HILLSIDE REHAB AND HEALTHCARE CENTER
For profit - Corporation
208 Beds
AMA HOLDINGS
Data: November 2025
5 Immediate Jeopardy citations
Trust Grade
0/100
#396 of 479 in MO
Photo by Hillside Rehab and Healthcare Center
Photo by Hillside Rehab and Healthcare Center
Photo by ZeE BCG
1 / 5 photos
Last Inspection: July 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Hillside Rehab and Healthcare Center has received a Trust Grade of F, indicating significant concerns about its care quality and safety. With a state rank of #396 out of 479, this facility is in the bottom half of Missouri nursing homes, and it ranks #10 out of 13 in St. Louis City County, meaning there are only a few local options that are worse. While the facility is improving, reducing its issues from 36 in 2024 to 9 in 2025, it still has troubling indicators, including a high fine total of $126,156, which is concerning as it is higher than 82% of Missouri facilities. Staffing is rated poorly with a turnover rate of 65%, which is above the state average, meaning staff may not stay long enough to build relationships with residents. Specific incidents of concern include failures to maintain safe temperatures for residents (up to 90 degrees), inadequate emergency preparedness for life support, and neglect in following wound care orders that led to serious health issues for residents. Overall, while there are some signs of improvement, families should weigh these significant issues when considering this facility for their loved ones.
- Trust Score
- F
- In Missouri
- #396/479
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 65% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ○ Average
- $126,156 in fines. Higher than 51% of Missouri facilities. Some compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 17 minutes of Registered Nurse (RN) attention daily — below average for Missouri. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 121 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 18%
Review needed
36 → 9 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 36 issues
2025: 9 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Missouri average (2.5)
Significant quality concerns identified by CMS
Staff Turnover: 65%
18pts above Missouri avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $126,156
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: AMA HOLDINGS
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (65%)
17 points above Missouri average of 48%
The Ugly 121 deficiencies on record
5 life-threatening 9 actual harm
Mar 2025
3 deficiencies
2 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
See F686 cited under Event ID 4F7E12
Based on observation, interview and record review, the facility failed to follow the facility's policy regarding wound care when staff failed to ensure continued w...
Read full inspector narrative →
See F686 cited under Event ID 4F7E12
Based on observation, interview and record review, the facility failed to follow the facility's policy regarding wound care when staff failed to ensure continued wound care treatments following a hospitalization with an identified pressure injury (a localized area of skin damage that develops when prolonged pressure is applied to the body) to the tailbone (sacrum) upon discharge for one resident (Resident #14). The failure resulted in the worsening of the identified sacral wound and the development of two additional pressure injuries. Staff failed to ensure accurate documentation, notify the physician of worsening wounds since hospitalization and obtain wound care orders. In addition, staff failed to ensure timely wound dressing change to identified saturated dressings (Resident #16). The census was 145.
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0697
(Tag F0697)
A resident was harmed · This affected 1 resident
See F697 cited under Event ID 4F7E12
Based on observation, interview and record review, the facility failed to implement an effective pain management regime for two sampled residents (Resident #18 and...
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See F697 cited under Event ID 4F7E12
Based on observation, interview and record review, the facility failed to implement an effective pain management regime for two sampled residents (Resident #18 and #14). Staff failed to notify ensure Resident #18, who experienced pain related to metastatic breast cancer with osseous (bone) involvement, most severe over bilateral lower extremities, received pain medications as ordered by the physician and failed to notify the primary physician when pain medications were not delivered from the pharmacy and of medications available in the emergency kit. The resident experienced uncontrolled pain and was transferred to the hospital two days after admission to the facility. For Resident #14, the facility staff failed to provide effective pain relief when, during care, staff removed wound dressings which were adhered to the wound sites. The resident had so much pain, he/she was observed to cry and requested Certified Nurse Aide (CNA) D spray over the counter Bactine (relieves the pain and itch of minor cuts, scrapes and burns on contact) onto the buttock wound sites. The sample was 16. The census was 145.
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
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
See F684 cited under Event ID 4F7E12
Based on observation, interview and record review, the facility failed to obtain physician orders and monitor a wound identified by staff for one resident (Residen...
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See F684 cited under Event ID 4F7E12
Based on observation, interview and record review, the facility failed to obtain physician orders and monitor a wound identified by staff for one resident (Resident #27). The census was 145.
Review of the Wound Management Policy, revised 10/24/22, showed:
-Purpose: provide a system for the treatment and management of residents with wounds including pressure and non-pressure ulcers;
-Definitions: Diabetic Neuropathic Ulcer: requires that the resident be diagnosed with diabetes mellitus and have peripheral neuropathy. The diabetic ulcer characteristically occurs on the foot;
-Procedure: Assessment:
-A licensed nurse will perform a skin assessment upon admission, readmission, weekly, and as needed for each resident;
-Upon identification of a wound the licensed nurse will:
-Measure the wound (length, width and depth);
-Initiate a wound monitoring record sheet:
-A wound monitoring record will be completed for each wound;
-If the wound monitoring record is not used, documentation will be recorded within the medical record which may include nursing notes, treatment records or care plans;
-An assessment of care needs for pressure ulcer and wound management will be made with emphasis on, but not limited to:
-Identifying risk factors;
-Treatment;
-Mechanical offloading and pressure reducing devices;
-Reducing skin friction, sheer, and moisture;
-Nutritional status;
-Evaluating and modifying interventions for a resident with an existing PU/PI;
-Wound Management:
-The attending physician will be notified to advise on appropriate treatment promptly;
-The licensed nurse will notify the responsible party of the presence of a pressure ulcer;
-Dietary contact will be made for nutritional assessment;
-Rehabilitation services will be contacted for appropriate devices or pressure redistributing devices;
-A licensed nurse will develop a care plan for the resident based on recommendations of dietary, rehabilitation and the attending physician;
-Per physician order, the nursing staff will initiate treatment and utilize interventions for pressure redistribution and wound management;
-The attending physician and interdisciplinary team (IDT) will be notified of:
-New pressure ulcers or wounds;
-Pressure ulcers or wounds that do not respond to treatment;
-Pressure ulcers or wounds that worsen or increase in size;
-Complaints of increased pain, discomfort or decrease in mobility by a resident;
-Signs of ulcer sepsis, presence of exudates (drainage), odor or necrosis (black, firm tissue), if not already noted by the physician;
-Residents refusing treatment;
-Certified Nurse Aides (CNAs) will complete body checks on resident's shower days and report unusual findings to the licensed nurse;
-Documentation:
-New pressure ulcers or wounds will be documented on the 24 hour log and an incident report will be completed by the licensed nurse;
-Wound documentation will occur at a minimum of weekly until the wound is healed, documentation will include:
-Location of wound;
-Length, width, and depth measurements recorded in centimeters (cm);
-Direction and length of tunneling (a channel or tunnel that forms beneath the surface of a wound, extending into deeper tissue) or undermining (a separation of the wound edges from the underlying tissues, creating a space or pocket beneath the wound surface;
-Appearance of the wound base;
-Drainage amount and characteristics including color, consistency and odor;
-Appearance of wound edges;
-Description of the peri-wound condition or evaluation of the skin adjacent to the wound;
-Presence or absence of new epithelium at the wound rim;
-Presence of pain;
-IDT will document the discussions and recommendations for:
-Pressure ulcers and wounds that do not respond to treatment;
-Pressure ulcers and wounds that worsen or increase in size;
-Complaints of increased pain, discomfort or decrease in mobility by a resident;
-Signs of ulcer sepsis, presence on exudate, odor or necrosis;
-Residents refusing treatment;
-Licensed nurses will document effectiveness of current treatment in the resident's medical record on a weekly basis;
-Document notifications following a change in the resident's skin condition;
-Update the resident's care plan as necessary.
Review of Resident #27's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/21/25, showed the following:
-Diagnoses of diabetes and peripheral vascular disease (PVD, poor circulation in the extremities), low blood pressure;
-No cognitive impairment;
-Required moderate assistance of staff for personal hygiene;
-Required maximum assistance of staff for toileting, showering and dressing;
-No venous or arterial ulcers;
-No foot ulcers.
Review of the resident's care plan, updated 2/14/25, showed the following:
-Focus: Resident has PVD;
-Monitor, document, and report as needed any signs or symptoms of skin problems related to PVD: redness, edema, blistering, itching, burning, bruises, cuts, or other skin lesions.
Review of the resident's shower sheet, dated 3/7/25, showed no documentation of any wounds to the right heel.
Review of the facility's 24 hour shift report sheet, dated 3/8/25, showed a wound to the right heel.
Review of the resident's progress notes, dated 3/8/25 through 3/19/25, showed no documentation regarding a wound to the right heel.
Review of the resident's physician's order sheet (POS), dated March 2025, showed no treatment order for the resident's right heel.
Review of the resident's treatment administration record (TAR), dated March 2025, showed no treatment order for the resident's right heel.
Review of the resident's shower sheets, dated 3/10 and 3/13/25, showed no documentation regarding a wound to the right heel. The facility had no shower sheets for the week of 3/17 through 3/20/25.
Observation on 3/20/25 at 10:55 A.M., showed the resident lay in bed. The Director of Nurses (DON), Assistant Director of Nurses (ADON) and the facility's Wound Care Company's Nurse Practitioner (NP) assessed the resident's skin and noted a wound on the back of the resident's right foot just above the heel. The Wound Care NP said the wound was a diabetic ulcer secondary to pressure that measured 0.6 centimeters (cm) by 0.6 cm by 0.3 cm depth, 90% granulation (new tissue) and 10% slough (soft dead tissue).
During an interview on 3/20/25 at 12:02 P.M., CNA W said he/she was unaware of the wound on the resident's right heel. He/She hadn't taken care of the resident before and had assisted another aide giving him/her a shower. He/she could not remember the name of the aide who she assisted.
During an interview on 3/20/25, at 1:26 PM., ADON W said he/she was unaware of the wound on the back of the resident's heel. No one reported it to him/her nor did he/she see it on the 24 hour sheet. Staff are to document any changes in the progress note which can be generated on a summary sheet daily. He/She expected staff to document any changes found in the progress note and obtain treatment orders.
During an interview on 3/20/25 at 11:10 A.M., the DON said when staff find a wound, she expected the nurse to call the physician, get a treatment order, notify the DON and the wound company.
Feb 2025
6 deficiencies
2 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow the facility's policy regarding wound care when...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow the facility's policy regarding wound care when staff failed to ensure continued wound care treatments following a hospitalization with an identified pressure injury (a localized area of skin damage that develops when prolonged pressure is applied to the body) to the tailbone (sacrum) upon discharge for one resident (Resident #14). The failure resulted in the worsening of the identified sacral wound and the development of two additional pressure injuries. Staff failed to ensure accurate documentation, notify the physician of worsening wounds since hospitalization and obtain wound care orders. In addition, staff failed to ensure timely wound dressing change to identified saturated dressings (Resident #16). The census was 145.
Review of the Wound Management Policy, revised 10/24/22, showed:
-Purpose: provide a system for the treatment and management of residents with wounds including pressure and non-pressure ulcers;
-Definitions:
-Pressure ulcer: any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Although friction and shear are not primary causes of pressure ulcers, friction and shear are important contributing factors to the development of pressure ulcers. Pressure ulcers usually occur over bony prominences and are graded or staged to classify the degree of tissue damage observed;
-Procedure: Assessment:
-A licensed nurse will perform a skin assessment upon admission, readmission, weekly, and as needed for each resident;
-Upon identification of a wound the licensed nurse will:
-Measure the wound (length, width and depth);
-Initiate a wound monitoring record sheet:
-A wound monitoring record will be completed for each wound;
-If the wound monitoring record is not used, documentation will be recorded within the medical record which may include nursing notes, treatment records or care plans;
-An assessment of care needs for pressure ulcer and wound management will be made with emphasis on, but not limited to:
-Identifying risk factors;
-Treatment;
-Mechanical offloading and pressure reducing devices;
-Reducing skin friction, sheer, and moisture;
-Nutritional status;
-Evaluating and modifying interventions for a resident with an existing PU/PI;
-Wound Management:
-The attending physician will be notified to advise on appropriate treatment promptly;
-The licensed nurse will notify the responsible party of the presence of a pressure ulcer;
-Dietary contact will be made for nutritional assessment;
-Rehabilitation services will be contacted for appropriate devices or pressure redistributing devices;
-A licensed nurse will develop a care plan for the resident based on recommendations of dietary, rehabilitation and the attending physician;
-Per physician order, the nursing staff will initiate treatment and utilize interventions for pressure redistribution and wound management;
-The attending physician and interdisciplinary team (IDT) will be notified of:
-New pressure ulcers or wounds;
-Pressure ulcers or wounds that do not respond to treatment;
-Pressure ulcers or wounds that worsen or increase in size;
-Complaints of increased pain, discomfort or decrease in mobility by a resident;
-Signs of ulcer sepsis, presence of exudates (drainage), odor or necrosis (black, firm tissue), if not already noted by the physician;
-Residents refusing treatment;
-Certified Nurse Aides (CNAs) will complete body checks on resident's shower days and report unusual findings to the licensed nurse;
-Documentation:
-New pressure ulcers or wounds will be documented on the 24 hour log and an incident report will be completed by the licensed nurse;
-Wound documentation will occur at a minimum of weekly until the wound is healed, documentation will include:
-Location of wound;
-Length, width, and depth measurements recorded in centimeters (cm);
-Direction and length of tunneling (a channel or tunnel that forms beneath the surface of a wound, extending into deeper tissue) or undermining (a separation of the wound edges from the underlying tissues, creating a space or pocket beneath the wound surface;
-Appearance of the wound base;
-Drainage amount and characteristics including color, consistency and odor;
-Appearance of wound edges;
-Description of the peri-wound condition or evaluation of the skin adjacent to the wound;
-Presence or absence of new epithelium at the wound rim;
-Presence of pain;
-IDT will document the discussions and recommendations for:
-Pressure ulcers and wounds that do not respond to treatment;
-Pressure ulcers and wounds that worsen or increase in size;
-Complaints of increased pain, discomfort or decrease in mobility by a resident;
-Signs of ulcer sepsis, presence on exudate, odor or necrosis;
-Residents refusing treatment;
-Licensed nurses will document effectiveness of current treatment in the resident's medical record on a weekly basis;
-Document notifications following a change in the resident's skin condition;
-Update the resident's care plan as necessary.
1. Review of Resident #14's medical record, showed:
-Original admission: [DATE];
-Diagnoses included: quadriplegia (paralysis in all limbs), Parkinson's (a neurodegenerative disease causing muscle weakness and loss), diabetes, anxiety, muscle wasting, and reduced mobility;
-Able to make needs and wants known.
Review of the progress notes, showed:
-On 2/3/25 at 11:26 P.M., a nurse note: the resident remained up in his/her wheelchair. Staff offered to assist to bed to encourage wound healing;
-On 2/5/25 at 1:15 P.M., a nurse note: the resident said he/she was short of breath and complained of a sore throat and coughed thick, yellow mucus, complaint of minor chest pain. Vital signs: blood pressure 140/70 (normal, 120/80), temperature 101.3 degrees (normal range, 97.1-98.6 degrees Fahrenheit (F)), pulse 116 beats per minute (bpm) (normal range, 60-80 bpm) and oxygen saturation fluctuating between 87-90 percent (normal range, 90-100%). The physician notified and new orders to send to the emergency room for evaluation and treatment.
Review of the February Treatment Administration Record (TAR), dated 2/1/25 through 2/28/25, showed:
-An order, dated 2/6/25: enhanced barrier precautions related to wounds;
-An order, dated 1/28/25: Triad Hydrophilic (used to create a moist wound environment, that promotes healing and debridement (removal of dead tissue) wound dressing paste. Apply to right buttock and left thigh twice a day for wound. Discontinued 2/7/25. Documented as completed twice a day, until discharged to the hospital on 2/6/25.
Review of the hospital Discharge summary, dated [DATE], showed:
-admitted to the hospital: 2/5/25;
-Diagnoses: Pneumonia and sepsis;
-Wound dressing paste: apply one application topically twice a day to right buttock and left thigh wounds;
-Wound care instructions:
-Incontinent associated dermatitis (IAD, skin damage associated with incontinence) bilateral (both sides) buttocks;
-Dressing status: open to air;
-Site assessment: fragile, painful and pink;
-Shape/pattern: irregular;
-Peri-wound assessment: fragile, painful;
-Interventions: cleansed, protective ointment;
-Wound status: unchanged;
-Non-staged description: partial thickness;.
-Pressure injury to coccyx:
-Dressing status: open to air;
-Site assessment: Fragile, painful;
-Shape/pattern: Irregular;
-Peri-wound assessment: Fragile, painful;
-Interventions: cleansed, protective ointment;
-Pressure injury Stage: II (partial thickness skin loss, appearing as a shallow, open ulcer with a red or pink wound bed, or as an intact or open/ruptured blister);
-Measurements: length 3 cm x width 4 cm;
-Margins: Undefined edges;
-Wound status: Unchanged;.
-Medication list at discharge:
-Hydrophilic cream (used to treat and prevent dry, rough and itchy skin): one application topically twice a day to the right buttock and left thigh wounds.
-Nutrition orders:
-Juven (high protein supplemental drink) twice a day, with breakfast and dinner.
Review of the facility's admission assessment, dated 2/12/25, showed:
-admitted from: hospital;
-Skin assessment:
-Color: normal;
-Temperature: warm;
-Turgor: normal (skin returns promptly);
-Skin issues: no;
-Physician actions: no new orders;
-Were the list of medications from the hospital compared with the medications the resident was taking at home: yes;
-Was the physician notified if any discrepancies were noted during the medication reconciliation: yes, reconciliation necessary, physician agreed with new medications prescribed by hospital.
Review of the admission progress note, a late entry, dated 2/12/25 at 10:16 A.M., showed:
-The resident is chairfast. Skin color is normal, skin is warm and dry. No skin issues present.
Review of the February TAR, dated 2/1/25 through 2/28/25, showed no wound care orders and no documentation of treatments completed after re-admission on [DATE].
Review of the re-admission Physician Order Sheet (POS), showed:
-An order dated 2/13/25: wound care specialist to eval and treat if indicated;
-No orders noted for Juven.
Review of the Braden (a tool used to determine the person's risk to develop pressure injury) score, dated 2/17/25, showed:
-Sensory perception: ability to respond to pressure related discomfort: 3, slightly limited;
-Moisture: degree to which skin is exposed to moisture: 3, occasionally moist;
-Activity: degree of physical activity: 2, chairfast;
-Mobility: ability to change and control body position: 1, completely immobile;
-Nutrition: probably inadequate: 2, rarely eats a complete meal;
-Friction and shear: 2, potential problem;
-Score: 13, moderate risk.
Review of the progress notes, dated 2/17/25 at 1:25 P.M., showed a weekly skin observation note: late entry: the skin color is normal. Skin temperature is dry and warm. Skin turgor is normal as skin returns promptly. Skin issues present, refer to assessment.
Review of the weekly skin assessment, dated 2/17/25 at 1:25 P.M., showed:
-Skin color: normal;
-Skin temperature: dry and warm;
-Skin turgor: normal, skin returns promptly;
-Skin issues: yes;
-Skin condition:
-Right buttock: incontinent associated skin dermatitis;
-Left buttock: incontinent associated skin dermatitis;
-Sacrum: reddened area;
-No additional progress notes included.
Review of the progress note, dated 2/17/25 at 2:50 P.M., showed:
-A medication administration note: hydrocodone 5 milligram (mg)-325 mg (a narcotic pain reliever for moderate pain) administered for coccyx pain;
-No additional notes regarding assessments, treatment or physician notification.
Review of a nurse progress note, dated 2/20/25 at 2:37 P.M., showed the resident continued therapy and cooperative with care. The dressing on the coccyx changed and well tolerated. Redness noted to the groin, applied powder. The resident turned and repositioned in bed. (Note: Review of the February TAR, dated 2/1/25 through 2/28/25, showed no wound care orders and no documentation of treatments completed.)
Review of the skilled nursing note, dated 2/20/25 at 2:41 P.M., showed:
-Alert to person, place, time and situation;
-Skin integrity:
-No new changes to skin integrity noted;
-Wound care:
-The resident has treatable wounds
-No further description as to number, type, location;
-Dressing changed as per treatment orders: unselected;
-Dressing change not required: unselected;
-Changed were noted to wound: unselected.
Review of the POS, showed:
-An order, dated 2/20/25: wound consult to treat related to open area on the coccyx;
-No orders noted for Juven supplement.
Review of the progress notes, dated 2/23/25, showed:
-At 11:45 A.M.,: pain to the bottom, barrier cream applied; (Note: the resident did not have any order for barrier cream)
-At 1:34 P.M., medication note: Hydrocodone 5 mg, one tablet administered for buttock pain.
Review of the weekly skin assessment, dated 2/24/25, showed:
-Skin color: normal;
-Skin Temperature: dry and warm;
-Skin turgor: normal, returns promptly;
-Skin issues: yes;
-Skin condition: site:
-Right buttock: incontinent associated dermatitis;
-Left buttock: incontinent associated dermatitis;
-Sacrum: reddened area;
-Note: skin is normal. Temperature is dry and warm. Skin turgor is normal as skin returns promptly. Skin issues present, refer to assessment for more information.
Review of the progress notes on 2/28/25, showed:
-At 12:44 P.M., a nurse note: pain assessment every shift: buttock pain;
-No noted further assessment documented;
-At 1:21 P.M., a medication administration note: Hydrocodone administered for buttock pain;
-At 5:30 P.M., a late physician visit note: no notification of wound or skin impairment to buttocks.
Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/2/25, showed:
-Cognitively intact;
-Range of motion impaired upper and lower extremities;
-Dependent of staff for hygiene, bathing, dressing, bed mobility and transfers;
-Diagnosis included: Parkinson's disease, malnutrition, anxiety and depression;
-At risk for PU;
-Unhealed PU: no;
-Other problems: moisture associated skin damage (MASD, skin inflammation and erosion caused by prolonged exposure to moisture such as sweat, urine, stool and wound drainage);
-Skin treatments: pressure reducing device for chair and bed, ointments applied other than to feet.
Review of the POS in effect on 3/2/2025, showed:
-No orders for a pressure reducing device in the resident's bed including a low air loss mattress (LAL, used to distribute weight and prevent wound development).
Review of the progress notes, dated 3/2/25 at 10:22 P.M., showed a behavior note: the resident refused medication and agitated when staff unable to assist him/her. The resident threatened to call emergency services. Complaints of pain in wounds, administered pain medication and repositioned on his/her side for comfort. The resident refused to allow the nurse to dress the wounds and wanted the area left open to air and stated the bandages sting.
Review of the weekly skin assessment, dated 3/3/25, showed:
-Skin color: normal;
-Skin temperature: dry and warm;
-Skin turgor: normal, skin returns promptly;
-Skin issues: yes;
-Skin condition:
-Right buttock: incontinent associated dermatitis;
-Left buttock: incontinent associated dermatitis;
-Sacrum: reddened area;
-Note: skin color is normal. Temperature is dry and warm. Skin turgor is normal as skin returns promptly. Skin issues present. See assessment for more information;
-No documented physician notification of skin issues.
Review of the care plan, revised on 3/3/25, showed:
-Focus: the resident has a self-care deficit. The resident at times refuses to be placed in bed;
-Goal: maintain current level of function;
-Interventions: the resident is totally dependent on staff for repositioning and turning in bed, dependent on staff for personal hygiene, toileting and transfers;
-Focus: the resident has actual or potential skin impairment;
-Goal: the resident will maintain intact skin;
-Interventions: staff follow facility protocols for treatment of injuries, staff identify and document causative factors and eliminate/resolve where possible, keep skin clean, dry and intact. Use lotion on dry skin.
Focus: nutritional problem:
-Goal: the resident will comply with diet for weight loss;
-Interventions: RD to monitor, staff serve ordered diet and administer medications as ordered.
Review of the weekly skin observation, dated 3/10/25, showed:
-Skin color: normal;
-Skin temperature: dry and warm;
-Skin turgor: normal, returns promptly;
-Skin issues: yes;
-Skin condition:
-Right buttock: incontinent associated dermatitis;
-Left buttock: incontinent associated dermatitis;
-Sacrum: reddened area;
-Note: skin color is normal. Skin temperature is dry and warm. Turgor is normal as skin returns promptly. Skin issues present, see assessment for details;
-No documented physician notification of skin issues.
Review of the physician visit note, dated 3/10/25 at 11:16 A.M., showed no documented notification of skin issues.
Review of the progress notes, dated 3/12/25 at 9:52 A.M., showed a Registered Dietician (RD) note: skin intact.
Review of the weekly skin assessment, dated 3/17/25, showed:
-Skin color: normal;
-Skin temperature: dry and warm;
-Skin turgor: normal, returns quickly;
-Skin issues: yes;
-Skin condition:
-Right buttock: incontinent associated dermatitis;
-Left buttock: incontinent associated dermatitis;
-Sacrum: reddened area;
-Note: the skin is normal. Skin temperature is dry and warm. Skin turgor is normal as skin returns promptly. Skin issues present. Refer to assessment for more information;
-No documented physician notification.
Review of the physician visit progress notes, dated 3/18/25 at 12:50 P.M., showed no notification of skin issues or concerns, and no documentation of any refusals to see WCP in his/her record.
Observation and interview on 3/19/25 at 9:00 A.M., showed the resident up in the motorized wheelchair. He/She said he/she returned to the facility from the hospital on 2/12/25. Before the hospital stay, staff applied cream to his/her bottom. During the hospital stay, the hospital applied a cream treatment to his/her bottom and took photos of the wounds. Since he/she returned to the facility on 2/12/25, staff had not applied any treatments to his/her bottom. He/She is incontinent of bowel and used a catheter. His/Her bottom hurts and staff said he/she had wounds. He/She had not seen a wound specialist. At times, a nurse would apply gauze to his/her buttocks. When aides remove the gauze, it is painful. He/She does not like to lie down after getting up, because staff will not get him/her back up for meals, and he/she will remain in bed until the next day. The resident's bed did not have a LAL in place and the center of the mattress was noted to be sunk in.
Observation and interview on 3/20/25 at 7:30 A.M., showed the resident awake in bed. He/She lay on a standard mattress. CNA D and CNA E assisted the resident onto his/her side and exposed the buttocks. Noted to the sacrum, on his/her left and right buttock were multiple white gauze pads and foam dressings secured by gauze, undated and no staff initials were observed. Blood was noted to various areas of the gauze. CNA D and E said oh my God, (he/she) is bleeding, these are stuck to (him/her), CNA D used a warm soapy washcloth and squeezed the water onto the adhered gauze pads and slowly removed the gauze from the resident's skin. The resident yelled oh God, that hurts CNA D and E apologized and continued to remove the bandages. The resident requested the aides spray Bactine (pain relieving over the counter spray) spray and said the spray helps numb it. CNA D cleansed the entire buttock area and sprayed the area with Bactine. CNA E said he/she cared for the resident last week and reported the open wounds to the nurse. At 7:42 A.M., CNA E left the room and re-entered with Licensed Practical Nurses (LPN) B and C. LPN B said he/she worked the night shift and staff did not notify him/her of the wounds. He/She turned the resident in bed. The resident did not have active wound care orders. LPN C said he/she had just received report from LPN B. LPN B had not reported any skin issues. Both LPN B and C said the resident had various open areas and dark wounds to the buttocks, several areas were noted to be actively bleeding. LPN B and C added the resident had no current wound care orders and did not know how the dressings were applied to the resident's buttocks. The resident should have wound care orders to apply any treatments. The resident will be seen by the wound care specialist today.
Review of the March TAR, dated 3/1/25-3/31/25, showed no wound care orders or treatments.
Observation and interview on 3/20/25 at 7:55 A.M., showed the Assistant Director of Nursing (ADON) entered the resident's room. She asked the resident if he/she would be seen by the wound care specialist and the resident consented. Outside of the resident's room, the ADON said he/she has worked as the floor and she was familiar with the resident. The resident frequently refuses to lie down between meals and had refused to be assessed by the Wound Care Plus Nurse Practitioner (WCP NP). The resident refused to allow staff to apply ointments to the wounds. The ADON said the weekly skin assessments should be accurate to the current skin condition. The care plan should reflect the current skin condition. All refusals should be documented in the medical record. The resident did not have any current wound care orders as of his/her re-admission on [DATE]. The hospital wound orders should have been carried over to the facility TAR and POS. She noted the hospital orders were missed. The ADON said the resident's bottom had various open areas noted to be bleeding and several dark wounds. The initial re-admission skin assessment should have accurately reflected the skin condition and staff should have documented the wounds appropriately including measurements and the physician should have been notified. The ADON said the WCP NP would be coming today to assess the resident's wounds. The resident did not have a LAL in use and the facility would apply a LAL if the WCP NP ordered one. The facility did not apply LAL to residents at risk to develop pressure wounds, but relied on assessment from the WCP team.
Observation and interview on 3/20/25 at 9:47 A.M., showed the WCP NP said this was the first time she saw the resident since his/her re-admission in February. She had been told by the facility the resident had previously refused WCP consult. She did not speak to the resident regarding the refusal. The WCP NP obtained the following:
-Right buttock: 6.0 cm x 4.2 cm x 0.2 cm. Slough (yellow, stringy moist unhealthy tissue that impedes health
and can increase risk of infection) 15 percent (%), granulation (new, pink healing tissue) 60%;
-Sacrum: 5.6 cm x 5.0 cm x 0.2 cm. Slough 10%, 50% granulation;
-Left buttock: 5.5 cm x 4.5 cm x 0.2 cm. Slough 25%;
-All wounds are considered Stage III (involves full thickness skin loss with damage or necrosis (black, hard dead tissue) of subcutaneous tissue (fat), presenting as a deep crater, but without exposure to bone, tendon or muscle) pressure injuries;
-New orders: Clean wounds daily with wound cleanser, apply Santyl (used to debriding (removing dead tissue) from wounds), cover with calcium alginate (CA, used to absorb wound drainage and promote a healing wound environment), and staff apply a LAL mattress. The resident educated on importance of lying down and off-loading between meals.
During an interview on 3/20/25 at 12:04 P.M., CNA F said he/she noted the buttock wounds three weeks ago. He/She told the nurse. The wounds were smaller at that time. The resident does not like to lie down during the day. The resident's current mattress is not an LAL and is sunk in the middle of the mattress. He/She had assisted with the resident's care the last few weeks and noted saturated dressings to the buttock wounds. He/She reported saturated dressings and the mattress to the nurse.
During an interview on 3/26/25 at 10:07 A.M., the Regional Therapy Director said the resident received therapy two to three times a week at
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0697
(Tag F0697)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement an effective pain management regime for two ...
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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 implement an effective pain management regime for two sampled residents (Resident #18 and #14). Staff failed to notify ensure Resident #18, who experienced pain related to metastatic breast cancer with osseous (bone) involvement, most severe over bilateral lower extremities, received pain medications as ordered by the physician and failed to notify the primary physician when pain medications were not delivered from the pharmacy and of medications available in the emergency kit. The resident experienced uncontrolled pain and was transferred to the hospital two days after admission to the facility. For Resident #14, the facility staff failed to provide effective pain relief when, during care, staff removed wound dressings which were adhered to the wound sites. The resident had so much pain, he/she was observed to cry and requested Certified Nurse Aide (CNA) D spray over the counter Bactine (relieves the pain and itch of minor cuts, scrapes and burns on contact) onto the buttock wound sites. The sample was 16. The census was 145.
Review of the facility's Pain Management Policy, revised 10/24/22, included:
-Purpose: To ensure accurate assessment an management of the resident's pain;
-Policy: A Licensed Nurse will assess residents for pain on admission and routinely as indicated by the resident's health and functional status. Facility Staff is responsible for helping the resident attain or maintain their highest level of well-being while working to prevent or manage the resident's pain;
-Procedure:
--Pain Assessment:
---A Licensed Nurse will assess each resident for pain upon admission.
---The Licensed Nurse will complete Pain Assessment, or a substantively similar form, for residents identified as having pain within 8 hours of admission.
---The IDT Committee review the Pain Assessment for each newly admitted resident identified by the Licensed Nurse to have pain and at least quarterly thereafter.
---The Licensed Nurse will develop a care plan for pain management, including non pharmacological interventions.
---Pain Flow Sheet, or a substantively similar form, will be completed every shift for new residents for the first seventy-two (72) hours following admission.
---After medications/interventions are implemented, re-evaluate the resident's level of pain within one hour.
---A Licensed Nurse will reassess the resident for pain quarterly and eventfully.
--Pain Management
---The Licensed Nurse will administer pain medication as ordered and document medication administered on the Medication Administration Record (MAR).
---Nurses will complete the Pain Flow Sheet for residents receiving PRN pain to evaluate the effectiveness of the medication regimen.
---The Licensed Nurse will assess the resident for pain and document results on the MAR each shift using the 1-10 pain scale.
---The shift pain score will indicate the highest pain level that occurred on that shift.
---If there is a new onset of pain, if the pain has changed in nature, or the pain has not been relieved with current medication, the Licensed Nurse will notify the Attending Physician for a review of medications.
---Nursing Staff will implement timely interventions to reduce the increase in severity of pain.
---Nursing Staff will provide education to residents and families as to appropriate expectations for pain management.
---The Nursing Staff will attempt to become familiar with cognitive, cultural, familial, or gender-specific influences on the resident's ability or willingness to verbalize pain.
---Pain Management Tool to audit and assess the success of the Pain Management Program.
---Nursing Staff will also utilize non-pharmacological interventions by adjusting the resident's environment to reduce pain.
--Documentation
---Pain Assessments will be maintained in the resident's medical record.
---The Licensed Nurse will document resident's pain and response to interventions in the medical record on the weekly summary and as indicated on the progress notes.
---The Licensed Nurse will update the care plan for pain management with any change in treatment and/or medication.
