN) B said:
-The resident's hearing was not good and used hearing aids to hear.
-The red hearing aid was lost at the hospital the last time the resident was sent to the hospital (November 2023) and the blue hearing aid was broken.
-The blue hearing aid was given to the resident's son.
-The resident had not had hearing aids for a while.
-The family was working on getting the resident new hearing aids.
-The resident was able to notify staff if he/she was in pain or needed assistance.
-Sometimes the resident would yell for help and would just stare or say he/she forgot what he/she needed.
During an interview on 1/30/24 at 2:25 P.M., Certified Nurse Aide (CNA) F said the resident could hear when his/her hearing aids were in place, but if no hearing aids, staff would have to talk into the resident's left ear for him/her to hear what was being said. The resident had not had hearing aids for a while, but did not give time frame.
During an interview on 1/30/24 at 3:26 P.M., the Assistant Director of Nursing said:
-The family took the blue hearing aid to get it fixed and had to order a new red hearing aid.
-The facility was waiting for the hearing aids to arrive at the facility.
During an interview on 1/17/24 at 12:53 P. M., the Nurse Practitioner said the resident was not able to hear without his/her hearing aids. The hearing aids should have been fixed as soon as possible, but could not make the family get the hearing aids fixed any faster.
During an interview on 2/26/24 at 8:24 A.M.,the resident's family member said:
-The facility was to be taking care of getting the hearing aids fixed.
-He/she was paying a monthly payment to an outside company for servicing the hearing aids.
-The facility would not use this company, because they had a company they used as the facility.
-The resident went without hearing aids for at least eight months.
-The family paid a private company to care for the hearing aids.
-He/she was constantly in the social service office trying to get the hearing aids fixed.
-The day the resident was discharge from the hospital to a new facility the hearing aids arrived at this facility.
-He/she picked up the hearing aids and took them to the new facility.
-Social service employee who was to take care of this is no longer at the facility.
Sept 2023
3 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 Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to provide appropriate discharge notice for one sampled resident (Resident #2) out of four sampled residents. The facility census was 148 resi...
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Based on interview and record review, the facility failed to provide appropriate discharge notice for one sampled resident (Resident #2) out of four sampled residents. The facility census was 148 residents.
Review of the facility policy titled, Transfer and Discharge, dated 6/2020, showed:
-To ensure that residents are transferred and discharged from the facility in compliance with state and federal laws and to provide complete, safe, and appropriate discharge planning and necessary information to the continuing care provider.
-Prior to transfer/discharge, social services staff or designee will provide the resident or responsible party with reasonable notice that the resident is going to be transferred or discharged .
-Social Service staff or designee will provide the resident or responsible party with Notice of Proposed Discharge letter.
-If the resident is transferred because his/her needs cannot be met, the facility must document attempts to meet the resident's needs and the service available at the receiving facility to meet the need(s).
-The medical record will contain written documentation from a physician if the resident is discharged because:
--The safety of individuals in the facility is endangered by the resident's presence or
--the health of individuals in the facility would otherwise be endangered by the resident's presence.
1. Review of Resident #2's facility face sheet, showed he/she was admitted to the facility on the Secure Care Neighborhood unit, 7/10/23 with diagnoses that include:
-Neurocognitive Disorder with Lewy Bodies (a type of progressive dementia that leads to a decline in thinking, reasoning and independent function).
-Impulsiveness.
-Cognitive Communication Deficit (difficulty with thinking and how a person uses language).
-Dementia with Psychotic disturbance (dementia with hallucinations and delusions).
-Major Depression.
-Mood Disorder (General emotional state or mood is distorted or inconsistent with circumstances and interferes with ability to function).
Review of the resident's facility Notice of Proposed Discharge form dated 8/11/23 showed:
-Discharge to local hospital.
-Reason for discharge:
--The discharge was necessary for the resident's welfare, and his/her needs cannot be met by the facility.
-Signed by:
--Nurse Manager B, Administrator and notation of verbal consent by Durable Power of Attorney (DPOA- a person appointed to act on the resident's behalf).
During an interview on 8/17/23 at 4:00 P.M., the DPOA said:
-The resident has dementia.
-Last Friday on 8/11/23 the facility called and staff said that the resident needed sent to the hospital because he/she was aggressive.
-He/she was asked for consent to send the resident to the hospital.
-Once at the hospital, he/she found out that the facility remarked that he/she given consent to discharge the resident.
-He/she felt like the facility lied just to get rid of the resident and dump him/her at the hospital.
-The resident was still at the hospital waiting for placement.
-He/she had a copy of the paperwork from the facility that was fraudulently marked that he/she gave consent to discharge.
During an interview on 8/18/23 at 1:30 P.M., Nurse Manager B said:
-The Regional Nurse instructed him/her to discharge the resident to the hospital on 8/11/23.
-He/she explained to the DPOA that the resident was being sent to the hospital and that he/she was not appropriate for there unit.
During an interview on 8/18/23 at 2:00 P.M., the Administrator said he/she understood that discharging a resident to the hospital could result in a regulatory violation, however, he/she was doing what he/she was told by administration.
During an interview on 9/7/23 at 1:10 P.M., the hospital Social Worker said:
-The DPOA was not aware that he/she had given verbal consent to send the resident to the hospital for a discharge.
-DPOA was under the impression that the resident was sent to the hospital for a psychiatric evaluation.
-The resident was admitted to their Senior Behavioral Unit, without a discharge plan on admission.
-There was no medical or psychiatric reason why the resident could not return to the facility when requested.
MO00223092
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 Transfer
(Tag F0626)
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 allow one sampled resident (Resident #2) out of four sampled reside...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to allow one sampled resident (Resident #2) out of four sampled residents, to return to the facility after a hospitalization. The facility census was 148 residents.
Review of the facility policy titled, Transfer and Discharge, dated 6/2020, showed:
-To ensure that residents are transferred and discharged from the facility in compliance with state and federal laws and to provide complete, safe, and appropriate discharge planning and necessary information to the continuing care provider.
-Prior to transfer/discharge, social services staff or designee will provide the resident or responsible party with reasonable notice that the resident is going to be transferred or discharged .
-If the resident is transferred because his/her needs cannot be met, the facility must document attempts to meet the resident's needs and the service available at the receiving facility to meet the need(s).
-The medical record will contain written documentation from a physician if the resident is discharged because:
--The safety of individuals in the facility is endangered by the resident's presence or
--the health of individuals in the facility would otherwise be endangered by the resident's presence.
1. Review of Resident #2's facility face sheet, showed he/she was admitted to the facility on the Secure Care Neighborhood unit, 7/10/23 with diagnoses that include:
-Neurocognitive Disorder with Lewy Bodies (a type of progressive dementia that leads to a decline in thinking, reasoning and independent function).
-Impulsiveness.
-Cognitive Communication Deficit (difficulty with thinking and how a person uses language).
-Dementia with Psychotic disturbance (dementia with hallucinations and delusions).
-Major Depression.
-Mood Disorder (General emotional state or mood is distorted or inconsistent with circumstances and interferes with ability to function).
Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool used by facilities for care planning) dated 7/17/23 showed:
-Brief Interview of Mental Status (BIMS-an assessment that measures cognitive status), score of 2, which indicated the resident was severely cognitively impaired.
-Resident wanders.
-Requires supervision, oversight, encouragement and cueing for locomotion off of the unit.
Review of resident's care plan dated 7/11/23 showed:
-Resident resides on the memory care unit related to elopement risk/wandering.
-Monitor resident per protocol to ensure safety.
-Explain all procedures using terms that the resident can understand.
-Address the resident by name when giving care, involve him/her as much as possible.
Review of the resident's Level One Nursing Facility Pre-admission Screening for Mental Illness, Intellectual Disability, or Related Condition, dated 7/10/23 showed the following diagnoses/conditions:
-Major Depressive Disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life).
-Mood Disorder (general emotional state or mood is distorted or inconsistent with your circumstances and interferes with your ability to function).
-Lewy Body dementia with behavioral disturbance (a common type of dementia that happens when clumps of proteins called Lewy bodies build up in your brain - these damage parts of your brain that affect cognition, behavior movement and sleep).
-Worsening psychosis (a mental disorder characterized by a disconnection from reality) and erratic behavior.
-Withdrawn/depressed.
-Suspicious/paranoid.
-Aggressive (physical/verbal).
-Oriented to person and place.
-Rarely or never has the capability to make decisions or displays consistent unsafe/poor decision making or requires total supervision requiring reminders, cues, or supervision at all times to plan, organize and conduct daily routines and rarely or never understood/able to understand others.
Review of resident's Elopement Risk Evaluation dated 7/25/23, showed he/she had an elopement risk of 7, which indicated he/she was at moderate risk for elopement.
Review of the resident's progress notes dated 8/10/23 showed:
-Continuous and extreme crying out, yelling, danger to self/others, and/or prevents staff from giving care every shift.
-Resident pushing staff member providing one on one care and threatened to strangle him/her.
Review of the resident's progress notes dated 8/11/23 showed:
-Resident was taken by ambulance on 8/11/23 at 7:30 P.M., to a local hospital.
-Resident has had episodes of increased agitation, constantly exit seeking.
-Nurse Manager B, for the unit said the resident was no longer appropriate for their locked unit and the resident's spouse who was the resident's DPOA agreed that the resident needed a psychological evaluation.
-Nurse Manager B stated medication changes had occurred recently and had been ineffective.
Review of the resident's facility Notice of Proposed Discharge form dated 8/11/23 showed:
-Discharge to local hospital.
-Reason for discharge:
--The discharge was necessary for the resident's welfare, and his/her needs cannot be met by the facility.
-Signed by:
--Nurse Manager B, Administrator and notation of verbal consent by Durable Power of Attorney (DPOA- a person appointed to act on the resident's behalf).
During an interview on 8/17/23 at 4:00 P.M., the DPOA said:
-The resident has dementia.
-Last Monday, 8/7/23, the resident took off from the facility.
-The resident was found at a convenience store down the road.
-He/she was told that everything was okay and they would pay better attention to the doors.
-Last Friday on 8/11/23 he/she was called and staff said that the resident needs to be sent to the hospital because he/she was aggressive.
-He/she was asked for consent to send the resident to the hospital.
-Once at the hospital, he/she found out that the facility remarked that he/she had given consent to discharge the resident.
-He/she felt like the facility lied just to get rid of the resident and dump him/her at the hospital.
-The resident was still at the hospital waiting for placement.
-He/she had a copy of the paperwork from the facility that was fraudulently marked that he/she gave consent to discharge.
During an interview on 8/18/23 at 1:30 P.M., Nurse Manager B said:
-The Regional Nurse instructed him/her to discharge the resident to the hospital on 8/11/23.
-While the resident was on one to one observation, he/she had become aggressive and threatened to strangle the staff member.
-He/she explained to the DPOA the resident was being sent to the hospital and he/she was not appropriate for this unit.
During an interview on 8/18/23 at 2:00 P.M., the Administrator said:
-He/she understood discharging a resident to the hospital could result in a regulatory violation, however, he/she was doing what he/she was told by administration.
-The facility was still seeking active placement for the resident.
During an interview on 8/29/23 at 2:27 PM, Hospital Social Worker A said:
-The resident was hospitalized on [DATE] for a psychiatric hospitalization.
-The resident was sent with a discharge notice from the facility, stating he/she was being discharged to the hospital.
-The Ombudsman was contacted and reported it was an improper and invalid discharge.
-The Senior Behavioral Health Director at the hospital communicated with the facility, the facility reported they would accept the resident back upon discharge and that they would look for alternative placement for him/her.
-The facility Social Worker and the Social Worker liaison reported to sending out referrals for the resident and reported the resident was able to return should alternative placement not be identified.
-On 8/28/23 the facility was informed that the resident was ready for transfer back to the facility as there was no medical or psychiatric acute need to keep him/her and was told the facility would take the hit and that the patient would not be able to return.
-As of 8/29/23 the resident was in the ER with no medical reason to be admitted due to the refusal to let the resident in the facility.
During an interview on 9/7/23 at 10:05 A.M., Social Service Designee said:
-He/she sent referrals out to other facility's for residents who wish to move and for residents whose needs cannot be met.
-He/she knew that resident discharge plans did not include a discharge to a hospital.
During an interview on 9/7/23 at 1:10 P.M., the hospital Social Worker said:
-The DPOA was not aware that he/she had given verbal consent to send the resident to the hospital for a discharge.
-DPOA was under the impression that the resident was sent to the hospital for a psychiatric evaluation.
-The resident was admitted to the Senior Behavioral Unit, without a discharge plan on admission.
-There was no medical or psychiatric reason why the resident could not return to the facility when requested.
MO00223092
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to maintain the memory care unit doors to properly close allowing unauthorized exit by residents. On 8/7/23, one sampled resident (Resident #2...
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Based on interview and record review, the facility failed to maintain the memory care unit doors to properly close allowing unauthorized exit by residents. On 8/7/23, one sampled resident (Resident #2), wandered from the secured unit and was found .3 mile from the facility after the magnetic door lock failed to securely lock out of three sampled residents. The facility census was 148 residents.
On 8/11/23, the Administrator was notified of the past noncompliance which occurred on 8/7/23. The facility administration was notified on the same day of the incident and the investigation was started. Facility staff were educated on the facility Wandering and Elopement policy, resident interventions and behaviors before the start of the next shift. Resident care plans were updated. The magnetic locks were fixed and self closing hinges for the door were installed. The deficiency was corrected on 8/8/23.
Review of the facility policy titled Wandering and Elopement, dated 8/2020, showed:
-The facility would identify residents at risk for elopement and minimize any possible injury as a result of elopement.
-The Licensed Nurse, in collaboration with the Interdisciplinary Team (IDT), will assess residents upon admission, readmission, quarterly and upon identification of significant change in condition to determine their risk of wandering/elopement.
-Facility staff will reinforce proper procedures for leaving the facility for residents assessed to be at risk of elopement.
Review of the facility policy titled Secure Care Neighborhood, dated 8/2020 showed:
-The goal of the Secure Care Neighborhood was to meet the individual needs of residents with dementia related illnesses.
-The Secure Care Neighborhood would provide a safe environment that maximizes independence and provides an activity intensive atmosphere.
-Criteria must be met in order for the resident to participate in the Secure Care Neighborhood program, including:
--The resident must have a diagnosis of dementia related illness.
--The resident must be able to assist in activities of daily living, including dressing, bathing and toileting independently or with the assist of one staff.
-The resident must be a high-risk wanderer.
Record review of the Logbook Documentation for the exit doors from the dementia unit showed:
-The exit door from the dementia unit was not documented as inspected separately from all other exit doors, on the following dates prior to the elopement incident 6/14/23, 6/20/23, 6/28/23, 7/4/23, 7/11/23, 7/20/23, 7/25/23, 7/31/23 and 8/3/23.
1. Review of Resident #2's facility face sheet, showed he/she was admitted to the facility on the Secure Care Neighborhood unit, 7/10/23 with diagnoses that include:
-Neurocognitive Disorder with Lewy Bodies (a type of progressive dementia that leads to a decline in thinking, reasoning and independent function).
-Impulsiveness.
-Cognitive Communication Deficit (difficulty with thinking and how a person uses language).
-Dementia with Psychotic disturbance (dementia with hallucinations and delusions).
-Major Depression.
-Mood Disorder (General emotional state or mood is distorted or inconsistent with circumstances and interferes with ability to function).
Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool used by facilities for care planning) dated 7/17/23 showed:
-Brief Interview of Mental Status (BIMS-an assessment that measures cognitive status), score of 2, which indicated the resident was severely cognitively impaired.
-Resident wandered.
-Required supervision, oversight, encouragement and cueing for locomotion off of the unit.
Review of resident's care plan dated 7/11/23 showed:
-He/she resides on the memory care unit related to elopement risk/wandering.
-He/she was monitored per protocol to ensure safety.
-Facility staff should explain all procedures using terms that the resident could understand.
-Facility staff should address the resident by name when giving care, involve him/her as much as possible.
Review of resident's Elopement Risk Evaluation dated 7/25/23, showed he/she had an elopement risk of 7, which indicated he/she was at moderate risk for elopement.
Review of the facility investigation dated 8/7/23 showed:
-On 8/7/23 at 9:40 A.M., the resident was last seen wandering the secure unit hallway by Certified Nursing Assistant (CNA) B.
-At 9:45 A.M., CNA B was unable to locate the resident and alerted Licensed Practical Nurse (LPN) A of the missing resident.
-A Code Pink Protocol (an alert to staff for a missing resident) was immediately initiated.
-Administrator and Director of Nursing (DON) were notified.
-Staff simultaneously searched the unit, premises and local businesses.
-Resident's responsible party was notified.
-Appropriate staff were interviewed.
-At approximately 9:55 A.M., the resident was located by the Dietary Manager at a local store that was closest to the facility.
-Dietary Manager alerted the Administrator and the DON.
-Resident was not in any distress, dressed appropriately, and returned to the facility with the Dietary Manager without any resistance.
-The following actions were immediately taken, upon the resident returning to the facility:
-Head to toe assessment completed on the resident with no injuries noted.
-Primary Care Physician contacted.
-Resident was interviewed.
-Unit inspected to check the exit doors and windows to ensure proper functioning.
-Upon further investigation it was noted that the entry door to the foyer between the secure unit and the outside of the facility was not securely closed to allow the magnetic strip to engage.
-Interventions have been put in place to prevent further occurrences.
-Resident remains at baseline and the staff will continue his/her plan of care.
During an interview on 8/10/23 at 11:00 A.M., the resident said:
-He/she was an outdoor person, and he/she always has been, he/she just enjoys being outside.
-He/she just wanted to go and see what was out there, it was nice.
-He/she liked to enjoy it like when he/she was a kid.
-He/she guessed he/she will not do that again, as it caused a ruckus.
During an interview on 8/10/23 at 11:54 A.M., the resident's spouse said:
-The staff let him/her know right away after he/she got out of the facility.
-He/she wasn't worried, and knew that the resident did this at home also.
-He/she was sure that the facility will take care of the issue.
During an interview on 8/10/23 at 12:30 P.M.,CNA B said:
-The unit had a lot of staff on it when the incident happened.
-They were finishing serving breakfast, and therapy and dietary staff were back on the unit also.
-He/she had never saw the resident trying and get out of the unit before, just wandered around the unit.
-He/she notified the nurse immediately.
During an interview on 8/10/23 at 12:40 P.M., LPN A said:
-They were finishing up breakfast and the resident is constantly wandering around.
-The resident had never gotten off the unit before.
-He/she had left the unit to attend a meeting, and had let CNA B know he/she was leaving.
-As soon as he/she had left the unit, he/she heard a Code Pink alert called.
-He/she found that the code Pink was for the resident.
-He/she notified the Administrator and the DON, and called the spouse.
-The spouse shared that the resident had been eloping when he/she was at home.
During an interview on 8/10/23 at 1:00 P.M., the Maintenance Director said:
-The magnetic lock (a lock which used an electromagnetic force to stop doors from opening; that is made up of an electromagnet and an armature (a metal which produced an electric current when it is exposed to a magnetic field) plate.
-The plate is attached to the door, and the magnetic is attached to the door frame for the outer door (the door to the parking lot) that was not working.
-The inner door was left open by a staff person from another department, but he/she was unsure of which employee.
-A local electrical repair company fixed the door on 8/9/23, after the elopement incident occurred.
-The exit door from the dementia unit to the parking lot was not specifically checked until a new door checking system was implemented.
-The exit doors are to be checked weekly.
-There was no written policy on how often the doors should be checked for proper functioning, but the general practice has been to check the doors weekly.
-Self closing hinges are now in place, so that the door will not be ajar at anytime.
-Staff checked the magnetic locks weekly, but now staff are checking the locks daily to assure proper functioning.
-The facility had also installed an additional precaution with touch sensitive alarm on the outer door, in addition to the magnetic lock.
-The touch sensitive alarm sounded a high pitched noise when touched.
During an interview on 8/10/23 at 1:20 P.M., the Technician from a local contracted electrical company said the magnetic lock went bad on the outer door, and was replaced with a new lock on 8/8/23.
During an interview on 8/10/23 at 1:25 P.M., Dietary Aide (DA) A said the notification alarm (a function which made a sound when he/she pushed the bar for the door) was not working at the time the elopement occurred.
During an interview on 8/10/23 at 1:30 P.M., the Administrator said:
-The south door did not shut completely, and the outer door magnetic lock malfunctioned, which is how the resident walked out of the unit.
-Then the outer door magnetic lock malfunctioned.
-Now the magnetic lock has been replaced, the hinges on the inner door are now self closing, and they have an additional touch sensitive alarm on the outer door.
MO00222671
Mar 2023
28 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
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 accommodate the eating and ambulation (walking) needs...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accommodate the eating and ambulation (walking) needs for one visually impaired sampled resident (Resident #104) out of 30 sampled residents and nine supplemental residents. The facility census was 148 residents.
A policy regarding Care for the Visually Impaired was requested and not received at the time of exit.
1. Record review of Resident #104's undated face sheet showed he/she admitted to the facility with legal blindness.
Record review of the resident's annual Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 1/29/23 showed:
-The resident was cognitively intact.
-The resident's vision was severely impaired meaning the resident had no vision or saw only light, colors, or shapes and his/her eyes did not appear to track.
Observation on 3/20/23 at 9:48 A.M. showed:
-The resident was led down the hall by a resident (Resident #86).
-Resident #86 was walking with his/her walker in front of him/her and was pulling Resident #104's walker behind him/her in order to guide the Resident #104 around the hall.
NOTE:
-Record review of Resident #86's quarterly MDS dated [DATE] showed the resident was cognitively intact.
During an interview on 3/20/23 at 9:48 A.M. the resident said:
-He/she found it difficult to get help around the facility.
-He/she was blind and the facility staff do not set up his/her meals for him/her and when in the dining room. Resident #86 was the only one that helped him/her set up the meals.
Record review of the resident's care plan dated 3/21/23 showed:
-The resident had an Activities of Daily Living (ADLs) self-care performance deficit.
-The resident was accompanied by Resident #86 for ambulation to and from activities.
-The resident was independent with eating with setup help for eating.
Observation on 3/21/23 at 9:21 A.M. showed Resident #86 guiding the resident down the hall to go out to smoke.
During an interview on 3/21/23 at 9:21 A.M. the resident said he/she was angry because the smoking door was always crowded with other residents making it very difficult to get around.
Observation on 3/21/23 at 1:04 P.M. showed:
-The resident's meal was wrapped and placed in front of the resident.
-Resident #86 set up the meal for the resident.
--Resident #86 unwrapped the resident's plate.
--Then he/she took the resident's hamburger and put mayonnaise on it.
--He/she placed the hamburger back on the tray and told the resident where all of his/her food was.
--The staff in the dining room did not assist the resident.
During an interview on 3/28/23 at 2:13 P.M. Certified Nursing Assistant (CNA) D said:
-When he/she went down the hall to check on residents, he/she would ask the resident if he/she needed anything.
-In the past he/she had helped the resident with laundry and toileting.
-He/she had not been told by the resident that he/she was having difficulty in getting help.
-He/she had heard of complaints made by the resident about not getting help.
-He/she felt like the facility depended on Resident #86 to assist the other resident.
-He/she felt like the facility should not be making Resident #86 responsible for the other resident's care.
During an interview on 3/28/23 at 1:05 P.M. Licensed Practical Nurse (LPN) D said:
-He/she was new to the facility and he/she knew about the care of the resident was based on what the resident told her.
-He/she helped the resident when he/she was able.
During an interview on 3/28/23 at 1:39 P.M. LPN B said:
-The resident admitted to the facility before Resident #86.
-Before Resident #86 arrived the CNAs were the ones that would help the resident around.
-The CNAs would help the resident with meal set-up, guide him/her around the facility, and give assistance in the shower.
Observation on 3/28/23 at 2:11 P.M. showed the resident receiving guide from Resident #86 to get back to his/her room.
During an interview on 3/28/23 at 2:13 P.M. the resident said he/she felt like the facility depended on Resident #86 to meet his/her care needs.
During an interview on 3/28/23 at 2:32 P.M. Resident #86 said:
-He/she felt like the facility was depending on him/her to set up the resident's food during meal times.
-The facility would just set the resident's food in front of him/her and not tell the resident that the food was there or where the food was at.
-He/she went out to appointments with the resident because he/she felt like he/she knew more about the resident than the rest of the staff.
-He/she felt like the staff did not have the time to take the resident anywhere around the facility.
During an interview on 3/29/23 at 2:05 P.M. the Director of Nursing (DON) said:
-He/she would expect the staff to do the following:
--Not move things around his/her room without telling the resident.
--To orient the resident to his/her surroundings if the resident was unfamiliar with the surroundings.
--Put clothing in place in a system that worked for the resident.
--Setting up the resident's meals.
--Knocking on the resident's door before entry as to keep the resident's privacy and not scare the resident.
-Resident #86 should not be responsible for setting up the meals for the resident.
-The CNAs should be escorting the resident around the building and going out to appointments with the resident, not Resident #86.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure infection control practices were maintained dur...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure infection control practices were maintained during the placement of indwelling Foley catheter (a urinary bladder catheter inserted through urethra) drainage bag (catheter bag, a bag that hold drained urine) during before and after care for one sampled resident (Resident #153) who was at risk for Urinary Tack Infections (UTI - an infection of one or more structures in the urinary system) out of 30 sampled residents. The facility census was 148 residents.
Record review of the Facility Catheter Care policy revised on 6/2020 showed:
-Position the catheter drainage system and bag utilizing gravity to facilitate drainage of the urine. The collection bag (drainage bag) will be kept below the level of the bladder, including during transport and avoiding contact with the floor.
-Facility staff were to ensure the collection bag does not touch the floor at any time.
1. Record review of Resident #153's admission Face sheet showed he/she had the following diagnoses:
-Retention of urine.
-Cancer of the kidney.
-Urinary tract infection diagnosed on [DATE].
Record review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 2/16/23, showed he/she:
-Was severely cognitively impaired and had short term and long term memory problems.
-He/she was able to understand others and make his/her needs known.
-Required total assistant for staff for all cares and transfer.
-admitted with indwelling catheter.
Record review of the resident's Physician Order Sheet (POS) dated 3/2023 showed:
-Indwelling Catheter 16 French (Fr) 10 milliliter (ml) balloon. Indwelling Catheter Indication for Urinary Retention (order on 2/22/23).
-Indwelling Catheter Care and check catheter anchor placement to prevent excessive tension on the catheter. Keep tubing free of kinks and positioned below level of bladder. Monitor every shift and as needed (Ordered 2/22/23).
Record review of the resident's Foley catheter care plan dated 3/6/23 showed:
-The resident will remain free from catheter-related trauma through review date.
-Facility staff were to observe for potential complications involving catheter occlusion (decreased or no output), catheter migration (catheter movement), and skin breakdown at insertion site. Notify licensed nurse if any complications observed.
-Monitor and document intake and output as per facility policy.
-Nursing staff were to monitor for signs and symptoms (s/sx) of discomfort on urination and frequency.
-Facility care staff were to monitor and document for pain or discomfort due to catheter.
-Monitor/record/report to doctor for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns.
-Provide catheter care every shift.
Record review on the resident's Nursing Note dated 3/18/23 at 4:42 P.M. showed:
-The resident noted to have very dark red blood in his/her catheter bag and tubing.
-The catheter was flushed and ran almost clear for a short time, then started bleeding in catheter bag again.
-Notified Nurse Practitioner (NP) and received orders to send to hospital for evaluation and treatment
-Nurse had notified resident spouse of his/her transfer to hospital.
-The resident left the facility by ambulance on 3/18/23 at 4:30 P.M.
Record review of the resident's nursing notes dated 3/18/2023 at 9:42 P.M. showed:
-The resident had returned from hospital with new physician's order for Cefpodoxime (antibiotic) 200 milligrams (mg), 1 tab every 12 hrs for 14 doses for UTI.
-Nursing sent the prescription by fax to the facility pharmacy.
Observation on 3/27/23 at 7:50 A.M. of the resident showed:
-The resident's bed was in the lowest position, within inches from the floor.
-The resident's catheter drainage bag was attached to the bed frame and the bottom of the bag was lying on the ground on top of the fall mat without a barrier.
-Observed a empty bath basin located underneath the resident's bed.
Observation on 3/28/23 at 10:18 A.M., of the resident's wound care showed:
-His/her bed was in the lowest position, within inches from the floor.
-The resident's catheter drainage bag was attached to the bed frame and the bottom of the bag was lying on the ground on top of the fall mat without a barrier.
-Certified Nursing Assistant (CNA) O, Licensed Practical Nurse (LPN) E and LPN F assisted in the resident's care.
-The resident's catheter drainage bag was placed on the bed toward the foot of the bed and level with the bladder.
-After the resident's care was completed, facility staff had placed drainage bag below the bladder hooked onto the bottom left side of the bed frame.
-When they lowered the resident bed to ground the catheter bag was touching the fall mat without a barrier.
During an interview on 3/28/23 at 10:25 A.M., LPN E and LPN F said:
-The resident's catheter bag should have been kept below the resident's bladder and not placed on top of bed level with the bladder.
-LPN F said he/she placed the catheter bag on top of bed so it would not pull while repositioning the resident.
-Should have not been laid at foot of the bed at the level of the bladder while performing resident's cares.
-The placement of the catheter bag should not be touching the floor.
During an interview on 3/29/23 at 9:20 A.M., Certified Medication Technician (CMT) D said:
-Foley catheter should be hooked on bottom bed rail and catheter bag should not be touching the ground.
-He/she would place the resident's Foley catheter bag below the resident bladder during cares and placement.
-If the resident's bed was in lowest position to ground, he/she would place a barrier underneath the bag or would use a bath basin to place the catheter bag in.
During an interview on 3/29/23 at 2:05 P.M., the Director of Nursing (DON) said:
-Catheter drainage bag placement during wound care or personal cares, should be kept below the bladder and placed on side turn to (other side of the bed).
-Catheter drainage bag should never be laid on the bed during care or for extended period of time.
-The resident catheter bag should never touch the ground.
-Would expect facility care staff to ensure have some type barrier when bed in lowest position and to be monitoring catheter bag placement during rounds by any staff, CNA or nursing staff.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure the appropriate care was completed during enteral feeding (tube feeding- the delivery of nutrients through a feeding t...
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Based on observation, interview, and record review, the facility failed to ensure the appropriate care was completed during enteral feeding (tube feeding- the delivery of nutrients through a feeding tube directly into the stomach, duodenum (first part of small intestine), or jejunum (middle part of the small intestine)) for one sampled resident (Resident #97) out of 30 sampled residents and nine supplemental residents. The facility census was 148 residents.
A policy for tube feeding was requested and not received at the time of exit.
1. Record review of Resident #97's undated face sheet showed he/she was admitted to the facility with the following diagnoses:
-Cerebral Infarction (stroke- a disruption of blood flow to the brain).
-Unspecified Protein-Calorie Malnutrition (lack of proper nutrition).
-Acute on Chronic Respiratory Failure (a short term condition turning into a long term condition in which the lungs cannot provide enough oxygen to the blood).
Record review of the resident's Physician Order Sheet (POS) dated March 2023 showed:
-Nothing by Mouth (NPO) indicating the resident could not eat any food through his/her mouth.
-Enteral Feed, every shift Jevity 1.5 (a fiber-fortified tube feeding formula) at 70 milliliters (ml) per hour for 22 hours per day.
-Elevate Head of Bed (HOB) 30 to 45 degrees at all times during feeding and for at least 30-40 minutes after feeding is stopped.
Observation on 3/20/23 at 11:39 A.M. showed the resident was lying flat on his/her back while his/her tube feeding was running.
Observation on 3/21/23 at 9:27 A.M. showed the resident was lying flat on his/her back while his/her tube feeding was running.
Observation on 3/23/23 at 10:20 A.M. showed:
-The resident was lying on his/her back at an approximate angle of 15-20 degrees while his/her tube feeding was running.
-The resident's tube feeding bottle was undated.
Observation on 3/28/23 at 10:42 A.M. showed the resident's water bolus bag and tubing was dated 3/27/23 with no time included.
During an interview on 3/28/23 at 12:29 P.M. Certified Nursing Assistant (CNA) D said:
-A resident receiving tube feeding should be positioned at a 45 degree angle.
-If he/she found a resident not in the correct tube feeding position he/she would get the resident in the correct placement.
-Before repositioning a resident with tube feeding he/she would ask the nurse if the tube feeding needed to be turned off before repositioning.
During an interview on 3/28/23 1:08 P.M., Licensed Practical Nurse (LPN) D said:
-A resident receiving tube feeding should be positioned on his/her back at a 30 degree angle.
-He/she would reposition the resident if he/she found the resident in the incorrect position for tube feeding.
-If he/she saw a resident's tube feeding tubing unlabeled (with date and time) he/she would get new tubing.
-Tube feeding tubing needs to be replaced every 24 hours or after the bottle of tube feeding is empty.
During an interview on 3/28/23 at 1:34 P.M. LPN B said:
-A resident receiving tube feeding should be positioned at a 90 degree angle.
-If a resident needed care when tube feeding is running then that care taker would need to get the nurse to turn off the tube feeding before care could be given.
-If he/she found a resident not in the correct position for tube feeding he/she would re-position the resident and assess them for aspiration.
-He/She would assess the resident's lung sounds, check the abdomen, and see if the resident was nauseous.
During an interview on 3/29/23 at 9:11 A.M. Certified Medication Technician (CMT) D said:
-A resident receiving tube feeding should be positioned up in bed at a 90 degree angle.
-If he/she found a resident receiving tube feeding in the incorrect position he/she would reposition the resident, then go get a nurse to assess the resident.
During an interview on 3/29/23 at 2:05 P.M. the Director of Nursing (DON) said:
-When a resident is receiving tube feeding the HOB needs to be at minimum a 30 degree angle.
-He/she would expect staff to reposition a resident receiving tube feeding if found in the incorrect position.
-He/she would expect staff to stop the tube feeding, reposition, and get a nurse to assess the resident before tube feeding could resume.
-He/she would expect the nurses to assess lung sounds after a resident receiving tube feeding was found in the incorrect position.
-He/she expected the tube feeding bottle and tube feeding tubing to be dated and timed.
-He/she would expect a nurse to dispose of the tubing/tube feeding bottle if the nurse found them undated or untimed.
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 follow physician's orders for obtaining and recording ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow physician's orders for obtaining and recording weights and monitoring the fistula (a procedure that connects an artery to a vein that allows blood to pass freely) for one sampled resident (Resident #114) who received dialysis (procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) treatments out of 30 sampled residents. The facility census was 148 residents.
1. Record review of Resident #114's Face Sheet showed he/she was admitted on [DATE] with diagnoses including heart failure, diabetes, hepatitis (a disease that attacks the liver), human immunodeficiency virus (a virus that attacks the body's immune system) and end stage renal disease (ESRD- permanent kidney failure that requires a kidney transplant or scheduled dialysis).
Record review of the resident's Care Plan dated 8/2022, showed the resident received dialysis on Tuesday, Thursday and Saturday at 11:00 A.M. It showed the resident had a self-care deficit and needed assistance. Interventions showed staff would:
-Check and change dressing daily at his/her access site. Document.
-Do not draw blood or take blood pressure in his/her arm with the fistula.
-Monitor the resident for dry skin and apply lotion as needed.
-Monitor the resident's intake and output.
-Monitor labs and report to the physician as needed.
-Monitor, document and report to the physician any signs/symptoms of depression and obtain orders for a mental health consult if needed.
-Monitor, document and report any signs/symptoms of infection to the access site: redness, swelling, warmth or drainage.
-Monitor, document and report signs/symptoms of renal insufficiency: changes in level of consciousness, changes in skin, changes in heart and lung sounds.
Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 2/8/23, showed the resident:
-Was alert oriented and cognitively intact.
-Had no behaviors.
-Only needed supervision with transfers, mobility, bathing, dressing, eating and toileting.
Record review of the resident's Physician's Order Sheet (POS) dated 3/2023, showed:
-The resident was to receive dialysis on Tuesday, Thursday, and Saturday at 11:00 AM (6/3/21).
-Nursing staff was to check the resident's fistula site every day and night shift daily for bruit (a rumbling sound that indicates good blood flow) and thrill (a rumbling sensation that indicates good blood flow), If bruit and thrill are not present notify the physician immediately.
-Nursing staff was to check the resident's fistula daily for bleeding and signs and symptoms of infection and notify the physician if present (6/3/21).
Record review of the resident's Treatment Administration Record (TAR) dated 3/2023, showed physician's orders to check the resident's fistula site daily for bleeding and signs and symptoms of infection, notify the physician if infection is present, check the resident's fistula site daily on the day and evening shift for bruit and thrill and notify the physician immediately if bruit and thrill is not present, and record the resident's weights after every dialysis visit on Tuesday, Thursday and Saturday. The TAR showed:
-The nurse documented 'No they did not check the resident's fistula on 3/4/23, 3/5/23, 3/8/23, 3/19/23, 3/22/23, 3/23/23, 3/25/23, 3/26/23, and 3/27/23 (9 days).
-The nurse documented yes they checked the resident's fistula on 3/13/23 and 3/18/23.
-On all days that were not marked with a Y or N there was an x' documented and a number 9 (9 was code to check the progress notes).
-The progress notes on those dates that were documented with a 9, showed there was no documentation showing what occurred on those dates or why the resident's fistula was not checked.
-The nurse documented the resident's weight on 3/18/23, 3/23/23 and 3/25/23. All other dates the weight was supposed to be documented (eight days) showed a x and the number 9.
-On the dates documented with an x and 9, there was no documentation showing why the weights were not performed and documented.
-Regarding the physician's order to check the resident's thrill and bruit on the day and evening shift daily, documentation showed the nursing staff checked the thrill and bruit on 3/13/23 and 3/18/23 on the day shift and on 3/4/23, 3/5/23, 3/8/23, 3/17/23, and 3/27/23 on the night shift. All other dates were marked N showing the staff did not check or were marked with a x and 9. There was no documentation showing why the physician's orders were not followed on those dates.
-The TAR showed the nursing staff did not consistently record that they were checking the resident's fistula daily as ordered or that they were documenting the resident's weights per the physician's order.
During an interview and observation on 3/27/23 at 11:07 A.M., the resident was sitting in a chair interacting with a peer. He/she stood up and ambulated to his/her room without an assistive device. Observation of the resident's fistula site in his/her left upper arm showed it was clean and had no redness or swelling and the resident denied pain in the area. The resident said:
-He/she had never had any issues with his/her fistula and at the hospital where he/she received dialysis, they performed a fistulagram (an x-ray procedure to look at the blood flow and check for blood clots or other blockages in your fistula) to ensure there are no blockages.
-When he/she goes to dialysis, he/she takes a dialysis book with him/her and the nursing staff take his/her vital signs before he/she leaves and document it in the book.
-When he/she leaves dialysis, the nursing team will return documentation in the dialysis book and he/she will bring the book back to the facility and give it to the nurse.
-None of the nurses checked his/her fistula for patency daily or on the day and evening shift. Sometimes someone will check it but this is not routine.
-He/she received weights monthly, but no one weighed him/her after each dialysis treatment.
During an interview on 3/27/23 at 12:13 P.M., Registered Nurse (RN) D said:
-He/she has seen and assessed the resident's fistula site.
-He/she assessed the site daily during his/her shift and before he/she went to dialysis.
-He/she usually documented that the site was assessed in the resident's TAR.
-The nurses were supposed to follow the physician's orders for assessing the resident's fistula and monitoring his/her weights.
During an interview on 3/28/23 at 2:27 P.M., RN D said:
-If there is a Y or checkmark, it means the nurse checked the fistula, if there is an N documented, it was not completed. If there is an X it is accompanied by a 9, which means there should be a note in the nursing notes documenting why they did not complete the check of his fistula site.
-The nurses should also document an 'N' if there is no infection at the site and Y if there is infection at the site. If there is an X, they should show documentation in the notes that show why they were unable to complete the check of his/her fistula site.
-After looking at the resident's TAR dated 3/2023, he/she said not everyone is documenting any notes for why they were not checking the resident's fistula site as ordered, and they weren't documenting correctly on the TAR.
-Regarding the weights, the resident is only supposed to be weighed on the days he/she goes to dialysis.
-The nurse is supposed to weigh the resident and document the weight on the TAR with his/her initials showing who obtained the weight.
-On the days that the resident does not go to dialysis, they document an X to show no weight was obtained.
-After looking at the resident's TAR dated 3/2023, he/she said not everyone was documenting the resident's weights as they should.
During an interview on 3/29/23 at 2:05 P.M., the Director of Nursing (DON) said:
-He/she expects physicians orders to be followed for assessing the resident's fistula site and monitoring his/her weights.
-The charge nurse is responsible for completing the assessment of the resident's fistula according to the physician's orders and documenting on the TAR.
-When the resident is weighed, the Charge Nurse should document the weight on the TAR.
-The Unit Manager was responsible for ensuring the nurses were monitoring and documenting the resident's fistula and monitoring the site daily.
-He/she was not aware they were not monitoring the resident's dialysis site and weights as ordered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to provide pharmacy medication regimen review (MRR) for 11 out of 12 months for one sampled resident (Resident #58) out of 30 sampled resident...
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Based on interview and record review, the facility failed to provide pharmacy medication regimen review (MRR) for 11 out of 12 months for one sampled resident (Resident #58) out of 30 sampled residents. This practice had the potential to effect each resident's physical and mental well-being. The facility census was 148 residents.
Record review of the facility's Documentation and Communication of Consultant Pharmacist Recommendations, dated August 2020, showed:
-The consultant pharmacist worked with the facility to establish a system where the consultant pharmacist observed and recommended medication therapies for residents.
-Those recommendations were communicated to facility authority and responded to in a timely manner.
-Records of the consultant pharmacist's observations and recommendations were made available to nurses, prescribers and the care planning team, which included:
--Documentation of the date each MRR was completed and notated of findings.
--Potential or actual medication-related problems, irregularities and other MRR findings appropriate for prescriber and/or nursing review.
--Problems requiring the immediate attention of the prescriber or designee was contacted by the consultant pharmacist and the prescriber response was documented on the consultant pharmacist review record or elsewhere in the resident's medical record.
-Timing of these recommendations should enable a response prior to the next MRR.
1. Record review of Resident #58's face sheet, undated showed:
-The resident was diagnosed with:
--Unspecified dementia (progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses).
-Generalized anxiety (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus).
-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).
Record review of the resident's annual Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 9/26/22, showed:
-The resident scored a one on the Brief Interview for Mental Status (BIMS), an assessment tool that shows a score between 3 and 15 which shows the resident's mental status. This tool helps determine the resident's attention, orientation and ability to register and recall new information. These items are crucial factors in care planning decisions.
--This showed that the resident was severely cognitively impaired.
Record review of the resident's physician orders (POS), dated March 2023, showed:
-The resident was ordered Seroquel (a medication that works in the brain to treat schizophrenia) tablet, 50 milligrams (mg) by mouth two times a day for schizoaffective disorder (a mental condition that causes loss of contact with reality and mood problems).
-The resident was ordered Trazodone (a medication used to treat depression, anxiety, or a combination of depression and anxiety) HCI tablet, 25 mg by mouth three times a day for depression.
Record review of the resident's Electronic Health Record (EHR) nurse progress notes showed:
-No entries in progress notes for December 2022, February 2023 or March 2023.
-No pharmacist reviews.
-No copy of the MMR for December 2022, February 2023 and March 2023 were provided.
During an interview on 3/27/23 at 2:46 P.M. the Director of Nursing (DON) said:
-He/she could not find any pharmacy reviews for this resident for the requested period of March 2022 to March 2023 other than for January 2023.
-He/she said the March 2023 MMR's were in a pile on his/her desk but had not filed them.
-A copy was requested and not provided.
-He/she would find the resident's March MMR and provide a copy.
--NOTE: a copy of the March MMR was not provided by the end of the survey.
During an interview on 3/29/23 at 2:05 P.M., the DON said:
-The consultant pharmacist visited the facility monthly.
-The consultant pharmacist sent recommendations for the Nurse Practitioner (NP).
-He/she and the NP discuss the recommendations and the NP signs off on them.
-Some recommendations were just for nursing and the NP was made aware of them then he/she updated resident's records.
-Anything with an individual resident went in the resident's chart.
-Residents who were reviewed and did not require changes or had recommendations were filed in a book kept in the DON's office.
-He/she was responsible for ensuring MMR's were completed, followed up on by physician and filed or scanned to resident's file.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0790
(Tag F0790)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed provide dental services and complete comprehensive dental...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed provide dental services and complete comprehensive dental assessment for one sample resident (Resident #154) who had poor dental health and complaint of dental pain out of 30 sampled residents. The facility resident census was 148 residents.
A policy related to dental/oral care was requested but not received at the time of exit.
1. Record review of Resident #154's admission Face sheet showed he/she was admitted to the facility on [DATE] and had the following diagnoses:
-Abnormal weight loss
-Severe protein-calorie malnutrition (is a deficiency of protein and overall energy intake)
-He/she had Medicare and Medicaid for health insurance.
Record review of resident's All-Inclusive admission with Baseline Care Plans dated 2/27/23 at 10:00 P.M. showed:
-His/her teeth were not assessed.
-He/she did not have dentures.
-He/she was inadequate at brushing his/her teeth.
-Had no indication of any dental needs.
Record review of the resident's Physician Order Sheet dated 2/28/23 showed:
-He/she had physician order for regular heart healthy precaution diet and mechanical soft texture.
-Had no documentation of physician's order for referral for oral/dental evaluation and treatment as needed.
Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 3/3/23 showed:
-He/she was cognitively intact.
-He/she had no dental issue reported.
During an interview on 3/20/23 at 2:55 P.M. the resident said:
-He/she did not have any dentures, but he/she would like to have dentures.
-He/she was losing his/her teeth, but he/she could not do anything about it until he/she got out of rehab.
-He/she was not aware of any dental services offered by the facility.
Record review of the resident's care plan dated 3/21/23 showed:
-He/she was at risk for oral/dental health problems related to his/her poor nutrition.
-Facility nursing staff were coordinate arrangements for dental care as needed and as ordered on 3/21/23.
-Consult with dietitian and change diet if problems with chewing or swallowing.
-He/she was missing some teeth.
Record review of the resident's Social Services Note dated 3/22/23 at 11:32 A.M. showed:
-The resident had the ability to recall current events and states he/she was his/her own responsible party.
-No documentation noted related to his/her dental needs.
During an interview on 3/23/23 at 10:01 A.M. Licensed Practical Nurse (LPN) B said:
-If a resident had requested to see a dentist or if a nurse sees a dental problem, he/she would put in an physician order from their standing orders for a dental referral.
-The dentist comes to the facility to see resident.
-The list of residents to be seen would be found in Social Services office.