---Upon admission, quarterly, and eventfully the IDT Committee will meet to review the resident's Pain Assessment. The IDT Committee will document the following:
-Summary of event causing the pain;
-Root cause analysis;
-Referrals, as necessary;
-Interventions to prevent future pain
Review of the Ordering and Receiving Controlled Medication Policy, dated 1/20, showed:
-Policy:
--Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances, and medications classified as controlled substances by state law, are subject to special ordering, receipt, and record keeping requirements in the nursing care center, in accordance with federal and state laws and regulations. The nursing care center obtains and keeps current and on file any permits required by state agencies.
Procedures:
--The director of nursing and the consultant pharmacist monitors for compliance with federal and state laws and regulations in the handling of controlled medications. Only authorized, licensed nursing and pharmacy personnel have access to controlled medications.
--Medications listed in Schedules II, III, IV and V are dispensed by the pharmacy in readily accountable quantities and containers designed for easy counting of contents. When possible, injectable controlled substance medications are dispensed in ampoules or vials of the smallest available dosage unit. (Note: Refer to state regulations, as particular states do not require Schedule V medications to be dispensed in accountable quantities and containers.)
--The pharmacy or the nursing care center prepares an individual resident controlled substance record/receipt/log for each controlled substance medication prescribed for a resident as applicable per state law. This log is placed in the MAR or narcotic book to be counted every shift. The nursing care center may designate a particular medication, which is not mandated as a controlled substance by state or federal laws and subject to abuse or diversion, to be handled under these procedures for controlled medications. (Note: Refer to state regulations, as particular states do not require this documentation for Schedule V medications.) The following information is completed:
-Name of resident
-Prescription number
-Medication name
-Medication strength (if designated)
-Dosage form of medication
-Date received
-Quantity received
-Name of person receiving the medication supply
--The Drug Enforcement Agency (DEA) requires that a pharmacy must have a valid prescriber signed prescription in order to dispense controlled substances. A valid written prescription requires patient name, drug name and strength, quantity to dispense, directions for use, date and signature of the prescriber. (Refer to Section 2.2-Controlled Substance Medication Orders). In an emergency situation, verbal authorization may be given by the prescriber to the pharmacist for a new order as described by state law. (Refer to Section 3.4 Emergency Pharmacy Service and Emergency Kits (E-Kits))
--Refill Requests for CIII-CV, and Partial Fill Requests for CII
-If one or more refills (CIII-Vs) or a partial fill quantity (CIIs) remains:
-Written on a medication order form or ordered by peeling the top label from the label and placing it in the appropriate area on the order form provided by the pharmacy for that purpose, and requested from the pharmacy a minimum of 3 days in advance of need to assure an adequate supply is on hand.
-If only one refill remains ([NAME]-Vs) or only a partial fill quantity remains (CII), the pharmacy will simultaneously dispense the remaining fill, and, if necessary proactively seek out a new, complete prescription from the prescriber for future use. The facility may be asked to contact the prescriber for a new prescription upon request for a medication with no remaining fills available.
1. Review of Resident #18's electronic medical record (EMR), showed:
-admission: [DATE];
-discharged : 3/8/25;
-Diagnoses include malignant neoplasm left breast, malignant neoplasm of liver, and acute respiratory failure with hypoxia.
Review of the hospital discharge record, showed:
-Hospital Course: Acute respiratory hypoxia (not enough oxygen in the tissues in your body) secondary to progression of metastatic breast cancer.
-Cancer related pain: Diffuse pain related to metastatic breast cancer with osseous (bone) involvement, most severe over bilateral lower extremities. Regimen was adjusted to morphine extended release (ER) (opioid that treats moderate to severe pain) 15 milligram (mg) twice a day (BID) and oxycodone (opioid that treats moderate to severe pain) 10 mg every 6 hours as needed (PRN), continued on scheduled Tylenol 1000 mg three times a day (TID), gabapentin (used to treat nerve pain) 300 mg BID, and added Flexeril (muscle relaxer used to treat pain and stiffness) 5 mg TID PRN.
-Medications at hospital discharge included:
-Morphine ER 15 mg BID (last given 3/6/25 at 11:42 A.M.);
-Oxycodone 10 mg every 6 hours PRN (last given 3/6/25 at 12:47 P.M.);
-Flexeril 15 mg TID PRN (last given 3/6/25 at 11:42 A.M.);
-Gabapentin 300 mg BID (last given 3/6/25 at 9:05 A.M.);
-Tylenol 1000 mg TID (last given 3/6/5 at 9:05 A.M.).
Review of the admission assessment, dated 3/6/25 at 5:40 P.M., showed:
-Date of arrival: 3/6/25;
-Time of arrival: 5:35 P.M.;
-Was physician notified of the resident's admission: Yes;
-Were the resident's medications reviewed with the physician: Yes;
-Were there any significant medication issues found during review: No;
-Level of consciousness: Alert to situation, time, place;
-Mood: Flat;
-Pain: Does the resident report pain currently: No;
-Most recent pain level: 8 3/7/25 at 6:42 A.M.;
-Pain plan: Blank
-admission Actions: Physician/Nurse Practitioner (NP) notified of admission assessment;
-Physician/NP Actions: No new orders;
-Drug Regime Review (DRR): 3/6/25 at 9:00 P.M.;
-Was the list of medications from the hospital compared with the medications the resident was taking at home: Yes;
-Was the physician notified if any discrepancies were noted during medication reconciliation: No differences noted;
-Were all medications reviewed to ensure that proper labs were ordered: Yes;
-Select most accurate statement: Statement by nurse that admission DRR completed with no significant issues identified.
Review of the resident's pain assessment, dated 3/6/25 at 6:09 P.M., showed:
-Have you had pain or hurting at any time in the last 5 days: Yes;
-How much of the time have you experienced pain or hurting over the last 5 days: Frequently;
-Pain Effect on sleep: Frequently;
-Pain interference with therapy activities: Frequently;
-Pain interference with day-to-day activities: Frequently;
-Verbal descriptor: Severe;
-Staff assessment for pain: None of these signs observed or documented (non-verbal, vocal complaints, facial expressions, protective body movements);
-Frequency with which resident complains or shows evidence of pain or possible pain: Daily;
-Pain Management: Describe treatment, any side effects, effectiveness: ineffective;
-Received PRN pain medications: Blank;
-Received non-medication intervention: Blank.
Review of the resident's care plan, did not address his/her potential for pain.
Review of the resident's Pain Level Summary, showed:
-3/6/25 at 9:25 P.M., 0/10 pain;
-3/7/25 at 6:42 A.M., 8/10 pain;
-3/7/25 at 6:46 P.M., 10:35 P.M., and 11:33 P.M., 0/10 pain;
-3/8/25 at 3:38 A.M. and 6:48 A.M., 0/10 pain;
-3/8/25 at 10:57 A.M., 1:39 P.M., and 2:03 P.M., 10/10 pain.
Review of the resident's Physician Order Sheet (POS), included:
-An order, dated 3/6/25, Morphine 15 mg. Give 1 tablet by mouth every 12 hours for pain;
-An order, dated 3/6/25, Oxycodone tablet 10 mg. Give one tablet by mouth every 6 hours as needed for pain;
-An order, dated 3/6/25, Cyclobenzaprine (Flexeril) 5 mg. Give one tablet every 8 hours as needed for muscle spasms;
-An order, dated 3/7/25, Gabapentin 300 mg. Give 300 mg by mouth two times a day for pain;
-An order, dated 3/6/25, Tylenol 1000 mg. Give 1000 mg by mouth three times a day for pain.
Review of the resident's, March 2025, Medication Administration Record (MAR), showed:
-Morphine 15 mg:
-Showed given 3/6/25 at 9:00 P.M. and 3/7/25 at 9:00 P.M.;
-Marked 9 (other/see progress notes) 3/7/25 at 9:00 A.M. and 3/8/25 at 9:00 A.M.
-Oxycodone tablet 10 mg:
-Medication not administered to the resident.
-Cyclobenzaprine (Flexeril) 5 mg:
-Medication not administered to the resident.
-Gabapentin 300 mg by mouth two times a day for pain.
-3/7/25 at 9:00 A.M., Medication marked 5. No progress note related to medication not administered.
-Tylenol 1000 mg by mouth three times a day for pain:
-3/7/25 2:00 P.M. Not given. Marked 5 (Hold/See progress note).
Review of the resident's electronic medical record (EMR), showed:
-An administration note dated 3/7/25 at 3:03 P.M., New admit medication (Tylenol) will be delivered 3/7/25;
-An administration note, dated 3/8/25 at 12:47 P.M., Morphine sulfate. Medication on order, pharmacy notified;
-An administration note, dated 3/8/25 at 1:39 P.M., Morphine sulfate. Medication on order from pharmacy/new admit.
Review of the resident's EMR, showed:
-A progress note, dated 3/6/25 at 5:40 P.M., resident was admitted from hospital on [DATE] at 5:35 P.M. Resident is alert. Oriented to place time situation. Mood is flat. Resident is not able to report pain at this time. Physician/Nurse Practitioner notified of admission assessment findings and no new orders noted. Refer to full assessment for more information;
-A progress note, dated 3/7/25 at 6:33 A.M., resting in bed No signs of acute distress noted. Complained of general discomfort. Scheduled pain medication given with effectiveness. Plan of care ongoing;
-A progress note, dated 3/8/25 at 4:38 A.M., monitoring for new admission status. Remains alert and oriented. Able to make needs known. Resident is making adjustments to new environment;
-A progress note, dated 3/8/25 at 3:15 P.M., resident sent to hospital for uncontrolled pain. Physician, family, Director or Nursing (DON) aware.
Review of the facility's Controlled II Emergency Medication Kit, showed:
-Morphine Sulfate 100 mg/5 milliliter (ml) solution 30 ml;
-Fentanyl (used to treat severe pain) 25 mcg patch;
-Oxycodone 5 mg tab;
-Oxycodone/Apap (Tylenol) (used to treat moderate to moderately severe pain) 5/325 mg tab and 10/325 mg tab;
-Hydrocodone/Apap (used to treat moderate to severe pain): 5/325 mg tab, 7.5/325 mg tab, and 10/325 mg tab.
Review of the facility's Controlled III-V Emergency Medication Kit, showed:
-APAP/Codeine #3 (used to treat moderate to moderately severe pain);
-Tramadol (used to treat moderate to severe pain) 50 mg.
Review of the Situation-Background-Assessment-Request (SBAR), dated 3/8/25 at 1:11 P.M., showed:
-Situation- Patient in severe pain related to recent lumpectomy, breast cancer:
-Started on 3/8/25;
-Since started it has gotten worse;
-Things that make the condition/symptom worse: unmedicated/pharmacy has not delivered;
-Things that make the condition/symptom better: medication;
-Treatment for last episode: new admit;
-Background:
-Resident in nursing home for post-acute care;
-Primary diagnosis: left breast cancer;
-Other pertinent history: neoplasm liver, neoplasm of vocal cords;
-Assessment:
-Registered Nurse (RN): Think the problem may be uncontrolled pain;
-Licensed Practical Nurse (LPN): The resident appears in excruciating pain;
-Request:
-Suggest or Request: Transfer to the hospital
-Nursing notes: Resident has facial grimacing and furrowed brow in relation to severe pain from lumpectomy/other cancer.
-Reported to primary care clinician: 3/8/25 at 1:00 P.M.
Observation and interview on 3/19/25 at 11:30 A.M., showed Licensed Practical Nurse (LPN) H open the narcotic box in the nurse medication cart. Resident #18 had one card of Oxycodone with 30 out of 30 pills and one card of Morphine 15 mg with 28 out of 28 pills. (The issue date of the medications was March 8, 2025.) Review of the narcotic book showed nothing signed out for the resident. LPN H said there was an emergency kit (e-kit), but he/she was not sure where it is located. When a resident is a new admission, it typically takes pharmacy about an hour to get medications sent to the facility.
During an interview on 3/19/25 at 12:04 P.M., LPN A said if a resident is a new admission and they do not have the medication at the facility, then the nurse can pull the medication from the e-kit. There is a controlled medication e-kit and a regular one. LPN A said when the resident was admitted , the facility did not have his/her medications. They were waiting on the doctor to approve it because pharmacy would not send the medication without doctor approval. LPN A believes the medication was sent to the facility after the resident was at the hospital because he/she never received the medication while he/she was at the facility. The medication was still listed as pending while he/she was here. The resident was sent to the hospital because of his/her pain and the facility not being able to manage it.
During an interview on 3/19/25 at 12:46 P.M., the Pharmacist said the facility sent the order for the resident's Morphine 15 mg and Oxycodone 10 mg on 3/6/25 at 1:30 P.M. Usually, if the medication is not covered, there is a billing issue like trying to refill too soon or it is on back order. The Pharmacist believes the morphine was on back order, a card was sent to the facility and now it is on back order again. The Pharmacist said their system shows the pharmacy sent the resident's Morphine and Oxycodone to the facility on 3/8/25 at approximately 11:00 A.M. Typically, once an order is received, the pharmacy can get it to the facility within an hour. The pharmacy is local.
During an interview on 3/19/25 at approximately 1:00 P.M., the controlled log inventory sheet for controlled medication sent from the pharmacy to the facility from 3/1/25 to 3/14/25 was requested from the DON. At 1:42 P.M., the DON said no controlled medication had come in or out for the first floor from 3/1/25 to 3/14/25.
During an interview on 3/20/25 at 3:50 P.M., LPN K said he/she admitted the resident to the facility. LPN K did not know what the resident was admitted for , but the resident had a left breast mastectomy. The resident had orders for two different narcotics. He/She called the physician because the hospital did not send the prescriptions. The resident did not get either medication while he/she was here. LPN K is not sure why he/she signed off on giving the medication. LPN K might have just checked it as given to get the screen off red so the admission could be completed. LPN K did not remember giving the resident any morphine.
During an interview on 3/20/25 at 11:50 A.M., Certified Nursing Assistant (CNA) I said the resident was at the facility for about a day. The resident called 911 to get out of the facility. CNA I said things were chaotic when the resident was admitted . They could not find things like the resident's oxygen concentrator so he/she thinks the resident got frustrated that they could not do things as quick as the resident would like. Then they had to change out his/her bed. Then the next thing they know, the resident is on the ambulance. The resident did not say what brought him/her to the facility but still complained of pain when he/she left. The resident had complained of pain since he/she got there. The resident just looked tired. The resident was constantly grimacing and said his/her lower back hurt. The resident was always complaining of pain. CNA I remembered the nurse telling the resident that he/she could not have anything else, because it was not time yet and the resident still had a couple hours to go. The resident called his/her son/daughter once and CNA I talked to them. The family member said the resident was uncomfortable. The resident was just having a lot of pain.
During an interview on 3/20/25 at 12:28 P.M., Certified Medication Technician (CMT) F said the resident was not there very long. CMT F only went in once when the resident's bathroom call light was going off and did not remember if he/she gave the resident any medications. CMT F did not remember why he/she would not have given the resident a Tylenol. CMT F said when a 5 is charted in the MAR, then a progress note should be entered. The resident was just very quiet.
During an interview on 3/20/25 at 12:45 P.M., LPN K said he/she did not really remember the resident. LPN K said the CMT gave the resident his/her medications. When asked about the MAR, LPN K said the resident did get morphine. The resident complained of back pain. The morphine was pulled from the medication cart on his/her card,. It may have been a liquid dose, LPN K cannot recall off hand if it was a liquid or pill form. LPN K said he/she did not pull anything from the e- kit and is unsure if the resident had pain medicine. When a medication is pulled from the e-kit, the pharmacy has to give a code to access the e-kit.
During an interview on 3/20/25 at 12:57 P.M., the DON said when a resident is admitted , the nurse is expected to complete the admission assessment and verify medications with the physician. The medications are put in the EMR and then the pharmacy should receive it. If the facility does not have a medication, then she expected the nurse to call the pharmacy. She also expected the nurse to notify management, like the Assistant Director of Nursing (ADON), and the physician. If the medication is a controlled pain type medication and the pharmacy says they do not have a prescription, then get the prescription sent to the pharmacy and sign it out from the e-kit. Once signed out, then the pharmacy sends it. If it is not in the e-kit, staff should call the physician and try to get an order for something different. She expected nursing staff to call the physician and get something else for the resident's pain. She is not sure if Tylenol is stock or not. The DON is not sure of the process but believes when the e-kit is open, the nurse calls the pharmacy to get a code which unlocks the kit. The resident was admitted with pain. She received a call on Saturday the resident wanted to go back to the hospital because his/her pain was uncontrollable. The nurse called the physician and sent him/her out. The DON did not get a call prior to that related to the resident. Staff should have called the physician immediately when the medication did not arrive. She and the ADON reviewed the resident's admission on [DATE] and this did not come up. The DON expected a resident's pain to be reassessed within the hour. She would not expect staff to document they gave a medication if they did not actually give the medication.
During an interview on 3/20/25 at 1:35 P.M., the ADON said they look at the missed medication report every day. The report is generated by what code is entered and a report can be pulled. The resident was there about a day and a half. The resident came late in the day. For the resident's pain medication, they have a narcotic e-kit with morphine. E-kits are kept on the first floor, and there is one box with a combination code. The process is to call the pharmacy. The pharmacy will give a combination to that box and they will approve doses until they deliver the meds. They have morphine in the e-kit. The nurses should have called the physician to get an order for the liquid pain medication. A nurse should not document a medication was given if the medication was not in the building and should not borrow any medications from other residents. The nurses have access to what is in the e-kit as it is on the e-kit box. When staff pull out of the e-kit, it is faxed to the pharmacy, then the pharmacy would know what to replace. The nurse should document a progress note if the e-kit was accessed for a medication.
During an interview on 3/20/25 at 9:45 A.M., the NP said he/she did not have a chance to assess the resident in person. The resident came and went. Usually when a patient comes, they send medications, but they did not have the chance. The resident was in bad shape. They did not get a call from the pharmacy regarding the resident's pain medications. The facility did not call either. If a patient needs pain medication, the NP expected a phone call. They have to let the doctor know. They always look for another option if the resident does not have ordered pain medication. If a resident has pain and is not covered/available, then the doctor will give an alternate prescription.
2. Review of Resident #14's medical record, showed:
-re-admitted [DATE];
-Diagnoses included: quadriplegia (paralysis in all limbs), Parkinson's (a neurodegenerative disease causing muscle weakness and loss), diabetes, anxiety, muscle wasting, and reduced mobility;
-Able to make needs and wants known.
Review of the hospital's Discharge summary, dated [DATE], showed:
-admitted : 2/5/25;
-Diagnoses: Pneumonia and sepsis;
-Wound dressing paste: apply one application topically twice a day to right buttock and left thigh wounds;
-Wound care instructions:
-Incontinent associated dermatitis (IAD, skin damage associated with incontinence) bilateral (both sides) buttocks;
-Dressing status: open to air;
-Site assessment: fragile, painful and pink;
-Shape/pattern: irregular;
-Peri-wound assessment: fragile, painful;
-Interventions: cleansed, protective ointment;
-Wound status: unchanged;
-Non-staged description: partial thickness;
-Pressure injury to coccyx:
-Dressing status: open to air;
-Site assessment: Fragile, painful;
-Shape/pattern: Irregular;
-Peri-wound assessment: Fragile, painful;
-Interventions: cleansed, protective ointment;
-Pressure injury Stage: II (partial thickness skin loss, appearing as a shallow, open ulcer with a red or pink wound bed, or as an intact or open/ruptured blister);
-Measurements: length 3 cm x width 4 cm;
-Margins: Undefined edges;
-Wound status: Unchanged.
Review of the facility admission assessment, dated 2/12/25, showed:
-admitted from: hospital;
-Pain: does the resident report pain currently: no;
-Most recent pain level: 8;
-Pain plan:
-Focus: the resident has acute/chronic pain;
-Goal: pain will be minimized with the use of scheduled and/or PRN meds;
-Interventions: administer analgesia as ordered, anticipate needs for pain relief, evaluate effectiveness of pain inte
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policies for Transfer and Discharge & Elopement and Wa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policies for Transfer and Discharge & Elopement and Wandering for one resident (Resident #1), when facility staff failed to provide written discharge notice to the resident and his/her legal guardian- when the resident eloped (left the premises without authorization and/or any necessary supervision to do so) from the facility. The facility considered the resident leaving Against Medical Advice (AMA), although the resident had a legal guardian and was unable to make medical decisions on their own. Facility staff did not have a consistent understanding of the difference between a resident having a leave of absence, elopement, and against medical advice, to ensure policies and procedures were followed accordingly. The facility failed to allow the resident to return to the facility when the guardian brought the resident to the facility two days later. The resident was not provided discharge planning or appeal rights to the discharge. The resident sample was 13. The census was 144.
Review of the facility's Transfer and Discharge policy, revised 10/24/22, showed residents are transferred/discharged based on physician order unless the resident signs themselves out against medical advice.
Review of the facility's Discharge Against Medical Advice policy, last revised 10/24/22, showed:
-A resident may discharge themselves from the facility against the advice of his/her physician;
-The facility and/or physician will discuss with the resident and/or the resident's representative, if applicable, the reason for AMA decision and will advise them of the potential consequences of the AMA decision;
-No medications are dispensed to a resident leaving AMA;
-Nursing staff will document in the progress notes all pertinent information concerning the resident's actions, including the resident's stated reason for his/her desire to leave the facility;
-The AMA policy did not address residents who were deemed incompetent and/or had a legal guardian and were unable to make the decision to leave AMA.
Review of the facility's Wandering and Elopement policy, last revised on 10/24/22, showed:
-If facility staff observes a resident leaving the premises without having followed proper procedures, he/she may: Try to prevent the departure, get help from other facility staff in the immediate vicinity, direct another facility staff member to inform the charge nurse or Director of Nursing (DON) that a resident is trying to leave the premises;
-Return of a Resident
- When an individual who departed without following proper procedures returns to the Facility, the Director of Nursing Services or Licensed Nurse should:
--Examine the resident for nay possible injuries;
--notify the attending physician;
--notify the resident's responsible party.
-The licensed nurse will initiate or update the resident's care plan and implement immediate intervention(s) to prevent further wandering/elopement by the resident.
-The IDT, with input from the licensed nurse, will conduct a thorough review of the elopement, document its findings in the IDT notes, and update the Care Plan to prevent a recurrence.
-The Quality Assessment & Assurance Committee will review all instances of elopement.
-The policy did not indicate that a resident who has been deemed incompetent and who leaves the facility without following proper protocol as leaving AMA and did not instruct staff to discharge the resident instead of following the Wandering and Elopement policy;
-The policy failed to define elopement.
Review of Appendix PP State Operations Manual, showed:
-Definition for resident-initiated transfer or discharge: Means the resident or, if appropriate, the resident representative has provided verbal or written notice of intent to leave the facility. Leaving the facility does not include the general expression of a desire to return or the elopement of residents with cognitive impairment;
-Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so.
Review of Resident #1's Circuit Court Petition to Appoint Successor- Guardian, showed:
-On or about May 28, 2013, the court found Resident #1 to be incapacitated and appointed Guardian A, as guardian;
-Due to health and other reasons, Guardian A wishes to resign as guardian and asks the court to appoint Guardian B as successor guardian.
Review of the resident's face sheet, showed:
-admitted on [DATE];
-Diagnoses included type II diabetes, psychotic disorder with delusions due to known physiological condition, cocaine dependence, paranoid schizophrenia (mental disorders characterized in disruptions in thought process, emotions, and social interactions), post-traumatic stress disorder (PTSD, mental health condition that is caused by an extremely stressful or terrifying event), borderline personality disorder (condition characterized by intense and unstable emotions, impulsive behaviors, and difficulty maintaining healthy relationships), moderate intellectual disabilities, and anxiety disorder;
-Has a guardian;
-discharged on 10/10/24.
Review of the resident's care plan, revised 9/19/24, showed:
-Focus: Resident is not allowed to go Leave of Absence (LOA) from facility with anyone per guardian request;
-Goal: Guardians wishes will be honored and protective oversight will be ensured;
-Interventions: Guardian will re-evaluate LOA privileges once the resident is acclimated to facility;
-Inform and notify staff that resident is not allowed to go LOA. Information given to resident, receptionist, and nursing staff;
-No documentation of the resident's history of wandering or elopement risk.
Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/23/24, showed:
-Cognitively intact;
-Diagnoses included high blood pressure, acid reflux, diabetes, hyperlipidemia (high level of lipids in the blood), malnutrition, anxiety, psychotic disorder, schizophrenia, PTSD;
-Independent with mobility;
-No behaviors;
-Has resident wandered: Behavior not exhibited.
Review of the resident's progress notes, showed:
-On 10/10/24 at 3:19 P.M., documented by Licensed Practical Nurse (LPN) D, showed resident went to activities and left the facility. Assistant Director of Nursing (ADON) was made aware;
-On 10/10/24 at 5:06 P.M., documented by Assistant Director of Nursing (ADON) showed resident left against medical advice after being educated on the risk of leaving Against Medical Advice (AMA). Contacted Guardian B in which he/she was in agreement with decision made. Contacted Physician K and Physician L in regard to AMA status and stated ok.
Review of the resident's Against Medical Advice Discharge form, dated 10/10/24, showed:
-Resident refused to sign with education provided;
-Verbal consent from Guardian B;
-Signed by ADON on 10/10/24.
Review of the facility's investigation, showed:
-Date of Incident: 10/10/24;
-Type of Incident: AMA discharge;
-Initial investigation: Resident had a diagnoses of, but not limited to, Borderline Personality disorder, high risk heterosexual behavior, herpes viral infection, paranoid schizophrenia, diabetes, history of cocaine dependence, generalized anxiety disorder, mild cognitive impairment (a condition in which people have more memory or thinking problems than other people their age), moderate intellectual disabilities, and PTSD. Resident has a BIMS of 15 (cognitively intact). At admission, resident deemed a low risk for elopement;
-Resident attended an activity off the unit. He/She went to use the bathroom and attempted to leave the facility. She was asked to sign out, but refused. He/She was also asked to sign out AMA if he/she was leaving. Resident refused to sign out AMA after attempted education and left facility with his/her boyfriend in a black sedan at 2:34 P.M. ADON notified guardian of AMA and stated he/she was not surprised by his/her behaviors;
-Findings: Resident refused to follow Against Medical Advice policy. Resident refused to sign AMA form after given education on the risks of leaving AMA;
-Conclusion: Resident refused to sign AMA. If resident shows interest in returning to the facility, he/she will need to follow our admission process as a new referral. Receptionist is aware that resident is not allowed to return until admission process has been completed. Guardian is supportive regarding AMA and re-admission process and lack of being re-admitted as resident's behavior are mirroring the same as 10 years ago;
-AMA: Resident ran out of facility AMA appropriately 2:34 P.M.;
-Staff attempted to have resident sign AMA paperwork although resident did refuse and had things to do;
-Review of the facility's investigation showed no statement from staff who attempted to stop resident from leaving;
-No written statement from the receptionist;
-No written statement from the ADON.
Review of a form titled Against Medical Advice Discharge Form, dated 10/10/24, showed two places for the resident's signature. Under the first section, Resident #1 refused to sign the form acknowledging the risks involved and danger to health and safety if they left the facility, and releasing the facility and administration from responsibility. Under the 2nd section under a statement, Authorization must be signed by the resident, by the nearest relative in the case of a minor, or by the Durable Power of Attorney when the resident is physically or mentally incompetent., showed the resident's signature and a statement verbal consent via (name).
During an interview on 2/4/25 at 10:45 A.M., Guardian B said the resident was supposed to be in a secured area. The resident went downstairs for something. Guardian B does not know how the resident walked out the door or if he/she got a ride with someone, but Family Member C found the resident. The resident and Family Member C returned to the facility and staff told them that the resident could not come back. The resident was taken to a local hospital and the resident has been there ever since. Someone from the facility did call him/her and Family Member C. There was no discussion about AMA. The resident was gone for two days. When Family Member C brought the resident back, whomever met them at the door told them they could not come back. Staff packed up the resident's belongs. The resident came from a facility that closed and he/she did elope from the prior facility.
During an interview on 2/4/25 at 11:00 A.M., Family Member C said the facility called him/her the day he/she left and asked if he/she had the resident. He/She told the facility, no. There was no further discussion at that time. Another staff called later and said the resident was not at the facility, that he/she ran out the door and hopped in a car. The next day, the resident called him/her and asked him/her to come and pick the resident up. The resident was on Kingshighway. He/She asked the resident what happened, and the resident said he/she called a guy and told him to get him/her, then he/she ran out of the building, hopped in the car, and said go, go, go! He/She had escaped this place. Family Member C took the resident back to the facility and staff said they would not take the resident back. Family Member C asked staff where they should take the resident, and staff said that is the guardian's responsibility. Family Member C took the resident to the hospital psychiatric ward and that is where he/she still is. There was no discussion about AMA and they did not ask him/her to sign anything. They handed him/her belongings and a bag of medication.
During an interview on 2/4/25 at 11:35 A.M. and 2/5/25 at 11:43 A.M., LPN D, the resident's nurse at the time of the elopement, said he/she does remember the resident. The resident and one other resident were admitted from a nursing home in Arkansas. He/She was the staff person who drove to pick them up. During the ride back, the other resident informed him/her to watch because Resident #1 runs off. He/She was aware the resident was at risk for elopement. The resident said he/she was going to an activity. Activity staff took the resident downstairs. About 15 to 30 min later, activity staff said the resident was gone. Staff informed him/her the resident ran out the front door and got into a car. The front desk staff saw it. The resident did not tell anyone and he/she was supposed to be watched at all times. Staff was told the resident would run when he/she was admitted . He/She notified the Assistant Director of Nursing (ADON) and DON E, who was the DON at the time. The DON notified the family that the resident had left. The resident left his/her belongings upstairs. LPN D first said this incident was an elopement, then said if a resident on a locked unit leaves without telling staff it is AMA and not elopement, so now he/she thinks it was AMA because the resident was diabetic and had medical issues. Elopement means they just take off. The resident did not sign out and did not say anything about leaving. Activity staff were supposed to watch the resident.
During an interview on 2/4/25 at 1:47 P.M., CMT I said he/she was working the day the resident left. Resident #1 left the floor with activity staff. The next day he/she was made aware the resident was gone. He/She heard the resident went to the bathroom, came out, and left. Staff never heard him/her say anything about leaving. He/She was not aware if the resident was an elopement risk. It was just reported that he/she left and was seen getting into a car. If a resident leaves without telling anyone and runs out of the building into a car, it is an elopement.
During an interview on 2/4/25 at 1:30 P.M., Activity Director H said Resident #1 was seen running out the door. Staff reported he/she came out of the bathroom and ran up the hall. The aide said the resident got out and got in the car. He/She saw the resident when family brought him/her back. He/She looked rough like he/she was under the influence. He/She asked the resident why he/she did that and resident said he/she did not know why. Activity staff are responsible for protective oversight. Residents cannot go outside without staff. Resident used to be able to go to the bathroom alone, but now staff must stand outside the door because Resident #1 ran out. To his/her knowledge the resident was not an elopement risk. It was not an elopement because the resident was in activities at the time, he/she did not escape from the unit. If a resident leaves it is AMA, only if they are their own responsible party. It would be an elopement if the resident had a guardian. Resident with a guardian cannot leave AMA.
During an interview on 2/5/25 on 9:30 A.M., Nurse Practitioner (NP) J, the NP for Physician K, said the resident came from another facility. He/She had a drug problem and has schizophrenia. He/She was alert and oriented, able to tell staff where he/she was, but he/she was not sure if the resident had a guardian. The facility told him/her the resident left AMA and was educated, but the resident still decided to leave. If the resident had a guardian and left the facility, that would be an elopement. He/She would expect the facility staff to understand the difference between elopement and AMA. If a resident leaves, does not sign out, and does not have a discussion about leaving, it is an elopement. It would not be appropriate for a resident to leave without staff knowledge or guardian knowledge and determined it was AMA, it would be an elopement.
During an interview on 2/4/25 at 2:09 P.M., with the administrator, Regional Nurse, and Director of Clinical Reimbursement Services, they said they define elopement as an unauthorized, unwitnessed leave. If staff does not have eyes on them, guardian does not know, and they leave. The Regional Nurse said in this instance, she believes it was AMA because the resident was told to sign out. The Director said when the resident left, he/she was in activities. He/She wanted to leave and staff tried to stop him/her. They talked to him/her about signing out and he/she did not want to sign out. They then pulled up AMA paperwork. They contacted the responsible party and they said they knew he/she would do this.
During an interview on 2/5/25 at 12:56 P.M., the ADON said he/she remembered the resident. The resident was alert and oriented x 4 and had been in nursing homes for a long time. He/She was young and outgoing. He/She had mental issues and substance abuse, which was why he/she was on the secured unit. The resident was not an elopement risk. He/She was completely functioning and could tell you anything. There was nothing said that would alarm him/her as an elopement risk. The resident liked activities. The ADON worked on 10/10/24, but did not witness the resident attempting to leave or trying to leave. The ADON did not know who tried to stop. The ADON was asked who reported that the resident was leaving and he/she said, staff, but could not remember who. The resident wanted to leave AMA. He/she had a boyfriend on the outside. He/she was very knowledgeable because he/she was in a nursing home for a long time. The resident wanted to leave AMA, his/her guardian was called. The ADON contacted the guardian, educated the resident on the importance of not leaving AMA. The guardian was also educated on leaving AMA in general without speaking to the physician. The resident wanted to leave with his/her boyfriend. The ADON contacted the guardian because the resident was not his/her own responsible party and ADON wanted to make sure it was okay. The ADON presented the AMA form to the resident and he/she signed it without any concerns or issues. A couple of days later, he/she came back for her belongings with his/her family. ADON contacted the physician and guardian and informed staff. They were not told the resident could not return. That was their decision when they returned to the facility. If a resident leaves the building, without staff knowledge, did not sign out, that is considered an elopement. The ADON was asked if the resident exited the facility before the guardian was contacted. The ADON could not remember if the resident was still in the facility when the guardian was contacted, but remembered that the resident was in the process of leaving. The resident was physically in the building when the guardian was called. After the resident signed the AMA form, he/she gives it to the Administrator. The ADON confirmed there were no issues when the resident signed the AMA form. The resident did not refuse to sign.