-He/she was not aware the resident had requested to see the dentist or had any dental concerns.
During an interview on 3/23/23 at 10:14 A.M., the resident said:
-His/her teeth were all messed up and he/she needed to get set up with a dentist.
-His/her tooth on the bottom right (molar) was starting to get painful and he/she needed to have the tooth removed and get dentures.
-He/she had never asked the facility staff to see a dentist.
-He/she can still chew food and swallow with no problem.
Record review of the of most current resident's listed to see the dentist and Resident #154 was not on the list.
Observation on 3/24/23 at 8:51 A.M., of the resident showed:
-He/she was in room and breakfast tray on bedside table.
-He/she had soft diet and had eaten at least 50%-75% of his/her meal.
Record review of the resident's Social Services note dated 3/27/23 at 12:54 P.M. showed:
-The resident had been placed on the dentist list.
-He/she said had no urgent need at this time and is requesting to be on the next dentist list.
During an interview on 3/28/23 at 9:32 A.M., Social Service Designee (SSD) said:
-The facility Speech Therapist (ST) would be responsible for evaluation of the resident for any oral health concerns, then ST would let SSD know what dental issues the resident may have.
-He/she would also interview the resident for his/her wants and needs to include dental care.
-The dentist had been at the facility on 3/28/23. The resident was not listed as being seen.
-For any resident with any emergent dental needs, they would have been sent out for dental care.
-Resident #154 had not expressed any dental pain or any dental issues to him/her or reported to other facility staff.
-Any resident with Medicare would have to pay out of pocket for any dental care.
-The resident's dental list will auto-populate for those residents who need to be seen by the dentist.
During interview on 3/28/23 at 11:08 A.M., the resident said:
-He/she had told everyone (facility staff) about his/her dental needs.
-He/she had just figured out who the Social Services worker was.
-He/she does not remember any staff asking questions about his/her dental needs upon admission.
-He/she had been admitted to the short-term rehab unit.
During an interview on 3/29/23 at 2:05 P.M., Director of Nursing (DON) said:
-Resident #154 admission dental assessment had documented another issue and he/she had difficulty with chewing food.
-He/she would expect the resident to be assessed for dental care/needs upon admission by nursing staff and SSD.
-Residents on the Rehab unit (short term) would also have been offered dental screenings and care needs as requested.
-He/she would expect all residents to be assessed and monitored for dental needs by nursing staff and SSD.
-Social Services would be responsible for overall dental assessment, setting up dental appointments, and follow through with the resident's insurance carrier.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to maintain hot foods on the room trays in the sunset location and the 300 Hall at or close to 120 ºF (degrees Fahrenheit) o...
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Based on observation, interview and record review, the facility failed to maintain hot foods on the room trays in the sunset location and the 300 Hall at or close to 120 ºF (degrees Fahrenheit) on different days of the survey and failed to have a system of monitoring the temperatures of room trays in place. This practice potentially affected an unknown number of residents who received their meals towards the end of the delivery for those respective locations within the facility. The facility census was 148 residents.
1. Record review of the resident council minutes dated 2/17/23 showed:
-Weekend service for meals is terrible.
-Corporate needs to be at the resident council meeting because food carts were sitting on the halls for so long that food was cold.
The response dated 3/15/23 showed the dietary department took action to make the food more hot by making sure the plate warmers were on and that the steam tables were set to the correct temperature.
2. Observation during the lunch meal on 3/20/23 showed:
-At 12:55 P.M., showed lunch arrived on the sunset unit and was put behind the nurse station.
-At 1:35 P.M., an observation of the test tray on the sunset unit on 3/20/23 showed the following temperatures for the following hot foods: pork cutlet was 94.4 ºF, stuffing 105.0 ºF, and green beans were 89.3 ºF.
3. Observations on 3/24/23 at 8:43 A.M. through 8:46 A.M., showed the cart that was used to deliver the breakfast room trays on the 300 hall had a door which did not close tightly.
Observation with Certified Nurse's Assistant (CNA) E on 3/24/23 at 8:49 A.M., showed the dietary cart did not close after many attempts by the surveyor and the CNA E.
Observations with CNA C on 3/24/23 at 9:08 A.M., of hot food temperatures on a test tray on 300 hall during the breakfast meal on 3/24/23 showed the sausage was 100.2 ºF and the pancake was 102.7 ºF.
During an interview on 3/24/23 at 9:09 A.M., CNA C said he/she had not seen anyone from dietary come to the halls and check the food temperatures.
During an interview on 3/24/23 at 9:59 A.M., Certified Medication Technician (CMT) B said he/she had not seen anyone from dietary department go to the halls and check room trays for proper temperature.
During an interview on 3/24/23 at 10:29 A.M., the Dietary Manager (DM) said:
-He/she used to send people down the halls to check food temperatures but at that time during the last month it ( the dietary department) had been dysfunctional.
-He/she had spoken with the new Consultant Dietitian about getting new carts.
During an interview on 3/27/23 at 12:32 P.M., the Activity Director, who also conducted the resident council meetings said he/she has had several residents mention during those resident council meetings that the food was cold at various meals (breakfast, lunch and dinner).
Complaint MO00215144
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0813
(Tag F0813)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure all food items in the resident food refrigerator located on the Renew Unit, were labeled and dated. This practice poten...
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Based on observation, interview and record review, the facility failed to ensure all food items in the resident food refrigerator located on the Renew Unit, were labeled and dated. This practice potentially affected an unknown number of residents for whom food was stored in the refrigerator. The facility census was 148 residents.
Record review of The Visitor's Food Policy revised 2/2021, showed:
- Purpose: To provide residents with the option of having food prepared by the resident's family brought into the facility.
- Policy: Food may be brought to a resident by the family members, the resident's responsible party, or friends if the food is compatible with the Attending Physician's diet order.
- Procedure: If the resident desires to have food brought in by visitors, the Food and Nutrition Services staff will review the resident's diet with the visitor, and provide education regarding the resident's diet orders and safe food handling practices.
- Food from outside sources should be stored in a sealable container with the resident's name and date it was brought to the facility.
- Perishable food requiring refrigeration will be discarded after two (2) hours at bedside and if refrigerated, it will then be labeled, dated and discarded after 48 hours.
1. Observation of the resident Use Refrigerator on the Renew Unit with Licensed Practical Nurse (LPN) B on 3/20/23 from 3:19 P.M. through 3:24 P.M. showed:
- Items such as a bottle of relish, a container of potato salad, a bag of sliced deli meat were not dated or not labeled.
- One container of mustard and miracle whip were not labeled or dated when those items were received in facility.
During an interview on 3/20/23 at 3:25 P.M., LPN B said he/she checked the items weekly but he/she was not at the facility the weekend prior to 3/20/23 and the deli meat came in that weekend.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to ensure one trash container was inside the kitchen was kept closed while it was not in use and failed to ensure the outdoor dumpster was cover...
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Based on observation and interview, the facility failed to ensure one trash container was inside the kitchen was kept closed while it was not in use and failed to ensure the outdoor dumpster was covered for several hours on 3/20/23, and to ensure that all facility staff were able to close the dumpster lid after dumping a bag of trash inside the outdoor dumpster. This practice affected the kitchen and one outdoor area. The facility census was 148 residents.
1. Observations on 3/20/23 at 8:42 A.M., 9:23 A.M. and 10:52 A.M., showed one trash container inside the kitchen, was left open throughout the lunch meal preparation and was not being used.
2. Observation on 3/20/23 at 9:39 A.M., 10:02 A.M., 11:16 A.M., and 2:13 P.M., showed the lids of the outdoor dumpster's were left open.
During an interview on 3/20/23 at 2:14 P.M., the Dietary Manager (DM) said he/she expected dietary and all facility staff to close the dumpster lids after placing trash in the dumpster's.
3. Observation on 3/29/23 from 2:37 P.M., through 2:40 P.M., showed the following:
- Certified Nurse's Assistant (CNA) J took a trash bag down the service hall to the exit door of the service hall.
- CNA J opened the exit door from the service hall to go to the dumpster's.
- The lid of the dumpster was already opened.
- CNA J threw the bag of trash into the dumpster and failed to close it.
During an interview on 3/29/23 at 2:42 P.M., CNA J said he/she was able to reach the lid to close it.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Smoking Policies
(Tag F0926)
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 one sampled resident (Resident #84) out of 30 s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one sampled resident (Resident #84) out of 30 sampled residents did not smoke cigarettes in his/her room. This practice potentially affected at least six residents who reside in adjoining rooms or rooms across the hall in the same area of the hall as that resident. The facility census was 148 residents.
Record review of the facility's smoking policy revised in 3/2022, showed:
- Smoking was not allowed anywhere inside the facility.
- The facility discouraged smoking by residents and ensured that those residents who choose to smoke did so safely.
- All smoking materials would be stored in a secure area to ensure they are kept safe.
- Cigarette butts were disposed of only in provided receptacles.
1. Record review of Resident #84's Face sheet showed he/she was admitted on [DATE], with diagnoses which include:
-Acute and chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) with hypoxia (is low levels of oxygen in your body tissues).
-Unsteadiness on his/her feet,
-Hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) with heart failure (condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen).
-Vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain).
Record review of the resident's annual Minimum Data Set (MDS--a federally mandated assessment tool completed by the facility for care planning), dated 2/23/23, showed the resident had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS--an assessment tool that shows a score between 3 of 15 which shows the resident's mental status. This tool helps determine the resident's attention, orientation and ability to register and recall new information. These items are crucial factors in care planning decisions.) score of 7.
Record review of the resident's care plan related to smoking, dated 2/23/23, showed:
-The resident smoked and has been educated on/and signed smoking policy.
-The resident had risky behavior related to smoking in his/her room and is non-compliant with smoking policy.
-The resident will not sufferer injury from unsafe smoking practices through the review date.
-Cigarettes and lighter will be stored at nurse's station.
-Instruct resident about smoking risks and hazards and about smoking cessation aids that are available.
-Instruct resident about the facility policy on smoking: locations, times, safety concerns.
-Notify charge nurse immediately if it is suspected resident has violated facility smoking policy.
-The resident can smoke unsupervised.
Record review of the policy signed by the resident dated 2/27/23, showed:
-Smoking by residents is only permitted in designated facility area and at designated times regulated by the facility.
-There is to be no smoking inside of building at any time.
-Smoking will be monitored by the staff during the 15 minute (min.) smoking times.
-Residents will not be allowed to smoke during off times without supervision of staff.
-Smoking supplies (including, but not limited to tobacco, matches, lighters, lighter fluid, etc.) will be labeled with the patient's name, room number, and bed number, maintained by staff and stored in a suitable cabinet kept at the nursing station if the resident fails to follow smoking policy.
-If the patient is cognitively and physically able to secure all smoking materials, the facility may allow him/her to maintain his/her own tobacco or electronic cigarette product in a locked compartment.
-Facility leadership will consider special circumstances on an individual basis.
-It may be necessary to counsel patients or responsible parties who violate the smoking policy, violation of this policy may compromise the safety of all residents and staff due to potential negative consequences that can occur. For this reason, any violations will result in the following actions:
--1st offense: A written warning and counseling session with the understanding that continued violation will result in further action.
--2nd Offense: The facility will notify your attending physician and a care conference will occur to discuss further consequences, which may include discharge to a more appropriate setting.
--3rd offense: Due to safety risks posed to facility staff and other residents including harboring flammable materials and paraphernalia around medical equipment. The facility may initiate discharge based on resident safety concerns consistent with state and federal law.
Observation with the Maintenance Director on 3/27/23 at 11:05 A.M., showed the following in the resident's room:
-The presence of ashes and two cigarette butts in trash container.
-The smell of cigarette smoke in the resident's room.
-The presence of two lighters at the resident's bedside table.
During an interview on 3/27/23 at 11:08 A.M., the resident said he/she did not smoke in his/her room that day.
During an interview on 3/28/23 at 2:01 P.M., the resident said:
-He/she smoked a cigarette in his/her room on 3/27/23.
-No one told him/her that smoking in his/her room was against policy.
Observation on 3/28/23 at 2:02 P.M., showed a lighter and two cigarettes on the resident's night stand.
During an interview on 3/28/23 at 2:05 P.M., Certified Nurse's Assistant (CNA) B said:
- He/she learned in report that nursing staff had caught the resident smoking in his/her room in the past.
- Some residents do not understand that some residents used oxygen and the hazards of smoking near oxygen.
- This was the first facility he/she had worked at where residents can kept their cigarettes and lighters.
During an interview on 3/28/23 at 2:11 P.M., the Director of Nursing (DON) said he/she did not remember the resident having smoking issues in the past.
During a phone interview on 4/5/23 at 2:35 P.M, the DON and the Administrator both said yes, they expected the residents to follow the facility's smoking policy policy.
During an interview on 3/28/23 at 2:16 P.M., the Administrator said when he/she walked the halls, he/she had smelled cigarettes but assumed the resident had just came in from smoking outside.
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
Deficiency F0554
(Tag F0554)
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 provide oversight for three sampled residents, who di...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide oversight for three sampled residents, who did not have orders for self-administration of medications (Resident #23, Resident #24 and Resident #96), when staff left the residents medications at the bedside, left the room, and did not watch to ensure the residents took their medications out of 30 sampled residents. The facility census was 148 residents.
Record review of the facility's undated policy Medication Administration, showed:
-Medication would be administer by a licensed nurse per the order of an attending physician or licensed practitioner.
-Medications would not be left at bedside.
-The licensed nurse would remain with the resident until the medication was actually swallowed.
-When an as needed medication was given, it would be documented on the Medication Administration Record (MAR).
1. Record review of Resident #23's face sheet showed he/she was admitted to the facility with the following diagnoses:
-Metabolic encephalopathy (alterations in the brain caused by a chemical imbalance).
-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).
-Acute respiratory failure with hypoxia (an impairment of gas exchange between the lungs and the blood causing a decreased level of oxygen in the blood).
-Muscle weakness (a lack of muscle strength).
-Dysphasia (a difficulty swallowing).
-Dyspnea (difficulty breathing).
-Epilepsy (a disorder in which nerve cell activity in the brain are disturbed, causing seizures).
-Depression.
Record review of the resident's undated care plan showed:
-He/she had a physician's order for unsupervised self administration of the following medications:
-Hemorrhoid cream and Imodium (a medication to relieve diarrhea).
-Staff was to monitor the resident's self administration.
-He/she had behavior problems and was prone to hallucinations.
-Staff was to administer medications as ordered.
-He/she had impaired cognitive function or impaired thought processes related to metabolic encephalopathy and cognitive communication deficit.
-Staff was to cue, reorient and supervise as needed.
Record review of the resident's Minimum Data Set (MDS- a federally mandated assessment tool completed by the facility for care planning) re entry dated 3/13/23 showed:
-The resident's Brief Interview for Mental Status (BIMS) score was 15 out of 15 indicating he/she was cognitively intact.
-The resident needed limited assistance to eat.
Record review of the resident's March 2023 Physician's Order Sheet (POS) showed the following orders:
-AmoxK 500/125 milligram (mg) every 12 hours (Augmentin - medication used to treat infections).
-Bumetanide 1.0 mg daily (medication used to treat fluid retention and high blood pressure).
-Metoclopram 5.0 mg twice daily (medication used to treat nausea and vomiting).
-Divalproex 500 mg twice daily (medication used to treat seizures).
-Glipozide 5 mg daily (medication used by Diabetics that lowers the blood sugar).
-Metformin 1000 mg twice daily (medication used to lower blood sugar).
-Venlafaxine 37.5 2 tablets daily (medication used to treat anxiety).
-Gabapentin 400 mg three times a day (medication used to treat nerve pain).
-Aspirin 81 mg daily (medication used to reduce the risk of strokes by thinning out the blood).
-Lactobacilillus daily (medication used to help absorb foods).
-Vitamin D daily (used to help the body absorb and retain calcium and phosphorus for building bones).
-There was no order to allow the resident to self administer those medications.
Observation and interview on 3/27/23 at 10:40 A.M. showed the resident had a cup full of medication at his/her bedside.
-There were 11 pills in the cup.
-The resident said they were his/her morning medications that the nurse had left for him/her to take.
-The nurse had left the pills at his/her bedside about 30 minutes ago.
-He/she had requested the nurse to leave them at beside for him/her to take when he/she was ready.
-Nursing staff leaves his/her medications at bedside often.
During an interview on 3/27/23 at 10:50 A.M. Certified Medication Technician (CMT) B said:
-The resident did not have an order to leave his/her medications at bedside.
-The resident always argues with him/her every day about leaving the resident's medications at his/her bedside.
-He/she had left the resident's morning medications at bedside.
-He/she has told the nurse about the resident insisting for him/her to leave the medication at the resident's bedside.
-He/she knew he/she was not supposed to leave the medication at the resident's bedside.
-He/she was supposed to watch the resident take the medication.
During an interview on 3/27/23 at 11:00 A.M. Registered Nurse (RN) D said:
-They have always had problems with the resident wanting to keep his/her medications at bedside to take the medications when he/she wanted to.
-The resident would need to have a physician's order to keep the medications at bedside so the resident could self administer the medication when he/she wanted to take the medications.
-He/she did not think that the resident had an order to self administer his/her morning medications.
-He/she has given the resident education about the need for nursing staff to watch him/her take the medication.
-The resident is very argumentative about keeping the medications to take when he/she wants to take them.
During an interview on 3/27/23 at 11:10 A.M. CMT B said:
-The resident received the following medications this morning:
-AmoxK 500/125 mg.
-Bumetanide 1.0 mg daily.
-Metoclopram 5.0 mg.
-Divalproex 500 mg.
-Glipozide 5 mg daily.
-Metformin 1000 mg.
-Venlafaxine 37.5 2 tablets.
-Gabapentin 400 mg.
-Aspirin 81 mg.
-Lactobacilillus.
-Vitamin D.
2. Record review of Resident #24's face sheet showed he/she was admitted to the facility with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD - a group of lung diseases that block airflow and make it hard to breathe).
Record review of the resident's undated care plan did not show he/she could self administer his/her medications.
Record review of the resident's Annual MDS assessment dated [DATE] showed:
-His/her BIMS score was 15 out of 15 indicating he/she was cognitively intact.
-He/she needed help setting up his/her meal tray to eat.
Record review of the resident's January 2023 Treatment Administration Record (TAR) showed:
-Proventil Aerosol Solution (used to treat brochospasms) 108 microgram (mcg) 2 puffs inhale orally every six hours as needed for wheezing or shortness of breath, dated 10/4/22.
-No documentation it was given in January.
Record review of the resident's February 2023 TAR showed:
-Proventil Aerosol Solution 108 mcg 2 puffs inhale orally every six hours as needed for wheezing or shortness of breath, dated 10/4/22.
-No documentation it was given in February.
Record review of the resident's March 2023 TAR showed:
-Proventil Aerosol Solution 108 mcg 2 puffs inhale orally every six hours as needed for wheezing or shortness of breath, dated 10/4/22.
-No documentation it was given in March.
Record review of the resident's March 2023 POS showed the following order:
-Proventil Aerosol Solution 108 mcg 2 puffs inhale orally every six hours as needed for wheezing or shortness of breath, dated 10/4/22.
-There was no order for the resident to self administer the medication.
Observation and interview on 3/28/23 at 8:42 A.M. showed:
-The resident was observed with a Proventil inhaler in his/her possession.
-He/she took two puffs from the inhaler.
-He/she uses it when he/she needs it almost every day.
-He/she had got the inhaler from the nurse or CMT.
-He/she did not know if the physician had written an order for him/her to keep at bedside.
-He/she stuck the inhaler in his/her pocket.
During an interview on 3/28/23 at 9:00 A.M. CMT B said:
-He/she had seen the inhaler at the resident's bedside.
-He/she did not think the resident had an order for self administration of the inhaler.
-He/she did not know how you would know if the resident used it.
-If the resident used the inhaler it would be documented on the TAR.
During an interview on 3/28/23 at 9:20 A.M. RN D said:
-He/she may have seen the resident's inhaler at his/her bedside.
-The resident would have had to been evaluated to leave medications at bedside for him/her to self administer.
-The resident did not have a physician's order to keep the inhaler at bedside.
-Documentation would have been done on the TAR if the medication was given.
3. Record review of Resident #96's Face Sheet showed he/she was admitted on [DATE] with diagnoses including respiratory failure, COPD, obesity, heart failure, pain, anxiety disorder, depression, iron deficiency and sleep apnea (a common disorder in which you have one or more pauses in breathing or shallow breaths while you sleep). The Face Sheet showed the resident was his/her own responsible party.
Record review of the resident's admission MDS dated [DATE], showed the resident:
-Was alert oriented and cognitively intact.
-Had no behaviors and was not resistive to cares.
-Needed extensive assistance of one person with bed mobility, transfers, bathing, dressing, toileting and did not walk.
Record review of the resident's POS dated 3/2023, showed physician's orders for:
-Gabapentin 600 mg give two times daily for neuropathy pain (9/23/22).
-Metformin 500 mg two times daily for diabetes (9/23/22).
-Setraline (Zoloft) 25 mg one time daily for depression.
-There were no physician's orders stating the resident could self-administer these medications.
Observation and interview on 3/20/23 at 1:25 P.M., showed the resident was awake, alert and oriented, sitting up in his/her bed and wearing oxygen. His/her call light was within reach and his/her tray table was also within reach with beverages and other personal items on top of it. There was also a small medicine cup containing three pills that was also sitting on the resident's tray table. At 1:41 P.M., CMT C entered the resident's room, picked up the small cup with the pills inside and told the resident that he/she could not take the medication now because it was too late to take them. CMT C said:
-He/she identified the three pills that were in the cup as Metformin, Gabapentin and Zoloft.
-He/she knew that he/she was not supposed to leave pills/medication at the resident's bedside, but he/she had been through this with the resident before (the resident was not wanting to take his/her medication at the time he/she came in to administer it) and the resident's behavior was well documented in the resident's nursing notes.
-He/she delivered the pills to the resident this morning and the resident did not want to take them at the time, so he/she left the medication on the resident's tray table and the resident said he/she would take them.
-When he/she came back to see if the resident took the medication, he/she saw that they were still sitting on his/her tray table. Since the resident had not taken the medication, he/she picked the medications up because it was too late for him/her to take them.
-The resident did not have an order to self-administer these medications.
-The resident had accused him/her of being discriminatory against him/her for trying to make the resident take his/her pills in front of him/her and stated he/she was not a child.
-He/she has explained to the resident several times hat he/she was not trying to force the resident take the pills, but he/she has also told the resident that he/she was not supposed to leave the medication in his/her room, but the resident had been demanding that he/she do so anyway.
-He/she spoke with the nurses and nursing administration about it and they said the resident may not want to be watched so he/she was allowed to leave the resident's medication at bedside so the resident could take his/her pills independently, and to check on the resident periodically to see if the resident took the medication.
During an interview on 3/27/23 at 9:50 A.M., RN F said:
-All nursing staff should pass the resident's medications according to the physician's orders and watch the resident take their medications.
-There should be no medications left at the resident's bedside.
-The resident did not have a physician's order to self-administer any pills that were prescribed.
-If the resident was speaking with someone while the nursing staff came in to give medications, he/she would expect the nursing staff to ask if he/she wanted them to come back later, or she/he would expect the nursing staff to give the resident his/her medication with water and stay until the resident took them.
-The resident can be non-compliant at times and sometimes grumpy, but he/she has passed the resident's medications and has not had problems.
-He/She had not received any reports from nursing staff saying that the resident routinely refused his/her medications.
-He/she has not instructed any of the nursing staff to leave the resident's medications at his/her bedside for him/her to self-administer he/she was ready to take them.
-The resident is alert and oriented and probably could self-administer his/her medications, but they had not assessed the resident to self-administer them.
-The resident did not have any physician's orders to self-administer Gabapentin, Zoloft or Metformin and the nursing staff should not have left his/her medications at bedside for any reason.
-After looking in the resident's nursing notes, he/she said they do not have any nursing notes showing there had been problems with the resident not wanting the nursing staff to observe him/her to take his/her medications or that they could leave the resident's medications at the resident's bedside.
-The resident's care plan did not show a care plan showing the resident had any behaviors regarding the resident wanting staff to leave her medications at bedside or that it was okay to leave the resident's medications at bedside.
-If they do not have a physician's order for self-administration of medications, the nursing staff cannot leave the resident's medication at bedside.
4. During an interview on 3/29/23 at 2:05 P.M., the Director of Nursing (DON) said:
-Medications that have been approved by the resident's physician can be self-administered.
-If the resident is assessed and has been approved to self-administer, the nursing staff can leave the specific medications the resident is able to self-administer at bedside.
-They would need to have a physician's order for each medication.
-Medications that do not have a physician's order to self-administer cannot be left at the resident's bedside for any reason.
-He/she expected the nursing staff to administer and watch the resident take his/her medication. He/She said there is no reason the staff should leave the med at bedside and come back later.
-If a resident does not want to take their medication at the time the nursing staff is ready to administer it, nursing staff is expected to take the medication out of the room and notify the Charge Nurse or the Unit Manager.
-The nursing staff should document if the resident refuses to take the medication in the resident's electronic record.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain oscillating fans in resident use areas (the Sunset nurse's s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain oscillating fans in resident use areas (the Sunset nurse's station the 300 Hall shower room) free from a buildup of dust, and to maintain the sprinkler heads and the ceiling vent in the Main Dining room (MDR) free from a buildup of dust. This practice potentially affected at least 50 residents who used or resided in those areas of the facility. The facility census was 148 residents.
1. Observations with the Maintenance Director on 3/22/23 at 10:02 P.M., showed a heavy buildup of dust on the fan at the Sunset Nurse's Station.
2. Observations with the Maintenance Director on 3/24/23, showed:
- At 12:34 P.M., a buildup of dust on the sprinkler heads in the MDR.
- At 12:36 P.M., a buildup of dust on a ceiling vent in the MDR.
During an interview on 3/24/23 at 12:37 P.M., the Maintenance Director said he/she needed to to clean those sprinkler heads because they have not been cleaned in a long time.
3. Observation with the Maintenance Director on 3/27/23, showed:
- At 10:02 A.M., a buildup of dust was on the blades of a fan in resident room [ROOM NUMBER].
- At 10:19 A.M., there was a buildup of dust on the sprinkler head in resident room [ROOM NUMBER].
- At 11:42 A.M., there was a heavy buildup of dust on the fan in the 300 Hall shower room.
During an interview on 3/27/23 at 10:03 A.M., the Maintenance Director said the housekeeping department needed to clean the fans.
4. During an interview on 3/29/23 at 10:38 A.M., Housekeeper A said he/she had been told to the clean the fans once per week but after seeing the fan in the 300 hall shower, he/she acknowledged that it had been a lot longer than a week.
During an interview on 3/29/23 at 10:40 A.M., the Housekeeping Supervisor said he/she has told the housekeepers in the past to clean the fans once per week.
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 reassess the effectiveness of individualized resident care and inte...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to reassess the effectiveness of individualized resident care and interventions by not reviewing and revising resident care plans (a document that specified health care and support needs and outlined how the facility met resident requirements) for six sampled residents (Resident #58, #105, #31, #126, #95 and #88) out of 30 sampled residents. This practice had the potential to effect reach resident's physical and mental well-being. The facility census was 148 residents.
Record review of the facility's Care Planning policy, dated 10/24/2022, showed:
-The purpose of the policy was to ensure a comprehensive person-centered Care Plan was developed for each resident based on their individual assessed needs.
-A Licensed Practical Nurse (LPN) initiated and finalized the Care Plan.
-The Care Plan was updated as indicated for change of condition, on-set of new problems, resolution of current problems and as deemed appropriate by clinical assessment.
-The Interdisciplinary Team (IDT) revised the Comprehensive Care Plan as needed at the following intervals:
--Per Resident Assessment Instrument (RAI- helps the facility staff to gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan).
1. Record review of Resident #58's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 9/26/22, showed:
-The resident scored a one on the Brief Interview for Mental Status (BIMS), an assessment tool that shows a score between 3 of 15 which shows the resident's mental status. This tool helps determine the resident's attention, orientation and ability to register and recall new information. These items are crucial factors in care planning decisions.
--This showed the resident had severe cognitive impairment.
-The resident was diagnosed with:
--Schizoaffective disorder (a mental condition that causes loss of contact with reality and mood problems), generalized anxiety disorder ((anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus), and restlessness and agitation.
Record review of the resident's care plan in his/her electronic health record, dated 10/22/22 showed:
-The resident was at risk for falls related to decreased strength and endurance, unsteady gait and balance.
-The resident had an Activities of Daily Living (ADL) performance deficit related to decreased strength and endurance, unsteady gait and balance.
-No updates or revision dates were noted for focus areas, goals or interventions after 10/22/22.
2. Record review of Resident #105's quarterly MDS, dated [DATE] showed:
-The resident was admitted on [DATE].
-The resident scored a two on the BIMS.
-This showed the resident was severely cognitively impaired.
-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), unsteadiness on feet and communication deficit.
Record review of the resident's care plan, undated, showed no updates or revision dates were noted for focus areas, goals or interventions.
3. Record review of Resident #31's quarterly MDS, dated [DATE] showed:
-The resident scored a five on the BIMS.
-This showed the resident was severely cognitively impaired.
-The resident was diagnosed with unsteadiness on feet, major depressive disorder ((a mental disorder characterized by a feeling of profound and persistent sadness or despair and is frequently accompanied by a loss of interest in things that were once pleasurable), unspecified 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, judgement, and impulses).
Record review of the resident's care plan in PCC, dated 9/27/22 showed no updates or revision dates were noted for focus areas, goals or interventions.
4. Record review of Resident #126's MDS, dated [DATE], showed:
-The resident was admitted on [DATE].
-The resident scored a two on the BIMS.
-This showed the resident was severely cognitively impaired.
-The resident was diagnosed with senile degeneration of the brain (a disease of decreased cognitive ability or mental decline), anxiety disorder, and muscle weakness.
Record review of the resident's care plan, undated, showed no updates or revision dates were noted for focus areas, goals or interventions.
5. Record review of Resident #95's MDS, dated [DATE], showed:
-The resident was admitted on [DATE].
-The resident scored an eight on the BIMS.
-This showed the resident was moderately cognitively impaired.
-The resident was diagnosed with cognitive communication deficit, muscle weakness, major depressive disorder.
Record review of the resident's care plan, undated showed no updates or revision dates were noted for focus areas, goals or interventions.
6. Record review of Resident #88's MDS, dated [DATE], showed:
-The resident was admitted on [DATE].
-The resident scored a 13 on the BIMS.
-This showed the resident was cognitively intact.
Record review of the resident's care plan, dated 10/12/22 showed no updates or revision dates were noted for focus areas, goals or interventions.
7. During an interview on 3/21/23 at 12:17 P.M., the MDS Coordinator said:
-Assessments were updated quarterly.
-Care plans were updated following MDS updates.
During an interview on 3/27/23 at 9:58 A.M., the Social Worker said the MDS Coordinator updated care plans when there was a change in condition.
During an interview on 3/27/23 at 10:53 A.M., LPN C said:
-Care plans were updated after every fall and at least quarterly.
-The MDS Coordinator populated the care plans and were updated in electronic health record.
-Any nurse can update the care plan.
During an interview on 3/29/23 at 2:05 P.M., the Director of Nursing (DON)said:
-Care plans were updated when a resident had new interventions or any changes of condition.
-There was no schedule as to when care plans were updated.
-Resident care plans should have been updated since October of 2022.
-He/she believed care plans were updated quarterly.
-The MDS Coordinator or any nurse was able to update care plans as needed.
-He/she expected care plans to be to have a date as to when they were updated or revised.
-He/she expected care plans to be updated quarterly.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Record review of the facility's policy titled Hand Hygiene dated June 2020 showed:
-Facility Staff and volunteers must perfor...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Record review of the facility's policy titled Hand Hygiene dated June 2020 showed:
-Facility Staff and volunteers must perform hand hygiene with an alcohol-based product in the following circumstances, but not limited to:
--Immediately upon entering a resident occupied area regardless of glove use.
--Immediately upon exiting a resident occupied area regardless of glove use.
Record review of the facility's undated policy titled Medication Administration showed staff should wash hands before and after medication administration.
5. Record review of Resident #86's undated face sheet showed he/she admitted to the facility with the following diagnoses:
-Essential (primary) Hypertension (High Blood Pressure).
-Atherosclerotic Heart Disease of Native Coronary Artery (A build-up of fats, cholesterol, and other substances in and on the artery walls) without Angina Pectoris (chest pain).
-Peripheral Vascular Disease (PVD- inadequate blood flow to the extremities).
Observation on 3/24/23 at 7:48 A.M. of Resident #86's medication pass showed Certified Medication Technician (CMT) C:
-Removed the automatic wrist blood pressure cuff off the medication cart and walked into the dining room to take the resident's blood pressure without washing/sanitizing his/her hands.
-He/she took the resident's blood pressure, returned to the medication cart, sanitized the blood pressure cuff, and then started to place the resident's medications in a medication cup without washing/sanitizing his/her hands.
-He/she then went back to the resident and gave the resident his/her medication.
-After watching the resident take his/her medication he/she took the empty medication cup and walked back to the medication cart without washing his/her hands before starting the next medication pass.
6. Record review of Resident #104's undated face sheet showed he/she admitted to the facility with the following diagnoses:
-Legal Blindness.
-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).
-Malignant Neoplasm of Unspecified Site of Left Breast (breast cancer).
Observation on 3/24/23 at 7:57 A.M. of Resident #104's medication pass showed CMT C:
-Started putting medication into the medication cup without washing/sanitizing his her hands.
-He/she had trouble finding all of the resident's medications and was in several of the medication cart drawers and touched pill bottles and pill card packets while he/she searched for all of the medication.
-He/she then placed all of the resident's medication into a medication cup and handed the cup to the resident with a cup of water.
-The resident then took all of his/her medication and gave the medication cup and water cup back to CMT C.
-CMT C then threw all of the supplies away and did not wash his/her hands after completing the medication pass.
7. During an interview on 3/24/23 at 8:10 A.M. CMT C said:
-He/she thought the medication pass went so-so.
-He/she thought that he/she could have been a little less nervous during the medication pass, but would not have done anything differently.
-He/she thought the policy was to wash his/her hands after every three individual medication passes.
-He/she thought that if he/she was generally sanitizing his/her hands throughout the medication pass process then that good enough.
-He/she thought that if he/she sanitized the blood pressure cuff between each use then he/she did not need to wash/sanitize his/her hands.
During an interview on 3/28/23 at 1:43 P.M. Licensed Practical Nurse (LPN) B said:
-He/she would sanitize his/her hands before and after each medication pass.
-He/she thought the facility's policy was to sanitize his/her hands before and after each medication and wash his/her hands after every three residents.
-He/she thought the CMT should have performed hand hygiene before and after checking the blood pressure of a resident and then before and after each medication pass.
During an interview on 3/29/23 at 08:58 A.M. CMT D said:
-He/she thought it was the facility's policy to wash his/her hands before and after every third resident during medication pass.
-He/she would sanitize his/her hands before and after each medication pass.
-He/she would sanitize his/her hands before taking a resident's blood pressure and would wash his/her hands afterwards due to the contact with the resident.
During an interview on 3/29/23 at 2:05 P.M. the Director of Nursing (DON) said:
-He/she would expect the CMTs and nurses to sanitize his/her hands before and after each medication pass.
-He/she was unsure what the facility's policy was regarding washing hands after every third resident during medication pass.
-He/she thought the CMTs may have learned that practice from the CMT training classes.
-He/she would expect the care staff to sanitize their hands before and after resident contact.
-He/she thought that sanitizing a blood pressure cuff in between the resident contact and getting the medications ready did not indicate or replace hand hygiene during the medication pass.
Based on interview and record review, the facility failed to notify the resident's physician when the resident's blood sugar was outside prescribed parameters for two sampled residents (Resident #23 and Resident #119) out of 30 sampled residents; and to ensure proper hand hygiene was completed during medication passes for one sampled resident (Resident #104) and for one supplemental resident (Resident #86) out of 30 sampled residents and eight supplemental residents. The facility census was 148 residents.
A policy for physician notification was requested and not received at the time of exit.
Record review of the facility's undated policy, Medication - Administration showed:
-When administration of the drug is dependent upon vital signs or testing, the vital signs/testing would be completed prior to administration of the medication and recorded in the medical record; example finger stick blood glucose monitoring.
-The resident's Medication Administration Record (MAR) would be reviewed for special consideration for administration including:
-Manufacturer's specification regarding the administration of the drug or biological.
-Accepted professional standards and principles.
-Lab results as appropriate.
1. Record review of Resident #23's face sheet showed he/she was admitted to the facility with a diagnosis of 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 entry tracking, Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) assessment dated [DATE] showed:
-His/her Brief Interview for Mental Status (BIMS) score was 15 out of 15, indicating he/she was cognitively intact.
-He/she had diabetes.
Record review of the resident's undated care plan showed:
-He/she used insulin therapy (replaces or supplements the body's own insulin with the goal of achieving normal or near normal blood sugar levels) related to diabetes.
-Staff would administer medication as ordered by the physician.
-Staff would monitor for and document for effectiveness.
-Staff would educate the resident about complications of the disease.
-Staff would monitor and report any signs or symptoms of hyperglycemia (Blood sugar that was too high) no perimeters were given.
-Staff would monitor and report any signs or symptoms of hypoglycemia (Blood sugar that was too low) no perimeter were given.
Record review of the resident's January 2023 Physician's Order Sheet (POS) showed the following order for Accucheck (device that quickly measures for blood sugar level) for diabetic monitoring before meals and at bedtimes, dated 10/4/22. The order did not include parameters for notifying the resident's physician if too high or too low.
Record review of the resident's January 2023 Treatment Administration Record (TAR) showed:
-No order to include parameters for notifying the resident's physician if too high or too low.
-His/her blood sugar was greater than 400 three times with no documentation the physician was notified (in the Nurses' Notes).
-Seven times the TAR showed See Progress Notes with no documentation in the Nurses' Notes.
Record review of the resident's February 2023 POS showed the following order for Accucheck (device that quickly measures for blood sugar level) for Diabetic monitoring before meals and at bedtimes, dated 10/4/22. The order did not include parameters for notifying the resident's physician if too high or too low.
Record review of the resident's February 2023 TAR showed:
-No order to include parameters for notifying the resident's physician if too high or too low.
-His/her blood sugar was greater than 400 twice with no documentation the physician was notified (in the Nurses' Notes).
-Once the TAR showed See Progress Notes with no documentation in the Nurses' Notes.
-Twice the residents blood sugar was less than 70 with no documentation the physician was notified or that interventions were taken.
Record review of the resident's March 2023 POS showed the following order for Accucheck (device that quickly measures for blood sugar level) for Diabetic monitoring before meals and at bedtimes, dated 10/4/22. The order did not include parameters for notifying the resident's physician if too high or too low.
Record review of the resident's February 2023 TAR showed:
-No order to include parameters for notifying the resident's physician if too high or too low.
-His/her blood sugar was greater than 400 twice with no documentation the physician was notified (in the Nurses' Notes).
-Once the TAR showed See Progress Notes with no documentation in the Nurses' Notes.
-Twice the residents blood sugar was less than 70 with no documentation the physician was notified or that interventions were taken.
2. Record review of Resident #119's face sheet showed he/she was admitted to the facility with a diagnosis of diabetes.
Record review of the resident's annual MDS assessment dated [DATE] showed:
-His/her BIMS score was 15 out of 15 indicating he/she was cognitively intact.
-He/she had a medically complex condition.
-He/she was a diabetic.
Record review of the resident's undated care plan showed:
-The resident had diabetes.
-Staff was to administer medication as ordered by the physician.
-Staff was to monitor and document for side effects and effectiveness.
-Staff was to educate the resident regarding medications and importance of compliance.
-Staff was to have resident verbally state an understanding.
Record review of the resident's POS dated January 2023 showed the following order:
-Blood glucose monitoring before meals and at bedtime, dated 12/21/22.
-Call (the resident's physician) for blood glucose greater than 400, dated 1/6/23.
-The order did not include parameters for notifying the resident's physician if too low.
Record review of the resident's January 2023 TAR showed:
-His/her blood sugar was greater than 400 14 times with no documentation the physician was notified (in the Nurses' Notes).
-His/her blood sugar level was greater than 500 three times with no documentation the physician was notified (in the Nurses' Notes).
Record review of the resident's Physician's Progress Notes dated 1/5/23 showed:
-The Physician was aware the resident's BS level was greater than 400.
-The Physician changed the Insulin Glargine solution for 30 units to 35 units.
Record review of the resident's POS dated February 2023 showed the following order:
-Blood glucose monitoring before meals and at bedtime, dated 12/21/22.
-Call (the resident's physician) for blood glucose greater than 400, dated 1/6/23.
-The order did not include parameters for notifying the resident's physician if too low.
Record review of the resident's February 2023 TAR showed:
-His/her blood sugar was greater than 400 12 times with no documentation the physician was notified (in the Nurses' Notes).
-His/her blood sugar was less than 70 with three times no documentation the physician was notified or of any interventions (in the Nurses' Notes).
-The order did not include parameters for notifying the resident's physician if too low.
-Three times the TAR showed See Progress Notes with no documentation in the Progress Notes.
-Three times the TAR administration was blank.
Record review of the resident's POS dated March 2023 showed the following order:
-Blood glucose monitoring before meals and at bedtime, dated 12/21/22.
-Call (the resident's physician) for blood glucose greater than 400, dated 1/6/23.
-The order did not include parameters for notifying the resident's physician if too low.
-Record review of the resident's March 2023 TAR showed:
-Three administration times were blank.
-Three times showed See Progress Notes with no documentation in the Nurses' Notes.
-His/her blood sugar was less than 70 once with no documentation the physician had been notified or of any interventions (in the Nurses' Notes).
-The order did not include parameters for notifying the resident's physician if too low.
3. During an interview on 3/28/23 at 1:05 P.M. Registered Nurse (RN) D said:
-If a residents blood sugar was above 400 he/she would notify the physician.
-You should always follow the physician's orders.
-If a resident refused to have his/her blood sugar taken it should have been documented in the nurses' notes.
-If a resident refused to take his/her insulin it should have been documented in the nurses' notes.
-If the TAR was blank it was not done.
-The Nurse Practitioner was here every day and you could tell him/her about a high or low blood sugar, but it should have been documented that he/she was notified of the blood sugar level in the nurses' notes.
During an interview on 3/29/23 at 2:10 P.M., the Director of Nursing (DON) said:
-The parameter should have been in the orders.
-The parameter for holding insulin was under 70.
-Staff should have given the resident a small snack.
-Staff should have notified the physician.
-If the resident's blood sugar was greater than 400 the physician should have been notified.
-Staff should have documented the physician had been notified in the nurse's notes.
During an interview on 4/3/23 at 12:45 P.M. Nurse Practitioner (NP) A said:
-He/she was not notified every time the residents' blood sugars being out of parameter.
-If a resident's blood sugar was greater than 400 the physician should have been notified.
-If a resident's blood sugar was less than 70 the physician should have been notified.
-The nursing staff needed to call every time when the resident's blood sugar was outside of the perimeters and document it.
-Even if the resident was non-compliant the nursing staff needed to notify the physician.
-He/she had talked to the nursing staff three weeks ago about ensuring the residents with diabetes had perimeters when they should notify the physician.
-Nursing staff was to ensure the perimeters were on each chart and it was not done for the resident.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #23's face sheet showed he/she was admitted with the following diagnoses:
-Unsteadiness on feet.
-M...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #23's face sheet showed he/she was admitted with the following diagnoses:
-Unsteadiness on feet.
-Muscle weakness.
-Difficulty walking.
-Lower back pain.
Record review of the resident's Reentry MDS dated [DATE] showed:
-His/her Brief Interview for Mental Status (BIMS) score was 15 out of 15, indicating he/she was cognitively intact.
Record review of the resident's March 2023 POS showed the following orders:
-Restorative Aide arm range of motion, bilateral upper extremities two to three pounds, 15 to 20 repetitions as tolerated as needed (PRN).
-Group exercises Monday, Wednesday, and Friday as tolerated PRN for for 90 days, dated 3/5/23.
During an interview on 3/20/23 at 1:00 P.M. the resident said:
-He/she had fallen and would like to get stronger.
-He/she would go to the group exercise class (RA) but there usually was not enough staff to have it.
(here was no documentation in the resident's EMR that the resident was receiving RA therapy.
3. Record review of Resident #88's face sheet showed he/she was admitted to the facility with the following diagnoses:
-Unsteadiness on feet.
-Muscle weakness.
-Decreased mobility.
-Muscle wasting and atrophy (decline).
-Foot droop, left and right (muscle weakness in the front part of the foot).
Record review of the resident's care plan dated 10/22 showed:
-He/she has the potential decline in upper and or lower body range of motion related to terminal illness, dated 3/5/23.
-The resident would maintain his/her current functional status through the review period dated, 3/5/23.
-Arm range of motion four pound weight as tolerated.
-Lower leg extremities three to five pound weights as tolerated.
-Group exercises on Monday, Wednesday, and Friday as tolerated.
-Transfer training with slide board as tolerated as needed.
Record review of the resident's MDS annual assessment dated [DATE] showed:
-His/her BIMS score was 15 out of 15 - cognitively intact.
-Needs assistance of two staff members to move from bed to wheelchair.
Record review of the resident's March 2023 POS showed the following orders:
-Restorative Aide to perform arm range of motion for bilateral upper extremities with four pound weights as tolerated.
-Group exercise on Monday, Wednesday, and Friday as tolerated as needed.
-Range of motion lower leg extremities three to five pounds as tolerated as needed.
-Transfer training with slide board as tolerated as needed for 90 days.
During an interview on 3/20/23 10:35 A.M. the resident said:
-He/she had received therapy until his/her number of covered days was up.
-He/she was told that a RA would be working with him/her.
-That has not happened.
-They say that he/she refuses to get out of bed but they don't have enough staff to get him/her up out of bed.
-He/she would have liked to walk again so he/she could go home to visit.
(here was no documentation in the EMR that the resident had received RA therapy.
4. During an interview on 3/28/23 at 1:05 P.M. Registered Nurse (RN) said:
-Resident #23 and Resident #88 have physician orders for RA to work with them.
-There usually was not enough staff to allow the RA to work as a RA and was pulled to the floor to work as a CNA.
-They have a notebook they were to document in.
During an interview on 3/29/23 at 8:50 A.M. CNA H/RA said:
-He/she has been working on the floor as a CNA for the last two weeks.
-In the month of March he/she has only worked once as a RA.
-There have been a lot of call ins so she has had to work on the floor as a CNA.
-Resident #88 nor Resident #23 were receiving RA.
-There were a lot of new orders for residents to have RAs work with them but the orders have not been processed by the DON.
-The DON was aware RAs have not been able to work with the residents.
-It should be documented in the Care Plan RAs were to work with the residents.
During an interview on 3/29/23 at 2:10 P.M. the Director of Nursing said:
-The RA program was not getting done.
-They were behind getting the paperwork done.
-It was his/her responsibility to ensure the residents had RAs to work with them.
-The Restorative Aide should be working with the residents.
-The RA should work with the residents two or three times a week.
-The RAs are not able to work with the residents right now because if there were not enough CNAs, they were pulled to work on the floors as CNAs.
-The RA's should be able to do their RA duties at least two days per week and not be working on the floor.
-They document their RA in the resident's electronic record once the service each time they complete RA for the resident.
-He/she was aware that the RA services had not been getting completed due to staffing issues.
Based on observation, interview and record review, the facility failed to ensure physician's orders for restorative assist care (RA) were initiated timely and followed for three sampled residents (Resident #36, #23, and #88) out of 30 sampled residents. The facility census was 148 residents.
Record review of the facility Restorative Nursing Program Guidelines, revised June 2020, showed:
-The Restorative Nursing Program provides nursing interventions that promote the resident's ability to adapt and adjust to live as independently and safely as possible. This program actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning.
-A resident may be started on a Restorative Nursing Program:
--Upon admission to the facility with restorative needs but is not a candidate for formalized rehabilitive therapy.
--When restorative needs arise during a longer-term stay.
--In conjunction with formalized rehabilitive therapy.
--When a resident is discharged from a formalized physical, occupational, or speech rehabilitation therapy.
-The Director of Nursing (DON) or designee, manages and directs the Restorative Nursing Program. Licensed rehabilitation professionals (physical therapist, occupational therapist, speech therapist) provide ongoing consultation and education for the Restorative Nursing Program.
-General restorative nursing care is that which does not require the use of a qualified professional therapist to render such care. The basic restorative nursing categories include:
--Active Range of Motion.
--Passive Range of Motion.
--Splinting or Bracing.
--Bed mobility.
--Transfer training.
--Dressing and grooming.
--Walking.
-Residents will be reviewed by the Interdisciplinary Team (IDT) upon admission, readmission, quarterly, and as needed to identify any decline in activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting) function. If a decline is identified, the IDT will evaluate whether the resident is an appropriate candidate for restorative services.
1. Record review of Resident #36's Face Sheet showed he/she was admitted to the facility on [DATE], with diagnoses including respiratory failure, sleep apnea (a condition where breathing stops and starts during sleep), severe obesity, low back pain, diabetes, kidney failure, heart disease and difficulty walking.
Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 1/8/23, showed the resident:
-Was alert, oriented and cognitively intact.
-Was totally dependent on staff for transfers, mobility, bathing and toileting, and needed extensive assistance with grooming.
Record review of the resident's Occupational Therapy Discharge summary dated [DATE] showed the resident was to receive restorative maintenance program for bilateral upper extremities range of motion. The resident's prognosis was excellent.
Record review of the resident's Restorative Program dated 1/6/23, showed the resident was to receive active range of motion of his/her right upper extremity, 15 to 20 repetitions, and passive range of motion of the resident's left upper extremity, 15 to 20 repetitions. There was also group exercise on Monday, Wednesday and Friday. The document did not show the frequency of the restorative maintenance program to be completed weekly.
Record review of the resident's Physical Therapy Discharge summary dated [DATE], showed:
-The resident was to receive restorative maintenance program to include lower extremity active range of motion, bed mobility and upright sitting.
-The resident's prognosis was excellent with consistent staff support.
Record review of the resident's Restorative Program dated 1/16/23, showed the resident was to receive active range of motion, 20 to 25 repetitions. The documentation did not show the frequency restorative maintained program was supposed to be completed weekly.
Record review of the resident's electronic record showed there was no documentation showing the restorative maintenance program was being completed.
Record review of the resident's Physician's Order Sheet (POS) dated 3/2023, showed physician's orders for:
-Restorative Assistance; active range of motion to the right upper extremity, 15-20 repetitions as tolerated, as needed; passive range of motion left upper extremity 15-20 repetitions as tolerated as needed; group exercises Monday, Wednesday and Friday as tolerated, as needed for 90 Days (3/5/23).
-There were no physician's orders for Physical therapy or Occupational therapy.
Record review of the resident's Treatment Administration Record (TAR) dated 3/2023, showed there was no documentation showing RA had ever been initiated or completed.
Record review of the resident's electronic Medical Record showed there was no documentation showing RA was being completed.
During an observation and interview on 3/20/23 at 11:56 A.M., the resident was in his/her bed and was alert and oriented and said:
-He/she had been receiving rehabilitative therapy until it ran out in January.
-He/she was supposed to receive restorative care, but he/she has not been receiving any restorative services because the Restorative Aide was being pulled to work as an aide on the floor and was not able to provide restorative care.
-They only have had one RA for the whole building and they just hired another one but they are usually pulled to work on the floor as aides.
-He/she needed to have exercises on his/her arms and legs because he/she did not want to lose the progress he/she made while he/she was in therapy.
-He/she did not participate in any exercise groups because they did not have them.
-He/she had limited range of motion in his/her shoulder and he/she also wants to be able to walk again.
-He/she spoke with the rehabilitative team and they said that they would follow up to see if his/her insurance was able to begin paying for rehabilitation again.
During an interview on 3/23/23 at 12:39 P.M., the Physical Therapy Assistant said:
-The resident was receiving Physical therapy from 11/8/ 22 to 1/16/23.
-They are waiting for his/her insurance to approve rehabilitative services to start again before they can complete the re-assessment for services to start again.
-The resident was supposed to be receiving RA services after therapy ended to maintain his/her flexibility and strengthening during the time he/she received therapy, but once they write up the restorative order, the RA is responsible for implementing it.
-They have open communication with the nursing staff and the RA if they notice any changes in the resident's mobility or range of motion, but they do not monitor the restorative program.
During an interview on 3/23/23 at 1:30 P.M., the RA A said:
-He/she had the resident on his/her caseload, but he/she has not been able to get the RA completed because he/she has had to work on the floor.
-He/she has an assistant that is a new employee who started three to four weeks ago for assistance with providing RA services, but he/she had also not been able to do so because he/she was pulled to work as a Certified Nursing Assistant (CNA) on the floor.
-For the last two weeks he/she has been working on the floor and has not been able to do RA.
-Today he/she was able to do a group exercise and is trying to complete all of the resident weights (which is also his/her responsibility).
-He/she also feeds residents in the dining room, which also cuts down on the time he/she has to complete RA.
-When he/she is able to complete RA, he/she documents in the resident's electronic medical record each time RA is completed.
-It had been a very long time since he/she was able to complete RA with the resident, so there probably was not much documentation in the resident's restorative section in his/her electronic medical record.
-The residents on his/her caseload receive restorative services to maintain their current range of motion and when they don't receive it they are at risk of declining.
-He/she knows the staffing coordinator tries to get adequate staff in the building, but staff call in and when they don't have enough staff on the floor, he/she has to provide assistance.
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 bathing/showers were completed at least once we...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure bathing/showers were completed at least once weekly and at the resident's preference for five sampled residents (Resident #60, #153, #8, #67 and #96) out of 30 sampled residents. The facility census was 148 residents.
Record review of the facility's undated policy titled Showering A Resident showed a shower bath is given to residents to provide cleanliness, comfort and to prevent body odors. Residents are offered a shower or bath at at a minimum of once weekly and given per resident request.
1. Record review of Resident #60's admission Sheet showed he/she had diagnoses of muscle weakness, unsteadiness on feet and pain.
Record review of the resident's care plan dated 8/9/22 showed:
-He/she had Activities of Daily Living (ADL's) self-care performance deficit related to pain, unsteady gait and balance, poor vision,
-His/her goal was to maintain current level of function in ADL.
-He/she was independent with transfers. Requires assistant with bathing and some personal cares.
-He/she prefers to shower once weekly (revised on 4/24/21).
Record review of the resident's Quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 1/18/23 showed he/she:
-Was cognitively intact.
-He/she was able to understand others and make his/her needs known;
-Required supervision assistant from staff for setup with bathing and personal hygiene.
Record review of the resident's February shower sheets/skin condition report showed:
-He/she had documentation for 2/7/23.
-Note: the resident only had documentation of one shower for the month of 2/2023.
During interview and observation on 3/21/23 at 9:08 A.M., the resident said:
-He/she had to get up at 5:00 A.M. today to get his/her shower.
-He/she had to sit in line to wait for the bath aide.
-The poor bath aide was the only one that was giving showers and then he/she was pulled to work on the floor as a Certified Nursing Assistant (CNA).
-The facility does not have anyone to give him/her a shower.
-He/she would prefer to get up around 8:30 A.M., but I want a shower more.
-He/she does not need assistance from facility staff except for bathing.
-The resident well-groomed and no lingering odors noted.
Record review of the resident's March 2023 shower sheets/skin condition report showed:
-He/she had documentation of having received a shower on 3/7/23, 3/14/23, and 3/21/23.
-Note: the resident only had documentation of one shower a week.
During an observation and interview on 3/23/23 at 1:44 P.M., the resident said:
-He/she did not ask to only be bathed once a week.
-He/she would like to shower twice a week.
-He/she did get a shower that week but had to get up at 5 am to get it.
-His/her hair and face was oily. He/she had a same green nightgown with paint worn on 3/22/23.
-He/she was able to brush own hair.
During an interview and observation on 3/27/23 at 8:43 AM, the resident said:
-He/she had concerns with bathing, only offered one time a week.
-Also concern with having to line up so earlier in morning for baths.
-The resident was well groomed and no odors noted.
-He/she was dependent on facility staff for personal cares to include bathing.
2. Record review of Resident #153's admission Face sheet showed he/she had the following diagnoses:
-Cerebrovascular Accident (CVA, stroke a blockage in the one or more of the arteries supplying blood to the brain).
-Anoxic brain damage (is harm to the brain due to a lack of oxygen).
-Respiratory failure (is a serious condition that makes it difficult to breathe on your own) with a tracheostomy (Trach, is a surgical opening into the wind pipe into which a tube is inserted to allow passage of air and removal of secretions).
Record review of the resident's care plan started on 2/11/23 showed the resident was totally dependent on staff and was to receive baths two times a week.
Record review of the resident's admission MDS dated [DATE], showed he/she:
-Was severely cognitively impaired and had short term and long term memory problems.
-He/she was able to understand others and make his/her needs known.
-Required total assistance from staff for all cares, including bathing, and transfers.
Record review of resident's shower sheet/skin condition report for February 2023 showed he/she had a shower and skin check on 2/3/23 and on 2/18/23.
Record review of the resident's shower sheet provided and had no documentation baths provided during month of 3/2023.
Observation and resident interview on 3/21/23 at 10:29 A.M., showed:
-The resident was able to to provide very little assistance during ADL's and required facility staff assistance.
-No lingering odors were noted.
Observation on 3/22/23 at 11:17 A.M., showed:
-The resident's hair was uncombed and his/her face was shiny.
-There was no lingering orders noted in his/her room.
Observation on 3/23/23 at 10:23 A.M. showed:
-The resident's hair was combed, appeared clean, and there were no odors present.
-The resident was wearing a clean hospital gown.
Observation on 3/24/23 at 8:41 A.M., showed:
-The resident was in bed with eyes closed and he/she had a hospital gown on.
-He/she had no lingering odors noted.
During an interview on 3/29/23 at 9:20 A.M., Certified Medication Technician (CMT) D said;
-He/she thought the resident was on Hospice (end of life) services.
-He/she does not received showers, the resident was bed bound and was offered a bed bath.
-He/she would document on the resident bath sheets and electronic record any personal care provided to the resident.
During an interview on 3/29/23 at 9:27 A.M. Licensed Practical Nurse (LPN) E said:
-The resident was bed bound and receive bed baths.
-The resident was not on Hospices services and bathes would be provided by facility staff.
-He/she would expect bed baths be documented on the CNA shower sheet or in electronic records.
3. Record review of Resident #8's Face Sheet showed he/she was admitted on [DATE], with diagnoses including severe obesity, Parkinson's Disease (a degenerative disorder of the central nervous system that often impairs the sufferer's motor skills and speech, as well as other functions), muscle weakness, cognitive communication deficit, anxiety disorder, depression, pain, dementia, edema (swelling in the tissues), high blood pressure, diabetes and history of falls.
Record review of the resident's annual MDS dated [DATE], showed the resident:
-Was alert, oriented and cognitively intact.
-Did not have any behaviors to include resisting care and treatment.
-Needed extensive assistance with bathing.
Record review of the resident's Care Plan dated 3/13/23, showed the resident had limited physical ability due to diagnoses including Parkinson's Disease, high blood pressure and diabetes, and required assistance with all activities of daily living (bathing, dressing, mobility, transfers, hygiene and eating). Interventions showed the resident needed assistance with mobility and staff was to assist with bathing.
Record review of the resident's Bathing Sheets showed:
-From 1/1/2023 to 3/24/23, the resident was given a bath/shower on 1/12/23, 2/10/23, 2/17/23, 3/3/23, and 3/24/23 (5 showers in three months).
-Showers/baths were not given once weekly.
Observation and interview dated 3/21/23 at 11:32 A.M., showed the resident was in his/her room, dressed for the weather. He/she was not odorous. The resident said:
-He/she chose how he/she spends his/her days.
-He/she was able to take himself/herself to the bathroom and the staff just provide him/her with gloves and briefs.
-He/she needed assistance with showers and their shower aide was supposed to give showers once weekly.
-He/she was supposed to have a shower on Fridays and missed it last week because of the St. Patrick's Day celebration.
-Staff did not offer to give him/ her shower at another time or on a different day and he/she hoped to get a shower on this Friday.
-He/she had not received a shower since March 10, 2023.
-Normally, he/she just washes up with a wet wipe at the sink in his/her room.
-He/she said she would like to receive bathing more frequently that once weekly, but they usually don't get them (showers) done once weekly.
Observation and interview on 3/24/23 at 10:36 A.M., showed the resident was sitting in his/her recliner watching television. The resident had a small bag with shower gel and shampoo inside and also had clothing on the seat of his/her roller walker. He/she said:
-Supposed to receive his/her shower today and he/she had all of his/her belongings ready.
-Did not know what time they would come to get him/her for his/her shower but he/she was happy to be receiving a shower today.
4. Record review of Resident #67's Face Sheet showed he/she was admitted on [DATE], with diagnoses including hemiplegia (paralysis on one side of the body) affecting the right dominant side, stroke, lack of coordination, low iron, pain, muscle spasms, high blood pressure, anxiety and depression.
Record review of the resident's quarterly MDS dated [DATE], showed the resident:
-Was alert, oriented and cognitively intact.
-Did not have any behaviors to include resistance to cares.
-Was totally dependent on staff for transfers and needed extensive assistance with bathing.
Record review of the resident's Care Plan dated 3/17/23, showed the resident required assistance with his/her care needs and had a performance deficit in activities of daily living related to stroke and right side hemiparesis. The resident also had a decreased range of motion. Interventions showed the resident was totally dependent on one staff for bathing and staff were to bathe him/her as necessary.
Record review of the resident's Bathing Sheets showed:
-From 1/1/2023 to 3/24/23, the resident was given a bath/shower on 1/6/23, 1/26/23, 2/10/23, 2/17/23, and 3/3/23 (5 showers in three months).
-Showers/baths were not given once weekly.
During an observation and interview on 3/20/23 at 12:02 P.M., the resident was sitting in his/her room in his/her wheelchair, dressed for the weather and was not odorous. He/she was cleaning personal care products from the vanity. He/she said:
-Staff has to assist him/her to bathe and toilet but he/she could complete grooming and hygiene independently.
-He/she did not have bathing twice weekly because they can't give baths that frequently, so it's usually once weekly.
-In a subsequent interview on 3/21/23 at 10:14 A.M., he/she said they are not getting showers like they should because they have one shower aide for the four halls.
-Currently they have been getting showers once weekly, but sometimes it's every two weeks.
-The shower aide said it was too much for him/her and he/she doesn't get any help from the other CNA staff.
-The nursing aides that care for him/her try to assist him/her when he/she is in the bathroom, but he/she wants to have a shower at least weekly.
-The shower aide sometimes gets pulled to work on the floor with residents and he/she is not able to get showers completed on those days.
-The CNA staff do not assist with the showers.
-They had several staff quit last year and they have not hired another shower aide to assist with giving showers.
5. Record review of Resident #96's Face Sheet showed he/she was admitted on [DATE] with diagnoses including respiratory failure, chronic obstructive pulmonary disease (COPD- a progressive disease that is characterized by shortness of breath and difficulty breathing), obesity, heart failure, pain, anxiety disorder, depression, iron deficiency and sleep apnea (a common disorder in which you have one or more pauses in breathing or shallow breaths while you sleep). The Face Sheet showed the resident was his/her own responsible party.
Record review of the resident's admission MDS dated [DATE], showed the resident:
-Was alert oriented and cognitively intact.
-Had no behaviors and was not resistive to cares.
-Needed extensive assistance of one person with bed mobility, transfers, bathing, dressing, toileting and did not walk.
Record review of the resident's Care Plan dated 3/8/23, showed the resident had a self-care performance deficit and needed assistance to complete activities of daily living. Regarding bathing, the interventions showed the resident needed extensive assistance of one staff for bathing.
Record review of the resident's Bathing Sheets showed:
-From 1/1/2023 to 3/24/23, the resident was given a bath/shower on 1/6/23, 1/12/23, 1/13/23, 3/22/23, and 3/24/23 (5 showers in three months).
-Showers/baths were not given once weekly. There was no documentation showing the resident received a bath/shower from 2/1/23 to 2/27/23.
Observation and interview on 3/21/23 at 10:59 A.M., showed the resident was awake, alert and oriented, sitting up in his/her bed and wearing oxygen. The resident said:
-He/she has not had a shower in almost six weeks because they don't have enough shower aide.
-The night shift staff offered him/her a bath at 9:00 P.M. last night but he/she did not want a bath that late, so he/she declined.
-The CNA staff don't normally give baths/showers and they do not offer to give the shower at other times or on a different day.
-When they do give showers/baths, it's only once weekly.
-Currently, they only had one bath aide.
6. During an interview on 3/23/23 at 12:04 P.M., CNA M said he/she would complete a shower sheet/skin condition report and give it to the charge nurse after the resident's shower or bath.
During interview on 3/23/23 at 12:12 P.M., LPN B said:
-The completed residents shower sheets were to be kept in his/her office.
-There was binder had all resident shower sheets for the past three months.
During an interview on 3/23/23 at 12:28 P.M., CNA P said:
-The CNA staff assist with transferring residents to give showers, but the bath aide actually gives the showers and the CNA's do not assist.
-The bath aide is not always able to give the showers/baths because he/she she is pulled to work on the floor when they have call-ins.
-Residents only get baths/showers once weekly, but they were supposed to receive two baths a week.
During an interview on 3/24/23 at 10:41 A.M., CNA C said:
-He/she was the Bath Aide for all four halls on the skilled unit.
-The CNA's rarely assisted with giving showers or baths to the residents.
-All of the residents were supposed to get showers twice weekly, but he/she was only able to give showers once weekly because she/was the only bath aide.
-He/she completed the showers on one hall each day except Wednesdays because he/she is off on Wednesdays.
-He/she regularly was pulled to work the floor and on those days, he/she is unable to give showers/baths.
-He/she was also pulled to work on the floor whenever they had staff call-ins, so he/she tried to do the best he/she could to get bathing done.
-When he/she completed bathing for a resident, he/she documented the bath/shower on the bath sheet and gave it to the Unit Manager.
-If a resident refused a shower/bath, he/she documented that the bath/shower was refused on the bath sheet and turned that in to the Unit Manager.
-He/she was off work all of last week due to an injury to his/her arm and no showers were completed while he/she was gone.
-He/she has about 100 showers he/she had to give in four days, and tried to give about 25 showers daily.
-When a resident is not able to get a shower, he/she tries to offer a different time or day to receive their shower.
-He/she did not know why the other CNA's don't assist, but they say it is because they are busy and don't have time.
-The CNA staff will assist with the lift for those residents who require the lift to get up.
-Sometimes he/she will provide bed baths to some of the residents.
-He/she would like some help with giving the showers/baths because it was hard to get them all completed.
During an interview on 3/29/23 at 2:05 P.M., the Director of Nursing (DON) said:
-Ideally showers should be given twice weekly for each resident, but at the minimum at least once weekly.
-He/she has been made aware that residents have not been receiving showers at least once weekly.
-Nursing staff will tell him/her it's due to staffing shortages.
-They previously had 2-3 bath aides on the skilled unit and 1 on the rehabilitation unit, but currently they have one CNA assigned as the bath aide.
-The CNA staff can give showers and have been instructed to assist with giving showers.
-The CNA staff don't assist with showers as he/she would like.
-He/she would expect the CNA would had been assigned to provide showers to those resident requiring a shower that day during their schedule shift.
-Bed baths would still be part of the CNA daily bath schedule.
-Resident #153 required total assistance from facility staff for all cares.
--He/she would be provided a bed bath by a CNA or the bath aid at least once a week.
-Resident #60 was able to make his/her needs known and when he/she wants to shower.
Complaint # MO00214895, #MO00215144 and #MO00215409
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
Accident Prevention
(Tag F0689)
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 residents were free from harm while outside smo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents were free from harm while outside smoking resulting in one sampled resident (Resident #63) who was visually impaired, while lighting his/her cigarette pulling his/her hand away and shaking it suddenly and saying ah when his/her finger was burned by the flame; the facility failed to maintain hot water temperatures on the Renew Unit below 120 ºF (degrees Fahrenheit) from 2/24/23 through 3/29/23, potentially affecting 19 residents who resided in resident rooms 520, 519, 518, 517, 516, 515, 514, 513, 512, 511, 509, 503, and 501; failed to ensure the hot water situation was addressed until 3/29/23, resulting in one cognitively impaired supplemental resident (Resident ##115) indicating the water was too hot for him/her when he/she washed his/her hands. The facility failed to complete and document a fall investigation, failed to complete and document neurochecks (neurological checkpoints to monitor: level of consciousness, ability to move extremities, eye responses and change in pupils and vital signs-blood pressure, temperature, pulse and respiration) at the time of the fall, failed to complete a comprehensive investigation and post fall monitoring for one sampled resident (Resident #96) who had a fall that resulted in skin tear injuries to his/her left elbow and hand, failed to ensure a comprehensive Investigation, to include root cause and any post follow-up monitoring and to update the residents fall care plan for one sampled resident, (Resident #153) who hit his/her head, out of 30 sampled residents and nine supplemental residents. The facility census was 148 residents.
Record review of the facility's policy titled Smoking by Residents, dated March 2022, showed:
-The facility discourages smoking by residents and ensures that those residents who choose to smoke do so safely.
-Residents who want to smoke will assessed for their ability safely prior to being allowed to smoke independently in these areas.
-Smokers shall be identified at the time of admission.
-All smokers shall be assessed related to smoking safety at the time of admission and then at least quarterly.
-Residents who smoke shall wear a smoking apron if they are found not to be safe (i.e., drop lit cigarettes or do not handle the ashes properly).
-If clothing is found to have cigarette burn holes the smoker must wear an apron to protect themselves from burns regardless of whether the resident is assessed as independent for smoking.
-All smoking materials will be stored in a secure area to ensure they are kept safe.
-Based on the individual resident smoking safety assessment facility staff shall determine the most appropriate method of secure storage.
-Examples of secure areas include but are not necessarily to:
--Locked drawers or cupboards in the resident's room.
--Locked box in resident's room.
--Labeled box in a locked medication room and clearly identified with the resident's name and room number.
-Smoking sessions will be limited to 15 minute segments.
-The facility shall determine the times of smoking sessions and post all information.
-All smoking sessions will be supervised by facility staff members.
-Cigarette butts are disposed of only in provided receptacles.
-Residents are strongly encouraged not to share their smoking materials with any other resident, staff, family, and/or visitor(s).
1. Record review of Resident #63's undated face sheet showed he/she was admitted to the facility with the following diagnoses:
-Unspecified Corneal Ulcer, Unspecified Eye (a condition in which inflammation of the outer most layer of the eye results in pain).
-Unspecified Cataract (clouding of the normally clear lens of the eye).
-Unspecified Glaucoma (the nerve connecting the eye to the brain is damaged, usually due to high eye pressure and can cause blindness).
-Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side (paralysis affecting the right side of the body due to a stroke (damage to the body from interruption of its blood supply)).
-Need for Assistance with Personal Care.
-Unspecified Dementia, Unspecified Severity (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control memory, judgement, and impulses).
Record review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning), dated 12/31/22, showed:
-The resident had severely impaired vision which indicated the resident had no vision or saw only light, colors, or shapes; his/her eyes did not appear to follow objects.
-The resident was moderately cognitively impaired.
Record review of the resident's smoking assessment, dated 3/3/23, showed:
-The resident was a smoker.
-The resident had a visual deficit.
-The resident smoked 10 plus times a day.
-The resident could light his/her own cigarette.
-The resident did not need any adaptive equipment for smoking.
-The facility did not need to store the resident's lighter or cigarettes.
-The resident was assessed as safe to smoke without supervision.
Observation on 3/21/23 at 10:27 A.M., showed:
-The resident received three cigarettes from another resident.
-The resident then went out to smoke.
-The resident started to light his/her own cigarette.
--The first attempt was unsuccessful as he/she was only able light a little bit of the cigarette.
--The lighter was in his/her right hand and the flame touched his/her left index finger.
-When the flame touched the left index finger the resident flinched, drew his/her hand back, said ah, and shook his/her hand back and forth.
-The resident extinguished his/her cigarette on the ground.
-The resident stopped smoking at 10:42 A.M.
-No staff were present to observe residents smoking in the designated smoking area.
During an interview on 3/21/23 at approximately 10:35 A.M., while the resident was smoking, the resident said:
-He/She usually lit his/her own cigarettes.
-The staff did not supervise the resident's while smoking.
-He/She did not know what a smoking apron was and had never been told to wear one.
-Everyone who smokes burns their fingers.
-He/She usually smoked two packs of cigarettes per day.
During an interview on 3/21/23 at 10:51 A.M. the resident said:
-He/She usually only smoked one cigarette per outing during the winter.
-He/She usually stayed outside all day and smoked all day during the summer.
Observation on 3/21/23 at 11:06 A.M., showed no staff had come out to the designated smoking area to check in on residents while smoking.
During an interview on 3/21/23 at 12:09 P.M., Certified Nursing Assistant (CNA) D said:
-He/She did not know of any residents who needed help with smoking besides the two visually impaired residents.
-The reason why the resident was in the last room on the hall was because he could easily get him/herself out the door due to his/her visual impairment.
-He/She felt that the resident should be a supervised smoker.
-He/She had never been told by the resident of getting burned while smoking.
-If he/she had ever been told by a resident that they burned themselves while smoking he/she would have told a nurse, so the nurse could go assess the resident.
-He/She had not looked specifically at the resident's care plan, but there is the Kardex within the facility's charting system that would tell him/her what type of care the resident needs.
-He/She was unsure of what the resident's care plan was regarding smoking.
-He/She had never seen the resident burn him/herself while smoking.
During an interview on 3/21/23 at 12:23 P.M., Licensed Practical Nurse (LPN) A said:
-The resident had never burned him/herself while smoking to his/her knowledge.
-The facility did a smoking assessment with the resident and the facility staff cleared him/her for smoking and cleared him to smoke independently.
-The reason why the resident was in the last room on the hall was so the resident could take him/herself out smoking independently due to his/her visual impairment.
-Had seen the resident smoke before and had not seen the resident burn him/herself.
-He/She was able to look at the resident's care plan, but any changes to the care plan were usually made at the care plan meetings.
During an interview on 3/21/23 at 12:28 P.M., CNA G said:
-The resident did not need supervision and he/she had not asked for help or to be escorted out to smoke.
-He/She had previously assessed the resident and was surprised how well the resident was able to smoke independently.
-He/She had assessed the resident about six months.
During an interview on 3/21/23 at 12:30 P.M. CNA H said:
-The resident was taken out to smoke when he/she lived on a different hall.
-The resident was moved to 300 hall and was now able to take him/herself out to smoke independently.
-He/She had never been outside with the resident when the resident was smoking.
-He/She was unsure if the resident had been assessed for safe smoking recently.
-He/She felt like the resident did not need any assistance.
-The resident wanted to be as independent as possible.
During an observation and interview on 3/21/23 at 12:34 P.M., LPN A said:
-The resident denied burning him/herself while lighting his/her cigarette.
-He/She did not see any injuries to the resident's hand.
-During the interview the resident lit a cigarette.
-He/she flinched and shook his/her hand while lighting the cigarette.
-LPN A said that it looked like the resident had most likely burned him/herself.
Observation of the resident's hands on 3/21/23 at 12:39 P.M., showed:
-The resident's finger tips on his/her left hand were speckled with tiny black dots.
-The resident did not have any redness or swelling to his/her left index finger.
During an interview on 3/21/23 at 12:39 P.M. the resident denied having burned his/her fingers while lighting his/her cigarette in the previous observations.
During an interview on 3/21/23 at 12:44 P.M. Resident #17 said:
-Resident #63 has burned his hands multiple times while smoking.
-He/She would usually tell Resident #63 that he/she had burned his/her finger(s).
-Resident #63 usually responded with an expletive when Resident #17 told him/her about burning his/her finger(s).
-He/She had not told staff about Resident #63 burning his/her finger(s) because he/she thought the Resident #63 had burned him/herself so much that his/her fingers were used to it and probably numb.
-NOTE: Record review of Resident #17's quarterly MDS dated [DATE] showed the resident was cognitively intact.
Record review of a Nurse Note, created by LPN A on 3/21/23 at 12:48 P.M., showed:
-LPN A watched the resident light his/her own cigarette.
-The resident was relying on touch to feel if the tip of the cigarette was lit.
-The resident's reflexes seemed to react as expected when someone burns themselves.
-He/She educated the resident on a safer way to confirm that his/her cigarette was lit by drawing a puff and detecting the presence of smoke in his/her mouth.
-The resident had expressed comprehension of the education.
During an interview on 3/21/23 at 12:56 P.M. the Regional Director of Therapy said therapy was not responsible for evaluating the residents for smoking.
During an interview on 3/21/23 at 1:15 P.M., CMT B said:
-If a resident was able to feed themselves and wheel themselves then that resident was able to smoke independently.
-The resident was blind, but he/she could go outside by him/herself and smoke.
An observation on 3/21/23 at 2:06 P.M. showed the camera above the smoking area only filmed the area behind the facility which was the shed and part of the driveway.
During an interview on 3/21/23 at 2:57 P.M. the Facility Nurse Practitioner (NP) said:
-He/She had previously seen the resident smoke and the resident seemed safe to smoke.
-He/She had not seen the resident light his/her own cigarette or put it out.
-If a resident is blind it does not mean that the resident is unsafe to smoke.
During an interview on 3/21/23 at 3:56 P.M., the Facility NP said:
-He/She had assessed the resident's hands and fingers and the resident did not show any signs of any injury.
-He/She saw to no redness to the resident's hands or fingertips and there was no indication that the resident had any trauma to his/her skin.
During an interview on 3/21/23 at 4:04 P.M., LPN B said:
-He/She was the one that performed the smoking assessment on the resident.
-During a smoking assessment the one performing the assessment would go out with the resident and observe the whole smoking process.
-The smoking process included how the resident lights a cigarette, how they smoke the cigarette, and how they distinguish the cigarette.
-The resident was able to smoke appropriately at the time of his/her assessment on 3/3/23.
--The resident was able to light his/her cigarette without burning him/herself, did not burn his/her clothing during the duration of smoking, was able to hold the cigarette for the whole duration of the smoking, and distinguished the cigarette with his/her fingers.
-He/She felt that the resident was safe to smoke independently without an apron.
-He/She was not the only person that could perform smoking assessments, most staff were able to perform the assessment.
-Thought that the smoking assessments were performed quarterly.
-A resident could be safe at the time of the smoking assessment, but two weeks later any resident could not be safe to smoke assessment.
-The residents usually told staff if they burned themselves while smoking.
Record review of the resident's care plan, updated on 3/22/23, showed:
-The resident had two different focuses related smoking.
-One focus and intervention indicated the resident did not need supervision to smoke; the resident only needed an escort to and from the designated smoking area.
-One focus and intervention indicated the resident did need supervision while smoking. This intervention was added to the updated care plan on 3/22/23.
-The facility staff were to observe the resident's clothing and skin for cigarette burns.
-The resident was to have his/her smoking supplies stored.
2. During an interview on 3/21/23 at 12:03 P.M., Certified Medication Technician (CMT) G said:
-Social Services or the Unit Managers were the ones that evaluate the resident's ability to smoke upon admission.
-The designated smoking area was outside of the 300 hall.
-The facility did not have smoking times and the residents could smoke whenever they want.
-The smoking assessments should be completed every 90 days.
-There were no residents who needed help to smoke.
-None of the residents needed to wear a smoking apron.
-The facility had about 15 to 20 residents who would go out daily to smoke.
-There was an ash tray and a red can that the residents would put the cigarette butts in.
-There were always cigarette butts on the ground of the smoking patio because the residents did not put the cigarette butts in the ash tray.
-No staff member was assigned to watch the residents who smoke on the smoking patio.
-There was only one resident who was blind and smoked.
-If a resident smoked that should be in the resident's care plan.
-If an issue occurred outside while smoking a resident would come inside and inform staff.
-The residents are allowed to keep their lighters and cigarettes themselves.
During an interview on 3/21/23 at 12:09 P.M., CNA D said:
-In the past the facility had designated smoking times, but was unsure why the facility stopped the designated smoking times.
-The residents now get to go out to smoke whenever they want.
-The facility used to have smoking vests/aprons, but he/she was not sure where they were currently located.
-If he/she had ever been told by a resident that they burned themselves while smoking he/she would have told a nurse, so the nurse could go assess the resident.
-Residents were usually assessed for smoking upon admission.
-He/She was unsure of when the smoking assessments were done after admission, he/she thought it was every six months and as needed.
-He/She had not looked specifically at the resident's care plan, but there is the Kardex within the facility's charting system that would tell him/her what type of care the resident needs.
During an interview 3/21/23 at 12:17 P.M., Care Plan Coordinator A said:
-He/She was not super familiar with who the smokers were at the facility.
-He/She was unsure of which residents needed assistance while smoking.
-The residents that were mobile could walk down the 300 hall and access the door to the smoker's area.
-Social Services and Nursing were the ones responsible for the smoking assessments.
-The smoking assessments were done monthly or quarterly, then they are documented in the facility's charting system.
-He/She was unfamiliar with smoking aprons and thought other staff may be able to answer more questions.
During an interview on 3/21/23 at 12:23 P.M., LPN A said:
-The smoking assessments are completed by staff who smoke.
-There was a nurse who smoked and could complete the assessment.
-Smoking assessments were completed every year and as needed.
-He/She had not seen smoking aprons used at the facility and thought that the use of them would cause an issue with resident dignity.
-He/She was unsure of what was on the facility's smoking policy.
-The facility did not have smoking times and resident smoking had no structure.
-He/She was unsure if the facility ever had smoking times.
During an interview on 3/21/23 at 12:28 P.M., CNA G said:
-No residents on his/her assigned hall needed assistance with smoking.
-Was unaware if smoking aprons were available.
-There were no designated staff for smoking residents.
-He/She would periodically check on the smokers.
-The facility did not have designated smoking times.
-The residents were able to go in and out to smoke whenever they felt like it.
-Not all residents kept their cigarettes and lighters with them.
-Residents who are cognitively intact who smoke without assistance are able to keep cigarettes in their rooms.
-Nurses are the ones who kept the cigarettes for residents who were not cognitively intact.
-Residents who need supervision were not allowed to go smoke.
During an interview on 3/21/23 at 12:30 P.M. CNA H said:
-No supervision was required for smoking.
-Some residents kept their own smoking supplies with them.
-The facility did not have designated smoking times.
-No resident was designated to have supervision while smoking.
-Staff do not smoke with the residents.
-Staff have their own designated smoking area.
During an interview on 3/21/23 at 1:15 P.M., CMT B said:
-If a resident needs assistance with smoking it would be in their chart.
-The residents smoke outside the door on the 300 hall.
-There were no scheduled times for smoking.
-If a resident was able to feed themselves and wheel themselves then that resident was able to smoke independently.
-The residents were able to keep their own smoking supplies in their rooms.
-Therapy and Social Services were the ones who performed smoking assessments.
-No staff member was assigned to monitor residents while they smoked.
-The CNA assigned to the 300 hall would sometimes peak outside and look at the smokers.
-He/She thought someone should be outside watching the smokers.
-If there was a problem while the residents were out smoking another resident would come in and alert staff to the problem.
-He/She thought there was a camera that pointed in the direction of the smoking patio.
-He/She was unsure if the camera actually filmed the smoking area or if it was watched by anyone.
During an interview on 3/21/23 at 2:06 P.M. the Maintenance Director said the camera above the smoking area did not point at the actual smoking area it monitored the shed and part of the driveway behind the facility.
During an interview on 3/21/23 at 2:57 P.M. the Facility Nurse Practitioner (NP) said:
-He/She expected staff to watch the resident's ability to light the cigarette, smoke safely, put out the cigarette and dispose if the cigarette in the appropriate receptacle.
-He/She expected the facility should reassess a resident's safety to smoke if they found a resident with smoking holes in their clothing and were previously safe to smoke.
-All residents should be monitored by staff when outside smoking.
During an interview on 3/21/23 at 3:43 P.M. the Social Services Director (SSD) said:
-He/She and another staff member had performed smoking assessments on the day of 3/2/23.
-He/She thought that nurses were the ones that typically performed the assessments.
-He/She did not normally perform smoking assessments, he/she was only helping out that day.
-During a smoking assessment he/she would assess if the resident was able to light his/her own cigarette, if the resident was able to hold the cigarette, and if the resident was able to appropriately extinguish the cigarette and place the cigarette butt in the proper receptacle.
During an interview on 3/24/23 at 11:37 A.M., the Medical Director (MD) and NP said:
-The facility should have had supervised smoking especially for the visually impaired residents.
-If any resident is assessed safe to smoke then they should be allowed to smoke.
-The facility interventions that were now in place were appropriate.
During an interview on 3/29/23 at 2:05 P.M. the Director of Nursing (DON) said:
-He/She was made aware that Resident #63 had not being supervised while smoking.
-He/She thought that supervision would be needed for Resident #63.
-Smoking assessments were done upon admission and if there was any change of condition.
-Social Services was responsible for completing smoking assessments, but nurses can reassess, or they could tell Social Services that a reassessment was needed.
-A smoking assessment needed to be completed in a certain way.
-He/She expected staff to watch the resident from the start of the smoking process to the end of the smoking process.
--This included how the resident is able to light the cigarette, how the resident smokes the cigarette, and how the resident disposes of the cigarette.
-If a resident were to burn themselves while smoking he/she would expect the nurse to assess for injury, notify the doctor, and reassess the resident for the ability to smoke safely.
-He/She thought there was a smoking agreement completed by the resident during the admission process.
-He/She was unsure of what guidelines were in the facility's smoking policy.
8. Record review of Resident #153's admission Face sheet showed he/she had the following diagnoses:
-Cerebrovascular Accident (CVA, stroke a blockage in the one or more of the arteries supplying blood to the brain).
-Anoxic brain damage (is harm to the brain due to a lack of oxygen).
Record review of the resident's admission MDS, dated [DATE], showed he/she:
-Was severely cognitively impaired and had short term and long term memory problems;
-He/she was able to understand others and make his/her needs known;
-Required total assistant for staff for all cares and transfer.
-Had no documentation that the resident had a history falls prior to admission or upon admission.
Record review of the resident's fall care plan, dated 3/6/23, showed:
-The resident was at risk for falls related to anoxic brain damage, cardiac arrest, cerebral aneurysm.
-Anticipate and meet the resident needs.
-The nursing staff were to follow facility fall protocol.
-Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes.
-Physical therapy were to evaluate and treat as ordered or as needed.
Record review of the resident nursing note, dated 3/14/23 at 8:39 A.M., showed:
-The nurse alerted by staff to go to the resident's room. The resident was on the floor.
-Upon entering the resident's room noted that the resident was laying face down by his/her bed.
-The resident stated that he/she had hit his/her head and reported that his/her head was hurting.
-He/she had voiced no other concerns of pain anywhere else.
-The nurse had placed a call to the NP and received a new physician's order to send to the resident to the hospital for further evaluation and treatment due to hitting his/her head.
-All parties were notified.
Record review of the resident's incident fall investigation, dated 3/14/23 at 8:39 A.M., showed.
-Had non-injury fall in his/her room.
-The resident was observed lying face down on the floor next to his/her bed. He/she reported that he/she had hit his/her head and had a headache.
-Documented that the resident had no other injury noted.
-Resident was confused and unable to tell why or how he/she had fallen.
-Immediate actions taken were to assess the resident for injury and assisted him/her back into his/her bed by using a mechanical lift.
-Nursing staff had notified the NP and had received physician's orders to send the resident to the hospital for evaluation and treatment.
-The resident was confused with impaired memory and had been treated for urinary tract infection (UTI).
-Family was notified.
-Did not provide a comprehensive fall investigation to include the post fall documentation and final Registered Nurse or DON investigation with root cause noted.
-Did not have documentation if any new fall interventions were implemented or past fall interventions were reviewed and the care plan not updated after fall.
Record review of the resident's fall risk assessment, dated 3/14/23 at 11:23 A.M., showed the resident was at high risk for falls with a score of 32 (range 18+ or higher).
During an interview on 3/21/23 at 10:36 A.M., LPN B said:
-The resident had fallen out of bed on 3/14/23.
-That was first time resident had fallen.
-Interventions were put in place to include added bolsters and fall mat.
-He/She thought the resident had just rolled out of bed.
-The resident had no major injury reported.
During an interview on 3/29/23 at 9:20 A.M., CMT D said:
-He/she thought the resident was on hospice services.
-Before the resident's most recent fall, he/she had a regular hospital bed and a fall mat.
-Interventions put in place after the resident's fall was provided with a low air loss mattress (LAM) and bolster.
During an interview on 3/29/23 at 9:27 A.M., LPN E said:
-Resident #153 was not on hospice services at that time.
-After the resident's fall, the facility had added new interventions to include fall mats and a new LAM with bolster.
-Prior to the resident's fall he/she did not have bolsters on the bed, during the IDT meeting it was determined the resident had rolled out of bed.
-The resident falls were reviewed during the IDT meeting and at that time facility IDT team would determine a root cause.
-IDT team would have reviewed the resident care plan and then would implement any new intervention at that time.
-Would expect to have an IDT team meeting note documented in the resident progress notes with any follow-up and outcome from investigation.
12. During an interview on 3/28/23 at 2:30 P.M., CNA O:
-He/she would report any falls to the charge nurse.
-He/she would be assigned to check the resident's vital signs and would assist transferring the resident to bed or chair, if the resident doesn't have an injury, or the nurse would send the resident to the hospital if they have an injury.
-He/she would monitor the resident with 15 minutes checks and as follow-up after a fall.
-Resident #145 fell on 3/7/23, his/her bed was in the lowest position to the floor and had fall mats on the side.
-He/She found Resident #145 and immediately notified the charge nurse who assessed the resident.
-Resident #145 had a history of crawling out of his/her bed and likes to wonder a lot.
-The CNAs were to provided frequent checks on the resident for safety.
-Resident #153 had received a new cradle soft sided mattress and his/her bed in the lowest position and frequent checks.
--He/She had found Resident #153 and appeared he/she had rolled or slide out bed.
--The resident had a different bed that did not work for him/her at that time.
--The facility had provided the resident a new LAM and soft side bolster.
During an interview on on 3/29/23 at 2;05 P.M., DON said:
-Resident #153 had a unwitnessed fall on 3/14/23 that he/she had rolled out of bed.
--The resident was given a new low loss air mattress with soft side bolster.
-He/she was not aware of any bed malfunction for this resident.
--Prior to the fall he/she thought the resident had a low air loss mattress with no bolster.
-He/she would expect the resident's care plan updated and reviewed after each fall.
-The facility fall investigation were under risk management.
-He/She would expect nursing staff to initiate the fall investigation and DON/ADON or IDT would complete the fall investigation.
--Would expect a fall investigation to be comprehensive and to include but not limited to the date and time of the fall, any past health conditions, nursing documentation of the fall incident, resident interview, immediate action taken, notification of family members, physician, DON and administrator, and if the resident was sent for treatment.
-Would expect the nursing staff to have initiated the resident fall investigation/report immediately after a resident fall.
-He/she would expect nursing staff to have completed a post fall follow-up note (was not sure time frame for the documenting).
-He/she would had expected a completed IDT incident note that would include the review of the nurse's note, root cause for the resident fall and any new intervention.
-During IDT meeting the DON or MDS coordinator would review the resident fall care plan and update with any new fall interventions during that time.
-The fall investigation for Resident#153 was not complete or comprehensive investigations.
--He/She said their investigation should have additional documentation that would include the post follow-up, root cause and any intervention initiated or reviewed.
Complaint #MO00215144, MO00215409
6. Record review of the facility's policy undated Fall Management Policy showed:
-Following a resident's fall, the licensed nurse will complete an incident report and a post fall investigation and assessment within 24 hours after the fall or as soon as practicable.
-The licensed nurse will review the circumstances of the fall, review the plan of care, implement new interventions as appropriate and revise the care plan as needed.
-The Interdisciplinary Committee will meet within 72 hours of the fall. The committee will review and document the summary of event following a fall, root cause analysis, referrals as necessary and interventions to prevent future falls.
-The policy did not show how the staff should monitor the resident after a fall or frequency of monitoring after a fall.
7. Record review of Resident #96's Face Sheet showed he/she was admitted on [DATE] with diagnoses including respiratory failure, chronic obstructive pulmonary disease (COPD- a progressive disease that is characterized by shortness of breath and difficulty breathing), obesity, heart failure, pain, anxiety disorder, depression, iron deficiency and sleep apnea (a common disor
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8. Record review of Resident #97's undated face sheet showed he/she readmitted to the facility on [DATE] with the following diag...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8. Record review of Resident #97's undated face sheet showed he/she readmitted to the facility on [DATE] with the following diagnoses:
-Cerebral Infarction (stroke- a disruption of blood flow to the brain).
-Aphasia (loss of ability to understand or express speech) following a cerebral infarction.
-Acute on Chronic Respiratory Failure (a short term condition turning into a long term condition in which the lungs cannot provide enough oxygen to the blood).
Record review of the resident's POS dated March 2023 showed:
-Monitor oxygen saturation (the balance of the specific amount of oxygen present in the blood) each shift.