During an interview on 2/7/25 at 10:15 A.M., Receptionist M said he/she worked as receptionist at the time of the incident. From his/her understanding, something was going on in activities. The resident plotted to leave. The resident went into the bathroom and came out, but wore a jacket with hood and had a purse on his/her shoulder. The resident was dressed and looked like a visitor. He/she booked it down the hall and walked by Receptionist M. Since he/she never seen him/her before, so Receptionist M thought it was a visitor. The resident stood at the front door with his/her back facing the receptionist desk. The resident stood there for several seconds. The resident looked like a visitor that was waiting at the door. The front entrance door system is not that good because if someone stuck their finger in between the small opening between the two doors, the doors open. That was how the door opened. Receptionist M saw the resident walk across the street, entering a parked car. The car drove away quickly. There were a lot of staff in the classroom at the time that saw the resident walk across the street. They came out and said the resident eloped, and receptionist said, who. He/She never saw the resident before that. The facility blamed Receptionist M for what happened. At the time of the incident, it was an elopement and not AMA. There was no one that stopped the resident, spoke to the resident about AMA prior to the resident exiting the building, and the resident did not sign a form before leaving. The resident tried to return to the building, but they denied him/her.
During an interview on 2/5/25 at 1:20 P.M., Receptionist G said if a resident runs out of the building, does not notify staff, and gets into a car, it's an elopement. They ran off and did not tell anyone. They have an elopement binder at the front desk.
During an interview on 2/6/25 at 10:06 A.M., Certified Nursing Assistant (CNA) V said an elopement is when a resident leaves the facility without staff knowledge.
During an interview on 2/6/25 at 10:23 A.M., CNA U said he/she did not know the difference between an elopement and AMA. The two run together.
During an interview on 2/6/25 at 10:23 A.M., CNA T said the code for an elopement is gray. At 10:41 A.M., he/she wanted to change their answer. It used to be yellow, but now it is pink. An elopement is when a resident leaves without anyone knowing, right out of the door.
Observation on 2/6/25 at 10:23 A.M., showed an elopement in-service posted on the door outside the entrance to the unit. The code was pink.
During an interview on 2/6/25 at 10:31 A.M., CNA S said he/she did not know the difference between elopement and AMA. He/She had trouble with the two.
During an interview on 2/6/25 at 10:36 A.M., CNA R said an elopement is when a resident left the building without staff knowing. They would do a head count, lock down the floor, and notify the supervisor. The code is pink.
During an interview on 2/6/25 at 10:39 A.M., Certified Medication Technician (CMT) Q said an elopement is when a resident escapes. They would call a code pink.
During an interview on 2/6/25 at 10:24 A.M., LPN D said he/she had trouble differentiating between elopement and AMA. The color code used to be gray. At 11:43 A.M., LPN admitted it was difficult distinguishing between elopement and AMA because of how it was presented to him/her when Resident #1 eloped.
During an interview on 2/6/25 at 12:27 P.M., the Administrator said she would expect staff to understand the difference between elopement and leaving AMA. Staff are expected to discuss AMA with the resident, notify the guardian/family, physician, and present the resident with an AMA form. She would expect staff to follow discharge policy and for all residents to be properly discharged from the facility. If the resident returned to the facility, she would expect staff to document it in the record.
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
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to obtain physician orders and monitor a wound identified by staff for one resident (Resident #27). The census was 145.
Review of...
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Based on observation, interview and record review, the facility failed to obtain physician orders and monitor a wound identified by staff for one resident (Resident #27). The census was 145.
Review of the Wound Management Policy, revised 10/24/22, showed:
-Purpose: provide a system for the treatment and management of residents with wounds including pressure and non-pressure ulcers;
-Definitions: Diabetic Neuropathic Ulcer: requires that the resident be diagnosed with diabetes mellitus and have peripheral neuropathy. The diabetic ulcer characteristically occurs on the foot;
-Procedure: Assessment:
-A licensed nurse will perform a skin assessment upon admission, readmission, weekly, and as needed for each resident;
-Upon identification of a wound the licensed nurse will:
-Measure the wound (length, width and depth);
-Initiate a wound monitoring record sheet:
-A wound monitoring record will be completed for each wound;
-If the wound monitoring record is not used, documentation will be recorded within the medical record which may include nursing notes, treatment records or care plans;
-An assessment of care needs for pressure ulcer and wound management will be made with emphasis on, but not limited to:
-Identifying risk factors;
-Treatment;
-Mechanical offloading and pressure reducing devices;
-Reducing skin friction, sheer, and moisture;
-Nutritional status;
-Evaluating and modifying interventions for a resident with an existing PU/PI;
-Wound Management:
-The attending physician will be notified to advise on appropriate treatment promptly;
-The licensed nurse will notify the responsible party of the presence of a pressure ulcer;
-Dietary contact will be made for nutritional assessment;
-Rehabilitation services will be contacted for appropriate devices or pressure redistributing devices;
-A licensed nurse will develop a care plan for the resident based on recommendations of dietary, rehabilitation and the attending physician;
-Per physician order, the nursing staff will initiate treatment and utilize interventions for pressure redistribution and wound management;
-The attending physician and interdisciplinary team (IDT) will be notified of:
-New pressure ulcers or wounds;
-Pressure ulcers or wounds that do not respond to treatment;
-Pressure ulcers or wounds that worsen or increase in size;
-Complaints of increased pain, discomfort or decrease in mobility by a resident;
-Signs of ulcer sepsis, presence of exudates (drainage), odor or necrosis (black, firm tissue), if not already noted by the physician;
-Residents refusing treatment;
-Certified Nurse Aides (CNAs) will complete body checks on resident's shower days and report unusual findings to the licensed nurse;
-Documentation:
-New pressure ulcers or wounds will be documented on the 24 hour log and an incident report will be completed by the licensed nurse;
-Wound documentation will occur at a minimum of weekly until the wound is healed, documentation will include:
-Location of wound;
-Length, width, and depth measurements recorded in centimeters (cm);
-Direction and length of tunneling (a channel or tunnel that forms beneath the surface of a wound, extending into deeper tissue) or undermining (a separation of the wound edges from the underlying tissues, creating a space or pocket beneath the wound surface;
-Appearance of the wound base;
-Drainage amount and characteristics including color, consistency and odor;
-Appearance of wound edges;
-Description of the peri-wound condition or evaluation of the skin adjacent to the wound;
-Presence or absence of new epithelium at the wound rim;
-Presence of pain;
-IDT will document the discussions and recommendations for:
-Pressure ulcers and wounds that do not respond to treatment;
-Pressure ulcers and wounds that worsen or increase in size;
-Complaints of increased pain, discomfort or decrease in mobility by a resident;
-Signs of ulcer sepsis, presence on exudate, odor or necrosis;
-Residents refusing treatment;
-Licensed nurses will document effectiveness of current treatment in the resident's medical record on a weekly basis;
-Document notifications following a change in the resident's skin condition;
-Update the resident's care plan as necessary.
Review of Resident #27's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/21/25, showed the following:
-Diagnoses of diabetes and peripheral vascular disease (PVD, poor circulation in the extremities), low blood pressure;
-No cognitive impairment;
-Required moderate assistance of staff for personal hygiene;
-Required maximum assistance of staff for toileting, showering and dressing;
-No venous or arterial ulcers;
-No foot ulcers.
Review of the resident's care plan, updated 2/14/25, showed the following:
-Focus: Resident has PVD;
-Monitor, document, and report as needed any signs or symptoms of skin problems related to PVD: redness, edema, blistering, itching, burning, bruises, cuts, or other skin lesions.
Review of the resident's shower sheet, dated 3/7/25, showed no documentation of any wounds to the right heel.
Review of the facility's 24 hour shift report sheet, dated 3/8/25, showed a wound to the right heel.
Review of the resident's progress notes, dated 3/8/25 through 3/19/25, showed no documentation regarding a wound to the right heel.
Review of the resident's physician's order sheet (POS), dated March 2025, showed no treatment order for the resident's right heel.
Review of the resident's treatment administration record (TAR), dated March 2025, showed no treatment order for the resident's right heel.
Review of the resident's shower sheets, dated 3/10 and 3/13/25, showed no documentation regarding a wound to the right heel. The facility had no shower sheets for the week of 3/17 through 3/20/25.
Observation on 3/20/25 at 10:55 A.M., showed the resident lay in bed. The Director of Nurses (DON), Assistant Director of Nurses (ADON) and the facility's Wound Care Company's Nurse Practitioner (NP) assessed the resident's skin and noted a wound on the back of the resident's right foot just above the heel. The Wound Care NP said the wound was a diabetic ulcer secondary to pressure that measured 0.6 centimeters (cm) by 0.6 cm by 0.3 cm depth, 90% granulation (new tissue) and 10% slough (soft dead tissue).
During an interview on 3/20/25 at 12:02 P.M., CNA W said he/she was unaware of the wound on the resident's right heel. He/She hadn't taken care of the resident before and had assisted another aide giving him/her a shower. He/she could not remember the name of the aide who she assisted.
During an interview on 3/20/25, at 1:26 PM., ADON W said he/she was unaware of the wound on the back of the resident's heel. No one reported it to him/her nor did he/she see it on the 24 hour sheet. Staff are to document any changes in the progress note which can be generated on a summary sheet daily. He/She expected staff to document any changes found in the progress note and obtain treatment orders.
During an interview on 3/20/25 at 11:10 A.M., the DON said when staff find a wound, she expected the nurse to call the physician, get a treatment order, notify the DON and the wound company.
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 interview and record review, the facility failed to follow their policy for Elopement and Wandering for one resident (R...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy for Elopement and Wandering for one resident (Resident #1) when the resident eloped (left the premises without authorization and/or any necessary supervision to do so) from the facility. The facility considered the resident leaving Against Medical Advice (AMA), although the resident had a legal guardian and was unable to make medical decisions on their own. Facility staff did not have a consistent understanding of the difference between a resident having a leave of absence, elopement, and against medical advice, to ensure policies and procedures were followed accordingly. The resident sample was 13. The census was 144.
Review of the facility's Discharge Against Medical Advice policy, last revised 10/24/22, showed:
-A resident may discharge themselves from the facility against the advice of his/her physician;
-The facility and/or physician will discuss with the resident and/or the resident's representative, if applicable, the reason for AMA decision and will advise them of the potential consequences of the AMA decision;
-No medications are dispensed to a resident leaving AMA;
-Nursing staff will document in the progress notes all pertinent information concerning the resident's actions, including the resident's stated reason for his/her desire to leave the facility;
-The AMA policy did not address residents who were deemed incompetent and/or had a legal guardian and were unable to make the decision to leave AMA.
Review of the facility's Wandering and Elopement policy, last revised on 10/24/22, showed:
-If facility staff observes a resident leaving the premises without having followed proper procedures, he/she may: Try to prevent the departure, get help from other facility staff in the immediate vicinity, direct another facility staff member to inform the charge nurse or Director of Nursing (DON) that a resident is trying to leave the premises;
-Return of a Resident
- When an individual who departed without following proper procedures returns to the Facility, the Director of Nursing Services or Licensed Nurse should:
--Examine the resident for nay possible injuries;
--notify the attending physician;
--notify the resident's responsible party.
-The licensed nurse will initiate or update the resident's care plan and implement immediate intervention(s) to prevent further wandering/elopement by the resident.
-The IDT, with input from the licensed nurse, will conduct a thorough review of the elopement, document its findings in the IDT notes, and update the Care Plan to prevent a recurrence.
-The Quality Assessment & Assurance Committee will review all instances of elopement.
-The policy did not indicate that a resident who has been deemed incompetent and who leaves the facility without following proper protocol as leaving AMA and did not instruct staff to discharge the resident instead of following the Wandering and Elopement policy;
-The policy did not define elopement.
Review of Appendix PP State Operations Manual, showed:
-Definition for resident-initiated transfer or discharge: Means the resident or, if appropriate, the resident representative has provided verbal or written notice of intent to leave the facility. Leaving the facility does not include the general expression of a desire to return or the elopement of residents with cognitive impairment;
-Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so.
Review of Resident #1's Circuit Court Petition to Appoint Successor- Guardian, showed:
-On or about May 28, 2013, the court found Resident #1 to be incapacitated and appointed Guardian A, as guardian;
-Due to health and other reasons, Guardian A wishes to resign as guardian and asks the court to appoint Guardian B as successor guardian.
Review of the resident's face sheet, showed:
-admitted on [DATE];
-Diagnoses included type II diabetes, psychotic disorder with delusions due to known physiological condition, cocaine dependence, paranoid schizophrenia (mental disorders characterized in disruptions in thought process, emotions, and social interactions), post-traumatic stress disorder (PTSD, mental health condition that is caused by an extremely stressful or terrifying event), borderline personality disorder (condition characterized by intense and unstable emotions, impulsive behaviors, and difficulty maintaining healthy relationships), moderate intellectual disabilities, and anxiety disorder;
-Has a guardian;
-discharged on 10/10/24.
Review of the resident's care plan, revised 9/19/24, showed:
-Focus: Resident is not allowed to go Leave of Absence (LOA) from facility with anyone per guardian request;
-Goal: Guardians wishes will be honored and protective oversight will be ensured;
-Interventions: Guardian will re-evaluate LOA privileges once the resident is acclimated to facility;
-Inform and notify staff that resident is not allowed to go LOA. Information given to resident, receptionist, and nursing staff;
-No documentation of the resident's history of wandering or elopement risk.
Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/23/24, showed:
-Cognitively intact;
-Diagnoses included high blood pressure, acid reflux, diabetes, hyperlipidemia (high level of lipids in the blood), malnutrition, anxiety, psychotic disorder, schizophrenia, PTSD;
-Independent with mobility;
-No behaviors;
-Has resident wandered: Behavior not exhibited.
Review of the resident's progress notes, showed:
-On 10/10/24 at 3:19 P.M., documented by Licensed Practical Nurse (LPN) D, showed resident went to activities and left the facility. Assistant Director of Nursing (ADON) was made aware;
-On 10/10/24 at 5:06 P.M., documented by Assistant Director of Nursing (ADON) showed resident left against medical advice after being educated on the risk of leaving Against Medical Advice (AMA). Contacted Guardian B in which he/she was in agreement with decision made. Contacted Physician K and Physician L in regard to AMA status and stated ok.
Review of the resident's Against Medical Advice Discharge form, dated 10/10/24, showed:
-Resident refused to sign with education provided;
-Verbal consent from Guardian B;
-Signed by ADON on 10/10/24.
Review of the facility's investigation, showed:
-Date of Incident: 10/10/24;
-Type of Incident: AMA discharge;
-Initial investigation: Resident had a diagnoses of, but not limited to, Borderline Personality disorder, high risk heterosexual behavior, herpes viral infection, paranoid schizophrenia, diabetes, history of cocaine dependence, generalized anxiety disorder, mild cognitive impairment (a condition in which people have more memory or thinking problems than other people their age), moderate intellectual disabilities, and PTSD. Resident has a BIMS of 15 (cognitively intact). At admission, resident deemed a low risk for elopement;
-Resident attended an activity off the unit. He/She went to use the bathroom and attempted to leave the facility. She was asked to sign out, but refused. He/She was also asked to sign out AMA if he/she was leaving. Resident refused to sign out AMA after attempted education and left facility with his/her boyfriend in a black sedan at 2:34 P.M. ADON notified guardian of AMA and stated he/she was not surprised by his/her behaviors;
-Findings: Resident refused to follow Against Medical Advice policy. Resident refused to sign AMA form after given education on the risks of leaving AMA;
-Conclusion: Resident refused to sign AMA. If resident shows interest in returning to the facility, he/she will need to follow our admission process as a new referral. Receptionist is aware that resident is not allowed to return until admission process has been completed. Guardian is supportive regarding AMA and re-admission process and lack of being re-admitted as resident's behavior are mirroring the same as 10 years ago;
-AMA: Resident ran out of facility AMA appropriately 2:34 P.M.;
-Staff attempted to have resident sign AMA paperwork although resident did refuse and had things to do;
-Review of the facility's investigation showed no statement from staff who attempted to stop resident from leaving;
-No written statement from the receptionist;
-No written statement from the ADON.
During an interview on 2/7/25 at 10:15 A.M., Receptionist M said he/she worked as receptionist at the time of the incident. From his/her understanding, something was going on in activities. The resident plotted to leave. The resident went into the bathroom and came out, but wore a jacket with hood and had a purse on his/her shoulder. The resident was dressed and looked like a visitor. He/she booked it down the hall and walked by Receptionist M. Since he/she never seen him/her before, so Receptionist M thought it was a visitor. The resident stood at the front door with his/her back facing the receptionist desk. The resident stood there for several seconds. The resident looked like a visitor that was waiting at the door. The front entrance door system is not that good because if someone stuck their finger in between the small opening between the two doors, the doors open. That was how the door opened. Receptionist M saw the resident walk across the street, entering a parked car. The car drove away quickly. There were a lot of staff in the classroom at the time that saw the resident walk across the street. They came out and said the resident eloped, and receptionist said, who. He/She never saw the resident before that. At the time of the incident, it was an elopement and not AMA. There was no one that stopped the resident, spoke to the resident about AMA prior to the resident exiting the building, and the resident did not sign a form before leaving. The resident tried to return to the building, but they denied him/her.
Review of a form titled Against Medical Advice Discharge Form, dated 10/10/24, showed two places for the resident's signature. Under the first section, Resident #1 refused to sign the form acknowledging the risks involved and danger to health and safety if they left the facility, and releasing the facility and administration from responsibility. Under the 2nd section under a statement, Authorization must be signed by the resident, by the nearest relative in the case of a minor, or by the Durable Power of Attorney when the resident is physically or mentally incompetent., showed the resident's signature and a statement verbal consent via (name).
During an interview on 2/5/25 at 12:56 P.M., the ADON said he/she remembered the resident. The resident was alert and oriented x 4 and had been in nursing homes for a long time. He/She was young and outgoing. He/She had mental issues and substance abuse, which was why he/she was on the secured unit. The resident was not an elopement risk. He/She was completely functioning and could tell you anything. There was nothing said that would alarm him/her as an elopement risk. The resident liked activities. The ADON worked on 10/10/24, but did not witness the resident attempting to leave or trying to leave. The ADON did not know who tried to stop. The ADON was asked who reported that the resident was leaving and he/she said, staff, but could not remember who. The resident wanted to leave AMA. He/she had a boyfriend on the outside. The resident wanted to leave AMA, his/her guardian was called. The ADON contacted the guardian, educated the resident on the importance of not leaving AMA. The guardian was also educated on leaving AMA in general without speaking to the physician. The resident wanted to leave with his/her boyfriend. The ADON contacted the guardian because the resident was not his/her own responsible party and ADON wanted to make sure it was okay. The ADON presented the AMA form to the resident and he/she signed it without any concerns or issues. A couple of days later, he/she came back for her belongings with his/her family. ADON contacted the physician and guardian and informed staff. They were not told the resident could not return. That was their decision when they returned to the facility. If a resident leaves the building, without staff knowledge, did not sign out, that is considered an elopement. The ADON was asked if the resident exited the facility before the guardian was contacted. The ADON could not remember if the resident was still in the facility when the guardian was contacted, but remembered that the resident was in the process of leaving. The resident was physically in the building when the guardian was called. After the resident signed the AMA form, he/she gave it to the Administrator. The ADON confirmed there were no issues when the resident signed the AMA form. The resident did not refuse to sign.
During an interview on 2/4/25 at 10:45 A.M., Guardian B said the resident was supposed to be in a secured area. The resident went downstairs for something. Guardian B does not know how the resident walked out the door or if he/she got a ride with someone, but Family Member C found the resident. The resident and Family Member C returned to the facility and staff told them that the resident could not come back. The resident was taken to a local hospital and the resident has been there ever since. Someone from the facility did call him/her and Family Member C. There was no discussion about AMA. The resident was gone for two days. When Family Member C brought the resident back, whomever met them at the door told them they could not come back. Staff packed up the resident's belongs. The resident came from a facility that closed and he/she did elope from the prior facility.
During an interview on 2/4/25 at 11:00 A.M., Family Member C said the facility called him/her the day he/she left and asked if he/she had the resident. He/She told the facility, no. There was no further discussion at that time. Another staff called later and said the resident was not at the facility, that he/she ran out the door and hopped in a car. The next day, the resident called him/her and asked him/her to come and pick the resident up. He/She asked the resident what happened, and the resident said he/she called a guy and told him to get him/her, then he/she ran out of the building, hopped in the car, and said go, go, go! He/She had escaped this place. Family Member C took the resident back to the facility and staff said they would not take the resident back. Family Member C asked staff where they should take the resident, and staff said that is the guardian's responsibility. Family Member C took the resident to the hospital psychiatric ward and that is where he/she still is. There was no discussion about AMA and they did not ask him/her to sign anything. They handed him/her belongings and a bag of medication.
During an interview on 2/4/25 at 11:35 A.M. and 2/5/25 at 11:43 A.M., LPN D, the resident's nurse at the time of the elopement, said he/she does remember the resident. The resident and one other resident were admitted from a nursing home in Arkansas. He/She was the staff person who drove to pick them up. During the ride back, the other resident informed him/her to watch because Resident #1 runs off. He/She was aware the resident was at risk for elopement. The resident said he/she was going to an activity. Activity staff took the resident downstairs. About 15 to 30 min later, activity staff said the resident was gone. Staff informed him/her the resident ran out the front door and got into a car. The front desk staff saw it. The resident did not tell anyone and he/she was supposed to be watched at all times. Staff was told the resident would run when he/she was admitted . He/She notified the Assistant Director of Nursing (ADON) and DON E, who was the DON at the time. The DON notified the family that the resident had left. The resident left his/her belongings upstairs. LPN D first said this incident was an elopement, then said if a resident on a locked unit leaves without telling staff it is AMA and not elopement, so now he/she thinks it was AMA because the resident was diabetic and had medical issues. Elopement means they just take off. The resident did not sign out and did not say anything about leaving. Activity staff were supposed to watch the resident.
During an interview on 2/4/25 at 1:47 P.M., CMT I said he/she was working the day the resident left. Resident #1 left the floor with activity staff. The next day he/she was made aware the resident was gone. He/She heard the resident went to the bathroom, came out, and left. Staff never heard him/her say anything about leaving. He/She was not aware if the resident was an elopement risk. It was just reported that he/she left and was seen getting into a car. If a resident leaves without telling anyone and runs out of the building into a car, it is an elopement.
During an interview on 2/4/25 at 1:30 P.M., Activity Director H said Resident #1 was seen running out the door. Staff reported he/she came out of the bathroom and ran up the hall. The aide said the resident got out and got in the car. He/She saw the resident when family brought him/her back. He/She looked rough like he/she was under the influence. He/She asked the resident why he/she did that and resident said he/she did not know why. Activity staff are responsible for protective oversight. Residents cannot go outside without staff. To his/her knowledge the resident was not an elopement risk. It was not an elopement because the resident was in activities at the time, he/she did not escape from the unit. If a resident leaves it is AMA, only if they are their own responsible party. It would be an elopement if the resident had a guardian. Resident with a guardian cannot leave AMA.
During an interview on 2/5/25 on 9:30 A.M., Nurse Practitioner (NP) J, the NP for Physician K, said the resident came from another facility. He/She had a drug problem and has schizophrenia. He/She was alert and oriented, able to tell staff where he/she was, but he/she was not sure if the resident had a guardian. The facility told him/her the resident left AMA and was educated, but the resident still decided to leave. If the resident had a guardian and left the facility, that would be an elopement. He/She would expect the facility staff to understand the difference between elopement and AMA. If a resident leaves, does not sign out, and does not have a discussion about leaving, it is an elopement. It would not be appropriate for a resident to leave without staff knowledge or guardian knowledge and determined it was AMA, it would be an elopement.
During an interview on 2/4/25 at 2:09 P.M., with the administrator, Regional Nurse, and Director of Clinical Reimbursement Services, they said they define elopement as an unauthorized, unwitnessed leave. If staff does not have eyes on them, guardian does not know, and they leave. The Regional Nurse said in this instance, she believes it was AMA because the resident was told to sign out. The Director said when the resident left, he/she was in activities. He/She wanted to leave and staff tried to stop him/her. They talked to him/her about signing out and he/she did not want to sign out. They then pulled up AMA paperwork. They contacted the responsible party and they said they knew he/she would do this.
During an interview on 2/5/25 at 1:20 P.M., Receptionist G said if a resident runs out of the building, does not notify staff, and gets into a car, it's an elopement. They ran off and did not tell anyone. They have an elopement binder at the front desk.
During an interview on 2/6/25 at 10:06 A.M., Certified Nursing Assistant (CNA) V said an elopement is when a resident leaves the facility without staff knowledge.
During an interview on 2/6/25 at 10:23 A.M., CNA U said he/she did not know the difference between an elopement and AMA. The two run together.
During an interview on 2/6/25 at 10:23 A.M., CNA T said the code for an elopement is gray. At 10:41 A.M., he/she wanted to change their answer. It used to be yellow, but now it is pink. An elopement is when a resident leaves without anyone knowing, right out of the door.
Observation on 2/6/25 at 10:23 A.M., showed an elopement in-service posted on the door outside the entrance to the unit. The code was pink.
During an interview on 2/6/25 at 10:31 A.M., CNA S said he/she did not know the difference between elopement and AMA. He/She had trouble with the two.
During an interview on 2/6/25 at 10:36 A.M., CNA R said an elopement is when a resident left the building without staff knowing. They would do a head count, lock down the floor, and notify the supervisor. The code is pink.
During an interview on 2/6/25 at 10:39 A.M., Certified Medication Technician (CMT) Q said an elopement is when a resident escapes. They would call a code pink.
During an interview on 2/6/25 at 10:24 A.M., LPN D said he/she had trouble differentiating between elopement and AMA. The color code used to be gray. At 11:43 A.M., LPN admitted it was difficult distinguishing between elopement and AMA because of how it was presented to him/her when Resident #1 eloped.
During an interview on 2/6/25 at 12:27 P.M., the Administrator said she would expect staff to understand the difference between elopement and leaving AMA. Staff are expected to discuss AMA with the resident, notify the guardian/family, physician, and present the resident with an AMA form. She would expect staff to follow discharge policy and for all residents to be properly discharged from the facility. If the resident returned to the facility, she would expect staff to document it in the record.
MO00248299
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
Respiratory Care
(Tag F0695)
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 respiratory services provided were consiste...
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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 respiratory services provided were consistent with professional standards of practice for one resident (Resident #3) when staff failed to ensure the oxygen was in working order when it was administered to the resident who had shortness of breath. The facility called Emergency Medical Services (EMS), who found the resident hypoxic (low level of oxygen) and the oxygen was not turned on. In addition, the facility failed to ensure staff followed physician's orders for the rate of oxygen and failed to properly change and date oxygen tubing (Resident #2). The facility identified three residents with orders for oxygen. The sample size was 13. The census 144.
Review of the facility's oxygen administration policy, revised 10/24/22, showed:
-Initiation of Oxygen: A physician's order is required to initiate oxygen therapy, except in an emergency situation. The order shall include:
-Oxygen flow rate;
-Method of administration (e.g. nasal cannula);
-Usage of therapy (continuous or as needed (PRN));
-Titration instructions (if indicated);
-Indication for use;
-In an emergency situation or when a physician's order cannot be immediately obtained, oxygen may be initiated by a Licensed Nurse in the presence of acute chest pain or any other acute situation in which hypoxia is suspected;
-A physician is to be contacted as soon as possible after initiation of oxygen therapy in emergency situations, for verification and documentation of the order for oxygen therapy consultation, and further orders;
-Oxygen saturations will be measured and documented at a minimum of daily for residents receiving oxygen therapy;
-Procedure: Explain the procedure to the resident;
-Check the physician's order;
-Wash hands;
-Assist resident to semi- or high Fowler's position (sitting posture in bed) , if tolerated;
-Attach oxygen tubing to nozzle on flowmeter;
-If using a high oxygen flow (> 4 liters), attach humidifier to the flowmeter;
-Attach oxygen tubing to humidifier;
-Turn on the oxygen at the prescribed rate;
-Check that oxygen is flowing through tubing;
-For nasal cannula: Hold nasal cannula in proper position with prongs curving downward;
-Place cannula prongs into nares (nostrils);
-Wrap tubing over and behind ears;
-Adjust plastic slide under chin until cannula fits snugly;
-Oxygen saturation levels as indicated;
-Patient's response to oxygen therapy;
-Turn off oxygen when not in use.
1. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 1/12/25, showed:
-Cognitively intact;
-Diagnoses included high blood pressure, diabetes, dementia, anxiety, depression, malnutrition, asthma, schizophrenia (serious mental illness) psychotic disorder;
-Impairment on one side of the lower extremity;
-Independent with mobility and transfers.
Review of the resident's care plan, in use during survey, showed:
-Focus: Resident has chronic obstructive pulmonary disease (COPD, lung diseases)/asthma;
-Goal: Resident will be free of signs and symptoms of respiratory infections;
-Interventions: Give aerosol or bronchodilators (medications that relax the muscle lining in the airways) as ordered. Monitor/document any side effects and effectiveness;
-Monitor for difficulty breathing on exertion. Remind resident not to push beyond endurance;
-Monitor/document/report as needed any signs and symptoms of respiratory infection.
Review of the resident's progress notes, showed:
-On 1/30/25 at 7:53 P.M., patient returned to the facility accompanied by his/her daughter. The daughter stated that patient had a colonoscopy scheduled today that was canceled related to fever and low oxygen. Patient was assessed, to exhibit shortness of breath (SOB), oxygen (O2) saturation (sats) fluctuating between 80-83% (normal 95% to 100%) via nasal cannula and temperature 100.9 Fahrenheit (F) (normal 97 F to 99 F). Patient was placed on 2 liters (L) of oxygen and PRN Tylenol was administered. Call was placed to Physician K, orders were given to increase O2 to 4 L and to send patient to emergency room if no improvement;
-At 8:23 P.M., crackles present by auscultation (listening to internal sounds of the body, usually with a stethoscope) in the right side of lung. Patient will be sent to hospital for further evaluation. Responsible Party (RP) notified message was left to call the facility concerning patient;
-At 8:50 P.M., patient was assessed before being sent to emergency room. No issues noted.
Review of the resident's hospital discharge record, showed:
-admission date: 1/30/25;
-discharge date : [DATE];
-Principal problems: Hypoxia (low level of oxygen);
-Active problems: Influenza A present;
- History is obtained from chart review and review of EMS report as patient is not a reliable historian. Patient resides at a nursing home due to his/her dementia. He/She underwent a routine colonoscopy yesterday which was uncomplicated. After returning to his/her nursing facility, the patient reportedly complained of shortness of breath; nursing home staff checked her oxygen saturation of peripheral capillaries (SpO2, measurement of the percentage of oxygen in the blood) which was 79% (resting oxygen saturation level between 95% and 100%). They placed him/her on supplemental 02 without improvement in his/her Sp02, so they called EMS. On EMS arrival, patient was wearing a nasal cannula, but the oxygen had not actually been turned on. After turning on the 02 and bringing the patient up to a seated position, his/her SpO2 improved to 100%. He/She was brought to the emergency department for further evaluation.
During an interview on 2/4/25 at approximately 1:30 P.M., the Administrator said she was unaware of any issues regarding oxygen administration.
During an interview on 2/6/25 at 11:00 A.M., the Administrator said she would expect staff to ensure the oxygen was turned on and connected accurately to the oxygen port.
2. Review of Resident #2's annual MDS, dated [DATE], showed:
-Mild cognitive impairment;
-Diagnoses included heart failure, high blood pressure, diabetes, anxiety, depression, asthma, respiratory failure, manic depression, schizophrenia;
-No rejection of care;
-Receives oxygen therapy.
Review of the resident's care plan, in use during survey, showed:
-Focus: The resident has oxygen therapy;
-Goal: The resident will have no signs or symptoms of poor oxygen absorption;
-Interventions: Encourage or assist with ambulation as indicated;
-For residents who should be ambulatory, provide extension tubing or portable oxygen apparatus;
-Give medications as ordered by physician. Monitor/document side effects and effectiveness;
-If the resident is allowed to eat, oxygen still must be given to the resident but in a different manner. Return resident to usual oxygen delivery method after the meal;
-Monitor for signs/symptoms of respiratory distress and report to Physician as needed;
-Oxygen per physician's orders;
-Promote lung expansion and improve air exchange by positioning with proper body alignment. If tolerated, elevate head of bed.
Review of the resident's electronic Physician's Orders Sheet (ePOS), showed:
-An order, dated 8/8/24, change oxygen tubing weekly and as needed on Tuesday, 10:00 P.M.-6:00 A.M. shift when in use. Date and initial tubing as needed related to chronic obstructive pulmonary disease;
-An order, dated 9/5/23, oxygen at 2 L per nasal cannula as needed for shortness of breath.
Observation on 2/5/25 at 8:40 A.M., showed the resident in bed with his/her eyes closed. The oxygen tubing was on the floor without a label. The nasal cannula was on the floor. The oxygen was turned on and set at 7 L.
Observation on 2/5/25 at 1:47 P.M., showed the resident in bed with his/her eyes closed. The oxygen was turned on and set at 8 L per nasal cannula. A sticker, dated 2/4 was on the oxygen tubing. The resident's roommate said they just placed the sticker on it.
During an interview on 2/6/25 at 11:43 A.M., Licensed Practical Nurse (LPN) D said the resident uses the oxygen when he/she is asleep. He/She has sleep apnea. He/She is okay during the day. The oxygen is set at 2 L per nasal cannula.