-Apply oxygen if oxygen saturation is below 92% (the normal range is 97%-100%, for someone with COPD the oxygen saturation percentage that is considered safe is 88%-92%).
-NOTE: The resident did not have an order in place for continuous oxygen therapy.
Observation on 3/20/23 at 11:39 A.M. of the resident showed:
-He/she had a concentrator at his/her bedside set to 2 Liters (L).
-He/she was receiving oxygen through a nasal cannula.
-The nasal cannula was lying on his/her neck and not in his/her nose.
Record review of the resident's care plan dated 3/21/23 showed:
-The resident only received as needed for low oxygen saturation.
-A note added to the care plan on 3/14/23 indicating the resident returned from the hospital with a thoracotomy (a surgical incision to the chest wall) site to the right side of the chest.
Observation on 3/21/23 at 9:27 A.M. of the resident showed:
-He/She was still using the oxygen concentrator set at 2L.
-The nasal cannula was hanging off of his/her face and not in his/her nose.
Observation on 3/22/23 at 11:52 A.M. showed the resident's nasal cannula was hanging off his/her face.
Observation on 3/24/23 at 7:44 A.M. showed the resident's nasal cannula was not on his/her face, it was in the resident's right hand.
Observation on 3/29/23 at 9:14 A.M. of the resident showed he/she had pulled the nasal cannula off of his/her face and was wrapped around his/her right hand.
9. During an interview on 3/28/23 at 12:21 P.M., CNA D said:
-If he/she was unsure if a resident was on oxygen he/she would look at the resident's Kardex within the facility's charting system to indicate what type of care the resident needed.
-Most of the residents who receive oxygen have a sign outside of their room.
-When the resident returned from the hospital he/she was told by the nurse that the resident was supposed to be on 2L of continuous oxygen.
-If he/she were to check in on the resident and the resident's nasal cannula was off his/her face then he/she would reapply it.
-The resident has some control over his/her right hands and can pull his/her oxygen tubing off.
-He/she thought there was an oxygen order in place.
During an interview on 3/28/23 at 1:10 P.M., LPN D said:
-He/she would know if a resident received oxygen by looking at the oxygen order.
-He/she would expect to be told if a resident was newly on oxygen during shift change report.
-All residents receiving oxygen therapy should have an order.
-An oxygen order should have the amount of liters, the parameters in which the oxygen needs to be taken on or off, when to call the doctor, when tubing and humidifier water needed to be changed.
-Oxygen therapy should be included in the care plan.
-If the resident's oxygen was not on correctly he/she would put it back in place and educate the resident on the importance of keeping the nasal cannula in place.
During an interview on 3/28/23 at 1:28 P.M. LPN B said:
-There should be an oxygen order in place for residents receiving oxygen therapy.
-An oxygen order should include the method of therapy, when to change the tubing, how many liters, and whether the oxygen is continuous or as needed.
-He/she would now a resident is receiving oxygen by the sign outside the resident's door.
-If a resident was receiving oxygen therapy and an order was not in place, then he/she would call the doctor to get an order.
-Oxygen therapy should be included in the care plan.
-The care plan should include the parameters and the order itself.
During an interview on 3/29/23 at 9:02 A.M., CMT D said:
-If he/she was unsure if a resident was supposed to receive oxygen he/she would look at the resident's care plan.
-An oxygen order should include the parameters and liters.
-He/She would also ask the nurse if a resident was supposed to receive oxygen therapy.
-There should be an order in place for a resident who received oxygen therapy.
During an interview on 3/29/23 at 2:05 P.M. the DON said:
-He/she would expect an order for oxygen to be in place for a resident receiving oxygen therapy.
-Oxygen therapy should be included in a resident's care plan.
-The MDS Coordinator and nurses could update care plans.
-An oxygen order should have:
--Whether the oxygen is continuous or as needed.
--The amount of Liters.
--The delivery system for oxygen.
-He/she would expect the nurses to get an order for oxygen therapy if there was not one already in place.
-Oxygen therapy should be included in the care plan.
4. Record review of Resident #23's face sheet showed he/she was admitted to the facility with the following diagnoses:
-Acute Respiratory failure with hypoxia (an impairment of gas exchange between the blood and the lungs making it difficult to breathe).
-Pneumonia (an infection of the lungs).
Record review of the resident's annual MDS assessment dated [DATE] showed his/her Brief Interview for Mental Status (BIMS) score was 15 out of 15, indicating he/she was cognitively intact.
Record review of the resident's March 2023 POS showed the following orders:
-Change oxygen tubing weekly.
-Label each component with date and initials.
-Change every Sunday on night shift, dated 3/10/23.
-Change oxygen tubing, humidifier bottle and plastic holding bag for oxygen on the night shift on Sundays, dated 3/10/23.
-Oxygen at 3 liters per nasal cannula continuously.
-Monitor every shift, dated 3/10/23.
Record review of the resident's undated care plan showed:
-He/she had an altered respiratory status and difficulty breathing related to acute respiratory failure with hypoxia.
-Oxygen at 3 liters via nasal cannula.
Record review of the resident's admission MDS dated [DATE] showed:
-His/her BIMS score was 15 out of 15, indicating he/she was cognitively intact.
-He/she had respiratory failure.
Record review of the resident's March Treatment Administration Record (TAR) showed:
-On 3/19/23 the tubing had been changed, labeled with dates and initials.
-On 3/19/23 the oxygen tubing, humidifier bottle, and plastic holding bag had been changed.
Observation on 3/20/23 at 11:13 A.M. showed:
-The resident's nasal cannula/tubing were laying on the floor.
-There was no date or initials on the tubing.
-There was no bag to put the oxygen tubing into in the resident's room.
-There was no date on the humidifier.
-The resident was not wearing the oxygen.
During an interview on 3/20/23 at 11:15 A.M. the resident said:
-His/her oxygen tubing may have been changed a week ago.
-The staff does not keep it in a bag usually.
-He/she did not have to wear oxygen at all times.
Observation on 3/20/23 at 11:31 A.M. of Certified Medication Technician (CMT) B showed:
-He/she came into the resident's room picked the oxygen tubing up off of the floor, wound it up, and put it on the resident's concentrator (machine that makes oxygen).
-He/she turned off the oxygen.
During an interview on 3/20/23 at 11:33 A.M., CMT B said:
-The oxygen tubing was changed on Sunday the night shift.
-You would look at the orders to see how much oxygen the resident was on.
-He/she did not think there was anything else you needed to do with the oxygen or tubing.
Observation on 3/20/23 at 11:35 A.M. showed the resident turned his/her oxygen back on and put the tubing back in his/her nose.
Observation and interview on 3/22/23 at 12:47 P.M., the resident said:
-It had been more than a week since the staff had changed the oxygen tubing.
-The oxygen tubing did not have a date it was changed on it.
-There was no bag to store the oxygen tubing.
-The oxygen was set at 4 liters.
-The resident was wearing the oxygen.
-There was no date on the humidifier.
-The resident did not know when the humidifier had last been changed, more than a coupe of weeks.
Observation on 3/27/23 at 10:50 A.M., showed:
-The oxygen tubing did not have a date on it.
-There was a bag that did not have initials or a date on it.
-The oxygen tubing was sitting on the concentrator not in the bag.
-The resident was out of the room.
-There was no date on the humidifier.
5. Record review of Resident #24's face sheet showed he/she was admitted to the facility with the following diagnoses:
-Obstructive sleep apnea.
-COPD.
Record review of the resident's annual MDS assessment dated [DATE] showed his/her BIMS score was 15 out of 15 indicating he/she was cognitively intact.
Record review of the resident's March 2023 POS showed an order for Albuterol Sulfate nebulization solution 2.5 mg/3 ml, 0.083 % 3 ml inhale orally via nebulizer every four hours as need for shortness of breath, dated 11/23/22.
Record review of the resident's March 2023 TAR showed the medication had not been used.
Observation on 3/20/23 at 3:51 P.M. showed the resident had a nebulizer not in a bag sitting on his/her dresser.
During an interview on 3/20/23 at 3:55 P.M. the resident said:
-He/she uses the nebulizer some times at night when he/she had a hard time breathing.
-It has been a while since he/she used it.
-He/she wanted to keep it at his/her bedside in case he/she needed to use it.
-He/she did not think the staff had ever cleaned the nebulizer or changed out the tubing.
Observation on 3/22/23 at 12:39 P.M. showed the resident's nebulizer was on chest of drawers not in bag.
Observation on 3/23/23 at 3:01 P.M. showed:
-The resident's nebulizer was on chest of drawers not in bag.
-The resident's nebulizer was hanging between the resident's chest of drawers and his/her refrigerator.
During an interview on 3/24/23 at 11:36 A.M. Registered Nurse (RN) D said:
-Oxygen tubing or nebulizer tubing should be changed weekly by the night shift.
-It should be documented on the TAR when it was changed.
-The tubing should be dated and initialed when it was changed and who changed it.
-The tubing or nebulizer should be in a bag when not in use.
-There should be a date and pintails also on the bag showing when it was changed.
-The resident had an active order for a nebulizer but did not remember the last time he/she used it.
6. Record review of Resident #88's face sheet showed the resident was admitted to the facility with the following diagnoses:
-COPD.
-Chronic respiratory failure.
-Sleep apnea.
Record review of the resident's quarterly MDS assessment dated [DATE] showed:
-His/her BIMS score was 13 out of 15 indicating he/she was cognitively intact.
-He/she needed extensive assistance with bed mobility.
-He/she had COPD.
-He/she had oxygen therapy.
Record review of the resident's March 2023 POS showed the following orders:
-Oxygen at 3 liters via nasal cannula continuously to keep oxygen saturation greater than 90% as needed, dated 6/3/22.
-Oxygen tubing to have been changed weekly, label each component with date and initials every Sunday on the night shift, dated 5/25/22.
-Ipratroplum-Albuterol solution 0.5-2.5 (3) mg/ml orally every four hours as needed for shortness of breath or wheezing, may self-administer via nebulizer, dated 5/23/22.
Record review of the resident's care plan dated 10/20/22 showed:
-He/she had an altered respiratory status.
-He/she uses oxygen at 3 liters continuously via nasal cannula, dated 3/3/20.
-He/she has been seen removing his/her own oxygen tubing and tossing it on the bed or across the oxygen concentrator, education has been given to place tubing a bag for infection control, dated 11/15/19.
-He/she and caregivers would properly store oxygen tubing supplies when not in use, dated 3/10/23.
-He/she has COPD with chronic respiratory failure.
-Give aerosol or broncobusters as ordered.
Observation on 3/20/23 at 10:36 A.M. showed:
-The resident was wearing oxygen via nasal cannula.
-There was a bag on the oxygen concentrator dated 3/16.
-He/she had an nebulizer laying on his/her bed not in a bag.
-The nebulizer was not dated.
During an interview and observation on 3/20/23 at 10:38 A.M. the resident said:
-The staff only change the oxygen tubing monthly, they used to change it every week.
-The staff has never changed the tubing or nebulizer.
-There was no date on the nebulizer or tubing.
-There was no bag for the nebulizer.
-The nebulizer was sitting on the resident's bed.
Observation on 3/27/23 at 10:50 A.M. showed:
-The resident was sitting on his/her bed with oxygen on via nasal cannula.
-The same bag was attached to the oxygen concentrator dated 3/16.
-His/her nebulizer was sitting on his/her night stand not in a bag.
Observation and interview on 3/28/23 at 1:00 P.M. showed.
-The resident was sitting on his/her bed with oxygen on via nasal cannula.
-The same bag was attached to the oxygen concentrator dated 3/16.
-His/her nebulizer was sitting on his/her night stand not in a bag.
-He/she said staff had not changed the oxygen tubing for more than a week now.
-Staff still had never changed out the tubing for the nebulizer or cleaned it.
7. During an interview on 3/28/23 at 1:05 P.M. RN D said:
-If a resident was on oxygen or used a nebulizer they should be changed out weekly on the night shift.
-Staff should document it out on the TAR.
-Oxygen tubing and the Nebulizer should be in a bag when not in use.
-Staff should document and initial the bag and the tubing when they change it out.
During an interview on 3/29/23 at 2:10 P.M. the Director of Nursing (DON) said:
-Nursing staff should change the oxygen tubing, nasal cannulas and face masks weekly and as needed.
-If a resident had oxygen or a nebulizer the tubing should be changed out weekly and as needed.
-Staff should document when it was changed on the TAR.
-Staff should ensure the oxygen tubing was in a bag with the date it was changed and their initials on it.
-All oxygen equipment should be in a bag when not in use.
-If the oxygen tubing was on the floor it should have been changed out.
-CNA staff can change out the tubing and face masks and anyone that is at the resident's bedside should be checking.
-Bags for storing oxygen equipment are located in central supply and nursing staff should get a bag from central supply or from the charge nurse.
Based on observation, interview and record review, the facility failed to store oxygen face masks, tubing and nasal cannulas (a lightweight tube which on one end splits into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows) to prevent cross-contamination when not in use for four sampled residents (Resident #96, #23, #24, and #88) and one supplemental resident (Resident #65); to perform tracheostomy (trach - a surgical procedure to create an opening through the neck into the trachea windpipe; a tube is usually placed through this opening to provide an airway and to remove secretions from the lungs) care using a sterile technique for one sampled resident (Resident #153), and to ensure an oxygen order was in place for one sampled resident (Resident #97) who received continuous oxygen out of 30 sampled residents. The facility census was 148 residents.
Record review of the facility's policy titled Oxygen Administration dated June 2020, showed:
-All oxygen tubing, humidifiers, cannulas and face masks used to deliver oxygen are for single resident use only and will be changed weekly and when visibly soiled or as indicated by state regulation.
-Turn oxygen off when oxygen is not in use.
-Oxygen items will be stored in a plastic bag at the resident's bedside to protect the equipment from dust and dirt when not in use.
-A physician ' s order is required to initiate oxygen therapy, except in an emergency situation.
-The order shall include:
--Oxygen flow rate.
--The method of administration.
--Usage of therapy.
--Titration instructions if indicated.
--Indication for use.
Record review of the facility's policy titled Hand Hygiene dated June 2020 showed:
-Facility Staff and volunteers must perform hand hygiene with an alcohol-based product or hand washing in the following circumstances, but not limited to:
--Immediately upon entering a resident occupied area regardless of glove use.
--Immediately upon exiting a resident occupied area regardless of glove use.
--In between glove changes.
--Before applying sterile gloves.
A policy and procedure on Tracheostomy Care was requested, but not provided by the the time of exit.
1. Record review of Resident #153's admission Face sheet showed he/she had the following diagnoses:
-Cerebrovascular Accident (CVA, stroke a blockage in the one or more of the arteries supplying blood to the brain).
-Anoxic brain damage (is harm to the brain due to a lack of oxygen).
-Respiratory failure (is a serious condition that makes it difficult to breathe on your own) with a tracheostomy.
Record review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 2/16/23, showed he/she:
-Was severely cognitively impaired and had short term and long term memory problems.
-He/she was able to understand others and make his/her needs known.
-Required total assistant for staff for all cares and transfer.
-Required a trach.
Record review of the resident's Physician Order Sheet (POS) dated 2/20/23 to 3/27/23 showed:
-He/she had a physician order for Trach care that included:
--Suction Trach as needed, ordered on 2/20/23.
--Complete Trach Care: Change inner cannula daily and T-sponge every day shift and as needed, ordered on 2/20/23.
-Check and maintain Ambu bag (artificial manual breathing unit, refers to a type of device known as a bag valve mask, which is used to provide respiratory support to patients), replacement trach tube, and suction setup at bedside every day-shift on Wednesday and Friday, ordered on 2/22/23.
-Trach tube of equal size 8 (specify equal size) and one size down of a 7 (specify 1 size down) maintained at bedside, every shift, ordered on 2/22/23.
-Clean non-disposable inner cannula every day shift and as needed, ordered on 2/22/23.
-Trach tube Type was a cuffed Shiley Trach tube (Disposable Inner Cannula) Size: 8, ordered on 2/22/23.
-Send to emergency room if unable to re-insert trach tube, ordered on 2/22/23.
Record review of the resident's Care Plan dated 3/6/23 showed:
-He/she required the use of tracheostomy.
-Nursing staff were to use universal precautions as appropriate.
-Ensure that trach ties are secured at all times.
-Suction as necessary.
-He/she had a communication problem related to/ anoxic brain damage, cerebral aneurysm, respiratory failure with a tracheostomy.
-Did not give detail on how to care for the resident trach site or suctioning.
Observation on 3/22/23 at 11:22 A.M., of the resident showed:
-He/she was in no distress head of the bed was elevated 30 degrees.
-He/she had suction equipment and ambu bag were at bedside and was operational.
-His/her trach site appears clean at that time.
Observation on 3/23/23 at 10:26 A.M. of resident's tracheostomy care by Licensed Practical Nurse (LPN) A showed:
-He/she entered the resident's room, performed hand hygiene, and put on gloves.
-He/she then looked through the resident's drawers for supplies, removed two disposable cups, and filled both with tap water, and removed gauze from a drawer.
-He/she removed his/her gloves and put on new gloves without performing hand hygiene.
-He/she removed the oxygen mask from the resident's tracheostomy tube, opened multiple drawers of the resident's bedside table in search of more supplies.
-He/she then removed his/her gloves and left the room without performing hand hygiene.
Observation on 3/23/23 at 10:33 A.M. showed LPN A:
-Reentered the resident's room with more supplies, did not perform hand hygiene, and put on new gloves.
-Lifted the resident's head, removed the gauze from under the tracheostomy tube, removed one glove (with used gauze in it) and threw it away, picked up the trash can and brought it closer, and put on a new glove without performing hand hygiene.
-Opened the packaging of each supply exposing the supplies but not removing from package.
-Removed his/her gloves, did not perform hand hygiene, and put on sterile gloves.
-Attached a cannula to the suction tubing, placed suction tubing into one cup of tap water, then suctioned the resident's tracheostomy tube, used suction tubing to then suction more water from the same cup of tap water.
-Then suctioned a liquid substance from the tracheostomy kit, turned off the suction machine, covered the suction tubing and placed in a plastic bag.
-Gauze lifted from packaging, cut with scissors that were on the bedside table without a barrier, and placed around the resident's tracheostomy tube.
-Replaced the oxygen mask over the tracheostomy tubing.
-Moistened a mouth swab in the second plastic cup of tap water and swabbed the resident's mouth and lips.
-Placed unused supplies in the resident's drawers with same gloves used to provide cares.
-Removed his/her gloves and washed his/her hands.
During an interview on 3/23/23 at 10:44 A.M., LPN A said he/she has run out of gloves during the last stage of cleaning but knew he/she should have changed gloves one more time.
During an interview on 3/23/23 at 10:45 A.M., LPN A said:
-His/her hands should be washed before he/she had started, before gloving up, entering or exiting a room.
-He/she should have sanitized between glove changes.
-He/she had not sanitized because he/she did not have hand sanitizer in the room with him/her.
During an interview on 3/28/23 at 2:35 P.M., Registered Nurse (RN) B said:
-For trach care and suctioning should use sterile water that comes in the trach kit.
-He/she would not use tap water for care or suctioning the resident's trach.
During an interview on 3/29/23 at 2:05 P.M., Director of Nursing (DON) said:
-He/she would expect nursing staff to use standard precaution during care of the trach
-He/she would expect use trach care kit that include sterile water when suction and care of the trach site.
-Nursing staff should not being using tab water when suctioning or cleaning the site.
-replacement of trach would be sterile process.
-He/she would expect hand hygiene of washing hand before placing of sterile gloves.
Complaint MO00215409
2. Record review of Resident #96's Face Sheet showed he/she was admitted on [DATE] with diagnoses including respiratory failure, chronic obstructive pulmonary disease (COPD- a progressive disease that is characterized by shortness of breath and difficulty breathing), obesity, heart failure, pain, anxiety disorder, depression, iron deficiency and sleep apnea (a common disorder in which you have one or more pauses in breathing or shallow breaths while you sleep).
Record review of the resident's admission MDS dated [DATE], showed the resident:
-Was alert oriented and cognitively intact.
-Had no behaviors and was not resistive to cares.
-Needed extensive assistance of one person with bed mobility, transfers, bathing, dressing, toileting and did not walk.
-Had not had any falls prior to admission or since admission.
-Had shortness of breath and received oxygen therapy.
Record review of the resident's POS dated 3/2023, showed physician's orders for:
-Oxygen at 5 liters per minute via nasal cannula continuously or as needed to keep oxygen saturation greater than 90% every day and night shift shortness of air and as needed (12/17/22).
-Albuterol Sulfate (medication used to increase the movement of air in the lungs) inhaler 2 puff inhale orally every four hours as needed for shortness of air; resident can keep at bedside (1/2/23).
-Ipratropium-Albuterol Solution (used to treat residents with narrowing and spasm of the bronchial tubes in the lungs) 0.5-2.5 milliliters (ml); 3 ml, inhale one vile orally via nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) four times a day for shortness of air, rinse mouth after use; unsupervised self-administration (9/23/22).
-Clean oxygen filter weekly on night shift every seven days (9/24/22).
-Oxygen tubing: change weekly, label each component with date and initials every night shift every Sunday (9/25/22).
Record review of the resident's Care Plan dated 2/25/23, showed the resident had chronic lung disease related to COPD and sleep apnea. Interventions showed staff would:
-Administer oxygen as ordered.
-Give aerosol or bronchodilators as ordered, monitor and document any side effects and effectiveness.
-Keep the head of his/her bed elevated or have him/her out of bed upright in a chair during episodes of difficulty breathing.
-Monitor him/her for difficulty breathing on exertion. Remind resident not to push beyond his/her endurance.
-Monitor for signs and symptoms of acute respiratory insufficiency: anxiety, confusion, restlessness, shortness of breath while at rest.
-Monitor, document and report as needed any signs or symptoms of respiratory infection.
During an observation an interview on 3/20/23 at 1:25 P.M., showed the resident was laying in his/her bed, dressed for the weather wearing oxygen via a nasal cannula. The resident said:
-He/she was not having any difficulty breathing.
-The filters on his/her oxygen concentrator were dirty because they had not been changed in weeks.
-Observation of the oxygen filter on the side of the oxygen concentrator showed it was dirty.
-He/she was to receive breathing treatments daily and the nursing staff had not changed his/her face mask in months.
-The resident opened a drawer showing his/her nebulizer machine and face mask that was not covered. The face mask showed the date 11/26. The resident said it was not changed since November.
-He/She took his/her breathing treatments four times daily, using the current face mask because he/she did not have another one to use.
Observation on 3/24/23 at 7:25 A.M., showed the resident was in his/her bed with oxygen on. The resident's eyes were closed and there was no signs of respiratory distress or discomfort. The face mask to his/her nebulizer was still in the drawer next to his/her bed uncovered and dated 11/26.
Observation and interview on 3/28/23 at 10:46 A.M., showed the resident was laying awake in his/her bed. He/She was wearing his/her oxygen. The oxygen concentrator showed the water bottle was full but the filter had not been changed. He/she did not seem to be in any respiratory distress. His/her nebulizer machine was sitting on top of the dresser beside his/her bed. The face mask was sitting on top of the machine and was uncovered and dated 11/26. The resident said:
-The staff have come into his/her room to change the water on her concentrator but they still have not changed the face mask on his/her nebulizer machine.
3. Record review of Resident #65's Face Sheet showed he/she was admitted on [DATE], with diagnoses including COPD, fainting, low iron, pain, falls, high blood pressure, muscle weakness and anxiety.
Record review of the resident's quarterly MDS dated [DATE], showed the resident:
-Was alert, oriented and cognitively intact.
-Was independent with mobility, eating and needed limited assistance with toileting, hygiene, bathing and transfers.
-Did not use oxygen during the lookback period.
Record review of the resident's POS dated 3/2023, showed physician's orders for:
-Albuterol Sulfate 0.5 ml, inhale orally via nebulizer every six hours as needed for shortness of air; unsupervised, resident can self-administer (6/16/22).
-Oxygen at 2 liters per minute for shortness of air (3/24/23).
Observation on 3/21/23 at 3:44 P.M., showed the resident was sitting on his/her bed taking his/her breathing treatment. The resident's oxygen concentrator was sitting on the floor across from his/her bed with the nasal cannula and tubing coiled around the concentrator, uncovered. There was no bag visible on or around the oxygen concentrator to place his/her nasal cannula and tubing in.
Observation on 3/23/23 at 1:19 P.M., showed the resident was not in his/her room. His/her oxygen concentrator was across from his/her bed with the nasal cannula and tubing coiled around the concentrator and uncovered. The resident's nebulizer machine was sitting on top of the dresser with the facemask uncovered. There was no bag observed to put either of the supplies in.
Observation on 3/24/23 at 7:14 A.M., showed the resident was not in his/her room. The oxygen tubing and nasal cannula were sitting on top of his/her oxygen concentrator uncovered. The face mask to his/her nebulizer machine was laying on top of her dresser uncovered. There were no bags visible to put the oxygen equipment in.
During an interview on 3/28/23 at 1:39 P.M., Certified Nursing Assistant (CNA) L said:
-The oxygen nasal cannulas and face masks are supposed to be stored in a bag when not in use.
-Some residents have a bag on their concentrator and some have them on their walker. -Each shift should check to ensure there were bags available, but as they go into the resident's room if they see there is no bag on the room they can get one from central supply or the nurse.
-All shifts should be checking to make sure the oxygen tubing and face masks are stored in the bags when not in use.
-Oxygen and nebulizer tubing and face masks should be changed out weekly or every two weeks. The filter should be cleaned or replaced as needed.
-The night shift had been responsible for changing the oxygen equipment out and this task was on their to do list.
-The day shift should also check to see if the equipment needed to be changed out and if the night shift did not change it out, they can also change it.
-The resident's face mask should have been changed several times since 11/26/22.
-He/she will ensure the resident's face mask was changed and check the filter.
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** 2. Record review of Resident #24's face sheet showed he/she was admitted to the facility with the following diagnoses:
-Orthoped...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #24's face sheet showed he/she was admitted to the facility with the following diagnoses:
-Orthopedic aftercare following surgical amputation (surgical removal of a body part).
-Peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs which can cause pain when walking).
-Ischemic cardiomyopathy (a narrowing of the blood vessels that supply blood and oxygen to the heart which in turn the heart can not pump enough blood to the rest of the body).
Record review of the resident's Annual MDS assessment dated [DATE] showed:
-He/she had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating he/she was cognitively intact.
-He/she had pain and received as needed (PRN) pain medication.
-Pain assessment showed he/she had almost constant pain.
Record review of the resident's undated care plan showed:
-He/she she was on pain medication therapy.
-Staff was to administer analgesic medications as ordered by the physician.
-Staff was to monitor and document side effects and effectiveness every shift.
-Review medication for pain medication efficacy.
-Assess whether pain intensity was acceptable to resident
-Therapeutic regimen followed, but pain control not adequate, changes required.
-He/she had chronic pain related to gangrene (dead tissue caused by an infection or lack of blood flow).
Record review of the resident's January 2023 POS showed a physician order for Oxycodone Hydrochloride (HCL) 10 mg one tablet to have been given by mouth every eight hours as needed for pain, dated 10/5/22.
Record review of the residents January 2023 MAR showed Oxycodone HCL 10 mg tablet was given nine out of 31 opportunities on the night shift.
Record review of the resident's February 2023 MAR showed Oxycodone HCL 10 mg tablet was given seven out of 28 opportunities on the night shift.
Record review of the resident's March 2023 POS showed a physician order for Oxycodone HCL 10 mg one tablet to have been given by mouth every eight hours as needed for pain, dated 10/5/22.
Record review of the resident's March 2023 MAR showed:
-Oxycodone HCL 10 mg tablet was given 18 out of 68 opportunities on the night shift.
-Pain monitoring showed the resident had zero pain at night 19 out of 19 nights.
During an interview on 03/20/23 at 3:43 P.M. the resident said:
-He/she was not getting adequate pain relief at night.
-He/she rated his/her pain at 8 or higher at night.
-He/she had five toes on the right side amputated and there was a lot of phantom pain.
-The night nurse does not come in to his/her room when he/she puts the call light on.
-One night he/she and his/her roommate heard the night nurse out in the hall talking to another staff member about his/her medications after he/she had put on the call light to ask for pain medication.
-He/she and his/her roommate the night nurse say there was an issue with the pain medication he/she had requested (Oxycodone).
-He/she and his/her roommate heard the nurse say he/she thought his/her pain medications may have been stolen.
-This happened a few weeks ago was not sure of the date.
-He/she had told the day nurse about the night nurse not answering the call light when he/she needed pain medications.
During an interview 3/23/23 at 10:00 A.M. the resident's roommate said:
-The night nurse hates him/her and would not come into the room to give them pain medication when they ask for it.
-He/she had heard the night nurse and another staff member talking in the hallway outside of their room when the nurse said there was a problem with the roommates pain medication
-It may have been stolen.
-His/her roommate has pain almost every night in his/her leg and the nurse will not answer the call light to come in and give either of them anything.
-The nurse was too busy on his/her phone to help them.
-They have both complained to the day staff and nothing changes.
3. Record review of Resident #119's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-Orthopedic aftercare (surgery of bones, joints, ligaments, tendons, or muscles).
-Fracture of the left femur (a crack in the thigh bone).
-Chronic kidney disease (a longstanding disease of the kidneys leading to renal failure).
Record review of the resident's undated care plan showed:
-He/she had chronic pain related to chronic physical disability.
-Staff was to anticipate the resident's need for pain relief and respond immediately to any complaint of pain.
-Monitor, record, and report to nurse the resident's complaints of pain or requests for pain treatment.
-Observe and report changes in usual routine, sleep patterns, decrease in functional abilities or resistance to care.
-He/she was on pain medication therapy related to chronic back pain and hip fracture.
-Staff was to administer analgesic medications as ordered by the physician.
-Monitor and document effectiveness every shift.
Record review of the resident's MDS annual assessment dated [DATE] showed:
-His/her BIMS score was 15 out of 15, indicating he/she was cognitively intact.
-He/she had received scheduled pain medications.
-He/she frequently had pain.
Record review of the resident's January 2023 POS showed the following orders:
-Tramadol (pain medication) HCL tablet 50 mg one tablet by mouth every six hours as needed for pain, dated 12/21/23.
-Hydrocodone-Acetaminophen (medication to relieve moderate to severe pain) tablet 5/325 mg one tablet by mouth every six hours as needed for pain, dated 1/12/23.
Record review of the resident's January 2023 MAR showed:
-21 out of 28 nights the resident exhibited no pain.
-Tramadol was given seven out of 28 night shift opportunities.
-Hydrocodone-Acetaminophen was given 14 out of 28 night shift opportunities.
Record review of the residents's February 2023 POS showed the following orders:
-Tramadol HCL tablet 50 mg one tablet by mouth every six hours as needed for pain, dated 12/21/23.
-Hydrocodone-Acetaminophen tablet 5/325 mg one tablet by mouth every six hours as needed for pain, dated 1/12/23.
Record review of the resident's February 2023 MAR showed:
-23 out of 26 nights the resident exhibited no pain.
-Tramadol was given once out of 28 opportunities.
-Hydrocodone-Acetaminophen was given 15 out of 28 opportunities.
Record review of the resident's March 2023 POS showed the following orders:
-Tramadol HCL tablet 50 mg one tablet by mouth every six hours as needed for pain, dated 12/21/23.
-Hydrocodone-Acetaminophen tablet 5/325 mg one tablet by mouth every six hours as needed for pain, dated 1/12/23.
Record review of the resident's March 2023 MAR showed:
-19 out of 19 nights the resident had not exhibited pain.
-Tramadol was given once out of 28 opportunities.
-Hydrocodone-Acetaminophen was given 15 out of 28 night shift opportunities.
During an interview on 3/21/23 at 10:24 A.M. the resident said:
-The night nurse hates him/her and would not give him/her any prn pain medications.
-He/she rated his/her pain every night at a 5 on 0 - 10 scale.
-He/she said it was hard to sleep.
4. Record review of Resident #37's face sheet showed he/she was admitted to the facility with the following diagnoses:
-Muscle wasting and atrophy.
-Chronic pain syndrome.
-Lower back pain.
Record review of the resident's undated care plan showed:
-He/she was on pain medication therapy.
-Staff was to administer analgesic medication as ordered by the physician.
-Staff was to monitor and document side effects and effectiveness every shift.
-He/she had chronic pain related to chronic physical disability.
-Staff was to administer analgesia as per orders, give 1/2 hour before treatment or cares if reasonable.
-Staff was to evaluate the effectiveness of pain interventions.
-Staff was to review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition.
-His/her pain was alleviated by pain medications and rest.
Record review of the resident's MDS annual assessment dated [DATE] showed:
-His/her BIMS score was 15 out of 15, indicating he/she was cognitively intact.
-He/she had received scheduled pain medications.
-He/she had received PRN pain medications.
Record review of the resident's March 2023 POS showed the following orders:
-Pain monitoring every shift, dated 3/5/23.
-Oxycodone HCL oral tablet 15 mg one tablet by mouth every six hours as needed for pain, dated 2/2/23.
-Tizanidine HCL (a muscle relaxer that works by blocking nerve impulses that were sent to the brain) oral tablet 4 mg one tablet by mouth every eight hours as needed for muscle spasms, dated 2/2/23.
Record review of resident's March 2023 MAR showed:
-On the pain monitoring sheet it showed he/she had pain once out of 23 opportunities (on nights).
-Oxycodone was given 36 out of 58 opportunities (on nights).
-The pain scale for giving Oxycodone rated the resident's pain from 4 to 8 on a 0 to 10 scale.
-Tizanidine was given 19 out of 58 opportunities (on nights).
During an interview on 3/29/23 at 1:00 P.M. the resident said:
-He/she was very tired and very angry because the night nurse would not give him/her the PRN pain medication at night so he/she could sleep.
-The night nurse usually did on-line shopping on his/her phone while at work.
-The night nurse only comes into his/her room once at night.
-He/she would rate his/her pain at a 7 at night, every night.
-He/she had the problem with one specific night nurse.
-He/she had told the day nurse about this problem before and nothing had happened.
5. During an interview on 3/28/23 at 1:05 P.M. Registered Nurse (RN) D said:
-Staff should have the resident rate his/her pain then give the PRN pain medication if it was times.
-About an hour later staff should ask the resident to once again rate his/her pain.
-The pain rating should be charted on the MAR.
-He/she had heard from some of the residents including Residents #24, #37, and #119, that they don't get their pain medications at night.
-He/she told the Unit Manager about that problem.
During an interview on 3/29/23 at 2:10 P.M. the Director of Nursing (DON) said:
-He/she would expect the nursing staff to see if a resident had pain medication on the MAR if they said they were experiencing pain.
-Pain medications (PRN and scheduled) should have been given if it was time to give it.
-Staff should document the resident's pain score before and after a pain medication was given.
-Staff should document the level of pain on the MAR.
Based on observation, interview and record review, the facility to ensure pain medication was ordered, obtained and provided in a timely manner for one sampled resident with chronic pain (Resident # 36); and did not provide adequate pain relief for three sampled residents (Resident #24, Resident #37, and Resident #119) out of 30 sampled residents. The facility census was 148 residents.
Record review of the facility's policy, Pain Management, dated 6/2020 showed:
-The Licensed Nurse would administer pain medication as ordered and document medication administered on the Medication Administration Record (MAR).
-The Licensed Nurse would assess the resident for pain and document results on the MAR each shift using the 1-10 pain scale.
-The shift pain score would indicate the highest pain level that occurred on that shift.
1. Record review of Resident #36's Face Sheet showed he/she was admitted to the facility on [DATE], with diagnoses including respiratory failure, sleep apnea (a condition where breathing stops and starts during sleep), severe obesity, low back pain, diabetes, kidney failure, heart disease and difficulty walking.
Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 1/8/23, showed the resident:
-Was alert, oriented and cognitively intact.
-Was totally dependent on staff for transfers, mobility, bathing and toileting, and needed extensive assistance with grooming.
-Had pain and received scheduled pain medication.
Record review of the resident's Physician's Order Sheet (POS) dated 3/2023, showed physician's orders for:
-Hydrocodone-Acetaminophen tablet 325 milligrams (mg), every 5 hours for pain (5/12/22).
-Lidocaine Patch 4 percent (%), apply to bilateral shoulders topically one time a day for pain (3/1/23).
-Biofreeze Gel 4% apply to left arm topically four times a day for pain (11/12/22).
-Biofreeze Gel 4% apply to shoulders and neck topically every 4 hours (5/29/22).
-Acetaminophen 500 mg every 24 hours as needed for pain not to exceed 4000 mg in 24 hours (5/11/22).
Record review of the resident's MAR dated 3/2023, showed a physician's order for Hydrocodone-Acetaminophen tablet 325 mg, every 5 hours for pain (5/12/22). The MAR showed:
-The resident received Hydrocodone as ordered from 3/1/23 to 3/17/23.
-The nurse documented 9 daily showing no Hydrocodone was provided from 3/18/23 to 3/24/23 the resident did not receive 36 administrations of pain medication).
-Record review of the progress notes on the dates showing 9 showed on 3/17/23 at 6:05 A.M. documentation showed the medication was reordered and they were waiting for the pharmacy. On 3/19/23 documentation showed nurse notified the pharmacy and the refill request had been sent to the pharmacy. On 3/20/23 the nurse documented a refill request had been sent to the physician. At 12:49 P.M., the nurse documented they were waiting on the pharmacy and needed a new script. From 3/20/23 to 3/23/23 documentation showed they were still waiting for the pharmacy. On 3/23/23 at 12:26 P.M., documentation showed they were waiting for the script to be sent over to the pharmacy. On 3/24/23 documentation showed they were still waiting on the pharmacy to send the resident's pain medication.
Record review of the resident's Nursing Notes showed there were no notes showing the nursing staff had notified the physician or the Nurse Practitioner about the difficulty receiving the resident's Hydrocodone. There was no documentation showing any effort was made to try to expedite the resident receiving his/her pain medication or find out why they had not received it.
Observation and interview on 3/20/23 at 11:56 A.M., showed the resident was in bed and was alert and oriented. He/she said:
-The pain in his/her arm and shoulder that is constant.
-When speaking with the physician and Nurse Practitioner and they told him/her the pain is from arthritis.
-He/She was supposed to see the orthopedic physician, but has not had an appointment yet.
-The Hydrocodone he/she was supposed to receive every five hours, but he/she had not received the pain medication for three days.
-Nursing staff told him/her that they had to reorder the pain medication and the script was sent but the pharmacy had not delivered it yet.
-He/she was in pain daily and his/her pain was not managed.
During an interview on 3/23/23 at 1:46 P.M., the resident was sitting up in his/her wheelchair in his/her room. The resident said:
-He/she still has pain and had not received her Hydrocodone pain pill in about a week.
-He/she had a Lidocaine pain patch that the nurse also placed daily, he/she had Tylenol and used Biofreeze on his/her shoulder to try to relieve pain, but it relieves her pain temporarily.
-He/she spoke with the Nurse Practitioner today about his/her pain and why he/she had not received his/her Hydrocodone and he/she said they should have his/her pain medication ordered.
-His/her pain has been at 8 of 10 (in a pain scale from zero to 10. 10 is extreme pain).
During an interview on 3/23/23 at 2:11 P.M., Registered Nurse (RN) D said:
-Sometimes there have been problems getting medications from the pharmacy.
-After looking in the resident's MAR progress notes, he/she said there was a note in the resident's medical record with today's date stating they were waiting for the physician to send the physician's order for Hydrocodone to the pharmacy.
-The resident was supposed to have his/her Hydrocodone pain medication every 5 hours and it was scheduled.
-The Certified Medication Technician (CMT) was able to give Hydrocodone and they documented it in the resident's MAR.
-The CMT was supposed to tell the nurse when the medication was running out so that the nurse could get the medication re-ordered from the pharmacy or notify the physician or Nurse Practitioner to obtain an order.
-The resident did not have Hydrocodone for a week because it had not been ordered according to the notes in the resident's medical record.
-He/She would make sure the order is obtained so they can send it to the pharmacy.
During an interview on 3/24/23 at 10:09 A.M., RN A said:
-He/she was not aware that the resident had not been receiving his/her Hydrocodone.
-Because the prescription is scheduled, the CMT would be giving it to the resident.
-The process is: when the medication is running out or has run out, the CMT is supposed to notify the charge nurse who will check the order, then notify the physician and obtain the order for the pain medication and then send it to the pharmacy.
-They also have an automatic medication dispensing system on site that contains Hydrocodone, but they need to have a signed physician's order in order to release the medication for the resident.
-It takes between 24 to 48 hours to receive the order from the physician and they could get the pain medication from the automated system, so he/she did not know why it has taken a week for the resident to receive his/her pain medication.
-He/she would check the order and follow up to ensure the resident received his/her pain medication.
During an interview on 3/29/23 at 10:05 A.M., the resident was in his/her bed awake. He/she said he/she received his/her Hydrocodone for three days (including today) according to his/her physician's orders and his/her pain had decreased.
During an interview on 3/29/23 at 2:05 P.M., the Director of Nursing (DON) said:
-He/she would expect the CNA to report the resident's pain to the charge nurse and try to provide non-pharmacological pain relief to the resident.
-Nursing staff should ask the resident to rate their pain prior to administering pain medication.
-Pain medication can be ordered through the resident's electronic charting. The nurse would be responsible for ensuring the resident's medication is re-ordered timely, prior to it running out.
-Once they receive the resident's pain medication they should administer it as ordered.
-He/she would not expect the turnaround for ordering and receiving pain medication to take a week or longer.
-He/she would not expect a resident to go a week without receiving their pain medication.
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
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure proper documentation was completed for the shift change narcotic count books and the individual narcotic count sheets ...
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Based on observation, interview, and record review, the facility failed to ensure proper documentation was completed for the shift change narcotic count books and the individual narcotic count sheets for two sampled residents (Resident #51 and Resident #119) and one supplemental resident (Resident #11) out of 30 sampled residents and nine supplemental residents. The facility census was 148 residents.
Record review of the facility's policy titled Controlled Substance Administration and Accountability dated October 2022 showed:
-All controlled substances obtained from a non-automated medication cart or cabinet are recorded on the designated usage form.
-Written documentation must be clearly legible with all applicable information provided.
-All specially compounded or non-stock Schedule II controlled substances (drugs with a high potential for abuse, with use potentially leading to severe psychological or physical dependence) dispensed from the pharmacy for a specific patient are recorded on he Controlled Drug Record supplied with the medication or other designated form as per facility policy.
-In all cases, the dose noted on the usage form must match the dose recorded on the Medication Administration Record (MAR), Controlled Drug Record, or other facility specified form and placed in the patient's medical record.
-The Controlled Drug Record (or other specified form) serves a dual purpose of recording both narcotic disposition and patient information.
-The Controlled Drug Record is a permanent medical record document and in conjunction with the MAR is the source for documenting any patient-specific narcotic dispensed from the pharmacy.
-Any discrepancy in the count of controlled substances or disposition of the narcotic keys is resolved by the end of the shift during which it was discovered.
1. Record review of Resident #51's undated face sheet showed he/she admitted to the facility with the following diagnoses:
-Spinal Stenosis, Lumbar Region with Neurogenic Claudication (a narrowing of the spinal cord in the lower part of the spine with compression of the spinal nerves).
-Wedge Compression Fracture of First Lumbar Vertebra (a single part of the back bone), Subsequent Encounter for Fracture with Routine Healing (when the front of the vertebral body collapses but not the back).
-Low Back Pain.
-Other Chronic Pain.
Record review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 12/19/22 showed the resident was cognitively intact.
Record review of the resident's Physician Order Sheet (POS) dated March 2023 showed an order for Norco Tablet -5-325 milligrams (mg) (Hydrocodone-Acetaminophen (APAP)- a combination medication used to relieve moderate to severe pain), take one tablet orally (by mouth) every six hours as need for pain.
Record review of the resident's designated Narcotic Count Sheet for the medication Norco Tablet 5-325 mg dated 1/4/23 showed the resident received doses of the pain medication two times on 3/4/23 and one dose on 3/11/23.
Record review of the resident's Medication Administration Record (MAR) dated March 2023 showed the resident only received one dose of the Hydrocodone-APAP 5-325 mg on 3/11/23 as of 3/23/23.
During an interview on 3/21/23 at 9:30 A.M. the resident said:
-He/She only takes narcotics once in a blue moon.
-He/She thought a nurse may have charted that a dose of his/her narcotic was given to him/her, but a dose was never actually received.
-He/She was told by a nurse that his/her medication was stolen.
2. Record review of the Resident #11's undated face sheet showed he/she was admitted to the facility with the following diagnoses:
-Primary Generalized Osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones are wore down).
-Age-Related Osteoporosis (bone loss that results from aging).
-Unspecified Pain.
-Contractures (a condition of shortening and hardening of muscles, tendons, or other tissue often leading to deformity and rigidity of joints) of the Right Knee, Left Knee, Right Ankle, and Left Ankle.
Record review of the resident's designated Narcotic Count Sheet for the medication Hydrocodone-Acetaminophen Tablet 5-325 mg dated 12/16/22 showed:
-The resident received doses of the medication on as of 3/23/23:
--3/1/23.
--3/4/23 at 8:00 A.M.
--3/4/23 at 12:00 P.M.
--3/5/23.
--3/9/23.
--3/13/23 at 12:50 A.M.
--3/13/23 at 9:00 P.M.
--3/20/23.
--3/21/23.
--3/22/23.
--3/23/23.
Record review of the resident's POS dated March 2023 showed an order for Hydrocodone-Acetaminophen Tablet 5-325 mg, give one tablet by mouth every four hours as needed for pain.
Record review of the resident's MAR for the medication Hydrocodone-Acetaminophen Tablet 5-325 mg dated March 2023 showed:
-The resident received doses of the medication on:
--Only one dose on 3/13/23.
--3/21/23.
--3/22/23.
--3/23/23.
3. Record review of the Certified Medication Technician's (CMT) shift change Narcotic Count Book for the 400 Hall dated March 2023 showed:
-From 3/1/23-3/23/23 the CMTs missed 9 out of 46 opportunities of counting on the day shift from the off going nurse on the night shift.
-From 3/1/23-3/23/23 the CMTs missed 23 out of 46 opportunities of counting on the evening from the off going day shift CMT.
-From 3/1/23-3/22/23 the CMTs missed 25 out of 44 opportunities of counting from the off going evening shift CMT.
Record review of the 300/400 Hall shift change Narcotic Count Book dated March 2023 showed:
-On 3/5/23 for the 7:00 A.M.-7:00 P.M. shift the on-coming nurse did not sign the count sheet.
-On 3/5/23 for the 7:00 P.M.-7:00A.M. shift the off-going nurse did not sign the count sheet.
-On 3/6/23 for the 7:00 A.M.-7:00 P.M. shift the on-coming nurse did not sign the count sheet.