During an interview on 2/6/25 at 12:27 P.M., the Administrator said she would expect staff to follow physician's orders. She would expect staff to ensure the oxygen is set per physician's orders and if it needed to be increased, staff are expected to assess the resident, notify the Assistant Director of Nursing (ADON) and physician.
MO00248925
Nov 2024
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
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure all residents were treated in a manner to maintain dignity and respect for one sampled resident (Resident #5) after sta...
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Based on observation, interview and record review, the facility failed to ensure all residents were treated in a manner to maintain dignity and respect for one sampled resident (Resident #5) after staff failed to close the door and pull the privacy curtain before providing incontinence care. The sample size was eight. The census was 145.
Review of the resident bill of rights, showed:
-Right to privacy: Residents have the right to privacy in their treatment and care, and to have their personal affairs kept confidential;
-Right to dignity: Residents have the right to be treated with dignity and respect at all times.
Review of Resident #5's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/9/24, showed:
-Cognitively intact;
-Diagnoses included deep venous thrombosis (blood clots), neurogenic bladder (urinary problems due to disease or injury to the central nervous system), septicemia (blood poisoning), seizure disorder, and anxiety;
-Required substantial/maximum assistance with showers/bathe self and personal hygiene.
Review of the resident's care plan, in use during survey, showed:
-Focus: Resident has an Activity of Daily Living (ADL) care performance deficit;
-Goals: Resident will maintain current level of function in ADLs;
-Interventions: Provide sponge bath when a full bath or shower cannot be tolerated;
-Resident is totally dependent on one staff to provide bath/shower;
-Resident is bedfast all or most of the time;
-Resident is totally dependent on one staff for dressing;
-Resident requires extensive assistance for personal hygiene/oral care;
-Resident is not toileted.
Observation on 11/4/24 at 1:45 P.M., showed the resident in his/her bed, receiving a bed bath from staff. The resident was in a room with three other roommates. Only one roommate was present at the time. The roommate was across the room from Resident #5. The resident's bed was located on the further side of the entrance. The resident's roommate to the right of him/her was not in bed and the privacy curtain between the two beds was not pulled and the door was not closed. The resident was visible from the hall as staff provided the bed bath. The resident lay naked in bed as staff provided care. No privacy curtain was available to provide privacy in front of the resident's bed for privacy between him/her and roommate across the room. Staff carried incontinence supplies to the trash can in the hall and reentered the resident's room again without closing the door. Residents and staff walked by the room with the door open as the resident lay exposed to the hallway.
During an interview on 11/5/24 at 1:42 P.M., the resident said he/she wished staff would close the door during care. He/She was not bothered about the privacy curtain not pulled because his/her roommates are the same gender. They do not close the door when his/her roommate is getting dressed either. The resident pointed out that there was no privacy curtain between the roommate on the other side of the room; however, there was a privacy curtain between him/her and the roommate next to him/her.
Observation and interview on 11/5/24 at 1:50 P.M., showed the Assistant Director of Nursing (ADON) walked down the hall and was asked if it was appropriate for staff to leave the door open while a resident received incontinence care. The ADON saw the open door and said it was not appropriate. The staff inside the resident's room shut the door at that time. The ADON said she would expect the privacy curtain to be pulled and the door closed for privacy.
During an interview on 11/5/24 at 2:00 P.M., the Director of Nursing (DON) and Administrator said personal care should be provided in privacy by pulling the curtain and closing the door. It is not acceptable to provide personal care with the curtain and door open. The incident has already been addressed with the staff member and they have started educating all nursing staff on providing resident privacy during all cares.
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
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike envir...
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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 a safe, clean, and comfortable homelike environment for two of three dining rooms in use by residents and several common areas. The 300 main dining room had leaks, broken chairs, trash bags stored on the floor, and soiled curtains. The 200 main dining room had a leak. The 200 main day room with water leaks on the carpet. The 200 hall had cracks in the floor. In addition, the 100 hall had a Personal Protective Equipment (PPE) container in use that was soiled. The facility census was 145.
1. Observation of 300 Main dining room, showed:
-On 11/4/24 at 10:53 A.M., large brown stains covered the lower half of the curtains that hung up in the windows. There was a wet spot located on the floor and a yellow substance underneath the curtains;
-On 11/4/24 at 11:30 A.M., six chairs with torn or detached seats. One resident sat on the edge of a chair that had a large tear visible in the center of the seat. During an attempted interview at this time, the resident was unable to explain why he/she sat on edge of the seat. He/She then scooted over some but attempted to avoid the large tear in the middle of the seat. At 12:32 P.M., staff served the resident his/her meal;
-At 12:32 P.M., a trash bag sat directly on the floor with Styrofoam cups, napkins, and other trash inside the bag. Residents placed their trash in the bag, on the floor. No trash can visible in the dining room for resident or staff use;
-On 11/5/24 at 10:14 A.M., the dining area was empty and contained approximately 22 chairs total. 11 of the chairs had torn seats and/or the seat was loose and nearly detached from the chair.
2. Observation of the 200 Main dining room on 11/4/24 at 10:43 A.M., showed water leaked onto the floor against the back wall and underneath the windows. A wet floor sign was on the floor. Several soaked sheets and towels that absorbed the water lay on the floor. The leak started at the right side of the back wall and extended to the other side of the back wall, approximately 22 feet.
During an interview on 11/4/24 at 10:43 A.M., two residents sat at a table with water under their feet and said this is not the first time there has been water on the floor. The staff will sometimes throw towels or covers down to soak up the water, but most times they do nothing. They do not even put up wet floor signs. Both residents said they were afraid they were going to fall on the wet floor.
During an interview on 11/4/24 at 10:50 A.M., Certified Nurse Aide (CNA) A said the floor was wet this morning and he/she put towels down and made sure none of the residents were sitting nearby.
3. Observation of the 200 Main day room on 11/4/24, showed:
-At 10:56 A.M., six residents sat in the day room. Four of the residents sat in chairs and two sat in wheelchairs. The carpeting in front of the windows was wet. All residents sat in the wet area. One resident did not have on shoes, only socks. His/her socks sat on the wet carpeting and appeared wet.
-At 11:00 A.M., wet carpet on the back, right corner of the room. The wet spot measured approximately 3 feet by 5 feet. Water leaked onto the floor against the back wall, underneath the windows. The carpet was wet from one side of the wall to the other side, approximately 12 feet. Track marks from the wheels of residents' wheelchairs were visible after residents propelled on the wet carpet.
During an interview on 11/4/24 at 11:10 A.M., Resident #3 said the floor in the day room was wet and his/her socks were wet from walking in the day room. He/she was walking around and standing by the door because his/her socks were wet and he/she did not want to slip on the floor in the hall.
Observation and interview on 11/4/24 at 11:12 A.M., showed CNA A in the hall charting and overheard the conversation with Resident #3. CNA A came over and asked if the resident's feet where wet. He/She assisted Resident #3 down the hall to put dry socks on him/her. As they walked down the hall, Resident #3 left wet footprints on the hard floor.
4. Observation on 11/4/24 at 11:04 A.M., showed large cracks in the hardwood floor outside of rooms [ROOM NUMBERS]. The cracks measured approximately 20 feet, from rooms [ROOM NUMBERS] to the day room.
5. Observation of 100 Main hall on 11/4/24 at 10:37 A.M. and 11/5/24 at 10:41 A.M., showed a three tier Personal Protective Equipment (PPE) container covered with dirt, dust and debris outside of rooms [ROOM NUMBERS].
6. During an interview on 11/5/24 at 12:10 P.M., the Interim Regional Director of Maintenance said his first day was 11/4/24. He was not aware of the leaks in the dining rooms and day room until yesterday, so he did not know how long it was leaking. The building has bad seals on the windows and the roof. The caulk joints have fallen apart where the brick ledge starts. He can fit his thumb inside, so he was sure the leak had something to do with that. They have made calls to start repairs. When he came in, staff said they had water problems. He planned to do a thorough walk through. The chairs in the dining room will be replaced and curtains will be cleaned. The staff use TELs to report maintenance request, but nothing was reported regarding equipment. At 1:23 P.M., the Regional Director of Maintenance said they found eight chairs that were not being utilized and replaced them with the eight worst chairs on the floor. They only had eight chairs available.
7. During an interview on 11/5/24 at 12:30 P.M., the prior Regional Director of Maintenance was contacted. He was not aware of the condition of the chairs in the 300 dining room, but said they can be replaced. The cracks in the floor were from a previous resident that resided on the hall. He/She took furniture and pushed it up and down the hallway so there are some decent sized gouges. They have bids to replace the flooring. The previous maintenance director that was here did not mention the issues. When there is an issue, they try to take care of it. They repaired the roof, so they did not know there was that much water. Staff did not report to maintenance that when it rained, there were leaks in the dining rooms and day room. The TELs system will tell staff what to do in case something needed to be repaired. They do not have a policy to address maintenance duties.
8. During an interview on 11/5/24 at 2:00 P.M., the Director of Nursing (DON) and Administrator said 11/4/24 was the first time they saw or were aware of water leaking onto the floors in the 200 and 300 hall dining rooms and day area. Staff had not notified them of the issue. Staff should have either verbally reported the issue or placed a work order through the TELS system. The roofing company will be at the facility on 11/6/24 to address the issue. The soiled curtains had been taken down and replaced. They should be cleaned per the cleaning schedule, not sure what the schedule is, and as needed. They were not acceptable and should have been cleaned. Staff did not notify them of the broken chairs. Audits were done after the annual survey and they did replace some chairs, these were missed. Audits of chair conditions has been added to the maintenance task list for two times per year. They were able to replace some of the chairs. They were not aware of the cracks in the 200 hall flooring. An audit will be done and it will be repaired.
MO00244101
MO00244299
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 F0924
(Tag F0924)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the handrails on each resident hall were proper...
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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 handrails on each resident hall were properly maintained. This deficient practice had the potential to affect all residents on these halls. The facility census was 145.
1. Observation of 100 South unit on 11/4/24 at 10:25 P.M., showed:
-Loose handrail outside of room [ROOM NUMBER]. The handrail was detached from the wall on one side;
-Missing handrail between rooms [ROOM NUMBERS];
-Loose handrail outside of room [ROOM NUMBER] and 104. The handrail was missing screws;
-Loose handrail outside room [ROOM NUMBER];
-Loose handrail outside of room [ROOM NUMBER];
-Loose handrail outside of the soiled utility room and nurse's station;
-Loose handrail outside of the shower room;
-Loose handrails on both left and right side outside the TV room.
2. Observation of 100 Main unit on 11/4/24 at 10:37 A.M., showed:
-Loose handrail outside of room [ROOM NUMBER]. Plaster on the wall also detached;
-Loose handrail outside of shower room in front of nurse's station.
3. Observation of 200 Main unit on 11/4/24 at 10:43 A.M., showed:
-Missing end cap on the handrail outside of the stairwell and room [ROOM NUMBER];
-Missing end cap on the handrail in the hallway outside of the dining room.
4. Observation of 300 Main unit on 11/4/24 at 11:14 A.M., showed:
-Missing handrail between rooms [ROOM NUMBERS];
-Missing handrail between rooms [ROOM NUMBERS];
-Missing handrail outside of room [ROOM NUMBER];
-Loose handrail outside of room [ROOM NUMBER];
5. Observation of 300 South unit on 11/4/24 at 11:24 A.M., showed:
-Missing handrail outside of room [ROOM NUMBER];
-Missing handrail outside of the bathtub room and across from room [ROOM NUMBER];
-Missing end cap on the handrail covered in foil, outside of the shower room;
-Loose handrail outside of room [ROOM NUMBER];
-Missing end cap on the handrail covered in foil, outside of room [ROOM NUMBER];
-Missing handrail outside of the dining room.
6. During an interview on 11/5/24 at 12:10 P.M., the Interim Regional Director of Maintenance said his first day was on 11/4/24. He was not aware of the loose/missing handrails but planned to do a thorough walk through. He has not assessed the equipment. They use the TELs system, but handrails were not reported. Handrails are a big priority.
7. During an interview on 11/5/24 at 12:30 P.M., the Interim Regional Director contacted the previous maintenance director for additional information. The previous Regional maintenance director said there were a few handrails that were missing and the facility was in the process of replacing them. There are a large amount of handrails in the garage to replace the damaged and missing handrails. They come in custom sizes, but they have to put in a work order in the TELs system. The TELs system will notify staff what to do in case something needs to be fixed and they have monthly tasks as well. They do not have a policy.
8. During an interview on 11/5/24 at 2:00 P.M., the Director of Nursing (DON) and Administrator said they were aware of missing handrails and are in the process of replacing them. They were not aware of the damaged handrails. A facility wide audit was done and hey are looking in the garage for surplus handrails and will replace them.
MO00244101
MO00244299
Jul 2024
32 deficiencies
3 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
Quality of Care
(Tag F0684)
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 obtain and follow physician orders for wound care for ...
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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 and follow physician orders for wound care for two sampled residents (Residents #89 and #72). Both residents required hospitalization for assessment and treatment of wound conditions, including amputations. The census was 151.
The Administrator was notified on 7/12/24 at 10:49 A.M., of an immediate jeopardy (IJ) that began on 7/1/24. The IJ was removed on 7/12/24 as confirmed by surveyor on-site verification.
Review of the wound management policy, revised 10/24/22, showed:
-Purpose: To provide a system for the treatment and management of residents with wounds including non-pressure ulcers;
-Definitions:
-Arterial Ulcer- an ulceration that occurs as the result of arterial occlusive disease when no pressure related disruption or blockage of the arterial blood flow to an area causes tissue necrosis (death). Arterial/ischemic (lack of blood flow) ulcers may be present in persons with moderate to severe peripheral vascular disease (PVD, poor blood flow in the lower extremities), generalized arteriosclerosis (stiffening and thickening of the blood vessels) or vascular disease elsewhere. The arterial ulcer is characteristically painful, usually occurs in the distal (farther area) portion or the lower extremity, and may be over the ankle or bony area of the foot;
-Procedure:
-Assessment:
-A licensed nurse will perform a skin assessment upon admission, re-admission, weekly and as needed (PRN) for each resident;
-Upon identification of a new wound the licensed nurse will:
-Measure the wound (length, width, depth);
-Initiate a wound monitoring record sheet;
-A wound monitoring record will be completed for each wound;
-If the wound monitoring record is not used, documentation will be recorded within the medical record which may include nursing notes, treatment records or care plans;
-Implement a wound treatment per physician's order;
-An assessment of care needs for wound management will be made with emphasis on, but not limited to:
-Identifying risk factors;
-Treatment;
-Mechanical off-loading and pressure reducing devices;
-Reducing skin friction, sheer and moisture;
-Nutritional status;
-Evaluating and modifying interventions for a resident with an existing skin injury;
-Wound management:
-The physician will be notified to advise on appropriate treatment promptly;
-The nurse will notify the responsible party of the presence of a skin injury;
-Dietary contact will be made for nutritional assessment;
-Rehabilitation services will be contacted for appropriate devices or pressure redistributing devices;
-A nurse will develop a care plan for the resident based on recommendations from dietary, rehabilitation and the physician;
-Per physician order, the nursing staff will initiate treatment and utilize interventions for pressure redistribution and wound management;
-Per attending physician order, the nursing staff will initiate treatment and utilize interventions for wound management;
-The attending physician and interdisciplinary team (IDT) will be notified of:
-New wounds;
-Wounds that do not respond to treatment;
-Wounds that increase in size;
-Complaints of increased pain, discomfort or decrease in mobility;
-Signs of ulcer sepsis (infection), odor, necrosis, if not already noted by the attending physician;
-Certified Nurse Aides (CNA) will complete body checks on resident shower days and report unusual findings to the nurse;
-Documentation:
-New wounds will be documented on the 24 hour log and incident report will be completed by the nurse;
-Wound documentation will occur a minimum of weekly until the wound is healed. Documentation will include:
-Wound location;
-Length, width and depth measurements in centimeters (cm);
-Direction and length of tunneling (wound extends deeper into the tissue) and undermining (separation of the wound edges from the surrounding healthy tissue) if applicable;
-Appearance of the wound base;
-Drainage amount and characteristics including color, consistency and odor;
-Appearance of wound edges;
-Description of the peri-wound (skin surrounding the wound) condition or evaluation of the skin adjacent to the wound;
-Presence or absence of new skin growth at wound rim;
-Presence of pain;
-IDT will document discussion and recommendation for:
-Wounds that do not respond to treatment;
-Wounds that worsen or increase in size;
-Complaints or increased pain, discomfort or decrease in mobility by a resident;
-Signs of ulcer sepsis, presence on drainage, odor or necrosis;
-Residents refusing treatment;
-Nurses will document effectiveness of current treatment in the medical record on a weekly basis;
-Document notifications follow a change in skin condition;
-Update the care plan as necessary.
1. Review of Resident #89's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/1/24, showed:
-No cognitive impairment;
-No behaviors;
-Diagnoses included heart failure, high blood pressure, diabetes, malnutrition, anxiety, bipolar (episodes of emotional highs and lows), and asthma;
-Has surgical wounds;
-Receives oxygen;
-Uses wheelchair;
-No Range of Motion (ROM) to the upper and lower right and left extremity;
-Occasionally incontinent of bowel and bladder;
-Weight: 445 pounds;
-Skin and ulcer treatments:
-Pressure reducing device for chair;
-Pressure reducing device for bed;
-Nutrition or hydration intervention to manage skin problems;
-Surgical wound care;
-Application of nonsurgical dressings (with or without topical medications) other than to feet;
-Applications of ointments/medications other than to feet.
Review of the care plan, in use during survey, showed:
-Focus: Resident is resistive to care related to wound healing and ADLs; he/she has been observed removing his/her dressings to his/her foot and abdomen/chest;
-Goal: Will cooperate with care;
-Interventions: Education provided on cleanliness of his/her dressings and skin/hygiene;
-Reported; he/she will pick at his/her wounds to his/her abdomen and chest placing removed skin and tissue into his/her mouth. States that he/she is cleaning off his/her fingers to prevent smearing blood onto his/her clothing;
-Staff to educate and remind him/her importance of leaving his/her dressings in place until time for changes;
-Focus: He/She is on antibiotic therapy related to infection. Doxycycline (treat and prevent infections) Hyclate Oral Tablet 100 milligrams (mg). Give 100 mg by mouth two times a day for infection until 5/12/24;
-Goal: He/She will be free of any discomfort or adverse side effects of antibiotic therapy;
-Interventions: Administer antibiotic medications as ordered by physician. Monitor/document side effects and effectiveness every shift;
-Monitor/document/report as needed adverse reactions to antibiotic therapy: diarrhea, nausea, vomiting, anorexia (loss of appetite), and hypersensitivity/allergic reactions (rashes, welts, hives, swelling face/throat);
-Monitor/document/report as needed signs/symptoms of secondary infection related to antibiotic therapy: oral thrush (white coating in mouth, tongue), persistent diarrhea, and vaginitis/itchy perineum/whitish discharge/coating of the vulva/anus;
-Focus: He/She has potential/actual impairment to skin integrity;
-Abdomen midline: Trauma;
-Sternum: Trauma;
-Right groin abscess,1/20/24, full thickness;
-Anterior nose, full thickness: Resolved 5-15-24;
-Right shin, cellulitis (skin infection): Resolved 5-29-24;
-Left thigh;
-Goal: Affected areas will show adequate progress towards healing;
-Interventions:11/20/23: Chest wound bleeding due to the resident scratching at site. Education provided by nurse and wound nurse in importance of not scratching at site;
-6/19/2024: Multivitamin plus minerals daily;
-6/19/2024: Pro stat (protein supplement) 30 milliliters (ml) by mouth, twice a day for skin integrity;
-Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short;
-Educate resident/family/caregivers of causative factors and measures to prevent skin injury;
-Encourage good nutrition and hydration in order to promote healthier skin;
-He/She needs pressure relieving mattress to protect the skin while in bed;
-He/She needs pressure relieving cushion to protect the skin while up in chair;
-Keep skin clean and dry. Use lotion on dry skin;
-Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs/symptoms of infection, maceration (softening of the skin due to moisture) to physician;
-Treatment per physician's orders.
-Weekly treatment documentation;
-Wound care to evaluate and treat as indicated;
-Focus: Resident has diabetic ulcer of the right lateral foot, left heel related to diabetes, lack of sensation to affected area, and poor glycemic control;
-Goal: Affected areas will show adequate progress towards healing through;
-Interventions: 10/26/23: Arterial Doppler with ankle brachial index (ABI, compares the blood pressure in the upper and lower limbs) for bilateral symptoms: Pain, edema, skin breakdown, with chronic non-healing wound with drainage to right foot. Diagnosis of ulcer of limb/non-healing wound;
-Avoid mechanical trauma: Constrictive shoes, cutting and trimming corns and calluses, adhesive tapes, improper shaving, and vigorous massage;
-Monitor blood sugar levels;
-Monitor/document wound: Size, depth, and margins: peri wound skin, sinuses, undermining, exudates, edema, granulation, infection, necrosis, eschar, and gangrene. Document progress in wound healing on an ongoing basis. Notify physician as indicated;
-Monitor/document/report as needed any signs/symptoms of infection: [NAME] drainage, foul odor, redness and swelling, red lines coming from the wound, excessive pain, and fever;
-Monitor/document/report as needed changes in wound color, temperature, sensation, pain, or presence of drainage and odor;
-Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations;
-Wound care to evaluate and treat as indicated;
-Focus: He/She has bladder incontinence, activity intolerance, impaired mobility, poor toileting habits;
-Goal: Resident will be continent during waking hours and he/she will remain free from skin breakdown due to incontinence and brief use;
-Interventions: Brief use: Resident uses disposable briefs. Change as needed;
-Clean perineal area (peri-area, area between the genitals and the anus) with each incontinence episode;
-Encourage fluids during the day.
Review of the resident's electronic physician order sheet (ePOS), showed:
-An order, dated 5/6/24: wound care to right foot, cleanse with normal saline (NS) or Vashe (wound cleanser), pat dry, apply Santyl (used to remove dead tissue), nickel thick, edge to edge of wound bed, cover with calcium alginate (dressings are used on moderate to heavily exudative wounds during the transition from debridement to repair phase of wound healing) cut to fit cover with bordered gauze every day shift and as needed for soiling and unscheduled removal;
-An order, dated 5/6/24: wound treatment to groin. Cleanse with Vashe, pat dry, apply Santyl nickel thick, edge to edge to wound bed, cover with calcium alginate cut to fit, cover with abdominal (ABD) pad every day shift and as needed for soiling and unscheduled removal;
-An order, dated 6/19/24: Pro stat, 30 ml by mouth, twice a day for skin integrity;
-An order, dated 6/27/24: for size E Tubi grips (elasticated, multi-purpose bandage used for compression) to bilateral feet for dressing security;
-An order, dated 6/30/24: Wound care to left heel: Cleanse back of left heel with Vashe, pat dry, apply Santyl to wound bed only, apply calcium alginate to wound bed, only then cover with border gauze dressing every day shift for wound care management and as needed for wound care management for soiling and unscheduled removal;
-An order, dated 7/3/24: Doxycycline Hyclate Oral Tablet 100 mg. Give one tablet by mouth two times a day related to cellulitis of unspecified part of limb for seven days;
-An order, dated 7/3/24: for Levofloxacin (Levaquin, antibiotic) 750 mg. Give one tablet by mouth every evening shift for wound for seven days;
-An order, dated 7/3/24: arterial Doppler (ultrasound to check blood flow in large arteries and veins) to right lower extremity for wound;
-An order, dated 7/3/24: Wound care: Sternum (long, flat bone of the chest). Cleanse with wound cleanser or NS, pat dry, apply silicon bordered gauze every three days, every day shift for wound care. Chart nurse's notes if patient removes dressings and picks at open areas and as needed for soiling or unscheduled removal;
-An order, dated 7/4/24: Wound care: Abdomen midline. Cleanse with Vashe, pat dry, apply xeroform (sterile, fine mesh gauze) to wound bed only, then apply silicone bordered gauze, every day shift, every three days for wound treatment. Chart in nurse's notes if patient removes dressings and picks at wounds and as needed for soiling and unscheduled removal;
-An order, dated 7/6/24: Mupirocin external ointment (used to treat secondarily infected traumatic skin lesions) 2 percent (%). Apply to right hand/third digit topically two times a day for paronychia (infection of the tissue adjacent to a nail) until 7/12/24. Soak right hand third digit in soapy water, dry, and apply ointment;
-An order, dated 7/6/24: Right third finger: Paronychia. Soak right hand and fingers in warm soapy water for 15 minutes, dry, apply mupirocin ointment two times a day for infection of right hand third digit Paronychia until 07/12/2024, twice daily and PRN;
-No treatment orders for the Abdomen right lower quadrant.
Review of the resident's June 2024 Treatment Administration Record (TAR), showed:
-An order, dated 6/1/24: Treatment: Left Heel: Cleanse back of left heel with NS, pat dry, apply calcium alginate and cover with border gauze dressing every day shift for wound care management. Entries on 6/1, 6/4, 6/11, 6/14, 6/15, 6/17, 6/22, 6/27, and 6/28/24 were blank. It was discontinued on 6/29/24;
-An order, dated 6/1/24: Wound: Left thigh. Cleanse with NS, pat dry, apply calcium alginate, and cover with border gauze dressing every day shift. Entries on 6/1, 6/4, 6/11, 6/14, 6/15, 6/17, 6/22, 6/27, 6/28, and 6/28/24 were blank. The order was discontinued on 6/29/24;
-An order, dated 5/7/24: Wound: Right foot. Cleanse with NS or Vashe, pat dry, apply Santyl nickel thick edge to edge of wound bed, cover with calcium alginate cut to fit cover with bordered gauze every day shift. Entries on 6/1, 6/4, 6/11, 6/14, 6/15, 6/17, 6/22, 6/27, and 6/28/24 were blank;
-An order, dated 6/1/24: Wound: Abdomen midline. Cleanse with wound cleanser or NS, pat dry, apply bordered gauze every day shift for wound treatment. Entries on 6/1, 6/4, 6/11, 6/14, 6/15, 6/17, 6/22, 6/27, and 6/28/24 were blank;
-An order, dated 5/7/24: Wound treatment: Groin. Cleanse with Vashe, pat dry, apply Santyl nickel thick edge to edge to wound bed, cover with calcium alginate cut to fit, cover with ABD pad every day shift. Entries on 6/1, 6/4, 6/11, 6/14, 6/15, 6/17, 6/22, 6/27, and 6/28/24 were blank;
-An order, dated 6/1/24: Sternum. Cleanse with wound cleanser or NS pat dry apply bordered gauze every day shift. Entries on 6/1, 6/4, 6/11, 6/14, 6/15, 6/17, 6/22, 6/27, and 6/28/24 were blank.
Review of the progress notes, showed:
-On 6/3/24 at 11:03 A.M., Nurse Practitioner (NP) notified of wound care not done on 5/31/24 and 6/1/24. No new orders received at this time;
-On 6/10/24 at 12:12 P.M., NP notified of the refusal of all medications and care on 6/8/24 and 6/9/24. No new orders received at this time;
-On 6/11/24 at 12:22 P.M., NP notified of missing wound care and Santyl and rivaroxaban (blood thinner) on 6/10/24. No new orders received at this time;
-On 6/12/24 at 11:30 A.M., NP notified of missing wound care on 6/11/24. NP also notified of resident being hospitalized with medications for missing medications after day shift 6/11/24;
-On 6/15/24 at 12:45 P.M., NP notified of missing wound care and insulin injections on 6/14/24. No new orders received;
-On 6/16/24 at 4:29 P.M., NP notified of missed medication (lactulose, treats constipation and liver disease) and wound care on 6/15/24. No new orders received at this time;
-On 6/18/24 at 12:15 P.M., NP notified of missed wound care on 6/17/24. Care ongoing, no new orders received;
-On 6/24/24 at 12:12 P.M., NP notified of missing wound care on 06/22/24. Care ongoing, no new orders received;
-On 6/29/24 at 10:32 A.M., NP notified of missing wound care on 6/27/24 and 6/28/24. Care ongoing, no new orders received.
Review of the wound report, dated 6/26/24, showed:
-Abdomen- midline: Trauma;
-Measurement: 11.4 cm x 4.7 cm x 0.3 cm;
-Acquired;
-Sternum: Trauma;
-Measurement: 2.8 cm x 4 cm x 0.2 cm;
-Acquired;
-Right groin: Full thickness (damage extends below the epidermis and dermis (all layers of the skin) into the subcutaneous tissue (fat) or beyond (into muscle, bone, or tendons);
-Measurement: 1.2 cm x 1.2 cm x 0.2 cm;
-Acquired;
-Right lateral foot: Diabetic [NAME] (system for classifying diabetic ulcers) grade 2 (Deep ulcer without abscess or osteomyelitis);
-Measurement: 3.9 cm x 5.9 cm x 0.3 cm;
-No documentation of acquired or admitted with;
-Left heel: Diabetic [NAME] grade 2;
-Measurement: 3.2 cm x 4.1 cm x 0.5 cm;
-No documentation of acquired or admitted with;
-Left thigh: Resolved.
Review of the resident's July 2024 TAR, showed:
-An order, dated 5/6/24: wound care to right foot cleanse with NS or Vashe, pat dry, apply Santyl, nickel thick, edge to edge of wound bed, cover with calcium alginate cut to fit cover with bordered gauze every day shift. Treatment marked as other/see progress notes on 7/1 and 7/2/24; blank entries on 7/4 and 7/5/24;
-An order, dated 5/6/24: wound treatment to groin. Cleanse with Vashe, pat dry, apply Santyl nickel thick, edge to edge to wound bed, cover with calcium alginate cut to fit, cover with ABD pad every day shift. Treatment marked as other/see progress notes on 7/1 and 7/2/24; blank entries on 7/4 and 7/5/24;
-An order, dated 6/30/24: Wound care to left heel: Cleanse back of left heel with Vashe, pat dry, apply Santyl to wound bed only, apply calcium alginate to wound bed, only then cover with border gauze dressing every day shift for wound care management and as needed. Treatment marked as other/see progress notes on 7/1 and 7/2/24; blank entries on 7/4 and 7/5/24;
-An order, dated 7/3/24: Wound care: Sternum. Cleanse with wound cleanser or NS, pat dry, apply silicon bordered gauze every three days, every day shift for wound care. Chart nurse's notes if patient removes dressings and picks at open areas and as needed for soiling or unscheduled removal; blank entry on 7/4/24.
-An order, dated 6/1/24: Wound care: Sternum. Cleanse with wound cleanser or NS, pat dry, apply bordered gauze every day shift. Treatment marked as other/see progress notes on 7/1 and 7/2/24. Treatment administered on 7/3/24 and discontinued on 7/3/24;
-An order, dated 7/4/24: Wound care: Abdomen midline. Cleanse with Vashe, pat dry, apply xeroform to wound bed only, then apply silicone bordered gauze, every day shift, every three days for wound treatment. Chart in nurse's notes if patient removes dressings and picks at wounds and as needed; blank entries on 7/4/24 for scheduled treatment;
-An order, dated 6/30/24: Wound care: Abdomen midline. Cleanse with Vashe, pat dry, apply silicone bordered gauze every day shift. Treatment marked as other/see progress notes on 7/1 and 7/2/24. Treatment was administered on 7/3/24 and discontinued on 7/3/24.
Review of the progress notes, showed:
-On 7/1/24 from 12:12 to 12:14 P.M., the resident refused wound treatments to the following areas:
-Abdomen midline:
-Left heel:
-Groin.
-Right foot
-Sternum.
-On 7/2/24 from 2:38 P.M. to 2:39 P.M., health care provider (HCP) notified by this nurse, he/she was not able to carry out treatment orders; physically impossible related to nurse to patient ratio for the following treatment areas:
-Abdomen midline:
-Left heel:
-Groin.
-Right foot
-Sternum.
Review of the wound report, dated 7/3/24, showed:
-Abdomen- midline: Trauma;
-Measurement: 19.7 cm x 9.9 cm x 0.2 cm;
-Acquired;
-Sternum: Trauma;
-Measurement: 1.5 cm x 2.0 cm x 0.2 cm;
-Acquired;
-Right groin: Full thickness;
-Measurement: 1.3 cm x 1.6 cm x 0.2 cm;
-Acquired;
-Right lateral foot: Diabetic [NAME] grade 2;
-Measurement: 3.8 cm x 5.2 cm x 0.3 cm;
-Acquired;
-Left heel: Diabetic [NAME] grade 2;
-Measurement: 3.5 cm x 2.0 cm x 0.2 cm;
-Acquired;
-Abdomen, Right lower quadrant: Trauma;
-Measurement: 3.9 cm x 3.3 cm x 0.2 cm;
-Acquired.
Review of a wound care note, dated 7/3/24, showed: Wound care NP rounded with Licensed Practical nurse (LPN) S to discuss with staff importance of treatment changes, and skin care. Wound culture pending. Spoke with the physician regarding wound. Physician recommends levofloxacin 750 mg once daily for seven days. Nurse to ensure that treatment are being changed daily. Arterial Doppler with ABI. MolecuLight (wound imaging device that allows clinicians to visualize bacteria and measure wounds) positive of bacteria. Debridement (removal of damaged tissue) completed. Treatment plan updated.
Observation and interview on 7/8/24 at 9:39 A.M., showed the resident in bed, calling out for help. He/She sat up in bed, attempting to get up, but was unsuccessful. He/She did not have clothing on. He/She appeared obese with a pannus stomach (extra skin and fat deposits hang from the stomach or belly area on the abdomen) with several wounds that were actively bleeding onto to the floor. One wound appeared to be large, dark, and necrotic on the lower part of the stomach. The resident said he/she was unable to get up and was not able to hit his/her call light because it was stuck. Observation of the call light showed the cord was wrapped up and underneath the leg of a night table. The DON entered the room to assist the resident. The resident said it was an hour since nursing last checked on him/her. There was a room odor of urine, and resident's bed and sheets were wet. The DON closed the resident's door. The resident told the DON that he/she had not received any treatments in four days. At 9:48 A.M., the resident sat in his/her wheelchair across from his/he bed. He/She said staff were able to assist him/her to his/her wheelchair. He/She was bleeding on the abdomen because he/she had wounds on his/her stomach and did not get treatments in the last four days. The resident lifted up his/her gown and showed several wounds, size ranging from pen size to approximately two inches in length, that were red, inflamed and bleeding. He/She was told staff would be in to do his/her treatment. Flies were observed in the room. There was an odor of urine and feces in the room. Dried blood noted on the floor next to the resident's bed. At 11:58 A.M., the resident sat in the hall across from the nurse's station. The resident had a bedside table in front of him/her and ate his/her meal. Staff said the resident wanted to go to the
CRITICAL
(J)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Tube Feeding
(Tag F0693)
Someone could have died · This affected 1 resident
Based on observation, interview and record review, the facility to failed to provide appropriate administration of enteral (passing through the intestine) nutrition for a resident who was dependent up...
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Based on observation, interview and record review, the facility to failed to provide appropriate administration of enteral (passing through the intestine) nutrition for a resident who was dependent upon a gastrotomy tube (g-tube, a tube inserted through the belly that brings nutrition directly to the stomach) (Resident #22). Resident #22's physician's orders showed 40 milliliters (ml)/hour (hr) via g-tube continuously and water flushes 175 ml every four hours. On 7/9/24, the tube feeding machine was not set in the English language and infused at a rate of 140 ml/hour. Staff failed to ensure the g-tube machine settings were accurately set at 40 ml/hour during medication and treatment administrations and failed to report its language settings to management. The resident received approximately 400 cubic centimeters (cc) of feeding between 7:56 A.M. to 10:46 A.M., causing the resident to experience severe vomiting and he/she was transported to the hospital. The facility also failed to ensure g-tube site treatments were completed as ordered for one resident (Resident #45). The facility also failed to ensure staff completed a self-administration medication assessment and physician's orders to self administer medications via g-tube. The facility identified three residents dependent on a gastrotomy tubes. The census was 151.
The administrator was notified on 7/10/24 at 2:56 P.M. of an Immediate Jeopardy (IJ) which began on 7/9/24. The IJ was removed on 7/10/24 as confirmed by surveyor onsite verification.
Review of the facility's Feeding Tube-Site Care policy, dated 10/24/22, showed:
-Purpose: To inspect and prevent skin breakdown and complications for resident's with feeding tubes;
-Policy: Site care will be provided twice daily until healed in the post-operative period following the feeding tube insertion;
-The site of a well-established enteral feeding tube will be inspected daily for signs and symptoms of irritation, gastric leakage, or infection;
-Procedure: Explain the procedure to the resident;
-Wash hands.
-Don (put on) gloves;
-Remove old gauze if present;
-Inspect the site for irritation, drainage or leakage;
-Using a washcloth, gently clean around the site with warm water and mild soap;
-Rinse the area with water and dry well;
-Place a gauze drainage sponge around the site if needed for irritation, drainage, or leakage;
-A smear of blood or a bit of clear yellow drainage is normal following post-operative insertion. Notify the Attending Physician if drainage has increased, is cloudy, yellow or green, has a foul odor, or if the skin surrounding the site is irritated.
Review of the facility's Physician's Orders policy, dated 10/24/22, showed:
-Policy: The Medical Records Department will verify that physician orders are complete, accurate and clarified as necessary;
-Medication orders will include the following:
-Name of the medication;
-Dosage;
-Frequency;
-Duration of order;
-The route and the condition/diagnosis for which the medication is ordered, if applicable;
-Treatment orders will include the following: A description of the treatment, including the treatment site, if applicable;
-The frequency of treatment and duration of order (when appropriate);
-The condition/diagnosis for which the treatment is ordered;
-Other orders will include a description complete enough to ensure clarity of the physician's plan of care;
-Medication/treatment orders will be transcribed onto the appropriate resident administration record. Orders pertaining to other health care disciplines will be transcribed onto the appropriate communication system for that discipline;
-Supplies/medications required to carry out the physician order will be ordered;
-Documentation pertaining to physician orders will be maintained in the resident's medical record. Current month's administration records will be maintained in the Medication Administration Record (MAR)/Treatment Administration Record (TAR) binders.
Review of the facility's Medication-Self Administration policy, 10/24/22, showed:
-Policy: Residents who request to perform medication self administration will be assessed for capability. The assessment of medication self administration will ensure a clinically appropriate, effective process for the resident to provide self care. The Facility is responsible to ensure medications are administered as ordered by the Attending Physician even when self administered;
-Procedure: During the admission process, residents will be asked if they wish to self administer medications;
-Those residents who wish to self administer medications will be assessed during the admission process to ensure they have the necessary knowledge and skill(s) to safely self administer medications;
-Additional assessments will be completed at least quarterly based on OBRA timeframes;
-A referral for physical therapy/occupational therapy may be necessary to assess the resident for the necessary eye hand coordination and cognitive skills for medication self administration;
-Based on clinical judgment, a Licensed Nurse may reassess a resident related to the safe self administration of medications as needed;
-The resident must be able to demonstrate the following
-Knowledge of medications and medication schedule;
-The ability to read the medication label and manufacturer's insert;
-Self-administration techniques including use of packaging, reading label, opening containers;
-Ability to administer medication properly, e.g., insulin/syringe, eye drops, inhalers;
-Residents requesting to self-administer hand held nebulizers will be required to demonstrate their ability to safely and effectively use the hand?held nebulizers without the assistance of a Licensed Nurse;
-Agree to comply with Facility policy related to the self-administration of medication.
-The Licensed Nurse will inspect the contents of the medication containers for evidence that the resident may not unable to self-administer medications (i.e., non-drug items stored in pill container, different medications mixed together, medications which have expired or appear to be deteriorating)
-If the resident is assessed as clinically appropriate for medication self-administration, by the Interdisciplinary team (IDT), the Licensed Nurse obtains a physician's order for self-administration of selected medications;
-The resident's record should contain documentation that demonstrates that he/she was part of the IDT process in determining whether self-administration is safe and appropriate;
-Medications specifically excluded from self-administration for any reason must be specified in the Attending Physician's order;
-Self-administration is only permitted if approved in writing by the Attending Physician, which may be in the form of an order;
-The IDT develops and implements a care plan for medication self-administration;
-This care plan is reviewed at least quarterly with each reassessment based on OBRA timeframes;
-The care plan will identify:
-Where the medications are stored;
-Education for resident/family regarding medication self-administration process, specific medication information and safe, effective use of medications;
-Obtaining medication;
-Administering medication according to physician order;
-How Licensed Nurses will validate that medications are taken as ordered by the attending physician;
-How non-compliance and/or refusal to take medications will be managed;
-If the IDT and Attending Physician do not approve self-administration of medications, the resident or their representative will be informed, and the reason will be documented in the medical record;
-If the IDT team and Attending Physician approve self-administration of medications, the medications will be placed in a secured drawer or cabinet that is easily accessible to the resident;
-Controlled drugs (i.e., narcotics, hypnotics, etc.) are not to be left for open access to the resident;
-The Administrator/Director of Nursing Services or designee ensures the resident has access to a secure container for proper medication storage if the medications are not stored on the medication cart;
-The Licensed Nurse on each shift ensures that medications are taken as ordered by the Attending Physician and documents on the MAR;
Refusals and/or non-compliance with self-administration of medications as ordered by the Attending Physician is documented on the MAR and in the nurses' notes;
-All self-administered medications will have pharmacy labels with complete directions for use of the medication;
-No labels may read as directed;
-Non-prescription (over the counter, OTC) medications may be allowed if the medical label is intact;
-A resident may withdraw from being able self-administer medications at any time;
-Residents will be re-evaluated if any member of the IDT suspects non-compliance with the self-administration authorization or any change in the resident's cognitive status;
-The Attending Physician is notified of habitual and/or frequent non-compliance or refusal of medication self-administration;
-In the case of suspected medication non-compliance (e.g. dosage in excess of the amount anticipated, loss of therapeutic control or suspected drug toxicity) the nursing staff will complete an assessment. The Attending Physician will be notified if the resident is no longer deemed appropriate for self-medication administration. The Licensed Nurse will obtain orders as necessary;
-Documentation: The physician's order approving the self-administration of medication will be maintained in the resident's medical record;
-The Assessment for self-Administration of Medications will be maintained in the resident's chart;
-Self-administration of medications will be documented in the resident's Care Plan and the MAR.
1. Review of Resident #22's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/17/24, showed:
-Severe cognitive impairment;
-Diagnoses included anemia, aphasia (language disorder), cerebral palsy (congenital disorder of movement, muscle tone, or posture), dementia, quadriplegia (paralysis of all four limbs), seizure disorder;
-Impairment on both sides of the upper and lower extremities;
-Weight of 97 pounds;
-Feeding tube;
-51% or more total calories received through parenteral (nutrition given through the vein) or tube feeding;
-Average fluid intake per day by tube feeding: 500 cubic centimeters (cc) or more.
Review of the resident's care plan, in use during the survey, showed:
-Focus: Resident has history of diagnosis aspiration pneumonia (occurs when food or liquid is breathed into the airways or lungs) at risk for respiratory complications. Shortness of breath returned on 4/26/17, with tube feeding continues, has history of drooling 8/7/20 diagnosis of postnasal drip, diagnosis of dysphagia (difficulty swallowing) 7/21/22. Weight lost noted. History of g-tube becoming dislodged. History of nausea and vomiting. History of weight variances;
-Goal: Resident will have clear lungs, no signs and symptoms of aspiration;
-Interventions: Assess level of care every shift and as needed (PRN);
-Change tube feeding formula to 2 CAL HN (calorie and protein dense nutrition to support patients with volume intolerance and/or fluid restriction) related to emesis (vomiting) and increase residual (the volume of fluid remaining in the stomach at a point in time during enteral nutrition feeding);
-Check for aspiration, hold tube feeding if residual greater than 60 cc and inform physician;
-Cleanse g-tube site daily and cover with dry dressing;
-Dietician to evaluate as needed;
-Flush g-tube as ordered;
-Head of board (HOB) elevated at 45 degrees at all times;
-Medication as ordered for nausea/vomiting;
-Monitor for shortness of breath, choking, labored respirations, lung congestion;
-Monitor input every shift;
-Monitor tolerance to tube feedings;
-Nothing by mouth (NPO);
-Scopolamine (a medication used to manage and treat postoperative nausea and vomiting and motion sickness) patch every 72 hours;
-Sent to hospital for g-tube replacement.
Review of the resident's Physician's Orders Sheet (POS), dated July 2024 showed:
-An order, dated 4/27/17, cleanse g-tube site with normal saline (NS)/DWD (dermal wound cleanser); cover with dry dressing every night shift for g-tube;
-An order, dated 5/1/17, check residual, if greater than 60 cc hold feeding and call physician every shift for enteral feeding;
-An order, dated 11/8/17, for Scopolamine patch 72 hour. Apply one application transdermal every 72 hours for drooling;
-An order, dated 12/7/19, for Vitamin D liquid. Give 2000 unit via g-tube one time a day for vitamin D deficiency;
-An order, dated 4/1/20, for Glycolax Powder (Polythylene Glycol 3350, used to treat constipation). Give 17 gram via PEG-tube one time a day for constipation. Mix with 6 ounces of water until completely dissolved;
-An order, dated 6/11/20, for Senna Syrup (used to relieve constipation). Give 8.6 mg via g-tube two times a day for constipation;
-An order, dated 3/12/21, Multivitamin Liquid (multiple vitamins-minerals). Give 5 ml via PEG-tube one time a day for vitamin deficiency;
-An order, dated 2/25/22, for Keppra (used to treat seizures) Solution 100 milligram (mg). Give 10 ml via g-tube three times a day for seizures;
-An order, dated 7/6/22, enteral feed every shift. Hold tube feeding one hour after each medication pass every shift;
-An order, dated 12/29/22, enteral feed, three times a day, 30 ml water before and after medication;
-An order, dated 1/1/23, g-tube charting to include inspection of site, how the g-tube flushes, any redness/pain/drainage, toleration of feeding and medications every shift for g-tube charting;
-An order, dated 7/2/23, for Valproic Acid (anticonvulsant to treat seizures) solution. Give 30 milliliters via g-tube three times a day for seizure;
-An order, dated 2/19/24, ensure HOB is elevated at 45 degree angle at all times. Hold tube feeding pump for any activities of daily living (ADLs) requiring flat bed. Run tube feeding pump after patient is re-positioned at 45 degrees after ADLs every shift for prevention of aspiration;
-An order, dated 4/1/24, for 2 CAL tube feeding at 40 ml/ hr continuously per pump every shift for g-tube feeding status;
-An order, dated 4/1/24, enteral feed every 4 hours. Free water flush 175 ml every four hours. Push slowly he/she has a history emesis. Monitor tolerance.
Observation on 7/8/24 at 10:19 A.M., showed the resident in his/her room. He/She lay in the bed, which was lowered to floor. The HOB was at 45 degrees and his/her eyes were closed. The resident was covered with a blanket. The tube feeding machine showed it was on hold and beeped continuously. The tube feeding stand showed 2.0 CAL container hung with handwritten documentation 7/8 at 3:00 A.M., and 40 cc on the bottle. A full flush bag was hung with handwritten documentation 7/8/24. The tubing was not connected, and lay across on the tube feeding stand. The end was not capped or covered. At 10:44 A.M., no beeping was heard from tube feeding machine upon entering room. The tubing was connected to the resident and the tube feeding machine showed it was set to infuse at 40 ml/ hr. The flush showed 175 ml every four hours. There was approximately 750 cc of fluid remaining in the 2.0 CAL bottle. There was dried tube feeding fluid on the floor around the tube feeding stand and on the metal stand. The resident had dried white substance around his/her facial hair. At 4:53 P.M., there was approximately 550 cc of fluid remaining in the 2.0 CAL bottle. The machine showed it was infusing at 40 ml/ hr and 175 cc of flush every four hours.
Observation and interview on 7/9/24 at 7:56 A.M., showed the resident in bed, positioned on his/her left side. There was approximately 900 cc remaining in the 2.0 CAL bottle that was hung. The tube feeding machine screen showed the settings were not in English language. There were no words written in English on the screen. The machine showed a rate of 140 ml/hr. There was no written documentation on the 2.0 CAL bottle or flush bag. The flush bag showed approximately 600 cc remaining. At 10:46 A.M., staff was in the room with the resident. Certified Nurse Aide (CNA) V said he/she provided the resident with peri care. The resident was in bed with eyes closed. The tube feeding machine screen showed no words in the English language and a rate of 140 ml/hr. There was approximately 500 cc of fluid left in the 2.0 CAL bottle. At 11:01 A.M., upon entering room, CNA V said the resident just vomited. There was a small amount of emesis on the resident's lower half of face and neck which was a light beige in color. The resident continued to cough until thick saliva excreted from his/her mouth onto his/her lower face, neck, and bed pillow. At 11:03 A.M., the surveyor asked Licensed Practical Nurse (LPN) S to assess the g-tube machine. LPN S was asked if the 140 ml/hr on the machine was correct. He/She said the tube feeding was not supposed to be at 140 ml/hr. He/She did not work on the floor often, but the last time the rate was 40 or 60 ml/hr. CNA V began to clean the resident's face. LPN S was asked to check the residual. LPN S attempted to change the settings on the g-tube machine, but was not successful. LPN S turned off the g-tube machine and exited the room to get supplies. There was tube feeding fluid on the floor next to the stand. The Assistant Director of Nursing (ADON) BB entered the room and assessed the g-tube machine. She did not know what language the g-tube machine was set on. She attempted the change the settings, and was successful with changing the language setting back to English. ADON BB later exited the room. LPN S returned to the room and disconnected the tube feeding from the resident to complete the residual check. The syringe showed approximately 10 ml of fluid. LPN S said night shift is responsible for hanging the g-tube and checking the settings on the machine. The machine stops when the bottle is empty on night shift. The resident has a history of aspiration. He/She also becomes dizzy and nauseous, that was why he/she had the sticker behind his/her ear. If he/she received 140 ml/hr of feeding, he/she would have projectile vomiting. The resident was observed with a round sticker behind his/her ear. LPN S began to press buttons on the tube feeding machine and cleared the machine. The settings were returned to English. LPN S exited the room to report to the Director of Nursing (DON). At 11:18 A.M., the resident began to cough and gag until he/she vomited. The light beige colored vomit poured out of the resident's mouth, covering his/her upper torso. At 11:20 A.M., LPN S entered the room and saw the emesis. He/She said the emesis was the same color as the tube feeding and the resident threw up half the bottle. LPN S said the emesis was definitely from the tube feeding. LPN S checked the resident's vitals. The resident's oxygen saturation was 93% on room air, heart rate showed 112, the blood pressure was 117/73 and his/her temperature was 97.5 degrees Fahrenheit (F). LPN S said they may have to send the resident to the hospital because the g-tube was infusing at 140 cc/hr and he/she had a history of aspiration. At 11:29 A.M., Restorative Aide W and CNA V entered the room. ADON BB entered the room with a suction machine. Restorative Aide W started to clean the resident and said (he/she) never vomited like this before. This is not normal. At 11:40 A.M., LPN S said he/she spoke to the Nurse Practitioner and reported the resident threw up half the bottle. The resident will be transported to the hospital. LPN B came into the room and assessed the resident's lung and bowel sounds. He/She said the lungs sounded clear. LPN B said he/she gave the resident's g-tube medication at 8:40 A.M.
Review of the resident's MAR, dated 7/8/24 and 7/9/24, showed:
-An order, dated 4/27/17, cleanse g-tube site with NS/DWD; cover with dry dressing every night shift for g-tube, showed completed on 7/8/24, during the night shift by LPN C;
-An order, dated 4/1/24, enteral feed every four hours free water flush 175 ml every four hours. Push slowly he/she has a history emesis and monitor tolerance was documented as administered on 7/9/24 at 1:00 A.M. and 5:00 A.M. by LPN C;
-An order, dated 7/2/23, for Valproic Acid solution. Give 30 milliliters via g-tube three times a day for seizure was documented as administered on 7/9/24 at 6:00 A.M. by LPN C;
-An order, dated 2/9/23, to change graduate and syringe daily one time a day was documented as completed on 7/9/24 at 6:00 A.M. by LPN C.
During an interview on 7/10/24 at 6:42 A.M., LPN C said he/she worked the night shift. The night shift staff hang the tube feeding if ordered as continuous. He/She did not notice it was in a weird language and the rate of the feeding is preset. LPN C said all you should be pressing is the run or stop. The resident did not have any vomiting during the shift. The feeding normally runs at 40 ml/hr. Sometimes the aides will stop the machine when they provide care and then restart the feeding after care. The feeding should run slowly since the resident is prone to vomiting.
Review of the resident's MAR, dated 7/9/24, showed:
-An order, dated 12/29/22, enteral feed, three times a day, 30 ml water before and after medication documented as administered on the day shift by LPN B;
-An order, dated 4/1/24, enteral feed every 4 hours free water flush 175 ml every four hours. Push slowly he/she has a history emesis. Monitor tolerance was documented as administered at 9:00 A.M. by LPN B;
-An order, dated 6/11/20, for Senna Syrup. Give 8.6 mg via g-tube two times a day for constipation was documented as administered at 9:00 A.M. by LPN B;
-An order, dated 12/7/19, for Vitamin D liquid. Give 2000 unit via g-tube one time a day for vitamin D deficiency was documented as administered at 9:00 A.M. by LPN B;
-An order, dated 4/1/20, for Glycolax Powder (Polythylene Glycol 3350). Give 17 gram via PEG-tube one time a day for constipation. Mix with 6 ounces of water until completely dissolved was documented as administered at 9:00 A.M. by LPN B;
-An order, dated 3/12/21, Multivitamin Liquid (multiple vitamins-minerals). Give 5 ml via PEG-tube one time a day for vitamin deficiency was documented as administered at 9:00 A.M. by LPN B;
-An order, dated 2/25/22, for Keppra Solution 100 milligram (mg). Give 10 ml via g-tube three times a day for seizures as documented as administered at 9:00 A.M. by LPN B.
Review of the resident's MAR, dated 7/9/24, showed:
-An order, dated 4/1/24, for 2 CAL tube feeding at 40 ml /hr continuously per pump every shift for g-tube feeding status documented as completed on the day shift by LPN A;
-An order, dated 5/1/17, check residual, if greater than 60 cc hold feeding and call physician every shift for enteral feeding documented as completed on the day shift by LPN A;
-An order, dated 2/19/24, ensure HOB is elevated at 45 degree angle at all times. Hold tube feeding pump for any ADLs requiring flat bed. Run tube feeding pump after patient is re-positioned at 45 degrees after ADLs every shift for prevention of aspiration documented as completed on the day shift by LPN A;
-An order, dated 7/6/22, enteral feed every shift. Hold tube feeding one hour after each medication pass every shift documented as completed on the day shift by LPN A;
-An order, dated 1/1/23, G-Tube charting to include inspection of site, how the g-tube flushes, any redness/pain/drainage, toleration of feeding and medications every shift for g-tube charting documented as completed on the day shift by LPN A.
During an interview on 7/9/24 at 1:36 P.M., LPN A said he/she worked the day shift and arrived at 7:30 A.M. after night shift left. When he/she arrived, report was received from LPN C. LPN A did not notice problems with the g-tube machine LPN C reported to LPN A that the resident had emesis during the night shift. LPN B started the tube feeding and they normally cut the g-tube machine off at that time LPN A said he/she worked on the South end at the time the feeding. LPN A was not aware of any issues with the machine. LPN A later clarified his/her statement and said he/she was in the room with LPN C when LPN C hung the 2.0 CAL bottle. LPN C hung the tube feeding bottle and made sure the water was there. LPN A said he/she did not look at the tube feeding machine. He/She only looked at the resident to check if he/she was breathing. LPN C also did not report anything to LPN B at that time. LPN C came out of the room and started giving report. LPN A said if he/she saw a g-tube did not have correct setting for infusion or if the settings were in a different language, he/she would shut down the machine. LPN A said he/she did not know how to change the settings, so he/she would shut it down and report to the ADON or DON. LPN A would go back to the medical record and check the physician's orders. The resident has a history of emesis and has it all the time. LPN A said he/she did not check the resident's residual. LPN B checked it. LPN A was not in the room with LPN B at the time and was not sure if there was any residual. LPN A said they had a skilled check list they had to complete.
During an interview on 7/9/24 at 2:07 P.M., LPN B said he/she saw the resident this morning. LPN B confirmed the screen on the tube feeding machine was set in a language that he/she did not understand. He/She shut the machine off at 10:00 A.M. because it was in another language. LPN B did not report it because there was an emergency with another resident who was calling for the nurse. He/She could not recall what the rate settings were on the tube feeding machine, but did not remember seeing it set to infuse at 140 ml/ hr. He/She administered the resident's medication right before 10:00 A.M. The resident had approximately 25 ml of residual. There was no gagging, vomiting, or coughing. LPN B did turn the machine off, but did not turn it back on. The next time he/she saw the resident, it was at 11:30 A.M. and the nurses were in the room at the time. He/She did not know who turned the machine back on. LPN B did not have orientation or in-service/education prior to 7/9/24.
Review of the resident's hospital record, dated 7/9/24, showed:
-Reason for visit: Nausea and vomiting;
-Diagnosis: Nausea and vomiting;
-Provider notes: Resident with past medical history significant for cerebral palsy, quadriplegia, seizures, and anemia. Sent to the emergency room for nausea and vomiting. Patient is non-verbal and contracted baseline. Per Emergency Medical Service (EMS), too much feeding today. Patient was also given an additional 100 ml and vomited. Patient appears to be stable at this time;
-X-ray (used to generate images of tissues and structures inside the body) of the chest and computed tomography (CT, a medical imaging technique used to obtain detailed internal images of the body) scan of abdomen and pelvis were unmarkable. Will discharge patient back to facility.
During an interview on 7/10/24 at 6:30 A.M., LPN GG said the resident receives continuous tube feeding. He/She has occasional emesis. Night shift nurses are responsible for g-tube care, such as changing out dressings, syringes, and inspecting the tube feeding sites. When a resident has orders for continuous tube feeding, 23 hours on and one hour off, the hour off is to account for time used for medication administration. He/She has not been in-serviced recently on tube feeding.
During an interview on 7/10/24 at 10:00 A.M., the DON said the licensed nurses are responsible for hanging the tube feeding container and ensuring the machine settings and infusion rates are accurate, but the resident is on a continuous feed, so nursing should check the machine. If nursing completed their rounds, they would know if there was an issue with the machine. It was reported to the DON on 7/9/24 at 10:50 A.M. that the resident's machine was set in another language and set to infuse at 140 ml/hr. It is not acceptable for nursing to document tube feeding orders, treatments, and check and assess the resident and machine settings on the MARs if it was not done. Nursing is expected to check the MAR, orders, and placement. It is not acceptable to document it if it was not completed. It was not reported to the DON that the machine was turned off. When it was reported, the ADON got the machine back in English. There were no reports of CNAs changing the machine. If a CNA was providing care, they can pause it. She expected nursing to have reported the machine was set in another language when it was discovered. She e
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0760
(Tag F0760)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to keep one resident with epilepsy (a brain disease where nerve cells ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to keep one resident with epilepsy (a brain disease where nerve cells don't signal properly, which causes seizures) free from a significant medication error, when the facility failed to administer the ordered Keppra (used to prevent seizures). The resident experienced a grand mal seizure (a tonic-clonic seizure, causing the loss of consciousness and violent muscle contractures) with fall at the facility and he/she sustained a fracture of the right proximal fibular shaft (lower leg outer bone) (Resident #14). In addition, staff administered Ambien (a sedative) to Resident #69, for which he/she had a known medication allergy. The census was 151.
The Administrator was notified on 7/12/24 at 12:45 P.M., of an immediate jeopardy (IJ) which began on 4/17/24. The IJ was removed on 7/12/24 as confirmed by surveyor on-site verification.
Review of the Medication Administration Policy, revised 10/24/22, showed:
-Purpose: to provide practice standards for safe administration of medication for residents in the facility;
-Policy:
-Medication will be administered by a licensed nurse per the order of an attending physician or licensed practitioner;
-Medications must be given to the resident by the licensed nurse preparing the medication or as consistent with state law;
-Medications are not to be left at bedside;
-Documentation:
-The time and dose of the drug or treatment administered to the resident will be recorded in the medication record by the person who administered the drug or treatment;
-The recording will include the date, the time and dosage of the medication or type of the treatment.
1. Review of Resident #14's medical record, showed:
-admitted : 6/18/20.
-discharged to hospital: 4/17/24;
-re-admitted : 4/21/24;
-Diagnoses included: Fracture of the right fibula (re-admitted with), epilepsy, intellectual disability, dementia, schizophrenia (a mental disorder that affects a person's ability to think, feel, and behave clearly) and anxiety.
Review of the electronic physician order sheet (ePOS), showed an order, dated 3/4/24: Keppra (levetiracetam) oral solution 100 milligrams (mg)/milliliter (ml). Give 20 ml by mouth twice a day related to convulsions.
Review of the pharmacy shipping manifest, dated 4/13/24 at 4:27 P.M., showed Levetiracetam 100 mg/ml solution delivered to the facility.
Review of the April 2024 medication administration record (MAR), showed:
-An order, dated 3/4/23: Keppra oral solution 100 mg/ml. Give 20 ml twice a day related to unspecified convulsions. Scheduled daily at 9:00 A.M. and 5:00 P.M.
-On 4/16/24:
-At 9:00 A.M., documented as given;
-At 5:00 P.M., documented as 9 or see progress notes.
Review of the progress notes, showed:
-On 4/16/24 at 5:15 P.M.: give Keppra 100 mg/ml, give 20 ml twice a day. Not available, on order.
Review of the April 2024 MAR, showed:
-On 4/17/24:
-At 9:00 A.M., documented as given;
-At 5:00 P.M., documented at 9 or see progress notes.
Review of the progress notes, showed:
-On 4/17/24 at 5:30 P.M., Keppra 100 mg/ml, give 20 ml twice a day. Not available;
-On 4/17/24 at 11:49 P.M., staff notified of the resident lying face down on the bathroom floor seizing, halfway in the bathroom and in the hallway, saturated with urine. Observed in a grand mal seizure, lasted approximately 3-4 minutes. He/She continued to lie on the floor making a snoring sound, difficult to rouse. The physician was notified and new orders to send to the emergency room (ER) for evaluation and treatment.
Review of the ER history and physical, dated 4/18/24 at 2:24 P.M., showed:
-Briefly admitted for breakthrough seizure. Corroborating information helped us determine the patient was likely not receiving daily Keppra due to the facility running out of medication. He/She was found to have a right lower extremity fibular fracture. The patient was seen by Orthopedics and placed in an air boot with weight bearing as tolerated allowances;
-Subjective: Per Emergency Medical Services (EMS) report and patient, the facility had apparently ran out of the prescribed liquid Keppra, and he/she had not been taking it for an unclear period of time. Per EMS it was around three days, and per patient, he/she had not received it in over two weeks. He/She arrived to the ER, was lethargic and post-ictal (altered state of consciousness after an epileptic seizure) state, he/she received a Keppra load of 4500 mg and alertness improved over time, and no seizure activity was noted. The patient stated, he/she did not receive the prescribed liquid Keppra as the facility ran out and were unable to obtain refills. On chart review the patient had to prior ED visits due to seizures, with similar presentation in which the facility ran out of Keppra. He/She was discharged with liquid Keppra at that time and Keppra levels at those times were low and corresponded with a lack of adherence. The facility was contacted and staff reported no supply issue with Keppra;
-Assessment and plan:
-History of epilepsy: patient has longstanding history of epilepsy, previous neurology note, showed the patient is supposed to be on liquid Keppra. Appears to be provoked in setting of Keppra nonadherence per discussion with EMS and patient. Since arrival at the ED, no further seizures;
-Plan: Keppra and carbamazepine (used to treat seizure disorders) levels ordered. Carbamazepine level normal, awaiting Keppra level.
Review of the hospital emergency physician note, dated 4/19/24 at 3:07 A.M., showed:
-History of present illness: history of intellectual disability, convulsion disorder, epilepsy and anxiety. To ER for witnessed seizure lasting several minutes. Per EMS, the facility has been out of liquid Keppra for an unknown amount of time. Complaint of pain in the right leg;
-Physical exam:
-Head, ear, nose and throat (HENT): hematoma (an area of pooled blood) to the left outer eyebrow;
-Decision making:
-Diagnoses: fall, seizure like activity, hematoma to the left eyebrow and right sided leg pain;
-Plan: therapeutic Keppra load, imaging of right leg and facial bone;
-Emergency Department (ED) course:
-At 1:23 A.M.: 4,500 mg of Keppra given in fluids;
-At 1:53 A.M.: 4,500 mg of Keppra administration was stopped;
-At 3:50 A.M.: Orthopedics consulted;
-At 4:15 A.M.: reviewed imaging, the patient has a right fibular fracture. Facial imaging is negative;
-At 5:42 A.M.: patient will be admitted for management of seizure-like activity.
Review of the hospital levetiracetam level, resulted 4/20/24 at 2:12 A.M., showed:
-Levetiracetam level: value: below 2;
-Reference range: 10-40 microgram/milliliter (ug/mL);
-Flag: low (L).
Review of the hospital neurology progress note, dated 4/20/24 at 7:28 A.M., showed:
-Subjective: Levetiracetam level came back undetectable from admission labs, this essentially definitively shows etiology of seizure medication nonadherence;
-Hospital course: Per EMS and family, the facility ran out of Keppra and the resident had not taken the medication for three days, per the patient, it has been two weeks. When the hospital primary team called the facility, it was stated the facility did not have issues with medication supply. On previous admissions July 2023 post seizure, it was determined to have Keppra non-adherence at those times;
-Recommendations:
-Keppra level undetectable which strongly suggests non-adherence to prescribed Keppra regimen;
-Resuming antiseizure regimen will likely resolve episode as this was an effective regimen in the past.
Review of the hospital Discharge summary, dated [DATE] at 12:23 P.M., showed:
-Hospital course: Neurology was consulted for the seizures and determined to be related to missed doses of Keppra. In discussions with the family and the facility, it was confirmed he/she missed two doses of the Keppra. Keppra level at the hospital came back low, confirming the missed doses.
During a phone interview on 7/12/24 at 10:11 A.M., CMT XX said that he/she attempted to give the resident his/her ordered Keppra, but it was not available on the cart around 4/16/24. The resident was getting the liquid form of Keppra. He/She reported to an unknown nurse the resident was out of the medication. He/She was off the next day. When he/she returned the following day, he/she noted the medication was still not available. The staff from the day before had documented on the MAR the medication was given. He/She called the pharmacy, and the pharmacy said the medication was not sent. He/She told the nurse, who was working on a different floor, about the Keppra not being available and to get the medication from the e-kit. He/She called the pharmacy, told them the medication was not available and was not delivered. The pharmacy stated the medication would be delivered the evening of 4/17/24. When the charge nurse returned to the floor, the resident was experiencing a seizure. Management conducted an investigation, and he/she was in-serviced on 4/18/24.
During an interview on 7/9/24 at 10:59 A.M., the former regional nurse, said the facility was notified by the hospital physician regarding the Keppra level was low and not measurable. The facility conducted an investigation and discovered the resident did not receive two to three doses of ordered Keppra. The facility conducted in-servicing immediately.
Review of the facility in-services regarding medication administration, dated 4/18/24 through 5/29/24, following the resident's seizure and hospitalization, showed nine of 19 currently employed Licensed Practical Nurses (LPN) were in-serviced. No current employed graduate nurses (GN) were in-serviced and one currently employed Registered Nurse (RN) was not in-serviced.
During an interview on 7/9/24 at 11:11 A.M., the Minimum Data Set (MDS) Coordinator said he/she assisted management with in-servicing on missed medication, medications not available and expectations on what staff should do if medications are not available. In-servicing was done for a month. New staff had been hired at the facility. She is unaware if the new staff had been in-serviced.