-On 3/7/23 for the 7:00 A.M.-7:00 P.M. shift the off-going nurse did not sign the count sheet.
-On 3/10/23 for the 7:00 A.M.-7:00 P.M. shift the on-coming nurse did not sign the count sheet.
-On 3/11/23 for the 7:00 A.M.-7:00 P.M. shift the on-coming nurse did not sign the count sheet.
-On 3/11/23 for the 7:00 P.M.-7:00 A.M. shift the off-going nurse did not sign the count sheet.
-On 3/16/23 for the 7:00 A.M.-7:00 P.M. shift the on-coming nurse did not sign the count sheet.
-On 3/18/23 for the 7:00 A.M.-7:00 P.M. shift the on-coming nurse did not sign the count sheet.
-On 3/18/23 for the 7:00 P.M.-7:00 A.M. shift the off-going nurse did not sign the count sheet.
-On 3/20/23 for the 7:00 A.M.-7:00 P.M. shift the on-coming nurse did not sign the count sheet.
-On 3/21/23 for the7:00 A.M.-7:00 P.M. shift the on-coming nurse did not sign the count sheet.
-On 3/23/23 for the 7:00 A.M.-7:00 P.M. shift the off-going nurse pre-signed the count sheet. (signed prior to the end of his/her shift before he/she counted with the on-coming shift).
-On 3/24/23 for the 7:00 P.M.-7:00 A.M. shift the off-going nurse pre-signed the count sheet.
Observation on 3/24/23 at 6:50 A.M. of the 300/400 hall shift change narcotic count completed by Licensed Practical Nurse (LPN) F the off-going nurse and LPN A the on-coming nurse showed:
-The treatment cart had 15 cards of controlled medication and six bottles of controlled medication.
-LPN A did not sign the count sheet after the count was completed.
During an interview on 3/24/23 at 6:53 A.M. LPN A said:
-The shift change narcotic counts typically went as observed.
-He/She would not have done anything differently.
-When he/she counts, the count is always correct.
Observation on 3/24/23 at 6:58 A.M. of the 300 and 400 hall shift change narcotic count completed by LPN F the off-going nurse and CMT C the on-coming CMT showed:
-Both narcotic counts were correct.
-LPN F did not sign after the count as he/she had signed the narcotic count sheets before the count occurred.
During an interview on 3/24/23 at 8:15 A.M. LPN A said:
-There have been multiple times on different residents when the narcotic count sheets for residents did not match the documentation on the resident's MAR.
-He/She had discussed the issue before with the Director of Nursing (DON).
-He/She had mentioned both Resident #51 and Resident #11.
During an interview on 3/27/23 at 9:42 A.M. the Regional Corporate Nurse said:
-The facility was planning on destroying one of Resident #51's narcotic cards to better decrease the risk of diversion as the resident did not take the medication that often to warrant two cards.
Complaint- MO00215032
4. Observation and interview on 3/24/23 at 6:52 A.M. with LPN G showed:
-LPN G pre-signed the narcotic log before the day nurse arrived.
-The night nurse did not have a second person to count the narcotics with.
-He/she said he/she knew was not supposed to pre-sign the narcotic sheet before the day shift got here.
-He/she declined to answer any further questions.
Record review of the January 2023 100 hall Narcotic Count Sheet showed:
-The sheet was blank 18 out of 93 opportunities.
-The sheet was signed by one nursing staff 35 out of 93 opportunities.
-The sheet had not verified the narcotic count was correct by the required two nursing staff total of 53 out of 93 opportunities.
Record review of the February 2023 100 hall Narcotic Count Sheet showed:
-The sheet was blank 64 out of 84 opportunities.
-The sheet was signed by one nursing staff 11 out of 84 opportunities.
-The sheet had not verified the narcotic count was correct by the required two nursing staff total of 75 out of 84 opportunities.
Record review of the February 2023 200 hall Narcotic Count Sheet showed:
-The sheet was blank 61 out of 84 opportunities.
-The sheet was signed by one nursing staff 17 out of 84 opportunities.
-The sheet had not verified the narcotic count was correct by the required two nursing staff total of 78 out of 84 opportunities.
Record review of the March 2023 100 hall Narcotic Count Sheet showed:
-The sheet was blank 23 out of 79 opportunities.
-The sheet was signed by one nursing staff 27 out of 79 opportunities.
-The sheet had not verified the narcotic count was correct by the required two nursing staff total of 50 out of 79 opportunities.
Record review of the March 2023 200 hall Narcotic Count Sheet showed:
-The sheet was blank 22 out of 79 opportunities.
-The sheet was signed by one nursing staff 32 out of 79 opportunities.
-The sheet had not verified the narcotic count was correct by the required two nursing staff total of 54 out of 79 opportunities.
During an interview on 3/24/23 at 6:58 A.M. Registered Nurse (RN) A said:
-He/she usually works the 100/200 halls on the day shift.
-The night shift pre-signs the Narcotic Count Sheet often before he/she came to work.
-This has happened about 10 times so far this month.
-The facility had an inservice a month or so ago about not pre-signing narcotic sheets.
-The MAR and Narcotic Count Sheet should match, if not it is a discrepancy.
-In the last 6 months it is frequent that the MAR and Narcotic Count Sheet did not match.
-It was a discrepancy.
-When this happened he/she would tells the DON.
-The facility also had an inservice about a month ago.
-He/she has had a couple of residents on the night shift tell him/her that the night nurse hates them and doesn't give them their pain medications.
-He/She had told the Administrator what the residents had said.
-The Administrator talked to the residents and filed a grievance for them.
During an interview on 3/24/23 at 7:25 A.M. CMT B said:
-The Narcotic Count Sheet had many blank areas where a second signature was not done.
-There should should have been a signature the person going off shift and the one coming on.
-They would count and sign at the same time to verify the count was correct.
-Two signatures were required.
-They had an inservice a month and a half ago about how to verify the narcotics count.
-The Assistant Director of Nursing (ADON) or the Unit Manager was ultimately responsible for ensuring the narcotic count was correct.
5. Record review of Resident #119's March 2023 MAR showed:
-He she had an order for Hydrocodone/Acetaminophen (Scheduled pain medication) table 5/325 milligram (mg) one tablet by mouth every six hours as needed for pain dated 1/12/23.
-From March 15 to March 23 the MAR showed the medication was administered 17 times.
Record review of the resident's Narcotic Sheet Hydrocodone/Acetaminophen) showed:
-From March 15 to March 23 the Narcotic Sheet showed the medication was administered 28 times.
-The Narcotic sheet from March 1 to March 14 had been requested and not provided.
During an interview on 3/28/23 at 1:05 P.M. RN D said:
-Verified the narcotic count was correct.
-Verified there were more entries on the Narcotic Sheet showing the medications had been given than what the MAR showed the resident had been given.
-He/she could not explain the discrepancy unless the nurse had forgotten to sign it off on the MAR.
-The two sheets, narcotic sign out sheet and the MAR, should match.
-The narcotic count had always been correct.
6. During an interview on 3/27/23 at 9:42 A.M. the DON said:
-The main problem with the Narcotic Counts was not that the counts were not being completed, but that there was a lack of documentation.
-There had been an issue before with a controlled medication card went missing, but the issue was resolved, and the card was found.
-The DON had been in-servicing about the documentation and the facility's new system to keep staff accountable for the narcotics and narcotic sheets.
-The nurses were now only able to add controlled substances to the medication carts.
-The Unit Managers and the DON were the only staff that could remove the controlled substances from the cart.
During an interview on 3/28/23 at 1:07 P.M. LPN D said:
-He/She thought all of the nurses were good at counting the narcotics at each shift change.
-He/She had never experienced a count being off at any of his/her shifts at the facility.
During an interview on 3/28/23 at 1:46 P.M. LPN B said:
-He/She had heard about some controlled medications going missing.
-If he/she had a nurse come to him/her about a missing controlled medication then he/she would start an investigation and tell the DON.
-He/She had never experienced a count not being correct at shift change.
-If he/she completed a narcotic count and the count was off he/she would re-count and tell the DON.
-The facility had a new policy that had been initiated recently because there had been an issue.
-Nurses should never pre-sign narcotic count sheets.
-If he/she found a missing signature on a narcotic count sheet he/she would find out who that person was and ask them to count the narcotics in front of him/her, then have that person sign the count sheet.
-He/She would also give that person a verbal education related to narcotic counting at shift change and tell the DON.
-He/She did not think there was an issue on his/her side of the building.
During an interview on 3/29/23 at 10:00 A.M. the DON said:
-He/she expected the staff to count the narcotics at the end of each shift with one off going staff and one on coming staff at the same times.
-There should always be two signatures.
-The amount of Narcotics given should equal the amount of Narcotics given on the MAR.
-He/she was ultimately responsible to ensure the counts were correct and the staff was documenting correctly.
-He/she did not think this was a diversion but a lack of documentation.
During an interview on 3/29/23 at 2:05 P.M. the DON said:
-The Unit Managers were supposed to be auditing the narcotic count sheets and he/she was supposed to audit the unit managers. This was not being done at this time.
-He/She expected the documentation to be accurate and that the narcotic sheets and the MAR should match.
-He/She expected staff to complete the narcotic count at each shift change.
-The staff should not be pre-signing the narcotic count sheet before shift change.
-If staff were to find that the narcotic count was wrong, he/she would expect staff to notify him/her and those responsible for the count would not be allowed to leave until the discrepancy was resolved.
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
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure resident's medication that had been prescribed by a physician were dated when they were opened and to ensure staff's p...
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Based on observation, interview, and record review, the facility failed to ensure resident's medication that had been prescribed by a physician were dated when they were opened and to ensure staff's personal items were not in the same drawer with resident's medications, out of 30 sampled residents. The facility census was 56 residents.
Record review of the facility's policy, Storage of Medications, dated 9/2018 showed:
-Medications and biologicals were stored safely, securely, and properly.
-Outdated, medications were immediately removed from inventory.
-Medication storage areas were kept clean, and free of clutter.
1. Observation on 3/24/23 at 7:30 A.M. of the medication cart on 100 hallway with Certified Medication Technician (CMT) B showed:
-A resident's medication (prescribed by a physician) Levetiracetam (a medication used to control seizures) a 300 milliliter (ml) bottle was opened without the date it had been opened written on it.
-A resident's medication (prescribed by a physician) Miralax (a medication used to pass a bowel movement) a 17.9 gram bottle was opened without the date it had been opened written on it.
-A resident's medication (prescribed by a physician) Lactulose (a medication used aid in passing a bowel movement) a 946 milligram (mg) bottle was opened without the date it had been opened written on it.
-In the same compartment as the resident's Lactulose was a used hair brush.
-Brown hair was visible in the brush.
During an interview on 3/24/23 at 7:30 A.M. CMT B said:
-The resident's medication should have the date they were opened written on them.
-The used hair brush belonged to the night CMT.
-The hair brush should not have been in the cart and especially not in with the resident's medications.
-Everyone who used the medication cart was responsible for ensuring it was kept clean.
-The staff who opened the medication should have written the date they had opened it on the bottle.
During an interview on 3/24/23 at 8:58 A.M. Registered Nurse (RN)A said:
-The person who uses the medication cart was responsible to keep it clean.
-There should not have been a brush in the medication cart for any reason.
-If a medication was opened the person who opened it would write the date it was opened.
During an interview on 3/29/23 at 10:15 A.M. the Director of Nursing (DON) said:
-The Nurse or the CMT would be responsible for keeping the medication carts clean.
-He/she would not have expected a staff member to keep personal belongings in the medications cart especially not a hair brush.
-When a nurse or CMT opened a resident's medication they need to write the date it was opened on the bottle.
-The unit manager should have been ensuring the medication carts were clean and dates written on open medications.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to follow the menus by cooking meals according to the menu; to ensure recipes were available for breakfast meals, and to documen...
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Based on observation, interview, and record review, the facility failed to follow the menus by cooking meals according to the menu; to ensure recipes were available for breakfast meals, and to document meal substitutions in the substitution log book for the Registered Dietitian (RD) to sign off on when the RD's came to the facility for their consults. This practice potentially affected 145 residents who ate food from the kitchen. The facility census was 148 residents.
1. Record review of the menu for the breakfast meal on 3/24/23, showed the residents were supposed to receive the following: Vitamin C juice, choice of cold or hot cereal, assorted fresh fruit, western egg bake, blueberry muffin and whole milk.
Observation on 3/24/23 at 7:05 A.M., showed the absence of western egg bake form the steam table.
During an interview on 3/24/23 at 7:07 A.M., Dietary [NAME] (DC) C said they did not prepare the western egg bake according to the menu on that day because the residents did not like it.
Observation on 3/24/23 at 7:11 A.M., showed DC B made pancakes which were not on the menu for that day.
Observation on 3/24/23 at 7:22 A.M., showed DC C pureed (blend, chop, mash, or strain a food until it reaches this soft consistency) pancakes without the recipe book being open. During the process of pureeing the pancakes, DC C, added water to the pureed mixture.
2. Record review of Resident #96's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning), dated 2/25/23, showed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS-an assessment tool that shows a score between 3 of 15 which shows the resident's mental status. This tool helps determine the resident's attention, orientation and ability to register and recall new information. These items are crucial factors in care planning decisions.) of 15 out of 15.
During an interview on 3/24/23 at 8:59 A.M., the resident said he/she did not get the assorted fruit that morning for breakfast.
During an interview on 3/24/23 at 10:12 A.M., DC C said:
-There was not a recipe available for the pureed pancakes on the morning of 3/24/23.
-He/she added syrup and water to the pureed pancake mixture.
-There was not any fresh fruit to serve this morning.
During an interview on 3/24/23 at 10:29 A.M., the Dietary Manager (DM) said they did not have the staff available to place the fruit in the cups for the residents or they would have had mixed fruit available for the resident according to the menu, that morning.
During an interview on 3/28/23 at 11:57 A.M., Registered Dietitian (RD) A said
-He/she was not aware that the facility the did not have recipes for breakfast meals.
-There should have been a substitution log in the kitchen that dietary staff have to fill out.
-He/she expected them to use milk instead of water, for pureed pancakes, because milk is more nutritious.
3. Record review of the menu for the dinner meal on 3/27/23 showed pizza burger on a garlic bun, homemade potato wedges, ketchup, oatmeal raisin bar and whole milk.
During an interview on 3/28/23 at 10:46 A.M., Resident #96 said:
-For the dinner meal on the night of 3/27/23, the residents were supposed to receive pizza burger on garlic bun, potato wedges, and an oatmeal raisin bar and instead, they received chili with cornbread, salad and a cookie.
-No one informed them that the meal would not be what they documented on the diet card.
During an interview on 3/28/23 at 12:12 P.M., RD B said the last meal substitution was documented on 3/18/23.
During an interview on 3/28/23 at 2:35 P.M., DC D said the following about the dinner meal on 3/27/23:
-One of the main ingredients and buns were not available, so that is why they made a simpler meal.
-He/she forgot to place that in the substitution log book.
Complaint MO MO 00215144.
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
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to assess the dietary preferences of four sampled residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to assess the dietary preferences of four sampled residents (Residents #24, #96, #73, and #88) out of 30 sampled residents and one supplemental Resident (Resident #78), by not doing a dietary profile and to ensure food substitutes which were consistent with ordinary food items which were provided by the facility, were available for residents who did not prefer to eat the items which were offered. This practice potentially affected 144 residents who ate food from the kitchen. The facility census was 148 residents.
1. Record review of the resident council minutes dated 12/16/22, showed the residents stated that alternates were not available on weekend meals.
Record review of the Resident Council Concern Response form dated 1/1/23 showed the following statement has active response and did not give back.
2. Record review of Resident #24's face sheet showed diagnoses which included:
-Hypertensive heart disease (changes in the left ventricle, left atrium, and coronary arteries as a result of chronic blood pressure elevation. Hypertension increases the workload on the heart) with heart failure (occurs when the heart muscle doesn't pump blood as well as it should).
-Severe obesity (a chronic condition, that is progressive which refers to excess body fat).
-Peripheral vascular disease (a slow and progressive circulation disorder.).
-Muscle weakness (commonly due to lack of exercise, ageing, muscle injury or pregnancy. It can also occur with long-term conditions such as diabetes or heart disease).
-Depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act ).
Record review of the resident's complete medical record showed the resident was admitted to the facility on [DATE] and the absence of a dietary profile (a segment of a resident's medical record which accounts for a resident's concerns about his/her diet, a resident's dietary likes and dislikes, a resident's cultural food preferences).
Record review of the resident's annual Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning), dated 12/31/22, showed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS-an assessment tool that shows a score between 3 of 15 which shows the resident's mental status. This tool helps determine the resident's attention, orientation and ability to register and recall new information. These items are crucial factors in care planning decisions.) of 15 out of 15.
During an interview on 3/20/23 at 10:53 A.M., the resident said he/she:
-Did not want pork or processed food.
-Requested that his/her family bring turkey in for him/her.
-Was offered a pork cutlet on 3/21/23 and he/she declined.
-Ate the turkey hot dog that day.
-Wanted turkey and cheese sandwiches or cheese burgers.
-Was offered pork products three days in a row.
-Was offered a peanut butter sandwich for lunch.
-Didn't think a peanut butter sandwich was not a substitute for the main entree of the day.
-The facility offered him/her pork on a daily basis.
-The smell of pork made him/her nauseous and his/her family had to bring in turkey to keep in his/her refrigerator.
During an interview on 3/24/23 at 9:43 A.M. the resident said:
-No one from the dietary department had asked him/her about his/her food preferences.
-He/she was offered pork too many times per week.
-No one came around and tried to find out a reasonable substitute for him/her.
-Food choices are very important to him/her.
3. Record review of Resident #96's face sheet showed diagnoses which include:
-Chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body).
-Type II diabetes mellitus with hyperglycemia (occurs when a person living with type II diabetes has high blood sugar levels).
-Hypertensive heart disease with heart failure.
-Anxiety disorder (a type of mental health condition in which a person may respond to certain situations with fear and dread.)
-Morbid obesity, and
-Obstructive sleep apnea (occurs when one's breathing is interrupted during sleep, for longer than 10 seconds at least 5 times per hour (on average) throughout a sleep period.)
Record review of the resident's complete medical record showed he/she was admitted to the facility on [DATE] and an incomplete dietary profile was present.
Record review of the resident's quarterly MDS dated [DATE] showed the resident was cognitively intact with a BIMS of 15 out of 15.
During an interview on 3/20/23 at 12:44 P.M., the resident said he/she:
-Thought the food was horrible and if they don't eat what is prepared, he/she did not eat.
-Would like to have the option of an alternate when he/she did eat.
-Was told they did not have hamburgers.
-Did not think a hot dog was an adequate meal replacement.
-Sometimes they offer salad, peanut butter sandwiches, and grilled cheese sandwiches.
During an interview on 3/24/23 at 8:45 A.M., the resident said he/she:
-Said no to sausage links that morning and he/she received them anyway even though sausage links was crossed out on his/her ticket.
-Liked scrambled eggs and toast and was not offered scrambled eggs that day.
-No one had spoken with him/her about his/her food likes and dislikes.
4. Record review of Resident #78's face sheet showed diagnoses which included:
-Chronic obstructive pulmonary disease (COPD - a group of diseases that cause airflow blockage and breathing-related problems),
-Chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should).
-Emphysema (a lung condition that causes shortness of breath because the air sacs in the lungs (alveoli) are damaged), and
-Unspecified heart failure.
Record review of the resident's complete medical record showed he/she was admitted to the facility on [DATE] and the absence of a dietary profile.
Record review of the resident's quarterly MDS dated [DATE], showed the resident had moderate cognitive impairment with a BIMS of 8 out of 15.
During an interview on 3/20/23 at 10:28 A.M., the resident said:
-The food was not good and not fit to eat.
-Even the substitutes, when available were not good.
-In the past the facility ran out of what he/she had ordered. He/she was given a food substitute and he/she did not like it.
-There were times that he/she did not eat because of the poor quality of the food.
-He/she would like a salad sometimes.
During an interview on 3/24/23 at 9:31 A.M., the resident said:
-Residents do not have choices when it comes to meals.
-Facility staff have not asked him/her about food choices for several weeks.
-He/she did not get a ticket today.
-He/she did not know how to contact the Registered Dietitian (RD)
-No one from the dietary department has asked him/her about his/her food choices.
-He/she was not offered fresh fruit that day.
-He/she would like to eat three times per day like often ends up eating once per day.
-His/her preferences would include a tender chicken breast patty, if it is tender.
5. Record review of Resident #73's face sheet showed diagnoses which include:
-Anemia (a condition of low blood iron) in chronic kidney disease.
-Chronic osteomyelitis (inflammation of the bone due to an infection).
-Type II diabetes mellitus,
-Major depressive disorder (diagnosed when an individual has a persistently low or depressed mood).
-Keratosis (a rough, scaly patch or bump on the skin),
-Generalized edema (swelling caused by fluid in your body's tissues).
-Atherosclerotic (the buildup of fats, cholesterol and other substances in and on the artery walls) heart disease.
Record review of the resident's complete medical record showed he/she was admitted to the facility on [DATE] and the absence of a dietary profile.
Record review of the resident's quarterly MDS dated [DATE], showed the resident was cognitively intact with a BIMS of 15 out of 15.
During an interview on 3/20/23 at 1:05 P.M., the resident said:
-He/she did not eat pork or processed food.
-On that day, a pork cutlet was included as the entrée for the lunch meal.
-He/she declined that and was offered a hot dog which he/she also could not eat.
-On that day, he/she did not get any food for lunch only drinks.
-It happens about once per week.
During an interview on 3/22/23 at 1:01 P.M., the resident said:
-He/she often went without a tray because he/she did not want pork or processed food.
-The facility staff tried to offer him/her a peanut butter or cheese sandwich.
-He/she would like tuna or chicken salad sandwich.
-He/she has asked the Certified Nurse's Assistants (CNAs) who serve the food, for a better substitute.
During an interview on 3/24/23 at 9:14 A.M., the resident said:
-He/she did not like pork and the facility served pork a lot.
-He/she did not like processed meats such as the hot dog that is often offered as an option.
-He/she would prefer chicken salad or tuna salad.
-The facility used to have turkey and cheese sandwiches.
-Facility staff had not sat down with him/her to find out what his/her dietary preferences were.
-There was nothing on his/her meal tickets which stated no pork products or processed foods.
-He/she would like to get fresh fruit for breakfast sometimes.
-When he/she did not get an adequate substitute on 3/20/23 for lunch, he/she just stayed hungry until dinner.
6. Record review of Resident #88's face sheet showed diagnoses which include:
-COPD.
-Muscle weakness.
-Chronic atrial fibrillation (an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart).
-Generalized anxiety disorder.
-Reduce mobility.
Record review of the resident's complete medical record showed he/she was admitted to the facility on [DATE] and the absence of a dietary profile.
Record review of the resident's quarterly MDS dated [DATE], showed the resident was cognitively intact with a BIMS of 13 out of 15.
During an interview on 3/20/23 at 1:28 P.M., the resident said sometime in February 2023, the facility stopped going around to the residents and letting the residents know what substitutes were available and the residents were not offered bread anymore.
During an interview on 3/24/23 at 9:23 A.M., the resident said:
-He/she did not get to choose what he/she eats.
-He/she wanted fried eggs that day.
-No facility staff asked him/her about fried eggs.
-He/she would love fresh fruit.
-It was a long time ago that someone sat down with him/her and asked his/her food preferences.
-He/she was frustrated about finding out information about seeing the RD.
7. During an interview on 3/22/23 at 2:13 P.M., the [NAME] President of Regulatory Compliance acknowledged the dietary profiles were absent or incomplete and the residents had been at the facility long enough to have had a dietary profile completed.
During an interview on 3/20/23 at 2:19 P.M., the Dietary Manager (DM) said:
-The dietary department only had sliced ham.
-The dietary department ran out of hamburgers on 3/20/23, because they used burgers on 3/19/23 to prepare Salisbury Steak.
-He/she was limited by their budget when ordering.
-Sometimes they run out of lettuce for salads.
-Some residents have complained about not having adequate substitutes.
During an interview on 3/24/23 at 10:46 A.M. Dietary [NAME] D said:
-The dietary department has had problems getting certain items on the menu.
-At that time, the facility only had salads, burgers, peanut butter and jelly sandwiches and turkey hot dogs.
During an interview on 3/27/23 at 12:32 P.M., the Activity Director said he/she has heard from several residents in resident council meetings that there were not enough alternates for various meals, especially on the weekends.
During a phone interview on 4/4/23 at 4:09 P.M., Registered Dietitian (RD) B said the expectation was to obtain preferences from residents within a timely manner, perhaps within two weeks of admission, but he/she was not familiar with this facility's policy because he/she was newly assigned to this facility.
Complaint #MO00215144.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to re-train Certified Nursing Assistants (CNA) by not providing a competency evaluation program for five out of five CNA's. This had the poten...
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Based on interview and record review, the facility failed to re-train Certified Nursing Assistants (CNA) by not providing a competency evaluation program for five out of five CNA's. This had the potential to affect all residents. The facility census was 148 residents.
Record review of the facility's Care Standards Policy, dated June 2020, showed:
-The purpose of this policy was to ensure all residents receive necessary care and services that are evident-based and in accordance with accepted professional clinical standards of practice.
-The Director of Nursing (DON) ensured care and services were delivered according to accepted standards of clinical practice
-The DON or designee evaluated staff competency in skills and techniques necessary to care for resident's assessed needs.
-The DON ensured that permanent and non-permanent caregivers met competency knowledge and skill requirements to the same extent as permanent personnel.
-The administrator, Health Information Management Coordinator or designee ensured that documentation of observations and evaluation of therapeutic interventions was filed in appropriate files.
1. Record review of the facility's Competency Based Evaluations for April 2022 through March 2023 showed:
-The facility provided skills fairs for Licensed Practical Nurses (LPN) and Registered Nurses (RN).
-No records were provided for CNA competency evaluation.
During an interview on 3/28/23 at 8:44 A.M. CNA L said:
-Every two to three months staff had in-services and if there were any changes on equipment.
-Every six months to a year employee evaluations were done.
-The facility usually did an in-service type training every 3-6 months.
-Relias (a computer based training program) tracked their training and hours completed.
-It showed videos and tested when the video was complete.
-Management kept track of training, usually the DON.
During an interview on 3/28/23 9:04 A.M., CNA D said:
-He/she received training at a skills fair about a year ago.
-Sometimes therapy showed CNA's how to use equipment but it was not a formal training.
During an interview on 3/28/23 at 9:19 A.M., CNA F said:
-He/she was unaware of any skills training or evaluation.
-He/she received training in CNA classes.
-He/she had worked at the facility as a CNA for three years.
-He/she did not remember participating in or being offered a skills fair.
During an interview on 3/28/23 at 9:34 AM, CNA J said:
-He/she received training at the facility and at CNA training.
-In-services were every couple of months, this was where staff had training to fix issues.
-He/she mainly learned how to operate equipment from other employees and CNA's.
-He/she thought a skills fair was offered but he/she did not participate.
-He/she did testing on computer programs and in meetings.
-The Staffing Coordinator was responsible for ensuring CNA training was completed.
During an interview on 3/28/23 at 9:54 A.M., the Staffing Coordinator said:
-In-services were held every pay day with sign-in sheets and agendas.
-The Quality Assurance (QA) Coordinator, usually a nurse, kept the training records.
-The facility currently did not have a QA nurse.
-The position was vacant for about six months.
-The in-services offered lately included customer service and fall risk residents.
-The skills fairs used to be done every year.
-He/she was unaware of when the last skills fair was.
-The Administrator had all in-services sign-in sheets.
During an interview on 3/29/23 at 2:05 P.M., the DON said the Administrator had records of skills fairs.
During an interview on 3/29/23 at 3:45 P.M., the Administrator said:
-He/she had the sign-in sheets for nursing staff competencies.
-He/she was unable to provide CNA competency evaluations.
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 have sufficient staffing on a 24-hour basis to care for resident's ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have sufficient staffing on a 24-hour basis to care for resident's needs and to ensure resident safety by not having adequate staff in the building for all shifts. This practice had the potential to effect all residents. The facility census was 148 residents.
Record review of the facility's Nursing Department - Staffing, Scheduling and Postings policy, dated June 2020, showed:
-The purpose was to ensure an adequate number of nursing personnel were available to meet resident needs.
-The facility employed sufficient nursing staff on a 24 hour basis.
-Schedule was done as needed to meet resident needs and accounted for the number, acuity and diagnoses the of the facility's resident populations.
-The facility utilized the Facility Assessment to identify competency needs of the nursing staff.
-The facility submitted complete and accurate staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data.
-The Director of Nursing (DON) was responsible for validating the accuracy of data on staffing and census forms.
Record review of the facility's Facility Assessment, undated, showed:
-The facility considered resident population in order to assess what staffing was necessary to care for the facility's residents.
-Resident ethnic, cultural and religious factors or personal resident preferences that may potentially affect the care provided to residents were considered when determining the staffing needs of the facility.
-The resident population characteristics included: indwelling or external catheter (a tube with retaining balloon passed through the urethra into the bladder to drain urine); urinary toileting program, bowel toileting program, bedfast most or all the time, chairfast most or all of the time, need assistance with ambulation; contractures; 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, judgement, and impulses); pressure ulcers (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); dialysis (process of cleansing the blood by passing it through a special machine - necessary when the kidneys are not able to filter the blood); intravenous (process of giving medication directly into a resident's vein) therapy; ostomy (artificial or surgical opening); tracheostomy (surgical opening into the wind pipe into which a tube is inserted to allow passage of air and removal of secretions); and tube feeding (a medical device used to provide nutrition to patients who cannot obtain nutrition by swallowing).
1. Record review of the Payroll Based Journal (PBJ- a report that provides staffing dataset information submitted by nursing homes on a quarterly basis) Quarterly Data Report for January 1, 2022 through March 31, 2022, showed the facility triggered for low weekend staffing during the quarter.
Record review of the PBJ Quarterly Data Report for April 1, 2022 through June 30, 2022 showed the facility triggered for low weekend staffing during the quarter.
Record review of the PBJ Quarterly Data Report for October 1, 2022 through December 31, 2022 showed the facility triggered for low weekend staffing during the quarter.
2. Record review of Resident #36's Occupational Therapy Discharge summary dated [DATE] showed the resident was to receive restorative maintenance program for bilateral upper extremities range of motion. The resident's prognosis was excellent.
Record review of the resident's Restorative Program dated 1/6/23, showed the resident was to receive active range of motion of his/her right upper extremity, 15 to 20 repetitions, and passive range of motion of the resident's left upper extremity, 15 to 20 repetitions. There was also group exercise on Monday, Wednesday and Friday. The document did not show the frequency of the restorative maintenance program to be completed weekly.
Record review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning), dated 1/8/23, showed:
-The resident scored a 15 on the Brief Interview for Mental Status (BIMS), an assessment tool that shows a score between 3 of 15 which shows the resident's mental status. This tool helps determine the resident's attention, orientation and ability to register and recall new information. These items are crucial factors in care planning decisions.
--This showed the resident was cognitively intact.
Record review of the resident's Physical Therapy Discharge summary dated [DATE], showed:
-The resident was to receive restorative maintenance program to include lower extremity active range of motion, bed mobility and upright sitting.
-The resident's prognosis was excellent with consistent staff support.
Record review of the resident's Restorative Program dated 1/16/23, showed the resident was to receive active range of motion, 20 to 25 repetitions. The documentation did not show the frequency restorative maintained program was supposed to be completed weekly.
Record review of the resident's electronic record showed there was no documentation showing the restorative maintenance program was being completed.
Record review of the resident's Physician's Order Sheet (POS) dated 3/2023, showed physician's orders for:
-Restorative Assistance; active range of motion to the right upper extremity, 15-20 repetitions as tolerated, as needed; passive range of motion left upper extremity 15-20 repetitions as tolerated as needed; group exercises Monday, Wednesday and Friday as tolerated, as needed for 90 Days (3/5/23).
-There were no physician's orders for Physical therapy or Occupational therapy.
Record review of the resident's Treatment Administration Record (TAR) dated 3/2023, showed there was no documentation showing Restorative Assistance had ever been initiated or completed.
Record review of the resident's electronic Medical Record showed there was no documentation showing Restorative Assistance was being completed.
During an observation and interview on 3/20/23 at 11:56 A.M., the resident said:
-He/she had been receiving rehabilitative therapy until it ran out in January.
-He/she was supposed to receive restorative care, but he/she has not been receiving any restorative services because the Restorative Aide (RA)was being pulled to work as an aide on the floor and was not able to provide restorative care.
-They only have had one RA for the whole building and they just hired another one but they are usually pulled to work on the floor as aides.
-He/she needed to have exercises on his/her arms and legs because he/she did not want to lose the progress he/she made while he/she was in therapy.
-He/she did not participate in any exercise groups because they did not have them.
-He/she had limited range of motion in his/her shoulder and he/she also wants to be able to walk again.
-He/she spoke with the rehabilitative team and they said that they would follow up to see if his/her insurance was able to begin paying for rehabilitation again.
-Sometimes they don't have enough staff to care for everyone.
-Residents had to wait for staff to come in when they ring the call light.
During an interview on 3/23/23 at 12:39 P.M., the Physical Therapy Assistant said:
-The resident was supposed to be receiving Restorative Assistance services after therapy ended to maintain his/her flexibility and strengthening during the time he/she received therapy, but once they write up the restorative order, the RA is responsible for implementing it.
-They have open communication with the nursing staff and the RA if they notice any changes in the resident's mobility or range of motion, but they do not monitor the restorative program.
During an interview on 3/23/23 at 1:30 P.M., the RA A said:
-He/she had the resident on his/her caseload, but he/she has not been able to get the Restorative Assistance completed because he/she has had to work on the floor.
-He/she has an assistant that is a new employee who started three to four weeks ago for assistance with providing Restorative Assistance services, but he/she had also not been able to do so because he/she was pulled to work as a Certified Nursing Assistant (CNA) on the floor.
-For the last two weeks he/she has been working on the floor and has not been able to do Restorative Assistance.
-Today he/she was able to do a group exercise and is trying to complete all of the resident weights (which is also his/her responsibility).
-He/she also feeds residents in the dining room, which also cuts down on the time he/she has to complete Restorative Assistance.
-When he/she is able to complete Restorative Assistance, he/she documents in the resident's electronic medical record each time Restorative Assistance is completed.
-It had been a very long time since he/she was able to complete Restorative Assistance with the resident, so there probably was not much documentation in the resident's restorative section in his/her electronic medical record.
-The residents on his/her caseload receive restorative services to maintain their current range of motion and when they don't receive it they are at risk of declining.
-He/she knows the staffing coordinator tries to get adequate staff in the building, but staff call in and when they don't have enough staff on the floor, he/she has to provide assistance.
3. Record review of Resident #88's face sheet showed the resident was admitted to the facility with the following diagnoses:
-Unsteadiness on feet.
-Muscle weakness.
-Decreased mobility.
-Muscle wasting and atrophy (decline).
-Foot droop, left and right (muscle weakness in the front part of the foot).
Record review of the resident's care plan dated 10/22 showed:
-He/she has the potential decline in upper and or lower body range of motion related to terminal illness, dated 3/5/23.
-The resident would maintain his/her current functional status through the review period dated, 3/5/23.
-Arm range of motion four pound weight as tolerated.
-Lower leg extremities three to five pound weights as tolerated.
-Group exercises on Monday, Wednesday, and Friday as tolerated.
-Transfer training with slide board as tolerated as needed.
Record review of the resident's MDS annual assessment dated [DATE] showed:
-His/her BIMS score was 15 out of 15 - cognitively intact.
-Needs assistance of two staff members to move from bed to wheelchair.
Record review of the resident's March 2023 POS showed the following orders:
-Restorative Aide to perform arm range of motion for bilateral upper extremities with four pound weights as tolerated.
-Group exercise on Monday, Wednesday, and Friday as tolerated as needed.
-Range of motion lower leg extremities three to five pounds as tolerated as needed.
-Transfer training with slide board as tolerated as needed for 90 days.
Record review of the resident's medical records showed there was no documentation the resident had received Restorative Assistance therapy.
During an interview on 3/20/23 10:35 A.M. the resident said:
-He/she had received therapy until his/her number of covered days was up.
-He/she was told that a RA would be working with him/her.
-That has not happened.
-They say that he/she refuses to get out of bed but they don't have enough staff to get him/her up out of bed.
-He/she would have liked to walk again so he/she could go home to visit.
-There was not enough staff on the weekends.
-He/she was ordered to have his/her blood pressure checked before given medications.
-This did not always happen on the weekends.
-He/she told the nurse who works during the week.
4. Record review of Resident #23's face sheet showed he/she was admitted with the following diagnoses:
-Unsteadiness on feet.
-Muscle weakness.
-Difficulty walking.
-Lower back pain.
Record review of the resident's Reentry MDS dated [DATE] showed his/her Brief Interview for Mental Status (BIMS) score was 15 out of 15, indicating he/she was cognitively intact.
Record review of the resident's March 2023 POS showed the following orders:
-Restorative Aide arm range of motion, bilateral upper extremities two to three pounds, 15 to 20 repetitions as tolerated as needed (PRN).
-Group exercises Monday, Wednesday, and Friday as tolerated PRN for for 90 days, dated 3/5/23.
Record review of the resident's medical records showed there was no documentation the resident had received RA therapy.
During an interview on 3/20/23 at 1:00 P.M. the resident said:
-He/she had fallen and would like to get stronger.
-He/she would go to the group exercise class (Restorative Assistance) but there usually was not enough staff to have it.
5. Record review of Resident #8's Face Sheet showed he/she was admitted on [DATE], with diagnoses including severe obesity, Parkinson's Disease (a degenerative disorder of the central nervous system that often impairs the sufferer's motor skills and speech, as well as other functions), muscle weakness, cognitive communication deficit, anxiety disorder, depression, pain, dementia, edema (swelling in the tissues), high blood pressure, diabetes and history of falls.
Record review of the resident's annual MDS dated [DATE], showed the resident:
-Was alert, oriented and cognitively intact.
-Did not have any behaviors to include resisting care and treatment.
-Needed extensive assistance with bathing.
Record review of the resident's Care Plan dated 3/13/23, showed the resident had limited physical ability due to diagnoses including Parkinson's Disease, high blood pressure and diabetes, and required assistance with all activities of daily living (bathing, dressing, mobility, transfers, hygiene and eating). Interventions showed the resident needed assistance with mobility and staff was to assist with bathing.
Record review of the resident's Bathing Sheets showed:
-From 1/1/2023 to 3/24/23, the resident was given a bath/shower on 1/12/23, 2/10/23, 2/17/23, 3/3/23, and 3/24/23 (5 showers in three months).
-Showers/baths were not given once weekly.
Observation and interview dated 3/21/23 at 11:32 A.M., showed the resident was in his/her room, dressed for the weather. He/she was not odorous. The resident said:
-He/she needed assistance with showers and their shower aide was supposed to give showers once weekly.
-He/she was supposed to have a shower on Fridays and missed it last week because of the St. Patrick's Day celebration.
-Staff did not offer to give him/ her shower at another time or on a different day and he/she hoped to get a shower on this Friday.
-He/she had not received a shower since March 10, 2023.
-He/she said she would like to receive bathing more frequently that once weekly, but they usually don't get them (showers) done once weekly.
6. Record review of Resident #67's Face Sheet showed he/she was admitted on [DATE], with diagnoses including hemiplegia (paralysis on one side of the body) affecting the right dominant side, stroke, lack of coordination, low iron, pain, muscle spasms, high blood pressure, anxiety and depression.
Record review of the resident's quarterly MDS dated [DATE], showed the resident:
-Was alert, oriented and cognitively intact.
-Did not have any behaviors to include resistance to cares.
-Was totally dependent on staff for transfers and needed extensive assistance with bathing.
Record review of the resident's Care Plan dated 3/17/23, showed the resident required assistance with his/her care needs and had a performance deficit in activities of daily living related to stroke and right side hemiparesis. The resident also had a decreased range of motion. Interventions showed the resident was totally dependent on one staff for bathing and staff were to bathe him/her as necessary.
Record review of the resident's Bathing Sheets showed:
-From 1/1/2023 to 3/24/23, the resident was given a bath/shower on 1/6/23, 1/26/23, 2/10/23, 2/17/23, and 3/3/23 (5 showers in three months).
-Showers/baths were not given once weekly.
During an observation and interview on 3/20/23 at 12:02 P.M., the resident was sitting in his/her room in his/her wheelchair, dressed for the weather and was not odorous. He/she was cleaning personal care products from the vanity. He/she said:
-Staff has to assist him/her to bathe and toilet but he/she could complete grooming and hygiene independently.
-He/she did not have bathing twice weekly because they can't give baths that frequently, so it's usually once weekly.
-In a subsequent interview on 3/21/23 at 10:14 A.M., he/she said they are not getting showers like they should because they have one shower aide for the four halls.
-Currently they have been getting showers once weekly, but sometimes it's every two weeks.
-The shower aide said it was too much for him/her and he/she doesn't get any help from the other CNA staff.
-The nursing aides that care for him/her try to assist him/her when he/she is in the bathroom, but he/she wants to have a shower at least weekly.
-The shower aide sometimes gets pulled to work on the floor with residents and he/she is not able to get showers completed on those days.
-The CNA staff do not assist with the showers.
-They had several staff quit last year and they have not hired another shower aide to assist with giving showers.
7. Record review of Resident #96's Face Sheet showed he/she was admitted on [DATE] with diagnoses including respiratory failure, chronic obstructive pulmonary disease (COPD- a progressive disease that is characterized by shortness of breath and difficulty breathing), obesity, heart failure, pain, anxiety disorder, depression, iron deficiency and sleep apnea (a common disorder in which you have one or more pauses in breathing or shallow breaths while you sleep). The Face Sheet showed the resident was his/her own responsible party.
Record review of the resident's admission MDS dated [DATE], showed the resident:
-Was alert oriented and cognitively intact.
-Had no behaviors and was not resistive to cares.
-Needed extensive assistance of one person with bed mobility, transfers, bathing, dressing, toileting and did not walk.
Record review of the resident's Care Plan dated 3/8/23, showed the resident had a self-care performance deficit and needed assistance to complete activities of daily living. Regarding bathing, the interventions showed the resident needed extensive assistance of one staff for bathing.
Record review of the resident's Bathing Sheets showed:
-From 1/1/2023 to 3/24/23, the resident was given a bath/shower on 1/6/23, 1/12/23, 1/13/23, 3/22/23, and 3/24/23 (5 showers in three months).
-Showers/baths were not given once weekly. There was no documentation showing the resident received a bath/shower from 2/1/23 to 2/27/23.
Observation and interview on 3/21/23 at 10:59 A.M., showed the resident was awake, alert and oriented, sitting up in his/her bed and wearing oxygen. The resident said:
-He/she has not had a shower in almost six weeks because they don't have enough shower aide.
-The CNA staff don't normally give baths/showers and they do not offer to give the shower at other times or on a different day.
-When they do give showers/baths, it's only once weekly.
-Currently, they only had one bath aide.
8. Record review of the Resident #45's quarterly MDS, dated [DATE], showed:
-The resident scored a 15 on the BIMS.
--This showed the resident was cognitively intact.
During an interview on 3/22/23 at 11:31 A.M., the resident said:
-In general the staffing was poor.
-Aides were lacking on the weekends.
-Sometimes there was only one aide for all the halls, and sometimes there were only two during the weekdays.
9. Record review of the Resident #142's quarterly MDS, dated [DATE], showed:
-The resident scored a 15 on the BIMS.
--This showed the resident was cognitively intact.
During an interview on 3/23/23 at 1:51 P.M., the resident said:
-They just don't have the staff to make this place happy.
-When he/she was first admitted he/she would be left on a bed pan for an hour or two.
-Once he/she was left on the bed pan until shift change.
-He/she wore a brief now because it was easier to get that changed than the bed pan.
-He/she was frequently left in his/her soiled brief.
10. During an interview on 3/22/23 at 11:05 A.M., the Staffing Coordinator said:
-Nurses rotated every other weekend.
-If staffing was low then unit managers stepped up and worked the floor as a CNA.
-Restorative Aides (RA) also will worked the floor.
-CNA's work 7:00 A.M. -3:00 P.M., 3:00 P.M.-11:00 P.M., and 11:00 P.M.-7:00 A.M
--One CNA per hall.
--Two CNA's on Renew (therapy) and two CNA's on Sunset (memory care).
-Certified Medication Technicians (CMT) work 7:00 A.M. -3:00 P.M. and 3:00 P.M.-11:00 P.M
--Two to three 3 CMT's on the skilled units.
--One CMT on Sunset and one CMT on Renew.
-Nurses worked 12 hour shifts from 7:00 A.M. - 7:00 P.M., and 7:00 P.M. -7:00 A.M
-- Two nurses on days on the skilled halls, and two nurses on nights.
--One to two nurses on days on Renew and one on sunset on nights.
--One nurse on days and one on nights in Sunset.
--Sometimes there are only three nurses scheduled for the facility at night.
--Nurses are not back on the Sunset Unit but staff can come get a nurse if needed.
During an interview on 3/23/23 at 12:28 P.M., CNA P said:
-The CNA staff assist with transferring residents to give showers, but the bath aide actually gives the showers and the CNA's do not assist.
-The bath aide is not always able to give the showers/baths because he/she she is pulled to work on the floor when they have call-ins.
-Residents only get baths/showers once weekly, but they were supposed to receive two baths a week.
During an interview on 3/24/23 at 10:41 A.M., CNA C said:
-He/she was the Bath Aide for all four halls on the skilled unit.
-The CNA's rarely assisted with giving showers or baths to the residents.
-All of the residents were supposed to get showers twice weekly, but he/she was only able to give showers once weekly because she/was the only bath aide.
-He/she regularly was pulled to work the floor and on those days, he/she is unable to give showers/baths.
-He/she was also pulled to work on the floor whenever they had staff call-ins, so he/she tried to do the best he/she could to get bathing done.
-He/she did not know why the other CNA's don't assist, but they say it is because they are busy and don't have time.
-He/she would like some help with giving the showers/baths because it was hard to get them all completed.
During an interview on 3/27/23 at 9:52 A.M., CNA L said:
-During the day there are two aides, a nurse, a CMT on the memory care unit and it runs pretty good back here.
-He/she was reassigned to units where he/she was needed.
During an interview on 3/27/23 at 10:16 A.M., CNA M said:
-He/she wanted more staff on the memory care unit.
-Usually there were two aides, a CMT and a nurse.
-Need two people on the floor
-Could use a shower aide.
-The Staffing Coordinator pulled people from other floors if staffing ratio was higher than expected.
-People were called to come in if there were no-call/no-shows.