During an interview on 7/10/24 at 6:30 A.M., LPN GG said he/she works night shift. There is no Certified Medication Technician (CMT) on night shift. The nurses administer medications as needed on night shift. If a medication was not on the medication cart, he/she would double check the cart, check the emergency kit (e-kit, supply of emergency stock medications), and contact the pharmacy. He/She has never used the e-kit and he/she is unsure what medications it contains. If the medication cannot be administered, he/she would notify the resident's responsible party and physician. On the MAR, he/she would document other, see progress notes, and he/she would make a note as to why the medication was not administered.
During an interview on 7/11/24 at 11:47 A.M., Graduate Practical Nurse (GPN) FF said if he/she could not find a resident's medication on the medication cart, he/she would check the storage room. If he/she could not locate the medication in the storage room, he/she would order the medication from the pharmacy. If the pharmacy could not deliver the medication the nurse needed to notify the DON and access the e-kit for the medication. He/She has not had any training on e-kits. He/She does not have access to an e-kit and does not know what an e-kit is. He/She asked if an e-kit is where narcotic medications are stored.
During an interview on 7/11/24 at 12:06 P.M., LPN HH said CMTs and nurses are responsible for medication administration. If a medication is not on the cart, staff should check the storage room, call the pharmacy, and call the doctor. Staff could pull the medication from the e-kit, if possible. He/She does not have access to the facility's e-kits.
During a interview on 7/9/24 at 10:26 A.M., the nurse practitioner said, Keppra is an important medication used to prevent the occurrence of seizures. If Keppra doses are missed, the resident could experience a seizure. If Keppra is missed, the medical provider should be notified.
2. Review of Resident #69's resident's hospital record, showed:
-admission: [DATE];
-discharge: [DATE];
-Known allergies: Xanax (sedative), Ziprasidone (antipsychotic), Seroquel (antipsychotic), Geodon (antipsychotic), Ambien (sedative), Wellbutrin (antidepressant), and Venlafaxine (antidepressant).
Review of the resident's quarterly MDS, a federally mandated assessment instrument completed by facility staff, dated 5/10/24, showed:
-Mild cognitive impairment;
-No behaviors;
-Diagnoses included high blood pressure, wound infection, septicemia (blood infection), hip fracture, anxiety, depression;
-Administered anti-depressant, hypnotic, anticoagulant, opioids in the past seven days;
-Drug regimen review: Yes, issues found during review.
Review of the medical record, showed:
-admitted [DATE];
-Allergies: Flu Virus Vaccine, Venlafaxine, Ambien, Geodon, Wellbutrin, Xanax;
-An order, dated 5/30/24, Ambien Oral Tablet 5 mg. Give 5 mg by mouth every 24 hours as needed for insomnia for 30 Days. Order was discontinued on 6/11/24;
-The June 2024 MAR, showed Ambien oral tablet 5 mg. Give 0.5 (half) tablet by mouth every 24 hours as needed for insomnia was administered on 6/30/24.
Review of the care plan, in use during survey, showed:
-Focus: Resident is on sedative/hypnotic therapy related to insomnia;
-Goal: Will be free of any discomfort or adverse side effects of hypnotic use;
-Interventions: On 4/2/2024:
-The Nurse Practitioner (NP) has provided education to resident regarding his/her sleeping habits. Encouraged to avoid caffeine after lunch and all alcohol;
-Administer sedative/hypnotic medications as ordered by physician;
-Evaluate other factors potentially causing insomnia, for example: environment (excessive heat, cold, or noise), lighting, inadequate physical activity, facility routines, caffeine/medications. Attempt to modify and control these external factors before initiating hypnotic therapy;
-Monitor/Document/Report as needed (PRN) for following adverse effects of Sedative/Hypnotic therapy: daytime drowsiness, confusion, loss of appetite in the morning, increased risk of falls and fractures, dizziness.
Review of the resident's July 2024 ePOS, showed an order, dated 6/25/24: Ambien oral tablet 5 mg. Give 0.5 mg tablet by mouth every 24 hours as needed for insomnia.
Review of the resident's July 2024 MAR, showed Ambien oral tablet 5 mg. Give 0.5 tablet by mouth every 24 hours as needed for insomnia. Noted as administered on 7/13/24 and 7/14/24.
Review of the resident's progress notes, showed:
-On 7/13/24 at 10:40 P.M., Ambien oral tablet 5 mg. Give 0.5 tablet my mouth every 24 hours as needed for insomnia. PRN administration was effective;
-On 7/15/24 at 5:44 A.M., Ambien oral tablet 5 mg. Give 0.5 tablet my mouth every 24 hours as needed for insomnia. PRN administration was effective;
-No further documentation on the resident's allergy to Ambien or symptoms after administered Ambien.
Observation and interview on 7/11/24 at 10:45 A.M., showed the resident in bed, eyes closed, and he/she briefly opened them. The resident said he/she was sleeping and usually slept a lot during the day. He/She did not have trouble sleeping at night;
-On 7/15/24 at 8:07 A.M., the resident lay in bed; eyes closed.
-On 7/16/24 at 1:23 P.M., the resident in bed and said he/she did not have a problem sleeping during the day. He/She was told he/she had an allergy to some psychotropic medications. The surveyor named off medications from the resident's allergy list. He/She was unsure if he/she was allergic to Ambien or Xanax, and he/she was unsure what the allergy symptoms were. The resident confirmed he/she was allergic to flu shot vaccines for sure.
During an interview on 7/15/24 at 10:47 A.M., LPN S said the resident was not a heavy sleeper. He/She naps a lot during the day. He/She will wake up and do whatever he/she wants, maybe smoke and then go back and nap.
During an interview on 7/16/24 at 8:53 AM, CMT YY said staff should automatically know to check for allergies. When he/she administers medications, he/she checked the resident's name, medication name and allergy list. CMT YY said the allergy list shows in the resident's medical record at the top, and all allergies are in RED font. If the medication was ordered and listed on their allergies, he/she would report it to the nurse.
During an interview on 7/16/24 at 11:18 A.M., the Director of Nurses (DON) said nursing is responsible for re-capping and ensuring orders are accurate. If there are allergies, it is in red in the medical record. It is on the profile, and staff should note any allergies. She would expect staff to contact the physician if a resident was ordered a medication that was on the allergy list. Nursing should not administer the medication and notify the physician. It should be documented if the physician was notified. The DON was not aware if an assessment was completed or what type of symptoms the resident has with use of Ambien.
Note: At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective actions to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements.
At the time of the exit, the deficiency was lowered to the D level. This statement does not denote the facility has complied with state law (section 198.026.1 RSMO) requiring that prompt remedial action to be taken to address Class I violation(s).
MO00234902
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one resident received care consistent with professional stan...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one resident received care consistent with professional standards and facility policy to prevent and/or treat pressure ulcers (a localized injury to skin and/or underlying tissue usually over a bony prominence, as a result of pressure or friction). The facility failed to ensure wound treatments were completed as ordered, and failed to notify the attending wound Nurse Practitioner (NP) of the missed treatments. The resident was sent to the hospital and received a surgical debridement of a sacral (tailbone) wound. The facility failed to administer ordered antibiotics for a 6 week time frame, which were ordered by the hospital infectious disease (ID) physician (Resident #72). The sample size was 30. The census was 151.
Review of the wound management policy, dated 10/24/22, showed:
-Purpose: to provide a system for the treatment and management of residents with wounds including pressure ulcers;
-Policy: a resident who has a wound will receive necessary treatment and services to promote healing, prevent infection and prevent new pressure ulcers from developing;
-Definitions:
-Pressure ulcer: any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers usually occur over bony prominences and re-graded or staged to classify the degree of tissue damage observed;
-Wound management:
-The attending physician will be notified to advise on appropriate treatment promptly;
-The licensed nurse will notify the responsible party of a pressure ulcer;
-Rehabilitation services will be contacted for appropriate devices or pressure redistributing devices;
-Per physician orders, the nursing staff will initiate treatment and utilize interventions for pressure redistribution and wound management;
-The physician and interdisciplinary team (IDT) will be notified of:
-New pressure wounds;
-Pressure wounds that do not respond to treatment;
-Pressure wound that worsen or increase in size;
-Complaints of increased pain, discomfort or decreased mobility by the resident;
-Signs of wound sepsis (severe infection), presence of drainage, odor, necrosis (black, firm dead skin) if not already noted by the physician;
-Residents who refused treatment;
-Certified Nurse Aides (CNA) will complete body checks on the resident's shower days and report unusual findings to the nurse;
-Documentation:
A. New wounds will be documented on the 24 hour log and an incident report will be completed by the nurse;
B. Wound documentation will occur weekly until the wound is healed. Documentation will include:
-Wound location;
-Length, width, and depth measurement recorded in centimeters (cm);
-Direction and length of tunneling (wound extends deeper into the tissue than its surface, creating a channel) or undermining (separation of the wound edges from the surrounding healthy tissue, often creating a pocket under the wound surface);
-Appearance of the wound base;
-Drainage amount, characteristics such as color, consistency and odor;
-Appearance of wound edges;
-Description of the peri-wound (skin next to the wound) condition;
-Presence of absence of new epithelium (skin) at the wound edge;
-Presence of pain;
C. IDT will document discussion and recommendations for:
-Pressure wounds that do not respond to treatment;
-Pressure wounds that worsen or increase in size;
-Complaints of increased pain, discomfort of decrease in mobility by the resident;
-Signs of sepsis, drainage, odor or necrosis;
-Residents refusing treatment;
D. Nurses will document effectiveness of current treatment in the medical record;
E. Document notifications following a change in the resident's skin condition;
F. Update the care plan as needed.
Review of Resident #72's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 4/9/24, showed:
-Cognitively intact;
-Staff provide substantial to maximal assistance for toileting, transfers, showers, dressing and bed mobility;
-Diagnoses included heart failure, high blood pressure, diabetes, cerebral palsy (a group of conditions that affect movement and posture), malnutrition, anxiety and depression;
-Has a Stage 1 pressure injury (observable, pressure related alteration of intact skin with non-blanchable redness of a localized area): 1;
-At risk for pressure injury;
-Unhealed pressure injury;
-Stage 3 pressure ulcer (full thickness tissue loss. Subcutaneous fat maybe visible, but bone, tendon or muscle is not exposed. Slough (yellow, stringy tissue) maybe present): 3
-Number present on admission or re-admission: 3;
-Stage 4 pressure ulcer (full thickness loss, with exposed bone): 1
-Number present on admission or re-admission: 1
-Unstageable ulcer: (a wound that occurs due to prolonged pressure, full tissue loss which the depth of the wound of bed sore is completely obscured by eschar (black, dead tissue) number of unstageable ulcers: 1
-Number of these ulcers that were present on admission or re-admission: 0;
-Skin and ulcer treatment:
-Pressure reducing device for chair and bed;
-Turn and repositioning program;
-Nutrition and hydration interventions;
-Pressure ulcer care;
-Application of nonsurgical dressing other than to feet;
-Application of ointments or medications other than to feet.
Review of the May 2024, Treatment Administration Record (TAR), showed the following physician order:
-An order, dated 3/16/24: Santyl ointment (used to remove dead tissue from a wound) 250 milligram (mg) to coccyx every day shift. Undocumented and blank on 5/1 and 5/2.
Review of the progress notes, showed no documentation regarding the missed treatment or physician notification.
Review of the facility wound report, showed on 5/3/24:
-Location: Coccyx;
-Stage: IV;
-Treatment: Santyl, calcium alginate (highly absorptive dressing) and dressing;
-Measurements: length (L) 6.9 centimeter (cm) x 9.8 width (w) cm x 0.6 depth (d) cm;
-Acquired.
Review of the May 2024, TAR, showed:
-An order, dated 3/16/24: Santyl ointment 250 mg to coccyx every day shift. Undocumented and blank on 5/4;
-An order, dated 5/7/24: Gentamycin ointment (topical ointment for bacterial skin infections) 0.1%, apply to coccyx every day shift for 30 days. Undocumented and blank on 5/7.
Review of the progress notes, showed no documentation regarding the missed treatments or physician notification.
Review of the facility wound report, dated 5/9/24, showed:
-Location: Coccyx
-Stage: IV;
-Treatment: Santyl, calcium alginate and gentamycin;
-Measurements: 6.8 cm (l) x 9.8 cm (w) x 1.5 cm (d);
-Acquired.
Review of the May 2024, TAR, showed:
-Gentamicin ointment 0.1 %, apply to coccyx everyday shift for 30 days. Undocumented and blank on 5/10 and 5/15;
-Santyl ointment 250 mg to coccyx every day shift. Undocumented and blank on 5/10.
Review of the progress notes, showed on 5/13/24 at 2:48 P.M., a nurse note: NP notified about missing wound care on 5/10/24, 5/11/24 and 5/12/24. No new orders at this time.
Review of the facility wound report, dated 5/15/24, showed:
-Location: Coccyx
-Stage: IV;
-Treatment: Santyl, calcium alginate and gentamycin;
-Measurements: 12.3 cm (l) x 6.6 cm (w) x 2.8 cm (d);
-Acquired.
Review of the specialized wound report, dated 5/16/24, showed:
-Wound state: open;
-Cause: Pressure;
-Wound cause: at facility;
-Measurements: 7.2 cm (l) x 8.6 cm (w) x 0.7 cm (d);
-Tissue type:
-Granulation type: 65 %;
-Slough: 15 %;
-Pressure versus non-pressure:
-Is the patient or patient's body part immobile: yes;
-Did nursing staff note it is directly from positioning: yes;
-Was the patient's affected body part immobile recently (last 2 weeks) prior to wound development: yes;
-Wound details: pressure ulcer/pressure injury;
-Pressure injury: Stage IV;
-Exudate volume: moderate: wound is wet and drainage covers 25-75 % of the dressing:
-Exudate type: serosanguineous (clear, slightly blood tinged) drainage;
-Undermining: yes from 12 o'clock to 2 o'clock position;
-Wound orders:
-Clean with saline or vashe (wound cleanser), use to irrigate and scrub the wound bed. Apply Santyl and calcium alginate to wound base, cut to fit inside the wound edges, do not place on skin. Cover with bordered gauze. Change daily, for soiling and saturation
-Notes: Debridement to remove unhealthy tissue and stimulate healing;
-Measurements post procedure: 7.4 cm (l) x 8.5 cm (w) x 1.0 cm (d).
Review of the May 2024, TAR, showed:
-Gentamicin ointment 0.1 %, apply to coccyx everyday shift for 30 days. Undocumented and blank on 5/18;
-Santyl ointment 250 mg to coccyx every day shift. Undocumented and blank on 5/18.
Review of the progress notes, showed:
-On 5/21/24 at 12:25 P.M., a nurse note: NP notified of missing wound care on 5/18/24. No new ordered received;
-On 5/21/24 at 5:57 P.M., a nurse note: call placed to pharmacy due to being out of gentamycin ointment for coccyx. The pharmacy stated would attempt to send two tubes as the wound needed more than 1 gm at dressing changes. The insurance may not cover, wound measurements sent to aid in obtaining medication. Gentamycin to arrive tomorrow morning due to pharmacy closing at 5:00 P.M.
Review of the specialized wound progress note, dated 5/23/24, showed:
-Wound state: open
-Cause: Pressure;
-Wound cause: at facility;
-Measurements: 7.3 cm (l) x 9.3 cm (w) x 1.0 cm (d);
-Tissue type:
-Granulation type: 70%;
-Slough 10%;
-Pressure versus non-pressure:
-Is the patient or patient's body part immobile: yes;
-Did nursing staff note it is directly from positioning: yes;
-Was the patients affected body part immobile recently (last 2 weeks) prior to wound development: yes;
-Wound details: pressure ulcer/pressure injury;
-Pressure injury: Stage IV;
-Exudate volume: moderate: wound is wet and drainage covers 25-75% of the dressing:
-Exudate type: serosanguineous drainage;
-Peri-wound texture: friable (tissue that is easily irritated, more prone to inflammation and damage);
-Length, width and depth: stayed the same compared to previous visit;
-Undermining: yes from 12 o'clock to 2 o'clock position;
-Wound orders:
-Clean with saline or vashe, use to irrigate and scrub the wound bed. Apply Santyl and calcium alginate to wound base, cut to fit inside the wound edges, do not place on skin. Cover with bordered gauze. Change daily, for soiling and saturation.
Review of the May 2024, TAR, showed:
-Gentamicin ointment 0.1 %, apply to coccyx everyday shift for 30 days. Undocumented and blank on 5/27;
-Santyl ointment 250 mg to coccyx every day shift. Undocumented and blank on 5/27.
Review of the progress notes, dated 5/28/24 at 11:50 A.M., a nurse note: NP notified of missing wound care on 5/27/24. No new orders received.
Review of the specialized wound progress note, dated 5/29/24, showed:
-Wound state: open
-Cause: Pressure;
-Wound cause: at facility;
-Measurements: 6.7 cm (l) x 12.6 cm (w) x 1.9 cm (d);
-Tissue type:
-Granulation type: 70%;
-Slough 10%;
-Pressure versus non-pressure:
-Is the patient or patient's body part immobile: yes;
-Did nursing staff note it is directly from positioning: yes;
-Was the patients affected body part immobile recently (last 2 weeks) prior to wound development: yes;
-Wound details: pressure ulcer/pressure injury;
-Pressure injury: Stage IV;
-Exudate volume: moderate: wound is wet and drainage covers 25-75% of the dressing:
-Exudate type: serosanguineous drainage;
-Peri-wound texture: friable;
-Length, width and depth: stayed the same compared to previous visit;
-Undermining: yes from 12 o'clock to 2 o'clock position;
-Wound orders:
-Clean with saline or vashe, use to irrigate and scrub the wound bed. Apply Santyl and calcium alginate to wound base, cut to fit inside the wound edges, do not place on skin. Cover with bordered gauze. Change daily, for soiling and saturation;
-Assessment notes: debridement for removal of unhealthy tissue and promote wound healing;
Wound measurement after debridement: 14.2 cm (l) x 10.6 cm (w) x 6.7 cm (d). Debrided 60%.
Review of the facility wound report, dated 5/30/24, showed:
-Location: Coccyx
-Stage: IV;
-Treatment: Santyl, calcium alginate and gentamycin;
-Measurements: 6.7 cm x 12.6 cm x 1.9 cm;
-Acquired.
Review of the progress notes, showed on 5/30/24 at 9:48 A.M.: a nurse note: care plan held and discussed medical decline. Guardian agreed to hospice services.
Review of the May 2024 TAR, showed:
-Gentamicin ointment 0.1 %, apply to coccyx every day shift for 30 days. Undocumented and blank on 5/31;
-Santyl ointment 250 mg to coccyx every day shift. Undocumented and blank on 5/31
Review of the progress notes, dated 6/1/24 at 10:53 P.M., showed a nursing note: resident experienced vomiting and left sided abdominal pain. Resident requested to go to the hospital. Per physician, send to the hospital for evaluation and treatment.
Review of hospital Discharge summary, dated [DATE], showed:
-Overview: admitted : 6/2/24;
-discharged : 6/8/24;
-Problems:
-Active problem: decubitus ulcer, Stage 4 with infection;
-Details of hospital stay:
-Chronic osteomyelitis (bone infection) of the sacrum (coccyx) post multiple debridements with wound vacuum, who presented to the emergency department (ED) with abdominal pain. The legal guardian stated he/she was concerned regarding the pain and worsening wound. The patient was noted to be hypotensive (low blood pressure). Upon ED arrival, found to have sepsis (blood infection) and increasing sacral ulcer size and could not rule out sacroiliac septic arthritis. Wound cultures were obtained and sent. The patient was administered broad spectrum antibiotics. Surgical team was consulted and patient was taken to the operating room for debridement;
-Hospital course:
-Sepsis: infected sacral ulcer;
-Osteomyelitis: chronic osteomyelitis of sacrum with multiple surgical debridements of the sacral ulcer. Imaging showed mild enlargement of sacral ulcer. On 6/4/24 surgical debridement. Wound care service placed wound vacuum. Infectious diseases guided antibiotic treatments and bone culture positive for multiple bacterium. Antibiotics at discharge Doxycycline 100 mg twice a day for two weeks and Ciprofloxacin (antibiotic) and Flagyl (antibiotic) for six weeks;
-Post discharge: wound vac care and ordered blood testing in six weeks. Fax results of ordered blood testing to infectious diseases;
-Discharge to long term facility.
Review of the facility re-admission progress note, showed:
-On 6/8/24 at 8:36 P.M.: re-admitted from hospital today at 3:45 P.M. Oriented to person, place and time. Resident is bedfast. The physician/NP approves of the plan of care;
-On 6/9/24 at 9:53 P.M., give metronidazole (antibiotic) 500 mg, give one tablet 3 times a day for wound. On order, new prescription;
-On 6/9/24 at 4:52 A.M., the resident had new order for antibiotic, still awaiting on call back from physician to verify orders;
-On 6/9/24 at 2:52 P.M.: an order: wound to coccyx, cleanse with normal saline or vashe, pat dry, apply Santyl nickel thick edge to edge of the wound bed, apply Gentamycin ointment to wound bed, cover with calcium alginate, cut to fit, cover with bordered gauze, for every day shift. Physician called and orders unable to be verified, a protective covering applied instead;
-On 6/9/24 at 7:42 P.M., spoke to the physician and he does not want a stop date on the two antibiotics;
-On 6/9/24 at 9:39 P.M., Doxycycline 100 mg, take two time a day for 14 days, Ciprofloxacin 750 mg twice a day, order needs to be verified;
Review of the June 2024 MAR and TAR, showed:
-On 6/9/24: Ciprofloxacin 750 mg, Doxycxyline 100 mg and Metronidazole 500 mg not administered;
-On 6/9 and 6/10/24: Santyl ointment 250 mg, not administered on 6/9 and 6/10:
-On 6/9/24: Coccyx clean with NS apply Santyl nickel thick, apply Gentamycin to wound bed, cover with calcium alginate cut to fit, cover with bordered gauze, every day shift. Not administered, noted as blank.
Review of the progress notes, showed:
-On 6/10/24 at 2:54 P.M., Santyl ointment 250 mg, apply per TAR every day shift for 30 days. On order;
-On 6/11/24 at 12:23 P.M., NP notified of missed wound care and Santyl administration on 6/10/24. No new orders given;
-On 6/12/24 at 11:30 A.M., NP notified of missed wound care on 6/11/24. No new orders received.
Review of the June 2024 MAR and TAR, showed:
-On 6/14/24: Ciprofloxacin 750 mg, Doxycxyline 100 mg and Metronidazole 500 mg not administered;
-On 6/14/24: Coccyx clean with NS apply Santyl nickel thick, apply Gentamycin to wound bed, cover with calcium alginate cut to fit, cover with bordered gauze, every day shift. Noted as blank.
Review of the progress notes, showed:
-On 6/15/24 at 12:44 P.M., NP notified of missed wound care on 6/14/24. No new orders received;
-On 6/16/24 at 4:24 P.M., NP notified of missed wound care on 6/15/24. No new orders received.
Review of the June 2024 MAR and TAR, showed:
-On 6/17/24: Ciprofloxacin 750 mg, Doxycxyline 100 mg and Metronidazole 500 mg not administered. Noted as blank;
-On 6/17/24: Coccyx clean with NS apply Santyl nickel thick, apply Gentamycin to wound bed, cover with calcium alginate cut to fit, cover with bordered gauze, every day shift. Not administered.
Review of the progress notes, showed:
-On 6/17/24 at 7:47 P.M., Ciprofloxacin 750 mg on order;
-On 6/18/24 at 12:12 P.M.,: NP notified of missed wound care on 6/17/24. No new orders.
Review of the ePOS, showed a note on 6/19/24: Ciprofloxacin 750 mg: NP states 8 days was long enough for medication.
Review of the progress notes on 6/19/24, showed no documented order or NP visit note regarding the discontinuation of the ordered Ciprofloxacin 750 mg antibiotic.
Review of the June 2024 MAR and TAR, showed:
-On 6/22/24: Ciprofloxacin 750 mg stopped on 6/19/24, Doxycxyline 100 mg and Metronidazole 500 mg not administered;
-On 6/22/24: Coccyx, clean with NS apply Santyl nickel thick, apply Gentamycin to wound bed, cover with calcium alginate cut to fit, cover with bordered gauze, every day shift. Not administered.
Review of the progress notes, showed on 6/24/24 at 12:09 P.M., NP notified of missed wound care on 6/22/24. No new orders given.
Review of the June 2024 MAR and TAR, showed:
-On 6/27/24 and 6/28/24: Ciprofloxacin 750 mg, Doxycxyline 100 mg and Metronidazole 500 mg not administered;
-On 6/27/24 and 6/28/24: Coccyx clean with NS apply Santyl nickel thick, apply Gentamycin to wound bed, cover with calcium alginate cut to fit, cover with bordered gauze, every day shift. Noted as blank.
Review of the progress notes, showed:
-On 6/29/24 at 10:30 A.M.,: NP notified of missed wound care on 6/27 and 6/28/24. No new orders given;
-7/2/24 at 2:28 P.M.,: Coccyx wound: physician notified writer unable to carry out wound care orders related to nurse to resident ratio;
-On 7/7/24 at 5:07 P.M.,: nurse notified by aide that resident's catheter (hollow tube placed in the bladder to drain urine) contained pus (yellow, thick drainage). Voiced sore throat and hoarse voice, requested to go to hospital, stated feeling ill all day. Physician notified and new orders send to hospital for evaluation and treatment.
During an interview on 7/09/24 at 10:26 A.M., the physician's NP said he provided care for the resident the last several months. The resident is seen by the wound care specialist weekly. Neither he nor the physician had been notified of missed wound treatments or the missed ordered antibiotics. If wound treatments are missed, the wound care specialty team should be notified first, then the physician or NP.
During an interview on 7/10/24 at 9:35 A.M., the Director of Nursing (DON) said the facility wound nurse completes wound rounds with the specialty provider weekly. She also completes all wound care treatments during the week. On the weekends, the Charge Nurses are responsible to complete the ordered treatments. All missed wound treatments should be reported to the wound care team, if seen by them or by the physician. If a resident is ordered to take an antibiotic for a wound, the resident should remain on the antibiotic until discontinued by the ID physician. There should be no missed treatments. The risk of untreated wounds could be infection, and further injury. If a resident refused treatments, then staff should notify the MD, and document in the record.
During an interview on 7/11/24 at 7:29 A.M., the facility Wound Nurse said the facility staff had major issues completing wound care in May. She had been the facility wound nurse about two months. She works Tuesdays through Friday as the wound nurse. She works every other weekend as a floor nurse. When she completed audits, she observed multiple wound treatments had not been completed. The nurses should assess skin daily. The resident was on antibiotics for wounds from a hospital stay in June. The antibiotic was prescribed by the ID physician, it would have been very important for the resident to finish those. The staff documented in the physician order, that an NP stopped the ordered antibiotic, and it was stopped incorrectly.
During an interview on 7/11/24 at 9:23 A.M., the specialty wound care NP said she expected staff to administer wound care orders and medications as written. If residents resist wound care, staff should re-approach and if the resident continued to refuse, staff should document. Blanks on the TAR indicate a treatment was not done. The physician, NP or herself should be told when treatments are not done. She has educated staff multiple times of the importance of completing wound treatments. Resident #72 is totally dependent on staff for care. She and the facility's wound care nurse frequently provided hygiene care due to the resident being heavily soiled. The resident was in the hospital in June for worsening of the sacral wound. The hospital ID (Infectious Disease) physician prescribed antibiotics for an extended time, the facility should have administered those as ordered. Antibiotics are important for wound healing. Santyl is used to clean out the dead tissue in a wound. If Santyl is not administered as ordered, the wound is not debrided and dead tissue remaining in the wound bed can contribute to infection beginning.
During an interview on 7/17/24 at 3:16 P.M., the resident's physician said neither he nor the NPs were notified of missed wound care or questions regarding stopping the ID physician ordered antibiotics. The ID physician should have been contacted regarding stopping the ordered antibiotic. The resident is seen weekly by the wound care NP. The resident was sent to the hospital in June and received a surgical debridement of the sacral wound. The ID physician ordered the antibiotic and Flagyl for 6 weeks to treat various bacteria in the wound.
MO00237027
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0692
(Tag F0692)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify one resident's significant weight loss of -2...
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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 identify one resident's significant weight loss of -24.93% in a timely manner, resulting in delayed identification of interventions to support the resident's nutritional status (Resident #127). The facility failed to ensure three residents with significant weight loss were provided with therapeutic diets, supplemental food items, alternative food items, and/or feeding assistance to address weight loss (Residents #127, #123, and #50). The sample was 30. The census was 151.
Review of the facility's Nutrition/Hydration Management policy, revised 10/24/22, showed:
-Purpose: To ensure that each resident maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible based on the resident's comprehensive assessment. To ensure that a resident receives a therapeutic diet when there is a nutritional problem;
-Policy:
-The concept of nutrition management is an interdisciplinary process. The key components of this system are:
-a. Maintaining nutritional status as indicated by clinical measures such as body weight, biochemical measure, and hydration;
-b. Developing an individual nutrition/hydration program based on individual assessed needs;
-c. Implementing the nutrition/hydration program;
-d. Identifying new instances of unplanned weight loss or gain; and
-e. Ongoing assessment, monitoring, and evaluation of the effectiveness of the
nutrition/hydration management program;
-The goal of any nutrition/hydration management process is to improve quality of life. The goal of the interdisciplinary team is to promptly identify a resident with nutrition/hydration at risk factors and develop and effective management program;
-Procedure included:
-A comprehensive care plan is developed by the interdisciplinary team that addresses
nutrition/hydration and an individualized nutrition/hydration management program based on individualized assessed need;
-The nutrition/hydration management program may address the following;
-The factors contributing to actual or potential causes for inadequate nutrition or hydration status;
-Specific modification in the resident's meal plan including food from outside the facility and/or special food activities;
-Pertinent socialization and recreation factors;
-Dining locations and the type and level of dining assistance required; and
-Position, cueing/assistance, and adaptive equipment needed.
Review of the facility's Therapeutic Diets policy, revised 10/24/22, showed:
-Purpose: To ensure that the facility provides therapeutic diets to residents that meet nutritional guidelines and physician orders;
-Policy: Therapeutic diets are diets that deviate from the regular diet and require a physician order. Per the physician order, therapeutic diets are planned, prepared and served in consultation with the Dietitian;
-Procedure:
-The nursing staff is responsible for communicating the physician's order for a therapeutic diet to the dietary department in writing;
-The therapeutic diet will be reflected on the resident's tray card.
-The Dietary Manager will periodically review the resident's tray card and the physician's dietary orders to ensure that the information is consistent.
1. Review of Resident #127's medical record, showed:
-admission date 9/1/23;
-Diagnoses included malnutrition, abnormal weight loss, dysphagia (difficulty swallowing), cognitive communication deficit, depression, anxiety, hallucinations, diabetes, heart failure, high blood pressure, kidney failure, and muscle wasting and atrophy.
Review of the resident's electronic physician order sheet (ePOS), showed:
-An order, dated 9/1/23, for Remeron (antidepressant) Sol Tab oral disintegrating tablet, 15 milligrams (mg.), one tablet by mouth at bedtime for depression;
-An order, dated 9/26/23 through 1/12/24 for health shake three times daily with meals for weight loss;
-An order, dated 9/26/23 through 1/15/24 for Ensure (nutritional supplement) oral liquid, one can by mouth three times a day for supplement.
Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/4/23, showed:
-Moderate cognitive impairment;
-Supervision or touching assistance required for eating.
Review of the resident's medical record, showed:
-On 12/5/23, weighed 181.4 pounds (lbs.);
-A physician order, dated 12/30/23, for ice cream with meals;
-On 1/5/24, weighed 169.8 lbs;
-The resident had a significant weight loss of -6.39% between 12/5/23 and 1/5/24.
Review of the resident's physician progress note, dated 1/8/24, showed the resident eating poorly, refusing to drink Ensure sometimes. Staff informed patient likes food from outside, home food. Family brings food sometimes.
Review of the resident's ePOS, showed an order, dated 1/24/24, for megestrol acetate (medication used to treat loss of appetite) oral tablet 20 mg., give 40 mg. orally one time a day for appetite stimulant.
Review of the resident's physician progress note, dated 2/5/24, showed resident eating very poorly. Staff informed patient likes food from outside, home food. Family brings food sometimes. Patient lost 10 lbs. in 30 days. Continue Remeron, Megestrol, Ensure. Talked to patient's family, he/she wants gastrointestinal (GI) tube (a tube surgically inserted into the stomach to provide hydration, nutrition, and medications). Will consult GI.
Review of the resident's weights, showed on 2/6/24, the resident weighed 170.2 lbs.
Review of the resident's physician progress note, dated 3/4/24, showed resident continuing to refuse his/her foods. Staff informed he/she only eats food from outside of the facility when his/her family brings it. Watched him/her during lunch, did not take a single bite. Eating very poorly, limited activity. Continue Remeron, Megestrol. Facility trying to contact a GI.
Review of the resident's weights, showed on 3/5/24, the resident weighed 169.6 lbs.
Review of the resident's physician progress note, dated 3/26/24, showed talked to resident about his/her family's recommendation for GI tube as he/she is not eating or drinking. Resident said no GI tube. Eating very poorly, very limited activity. Continue Remeron, Megestrol. Facility trying to contact GI.
Review of the resident's ePOS, showed an order, dated 3/28/24, for Ensure with meals (scheduled to be administered at 7:00 A.M., 12:30 P.M., and 5:30 P.M.).
Review of the resident's weights, showed on 4/5/24, he/she weighed 171.2 lbs.
Review of the resident's physician progress notes, showed:
-On 4/8/24, the physician documented the resident's family called to inform he/she no longer wants to put in the GI tube. Family will bring food more often so resident will eat. Resident does not eat food from facility. Continue Remeron, Megestrol, Ensure. Family does not want GI tube anymore. Family will bring food from outside as resident only eats that. Resident does not drink Ensure;
-On 5/6/24, the physician documented the resident with low appetite. Does not eat food from facility. Continue Remeron, Megestrol, Ensure. Consult Registered Dietician (RD).
Review of the resident's weights, showed on 5/7/24, he/she weighed 172.5 lbs.
Review of the resident's quarterly MDS, dated [DATE], showed:
-Moderate cognitive impairment;
-No behaviors exhibited;
-Independent with eating;
-Weight: 173 lbs.
Review of the resident's quarterly dietary profile, signed by the Dietary Manager (DM), dated 5/22/24, showed:
-Percentage intake: 100%;
-Current nutritional supplement: Ensure;
-Appetite: Good;
-Likes: Turkey with dressing, burger with cheese, tenders. Dislikes: Broccoli.
Review of the resident's weights, showed:
-On 6/3/24, weighed 170.5 lbs.;
-On 6/5/24, weighed 129.5 lbs.
-The resident had a significant weight loss of -24.93% between 6/3/24 and 6/5/24.
Review of the resident's speech therapy evaluation, dated 6/4/24, showed:
-Reason for referral/current illness: Dysphagia due to decline in oral/pharyngeal (related to the pharynx, the conductive structure located in the midline of the neck) function, risk for weight loss, safety awareness, weight loss, and signs/symptoms of dysphagia;
-Recommendations: Mechanical soft texture, thin liquids. Occasional supervision.
Review of the resident's ePOS, showed an order, dated 6/4/24, for regular diet, mechanical soft texture.
Review of the resident's medical record, showed:
-On 6/7/24, the nurse documented the resident observed chewing fish during meal time, then proceeded to spit chewed fish into a small plastic bag. Resident asked about behavior and stated, I don't know what I'm doing. I won't do it again. RD notified;
-On 6/7/24, the RD documented significant weight loss triggering -41 lbs. in two days. Talked to nursing and current weight appears correct. 41 lb. weight loss not possible so questioning the weights before 6/5/24 at this point. Resident receiving regular, mechanical soft with ice cream and Ensure with meals. Resident needs supervision and encouragement. Per nursing, resident chewed up fish and then did not eat it today. Now working with speech therapy. Resident is a picky eater and sometimes refusal of supplementation noted. Receiving Megestrol and Remeron, both have potential for appetite stimulation;
-On 6/9/24, the nurse documented the resident observed during meal consumption this morning. Resident observed placing full spoon of oatmeal in mouth, chews it, and spits it back onto spoon. Resident places chewed oatmeal onto plate, separates it from what has not been chewed. Resident asked if there were any issues swallowing. Resident stated, I don't know. Resident provided chocolate Ensure and tolerated Ensure well without issues;
-On 6/13/24, the nurse documented the resident provided with Ensure this morning, poor meal consumption, less than 25%. Nurse continues to encourage and educate resident;
-Staff documented Ensure, Remeron, and Megestrol as administered per physician order on the June 2024 medication administration record (MAR).
Review of the resident's care plan, in use at the time of survey and reviewed 7/8/24, showed:
-Focus: Resident has an activities of daily living (ADL) self-care performance deficit;
-Interventions included: resident needs limited assistance of one for eating;
-Focus: Resident has nutritional problem or potential nutritional problem related to diet restrictions;
-Interventions included: Due to resident declining to consume his/her Ensure, order discontinued. Monitor weight as directed. Provide and serve diet as ordered, regular diet, mechanical soft texture, regular consistency. Provide and serve supplements as ordered: ice cream with meals. Staff reports of family with outside foods and he/she consumes with no complaints, encourage resident choose food from dietary that he/she enjoys, offer him/her snacks of his/her choice throughout the day and evenings. Weight at same time of day and record, resident is weighed during the day with the use of his/her wheelchair;
-The care plan failed to identify the resident's poor intake of food served at the facility, increased intake of meals eaten with family, and his/her behavior of chewing food and spitting it out, and to identify interventions to address the behavior.
Review of the resident's diet card, undated, showed Regular diet checked at the top of the card. No documentation of physician-ordered supplemental ice cream or Ensure. Likes and dislikes not documented.
Observation on 7/8/24 at 10:28 A.M., showed the resident seated in a wheelchair. The resident appeared thin with pronounced collar bones and jaw bones. During an interview, the resident exhibited some confusion. He/She said he/she ate breakfast. He/She was unable to answer questions when asked about his/her meal intake and weight loss.
Observation of lunch on 7/8/24 at 11:57 A.M., showed the resident sat at a table in the dining room. Staff served the resident mechanical soft Salisbury steak, mashed potatoes with gravy, a scoop of vegetables, and a carton of Ensure. No ice cream served to the resident. The resident consumed less than 25% of each food item and pushed his/her food around the plate. Staff provided the resident with two meat and cheese sandwiches. The resident took bites of one sandwich and spit the food onto his/her plate. Licensed Practical Nurse (LPN) D approached the resident and asked if he/she was spitting his/her food out and the resident said no. LPN D walked away, and the resident continued to take bites of the sandwich and spit it back onto the plate. At 12:21 P.M., LPN removed the resident's plate and encouraged him/her to drink the Ensure. At 12:29 P.M., the resident finished the Ensure.
Observation on 7/8/24 at 4:54 P.M., showed the resident on his/her left side in bed with a plate of whole egg rolls and noodles. No ice cream served to the resident. No Ensure observed. No staff in the resident's room to supervise or provide encouragement. The resident used his/her hands to rip up the food and put it in his/her mouth, spitting bits of food out of his/her mouth while he/she chewed.
Observation of lunch on 7/9/24 at 12:07 P.M., showed the resident sat in the dining room. Staff served the resident a chopped-up meat patty, mashed potatoes with gravy, mixed vegetables, a cup of ice cream, and a carton of Ensure. The resident took bites of his/her food and spit it back onto the plate. Staff did not offer alternatives or encourage the resident during the meal. At 12:26 P.M., staff removed the resident's plate. In total, the resident consumed the entire cup of ice cream, approximately 30% of the meat, and a couple bites of vegetables.
Observation of lunch on 7/12/24 at 11:43 A.M., showed the resident sat in the dining room. Staff served the resident a mechanical soft fish patty, spaghetti, sliced carrots, and a piece of cake. No ice cream served to the resident. No Ensure observed. The resident pushed the food around on his/her plate. Staff provided the resident with two meat and cheese sandwiches. The resident consumed some of both sandwiches, spitting the remainders of the sandwiches onto his/her plate. In total, the resident consumed just over one whole sandwich.
Observation on 7/15/24 at 11:44 A.M., showed the resident sat in the dining room with a whole hamburger and crinkle-cut fries. No ice cream served to the resident. No Ensure observed. The resident used his/her hands to rip up the hamburger and put it in his/her mouth, spitting bits of food out while he/she chewed.
Observation on 7/15/24 at 7:06 A.M., showed Certified Nurse Aide (CNA) E brought the resident to the shower room by the elevators on the first floor to have him/her weighed. CNA/Restorative Aide (RA) W entered the shower room and said he/she would leave the resident in his/her wheelchair and put him/her on the scale to obtain the weight. CNA E said no, he/she needed to get the wheelchair weight first. CNA E transferred the resident out of his/her wheelchair into a regular chair, then weighed the wheelchair on the scale. The wheelchair weighed 34.4 lbs. CNA E transferred the resident back to his/her wheelchair and positioned him/her on the scale. The scale showed 164.6 lbs. After subtracting the wheelchair weight, the resident's weight was determined to be 130.2 lbs.
During an interview on 7/15/24 at approximately 7:10 P.M., CNA E said CNA/RA W has been obtaining the weights for all residents in the facility. The weights were not obtained properly. Minutes ago, RA W wanted to weigh the resident in his/her wheelchair and that is not correct. The resident has visibly lost a lot of weight over the past few months. CNA E has talked to the resident's doctor and psychiatrist about the weight loss. Someone recommended a GI tube, but the resident or his/her family said no. A month ago, the resident began spitting out his/her food. The resident loves snacks, such as oatmeal pies and chocolate bars. He/She is supposed to be getting ice cream from dietary, but hasn't been.
During an interview on 7/15/24 at 11:28 A.M., CNA/RA W said he/she was he/she is responsible for obtaining weights on the residents in the facility at the beginning of each month. The facility has two stationary scales on the first floor, and a chair scale that CNA/RA W can bring to the other floors of the facility. He/She uses different scales every time he/she weighs different residents. Whichever scale he/she uses changes by resident or day, depending on what is closer at the time he/she obtains a resident's weight. He/She saw Resident #127 losing weight and getting smaller over the past few months, but the numbers on the scale stayed the same, so he/she went with that. Recently, he/she realized the chair scale wasn't calibrated, and he/she doesn't know how to calibrate it, so he/she told the MDS Coordinator.
During an interview on 7/15/24 at 2:48 P.M., CNA R said the resident used to be bigger and has lost a lot of weight since admission. He/She used to receive a mechanical diet. They switched his/her diet to regular last month and that's when he/she started spitting out his/her food. He/She eats well when his/her family comes to visit. His/Her average meal intake is about 50%. He/She is supposed to get ice cream at all meals, but dietary only gives out ice cream on certain days. The Certified Medication Technicians (CMTs) give the resident Ensure.
During an interview on 7/16/24 at 7:11 A.M., CNA EE said the resident has lost a lot of weight. For a while now, he/she has been chewing up his/her food and spitting it out. He/She doesn't like the food served at the facility. He/She needs to be served new foods instead of the same foods served over and over at the facility. When he/she doesn't eat, staff should offer him/her something else. The problem is that dietary staff don't send the right food texture or the right food items. When nursing calls down to the kitchen to ask for the right items or request something different, dietary staff gets mad. The only food they will send up as an alternative is a cold cut sandwich.
During an interview on 7/15/24 at 12:32 P.M., the Social Services Director (SSD) said the resident has dementia and has good and bad days. Sometimes the resident eats and sometimes he/she spits out his/her food. His/Her meal intake depends on who is there as well. He/She can eat a bunch when with family and eats well with them. He/She prefers food from outside of the facility. The SSD was not aware the resident had a significant weight loss. Weight loss is a topic discussed in the weekly interdisciplinary (IDT) meetings. She recalled them discussing the resident's weight loss before and people mentioned getting the resident more shakes.
During an interview on 7/16/24 at 9:30 A.M., the DM said the resident has been chewing his/her food and spitting it out. He/She eats well when his/her family comes to visit. He/She is supposed to receive a mechanical diet, not a regular diet. During the interview, the DM reviewed the resident's diet card, which showed regular diet. The DM said the resident's diet card had been changed by someone else, and he did not know who. Dietary staff should not change the diet cards and should always go by physician-ordered diet. The DM saw the resident when he/she was first admitted to the facility and the resident has visibly lost weight since then, and he/she is thin. The resident's weight has gone south and the DM does not know why. The resident eats well when his/her family comes to visit. The DM attends the IDT meetings, which are held weekly. The resident's weight loss was discussed during an IDT meeting one time and has not been mentioned since then.
During an interview on 7/16/24 at 11:09 A.M., the Speech Therapist (ST) said the resident was referred to her for an evaluation in June 2024, and she completed a swallow evaluation. The resident has been having issues with swallowing. He/She has been expelling his/her food, but not always. His/Her diet was downgraded to mechanical soft because he/she does not have enough teeth. She expects the resident to receive a mechanical soft diet. If dietary serves the resident whole foods, nursing staff usually chop up the food for the resident. The resident has been spitting out his/her food, which is a fairly new behavior. If the food is something the resident likes, he/she will eat it.
During an interview on 7/16/24 at 10:20 A.M., the MDS Coordinator said residents are weighed monthly by CNA/RA W. If there is a discrepancy, the resident may be moved to weekly weights. She does not know how Resident #127's significant weight loss was missed. Maybe staff was using a different wheelchair to weigh the resident. Maybe the resident was weighed using the chair scale, which was messing up a lot on people. When the weight loss was noted, she had the resident re-weighed to verify the weight was correct, and it was. The scales in the facility were recalibrated. When staff saw the resident was losing weight, but the numbers on the scale stayed the same, she would think staff should report it to the nurse. The resident doesn't always drink his/her Ensure and some CNAs have to take the time to sit with him/her and coax him/her to drink it. His/Her family can get the resident to eat. The MDS Coordinator was not aware of the resident's spitting out food while eating. She expects the resident to receive a mechanical soft diet as ordered. If the resident requests a regular texture diet, she expects nursing staff to let the ST know so she can evaluate the resident. If the resident was not eating, she expected staff to offer different types of foods and to get him/her something he/she wants. She expected the resident to be served ice cream at meals, per physician order. She attends the weekly IDT meetings. She does not recall discussing the resident's weight loss in the IDT meetings.
2. Review of Resident #123's medical record, showed:
-Rarely understood;
-Staff provide maximum assistance for toileting, dressing, hygiene and eating;
-Diagnoses included: quadriplegia (paralysis of all four limbs), mild protein calorie malnutrition, dysphagia, muscle weakness, and abnormal weight loss.
Review of the care plan, in use during the survey, showed:
-Focus: The resident has a diagnosis of adult failure to thrive due to decline in health;
-Goal: The resident will have needs met by staff;
-Interventions: Staff will assist the resident to consume food and fluids;
-Focus: The resident is at risk for dehydration related to memory impairment, decline in condition and poor fluid intake;
-Goal: The resident will be adequately hydrated;
-Interventions: Assess the need for fluids during rounds and meal times, Keep fluids at the bedside and staff assist with fluid consumption;
-Focus: Nutritional problem;
-Goal: Maintain adequate nutritional status as evidenced weight gain;
-Interventions: Serve diet as ordered, provide and serve supplements as ordered, staff encourage fluids, weigh at the same time of day.
Review of the current ePOS, showed a diet order: Regular diet, pureed texture, upon request mechanical soft diet with assistance from restorative therapy aide.
Review of the resident's monthly weights, showed:
-February 2024: 91.2 lbs.
-March 2024: 87.0 lbs.
Review of the ePOS, showed an order, dated 3/18/24 for Ready Care (nutritional supplement) 120 milliliters (ml), three times a day.
Review of the monthly weights, showed:
-April 2024: 82.5 lbs;
-May 2024: 80.0 lbs.
Review of the resident's dietary notes, showed:
-On 5/6/24 at 1:58 P.M., the resident continued on a pureed diet. He/She receives shakes three times a day, Ready Care 2.0 at 120 ml three times a day, Juven (protein supplement) and liquid protein 30 ml as supplement. The resident assisted by staff at meal times, intake fair at times. Current weight 80 lbs., reflecting a 3.1% loss in 30 days and 12.3% in 90 days. Increased calorie and protein needs secondary to malnutrition, weight loss and low body mass index (BMI, a measure of body fat based on height and weight). Speak with physician and family regarding non-oral nutrition;
-On 5/7/24 11:27 A.M., addendum to review note on 4/6/24: Discussed with IDT regarding recommendations. The resident's family declined both tube feeding and hospice services. Recommend discontinue shakes and replace with Ready Care 120 mls three times a day with meals in addition to currently ordered Ready Care.
Review of the ePOS, showed an order, dated 5/8/24, for Ready care 2.0 ml, give 120 ml, three times a day.
Review of the May 2024 MAR, showed:
-An order, dated 3/18/24, for Ready care 2.0, 120 ml three times a day. Scheduled daily at 9:00 A.M., 1:00 P.M., and 5:00 P.M. Staff documented administered daily all times;
-An order, dated 5/8/24, for Ready care 2.0, 120 ml three times a day. Scheduled daily at 9:00 A.M., 1:00 P.M., and 5:00 P.M. Staff documented administered daily all times.
Review of the resident's June 2024 monthly weights, showed: 82.3 lbs.;
Review of the June 2024 MAR, showed:
-An order, dated 3/18/24, for Ready care 2.0, 120 ml three times a day. Scheduled daily at 9:00 A.M., 1:00 P.M., and 5:00 P.M. Staff documented administered daily all times;
-An order, dated 5/8/24, for Ready care 2.0, 120 ml three times a day. Scheduled daily at 9:00 A.M., 1:00 P.M., and 5:00 P.M. Staff documented administered daily all times.
Review of the dietary note, dated 6/7/24 at 11:23 A.M., showed weight on 6/3/24: 82.3 lbs BMI 15.1 underweight. Significant weight loss -8.9 lbs. Noted weight has remained overall stable since 3/28/24. Receiving puree diet order, may have a mechanical soft diet with restorative aide. Receiving Ready Care 120 ml three times a day, new order given on 5/8/24 for additional ready care 120 ml three times a day with meals. Resident's family declined tube feeding support and hospice services. Multiple interventions in place for nutrition support. Stability guarded with multiple comorbidities and disease progression.
Observations on 7/8/24, showed:
-At 10:41 A.M., the resident asleep in his/her chair. He/She appeared thin;
-At 12:04 P.M., noted in the main dining room, at the assisted dining room table. CNA ZZ mixed all food together to feed the resident. Used a spoon, and the resident took two bites of food. CNA ZZ left the table to assist staff. At 12:19 P.M., CNA ZZ returned to the table, offered the resident another spoonful of food. The resident spat out the food. CNA ZZ cleaned the resident's face and pushed the resident toward the nurses station. No supplements were offered at the meal. CNA ZZ did not offer a warm meal or alternative to the resident.
Observation on 7/9/24 at 7:58 A.M., showed the resident in his/her chair at the nurse's station. Staff offered and assisted the resident to drink Ensure. The resident consumed 50% of the container.
Review of the resident's July 2024 monthly weight, showed the resident weighed 84.6 lbs.
Observation on 7/15/24 at 8:50 A.M., showed the resident awake on the edge of the bed. The breakfast plate sat on the table next to the door, away from the resident. The plate contained uneaten eggs and meat. CNA/RA W said he/she and another CNA were the only aides on the floor at the time. He/She had not fed the resident but a bite or two, because other residents needed help. The resident is thin. No supplements were provided on the tray. CNA/RA W did not know where to get the supplements or if the resident was ordered supplements.
During an observation and interview on 7/16/24 at 8:43 A.M., CNA/RA W weighed the resident. CNA/RA W placed the resident, who was seated in his/her wheelchair, onto the shower room scale. The weight was 173.8 lbs in his/her chair. RA W said the chair weighs 94.8 lbs. The resident's current weight was 79 lbs. The resident had lost an additional 5.6 lbs. since the beginning of the month. He/She weighs all the residents at the beginning of the month and documents in the medical records. The resident had lost weight. He/She had observed staff give the resident a bite or two, then leave to provide care to another resident, and do not return to assist Resident #123 to finish eating.
Observation on 7/16/24 at 7:55 A.M., showed the resident in the dining room at the assisted table. He/She was served a pureed breakfast plate at 7:58 A.M. RA W fed the resident. No supplement noted with the breakfast meal.
During an observation and interview on 7/16/24 at 9:35 A.M., the DM said the resident's meal ticket showed a pureed diet and 2.0 supplement. He and the kitchen staff do not put supplements on the meal trays. Nursing was responsible to provide all nutritional supplements. Resident #123 required staff assistance to eat. Staff should obtain the supplement from the medication room. Residents with weight loss should be discussed in the daily stand-up rounds. He was not aware Resident #123 experienced significant weight loss. He ordered supplements and if nursing staff do not have supplements or have low supply, he should be notified, and would order more.
3. Review of Resident #50's medical record, showed:
-Diagnoses included malnutrition, nutritional deficiency, diabetes, anemia, high blood pressure, depression, bipolar disorder (mood disorder), and schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves);
-A physician order, dated 11/1/22, for regular diet, regular texture, regular consistency. Directions: Boost (nutritional supplement) twice daily between meals.
Review of the resident's medication and treatment administration records, showed no order for Boost.
Review of the resident's quarterly dietary profile, signed by the DM, dated 1/11/24, showed:
-Appetite: Good;
-Likes: Finger food, cheese sandwiches. Dislikes: Pork loin.
Review of the resident's weights, showed:
-On 3/8/24, weighed 163.6 lbs.;
-On 4/5/24, weighed 150.0 lbs.;
-The resident had a significant weight loss of -8.31% between 3/8/24 and 4/5/24;
-On 5/3/24, weighed 147.0 lbs.
-The resident had a significant weigh loss of -10.15% between 3/8/24 and 5/4/24.
Review of the resident's RD note, dated 5/7/24, showed 9.9% weight loss in 90 days. Regular diet, Boost in between meals. Intake records indicate 25-100% consumed. No change warranted.
Review of the resident's weights, showed on 6/3/24, the resident weighed 149.5 lbs.
Review of the resident's RD note, dated 6/7/24, showed significant weight loss, 8.6% in three months. Overall stable for two months. Regular diet with Boost twice daily.
Review of the resident's quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-No behaviors exhibited;
-Independent with eating;
-No weight loss.
Review of the resident's care plan, in use at the time of survey, showed:
-Focus: Residents needs supervision with his/her ADLs;
-Interventions: Resident is supervised with his/her ADLs: Eating;
-Focus: Resident has nutritional problem or potential nutritional problem related to no teeth;
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SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Respiratory Care
(Tag F0695)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident with chronic obstructive pulmonary d...
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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 a resident with chronic obstructive pulmonary disease (COPD, a chronic lung disease which airflow is constricted and makes it difficult to breathe) symptoms, received ordered oral steroids. The resident continued to have audible wheezing and the facility obtained a STAT (immediate) chest x-ray. The facility did not obtain or report the results to the physician and the x-ray results reflected pneumonia. The resident experienced a change in condition on 7/13/24, was sent to the hospital, where he/she received steroids. He/She was diagnosed with a COPD exacerbation and ordered steroids and two separate antibiotics (Resident #4). In addition, the facility also failed to obtain physician orders for continuous positive airway pressure machines (C-PAP, a machine which provides a mild continual airflow pressure to maintain an open airway, used to treat sleep apnea) for two residents diagnosed with sleep apnea (sleep disorder in which breathing repeatedly stops and starts) (Residents #42 and #89). The census was 151.
Review of the physician order policy, revised 10/24/22, showed:
-Purpose: To ensure that all physician orders are complete and accurate;
-Policy: Medical record department will verify that physician orders are complete, accurate and clarified;
-Procedure: Physician orders will include the following:
-Name of the medication, treatment;
-Dosage, frequency and duration of the order;
-The route, condition and diagnoses for which the medication/treatment is ordered.
1. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/15/24, showed:
-re-admitted : 1/22/23;
-Severe cognitive impairment;
-Upper and lower extremity paralysis;
-Staff provide substantial to maximum assistance for toileting, transfers, dressing and hygiene;
-Diagnoses included: stroke, cancer, heart failure, vascular disease, diabetes, dementia, and COPD;
-No respiratory therapy provided in the last seven days;
-No respiratory treatments provided.
Review of the care plan, in used during the survey, showed:
-Focus: The resident has a diagnosis of COPD and is at risk for shortness of breath and respiratory failure related to lung cancer;
-Goal: The resident will be free of respiratory infection;
-Interventions: Staff administer respiratory medications as ordered, monitor for difficulty breathing, monitor and document any signs of respiratory infection and notify the nurse and physician of changes.
Review of the progress notes showed:
-On 6/26/24 at 10:41 A.M., a nurse note: The resident complained of shortness of breath. Oxygen saturation at 90% (normal 90-100% breathing room air). Breathing treatment given per orders. Nurse practitioner (NP) onsite, assessed the resident and new orders given for chest x-ray;
-On 6/26/24 at 2:07 P.M., a nurse note: The resident refused breakfast and lunch. Snacks offered and declined. Staff offered and encouraged fluids, the resident stated he/she was not hungry;
-On 6/26/24 at 6:35 P.M., a nurse note: Chest x-ray results received, diagnoses of pneumonia. New orders received: Vantin (antibiotic) 100 milligrams (mg) twice a day for seven days and Medrol dose pack (a titration lowering medication dose) as directed: (4 mg dose pack schedule: Day 1: take 2 tablets before breakfast, 1 after lunch, 1 after dinner, 2 at bedtime;
Day 2: take 1 tablet before breakfast, 1 after lunch, 1 after dinner, 2 at bedtime;
Day 3: take 1 tablet before breakfast, 1 after lunch, 1 after dinner, 1 at bedtime;
Day 4: take 1 tablet before breakfast, 1 after lunch, 1 at bedtime;
Day 5: take 1 tablet before breakfast and 1 at bedtime;
Day 6: take 1 tablet before breakfast.
Review of the electronic physician order sheet (ePOS), showed an order, dated 6/27/24: Medrol (used to treat inflammation) tablet 4 mg.
Review of the June Medication Administration Record (MAR), showed:
-An order, dated 6/27/24:
-Medrol 4 mg: Give 2 tablets in the morning, scheduled at 9:00 A.M., documented as 9 or see progress notes;
-Medrol 4 mg: Give 1 tablet in the afternoon, scheduled at 12:00 P.M., documented as 9, or see progress notes.
Review of the progress notes on 6/27/24 at 2:51 P.M., showed a nurse note: Medrol 4 mg, awaiting pharmacy delivery.
Review of the June MAR, showed:
-An order, dated 6/27/24:
-Medrol 4 mg: Give 1 tablet in the evening, scheduled at 5:00 P.M., documented as given;
-Medrol 4 mg: Give 2 tablets at bedtime, scheduled at 9:00 P.M.,, documented on 6/27/24 as given;
-An order, dated 6/28/24:
-Medrol 4 mg: Give 1 tablet in the morning, scheduled at 9:00 A.M., documented as given;
-Medrol 4 mg: -Medrol 4 mg: Give 1 tablet in the afternoon, scheduled at 12:00 P.M., documented as given;
-Medrol 4 mg: Give 1 tablet in the evening, scheduled at 5:00 P.M., documented as given;
-Medrol 4 mg: Give 2 tablets at bedtime, scheduled at 9:00 P.M.,, documented as given;
-An order, dated 6/29/24, showed:
-Medrol 4 mg: Give 1 tablet in the morning, scheduled at 9:00 A.M., documented as given;
-Medrol 4 mg: Give 1 tablet in the afternoon, scheduled at 12:00 P.M., documented as given;
- Medrol 4 mg: Give 1 tablet in the evening, scheduled at 5:00 P.M., documented as given;
- Medrol 4 mg: Give 1 tablet at bedtime, scheduled at 9:00 P.M., documented as given;
-An order, dated 6/30/24, showed:
-Medrol 4 mg: Give 1 tablet at 9:00 A.M., 12:00 P.M., and 9:00 P.M., documented as given.
Review of the July MAR, showed:
-An order, dated 7/1/24:
-Medrol 4 mg: take 1 tablet at 9:00 A.M., 12:00 P.M., documented as given on 7/1/24 and 7/2/24.
Review of the progress notes, showed on 7/5/24:
-At 12:53 P.M., a nursing note: The resident observed with abdominal breathing, family at bedside. The resident denies shortness of breath. Breathing treatment given. Physician notified;
-At 1:07 P.M., the physician provided new orders for a STAT chest x-ray and Prednisone (anti-inflammatory) at 50 mg day 1, 40 mg day 2, 30 mg day 3, 20 mg day 4, 10 mg day 5, then discontinue.
Review of the nurse practitioner visit note, dated 7/5/24 at 8:30 P.M., showed:
-Chief complaint: Completed antibiotics for pneumonia on 7/4/24, with reported shortness of breath. Increased shortness of breath and abdominal muscle use;
-Duration: Chronic condition;
-Respiratory: Complaint of dyspnea (shortness of breath, difficulty breathing), accessory abdominal muscle use, non-productive cough, shallow respirations, diminished breath sounds and mild expiratory wheezing;
-Labs: STAT chest x-ray ordered;
-Plan: New order Prednisone 10 mg burst- give 50 mg one time a day, then taper off. Medrol 4 mg- give 2 tablets at bedtime for COPD and Trelegy Elliptia inhalation (bronchodilator, opens lung airways) 1 inhalation once a day for COPD.
Review of the ePOS, showed:
-An order, dated 7/5/24: Ipratropium-albuterol inhalation (used to treat shortness of breath, and open the airways) 0.5-2.5 mg/3 milliliter (ml) solution. Inhale 3 ml twice a day;
-An order, dated 7/5/24: STAT chest x-ray.
Review of the progress note, showed:
-On 7/5/24 at 11:13 P.M., a nursing note: X-ray technician here to obtain chest x-ray. Results pending. No signs or symptoms of distress noted.
Review of the ePOS, showed an order, dated 7/5/24: Medrol 4 mg, give 2 tablets a day at bedtime.
Review of the July 2024 MAR, showed:
- An order, dated 7/5/24: Medrol 4 mg, give 2 tablets a day at bedtime at 9:00 P.M.,;
-Documented as given on 7/1/24 and 7/2/24;
-Documented as 9 or see progress notes on: 7/3/24 and 7/4/24;
-No progress note documented to reflect the non-administration on 7/3/24 or 7/4/24.
Review of the July MAR, showed:
-An order dated, 7/6/24 for: Prednisone give once a day at 9:00 A.M., scheduled:
-Prednisone 50 mg day 1, on 7/6/24: blank, undocumented;
-Prednisone 40 mg day 2, on 7/7/24: blank, undocumented;
-Prednisone 30 mg day 3, on 7/8/24: blank, undocumented;
-Prednisone 20 mg day 4, on 7/9/24: blank, undocumented:
-Prednisone 10 mg day 5, on 7/10/24: blank, undocumented;
-Prednisone 5 mg day 6, on 7/11/24: blank, undocumented.
Review of the progress notes, showed:
-On 7/6/24 at 8:20 P.M., a nurse note: Medrol 4 mg- medication not available;
-On 7/8/24 at 12:11 P.M., a nurse note: Nurse practitioner notified of missing Prednisone on the dates of 7/6/24 and 7/7/24. No new orders received;
-No documentation regarding STAT chest x-ray results.
During an interview on 7/8/24 at 2:02 P.M., the resident's next of kin (NOK) said the resident was diagnosed with pneumonia and recently finished antibiotics. He/She wanted another chest x-ray done earlier in the week and had not be told the results. The NOK said he/she was very concerned because he/she could hear the resident wheezing and a wet cough. The nursing staff were unable to tell him/her if the x-ray had been completed or if the results were reported. He/She was concerned the pneumonia is not completely treated.
Review of the progress notes, showed:
-On 7/8/24 at 8:46 P.M., a nurse note: Medrol dose pack completed;
-On 7/10/24 at 8:37 P.M., a medication note: Medrol 4 mg - medication pending from pharmacy.
During an interview on 7/11/24 at 10:26 A.M., the NP said he was familiar with the resident's care. The resident has a history of COPD and chronic pneumonia. He expected staff to administer medications as ordered. If a medication were not available, he expected staff to notify the physician or the NP. Prednisone is a steroid used to reduce inflammation. After checking communications with the facility, the NP said the office had not been notified of the chest x-ray results from 7/5/24 or the missed Prednisone doses from 7/6/24 thru 7/11/24.
Review of the progress notes, showed:
-On 7/13/24 at 4:02 A.M., the resident complained of pain, Tylenol (pain reliever) given. Audible wheezing heard. Oxygen saturations at 91% room air. Breathing treatment given. Head of bed elevated;
-On 7/13/24 at 4:15 A.M., the resident further assessed. Noted to have abdominal breathing, wheezing, moist lung sound, gurgling and desating (oxygen levels drop) physician called and message left. Oxygen saturation dropped to 85%, head of bed at high position, oxygen started at 3 liters per minute (LPM)/ nasal cannula (NC, hollow tube to the nose, used to deliver oxygen);
-On 7/13/24 at 4:30 A.M., a weekly skin note: skin assessment done, bed bath given before resident left;
-On 7/13/24 at 4:32 A.M., a nurse note: Ambulance called for transportation to emergency room (ER) for evaluation and treatment. Arrival approximately 20 minutes;
-On 7/13/24 at 4:50 A.M., a nurse note: Ambulance arrived, resident to ER;
Review of the hospital visit summary, dated 7/13/24, showed:
-Reason for visit: Shortness of breath;
-Diagnosis: COPD exacerbation;
-Discharge medications:
-Amoxicillin 875-125 (combination antibiotic) mg: Take one tablet every 12 hours;
-Azithromycin (antibiotic) 250 mg: Take 2 tablets for one day, then 1 tablet daily for 4 days, start taking on 7/13/24;
-Prednisone 20 mg: Take 40 mg daily for 4 days-start taking on 7/13/24.
Review of the progress notes, showed:
-On 7/13/24 at 11:17 P.M., nursing note: The resident alert and responsive. Assisted to bed by two staff. Coarse lung sounds and breathing treatment given as ordered. Oxygen saturation at 93% room air. The nurse notified the NOK no new medications were ordered.
Review of the ePOS, showed:
-An order, dated 7/14/24: Prednisone 40 mg, take one tablet daily for 4 days;
-An order, dated 7/14/24: Azithromycin 250 mg, take 2 tablets for one day, then 1 tablet daily for 4 days;
-An order, dated 7/14/24: Amoxicillin 875-125 mg, take one tablet every 12 hours.
Review of the progress notes, dated 7/14/24 at 5:42 P.M., showed a nursing note:
-Prednisone 40 mg tablet- give one every evening for respiratory infection. Medication pulled from E-kit (emergency medication supply);
-This administration was not documented on the July MAR;
-Amoxicillin 875-125 mg-give one tablet every 12 hours for 4 days. Medication pulled from E-kit;
-At 8:57 P.M., the resident remains on antibiotics and Prednisone. Denies pain and no signs or symptoms of discomfort.
Review of the July 2024 MAR, showed:
-An order, dated 7/14/24: Prednisone 40 mg: take one every evening for respiratory infection. Documented as zero 0, on 7/14/24, 7/15/24. Documented as 5 or digoxin (heart medication) level on 7/16/24.