During an interview on 3/27/23 at 10:30 A.M., Licensed Practical Nurse (LPN) C said:
-He/she came into work if there was not enough coverage.
-He/she was usually in the building if the staff was low.
-The Staffing Coordinator called people during the week and on the weekend if staffing was low.
-There is an on-call schedule and rotation.
-Usual staffing gets needs met.
During an interview on 3/28/23 at 9:19 A.M., CNA F said:
-He/she worked on 100 hall and had 23 residents to care for.
-He/she had worked some weekends.
-There was is always a call-in on weekends.
-Management reached out to employees through a group text.
-Sometimes the facility uses agency staff.
During an interview on 3/28/23 at 9:34 A.M., CNA J said:
-He/she was also the RA, and was not supposed to be working the floor.
-When staff call-in the RA goes to work the floor as a CNA.
-When he/she was scheduled for RA, he/she was pulled to the floor to work as a CNA. He/she was unable to do RA with the residents.
-Other RA's are on staff, CNA H has been doing the RA.
-Resident cares come first.
-He/she was seeing improvement in the staffing.
-The facility hired more CNAs.
During an interview on 3/28/23 at 9:54 A.M., the Staffing Coordinator said:
-Most employees have master schedules and a lot of as needed (PRN) staff and ask them to pick up on a daily basis.
-The Facility Assessment used to put two CNAs on heavy halls, otherwise it was one and half.
-The more residents and higher census, the more he/she struggled with having adequate staffing.
-Weekend staffing adjustments were also a struggle.
-The unit managers were asked to step in and do CNA duties.
-Management also received authorization to offer bonuses for staff who came in to work weekends.
-The facility also used agency in the past.
-He/she had communications with residents and family members regarding not enough staff in the facility.
-He/she had conversations with residents and family members and if they wish they can complete a grievance form, but no one has completed one that he/she was aware of.
During an interview on 3/28/23 at 1:21 P.M. the DON said:
-He/she started his/her position on December 10, 2022.
-During staff meetings the management team work together to be sure everyone is on the same page regarding staffing, and understands where the gaps are and how to fix them.
-There is always a licensed nurse on each shift.
-If staff call-in then the unit managers will cover gaps.
-All unit managers were LPN's.
-To help meet weekend staffing requirements there is an on-call schedule rotation.
-Management, Corporate and other staff will come in to meet fire code staffing.
-Management offered bonuses and incentives for those who came in.
-He/she did not have a lot of experience with the PBJ report or how to report numbers.
-He/she was unaware of who submits report staffing numbers to PBJ.
During an interview on 3/29/23 at 2:05 P.M., the DON said:
-The staffing coordinator was responsible for ensuring staffing was adequate to meet fire code safety.
-He/she worked together with the Staffing Coordinator.
-The unit managers and the DON was a team.
-It was a group effort to meet weekend staffing.
-Managers took turns being on call.
-Corporate offered incentives to staff for coming on weekends when not scheduled.
-The goal was to use minimal agency staff but at times they had to be used.
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 fan vent covers and the light fixture of the walk-in refrigerator free of a heavy dust buildup; maintain the ceiling and the lig...
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Based on observation and interview, the facility failed to maintain the fan vent covers and the light fixture of the walk-in refrigerator free of a heavy dust buildup; maintain the ceiling and the light fixtures in the kitchen free of a heavy dust buildup; maintain the ice machine free of brown colored grime; maintain the floor of the dry goods storage room free of food crumbs; maintain the nozzles of the automated dish washer spray wands free of debris inside the nozzles and free from a layer of grime on the upper part of the dishwasher; ensure the handle of the spatula was easily cleanable; ensure the mittens were free from rips and loose fibers that could potentially get into foods; and maintain the snack food refrigerator on the Sunset Unit in a clean manner and without expired containers of condiments. This practice potentially affected 144 residents who ate food from the kitchen. The facility census was 148 residents.
1. Observations during the lunch meal preparation on 3/20/23 from 9:31 A.M. through 2:07 P.M., showed:
- The presence of dust on the fan vent covers and the light fixtures inside the walk-in refrigerator.
- A layer of dust on the ceiling and the exit sign above the dishwasher area.
- A layer of brown colored grime on the upper part of the ice machine.
- Food crumbs on the floor on the dry goods storage room.
- Food debris and plastic particles inside the nozzles of the automated dishwasher
- A spatula with a handle that was partially melted which made that spatula not easily cleanable.
- The presence of food crumbs in the utensil drawer.
- One container of pepper pieces which was labeled Refrigerate after opening which was not refrigerated and was stored on the lower shelf of one of the food preparation tables.
- Several oven mittens with damaged areas including one with a 2.5 inch (in.) and two others with 3 in. damaged areas.
During interviews on 3/20/23 from 1:48 P.M. through 2:14 P.M., the Dietary Manager (DM) said:
- The dietary staff should clean the ice machine every two weeks and he/she was not sure the last time the dietary staff cleaned the ice machine.
- He/she expected the dietary staff to check the drawers at least once per week and as he/she observed that utensil drawer, also said it had been longer than once per week that the utensil drawer had been cleaned.
- The last time he/she contacted maintenance was about other kitchen issues, and not the dust on the ceiling. It was their responsibility to clean the ceiling.
- The facility had not ordered any new oven mittens within the last six months.
- The dietary staff had to do a better job of getting under the shelves when the sweep.
- The automated dishwasher should be cleaned daily and the dishwasher had not been delimed (a process designed to remove calcium lime and rust from the interior of automatic warewashing machines) in a while, but he/she was not for sure exactly.
2. Observations during the breakfast preparation meal on 3/24/23, showed a heavy buildup of a brown grime on the upper part of the automated dishwasher, a buildup of food particles on the lower screen from the night before, and a steel wool scrubber inside the dishwasher.
During an interview on 3/24/23 at 10:29 A.M., the DM said:
- The night staff are supposed to take out the bottom part of the dishwasher at night and let that part soak in a deliming solution.
- The dishwasher should be cleaned after the lunch meal and the dinner meal.
- He/she will have to have another meeting with the evening dishwashers.
3. Observations with Certified Medication Technician (CMT) A of the Sunset Unit snack resident refrigerator on 3/20/23 at 3:03 P.M., showed one condiment container which expired in 4/2022 and another condiment container which expired on 3/14/23 and very sticky shelves with stains inside the refrigerator.
During an interview on 3/20/23 at 3:07 P.M., CMT A said the hospitality aide cleaned the fridge last week, but did not clean the sides and the shelves.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review, the facility failed to ensure they developed and implemented a Quality Assurance and Performance Improvement (QAPI) Plan pertaining to on-going syste...
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Based on observation, interview and record review, the facility failed to ensure they developed and implemented a Quality Assurance and Performance Improvement (QAPI) Plan pertaining to on-going systemic issues regarding one resident (Resident #60) out of 30 sampled residents not receiving showers on a regular basis; and to implement a QAPI program to ensure safe smoking practices by staff and residents. The facility census was 148 residents.
1. Record review of the QAPI meeting minutes dated 1/3/23, showed the absence of any discussion of any matters related to enhancing the shower experience for residents or the promotion of safe smoking practices for facility staff and residents.
During a phone interview on 4/5/23 at 2:34 P.M., the Director of Nursing (DON) said he/she did not remember attending that QAPI meeting back in January 2023 and there was a different Administrator there at that time.
2. Record review of Resident #60's admission Sheet showed he/she had diagnoses of muscle weakness, unsteadiness on feet and pain.
Record review of the resident's care plan dated 8/9/22 showed he/she:
-Had Activities of Daily Living (ADL's-dressing, grooming, bathing, eating, and toileting) self-care performance deficit related to pain, unsteady gait and balance, poor vision,
-Required assistant with bathing and some personal cares.
-Preferred to shower once weekly (revised on 4/24/21).
Record review of the resident's Quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 1/18/23 showed he/she:
-Was cognitively intact.
-He/she was able to understand others and make his/her needs known;
-Required supervision assistant from staff for setup with bathing and personal hygiene.
Record review of the resident's 2/2023 and 3/2023 shower sheets/skin condition report showed he/she had documentation of having received a shower on 2/7/23, 3/7/23, 3/14/23, and 3/21/23.
During interview and observation on 3/21/23 at 9:08 A.M., the resident said:
-He/she had to get up at 5:00 A.M. today to get his/her shower.
-He/she had to sit in line for the bath aide.
-The poor bath aide was the only one that was giving showers and then he/she was pulled to work on the floor as a Certified Nursing Assistant (CNA).
-The facility does not have anyone to give the residents a shower.
-He/she would prefer to get up around 8:30 A.M., but I want a shower more.
-He/she does not need assistance from facility staff except for bathing.
During an interview and observation on 3/23/23 at 1:44 P.M., the resident said:
-He/she did not ask to only be bathed once a week.
-He/she would like to shower twice a week.
-He/she did get a shower that week, but had to get up at 5:00 A.M. to get it.
-His/her hair and face was oily. He/she had a same green nightgown with paint worn on 3/22/23.
-He/she was able to brush own hair.
During an interview on 3/24/23 at 10:41 A.M., CNA C said:
-He/she was the Bath Aide for all four halls on the skilled unit.
-The CNA's rarely assisted with giving showers or baths to the residents.
-All of the residents were supposed to get showers twice weekly, but he/she was only able to give showers once weekly because she/was the only bath aide.
-He/she completed the showers on one hall each day except Wednesdays because he/she is off on Wednesdays.
-He/she regularly was pulled to work the floor and on those days, he/she is unable to give showers/baths.
-He/she was also pulled to work on the floor whenever they had staff call-ins, so he/she tried to do the best he/she could to get bathing done.
-When he/she completed bathing for a resident, he/she documented the bath/shower on the bath sheet and gave it to the Unit Manager.
-If a resident refused a shower/bath, he/she documented that the bath/shower was refused on the bath sheet and turned that in to the Unit Manager.
-He/She was off work all of last week due to an injury to his/her arm and no showers were completed while he/she was gone.
-He/she has about 100 showers he/she had to give in four days, and tried to give about 25 showers daily.
-When a resident is not able to get a shower, he/she tries to offer a different time or day to receive their shower.
-He/she did not know why the other CNA's don't assist, but they say it is because they are busy and don't have time.
-The CNA staff will assist with the lift for those residents who require the lift to get up.
-Sometimes he/she will provide bed baths to some of the residents.
-He/she would like some help with giving the showers/baths because it was hard to get them all completed.
During an interview about quality assurance procedures for showers for residents on 3/29/23 at 1:03 P.M., the DON said:
-The facility restructured the shower schedules.
-The facility was able to divide the showers on the hall's amongst the CNA's.
-A CNA who was designated as a bath aide, unfortunately passed away in November 2022.
-A bath aide was added to replace his/her position, which caused there to be two bath aides until one of them became a Certified Medication Technician (CMT).
-At that current time, there was only one designated as a bath aide.
-The interim plan to address showers was not working as well he/she hoped it would.
-Ideally showers should be given twice weekly for each resident, but at the minimum at least once weekly.
-He/she has been made aware that residents have not been receiving showers at least once weekly.
-Nursing staff will tell him/her it's due to staffing shortages.
-They previously had two to three bath aides on the skilled unit and one on the rehabilitation unit, but currently they have one CNA assigned as the bath aide.
-The CNA staff can give showers and have been instructed to assist with giving showers.
-The CNA staff don't assist with showers as he/she would like.
-He/she would expect the CNA would had been assigned to provide showers to those resident requiring a shower that day during their schedule shift.
-Bed baths would still be part of the CNA daily bath schedule.
During a phone interview on 4/5/23 at 2:37 P.M, the DON said he/she did know if at the time, the plan for providing showers to the residents was a written plan. The plan was discussed with nursing staff and they were expected to carry out the plan.
3. Observations on 3/20/23 at 11:13 A.M., and 3/22/23 at 2:04 P.M., showed:
- Numerous cigarette butts on the ground in an unauthorized smoking area that was used by employees.
- Numerous cigarette butts were observed on leaves close to climate control units.
- Numerous cigarette butts on the ground close to the authorized employee smoking area.
- Numerous cigarette butts on the facility's grounds close to vegetation in areas such as outside the front entrance and outside the Renew Entrance.
During an interview on 3/29/23 at 1:21 P.M., the Administrator said the following about safe smoking practices by employee, normally employees are supposed to go their designated area and the smoking issue has not been discussed with employees.
During an interview on 3/29/23 at 1:25 P.M., the DON said the following about safe smoking practices by residents:
- There were about five residents to his/her recollection that may be prone to smoke in their rooms.
- The facility has designated smoking areas.
- The facility staff has warned the residents about the dangers of smoking around oxygen sources.
- All of the residents have signed agreements stating they understood the facility's smoking policy.
- He/she has done everything that he/she could, except have facility staff store cigarettes and cigarette lighters, because the facility just did not have enough staff to obtain the cigarettes from a storage location.
During a phone interview on 4/5/23 at 2:36 P.M., the DON said he/she expected the employees to follow safe smoking practices and to follow the facility policy.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected most or all residents
Based on observation and interview, the facility failed to repair two convection ovens (an oven that has fans to circulate air around food to create an evenly heated environment which causes a fan-ass...
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Based on observation and interview, the facility failed to repair two convection ovens (an oven that has fans to circulate air around food to create an evenly heated environment which causes a fan-assisted oven to cook food faster) and one regular oven for an unknown period of time. The facility census was 148 residents.
1. During an interview on 3/20/23 at 9:51 A.M. Dietary [NAME] (DC) A said Convection Oven #1 (the upper oven) convection ovens did not work at all and the Convection Oven #2 (the lower oven) only cooked at one temperature, and one of the regular ovens did not turn on at all.
Observation on 3/20/23 at 10:10 A.M., showed DC A placed two trays of pork cutlets into Convection Oven #2.
During an interview on 3/20/23 at 2:03 P.M., the Dietary Manager said:
- The top convection oven has not been working for about six months to a year.
- He/she was not sure how long the regular oven has not been working.
- The lower convection overcooks the meat at times.
- At that time, he/she did not have any way of documenting how often he/she notified the maintenance department.
- He/she notified the Maintenance Department about the regular oven not working.
During an interview on 3/24/23 at 10:29 A.M., the DM said he/she has not had a work order sheet to fill out for the non-working convection oven and the non-working regular oven and he/she was told that maintenance department was aware of the oven before he/she started working at the facility.
During an interview on 3/24/23 at 12:11 P.M., the Maintenance Director said:
- The DM told him/her about the convection oven on 3/23/23.
- For the regular oven, there was a sleeve that may fall on the pilot light and put out the pilot light and that causes that oven not to work properly.
- He/she had to work with that particular oven during February 2023.
- He/she needed to call someone to replace the metal sleeve on the oven.
- He/she has not had a system of where the dietary staff could check work orders as yet.
- Both the dietary staff and the maintenance staff forget stuff as well.
- He/she needed to put a service request for someone to come and take a look at convection oven and the range oven.
Jan 2023
3 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
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to notify one sampled resident's (Resident #2)'s responsible party of an incident when he/she was on the floor and repeatly kicked by Resident...
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Based on interview and record review, the facility failed to notify one sampled resident's (Resident #2)'s responsible party of an incident when he/she was on the floor and repeatly kicked by Resident #1 and was sent to the hospital out of eight sampled residents. The facility census was 154 residents.
1. Record review of Resident #2's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 10/10/22 showed the following staff assessment of the resident:
-Was severely cognitively impaired.
-Had a diagnosis of dementia (a progressive mental disorder characterized by memory problems, impaired reasoning and personality changes).
Record review of the resident's undated care plan showed he/she had a diagnosis of dementia.
Record review of the facility incident report dated 12/24/22 showed:
-Yelling was heard in Resident #1's room.
-Two Certified Nursing Assistants (CNA)s entered Resident #1's room and found Resident #2 on the floor.
-Resident #1 was kicking Resident #2.
-Resident #1 was yelling and cussing.
-Licensed Practical Nurse (LPN) A was called to the room and the CNA's had stopped Resident #1 and separated them.
-Neither resident had injuries observed after the incident.
-Resident #2 was sent to the hospital for an evaluation.
Record review of the resident's electronic health record on 1/10/23 showed:
-There was contact information for the resident's responsible party which included a phone number, an email address and an address.
-There was contact information for two additional people including a phone number for both.
During an interview on 1/11/23 at 10:17 A.M., the resident's responsible party said he/she was never notified of Resident #1 kicking Resident #2 or Resident #2 going to the hospital after the incident.
During an interview on 1/11/23 at 2:24 P.M., the Administrator said the charge nurse should have contacted the resident's responsible party about the incident and documented it in the chart.
During an interview on 1/12/23 at 8:08 A.M., LPN A said:
-Resident #2 was on the ground and Resident #1 was kicking Resident #2.
-He/she tried to look for Resident #2's responsible party information but could not find a phone number for the resident's responsible party.
-He/she left a message for the Unit Manager that he/she was unable to locate Resident #2's responsible party contact information.
During an interview on 1/12/23 at 12:25 P.M., the Unit Manager said:
-LPN A did not tell him/her that he/she was unable to contact the resident's responsible party.
-He/She did not have any missed calls, texts or voice messages from LPN A stating he/she was unable to contact the resident's responsible party.
-The resident's responsible party information was located in the electronic health records on the resident profile.
MO00211643
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** Based on interview and record review, the facility failed to ensure one sampled resident (Resident #2) was free from abuse when ...
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**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 #2) was free from abuse when Resident #1 kicked Resident #2 multiple times in the ribs and head out of eight sampled residents. The facility census was 154 residents.
Record review of the facility's Abuse Prevention and Prohibition Program policy dated as revised 10/24/22 showed:
-Each resident had the right to be free from abuse.
-The facility was committed to protecting residents from abuse by anyone including other residents.
1. Record review of Resident #1's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 11/24/22 showed the following staff assessment of the resident:
-Had moderately impaired cognition.
-Had no verbal or physical behaviors towards others.
-Walked independently.
-Had a diagnosis of psychosis (a mental disorder characterized by a disconnection from reality).
Record review of Resident #1's undated care plan showed:
-The resident had a history of being verbally and physically aggressive toward others.
-The resident had a history of intermittent explosive behaviors.
Record review of Resident #2's quarterly MDS dated [DATE] showed the following staff assessment of the resident:
-Had clear speech.
-Was understood by others.
-Usually understood others.
-Was severely cognitively intact.
-Walked independently.
-Had a diagnosis of dementia (a progressive mental disorder characterized by memory problems, impaired reasoning and personality changes).
Record review of Resident #2's undated care plan showed:
-The resident had a diagnosis of dementia.
-The resident could become verbally aggressive to staff.
-The resident wandered related to disorientation to place.
-The resident had impaired safety awareness.
-The resident wandered aimlessly.
Record review of the facility Incident report dated 12/24/22 showed:
-Yelling was heard in Resident #1's room.
-Two Certified Nursing Assistants (CNA)s entered Resident #1's room and found Resident #2 on the floor.
-Resident #1 was kicking Resident #2.
-Resident #1 was yelling and cussing.
-Licensed Practical Nurse (LPN) A was called to the room and the CNAs had stopped Resident #1 and separated them.
-Neither resident had injuries observed after the incident.
-Predisposing situation factors included behaviors.
During an interview on 1/10/23 at 9:23 A.M., Resident #1 said:
-Another resident (Resident #2) came into his/her room, so he/she kicked Resident #2 out.
-He/she escorted Resident #2 to his/her door and asked Resident #2 to leave.
-Resident #2 has come into his/her room every once in a while.
-He/she denied kicking Resident #2.
During an interview on 1/10/23 at 11:35 A.M., CNA A said:
-He/she was sitting in the sitting area by the nurses' station and heard a commotion.
-He/she went to Resident #1's room and saw Resident #2 on the floor and Resident #1 kicking Resident #2.
-LPN A took Resident #2 to the sitting area and Resident #2 was holding onto his/her ribs.
During an interview on 1/10/23 at 1:10 P.M., the Administrator acknowledged Resident #1 kicking Resident #2 was abuse.
During an interview on 1/10/23 at 1:34 P.M., Resident #2 was not able to say what happened between him/her and Resident #1.
During an interview on 1/10/23 at 2:39 P.M., the Nurse Practitioner said:
-He/she was informed of the abuse incident involving Residents #1 and #2.
-Resident #1 was aggressive if someone went into his/her space.
During an interview on 1/10/23 at 3:02 P.M., CNA B said:
-He/she was at the nurses' station and heard banging.
-He/she, CNA B and LPN A went to Resident #1's room.
-Resident #2 was on the floor just inside the doorway and Resident #1 was kicking Resident #2 in his/her ribs and head.
-He/she went over to Resident #1 and walked him/her over to the opposite side of the room to separate the two residents.
During an interview on 1/10/23 at 3:30 P.M., the Director of Nursing (DON) acknowledged Resident #1 kicking Resident #2 was abuse.
During an interview on 1/12/23 at 8:14 A.M., LPN A said:
-He/she heard yelling and screaming.
-He/she went to where the yelling and screaming was coming from.
-When he/she got there, the two residents were separated.
-One of the CNAs had Resident #1 over on the other side of the room and Resident #2 was on the floor.
-The two CNAs present both said Resident #1 was kicking Resident #2.
-There were no visible injuries but he/she didn't know if there were unknown injuries due to Resident #1 kicking Resident #2 in the ribs.
MO00211643
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 F0744
(Tag F0744)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to provide monitoring and supervision for one sampled resident (Resident #2). On 12/24/22 the resident with known wandering behavior wandered ...
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Based on interview and record review, the facility failed to provide monitoring and supervision for one sampled resident (Resident #2). On 12/24/22 the resident with known wandering behavior wandered into another resident's room resulting in the resident being kicked multiple times in the ribs and head out of eight sampled residents. The facility census was 154 residents.
Record review of the facility's Behavior Management policy dated as revised June 2020 showed:
-Facility staff should identify residents whose behaviors may pose a risk to self or others.
-Develop and implement individual care strategies based on assessed needs.
-Monitor the resident and evaluate the interventions.
-When a resident displayed an adverse behavioral symptom, the Licensed Practical Nurse (LPN) would assess the behavioral symptoms to determine possible causal factors and implement non-drug interventions to alleviate the behavioral symptoms.
1. Record review of Resident #2's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 10/10/22 showed the following staff assessment of the resident:
-Had clear speech.
-Was understood by others.
-Usually understood others.
-Was severely cognitively impaired.
-Walked independently.
-Had a diagnosis of dementia.
Record review of the resident's undated care plan showed:
-The resident had a diagnosis of dementia.
-The resident could become verbally aggressive to staff.
-The resident wandered related to disorientation to place.
-The resident had impaired safety awareness.
-The resident wandered aimlessly.
-A goal that the resident's safety would be maintained.
-Interventions included distracting the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, books.
-The resident's preferences were left blank under the interventions section.
-Instructions for staff to identify patterns of wandering such as purposeful, aimless, escapist, looking for something, or needs more exercise and intervene as appropriate.
-An intervention to monitor location every 15/30/60 minutes.
-An intervention to document wandering behavior and attempted diversional interventions in behavior log.
-10/30/22, the resident wandered without a purpose in and out of other resident rooms, talking out loud to himself/herself.
-10/30/22, the resident was found with other residents' belongings.
-Interventions included:
--Attempting to redirect the resident when he/she was entering other residents' rooms.
--Offering activities that were interesting to the resident.
--Discuss the resident's behavior if reasonable and explain why behavior was inappropriate or unacceptable.
--Intervene as necessary to protect the rights and safety of others.
--Approach the resident and speak in a calm manner.
--Divert the resident's attention.
--Remove from situation and take to alternate location as needed.
-Activities the resident enjoyed included music, reading, football, movies, being outdoor, and church.
Record review of the facility incident report dated 12/24/22 showed he/she had wandered into another resident room which resulted in him/her being kicked.
During an interview on 1/10/23 at 9:23 A.M., Resident #1 said:
-Resident #2 had come into his/her room, so he/she kicked Resident #2 out.
-Resident #2 came in his/her room in the past.
During an interview on 1/10/23 at 11:35 A.M., Certified Nurses Aide (CNA) A said:
-Resident #1 said Resident #2 should not have been in his/her room.
-He/she did not know the residents very well because they just slept on the night shift.
During an interview on 1/10/23 at 1:45 P.M., CNA C said:
-Resident #1 did not like other residents coming into his/her room.
-Resident #2 and a couple of other residents usually wandered the unit.
-The staff monitor the residents who wander the unit.
-If they notice a resident going into another resident's room, they should re-direct them away.
-He/she worked day shift and was not working the night shift when the altercation occurred.
During an interview on 1/10/23 at 1:55 P.M., the Unit Manager said:
-Resident #2 wandered occasionally and went into other residents' rooms.
-They should re-direct Resident #2 if he/she was wandering into other residents' rooms.
-Staff could walk with Resident #2 or re-direct him/her to the common area.
-Resident #2 liked to dance if music was on.
During an interview on 1/10/23 at 2:39 P.M., the Nurse Practitioner said:
-He/she felt the way to prevent incidents of wandering residents going into other resident's rooms was through staff monitoring of the residents.
-Resident #2 needed to be watched by staff to ensure he/she didn't go into other resident's rooms.
During an interview on 1/10/23 at 3:02 P.M., CNA B said:
-Resident #2 always wandered at night.
-He/she usually re-directed Resident #2 to sit in the common area when wandering during the night.
-After re-direction to the common area, Resident #2 would usually nap for an hour or two and then get back up and start walking around again.
-He/she usually did the night shift charting at the nurses' station while the other CNA on the unit watched the halls and any residents out of their rooms.
-That night they just did not see Resident #2 walking in the hallway.
During an interview on 1/10/23 at 3:30 P.M., the Director of Nursing (DON) said:
-In an ideal world there would be no resident to resident incidents.
-The residents who wandered were on the secure unit because they wander.
-They monitor the residents who wander.
-The staff should re-direct residents that wander, distract them and keep them busy.
During a phone interview on 1/12/23 at 8:14 A.M., LPN A said:
-If they saw Resident #2 go into another resident's room, they would get him/her and re-direct him/her to the lobby where he/she then would sleep in the recliner.
-A lot of the times, Resident #2 got into other residents' rooms without them seeing him/her.
During a phone interview on 1/19/23 at 7:58 A.M., CNA B said:
-He/she was at the nurses' station and CNA A was in the family living room when the incident occurred.
-He/she and the other CNA were watching the two hallways.
-They were supposed to watch the halls, do their charting, straighten up residents' closets, clean up the family sitting area and the dining room on night shift.
-When one person was cleaning, the other person was supposed to watch the hallways.
-Because some of the residents wander due to dementia, they were supposed to let them wander as long as they did not go into any other residents' rooms.
-If a resident went into another resident's room, they were supposed to re-direct the resident to the family sitting area, offer them a snack, have them sit down, turn the television on, or something else to keep them distracted.
-They have not figured out anything that Resident #2 liked to do to keep him/her distracted.
-Resident #2 usually did not go into other residents' rooms.
-They were trained to do patient care as needed on the night shift and to make sure to keep an eye on the residents and keep them out of other residents' rooms while residents were sleeping.
-He/She wasn't told where to be when monitoring the residents.
-Both halls were visible from the nurses' station and the family sitting area.
During a phone interview on 1/19/23 at 8:14 A.M. CNA A said:
-He/she was in the sitting area monitoring residents in the recliners when he/she heard the commotion.
-He/she could see the hallways but would have to get up to see who was walking in the halls.
-LPN A was down the hall reading a book.
-CNA B was at the nurses' station.
-They were supposed to do every two hour checks on all the residents.
-The facility staff had not provided him/her with any specific training for the memory care unit.
-The facility staff had not told him/her the expectations for monitoring the residents on the unit.
-He/she usually worked on the long-term care unit or the rehabilitation unit.
-He/she had not been on the special care unit in a long time.
During a phone interview on 1/19/23 at 3:51 P.M., LPN A said:
-He/she was at the far end of 700 hall in another resident's room helping a resident change his/her brief.
-He/she stepped out of the room when he/she heard the commotion and the two CNA's motioned him/her to come down there to Resident #1's room.
-All staff were responsible for watching wandering residents.
-He/she never saw the resident wandering that night.
-They usually kept an eye on Resident #2.
-When Resident #2 was wandering, they usually gave him/her a snack and took him/her to the sitting room where he/she would sleep.
-There were three residents on their unit who wandered at night.
-He/she was told to always keep an eye on the residents that wander.
-He/she could see the two halls on the unit when he/she was doing paperwork at the nurses' station.
-There were no specific assignments as to who should be watching the residents who wander while the other staff were busy in a location they could not see the residents wandering.
During a phone interview on 1/23/23 at 10:40 A.M. the DON said:
-Staff have had training specific for dementia and Alzheimer's.
-Staff have had training specific to be able to deal with and handle behaviors.
-Staff have had training specific to be able to deal with and handle wandering.
-He/she would expect staff to redirect any resident who was out of their room during the night shift.
--Residents could be redirected back to their room or to the living area.
-He/she would expect staff to be able to visualize the hallways and redirect any residents who came out of their room.
-He/she would expect staff to point the resident in a different direction if the resident was wandering into other resident rooms.
-He/she would expect staff to give the residents something to do that was appropriate for the shift.
-He/she would expect staff to be able to visualize the halls during the night shift.
-If staff were sitting at the nurse's station doing documentation, he/she would expect them to still be monitoring the halls by looking up occasionally and visualizing the halls.
-Staff were aware of who on the unit wanders, he/she would expect staff to monitor and redirect the resident's when they were out of their room.
-He/she would expect night shift staff to interact quietly with resident who were up.
-All staff on the unit should be monitoring and supervising the residents.
--Sitting at the end of one hall reading a book would not be appropriate.
-He/she expected staff to monitor, redirect and interact with residents who wandered more frequently.
-He/she expected all staff to keep their eyes and ears open, even when they were interacting with residents or doing documentation.
MO00211643
Mar 2020
14 deficiencies
1 Harm
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 interview and record review, the facility failed to identify a change in condition in a resident including a decrease o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to identify a change in condition in a resident including a decrease of alertness, decreased blood pressure, and decreased oxygen saturation; to notify the resident's physician of the resident's change in condition in a timely manner; to transfer a resident to a hospital when requested by the resident's family in a timely manner, resulting in the resident requiring transportation to the hospital by Emergency Medical Services (EMS) and admission to the Intensive Care Unit (ICU) due to critically low blood pressure for one sampled resident (Resident #316) out of 32 sampled residents. The facility census was 164 residents.
Record review of the facility Change of Condition Notification policy dated February 2019 showed:
-The purpose of the policy was to ensure that residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner.
-An acute change of condition (ACOC) is a sudden, clinically important deviation from a resident's baseline in physical, cognitive behavioral, or functional domains.
-Clinically important means a deviation that, without intervention, may result in complications or death.
-Members of the Interdisciplinary Team (IDT) are expected to report and document signs and symptoms that might represent and ACOC.
-The facility will promptly inform the resident, consult with the resident's attending physician and notify the resident's legal representative when the resident endures a significant change in their condition caused by, but not limited to a significant change in the resident's physical cognitive, behavioral or functional status, a significant change in treatment and/or a decision to transfer or discharge the resident from the facility.
-The licensed nurse will notify the resident's attending physician when there is a significant change in the resident's physical, mental or psychosocial status, e.g. deterioration in health, mental or psychosocial status, life-threatening conditions or clinical complications; a need to alter treatment significantly, a decision to transfer or discharge the resident from the facility.
-The licensed nurse will assess the resident's change of condition and document the observations and symptoms.
-The attending physician will be notified timely with a resident's change in condition.
-Notification to the attending will include a summary of the condition change and an assessment of the resident's vital signs and system review focusing on the condition and/or signs and symptoms for which the notification is required.
-In emergency situations, (e.g., a resident is experiencing unexpected shortness of breath, intense pain, unexpected bleeding, serious abnormal labs or x-ray) the licensed nurse will immediately call the attending physician; notify the nursing supervisor of an emergency situation.
-The licensed nurse will notify the resident, the resident's responsible party, or the family/surrogate decision-maker of any changes in the resident's condition as soon as possible.
-The licensed nurse will document the date, time and pertinent details of the incident and the subsequent assessment in the Nursing Notes.
-The licensed nurse will document the time the attending physician was contacted, the method by which he/she was contacted, the response time, and whether or not orders were received.
-The licensed nurse will update the care plan to reflect the resident's current status.
-The licensed nurse will include the incident and brief details in the 24-Hour Report (a communication document between different shift charge licensed nurses regarding important resident condition and care needs).
-If a resident is transferred to an acute care hospital the licensed nurse completes an inter-facility transfer form.
-A licensed nurse will communicate any changes in required resident interventions to the IT members involved in the resident's care.
-A licensed nurse will document each shift for at least 72 hours.
-Documentation pertaining to a change in the resident's condition will be maintained in the resident's medical record and on the 24-Hour Report.
Record review of the facility Negative Pressure Wound Therapy (NPWT - also known as wound VAC - vacuum-assisted closure - an high level wound treatment for chronic or complicated wounds consisting of a portable vacuum device to create negative pressure and a specialized sealed dressing with a drain and reservoir for collection of drainage and wound debris to aid in wound healing) ) policy dated February 2019 showed:
-Licensed nurses will initiate and maintain NPWT as ordered by the attending physician.
-The physician's order will specify the suction setting including continuous or intermittent and the frequency of the dressing change.
-Dressings should be changed every 48 to 72 hours per physician order, but should not be less than two times per week.
-The NPWT dressing should be removed if negative pressure is off for a period exceeding two hours; replace with a traditional dressing.
1. Record review of Resident #316's admission Record showed he/she:
-Was admitted to the facility on [DATE].
-Had diagnoses of stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure ulcer (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) of sacral (large, triangular bone at the base of the spine and at the upper and back part of the pelvic cavity) region, and morbid (severe) obesity.
Record review of the resident's Order Summary Report showed the following orders dated 2/11/20:
-Admit to facility with a diagnosis of weakness.
-Foley catheter (a tube with retaining balloon passed through the urethra into the bladder to drain urine).
-Gabapentin (anticonvulsant medication also used for pain management) 300 milligrams (mg), give one tablet by mouth three times a day for neuropathic pain (a complex, chronic pain state that usually is accompanied by tissue injury).
-Percocet (Oxycodone - an opioid, sometimes called narcotic medication for moderate to severe pain with acetaminophen) 5-325 mg, give one tablet by mouth every four hours for pain, give while awake, hold for sedation.
-Complete blood count (CBC - a blood test used to evaluate overall health and detect a wide range of disorders including anemia and infection) and a comprehensive metabolic panel (CMP - a group of blood tests that provide an overall picture of your body's chemical balance and metabolism, i.e. the chemical processes in the body that use energy).
Record review of the residents Nursing Note date 2/11/20 at 4:14 A.M. showed:
-The resident was admitted to the facility.
-He/she had a Foley catheter.
-He/she complained of pain.
-No mention of the resident's dressing/NPWT or his/her left buttock pressure ulcer.
-No assessment of the resident's level of alertness.
--NOTE: The facility staff documented the resident stage IV pressure ulcer was on his/her sacral area on his/her admission record dated 2/10/20.
Record review of the resident's Physician admission Progress Note dated 2/11/20 at 2:36 P.M. showed:
-He/she was new to the facility coming from another skilled nursing facility with a history of the following diagnoses:
--Sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock and death) due to Escherichia coli (E. coli) bacteria live in the intestines of people and animals, and are key to a healthy intestinal tract. Most E. coli strains are harmless, but some can cause diarrhea through contact with contaminated food or water while other strains can cause urinary tract infections, respiratory illness and pneumonia).
--Stage IV pressure ulcer.
--Paralysis (loss of the ability to move, and sometimes to feel anything, in part or most of the body, typically as a result of illness, or injury).
--Gastrointestinal (GI) bleed (any type of bleeding that starts in the digestive tract) related to perianal fistula (an abnormal tunnel that begins in the anus and exits through the [NAME] near the rectum).
--Hypoxemia (abnormally low oxygen concentration in the blood.
-The resident was awake and alert, and his/her cognitive status showed no 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).
-His/her stage IV pressure ulcer had a dressing and wound VAC.
Record review of the resident's Progress Notes dated 2/11/20 through 2/15/20 showed:
-No licensed nurse notes regarding the resident's wound VAC dressing.
-No mention of the presence of or non-presence of his/her wound vac.
-No notation regarding notification regarding the resident being sedated or having a decrease/change in his/her alertness/mental status.
-No notation regarding a decrease in the resident's blood pressure.
-No notation regarding a decrease in his/her oxygen saturation (blood oxygen level measured with a small device placed on a finger) .
-No notation regarding the resident having repeated loose stools.
-No notation regarding the resident's family being present at the facility, having concerns regarding the resident's condition and requesting the resident be transferred to hospital on 2/15/20.
-No notation of notification to facility management or to the resident's physician regarding a change in the resident's condition and the family requesting the resident be transferred to hospital on 2/15/20.
Record review of the resident's Medication Administration Record (MAR) dated February 2020 showed:
-Percocet 5/325 mg - give one tablet every four hours while awake for pain, hold for sedation.
--Documentation showed staff administered one tablet on 2/15/20 at 4:00 A.M., 8:00 A.M., 12:00 P.M. and 4:00 P.M.
Record review of the residents Nursing Note dated 2/15/20 at 11:13 P.M. showed:
-The resident's family called 911 to take him/her to the hospital.
-Emergency medical staff were at the facility at 9:30 P.M. and told the licensed nurse that a family member called 911 to send the resident to the hospital.
-Emergency medical staff took the resident's blood pressure with a result of 107/43 (an abnormally low bottom/diastolic reading - normal range for a healthy adult at rest is 90/60 to 120/80), a low oxygen saturation of 88% (normal range is 90 to 100%).
-He/she was responding to conversation and questions.
-After the emergency medical staff took the resident's vital signs, they took him/her to the hospital.
-The resident's physician and the Director of Nursing (DON) was notified.
Record review of the resident's Situation, Background, Assessment, Recommendation Communication Recommendation (SBAR -a framework for communication between members of the health care team about a resident's condition) Form and progress note dated 2/15/20 at 10:00 P.M. showed:
-The resident's family called 911 and the resident was taken to hospital.
-He/she had prescribed pain medication and had taken medication prior to the family arrival.
-The form was blank for things that make the condition or symptom worse, things that make the condition or symptom better, treatment, primary diagnosis, changes in the last week, if resident was on Warfarin (blood thinner) the results of the last international normalized ratio (INR - a laboratory measurement of how long it takes blood to form a clot used to determine the effects of oral anticoagulants on the body's clotting system).
-His/her vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) were in normal range; his/her oxygen saturation level was 92% (low, normal range is 95 to 100%) and the form was blank regarding if the resident was receiving supplemental oxygen at the time of the oxygen saturation measurement and if so, the rate of administration (liters per minute).
-The resident had mental status changes of decreased consciousness (sleepy, lethargic/sluggish).
-The resident had respiratory symptoms of low oxygen saturations of 88%.
-Recent lab results was blank.
-Advanced care planning information was blank.
-Assessment by Registered Nurse (RN) was that the resident's family called 911 and the resident was taken to the hospital; the resident had prescribed pain medications and had taken medication prior the family arrival.
-Nursing Notes for additional information on the Change in Condition was blank.
-The resident's Family/Health Care Agent was notified on 2/15/20 at 11:00 P.M.
-The resident's change in condition was reported to the resident's Primary Care Clinician on 2/15/20 at 11:00 P.M.
-The form was electronically signed by the Assistant Director of Nursing (ADON) on 2/17/20.
Record review of the resident's hospital ICU admission History and Physical (H&P) dated 2/16/20 showed:
-He/she was admitted from his/her nursing home with altered mental status (AMS - a disruption in how your brain works that causes a change in behavior. This change can happen suddenly or over days; AMS ranges from slight confusion to total disorientation and increased sleepiness to coma) and buttock pain.
-On arrival to the emergency room (ER) his/her only complaint was right buttock pain and he/she reported he/she had a chronic sacral wound.
-He/she had a stage IV sacral ulcer, very large and deep and on examination, bone could be palpated (felt by placing a hand over the area and applying pressure).
-EMS reported his/her blood pressure had been low during transport to the hospital, 80s over 50s.
-On arrival to the ER, he/she reported he/she had not been clean after his/her bowel movement many hours ago and he/she had a chronic wound in that area.
-Report from EMS was that the family noted a slight change from his/her normal mental status earlier in the day (2/15/20) at an undetermined time.
-He/she was given two liters of fluids intravenously (IV - into a blood vein) with a good response of his/her blood pressure.
-His/her wound VAC fell off two days ago per the RN report.
-He/she was initially admitted to the hospital medicine team but his/her blood pressure dropped to 70s despite getting two liters of IV fluid in the ER.
-She was started on Levophed (norepinephrine bitartrate - a medication used to treat life-threatening low blood pressure that can occur with certain medical conditions or surgical procedures) temporarily via his/her peripheral IV line until ICU was consulted, placed a right intrajugluar vein (IJ) central line (insertion of a tube into the large vein on the right side of the neck that allows rapid high-volume fluid administration, administration of multiple medications, and hemodynamic monitoring that measures the blood pressure inside the veins, heart, and arteries, how much oxygen is in the blood, checks how well the heart is pumping; and is often used for reliable venous access in ill persons) and admitted him/her to the ICU.
Record review of the resident's hospital History and Physical addendum dated 2/17/20 showed:
-He/she was critically ill with imminent threat to his/her life.
-His/her septic shock was being treated with broad spectrum (those able to treat a wide range of bacteria) antibiotics including Vancomycin and Zozyn for urinary tract infection and pneumonia.
-His/her urine culture was growing E. coli greater than 100,000.
2. During an interview on 2/15/20 at 8:11 A.M. RN B said:
-During shift report for the 7:00 P.M shift change, the off going licensed nurse told him/her that the family wanted the resident to go to the hospital because the resident was sleeping.
-He/she went to the resident's room around 7:14 P.M.
-The resident said no when asked if he/she needed anything.
-He/she went to the next hall and started doing his/her resident care.
-Later he/she was told that 911 was in the facility, that the family had called for the resident to go to the hospital so he/she went to the resident's room and EMS told him/her the family had called 911.
-EMS staff asked him/her what the resident's baseline was (the resident's usual condition, especially regarding mental alertness) and he/she said the resident could ask for what he/she needed and could use his/her call light.
-If the resident had been in distress, he/she would have called the resident's doctor, but the resident was not in distress.
-The family did not call him/her; they could have called the facility and asked for the nurse on duty.
-The resident's oxygen saturation was 90% to 92%.
-He/she could not turn the resident by himself/herself.
-He/she first saw the resident at 7:15 P.M.
-He/she had 12 residents needing Accuchecks (a blood sugar reading obtained by a small sample of blood from the finger) and residents also came to him/her for pain medications which had to be given on time.
-He/she saw the resident at 8:00 P.M. and helped a Certified Nursing Assistant (CNA) to turn the resident in bed; he/she asked the resident if he/she was OK and the resident said yes.
-He/she then went to do something else; he/she was always busy.
-EMS arrived at the facility at about 9:00 P.M.
-EMS checked the resident's vital signs and oxygen saturation and said they had to take him/her to the hospital.
-He/she told EMS that he/she had to go print something.
-He/she called the resident's family and the resident's Nurse Practitioner (NP), he/she thought this occurred prior the EMS taking the resident to the hospital.
During an interview on 3/4/20 at 5:48 A.M. RN B said:
-On 2/15/20 the resident's family called 911 to take him/her to the hospital.
-EMS arrived at the facility at 9:30 P.M.
-EMS told him/her a family member had called 911 to take the resident to the hospital.
-EMS took his/her vital signs; his/her blood pressure was low, 107/43 and his/her oxygen saturation was low at 88%.
-He/she was responding to commands and questions.
-After EMS took the resident's vital signs, they took him/her to the hospital.
-He/she notified the resident's physician and facility ADON A.
During an interview on 3/4/20 at 6:22 A.M. RN B said:
-When he/she came to work for the 7:00 P.M. to 7:30 A.M. shift on 2/15/20 the off going licensed nurse told him/her that the family wanted the resident to go to the hospital.
-Later, the family called 911 from outside the facility to take the resident to the hospital.
During an interview on 3/4/20 at 8:11 A.M. RN B said:
-The family wanted the resident to go to the hospital because he/she was sleeping.
-He/she went to the resident's room at around 7:15 P.M.; at that time the resident said he/she did not need anything.
-He/she went to the next hall to complete blood sugar testing for residents; staff told her later that EMS was at the facility and that the resident's family had called for him/her to be taken to the hospital.
-He/she went to the resident's room; EMS staff told him/her the resident's family had called for the resident to be taken to the hospital.
-EMS staff asked what was the resident's baseline, he/she responded that the resident was able to ask for what he/she needed and was able to use his/her call light.
-He/she would have called the resident's physician but the resident was not in distress so he/she did not call the resident's physician.
-The resident's family never called him/her; the family could have called the facility and asked for the nurse on duty.
-He/she told EMS that he/she needed to put a dressing on the resident's wound; EMS told him/her there was no need to put a dressing on the resident's wound.
-He/she was told the resident needed a dressing on his/her stage IV pressure ulcer when he/she first came to work for his/her 7:00 P.M. shift.
-He/she could not turn the resident by himself/herself. He/she thought the resident had a wound VAC.
During an interview on 3/4/20 at 9:21 A.M. RN B said
-During the 7:00 P.M. shift change report, the off going licensed nurse told him/her the resident needed a dressing on his/her stage IV pressure ulcer.
-He/she told the off going licensed nurse that he/she would put a dressing on the resident's stage IV pressure ulcer.
-The off going licensed nurse had not told him/her that the resident was supposed to go the hospital.
-After the shift report, he/she completed blood glucose monitoring for 12 residents.
-He/she first saw the resident at 7:14 P.M.
-Residents came to his/her for pain medication; he/she had to give pain medications on time.
-He/she was always busy.
-EMS arrived at the facility at about 9:00 P.M.;
-He/she then went to the resident's room.
-EMS took the resident's vital signs and oxygen saturation, told him/her the numerical results and said they had to take the resident to the hospital.
-After EMS took the resident to the hospital, he/she called the resident's Nurse Practitioner (NP).
-He/she called the resident's family member who was the resident's DPOA, he/she thought this call was before EMS took the resident to the hospital.
During an interview on 3/5/20 at 1:38 P.M. Licensed Practical Nurse (LPN) D said:
-The resident had a stage IV pressure ulcer.
-The resident's wound VAC was not on when he/she got to work.
-He/she discovered at about 11:00 A.M. or maybe around noon that the resident's wound VAC was not on his/her stage IV pressure ulcer; at that time he/she was helping another staff person turn and clean the resident because he/she had had a lot of loose stools.
-The resident continued to have loose stools throughout the rest of the 7:00 A.M. to 7:30 P.M. shift.
-He/she put a dressing on the resident's stage IV pressure ulcer at about 12:30 P.M. when he/she finished completed blood sugar testing for diabetic residents.
-At that time, there could have been an old dressing in the bed but he/she could not remember, but there was not a dressing on the resident's buttocks.
-The resident was receiving Percocet every four hours around the clock, he/she had been tolerating the Percocet but within an hour of getting her first dose for the 7:00 A.M. shift, the resident seemed sedated.
--NOTE: The first dose for the 7:00 A.M. shift was scheduled to be administered at 8:00 A.M. and was documented as administered by the facility staff at 8:00 A.M. on 2/15/20.
-He/she remembered taking the resident's vital signs and checking the resident's pupils and skin color.
-The resident's skin was moist.
-He/she thought he/she had done a blood sugar test for the resident, just to make sure his/her blood sugar was alright.
--NOTE: There was no documentation in the resident's medical record of vital signs or blood sugar checks at that time by the facility staff.
-He/she thought the resident's blood pressure was OK when he/she took it.
-The resident's breathing rate was normal, her pulse was in the low 100s and he/she did not have a fever.
-It seemed to him/her that resident's oxygen saturation was initially low; he/she turned the resident's oxygen up a little bit and then the resident's oxygen saturation came up to normal, as he/she slowly became more alert over the next couple of hours while he/she started to wake up more.
--NOTE: The resident did not have a valid physician's order for oxygen administration and there was no documentation in the resident's medical record staff notified the resident's physician of the resident's need for supplemental oxygen.
-He/she took the resident's vital signs several times, he/she left the equipment for taking the resident's vital signs in the resident's room.
--NOTE: There was no documentation by the facility staff of these vital signs in the residents medical record.
-He/she was first aware the resident was without a dressing on his/her stage IV pressure ulcer at around the lunch hour.
-He/she put a dressing on the resident's stage IV pressure ulcer at around 12:45 P.M, sometime before 1:00 P.M.
-The resident had a family member visitor and told him/her that they were concerned the resident had a decreased level of consciousness.
-He/she told the visitor that the resident had been having loose stools and discussed with the resident's family that the resident's decreased level of consciousness could be from a buildup of the resident's narcotic medication that he/she was getting every four hours.
--NOTE: There was no documentation in the resident's medical record by facility staff related to concerns of sedation due to scheduled Percocet administration and no documentation staff notified the resident's physician related to concerns of sedation or decreased levels of consciousness related to scheduled Percocet administration).
--NOTE: Documentation showed staff administered Percocet 5/325 mg at 8:00 A.M., 12:00 P.M. and 4:00 P.M. on 2/15/20.
-The resident started becoming more alert at about 4:00 P.M.
-The family member wanted the resident to be sent out to the hospital to be evaluated sometime between 5:00 P.M. to 6:00 P.M.
-At about 5:00 P.M. or 6:00 P.M. there was flooding in the building, on the 300 Hall (the resident's room was on the 100 Hall).
-He/she told ADON A that the resident's family member wanted the resident to be sent out to the hospital.
-ADON A was going to go look at the resident and then the flood on the 300 hall happened.
-He/she evacuated residents on the 300 hall out of their rooms and did not know if ADON A made it to the resident's room.
-He/she told the resident's family member that he/she was not trying to ignore the resident; he/she thought the family member was going to be upset; it was like he/she had just disappeared, he/she was helping with the flood on the 300 hall.
-The resident was more alert around that time and it seemed like the resident had come out of her prior state.
-He/she became aware the resident did not have a dressing on just before the fire alarm went off because he/she was assisting in turning the resident as he/she had been incontinent of stool again; at that time he/she saw that the resident had bowel movement all over her old dressing and bowel movement was in the residents wound.
-He/she made it back to the resident's room at 6:30 P.M., maybe; he/she had gone to the resident's room to check on him/her, the resident's family member had left.
-At that time (6:30 P.M.) he/she knew the resident did not have a dressing on his/her stage IV pressure ulcer because his/her dressing came off earlier when he/she was turning the resident; that was at the time he/she put the dressing on the resident.
-He/she was really busy and was behind on everything.
-He/she remembered that he/she had told the oncoming 7:00 P.M. nurse that he/she had not called anyone yet about the family wanting the resident to be sent to the hospital because ADON A wanted to assess the situation.
-ADON A had lost his/her stethoscope, he/she was going to go to the resident's room but then the flood happened.
-He/she did think the resident had a wound VAC on because he/she did not need to change the resident's dressing on his/her stage IV pressure ulcer; he/she had looked at the wound VAC the previous day and it was operation correctly.
-During the shift report he/she passed on that the resident did not have a dressing on his/her stage IV pressure ulcer.
During an interview on 3/6/20 CNA L said:
-The resident was not large.
-He/she had in the past completed incontinence care for the resident.
-He/she always took another staff person with him/her when he/she completed incontinence care with all residents.
-The resident's level of alertness and ability to assist in turning in bed depended on the time of day; he/she routinely had to explain to the resident what was being done.
-He/she was not aware of the resident ever having a change in condition or having loose stools.
-The resident would get confused; he/she never appeared sedated.
-The resident used oxygen, the resident had to put oxygen because he/she was short of breath.
During an interview on 3/9/20 at 10:50 A.M., the ADON A said:
-If a family member requested a resident be sent to the hospital, the licensed nurse was to assess the resident, based on the assessment notify the resident's physician, talk with the resident and the resident's responsible party (DPOA - the person named in a legal document to make health care decisions in the event the resident is unable) of the physician's recommendations and ability to treat the resident at the facility if able; if a the family and the resident still wanted for the resident to be sent to the hospital, the resident should be sent to the hospital by calling 911.
-If a resident was showing signs of a change in condition licensed nurses were to assess the resident, notify the ADON or DON, notify the resident's physician, and follow the physician's order and, treat the resident in the facility or send the resident to the hospital as soon as possible.
-Licensed nurses should act or react to situations in a timely manner.
-If an issue is identified, it should be addressed.
-Licensed nurses should not wait to assess, treat, or notify the resident's physician of any issues brought to their attention.
-The resident's family member who was in the facility who wanted the resident sent to the hospital was not the resident's DPOA.
-He/she was in the facility at the time the family member was requesting the resident be sent to the hospital; he/she was on his/her way to assess the resident when an emergency happened and staff had to address the situation.
-During the facility emergency the family member called 911.
-The family member in the facility who wanted the resident sent to the hospital was not the DPOA.
-The ADON was in the facility at the time the family member was requesting the resident be sent.
-The ADON was on his/her way to assess the resident when an emergency happened and staff had to address the situation.
-During the emergency is when the family member called 911.
During an interview on 3/9/20 at 12:59 the DON said:
-He/she had not been notified about the resident having a change of condition
-He/she was not at the facility when the resident went out to the hospital.
-He/she was told by the licensed charge nurse the resident was a little drowsy right before his/her family arrived at the facility.
-The resident had received pain medication prior to his/her family member coming to the facility.
-The residents oxygen saturations did drop below 90%, then when the licensed nurse talked with the resident, he/she was at baseline with cognition and his/her oxygen level went was back up.
-He/she did not remember any reports of what the resident's blood pressure was from the licensed charge nurse.
-If the family requested the resident to be sent to the hospital, the resident should be sent.
-He/she expected the nurse to assess first and try some changes here, if possible.
-He/she was unaware the family had expressed concerns earlier in the shift and had wanted the resident to go to the hospital.
-The licensed nurse mentioned to the family that pain medication had been given.
-A sprinkler head (a fire suppression device that provides a continuous overhead spray of water) had bust on the 300 hall early in the evening around 4-5 P.M.
-The SBAR should be completed and filled out to the license nurse best ability, including all areas of the change of condition.
-He/she would have expected the charge licensed nurse to pass on to the oncoming licensed nurse the information regarding the resident's change of condition.
-The nur
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
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 one sampled resident (Resident #121) was free f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one sampled resident (Resident #121) was free from restraints out of 32 sampled residents. The facility census was 164 residents.
Record review of the facility's Restraints policy revised 2/2019 showed:
-Residents shall be provided an environment that is restraint free, unless a restraint is necessary to treat a medical symptom in which case the least restrictive measure shall be used.
-There must be a physician's order for the use of a restraint, including the medical symptom, frequency, type of restraint, release protocols and a plan for reduction.
-Before any restraint is used, the licensed nurse would verify that informed consent has been obtained from the resident/responsible party, and education was provided including the risks and benefits of the restraint.
1. Record review of Resident #121's Face Sheet showed he/she was admitted to the facility on [DATE] and had the following diagnoses:
-Cognitive communication deficit (unable to communicate with words).
-Unspecified 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) with behavioral disturbance.
-Psychotic disorder with delusions (a type of serious mental illness called a psychotic disorder. People who have it cannot tell what is real from what is imagined. Delusions are the main symptom of delusional disorder).
Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) dated 11/5/19 showed he/she:
-Was severely cognitively impaired.
-Had short term and long term memory loss.
-Had inattention and disorganized thinking.
-Was rarely understood, had unclear speech, and rarely understands.
-Needed the extensive assistance of two staff member with transfers, bed mobility, toileting, and personal hygiene.
-Used a wheelchair for mobility.
-A restraint was not used.
Record review of the resident's Care Plan revised 2/13/20 showed he/she:
-Needed activities he/she was cognitively able to enjoy.
-Liked to wander around and clean.
-Used a low Broda chair (a specialized wheelchair for positioning) for mobility and was able to propel himself/herself at times in the chair.
-Had a history of wandering in and out of resident rooms.
Record review of the resident's physician's Order Summary Report (OSR) dated 4/5/20 showed the resident did not have orders for the use of a Broda chair as a restraint.
Record review of the resident's medical record showed:
-No assessment for the use of a Broda chair as a restraint.
-No consent from the resident and/or the resident's responsible party for the use of a Broda chair as a restraint.
Observation on 3/2/20 at 9:27 A.M. and 12:36 P.M. showed:
-The resident was in his/her Broda chair trying to pull himself/herself forward by rocking back and forth with much effort using his/her upper body.
-The resident was using his/her feet to try to pull the Broda chair forward.
-The Broda chair wheels were locked.
Observation on 3/2/20 at 12:36 P.M. showed:
-A staff member moved the resident in his/her Broda chair by the dining area and locked the Broda chair wheels.
-The resident was rocking his/her body hard back and forth, using his/her feet to pull the Broda chair forward.
-The resident moved the Broda chair a couple of feet with much effort.
-A staff member unlocked the Broda chair and moved the resident back into his/her original position and then locked the Broda chair wheels.
-The resident rocked his/her body again, using his/her feet to pull the Broda chair sideways.
-The resident did not show signs of distress.
Observation on 3/4/20 at 7:29 A.M. showed:
-The resident was in his/her Broda chair eating breakfast.
-The resident's Broda chair wheels were locked.
Observation on 3/4/20 at 9:08 A.M. showed:
-A staff member took the resident to be weighed.
-The staff member unlocked the Broda chair wheels and assisted the resident down the hall.
-At 9:12 A.M., the staff member brought the resident back to the common area in his/her Broda chair and locked the Broda chair wheels.
Observation on 3/5/20 at 9:07 A.M. showed:
The resident was in his/her Broda chair by the nurses station.
-The Broda chair wheels were locked.
-The resident tried to pull the chair forward by rocking his/her upper body back and forth and pulling with his/her feet.
-The resident was able to turn the Broda chair at an angle but could not move the Broda chair any further.
-The resident did not show signs of distress.
During an interview on 3/6/20 at 8:52 A.M. Certified Nurses Assistant (CNA) J said:
-The resident would stand up independently leaning forward so we (the staff) lock the Broda chair wheels.
-The resident did like to move around the secure care unit.
-A wheelchair was tried prior to the Broda chair.
-The Broda chair was locked for safety.
-He/she would move all around the unit when it was unlocked and try to transfer himself/herself.
-He/she did wander into rooms when the chair was unlocked.
-He/she could still move the chair some with it locked.
During an interview on 3/6/20 at 9:05 A.M., Assistant Director of Nursing (ADON) B said:
-He/she was the acting charge nurse today.
-The resident had been in a Broda chair for a while and was previously unsafe in a wheelchair, so the Broda chair was used.
-He/she would tip himself/herself forward in a wheelchair.
-He/she locked the back wheels of the Broda chair when the resident was in the Broda chair.
-When it was unlocked, the resident would go everywhere in the chair.
-He/she would go the dining room, his/her office, and wander into resident rooms.
-He/she could still move the Broda chair some when it was locked.
-He/she was unsure if a restraint assessment had been completed for the resident's Broda chair.
-He/she had not considered the Broda chair a restraint.
During an interview on 3/6/20 at 12:15 P.M., Social Services Designee A and Social Services Designee B said:
-Maybe the staff locked the Broda chair during meals.
-The staff should not be locking the resident's Broda chair to keep him/her from wandering.
-Locking the resident's Broda chair to prevent him/her from wandering was a restraint.
-The resident liked to wander and locking his/her Broda chair would potentially cause negative behaviors.
During an interview on 3/9/20 at 12:59 P.M., the Director of Nursing (DON) said:
-The resident was confused and fidgety at times.
-The resident did try to transfer himself/herself.
-The resident was friendly and pleasant.
-The resident liked to wander and the staff should not lock his/her wheelchair to keep the resident from wandering.
-Locking the resident's Broda chair was a restraint and could cause behaviors.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to accurately complete Minimum Data Set (MDS - a federall...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to accurately complete Minimum Data Set (MDS - a federally mandated assessment tool required to be completed by facility staff for care planning) assessments for two sampled residents (Residents #25 and #367) out of 32 sampled residents. The facility census was 164 residents.
1. Record review of Resident #25's Face Sheet showed he/she was admitted to the facility on [DATE].
Record review of the resident's Telephone Order Sheet (TOS) dated 12/3/19, showed an order for the resident to be evaluated by hospice (end of life care) services.
Record review of the resident's hospice agreement showed:
-He/she was admitted to hospice 12/4/19.
-His/her admitting diagnosis was heart failure.
Record review of the resident's Nurses' Progress Note dated 12/5/19, showed he/she was admitted to hospice.
Record review of the resident's Significant Change MDS dated [DATE], showed he/she did not have a condition or chronic disease that may result in a life expectancy of six months or less.
2. Record review of Resident #367's Face Sheet showed he/she was admitted to the facility on [DATE].
Record review of the resident's care plan initiated 2/21/20, showed he/she had oral/dental health problems.
Record review of the resident's admission MDS, dated [DATE] showed he/she had no dental issues.
Observation on 3/3/20 at 10:51 A.M. showed the resident had several missing and damaged teeth.
3. During an interview on 3/9/20 at 11:25 A.M., the MDS Coordinator said:
-Resident #25's Significant Change MDS should have shown the resident had a condition or chronic disease that may result in a life expectancy of six months or less.
-The MDS should accurately reflect the residents' conditions.
During an interview on 3/9/20 at 1:00 P.M., the Director of Nursing (DON) said:
-He/she would want the resident's MDS to be accurately updated when a resident goes on hospice.
-The MDS correction was submitted as of 3/9/20.
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 residents and their representative with a summary of the ba...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide residents and their representative with a summary of the baseline care plan for two sampled residents (Resident #50 and #126) out of 32 sampled residents. The facility census was 164 residents.
Record review of the facility's Care Planning Policy dated February 2019, showed:
-The facility will develop a person-centered baseline care plan for each resident within 48 hours of admission.
-Once the baseline care plan is completed, the facility must provide the resident and/or the resident's representative with a written summary of the baseline care plan.
-The baseline care plan summary must be provided to the resident and/or the resident's representative by the time the Comprehensive Care Plan is completed.
-Care plan summaries should be provided in a language and manner that the resident and/or resident's representative can understand.
-The medical record must contain evidence that the summary was given to the resident and/or resident's representative.
1. Record review of Resident #50's face sheet showed he/she was admitted to the facility 12/19/19.
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) assessment, dated 12/25/19, showed:
-The resident was moderately cognitively impaired.
-He/she needed extensive assistance with activities of daily living.
Record review of the resident's medical record showed his/her comprehensive care plan was initiated within 48 hours of admission and revisions made as of 1/3/20.
Record review of the resident's progress note dated 12/20/2019, showed Social Services staff was to contact the resident's family member by phone for a conference meeting.
During an interview on 3/03/20 at 10:43 A.M., the resident said:
-He/she did not understand why he/she was still in the facility.
-He/she did not receive a summary of his/her baseline care plan.
2. Record review of Resident #126's face sheet showed he/she was admitted to the facility 2/2/20.
Record review of the resident's admission MDS dated [DATE], showed:
-The resident was moderately cognitively impaired.
-He/She needed some assistance with activities of daily living.
Record review of the resident's comprehensive care plan showed:
-The first care plan focus was initiated 2/3/20.
-Updates and revisions continued in February 2020.
During an interview on 3/03/20 at 8:50 A.M., the resident said he/she did not receive a summary of his/her baseline care plan.
3. During an interview on 3/05/20 at 2:58 P.M., Social Services Designee A said:
-A written copy of baseline care plan summary was not given to the residents, but he/she did talk with the residents.
-A multi-disciplinary care plan meeting was held within 21 days of the residents' admission.
-The resident attends the meeting and signs the care plan at that time.
-He/she had not been giving the resident a copy of the care plan until their discharge.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person centered ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person centered care plan for one sampled resident (Resident #126), out of 32 sampled residents. The facility census was 164 residents.
Record review of the facility's Care Planning policy, revised February 2019, showed:
-A comprehensive person-centered Care Plan would be developed for each resident.
-Each resident's Comprehensive Care Plan would describe:
--Services that were to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being.
--Any services that would be required, but were not provided due to the resident's exercise of rights, which includes the right to refuse treatment.
-The Care Plan would include measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs.
1. Record review of Resident #126's face sheet showed he/she was admitted to the facility on [DATE].
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) assessment, dated 2/8/20, showed:
-The resident was moderately cognitively impaired.
-The resident needed limited assistance with his/her activities of daily living (ADL).
-He/she currently used tobacco.
During an interview on 3/3/20 at 8:55 A.M. the resident said:
-He/she fell outside yesterday at around 4:00 P.M. in the smoking area.
-Staff usually went out with him/her when he/she went out to smoke, but sometimes he/she went out on his/her own.
-His/her cigarettes and lighter were kept in his/her coat pocket.
Observation on 3/5/20 at 3:25 P.M. showed the resident returning from the smoking area with a staff member.
Record review of the resident's care plan showed he/she did not have a smoking care plan.
During an interview on 3/9/20 at 11:25 A.M., the MDS Coordinator said the Interdisciplinary Team prepares the resident's care plan.
During an interview on 3/9/20 at 1:00 P.M., the Director of Nursing (DON) said he/she would expect there to be a smoking care plan for a resident that smokes.
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 interview and record review, the facility failed to ensure a resident with a Stage IV (Full thickness tissue loss with ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident with a Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure ulcer (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) remained clean, free of stool, and coved with a dressing per physician's orders; to ensure a resident's Negative Pressure Wound Therapy (NPWT - also known as wound VAC - vacuum-assisted closure - an high level wound treatment for chronic or complicated wounds consisting of a portable vacuum device to create negative pressure and a specialized sealed dressing with a drain and reservoir for collection of drainage and wound debris to aid in wound healing) was applied to the resident's Stage IV pressure ulcer per the resident's physician's order for one sampled resident (Resident #316) out of 32 sampled residents. The facility census was 164 residents.
Record review of the facility Negative Pressure Wound Therapy (NPWT) policy dated February 2019 showed:
-Licensed nurses will initiate and maintain NPWT as ordered by the attending physician.
-The physician's order will specify the suction setting including continuous or intermittent and the frequency of the dressing change.
-Dressings should be changed every 48 to 72 hours per physician order, but should not be less than two times per week.
-The NPWT dressing should be removed if negative pressure is off for a period exceeding two hours; replace with a traditional dressing.
1. Record review of Resident #316's admission Record showed he/she:
-Was admitted to the facility on [DATE].
-Had diagnoses of Stage IV pressure ulcer of sacral (large, triangular bone at the base of the spine and at the upper and back part of the pelvic cavity) region, and morbid (severe) obesity.
Record review of the resident's Order Summary Report showed the following orders dated 2/11/20:
-Admit to facility with a diagnosis of weakness.
- Foley catheter (a tube with retaining balloon passed through the urethra into the bladder to drain urine).
-Gabapentin (anticonvulsant medication also used for pain management) 300 milligrams (mg), give one tablet by mouth three times a day for neuropathic pain (a complex, chronic pain state that usually is accompanied by tissue injury).
-Percocet (oxyCODONE opioid, sometimes called narcotic medication for moderate to severe pain with acetaminophen) 5-325 mg, give one tablet by mouth every four hours for pain, give while awake, hold for sedation.
-Complete blood count (CBC - a blood test used to evaluate overall health and detect a wide range of disorders including anemia and infection) and a comprehensive metabolic panel (CMP - a group of blood tests that provide an overall picture of your body's chemical balance and metabolism, i.e. the chemical processes in the body that use energy).
Record review of the residents Nursing Note date 2/11/20 at 4:14 A.M. showed:
-The resident was admitted to the facility.
-He/she had a Foley catheter.
-He/she complained of pain.
-No mention of the resident's dressing/NPWT or his/her left buttock pressure ulcer.
-No assessment of the resident's level of alertness.
--NOTE: The facility staff documented the resident Stage IV pressure ulcer was on his/her sacral area on his/her admission record dated 2/10/20.
Record review of the resident's Physician admission Progress Note dated 2/11/20 at 2:36 P.M. showed:
-He/she was new to the facility coming from another skilled nursing facility with a history of the following diagnoses:
--Sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock and death) due to Escherichia coli (E. coli) bacteria live in the intestines of people and animals, and are key to a healthy intestinal tract. Most E. coli strains are harmless, but some can cause diarrhea through contact with contaminated food or water while other strains can cause urinary tract infections, respiratory illness and pneumonia).
--Stage IV pressure ulcer.
--Paralysis (loss of the ability to move, and sometimes to feel anything, in part or most of the body, typically as a result of illness, or injury).
--Gastrointestinal (GI) bleed (any type of bleeding that starts in the digestive tract) related to perianal fistula (an abnormal tunnel that begins in the anus and exits through the [NAME] near the rectum).
--Hypoxemia (abnormally low oxygen concentration in the blood.
-The resident was awake and alert, and his/her cognitive status showed no 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).
-His/her Stage IV pressure ulcer had a dressing and wound VAC (vacuum-assisted closure - an high level wound treatment for chronic or complicated wounds consisting of a portable vacuum device to create negative pressure and a specialized sealed dressing with a drain and reservoir for collection of drainage and wound debris to aid in wound healing).
Record review of the resident's Skin and Wound Evaluation dated 2/11/20 showed:
-He/she had a Stage IV pressure ulcer on his/her left buttock, present on his/her facility admission.
-His/her Stage IV pressure ulcer measured 12.2 centimeters (cm) in length by 11.1 cm in width, a depth of 3.2 cm and with undermining (destruction of tissue or ulceration extending under the skin edges so that the pressure ulcer is larger at its base than at the skin surface).
-The wound bed had 3.8% of granulation collection of pink-red moist cells that fill and open wound when it starts to heal) tissue; 10.10% slough (layer or mass of dead tissue separated from surrounding living tissue, yellow, tan, gray green or brown, usually moist and may be attached to the base of the wound or present in clumps throughout the wound bed), and 10.10% eschar (dead tissue that is hard or soft, usually black, brown or tan in color, and may appear scab-like, usually firmly attached to the base of the wound and often the sides/edges of the wound); fibrin (white or yellowy shiny tissue that may cover chronic wounds) was present in the wound.
-There was a moderate amount of serosanguineous (containing blood and watery drainage) and no odor.
-The wound edges were both attached and unattached, the surrounding tissue was fragile (skin that was at risk for breakdown) and was normal in color, there was no induration (hardness) or edema (swelling) and the temperature of the surrounding skin was normal.
-The resident had no pain in the area of his/her right buttocks wound.
-The primary dressing was negative pressure wound therapy.
-Additional care included incontinence management, an air mattress with a pump, and repositioning/turning.
--NOTE: The facility staff did not describe or document the measurements of the resident's right buttocks wound and did not identify the wound as a pressure or non-pressure wound.
Record review of the resident's Order Summary Report showed the following orders dated 2/12/20:
-Treatment of left buttocks: cleanse with Vashe Wound Solution (a product intended for use in cleansing, irrigating, moistening and debriding acute and chronic wounds) apply NPWT at 125 millimeters of mercury (mmHb - a measurement of amount of pressure) on Monday, Wednesday and Friday and as needed (PRN); if unable to reapply NPWT, apply moistened 4 inch by 4 inch (4X4) gauze with Vashe solution followed by dry dressing, followed by foam dressing twice daily until NPWT can be reapplied.
Record review of the resident's Order Summary Report showed an order dated 2/13/20 for a Low Air Loss mattress (LAL mattress/LAM - A low air loss mattress is a mattress designed to prevent and treat pressure wounds; it is composed of multiple inflatable air tubes that redistribute pressure).
Record review of the resident's care plan, dated 2/13/20 showed:
-He/she had a self-care performance deficit and was totally dependent on one staff for repositioning and turning in bed.
-He/she had pressure ulcers, including a Stage IV pressure ulcer on his her left buttocks.
-Interventions included to administer treatment as ordered and to monitor the treatments for effectiveness, assist him/her to turn/reposition at least every two hours and more after is needed or requested LAL mattress, monitor the residents dressing every shift to ensure it is intact and adhering, report loose dressing to the licensed nurse, obtain and monitor lab/diagnostic work as ordered, report results to physician and follow up as indicated.
Record review of the resident's Treatment Administration Record (TAR) dated 2/1/20 through 2/29/20 showed:
- Treatment (TX) to left buttocks: Cleanse with Vashe solution, pat dry, apply NPWT at 125 mmHg on Monday, Wednesday, Friday and PRN; if unable to reapply NPWT, apply moistened 4x4 gauze with Vashe solution followed by dry dressing, followed by foam dressing twice daily until NPWT can be reapplied, as needed for wound if soiled or removed; start date 2/12/20 at 3:30 P.M.
-The boxes for documenting completion of the resident's left buttocks treatment has Xs for 2/1/20 through 2/12/20 and was blank for 2/12/20 through 2/16/20 showing no documentation of completion of treatment to the resident's left buttock wound.
--NOTE: The resident was sent to the hospital on 2/15/20. No documentation by the facility staff the resident's NPWT treatment to his/her left buttocks was completed two out of two opportunities.
--No documentation by the facility staff the resident's left buttock's wound treatment of Vashe solution followed by dry dressing followed by foam dressing twice daily until NPWT could be reapplied was completed twice daily between 2/12/20 through 2/15/20.
--No documentation by the facility staff related to the resident's right buttocks wound.
--No documentation by the facility staff related to the resident's low air loss mattress.
Record review of the resident's Progress Notes dated 2/11/20 through 2/15/20 showed:
-No licensed nurse notes regarding the resident's wound VAC dressing.
-No mention of the presence of or non-presence of his/her wound vac.
-No notation regarding notification regarding the resident being sedated or having a decrease/change in his/her alertness/mental status.
-No notation regarding a decrease in the resident's blood pressure.
-No notation regarding a decrease in his/her oxygen saturation.
-No notation regarding the resident having repeated loose stools.
-No notation regarding the resident's family being present at the facility, having concerns regarding the resident's condition and requesting the resident be transferred to hospital on 2/15/20.
-No notation of notification to facility management or to the resident's physician regarding a change in the resident's condition and the family requesting the resident be transferred to hospital on 2/15/20.
Record review of the resident's hospital Intensive Care Unit (ICU - a specialized area of a hospital where special medical equipment and services are provided for patients who are seriously injured or ill) admission History and Physical (H&P) dated 2/16/20 showed:
-He/she was admitted from his/her nursing home with altered mental status (AMS - a disruption in how your brain works that causes a change in behavior. This change can happen suddenly or over days; AMS ranges from slight confusion to total disorientation and increased sleepiness to coma) and buttock pain.
-On arrival to the emergency room (ER) his/her only complaint was right buttock pain and he/she reported he/she had a chronic sacral (area above the tail bone) wound.
-He/she had a Stage IV sacral ulcer, very large and deep and on examination, bone could be palpated (felt by placing a hand over the area and applying pressure).
-EMS reported his/her blood pressure had been low during transport to the hospital, 80s over 50s.
-On arrival to the ER, he/she reported he/she had not been clean after his/her bowel movement many hours ago and he/she had a chronic wound in that area.
-Report from EMS was that the family noted a slight change from his/her normal mental status earlier in the day (2/15/20) at an undetermined time.
-He/she was given two liters of fluids intravenously (IV - into a blood vein) with a good response of his/her blood pressure.
-His/her wound VAC fell off two days ago per the Registered Nurse (RN) report.
-He/she was initially admitted to the hospital medicine team but his/her blood pressure dropped to 70s despite getting two liters of IV fluid in the ER.
-He/she was started on Levophed (norepinephrine bitartrate -a medication used to treat life-threatening low blood pressure that can occur with certain medical conditions or surgical procedures) temporarily via his/her peripheral intravenous line until ICU was consulted, placed a right intrajugluar vein (IJ) central line (insertion of a tube into the large vein on the right side of the neck that allows rapid high-volume fluid administration, administration of multiple medications, and hemodynamic monitoring that measures the blood pressure inside the veins, heart, and arteries, how much oxygen is in the blood, checks how well the heart is pumping; and is often used for reliable venous access in ill persons) and admitted him/her to the ICU.
Record review of the resident's hospital History and Physical addendum dated 2/17/20 showed:
-He/she was critically ill with imminent threat to his/her life.
-His/her septic shock was being treated with broad spectrum (those able to treat a wide range of bacteria) antibiotics including Vancomycin and Zozyn for UTI and PNA.
-His/her urine culture was growing E. coli greater than 100,000.
-Awaiting culture and sensitivity but he/she seemed clinically improved.
During an interview on 2/15/20 at 8:11 A.M. RN B said:
-He/she went to the resident's room around 7:14 P.M.
-The resident said no when asked if he/she needed anything.
-He/she went to the next hall and started doing his/her resident care.
-The EMS staff said there was no need to do the resident's wound dressing.
-He/she had been told by the off going licensed nurse that the resident did not have a dressing on his/her Stage IV pressure ulcer.
-He/she could not turn the resident by himself/herself.
-He/she thought the resident was supposed to have a wound VAC.
-The off going licensed nurse said the resident needed a dressing but did not say the resident was going to the hospital.
-He/she told the off going licensed nurse that he/she would put a dressing on the resident's pressure ulcer after he/she finished his/her Accuchecks (checking blood sugar level by obtaining a small drop of a resident's blood by pricking a finger with a sharp device and using use of a small machine that provides a numerical result).
-He/she first saw the resident at 7:15 P.M.
-He/she had 12 residents needing Accuchecks, residents also came to him/her for pain medications which had to be given on time.
-He/she saw the resident at 8:00 P.M. and helped a Certified Nursing Assistant (CNA) to turn the resident (change the resident's position in bed); he/she asked the resident if he/she was OK and the resident said yes.
-He/she then went to do something else; he/she was always busy.
-EMS arrived at the facility at about 9:00 P.M.
During an interview on 3/5/20 at 1:38 P.M. Licensed Practical Nurse (LPN) D said:
-The resident had a Stage IV pressure ulcer.
-In the few days before the resident was transferred to the hospital a wet to dry dressing was being used for his/her Stage IV pressure ulcer.
-The resident had a wound VAC for his/her Stage IV pressure ulcer and that dressing had come off and licensed nurses had not been able to correctly reapply the wound VAC.
-The facility protocol was to apply a wet to dry dressing (a wet/moist gauze dressing is put on the wound and allowed to dry; wound drainage and dead tissue can be removed when the dressing is removed) until the facility wound nurse could reapply the wound VAC.
-The resident's wound VAC was not on when he/she got to work.
-He/she discovered at about 11:00 A.M. or maybe around noon that the resident's wound VAC was not on his/her stage IV pressure ulcer; at that time he/she was helping another staff person turn and clean the resident because he/she had had a lot of loose stools.
-The resident continued to have loose stools throughout the rest of the 7:00 A.M. to 7:30 P.M. shift.
-He/she put a dressing on the resident's stage IV pressure ulcer at about 12:30 P.M. when he/she finished completed blood sugar testing for diabetic residents.
-At that time, there could have been an old dressing in the bed but he/she could not remember, but there was no dressing on the resident's buttocks.
-During the shift report he/she passed on that the resident did not have a dressing on his/her Stage IV pressure ulcer.
-He/she was first aware the resident was without a dressing on his/her Stage IV pressure sore at around the lunch hour.
-He/she told the visitor that the resident had been having loose stools and discussed with the resident's family that the resident's decreased level of consciousness could be from a buildup of the resident's narcotic medication that he/she was getting every four hours.
-At about 5:00 P.M. or 6:00 P.M. there was flooding in the building, on the 300 Hall (the resident's room was on the 100 Hall).
-He/she put a dressing on the resident's Stage IV pressure ulcer at around 12:45 P.M, sometime before 1:00 P.M.
-Somehow with all the stools the resident was having, the dressing came off; he/she did not know exactly when the dressing came off.
-He/she became aware the resident did not have a dressing on just before the fire alarm went off because he/she was assisting in turning the resident as he/she had been incontinent of stool again; at that time he/she saw that the resident had bowel movement all over her old dressing and bowel movement was in the residents wound.
-He/she made it back to the resident's room at 6:30 P.M., maybe; he/she had gone to the resident's room to check on him/her, the resident's family member had left.
-He/she saw the resident did not have a dressing on his/her stage IV pressure ulcer, at that time he/she was trying to find someone to clean the resident; he/she did not remember what happened, the resident was big and he/she could not turn the resident by himself/herself.
-At that time (6:30 P.M.) he/she knew the resident did not have a dressing on his/her Stage IV pressure ulcer because his/her dressing came off earlier when he/she was turning the resident; that was at the time he/she put the dressing on the resident.
-The time he/she put the dressing on the resident was around 12:30 P.M.; he/she was helping to turn the resident while being changed was around 4:00 P.M., or something like that.
-He/she was really busy and was behind on everything.
-When asked what was going on that was more important than putting a dressing on the resident's Stage IV pressure that had bowel movement in it, he/she said that he/she just did not remember; he/she had looked for someone to help him/he and could not find anyone.
-He/she could have paged someone.
-He/she was sure he/she had paged someone; he/she thought that was later.
-When asked why he/she had not put a dressing on the resident's Stage IV pressure ulcer when he/she noticed there was no dressing, he/she said he/she did not know, he/she thought there was an ambulance for another resident, he/she just could not find anyone to help him/her with the resident; with the flood that was going on, then going being behind, just everything; it was just kind of chaotic; he/she thought that was after the flood; he/she did not know, it was all jumbled probably because it was so chaotic.
-He/she did think the resident had a wound VAC on because he/she did not need to change the resident's dressing on his/her stage IV pressure ulcer; he/she had looked at the wound VAC the previous day and it was operation correctly.
During an interview on 3/6/20 CNA L said:
-The resident was not large.
-He/she had in the past completed incontinence care for the resident.
-He/she always took another staff person with him/her when he/she completed incontinence care with all residents.
-The resident's level of alertness and ability to assist in turning in bed depended on the time of day; he/she routinely had to explain to the resident what was being done.
-He/she was not aware of the resident ever having a change in condition or having loose stools.
-The resident would get confused; he/she never appeared sedated.
-The resident used oxygen, the resident had to put oxygen because he/she was short of breath.
During an interview on 3/9/20 at 12:59 the Director of Nursing (DON) said:
-He/she had not been aware the resident was having loose stools and that the dressing and wound VAC had been left off.
-ADON A had said the resident had to have a dry dressing placed and had been cleaned up of loose stool when EMS arrived.
-A sprinkler head (a fire suppression device that provides a continuous overhead spray of water) had bust on the 300 hall early in the evening around 4-5 P.M.
-He/she expected the resident's dressing to be changed when soiled.
-The wound nurse would put a dry dressing in place until a wound VAC was placed back on the resident.
-The staff should be following the physician's orders for the resident's wound VAC.
-The dressing and wound VAC should be placed back on the resident as soon as possible.
-If this happen during the night, there should be a dry dressing in place.
-If this happened at night or on weekends, a dry dressing should be placed.
-The nurses should notify the ADON or the DON.
During an interview on 3/12/20 at 8:27 A.M. the resident's physician said:
-He/she expected licensed nurse's to check that the dressing is in place on a Stage IV pressure ulcer at least three times a day.
-He/she expected that if a resident was deteriorating, the facility would send the resident out to the hospital timely.
MO00166809
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #143) was provided adequate incontinence care when he/she was visibly wet, had puddles ...
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Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #143) was provided adequate incontinence care when he/she was visibly wet, had puddles under his/her wheelchair, and there was a strong urine odor in his/her room out of 32 sampled residents. The facility census was 164 residents.
Record review of the facility's policy titled Perineal Care (washing the genitals and anal area) dated February 2019 showed:
-The purpose was to maintain cleanliness of the genital area, to reduce odor, and to prevent infection of skin breakdown.
-Perineal care was provided as part of a resident's hygienic program, a minimum of once daily and per resident need.
1. Record review of Resident #143's face sheet showed he/she admitted tot he facility on 2/9/20 with diagnoses including:
-End stage renal disease (the last stage of chronic kidney disease).
-Chronic kidney disease (your kidneys are damaged and can't filter blood the way they should).
Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 2/15/20 showed he/she:
-Was severely cognitively impaired with a BIMS (brief interview for mental status) of six out of 15.
-Required extensive assistance from two staff members for toileting.
-Required limited assistance from one staff member for personal hygiene.
-Was frequently incontinent of bowel and bladder function.
Record review of the resident's Activities of Daily Living (ADL) self care performance care plan dated 2/9/20 showed he/she:
-Required extensive assistance from staff with bathing/showering and personal hygiene.
-Required limited assistance from staff with transfers.
-Required set up assistance from staff with toileting.
Record review of the resident's care plans last updated on 3/2/2020 showed he/she had an Activities of Daily living (ADL) self-care performance deficit and had the following interventions:
-For personal hygiene he/she required extensive assistance by two staff members.
-For toileting he/she required set up assistance by one staff member.
Observation on 3/4/20 of the resident showed:
-At 4:02 A.M. he/she was in his/her wheelchair with his/her eyes closed.
--The resident's pants were visibly wet.
-At 7:09 A.M. he/she had a liquid substance on the floor under his/her wheelchair.
--There was a significant smell of urine in room.
-At 7:38 A.M. a Certified Nursing Assistant (CNA) entered the resident's room and asked him/her what he/she wanted for breakfast.
--The CNA did not address the resident having wet pants, the liquid under his/her wheelchair, or the odor of urine in the room.
-At 7:54 A.M. the resident had changed his/her location in his/her room and a puddle of liquid was under his/her wheelchair in the new location.
--There was a significant smell of urine in the room.
-At 7:59 A.M. the resident's breakfast was delivered to the resident in his/her room.
--The resident was told his/her breakfast tray was delivered.
--Staff did not address the resident having wet pants, the liquid under his/her wheelchair, or the odor of urine in the room.
-At 9:30 A.M. two staff members entered the resident's room and began assisting the resident with cares including changing him/her out of wet clothes and cleaning up the puddles on the floor.
Observation on 3/5/20 at 8:50 A.M. of the resident showed:
-He/she was sitting in his/her wheelchair.
-His/her room and the hallway in front of his/her room had a strong odor of urine.
During an interview on 3/5/20 at 2:17 P.M. CNA E said:
-Residents are checked for incontinence every two hours, before and after meals.
-Residents should not be visibly wet for over 2 1/2 hours.
During an interview on 3/5/20 at 2:18 P.M., Certified Medication Technician (CMT) A said:
-Staff were to check residents for incontinence every two hours.
-Residents should not be visibly wet for over 2 1/2 hours.
During an interview on 3/5/20 at 2:19 P.M., CNA F said:
-Residents were checked for incontinence every two hours.
-Residents should not be visibly wet for over 2/12/ hours.
During an interview on 3/5/20 at 2:20 P.M., Licensed Practical Nurse (LPN) C said:
-He/she expected staff to check the residents every two hours for incontinence.
-He/she expected staff to check all residents, not just resident who had been identified as incontinent, and make sure assistance was not needed.
-Staff should help a resident who had wet pants to change into clean clothes and provide incontinence care.
-Residents should not be left visibly wet for over 2 1/2 hours.
During an interview on 3/9/20 at 10:50 A.M., the Assistant Director of Nursing (ADON) said:
-It was not acceptable for staff to walk by a resident who had visibly wet clothing.
-Staff should have addressed the resident's incontinence immediately upon noticing the resident needed to be changed.
-Residents should not be left visibly wet for over 2 1/2 hours.
During an interview on 3/9/20 at 1:45 P.M., the Director of Nursing (DON) said:
-The resident should be treated with with dignity and respect.
-The resident should be changed when needed, the resident should be checked every two hours at a minimum.
-The staff should change the resident if the resident had visible wet clothes, and puddles on the floor under the resident's wheelchair, and strong urine odor in the resident's room.
-The resident should not have been left in wet clothes for 2 1/2 hours.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0740
(Tag F0740)
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 meet the behavioral needs for one sampled resident (R...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to meet the behavioral needs for one sampled resident (Resident #85) who had an increase in his/her depression indicators out of 32 sampled residents. The facility census was 164 residents.
Record review of the facility's Social Services Program policy updated 2/2019 showed:
-The facility needed to provide medically related social services.
-The director of social services and/or designee would meet with the resident to evaluate the psychosocial needs of the resident.
-The resident needed to be assessed for negative impact on psychosocial development including anxiety, coping ability, depression, and anger.
1. Record review of Resident #85's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-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) without behavioral disturbance.
-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).
-Schizoaffective disorder (a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression).
-End stage renal disease (kidney failure).
Record review of the resident's annual Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for are planning) dated 11/5/19 showed he/she:
-Was moderately cognitively impaired.
-Did not have depression indicators.
-Was independent with supervision for Activities of Daily Living (ADLs-bathing, eating, dressing, grooming).
Record review of the resident's Nurses Note dated 1/30/20 at 10:29 A.M. showed he/she had refused to get up in the morning and stated he/she wanted to go home.
Record review of the resident's Nurses Note dated 1/30/20 at 1:09 A.M. showed:
-The resident's family member was contacted and told the resident was trying to hide his/her medications and not wanting to eat.
-The resident had been offered multiple choices of food and would refuse to eat what was offered.
Record review of the resident's Nurses Note dated 2/3/20 showed he/she was having a decline, came out to eat breakfast, and then left without eating or taking his/her supplements.
Record review of the resident's Nurses Note dated 2/11/20 showed:
-The resident had refused to go to dialysis (process of cleansing the blood by passing it through a special machine - necessary when the kidneys are not able to filter the blood).
-The resident stated he/she did not feel well and was not going to dialysis.
-The resident was educated on the importance of going to dialysis.
Record review of the resident's Nurses Notes dated 2/12/20 at 9:43 A.M. showed:
-The resident had refused dialysis so the nurse went to talk to the resident about the effects of not going to dialysis.
-The nurse had spoken with the resident's family member and explained the resident was refusing dialysis, breakfast meals, and medications.
-The family stated they would come to the facility to talk to the resident.
Record review of the resident's Nurses Notes dated 2/12/20 at 9:53 A.M. showed:
-The resident's family member and spouse came to the facility at lunch (on 2/11/20) and talked with the resident about his/her refusal of dialysis, breakfast meals, and medications.
-The resident voiced understanding of eating, taking medications, and going to dialysis.
-The resident stated he/she was happy when his/her spouse visited.
Record review of the resident's Care Plan updated 2/20/20 showed he/she:
-Had impaired cognitive function or impaired thought processes due to his/her diagnosis of dementia.
-Would refuse cares related to medications and restorative services.
-Would remain in long term care and was encouraged to discuss feelings or concerns with placement.
--Needed the staff to monitor him/her for signs of anxiety, fear, or distress.
Record review of the resident's Social Services assessment dated [DATE] showed:
-The resident was alert and oriented with some short term and long term memory loss.
-There were no comments under the resident's mood section.
-There were no comments made on the resident mental health/behavioral status related to his/her increase in depression.
-There were no comments under the summary section.
During an interview on 3/02/20 at 10:14 A.M., the resident said:
-He/she was very independent.
-He/she was unsure why he/she was here.
-He/she was very frustrated related to placement here on a locked secure care unit.
-He/she wanted to be with his/her spouse who lived in the area.
-He/she could not state how long he/she had been at the facility.
Observation on 3/2/20 at 12:51 P.M. showed the resident was in the main dining room eating his/her lunch independently.
During an interview on 3/6/20 at 8:52 A.M. Certified Nurses Assistant (CNA) J said:
-He/she encouraged the resident to call his/her family and come to activities.
-The resident would state he/she missed his/her family and missed being at home.
-The resident wanted to have someone to talk to him/her that can relate to him/her.
-The resident had recently found a friend on the unit that was more alert and he/she talked with this resident more now.
-The resident's family was aware the resident had depression at times.
-The resident did refuse dialysis at times.
During an interview on 3/6/20 at 9:05 A.M., Assistant Director of Nursing (ADON) B said:
-He/she was the acting charge nurse today.
-The resident refused dialysis one time and was getting depressed.
-The resident also stopped eating so the family came to see him/her.
-The resident was giving up is what we (the facility staff) thought.
-He/she had a meeting with the family and resident.
-The resident stated he/she was tired of dialysis and he/she was depressed.
-He/she was not aware that social services was involved.
-His/her family member stated he/she could not take care of him/her at home because his/her spouse had dementia and was already having to care for his/her spouse.
-The resident had an increase in depression.
-He/she did not talk to the family about behavioral health therapy.
-The resident's therapy was seeing his/her spouse.
During an interview on 3/6/20 at 12:15 P.M., Social Services Designee B said:
-The resident was on the dementia unit but was still alert with some memory loss.
-He/she was not aware of any depression.
-The resident was always cheerful when he/she saw the resident.
-When he/she assessed the resident on 2/20/20, the resident was cheerful.
-He/she had been aware ADON A was going to talk to family about hospice (end of life care) due to refusal of eating.
-He/she did look at nurses notes prior to interviewing and assessing the resident.
-ADON A had mentioned it in a morning meeting about hospice.
-He/she was unaware of the resident's depression.
-He/she could refer residents for counseling services and the resident also was a veteran and had veteran's benefits where counseling services were offered.
-Generally, the resident had a stoic affect during interviews.
During an interview on 3/9/20 at 12:59 P.M. the Director of Nursing (DON) said:
-The Social Services assessments should have captured the depression on the assessment and he/she expected Social Services to seek treatment including behavioral health counseling.
-Social Services should have assessed the resident for his/her depression.
-The resident was alert and oriented enough to receive counseling services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0742
(Tag F0742)
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 adequately assess one sampled resident (Resident #154)...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to adequately assess one sampled resident (Resident #154) for ongoing appropriate interventions related to the resident's behaviors; to complete a thorough investigation of an incident and provide appropriate monitoring at the time of the incident that occurred on 2/26/20; to notify the physician of one closed record resident's (Resident #85) mental status changes with increasing behaviors and failed to adequately monitor the resident as the behaviors increased out of 32 sampled residents. The facility census was 164 residents.
Record review of the facility's Behavior-Management policy revised 2/2019 showed:
-The key components were:
--Identifying residents whose behaviors may pose a risk to self or others.
--Develop practical care strategies based on assessed needs.
--Implementing a behavioral management program.
--On-going assessment and monitoring, and evaluation of the effectiveness of the behavioral management program including medications.
-If a resident exhibits behaviors, the staff were to:
-Ensure the safety of the resident as well as other residents.
-Document the notification of the physician and family.
-The charge nurse would assign a staff member to monitor/shadow the resident as needed.
1. Record review of Resident #154's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:
-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) without behavioral disturbances.
-Schizoaffective disorder (a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression).
Record review of the resident's admission Minimum Data Sheet (MDS-a federally mandated tool required to be completed by facility staff for care planning) dated 11/20/20 showed he/she:
-Was severely cognitively impaired.
-Had no behaviors.
-Needed limited staff assistance of one staff member for transfers and locomotion (using a wheelchair).
Record review of the resident's Behavioral Note dated 12/22/19 showed:
-The resident was exhibiting physical aggression towards other residents.
-No behaviors observed on this shift.
-The resident was on 30 minute checks.
-The resident's family visited today for approximately three hours.
-The family encouraged positive behavior with the resident.
Record review of the resident's Social Services Notes dated 12/22/19 showed:
-A family meeting was held with the Administrator and Director of Nursing (DON) to discuss his/her behavior towards one resident.
-The Administrator related to the family the resident had been aggressive toward another resident and the family had addressed the issue with the resident.
-The resident agreed to stay away from the resident and discontinue his/her aggressive behavior.
Record review of the resident's 15 minute checks sheets showed the resident was on 15 minute documented checks from 12/22/19 at 8:15 A.M. through 1/6/20 at 12:00 A.M.
Record review of the resident's Behavior Note dated 1/12/20 at 12:28 P.M. showed:
-The resident was harassing other residents and attempting to hit them.
-The resident was not being provoked by other residents.
-The resident was offered snacks and activities to re-direct him/her.
-The DON was notified.
-The resident was placed on one-on-one monitoring.
Record review of the resident's Behavior Note dated 1/12/20 at 12:48 P.M. showed:
-The nurse had called the resident's family member and explained the resident was cursing and trying to hit other residents.
-The family member stated he/she was aware of these inappropriate behaviors.
-The family member stated if the resident needed medications or needed to be sent to the hospital for a psychological evaluation he/she would support this.
-The resident was placed on one-on-one care and monitoring.
Record review of the resident's physician's Order Note showed a physician's order for Haldol 5 milligrams (mg) (antipsychotic medication) three times per day for dementia.
Record review of the resident's Behavioral Note dated 1/14/20 showed:
-The resident continued on 15 minute checks due to aggressive behaviors towards others.
-The resident had no aggressive behaviors today.
Record review of the resident's Physician's Progress Note dated 1/21/20 showed the resident's behaviors had improved since adding the Haldol medication.
Record review of the resident's 15 minute check sheets showed the resident had been on 15 minute checks from 2/4/20 at 6:45 P.M. through 2/6/20 through 8:00 P.M.
Record review of the resident's Behavioral Note dated 2/5/20 showed:
-Another resident was calling names in passing which caused a verbal altercation between the resident and Resident #154.
-The residents were advised to keep their distance from each other and the residents stated ok.
Record review of the residents Behavioral Note dated 2/6/20 at 6:24 A.M. showed:
-The resident continued to be combative and hit other residents, grabbing female staff butts, and yelling throughout the night from his/her room.
-When staff go to his/her room, he/she stated nothing was needed.
-The resident continued to come behind the nurses' station and when asked not to, he/she was not redirectable.
-He/she was refusing medications, treatments and cares.
-He/she would continue to monitor per the physicians orders.
Record review of the resident's Behavioral Note on 2/6/20 at 5:00 P.M., showed by the Assistant Director of Nursing (ADON) A:
-The staff reported to him/her the resident was not cooperative with cares, was verbally inappropriate and/or trying to hit the staff.
-ADON A had visited with the resident to discuss his/her behaviors and the resident politely responded he/she did not know what ADON A was talking about.
-The resident yelled at a staff member who walked by for absolutely no reason.
-ADON A told the resident his/her behaviors were inappropriate.
-The resident stated he/she would not do it again.
-The resident's medications were reviewed and the Haldol had been discontinued through a gradual dose reduction.
-He/she spoke with the physician and Haldol medication was started again.
-The physician ordered a psychological evaluation.
-At this time, the resident was at dinner and did not present with any aggressive behaviors.
Record review of the resident's Behavioral Note dated 2/7/20 at 7:14 A.M. showed:
-The resident was at the front desk and he/she was cussing at the staff and telling them that he/she was not going to leave the nursing station.
-The resident continued to hit the female staff on the butt when the night nurse asked him/her to stop the behaviors and tried to redirect him/her, he/she was still being combative but stated that he/she would stop.
-The resident then seen another resident (Resident #38) from the 100 hall and he/she mobilized up to him/her in a wheelchair and struck him/her in the shin.
-At this point the night nurse assisted the resident to his/her room and attempted to find out why he/she was continuing to strike the other residents and cuss out the staff.
-The resident stated that he/she did not know why he/she was doing it but he/she just wanted to.
-He/she then let him/her know this was not appropriate and that if he/she was not going to stop this behavior then he/she could not be out in the common area.
-The resident stated that he/she would stop with the behavior and then he/she went and sat in the hall when 15 minutes later we (the staff) heard a resident (Resident #137) screaming help.
-A Certified Nurses Assistant (CNA) came down the hall and asked if he/she would stop hitting and leave out his/her room.
-The resident then struck the CNA.
-He/she spoke to the residents and called Resident #137's family member.
-Resident #137's family member called the police and the resident pressed charges.
-The resident called the police names and asked them if they wanted him/her to kick their ass and at that point they placed the resident under arrest.
-The Administrator and DON were notified at that time.
-The resident was escorted out the building with the police at 9:19 P.M. (on 2/6/20).
Record review of the resident's 15 minute check sheets dated 2/6/20 showed the resident was monitored at the nurses station from 8:00 P.M. until the resident was arrested.
Record review of the resident's Behavioral Note dated 2/7/20 showed:
-The resident's family member called the facility.
-The resident had been admitted to the hospital and had a Urinary Tract Infection (UTI - an infection of one or more structures in the urinary system).
Record review of the facility investigation dated 2/7/20 completed by the Interim Administrator showed:
-An Incident Report:
-On 2/6/20, Resident #154 entered Resident #137's room to talk to his/her friend.
-Resident #154 was confused thinking Resident #137's roommate was his/her friend.
-Resident #137 said that his/her roommate was not his/her friend and asked Resident #154 to leave the room.
-Resident #137 used his/her wheelchair to physically push Resident #154 out of the room.
-When Resident #154 got in Resident #137's personal space and he/she started pushing Resident #154 back, Resident #154 started flailing his/her hands.
-Resident #154 had brushed against Resident #137's right lower cheek.
-Resident #137 stated it did not hurt.
-Resident #137's family member called the police and Resident #154 was taken to jail.
-Resident #154 was moderate to severely cognitively impaired and was found to have a UTI.
-Interview with Resident #137: He/she was in his/her room when a noise was heard outside.
-Resident #154 entered Resident #137's room and said he/she was visiting his/her friend pointed at the sleeping roommate.
-Resident #154 was confused and thought the sleeping roommate was his/her friend.
-Resident #137 corrected Resident #154 and when Resident #154 continued to enter the room near his/her roommate, Resident #137 tried to use his/her wheelchair to flush Resident #154 out of the room.
-Resident #137 got close to Resident #154 who was flailing his/her arms and he/she felt a light contact but it did not hurt.
-Another resident came in and pulled Resident #154's wheelchair out of the room.
-Resident #137 tried to swing at Resident #154 but the other resident got in-between them.
-The nurse came and took Resident #137 to the nurses station.
-The conclusion was Resident #154 entered Resident #137's room to talk to his/her friend. Resident #154 was confused and thought the sleeping roommate was his/her friend. Resident #137 tried to physically push Resident #154 out of the room. When Resident #154 got into the personal space of Resident #137, Resident #154 started flailing his/her hands and brushed against his/her cheek. Resident #137 was not injured.
--There was not documentation that showed staff interviews were completed, other resident interviews were conducted, including Resident #38, or that Resident #154 was put on additional monitoring after kicking Resident #38 in the shin.
Record review of the resident's admission summary dated [DATE] at 3:08 P.M. showed:
-The resident was re-admitted to the facility (to the special care unit (SCU - a living area of the facility secured with alarmed doors for residents with behavior symptoms and dementia).
-The resident appeared to be verbally and physically abusive to residents and staff.
Record review of the resident's Behavioral Note dated 2/10/20 at 3:31 P.M. showed:
-The resident was groping female staff, punching staff, and sitting in front of the exit door.
-The resident was swinging at the nurse and punched him/her in the stomach and stated I'm getting out of here.
-The physician gave orders to Depakote (an anticonvulsant used to treat mood disorders) 250 mg twice a day and monitor the resident for safety.
Record review of note text on 2/10/20 at 6:55 P.M. written by the DON showed:
-He/she had visited with the resident's family to review plan of care.
-The resident was going to be placed on Haldol 2 mg to also help with aggressive behaviors.
-The resident was on one-on-one monitoring tonight and tomorrow.
-The family member was ok with this plan of care and understood if the medication was not effective the resident would be referred to geriatric in-patient psychiatry for evaluation and medication adjustments.
-The family member was fine with that and understanding of the special needs of his/her family member.
Record review of the resident's Physician's Progress Note dated 2/11/20 showed:
-The resident had continued to have aggressive behaviors.
-The resident was non-compliant with medications.
-The resident had been at the hospital and treated for a UTI.
-The resident was on Depakote 250 mg mood disorder with behaviors and Haldol for Schizoaffective disorder.
-Social Services would work on getting the resident a psychological evaluation.
Record review of the resident's Social Services Note dated 2/12/20 showed:
-There were no beds available at a local psychiatric hospital.
-The resident was no longer requiring one on one monitoring.
-He/she was told to check back tomorrow to see if a bed was available.
-A referral was sent to other (psychiatric) facilities.
Record review of the resident's Nurses Notes dated 2/19/20 showed:
-The resident was alert and calm this morning but seemed to be sleepy today.
-The resident's morning medication was held and the resident was watched for continued sedation.
-The DON was on the SCU and talked with the resident.
Record review of the resident's Care Plan dated 2/28/20 showed the resident:
-Had verbally and physically aggressive behaviors related to dementia with behaviors.
-Would use profanity and was combative with staff.
-Had reports of resident physically hitting, throwing things, and swinging arm at the staff.
Record review of the resident's Behavioral Notes dated 3/1/20 at 12:15 P.M. showed:
-The resident's family members visited.
-The resident had been combative during the shift and was being monitored closely.
-The resident was re-directed when combative, offered snacks and activities.
Record review of the resident's Behavioral Notes dated 3/1/20 at 3:44 P.M. showed:
-The resident had been aggressive and attempting to hit other residents off and on this shift.
Record review of the resident's Behavioral Notes dated 3/2/20 at 11:05 A.M. showed:
-The resident had been very aggressive today towards staff and other residents.
-The resident argued with a female resident on the couch and tried to hit at her hand.
-The nurse spoke with the DON and the nurse practitioner would be notified in the morning.
Record review of the resident's Physician Progress Notes dated 3/3/20 showed:
-The staff had concerns related to the resident's physical aggressive behaviors.
-The resident hit a staff member in the throat, used inappropriate language, and inappropriately was touching staff.
-The resident's Haldol had been discontinued in an attempt to wean the resident off the medication.
-The resident's Haldol medication was being restarted.
Record review of the resident's Order Note dated 3/3/20 showed:
-The resident was started on Haldol 0.5 mg for increased aggressive behaviors.
-The resident was starting on a lower dose of the medication.
Observation on 3/4/20 at 9:30 A.M. showed the resident was asleep on the couch and did not have behaviors.
Observation of the resident on 3/5/20 at 8:42 A.M. showed:
-He/she was outside the dining area and self-propelled his/her wheelchair towards the dining room.
-Bumped into a female resident's wheelchair accidentally.
-He/she grabbed at the female resident's arm and the staff immediately intervened and took the resident by the television area away from other residents.
-He/She watched television with no other behaviors exhibited.
During an interview on 3/5/20 at 3:09 P.M., CNA A and CNA B said:
-CNA A:
--The resident had behaviors of getting violent towards staff and other residents.
--He/she saw the resident get verbally aggressive on the couch last week and the nurse intervened immediately.
--The resident would grab at staff members breasts.
-His/her behaviors were better since medications were changed but the resident still had behaviors every once in a while.
-CNA B:
--The resident had gone to the hospital and was now on the SCU.
--He/she had new medications and seemed to be better with less behavioral episodes.
-The CNAs had not witnessed any physical altercations towards other residents.
During an interview on 3/5/20 at 3:21 P.M., CNA C said:
-He/she had not witnessed a physical altercation involving the resident.
-He/she had been told Resident #137 had been hit in the face.
-He/she did see Resident #137 coming up the hall holding his/her face.
-The nurse kept Resident #137 at the nurses station.
-The resident kept trying to go into the nurses station.
-The resident tried to hit residents and staff every day.
-The resident would hit other residents and staff almost every day.
-This was a regular thing when he/she was on the skilled unit.
-He/she did not remember seeing a CNA on that hall at the time Resident #137 came up the hall.
-He/she was unsure who witnessed anything.
During an interview on 3/6/20 at 7:11 A.M., Licensed Practical Nurse (LPN) A said:
-When the resident was on the unit prior to his/her hospital stay, the resident had behaviors of hitting, yelling, combativeness.
-He/she would be redirected but would continue the behavior.
-He/she would throw items at staff and refuse cares.
-He/she would grab at the staff, inappropriate touching in all inappropriate areas.
-He/she would be in the hall and feel a hand on his/her butt.
-The resident kept having behaviors towards Resident #38.
-Resident #38 was hit by the resident prior to the incident and was following him/her around and kicked Resident #38.
-Resident #38 was assessed with no injury.
-Resident #38 was deaf, had a tablet, and could use sign language.
-He/she separated the resident and Resident #38.
-He/she took the resident into his/her room and talked to him/her and would state he/she knew what he/she was doing.
-He/she punched CNA D, staff member in the stomach when he/she was in the doorway and was being moved due to blocking the doorway.
-The resident had Resident #137 blocked in his/her room after this.
-Resident #137 tried to go out of his/her room because he/she was blocked in, then started yelling for help.
-CNA D went to the room and he/she got up to go down to the room and the resident was in the hallway.
-CNA D stated the resident was Resident #137's room and Resident #137 had been punched in the face.
-The resident was taken to his/her room.
-He/she took Resident #137 to the nurses station and he/she kept asking for his/her family member.
-Resident #137 was crying, upset, and wanted to talk to his/her family member.
-Resident #137 called his/her family member and told him/her she was hit in the face.
-He/she also notified the DON and was told to put Resident #154 on 15 minute checks.
-The resident was already on 15 minute checks.
-He/she did not place the resident on more monitoring.
-He/she notified the Interim Administrator and left a message.
-The family member hung up and called 911.
-The family member, per Resident #137 was on his/her way up.
-He/she was going to get a a urinary laboratory test on the resident to see if he/she had a UTI.
-The police came and talked to both of the residents.
-The resident was out of his/her room and was sitting on the outside of the nurses station.
-The resident did not touch anyone but was aggressive.
-The police officer was trying to talk to Resident #154 and he/she said I'm going to fuck you up and Do you want to be next.
-The police officer tried to talk him/her down but he/she kept being aggressive and tried to kick the police officer.
-The resident said to the police he/she wanted to press charges.
-The police arrested him/her and took him/her from the building.
-The resident was taken to the police station and then to the hospital.
-When he/she came back he/she was drugged up.
-The resident was lethargic so the Nurse Practitioner reduced the medications.
-He/she was better with behaviors now.
-He/she was not touching staff as much as he/she was.
-He/she was not grabbing at residents as much as he/she was.
-He/she still refused medications.
-He/she assessed Resident #137 and his/her face was flushed so it was hard to tell for injury.
-When he/she assessed him/her later when he/she stopped crying, there were no signs of injury or marks on his/her face.
During an interview on 3/6/20 at 9:05 A.M., Assistant Director of Nursing (ADON) B said:
-The resident had behaviors.
-When he/she first came back here after his/her hospital stay he/she was cussing at the staff, pinching the staff, and patting staff bottoms.
-The resident was so much better now and the behaviors had decreased.
-He/she was cussing at the residents and was aggressive towards other residents.
-He/she would sit in front of other residents and shake his/her fist at them.
-The resident never made any physical contact with other residents.
-For the first two days after being placed on the unit, he/she was on one-on-one monitoring on the unit.
-Medication changes were made by the physician related to his/her behaviors to his/her Haldol and the physician added Depakote.
-The behaviors were better and the resident had a few moments of behaviors since then.
-We held the Haldol because he/she was lethargic and he/she started to get aggressive again.
-He/she was seen by the nurse practitioner yesterday and the Depakote was increased and the Haldol was restarted.
During an interview on 3/6/20 at 11:55 A.M., ADON A said:
-The resident had behaviors and would lash out once in a while.
-He/she had behaviors around Resident #38, like shouting to get out of the way because Resident #38 was deaf.
-The resident assumed Resident #38 was not listening.
-The resident was placed on 15 minutes checks because he/she would try to keep an eye on him/her to prevent an incident from happening.
-He/she rarely had behaviors towards other residents.
-There was no physical contact prior to the incident.
-The resident mainly had issues with Resident #38.
-He/she was here on the day 2/6/20.
-He/she had started 15 minute checks due to Resident #154 following Resident #38 more on 2/3/20.
-He/she had left before the incident occurred.
-He/she was also started on Haldol for behaviors at one time.
-The resident had many behaviors per staff and more at night.
-When the resident was aggressive towards Resident #38, he/she expected the nurse to separate the residents.
-Both residents should be assessed for injuries.
-He/she expected the nurse to notify the resident's family and Physician.
-The resident was on 15 minute checks.
-He/she expected the charge nurse to separate the residents and get orders from the doctor for monitoring.
-He/she would expect the nurse to bring the resident to the nurses station to be watched and call the physician for orders.
-The monitoring depends on the incident.
-If someone was on one-on-one monitoring, he/she did not know what documentation was required.
-Investigations were completed by an incident report started by a nurse.
-The DON and/or Administrator would do the full investigation.
-The management always interviewed the staff and residents who were involved or witnessed it.
-The nurse would document skin assessments and assess all residents involved.
-If there was an injury, this would go on a risk management report.
During an interview on 3/9/20 at 10:47 A.M., the Interim Administrator said:
-He/she was the interim administrator at the time of the incident.
-He/she had received a call from LPN A around 9:45 P.M. and there was an incident between the resident and Resident #137.
-LPN A stated that the resident was going across the hall into Resident #137's room and Resident #137 was trying to keep him/her out of his/her room.
-LPN A stated there was no injury to either resident.
-LPN stated the resident was taken out of Resident #137's room.
-He/she talked to multiple CNAs but no one witnessed what happened.
-He/she had received statements from all CNAs but was unsure why they were not with the investigation.
-He/she did not read the nurses note related to the incident.
-He/she did not interview Resident #38.
-He/she did interview Resident #137 the next day and he/she stated Resident #154 brushed his/her cheek while his/her arms were flailing around and never stated he/she was hit or slapped.
-The nurse was responsible for putting in further interventions and would not comment on expectations of monitoring.
-CNA D did give a statement.
-He/she asked everyone on that shift what happened and no one saw it per the CNA.
-Resident #137 told him/her a hand went by his/her cheek but he/she was not actually hit.
During an interview on 3/9/20 at 12:59 P.M.,the Director of Nursing (DON) said:
-If resident had a change and was more aggressive, the nurse should have had close monitoring and not to let the resident out of sight.
-Depending on the incident itself, the staff would look back at the documentation (nurses notes) to include in the investigation.
-There was no injury as a result of the incident.
-Staff and residents should be interviewed and this should be included in the investigation.
2. Record review of Resident #132's Face Sheet showed the resident was admitted to the facility on [DATE]:
-With the following diagnoses:
-Schizoaffective disorder.
-Bipolar disorder (a mental condition marked by alternating periods of elation and depression).
-Respiratory failure.
-Chronic Obstructive Pulmonary Disease (COPD - a disease process that decreases the ability of the lungs to perform ventilation).
-And was his/her own responsible party.
Record review of the resident's Care Plan dated 2/26/20 showed:
-The resident was verbally aggressive with staff and other residents.
-The resident would try to manipulate staff.
Record review of the resident's Behavior Note dated 2/26/20 showed:
-The resident came to the nurse at 4:30 A.M. and wanted to file a complaint about someone stealing his/her cigarettes.
-The nurse stated he/she was unaware of this matter.
-The nurse asked the resident to lower his/her voice in which the resident began to get louder stating he/she did not appreciate someone stealing his/her cigarettes.
-The resident went to his/her room and continued to yell for 20 minutes then came back to the nurse and said he/she had found his/her cigarettes and lighter and he/she had taken his/her oxygen off to go outside and smoke.
-The resident was told he/she did not have permission to go out and smoke and he/she should remain in the building.
-The resident stated he/she had told his/her roommate if he/she was not back in 30 minutes to call the police because he/she had stopped breathing.
Record review of the resident's Social Services Notes dated 2/26/20 showed:
-The DON and Social Services Designee B met with the resident about the smoking policy and the resident re-signed the smoking policy.
-They discussed the recent event of bullying residents in the smoking area and he/she denied these allegations and stated he/she would adhere to the smoking policy.
Record review of the resident's Behavior Note dated 2/27/20 at 9:41 A.M. showed:
-The resident was speaking to his/her roommate in a very condescending tone.
-The resident was going on about being accused of stealing a resident's prostitute perfume stating he/she could take that bottle of dollar shit and shove it up his/her ass.
-The resident said he/she left a dollar out on the floor so the other resident could buy a better smelling bottle of perfume for the residents.
-There was no dollar in the hallway.
-The resident went in the hallway then returned to the room and continued to speak to his/her roommate telling him/her he/she was paying more for a two week stay than the roommate and the roommate needed to move out of the room because his/her fat ass isn't going to tell me to shut up.
-The nurse spoke with the ADON and a room move was completed for the resident's roommate because he/she was almost in tears because of constant belittling.
-After a room move was completed the roommate broke down in tears and said he/she had put up with his/her ridicule until he/she talked about my family and how fat he/she was.
--There was no staff documentation that showed the resident had been monitored or if the physician was notified of the resident's behaviors.
Record review of the resident's Nurses Notes dated 2/27/20 at 7:45 P.M. showed:
-The resident had repetitive statements which were upsetting other residents.
-The resident continued to yell and cause other resident's to feel unsafe and irritated Resident #80 at which point he/she yelled back at the resident.
-This nurse heard this and came around the corner and tried to re-direct the resident and offered to take him/her outside.
-The resident was educated that he/she was upsetting others.
-The resident continued to yell across the hall at Resident #80.
-This nurse immediately intervened making each resident go in separate directions.
-The resident went to the smoking area then went to bed.
-There were no further issues.
--There was no staff documentation that showed the resident had been monitored or if the physician was notified of the resident's behaviors.
Record review of the resident's Nurse Notes dated 2/28/20 at 6:26 A.M. showed:
-The resident came to the nurses desk this morning telling staff good morning and state he/she was getting some fresh air.
-The resident was not making repetitive statements or being verbally aggressive.
-At approximately 7:00 A.M. this nurse heard the resident come back from the smoking area making repetitive statements again.
-The resident said he/she had hot lined the nurse.
-The nurse did not say anything to the resident at that time.
-The resident pushed his/her wheelchair over by the wall and continued to talk to himself/herself about multiple things.
-The resident appeared to be in a repetitive loop.
-These behaviors were continuous and non-stop after the resident returned from the smoking area.
Record review of the resident's Nurses Note dated 2/28/20 at 6:50 A.M., showed:
-The resident continued to come to the nurses station and was yelling for assistance.
-The resident was asked to lower his/her tome and the resident said he/she was going to call the Administrator and let him/her know the staff were being mean to him/her and he/she had already called the State Agency (SA).
-The resident was told he/she had the right to call the SA but did not have the right to be disruptive to other residents.
-The resident stated he/she would continue to call the state and tell the Administrator the staff was mean to him/her until he/she got them all fired.
Record review of the resident's Behavioral Note dated 2/28/20 at 8:50 A.M. showed:
-The resident was sitting in his/her doorway stopping everyone and anyone who would listen to him/her that a hotline call was made be
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to have grievance forms accessible for all residents, and educate residents and review the grievance policy and procedures on how to file a gr...
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Based on interview and record review, the facility failed to have grievance forms accessible for all residents, and educate residents and review the grievance policy and procedures on how to file a grievance, for 15 sampled residents (residents attending the Resident Council Group Interview Meeting, conducted as a part of the survey process). The facility census was 164 residents.
1. During Resident Council Interview on 3/3/20, beginning at 2:00 P.M., the group responses included:
-Residents could not anonymously get a grievance form.
-Residents were concerned about staff members knowing they were getting a grievance form.
-Grievance forms were at the nurses' station and they are too high up for the residents to reach.
-Residents did not know how to file a grievance.
-Residents did not know if there was a grievance official.
-Twelve of the fifteen residents present did not feel a resident or family group could complain about care without worrying that someone would get back at them.
-Residents said retaliation included not getting ice water, not getting medication timely, not getting call light response in a timely manner, and not getting the help needed.
During Resident Council Interview on 3/3/20, at the 2:40 P.M., one of the residents present, [Resident #2] said:
-He/she observed a staff member being mean to another resident and reported the incident.
-The staff member asked him/her if he/she told about the incident.
-He/she was honest and told the staff member he/she reported the incident.
-The staff member would no longer respond to his/her request, would not provide him/her with ice water, or anything.
-Supervisory staff removed that staff member from caring for him/her, but this was an example of why residents worry about someone getting back at them.
During Resident Council Interview on 3/3/20, at 2:43 P.M., one of the residents present, [Resident #109] said:
-He/she asked a staff member for a washcloth.
-The staff member was doing something on his/her phone, and did not respond.
-He/she was too afraid of what would happen if he/she reported the incident.
Record review of the Resident Council minutes dated 2/21/20, showed the meeting format included review of at least four resident rights per meeting, and the Activities Director presented on the following resident rights:
-Residents have the right to have your own doctor.
-Residents have the right to receive mail unopened.
-Residents have the right to privacy.
-Residents have the right to complain.
During an interview on 3/04/20 at 8:03 A.M. Social Services Designee B said:
-If residents have complaints, there are forms to be completed.
-Social Services directs the information to the appropriate department head.
-Residents can come to social services office for complaint forms.
During an interview on 3/04/20 at 9:32 A.M., the Activities Director said:
-Social Services would normally handle grievances.
-He/She had not actually gone through how to file a formal grievance or use of grievance forms with the residents, but talked about how to complain at a recent Resident Council meeting.
During an interview on 3/6/20 at 8:55 A.M., Social Services Designee A said:
-Residents would submit grievance forms to the Social Services Department.
-The location of the grievance forms changed, and they are now outside the social services office on a lower wall. (Note: The location of grievance forms changed after the Resident Council Interview.)
During the Quality Assessment and Assurance (QAA) Interview on 3/09/20 at 11:33 A.M., the Administrator said:
-Department heads meet monthly.
-Questions are asked regarding frontline staff overall.
-The committee also used Resident Council notes during QAA.
During an interview on 3/9/20 at 1:00 P.M., the Director of Nursing (DON) said the placement of grievance forms should be accessible for all residents.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to ensure hot foods on a room tray for one sampled resident (Resident #4) was maintained at or around 120 degrees Fahrenheit (&or...
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Based on observation, interview and record review, the facility failed to ensure hot foods on a room tray for one sampled resident (Resident #4) was maintained at or around 120 degrees Fahrenheit (ºF) at the time the food was delivered to his/her room and, failed to maintain food temperatures on the steam table at or close to 135 ºF during the entirety of the breakfast and noontime meals and. This practice of holding cooked food on a steam table with temperatures over 135 ºF overcooks the food items and lowers the nutrient levels, values and benefits of those food items, affecting all of the residents who receive hot meals from the facility's kitchen. These practices potentially affects all of the residents who receive their meals from the facility's kitchen. The facility census was 164 residents.
1. Observations on 3/4/20 between 5:05 A.M. and 1:10 P.M. in the kitchen showed the following:
-Breakfast room trays were being placed in an open, metal-framed service carts with a clear plastic coverings, holding approximately 12 to 16 room trays per cart.
-At 7:25 A.M., the room trays were starting to be placed into the serving cart.
-At 7:45 A.M., the room trays were finished being placed on the service cart and delivered to the 300 hallway.
-At 7:46 A.M., on the 300 hallway, the room trays were delivered to the various residents.
-At 7:50 A.M., on the 300 hallway, food temperatures on a test tray were obtained.
-The temperature of the scrambled eggs was 99.4 ºF (eight degrees below the standard of 120 ºF), cool to the touch and taste.
-At 7:50 A.M., Certified Nursing Assistant (CNA) A acknowledged the temperature of the scrambled eggs was not at 120 ºF.
During interview on 3/04/20 at 7:52 A.M. CNA A, said:
-He/she did not know what the temperature of hot foods should be at the time of service.
-Food issues were reported to the charge nurse who then, reports the issues to dietary.
-He/she had not seen anyone take food temperatures in a long time.
During interview on 3/04/20 at 8:12 A.M., Resident #79 said food is usually cold, arrives late, and the menus are the same.
During interview on 3/04/20 at 8:22 A.M., Resident #70 said that the food is cold, carb heavy and not much of a variety.
2. During an observation and interview on 3/4/20 at 12:28 P.M., the Registered Dietician:
-Verified the temperatures obtained of the mixed vegetables of broccoli and carrots on the steam table to be 161.5 ºF.
-When asked of what the proper cooking and holding temperatures of vegetables were to be, she referred me to the Dietary Manager (DM).
-When asked of what happened to food and vegetables when they are overcooked, she referred to the DM.
During an interview on 3/4/20 at 12:32 P.M., the DM said:
-That they usually sampled room trays for temperatures and tastes once a week but could not remember if they had done so in the past week.
-The room tray service had some problems in the past.
-The cook should taste the foods for temperatures and tastes.
-Taking cooked foods' temperatures at the oven or stove should indicate whether they were sufficiently cooked or overcooked.
-The cook should taste the food for temperatures and tastes.
-Taking cooked foods' temperatures at the oven or stove should indicate whether they were sufficiently cooked or overcooked.
-Steam table temperatures should not be more than 160 ºF.
-When foods and vegetables are overcooked, they lose their nutrient values.
Record review of the 2013 edition of the Food and Drug Administration (FDA) Food Code Chapter 3-202.11, showed, (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under Section 3-501.19, and except as specified under paragraph (B) and in paragraph (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained:
(1) At 57 ºC (Celsius) (135 ºF) or above (for hot foods), except that roasts cooked to a temperature and for a time specified in paragraph 3-401.11(B) or reheated as specified in paragraph 3-403.11(E) may be held at a temperature of 54 ºC (130 ºF) or above; or
(2) At 5 ºC (41 ºF) or less [for cold foods].
Record review of the 2013 edition of the FDA, Chapter 3-401.13, showed, Fruits and vegetables that are fresh, frozen, or canned and that are heated for hot holding need only to be cooked to the temperature required for hot holding. These foods do not require the same level of microorganism destruction as do raw animal foods since these fruits and vegetables are ready-to-eat at any temperature. Cooking to the hot holding temperature of 57°C (135°F) prevents the growth of pathogenic bacteria that may be present in or on these foods. In fact, the level of bacteria will be reduced over time at the specified hot holding temperature.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
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 ample amounts of food on the regular menu was p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure ample amounts of food on the regular menu was prepared to serve all residents, including sampled residents (Resident's #80 and #369), and to ensure regular food preference items were available at meal time for two sampled residents (Resident's #52 and #146) out of 32 sampled residents. The facility census was 164 residents.
Record review of the facility's Dietary: Resident Preference Interview policy, revised February 2019, showed:
-Staff would complete the dietary questionnaire upon admission, readmission and no less than annually to capture the resident's dietary preferences.
-The tray card would reflect resident preferences.
1. Record review of Resident #80's face sheet showed he/she was admitted to the facility 10/25/19.
Record review of the resident's Quarterly Minimum Data Sheet (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 1/19/20 showed.
-The resident had a Brief Interview of Mental Status (BIMS) of 15 showing he/she was cognitive intact.
-He/she had no special nutrition approaches noted.
Observation on 3/2/20 at 9:10 A.M., showed:
-The resident received his/her breakfast.
-Staff delivering room trays told the resident he/she was getting toast and gravy because the kitchen ran out of biscuits for the biscuits and gravy.
-Note: Biscuits and gravy was the main item on the breakfast meal.
During an interview on 3/2/15 at 10:15 A.M., the resident said:
-He/she gets a room tray at all meals.
-He/she was on a regular diet.
-This morning the dietary department ran out of biscuits and gravy, and he/she had to have toast and gravy.
-Last night he/she asked for chocolate milk, but they were out of chocolate milk.
-He/she has to go to the kitchen almost every day to complain because he/she is not served double portions as ordered, and staff does not get his/her meal order right.
2. Record review of Resident #369's face sheet showed he/she was admitted to the facility 2/28/20.
Record review of the resident's medical record did not show specific orders for his/her diet.
During an interview on 3/2/20 at 10:22 A.M., the resident said:
-He/she discharged from the hospital and came to the facility three days ago.
-He/she was not able to get the biscuits and gravy that was on the menu for breakfast.
-Nothing seemed to have gone well since he/she arrived late Friday evening.
3. Record review of Resident #52's face sheet showed he/she was admitted to the facility 6/18/15.
Record review of the resident's Quarterly MDS dated [DATE], showed he/she:
-Was cognitively intact.
-Had a poor appetite.
-The resident weighed under 100 pounds.
Record review of the resident's Care Plan showed:
-A focus area initiated 1/3/19, revised 1/7/19, stating the resident had a behavior problem: His/her goal was to gain weight, but he/she was refusing to eat food he/she requested from dietary.
-The resident made continuous calls to the staff to report food and weight concerns.
Record review of the resident's Nutrition/Dietary Note dated 8/12/19, showed:
-The resident was on a regular diet with regular textures.
-The resident reported he/she had a good appetite, but does not like the food.
-The resident did not like pork, milk or eggs.
-The resident had a wide range of intakes.
Observation on 3/4/20 at 6:57 A.M. showed Certified Nurse Assistant (CNA) K taking resident's order for the breakfast meal.
During an interview at 6:59 A.M., CNA K said:
-The staff goes to the residents to ask what they would like for breakfast before the residents go to the dining room.
-They also take meal orders for room tray service.
Observation on 3/4/20 at 8:10 A.M. showed the resident receiving his/her breakfast.
-The resident received 2 slices of white toast with no butter, oatmeal and water.
-The resident did not want the breakfast because it was not what he/she ordered.
Review on 3/4/20 of the resident's breakfast meal order ticket showed the resident ordered three slices of crispy wheat toast with very little butter, oatmeal with brown sugar and three cups of water with no ice.
Observation on 3/4/20 at 8:15 A.M., showed the Interim Administrator came in to talk with the resident about his/her breakfast.
-The Interim Administrator was assisting in the kitchen.
-He/she told the resident they were out of brown sugar and wheat bread, and offered the resident something else.
Observation on 3/4/20 at 8:24 A.M., showed the Director of Nursing (DON) delivered three slices of toast covered in butter that was not melting.
During an interview on 3/4/20 at 8:25 A.M. the resident said:
-The staff thinks he/she is too finicky, but he/she does not like white bread and they seem to not be able to get the orders correct.
-The kitchen runs out of staple items often, like the brown sugar.
-It seems to have been worst lately.
-His/her family is bringing in food for him/her a couple of times a week so that he/she can eat and enjoy the food.
-He/she likes to eat, but what he/she eats matters to him/her.
-My order specifically said very little butter and the substitute toast came slathered in butter.
Observation of the preparation of the noon meal on 3/4/20 at 11:35 A.M. showed:
-The DON requested a grilled cheese sandwich on wheat toast for a resident.
-The dietary aide informed the DON that they were out of wheat bread.
-The dietary aide said they were expecting a food delivery the next morning.
4. Record review of Resident #146's face sheet showed he/she was admitted to the facility 8/9/18.
Record review of the resident's Quarterly MDS dated [DATE], showed:
-The resident had a BIMS of nine, indicating mild cognitive impairment.
-The resident had no special nutritional approaches noted.
Observation on 3/5/20 at 9:40 A.M., showed the resident received a room tray for the breakfast meal, but did not get what he/she ordered.
-A staff member came in to let the resident know he/she would need to order something different because they ran out of oatmeal.
-The resident said he/she likes oatmeal for breakfast.
-CNA K said to the resident he/she knew the resident liked oatmeal and tea every morning.
-The resident asked, How did they run out of oatmeal?
-CNA K said he/she did not know how they ran out of oatmeal, but cream of wheat was available.
-CNA K asked the resident to try cream of wheat.
-The resident agreed to try the cream of wheat.
-A staff member delivering the cream of wheat to the resident told the resident he/she brought him/her some brown sugar to add to the cream of wheat to possibly make it better.
During an interview on 3/5/20 at 10:19 A.M., the resident said:
-He/she tried to eat the cream of wheat he/she was served after finding out the kitchen staff ran out of oatmeal.
-He/she could not eat the cream of wheat because he/she did not care for cream of wheat.
During an interview on 3/9/20 at 1:00 P.M., the DON said:
-He/she would expect the dietary staff to have enough food prepared for residents to receive what is on the menu.
-There was actually wheat bread in the kitchen.
-Dietary had new management staff.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to properly store food in the refrigerated walk-in unit and to practice sanitary procedures before food preparation tasks. These ...
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Based on observation, interview and record review, the facility failed to properly store food in the refrigerated walk-in unit and to practice sanitary procedures before food preparation tasks. These practices potentially affects an unknown number of residents who received their meals from the facility's kitchen. The facility census was 164 residents.
1. Observations on 3/4/20 between 5:05 A.M. and 1:10 P.M. in the kitchen showed the following:
-At 5:05 A.M. in the kitchen, tomatoes and pickles stored on a shelf out their original containers in the refrigerated walk-in unit, were not dated as to when they were opened or how long they had been opened.
-The floors near the food preparation table, the electrical floor outlet near the steam table and floors surrounding the steam table were greasy, visibly and to the touch.
-There were two pieces of juice dispensing equipment, both with one nozzle connected to each to each of them, dispensing beverages of orange juice, a lemon beverage, cranberry juice, nectar honey and water. These nozzles were sticky with multi-colored debris on the inside and outside of the nozzles.
-The gray-colored, trashcans and lids contained sticky, red debris on the outer sides of the containers and their lids.
-Several utensils with rubberized handles were either chipped, cracked, missing their protective coating or all of those characteristics, making it difficult to clean and sanitize the utensils for use.
-The spice containers were dirty, grimy and greasy to the touch.
-The rubberized floor mats used surrounding the dish wash and 3-compartment sink areas were dirty and greasy.
-The gray-colored trashcan and lid located in the rehabilitation dining room under the big clock contained sticky, red debris on the outer sides of the container and its lid.
-At 12:59 P.M. and 1:03 P.M., two different dietary aides went from the serving/steam table area to discard trash, opened the gray-colored trashcan's lid with their gloves on, and returned directly to the serving/steam table area to continue touching plating and serving food without washing their hands.
During an interview on 3/4/20 at 1:08 P.M., the Dietary Manager said:
-The kitchen floors and dish mats were not cleaned properly by the previous (night) shift.
-The nozzles of the juice and beverage dispensing equipment and spice containers were not listed on any cleaning schedules, but would be placed on one.
-The gray-colored trashcans and their lids were on a weekly cleaning schedule, but he did not think that they were cleaned in the previous week.
-The dietary staff will be in-serviced on hand-washing techniques when handling trash to be discarded in the gray-colored trashcans.
Record review of the facility's kitchen equipment cleaning schedule (undated), showed the nozzles of the juice and beverage dispensing equipment and spice containers were not listed on the cleaning schedules. Also, the kitchen and dish-washing area floor mats were supposed to be cleaned nightly with the gray-colored trashcans and their lids cleaned on a weekly basis or as needed.
Record review of the 2013 edition of the Food and Drug Administration (FDA) Food Code Chapter 2-301.14, showed, FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under §(Section) 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLESERVICE and SINGLE-USE ARTICLES and:
(A) After touching bare human body parts other than clean hands and clean, exposed portions of arms;
(B) After using the toilet room;
(C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in (paragraph) 2-403.11(B);
(D) Except as specified in (paragraph) 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco, eating, or drinking;
(E) After handling soiled EQUIPMENT or UTENSILS;
(F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks;
(G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD;
(H) Before donning gloves to initiate a task that involves working with FOOD; and
(I) After engaging in other activities that contaminate the hands.
Record review of the 2013 edition of the FDA Food Code Chapter 3-501.17, showed,
(A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § (Section) 3-502.12, and except as specified in (paragraphs) (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.
(B) Except as specified in (paragraphs) (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (paragraph) (A) of this section and:
(1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and
(2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety.
Record review of the 2013 edition of the FDA Food Code Chapter 4-601.11, showed,
(A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch.
(B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations.
(C) Non-FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.
Record review of the 2013 edition of the FDA Food Code Chapter 4-602.11, showed,
(A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be cleaned:
(1) Except as specified in (paragraph) (B) of this section, before each use with a different type of raw animal FOOD such as beef, FISH, lamb, pork, or POULTRY;
(2) Each time there is a change from working with raw FOODS to working with READY-TO-EAT FOODS;
(3) Between uses with raw fruits and vegetables and with TIME/TEMPERATURE CONTROL FOR SAFETY FOOD;
(4) Before using or storing a FOOD TEMPERATURE MEASURING DEVICE; and
(5) At any time during the operation when contamination may have occurred.
Record review of the 2013 edition of the FDA Food Code Chapter 4-602.11, showed, Non-FOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to ensure that the facility's kitchen range hood (an open metal enclosure over cooking surfaces through which air is drawn in fro...
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Based on observation, interview and record review, the facility failed to ensure that the facility's kitchen range hood (an open metal enclosure over cooking surfaces through which air is drawn in from the surrounding spaces to exhaust heat and grease, and to control the flow of rising hot air into the range hood and filter grease) exhaust fan was in operational and functional condition. By having a faulty exhaust system the facility is placing in jeopardy the entire kitchen staff of smoke inhalation and the risk of grease building up in the hood creating a fire thus, affecting and the facility residents. The facility census was 164 residents.
1. Observations on 3/4/20 between 5:05 A.M. and 1:10 P.M. in the kitchen, showed the kitchen range hood's exhaust system non-functional and non-operational.
During an interview on 3/4/20 at 6:05 A.M., the Dietary [NAME] said that he/she had been working at the facility for approximately two to three weeks and since that time, the range hood exhaust fan has not worked.
During an interview on 3/4/20 at 6:10 A.M., the Maintenance Director said the faulty part of the range hood exhaust fan was a relay switch and had been on order for about one week now.
During an interview on 3/4/20 at 12:28 P.M., the Dietary Manager said that the faulty part of the range hood exhaust system was ordered on 3/2/20.
Record review of the 2013 edition of the Food and Drug Administration (FDA) Food Code Chapter 4-301.14, showed, If a ventilation system is inadequate, grease and condensate may build up on the floors, walls and ceilings of the food establishment, causing an insanitary condition and possible deterioration of the surfaces of walls and ceilings. The accumulation of grease and condensate may contaminate food and food-contact surfaces as well as present a possible fire hazard.
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: 1 life-threatening violation(s), 1 harm violation(s). Review inspection reports carefully.
- • 84 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $20,787 in fines. Higher than 94% of Missouri facilities, suggesting repeated compliance issues.
- • Grade F (16/100). Below average facility with significant concerns.
Bottom line: Trust Score of 16/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Carmel Hills Wellness & Rehabilitation's CMS Rating?
CMS assigns CARMEL HILLS WELLNESS & 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 Carmel Hills Wellness & Rehabilitation Staffed?
CMS rates CARMEL HILLS WELLNESS & REHABILITATION's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 59%, which is 13 percentage points above the Missouri average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 56%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Carmel Hills Wellness & Rehabilitation?
State health inspectors documented 84 deficiencies at CARMEL HILLS WELLNESS & REHABILITATION during 2020 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, and 82 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 Carmel Hills Wellness & Rehabilitation?
CARMEL HILLS WELLNESS & 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 EL DORADO NURSING AND REHABILITATION, a chain that manages multiple nursing homes. With 194 certified beds and approximately 151 residents (about 78% occupancy), it is a mid-sized facility located in INDEPENDENCE, Missouri.
How Does Carmel Hills Wellness & Rehabilitation Compare to Other Missouri Nursing Homes?
Compared to the 100 nursing homes in Missouri, CARMEL HILLS WELLNESS & REHABILITATION's overall rating (1 stars) is below the state average of 2.5, staff turnover (59%) 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 Carmel Hills Wellness & 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 Carmel Hills Wellness & Rehabilitation Safe?
Based on CMS inspection data, CARMEL HILLS WELLNESS & REHABILITATION has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (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 Carmel Hills Wellness & Rehabilitation Stick Around?
Staff turnover at CARMEL HILLS WELLNESS & REHABILITATION is high. At 59%, the facility is 13 percentage points above the Missouri average of 46%. Registered Nurse turnover is particularly concerning at 56%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. 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 Carmel Hills Wellness & Rehabilitation Ever Fined?
CARMEL HILLS WELLNESS & REHABILITATION has been fined $20,787 across 1 penalty action. This is below the Missouri average of $33,287. 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 Carmel Hills Wellness & Rehabilitation on Any Federal Watch List?
CARMEL HILLS WELLNESS & 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.