-An order, dated 7/14/24: Amoxicillin 875-125 mg. Give 1 tablet every 12 hours for 4 days for respiratory infection. Documented as administered at 9:00 A.M., and 9:00 P.M., daily;
-An order, dated 7/15/24: Azithromycin 250 mg: take 1 in the morning for respiratory infection. Documented as administered at 9:00 A.M., on 7/14/24, 7/15/24, 7/16/24 and 7/18/24;
On 7/15/24 at 9:25 A.M., the Regional Nurse provided the chest x-ray, completed on 7/5/24 at 4:41 P.M. The results are as follows:
-Date of service: 7/5/24;
-Time: 4:41 P.M.,
-Indication: Congestion;
-Findings: Patchy infiltrates in the left upper and lower lobe;
-Impression: Patchy left sided pneumonia;
-No physician signature or acknowledgement of the results.
During an interview on 7/16/24 at 11:16 A.M., the Director of Nursing (DON) and Administrator said after review of the chest x-ray results from 7/5/24, it appeared the physician was not notified of the results. Staff should follow up with the imaging results the next day or if ordered STAT, within a few hours of the testing. If ordered medications are not available, staff should pull the medication from the E-kit. If the medication is not available in the E-kit, the pharmacy should be called for an emergency delivery. Staff should notify the physician or nurse practitioner if medications are not available or missed.
During an interview on 7/17/24 at 3:10 P.M., the resident's Physician said the resident has lung cancer, COPD exacerbation and chronic pneumonia. He did not receive any communications from the facility regarding missed medication doses or the STAT chest x-ray results. He expected staff to follow up with the imaging company for results and report those to him or the NP. If medications are not available at the facility, the pharmacy should be called. The DON and Administrator should obtain the medications. He should be notified to order a different medication if needed. Prednisone is used to reduce inflammation quickly. The resident should have received the Prednisone, but he/she did receive the antibiotics. The Physician is unsure if the Prednisone would have prevented the change in condition or hospitalization.
2. Review of Resident #42's quarterly MDS, dated [DATE], showed:
-No cognitive impairment;
-Diagnoses include heart failure, high blood pressure, asthma, respiratory failure;
-Receives oxygen therapy.
Review of the resident's care plan, in use during survey, showed:
-Focus: COPD, C-PAP used during resting hours due to shortness of breath;
-Interventions: Resident will use C-PAP during his/her resting hours;
-Monitor his/her oxygen saturation as directed.
Review of the resident's ePOS, dated July 2024, showed:
-An order, dated 5/28/24: Does the resident experience shortness of breath while lying flat or avoids lying flat (utilizes pillows) due to shortness of breath? Every shift for COPD;
-An order, dated 5/28/24: Resident is at risk for malnutrition related to COPD, atrial fibrillation (Afib, abnormal heartbeat), congestive heart failure (CHF), rheumatoid arthritis (RA), high blood pressure. Interventions: Registered Dietician (RD) to evaluate as needed, weights as needed, labs as needed, medications as ordered;
-No physician's orders for use of the C-PAP machine.
Review of the resident's July 2024 MAR, showed:
-Does the resident experience shortness of breath while lying flat or avoids lying flat (utilizes pillows) due to shortness of breath? Every shift for COPD, showed:
-On 7/1, 7/3, 7/4, and 7/7/24 at 6:00 A.M., staff documented yes;
-On 7/9 and 7/10/24 at 2:00 P.M., staff documented yes;
-On 7/1 through 7/11/24 at 10:00 P.M., showed no shortness of breath.
Observation and interview on 7/11/24 at 9:15 A.M., showed resident in room, in bed. The resident had a C-PAP machine on the night table. He/She said the aides assist him/her every night with the C-PAP. The mask lay on the night table, uncovered.
Observation on 7/15/24 at 10:49 A.M., the resident's C-PAP mask on the resident's bed uncovered. The machine lay on the resident's night table. It was not in use.
During an interview on 7/15/24 at 3:00 P.M., Licensed Practical Nurse (LPN) SS said sometimes staff assist with the C-PAP or the resident can do it him/herself. The resident is still awake when LPN SS leaves at 11:00 P.M., so he/she is not using it yet.
During an interview on 7/16/24 at 8:28 A.M., the resident said he/she uses the C-PAP every night. He/She turned off the machine at 7:00 A.M. and starts it at 11:30 P.M. The aides put water in the machine and they turn it on. The CPAP mask was uncovered on top of the seat of the resident's wheelchair.
3. Review of Resident #89's annual MDS, dated [DATE], showed:
-No cognitive impairment;
-Diagnoses included: heart failure, hypertension (HTN, high blood pressure), hyperlipidemia (HLD, high level of lipids (fat particles) in the blood), diabetes, malnutrition, anxiety, bipolar (mental disorder where the person experiences manic highs to depressive lows), and asthma;
-Received oxygen.
Review of the resident's care plan, in use during survey, showed:
-Focus: Resident has a diagnosis of COPD;
-Interventions: Resident uses Bilevel positive airway pressure (bi-pap, machine that helps with breathing) at bedtime related to COPD and obstructive sleep apnea.
Review of the resident's ePOS, dated July 2024, showed:
-An order, dated 4/2/24, resident is at risk for malnutrition related to COPD, diabetes, chronic pain, depression, HTN, and HLD. Registered dietician to evaluate as needed, weights as needed, labs as needed, and medications as ordered;
-An order, dated 4/9/24, Does the resident experience shortness of breath while lying flat or avoids lying flat (utilizes pillows) due to shortness of breath? Every shift for COPD;
-No physician's orders for use of C-PAP;
-No physician's orders for use of oxygen therapy.
Review of the resident's MAR, dated July 2024, showed:
-Does the resident experience shortness of breath while lying flat or avoids lying flat (utilizes pillows) due to shortness of breath? Every shift for COPD, showed:
-On 7/1, 7/5, and 7/7/24 during the day shift, staff documented yes;
-On 7/1 and 7/7/24 during the evening shift, showed no shortness of breath;
-On 7/2, 7/6, and 7/7/24 during the night shift, staff documented yes.
Review of the resident's progress notes, showed:
-On 6/14/24 at 6:32 A.M., resting in bed. No signs of acute distress noted. Remains on increased observation after readmission. Breathing even and unlabored with C-PAP on. Activities of Daily Living (ADLs) performed by staff. No concerns or complaints voiced;
-On 7/3/24 at 2:09 A.M., resident resting quietly in bed. Leg thrown over side. Resident is not wearing C-PAP mask. Encouraged to do so.
Review of the resident's nurse practitioner notes, showed on 7/5/24 at 5:39 P.M., patient needs new tubing for C-PAP machine.
During observation and interview on 7/08/24 at 9:39 A.M., the resident was in room with the oxygen machine turned on and set at 3 liters (L) per nasal cannula. The tubing was on the floor. The resident had a C-PAP machine on his/her night table. The mask was uncovered.
Observation 7/08/24 at 4:56 P.M., and 7/9/24 at 8:00 A.M., showed the resident was in the hospital. The oxygen machine in the room remained on at 3 L. The oxygen tubing was on the floor. The C-PAP mask was uncovered on the night table.
During an interview on 7/15/24 at 2:53 P.M., Restorative Aide W said to his/her understanding, the resident only used oxygen at night.
During an interview on 7/15/24 at 3:00 P.M., LPN SS said the resident used oxygen, but it was only as needed.
During an interview on 7/15/24 at 3:27 P.M., LPN S said the resident did not use oxygen. His/Her C-PAP was broken. The cord broke on Sunday evening, on 7/7/24, the day before the resident went to the hospital. Observation of the cord showed a tear, approximately half an inch. There should be orders for use of C-PAP and the settings.
4. During an interview on 7/16/24 at 11:18 A.M., the DON said she would expect there to be an order for use of C-PAP machine. If resident was admitted with C-PAP, she would expect nursing to notify the physician to obtain orders. The settings and diagnosis for use of C-PAP should be documented on the orders. If the resident's C-PAP was broken, Central Supply could be an option for obtaining another tube. She would expect staff to have notified the physician for the use of oxygen therapy and document it in the medical record.
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 ensure a resident was assessed and demonstrated the ability to safely self-administer medications when the resident self-admi...
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Based on observation, interview, and record review, the facility failed to ensure a resident was assessed and demonstrated the ability to safely self-administer medications when the resident self-administered medications via a gastric tube (g-tube, tube surgically inserted into the stomach to administer food, fluid, and nutrition) and did not follow acceptable standards of practice. Staff present at the time failed to provide education on safe medication administration as the medications were being administered (Resident #45). The census was 151.
Review of the facility's Medication-Self Administration policy, dated 10/24/22, showed:
-Policy: Residents who request to perform medication self-administration will be assessed for capability. The assessment of medication self-administration will ensure a clinically appropriate, effective process for the resident to provide self-care. The facility is responsible to ensure medications are administered as ordered by the attending physician even when self-administered;
-Procedure: During the admission process, residents will be asked if they wish to self-administer medications;
-Those residents who wish to self-administer medications will be assessed during the admission process to ensure they have the necessary knowledge and skill(s) to safely self-administer medications;
-Additional assessments will be completed at least quarterly;
-Based on clinical judgment, a licensed nurse may reassess a resident related to the safe self-administration of medications as needed;
-The resident must be able to demonstrate the following:
-Knowledge of medications and medication schedule;
-The ability to read the medication label and manufacturer's insert;
-Self-administration techniques including use of packaging, reading label, opening containers;
-Ability to administer medication properly, e.g., insulin/syringe, eye drops, inhalers;
-Agree to comply with facility policy related to the self-administration of medication;
-If the resident is assessed as clinically appropriate for medication self-administration, by the Interdisciplinary Team (IDT), the licensed nurse obtains a physician's order for self-administration of selected medications;
-The resident's record should contain documentation that demonstrates that he/she was part of the IDT process in determining whether self-administration is safe and appropriate;
-Medications specifically excluded from self-administration for any reason must be specified in the attending physician's order;
-Self-administration is only permitted if approved in writing by the attending physician, which may be in the form of an order;
-The IDT develops and implements a care plan for medication self-administration;
-The care plan will identify:
-Where the medications are stored;
-Education for resident/family regarding medication self-administration process, specific medication information and safe, effective use of medications;
-Obtaining medication;
-Administering medication according to physician order;
-How licensed nurses will validate that medications are taken as ordered by the attending physician;
-How non-compliance and/or refusal to take medications will be managed;
-The licensed nurse on each shift ensures that medications are taken as ordered by the attending physician and documents on the medication administration record (MAR);
-Residents will be re-evaluated if any member of the IDT suspects non-compliance with the self-administration authorization or any change in the resident's cognitive status;
-In the case of suspected medication non-compliance (e.g. dosage in excess of the amount anticipated, loss of therapeutic control or suspected drug toxicity) the nursing staff will complete an assessment. The attending physician will be notified if the resident is no longer deemed appropriate for self-medication administration. The licensed nurse will obtain orders as necessary;
-Documentation: The physician's order approving the self-administration of medication will be maintained in the resident's medical record;
-The Assessment for self-Administration of Medications will be maintained in the resident's chart;
-Self-administration of medications will be documented in the resident's care plan and the MAR.
Review of Resident #45's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 4/26/24, showed the following:
-Diagnoses included severe protein-calorie malnutrition (inadequate intake of food containing calories and proteins), bipolar (mental disorder that affects a person's thoughts, feelings, and behaviors), depression, post-traumatic stress disorder (a past event that affects a person's thoughts, feelings, and behaviors) and anxiety;
-Feeding tube used;
-Cognitively intact.
Review of the resident's care plan, dated 6/11/24, showed:
-Focus: resident has declined to allow staff to administer his/her medication via oral route as directed;
-Goal: resident will have his/her medications administered as directed;
-Interventions: encouragement and retraining needed to allow resident to regain taste sensation of medication, monitor his/her intake of medications, if nausea/vomiting persists administer his/her medications via Peg Tube (a type of feeding tube) and document.
Review of the resident's physician order sheet, in use at the time of the survey, showed:
-An order dated 1/6/24, for staff to flush the enteral tube (feeding tube) with 30 milliliters (ml) of water before and after medication administration. Flush with 5-10 ml water between medications;
-An order dated 5/17/24, for g-tube site care every shift;
-An order dated 6/11/24, for staff to make a slurry of his/her medications;
-An order dated 6/27/24, for Protonix (treats acid reflux) delayed release, 40 milligrams (mg) via g-tube daily;
-No order to self-administer medications.
Review of the resident's progress notes, dated 7/8/24 at 11:43 A.M., showed the resident requested to self-administer medication through the g-tube. Staff made medical director (MD) aware. MD said decline to give order and stated that nurse must give resident his/her medication. The resident and Director of Nursing (DON) made aware.
Observation on 7/11/24 at 7:30 A.M., showed Licensed Practical Nurse (LPN) J prepared medications for the resident at the nurse's station. He/She crushed the resident's Protonix tablet and placed the resident's medication into a 5 ml medication cup and walked to the resident's room. LPN J filled a graduate (container used to measure liquids) with warm water from the sink in the resident's room, added an unmeasured amount to the medication cup, and handed the resident the cup of fluid containing medications. The resident exposed his/her abdomen and produced the g-tube, removed the stopper and inserted an empty syringe in the g-tube, the plunger remained on the bedside table. The resident poured approximately half of the liquid containing medication into the syringe, a large amount of air remained in the syringe, placed the plunger at the end of the syringe and then pushed the liquid containing medications in quickly and with force, approximately 9 cc of air also injected into the stomach. The resident removed the syringe from the g-tube slightly to allow the plunger to be removed without resistance. The resident placed the syringe back into the g-tube, poured more of the fluid containing medication into the syringe, a large amount of air remained in the syringe, inserted the plunger, and pushed the medications in quickly and with force. The resident removed the syringe from the g-tube slightly to allow the plunger to be removed without resistance. The resident then poured water from the graduate into the cup containing residual medications. The resident placed the syringe back into the g-tube, poured the remaining fluid in the medication cup, a large amount of air remained in the syringe, inserted the plunger, and pushed the medications in quickly and with force. The resident replaced the stopper and laid back into bed. LPN J observed the resident administering medication, did not cue the resident to allow the medication to be administered via gravity, did not cue the resident to not to push air into the stomach, and did not provide education on the risks of inserting air into the stomach.
During an interview on 7/11/24 at 8:47 A.M., LPN J said the resident will not allow staff to flush, administer the medication, or apply the gauze to the g-tube site. The resident has a history of refusing the medications if staff attempt to provide medications and treatments as ordered. The resident needs constant reminders to not push so much air into the stomach while administering the medications. The resident's medications that are in pill or capsule form, staff opens the capsules and crushes the contents along with the pills.
During an interview on 7/11/24 at 3:14 P.M., Pharmacist Y, a pharmacist with the pharmacy which supplies the facility's medications, said the Protonix is not to be crushed and the facility should have contacted the pharmacy for a liquid form of the medication.
During an interview on 7/15/24 at 2:53 P.M., LPN U said only the nurses should administer the medication through a g-tube. When the resident has an order to self-administer medications through a g-tube, the nurse should remain with the resident during administration and remind the resident about the steps.
During an interview on 7/16/24 at 12:14 P.M., the DON said a resident should have an order to self-administer medication and fluids through a g-tube. She expected staff to document refusals and to notify nursing management and the doctor. She expected staff to observe a resident self-administering their medications, and cue the resident as needed. She was unaware the Protonix was being crushed.
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 F0620
(Tag F0620)
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 update records of residents' personal possessions per...
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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 update records of residents' personal possessions per facility policy for two sampled residents (Resident #42 and #39). Resident #42 purchased dresses and socks that were not documented on the resident's inventory sheet and were missing after being sent to laundry. Resident #39 purchased shirts and pants that were not documented on the resident's inventory sheet and were missing after being sent to laundry. The sample was 30. The census was 151.
Review of the facility's admission policy, revised July 2022, showed:
-Laundry services: The facility will clean the resident's laundry (in commercial machines with industrial detergent) at no additional charge to the Resident. The family will pick up and clean the resident's laundry and the family will provide a covered, plastic laundry container to the facility;
-Family will ensure that the resident's clothing has been pre-marked with his or her name and is periodically remarked as needed. In addition, the resident understands that the facility does not assume responsibility for lost or damaged laundry except as required by state law.
Review of the facility's Lost and Prevention Policy, dated 10/24/22, showed:
-Policy: The facility is committed to preventing the misappropriation of resident property. The facility will exercise reasonable care for the protection of the resident's property from theft or loss;
-The facility investigates all reports of stolen items, makes reports to authorities as required by law, and maintains documentation of all reports of lost or stolen property;
-Upon admission, facility staff provides the resident and/or his/her representative with the facility's policy regarding theft prevention and the relevant sections of the state law relating to theft and loss;
-Inquiries regarding lost or stolen items are reported to the Administrator or Social Service Director;
-Measures to Secure Personal Property: Upon admission and upon request thereafter, the facility provides the resident and/or his/her representative with a copy of the resident inventory;
-Items brought into the facility after admission are added to the resident inventory at the request of the resident or his/her representative;
-The resident or his/her representative should notify the Administrator of any items removed from the facility that need to be deleted from the resident inventory;
-The facility is not liable for those items which the resident or representative has not requested be added to the resident inventory or for items that have been deleted from the resident inventory;
-It is at the discretion of the resident or their representative to indicate items that are not subject to addition or deletion from the Resident Inventory due to frequent removal from the facility (clothing, books, etc.);
-Items brought to the facility are marked, to the extent possible, identifying the owner of the item (engraving, tagging, marking clothing tags, etc.);
-The Administrator or designee investigates all reports of stolen items and documents the investigation Theft/Loss Report. The investigation may consist of the following:
-An interview with the facility staff member notifying the Administrator of the missing item(s);
-An interview with any witnesses that may have knowledge of the missing items;
-An interview with the resident (if medically appropriate);
-An interview with the person (if any) accused of taking the resident's property;
-A review of the resident Inventory record to determine if the missing items were recorded;
-Interviews with facility staff (on all shifts) having contact with the resident during the past 48 hours;
-Interviews with the resident's roommate, family members, and visitors;
-A search of the laundry room for missing articles of clothing.
1. Review of the Resident #42's medical record, showed he/she was admitted on [DATE].
Review of the resident's care plan, in use during survey, showed:
-Focus: Resident wishes to stay long term care;
-Goal: Will continue to express satisfaction with living arrangements;
-Interventions: Encourage social interactions and participation in activities with other residents; Evaluate discharge and long term care goals quarterly and as needed.
Review of the resident's personal inventory sheet, dated 2/21/24, showed:
-Seven T-shirts (purple, gray, powder blue, red, two white, and yellow);
-Three pairs of shorts (two navy blue and black);
-One pair of shoes;
-One pair of pink stockings;
-One Samsung cell phone and three chargers;
-One Continuous positive airway pressure (C-PAP, a machine helps treat sleep apnea) machine;
-One electric wheelchair.
Observation and interview on 7/15/24 at 8:18 A.M., showed the resident in bed and said he/she had clothing at one point. He/She had approximately seven or eight dresses. Four dresses have not been returned from laundry, but the name tags could have fallen off. The resident's closet contained five pairs of pants, four jackets, two sweaters, three shirts, and three dresses.
During observation and interview on 7/15/24 at 10:49 A.M., the resident said he/she told the Minimum Data Set (MDS) Coordinator and the person in laundry about the dresses but had heard nothing. There was an inventory sheet filled out.
During an interview on 7/15/24 at 10:50 A.M., Licensed Practical Nurse (LPN) S said there were a lot of changes with laundry. Anyone that could do laundry was doing it. Most of the laundry staff were let go.
During an interview on 7/15/24 at 11:24 A.M., Central Supply GGG said he/she found three of four of the resident's dresses. He/She returned them to the resident at that time.
During an interview 7/15/24 at 11:55 A.M., the resident said Central Supply GGG returned some dresses, and they were currently hanging in his/her closet, but there were four other dresses that were lost. Central supply GGG said he/she would keep his/her eye open for them. The dresses were a solid blue dress, a blue print dress, a purple and black dress, and a black and beige dress. The resident also had missing socks. The resident showed a pair of Bombas socks (designer socks with seamless toes and grippy bottoms and innovative features like blister tabs and arch support) from his/her drawer with his/her name inside the sock. The dresses were purchased by his/her friend. They were expensive. They came from a specialty company that has dresses that open in the back for people who are incontinent. When he/she has new clothing, he/she informs the social worker and the social worker updates the inventory sheet.
2. Review of Resident #39's medical record, showed he/she was admitted on [DATE] and re-admitted on [DATE].
Review of the resident's care plan, in use during survey, showed:
-Focus: Resident wishes to stay long term care;
-Goal: Will continue to express satisfaction with living arrangements;
-Interventions: Encourage social interactions and participation in activities with other residents; Evaluate discharge and long term care goals quarterly and as needed.
Review of the resident's personal inventory sheet, dated 3/6/23, showed:
-Six button down shirts;
-Five T-shirts;
-Five pairs of jeans
-12 pairs of boxers;
-10 pairs of socks;
-Two pairs of shoes;
-One pair of slippers;
-One Jacket;
-One coat.
Review of the resident's personal inventory sheet, dated 4/3/23, showed:
-Six button down shirts;
-Five T-shirts;
-Five pairs of jeans
-12 pairs of boxers;
-10 pairs of socks;
-Two pairs of shoes;
-One Jacket;
-One coat;
-One television.
Observation and interview 7/12/24 at 4:03 P.M., showed he/she wore a long sleeve, gray plaid shirt and jeans and said he/she bought some clothes, but they were either ruined or lost when it got to laundry. It did not come back. He/She was embarrassed to let the surveyor look into his/her closet because he/she did not have much clothing. His/Her clothes do not go to laundry anymore. He/She washes his/her clothes by hand and hangs them up in his/her room. The resident had four long-sleeved, button-down shirts, two short sleeved shirts, and one pair of jeans. The resident said he/she had approximately 12 pairs of jeans and 12 shirts.
During an observation and interview on 7/16/24 at 8:45 A.M., the resident was observed wearing a long sleeve, gray plaid shirt and jeans. He/She said he/she reported his/her missing clothes to staff at the time. It went to laundry and did not come back. There are so many new people in laundry and the resident said he/she was not the only one with missing clothing.
3. During observation and interview on 7/15/24 at 11:13 A.M., Laundry Aide EEE and Laundry Aide FFF said they worked for the facility for approximately one month. When they started, there was a lot of lost clothing. They had to reorganize everything. There are clothes on a rack on the back wall. Observation showed a long rack against the back wall with clothing. Laundry Aide EEE and Laundry Aide FFF said the clothing on the rack was mostly new clothing without names. If a resident lost clothing, they will look through the rack and see if there is something that matched the description and take it to the resident to identify it. Laundry Aide FFF and staff from Central supply found Resident #42's dresses. He/She found three of the resident's dresses. Laundry Aide EEE and Laundry Aide FFF did not know anything regarding Resident #39's clothing. Some challenges they face are nursing does not inform laundry if a resident moved rooms or if there was a new resident, so they had to keep following up to where the residents are. The Certified Nurse Aides (CNAs), nurses, and social workers come down to laundry and take clothing and they do not inform laundry staff. Nursing also does not separate the clothing. They may clean up a resident or give a bed bath, put everything together such as the resident's personal clothing, soiled brief, linen, wash cloths, and towels in a bag. There are separate bins for soiled linen. Laundry staff remove the bag from upstairs and do the laundry. As a result, they did not know residents' clothing was in the bag, so they have bleached residents' clothing and washed soiled briefs. They report it to management.
4. During an interview on 7/15/24 at 12:32 P.M., Social Worker said the social worker designee updates the inventory sheets. When there is a new admit, the designee completes the inventory sheet. The residents are encouraged to call Social Worker and Central Supply GGG if they are updating the inventory sheet. The Social Worker was unaware of the resident's missing clothing, but the resident knows to update the list.
5. During an interview on 7/16/24 at 11:18 A.M., the Administrator said residents are to report missing or lost clothing to social services and they report it to laundry. Any staff member can report it to laundry. The Administrator was aware of Resident #42's missing clothing, but not Resident #39's missing clothing. She would expect the inventory to be completed and updated. If there are missing clothing, they try to identify who the clothing belongs to.
MO00238297
MO00238490
MO00234580
MO00237491
MO00235408
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to address behaviors related to pulling the call light out of the wall, on the care plan for one sampled resident (Resident #96)....
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Based on observation, interview and record review, the facility failed to address behaviors related to pulling the call light out of the wall, on the care plan for one sampled resident (Resident #96). The sample was 30. The census was 151.
Review of Resident #96's medical record, showed his/her diagnoses included Alzheimer's disease, muscle weakness, insomnia, depression, low blood pressure, high cholesterol, anxiety disorder and difficulty in walking.
Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/30/24, showed:
-Severe cognitive impairment;
-Required supervision or touching assistance from staff with eating, oral hygiene, upper body dressing, putting on or taking off footwear and personal hygiene;
-Required partial to moderate assistance from staff with toileting, showering, lower body dressing;
-Independent for locomotion.
Review of the resident's care plan, in use at the time of survey, showed:
-Focus: The resident has an Activities of Daily Living (ADLs) deficit;
-Goal: The resident will maintain current level of function in ADLs;
-Interventions: The resident needs limited assistance with his/her dressing, bathing, personal hygiene, grooming, toileting, transfers, and bed mobility;
-Focus: The resident has a behavior problem by declining personal care, medications and yelling;
-Goal: The resident will have no evidence of behavior problems;
-Interventions: Redirect him/her with one to one conversation with staff to assess his/her needs and reasoning for being upset, anticipate and meet the resident's needs, encourage resident to express feelings appropriately, explain all procedures to resident before starting and allow the resident to adjust to the changes, and report to the Director of Nursing (DON) or Assistant Director of Nursing (ADON) of declining care and/or medications to be reported to the Primary Care Physician (PCP) and responsible party (RP);
-The care plan did not reflect the resident's behavior related to pulling out the call light.
Review of the medical record, showed there no documentation in the nurses notes and social service notes of the resident pulling out the call light.
Observation on 7/8/24 at 9:27 A.M., 11:01 A.M., and 4:59 P.M., showed the notification light above the resident's door was lit, the call light was not plugged into wall, and the call light box at the nurse's station was lit, but there was no audible sound.
Observation on 7/9/24 at 7:54 A.M., 9:53 A.M., and 10:56 A.M., showed the notification light above the door was lit, the call light was not plugged into wall, and the call light box at the nurse's station was lit, but there was no audible sound.
Observation on 7/10/24 at 8:05 A.M. and 1:21 P.M., showed the notification light above the door was lit, the call light was not plugged into wall, and the call light box at the nurse's station was lit, but there was no audible sound.
Observation on 7/11/24 at 7:20 A.M., 9:07 A.M., and 11:45 A.M., showed the notification light above the door was lit, the call light was not plugged into wall, and the call light box at the nurse's station was lit, but there was no audible sound.
Observation on 7/12/24 at 9:41 A.M., showed the notification light above the door was lit, the call light was not plugged into wall, and the call light box at the nurse's station was lit, but there was no audible sound.
During an interview on 7/12/24 4:37 P.M., Licensed Practical Nurse (LPN) D said the call light was removed due to the resident's behaviors, and sometimes he/she will remove the plug that is put into the call light port.
Observation on 7/12/24 at 5:14 P.M., showed the notification light above the door was lit, the call light was not plugged into the wall, and the call light box at the nurse's station was lit, but there was no audible sound.
During an interview on 7/15/24 at 11:09 A.M., LPN WW said residents use the call lights to ask for help.
Observation on 7/15/24 at 11:15 A.M., showed the notification light above the door was lit, the call light was not plugged into wall, and the call light box at the nurse's station was lit, but there was no audible sound.
During an interview on 7/15/24 at 11:18 A.M., Certified Nursing Assistant (CNA) E said the call light notifies staff that a resident needs assistance, a resident may have fallen, or is sick. The residents have bells they can use to notify staff, but CNA E does not know where the bells are stored. The resident has a history of pulling out the call light.
During an interview on 7/15/24 at 11:28 A.M., the Regional Director of Plant Operations (RDPO) and the Director of Maintenance (DM) said they were not aware the call light had been removed.
Observation on 7/15/24 at 2:40 P.M., showed the notification light above the door was lit, the call light was not plugged into wall, and the call light box at the nurse's station was lit, but there was no audible sound.
During an interview on 7/15/24 at 3:03 P.M., the RDPO said the call light was replaced. He was informed the resident would pull the call light out.
During an interview on 7/16/24 at 12:30 P.M., the Director of Nursing (DON) and Administrator said they expected each resident to have a functioning call light in their room and were unaware the call light was pulled from the wall in the resident room. Bells would be an alternative device used to notify staff until the call light was repaired or replaced. They expected the nurses to document any resident behaviors related to call lights and the behaviors would be in the 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
Based on interview and record review, the facility failed to document a resident's involvement in discharge planning for one resident (Resident #299), who was transferred to another facility. The cens...
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Based on interview and record review, the facility failed to document a resident's involvement in discharge planning for one resident (Resident #299), who was transferred to another facility. The census was 151.
Review of the facility's Transfer and Discharge Planning policy showed:
-Purpose: To ensure that adequate preparation and assistance is provided to residents prior to transfer or discharge from the facility;
-Policy: Social Services staff will conduct a Discharge Planning Assessment and will help orient the resident to the impending discharge.
-Procedure:
-Social Services staff will document the discharge planning, preparation, and the resident's post-discharge needs in a Discharge Planning Assessment, or similar form in the electronic health record;
-The Discharge Planning Assessment will be filed in the resident's medical record.
Review of Resident #299's medical record, showed:
-admission date 12/8/23;
-Resident is his/her own responsible party;
-Diagnoses included stroke, atrial fibrillation (irregular heartbeat), acquired absence of left leg below knee, acquired absence of right leg below knee, and need for assistance with personal care;
-On 5/10/24 at 1:35 P.M., the Social Services Director (SSD) documented the resident transferred to other facility today. Transported with all personal belongings and medications per physician;
-No documentation related to whether the transfer was initiated by the facility or resident, no documentation of the resident's involvement in the decision to transfer him/her to another facility, and no Discharge Planning Assessment.
During an interview on 7/15/24 at 12:32 P.M., the SSD said the resident was not happy at the facility and requested a transfer. He/She was transferred to another nursing facility in a different state. The discharge planning involved the resident and the SSD. The SSD did not document any of her conversations with the resident about his/her request to transfer to another facility. There should be documentation in the resident's medical record about the resident's involvement in discharge planning.
During an interview on 7/16/24 at 11:17 A.M., the Administrator said the resident transferred to a facility in another state because he/she wanted to be closer to his/her previous home. She expected staff to have documented in the resident's medical record that the transfer was the resident's choice. She expected the resident's medical record to include documentation of the resident's involvement in discharge planning.
MO00235408
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 F0661
(Tag F0661)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure a discharge summary was completed for one resident, including a recapitulation of the resident's stay and a final summary of the res...
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Based on interview and record review, the facility failed to ensure a discharge summary was completed for one resident, including a recapitulation of the resident's stay and a final summary of the resident's status at the time of discharge (Resident #299). The census was 151.
Review of the facility's Transfer and Discharge Planning policy showed:
-Purpose: To ensure that adequate preparation and assistance is provided to residents prior to transfer or discharge from the facility;
-Policy: Social Services staff will participate in assisting the resident with transfers and discharges and preparing the Discharge Summary and Discharge Care Plan as part of the interdisciplinary team (IDT);
-Social Services staff will assist in developing the Discharge Summary and Discharge Care Plan that is developed with the IDT;
-Members of the IDT may use Discharge Planning Questionnaire, or similar form in the electronic health record, to gather information to complete the Discharge Summary and Discharge Care Plan for the resident. The IDT team should ask the resident, resident's family members, attending physician, nursing staff, Social Services staff, and any other individuals who may be able to provide answers to the questions;
-A copy of the Discharge Summary will be provided to the resident and/or the resident's family member or caretaker upon discharge when return is not anticipated. The discharge summary will include the following information:
-Recapitulation of the resident's stay including, but not limited to, diagnoses, course of illness, treatment, and pertinent lab, radiology, and other consultation results;
-Summary of the resident's status based on the most recent comprehensive assessment;
-A copy of the Discharge Summary and Discharge Care Plan will be maintained in the resident's medical record.
Review of Resident #299's medical record, showed:
-admission date 12/8/23;
-Resident is his/her own responsible party;
-Diagnoses included stroke, atrial fibrillation (irregular heartbeat), acquired absence of left leg below knee, acquired absence of right leg below knee, and need for assistance with personal care;
-On 5/10/24 at 11:01 A.M., the Minimum Data Set (MDS) nurse documented order received to discharge to other facility with medications;
-On 5/10/24 at 1:35 P.M., the Social Services Director (SSD) documented the resident transferred to other facility today. Transported with all personal belongings and medications per physician;
-No documentation related to why the transfer occurred and if the resident was involved in the discharge planning, no recapitulation of the resident's stay, and no comprehensive final discharge summary of the resident's status at the time of discharge.
During an interview on 7/15/24 at 12:32 P.M., the SSD said the resident was not happy at the facility and requested a transfer. He/She transferred to another nursing facility in a different state. She did not document any of her conversations with the resident about his/her request to transfer to another facility. She did not document a discharge summary. This information should be documented in the resident's medical record.
During an interview on 7/16/24 at 10:20 A.M., the MDS nurse said on 5/10/24, she was notified the resident was accepted to another facility and a physician order for discharge was needed. She called the physician and got the order, then added a note to the resident's medical record. She was not the discharging nurse. On the day of transfer or discharge, the discharging nurse should perform a full assessment of the resident, including obtaining a full set of vital signs. A discharge summary should be completed by the discharging nurse, SSD, or both, and a copy of the discharge summary should be given to the resident, along with their list of medications and inventory sheet. The discharge summary should be signed by the resident and retained in the resident's medical record.
During an interview on 7/16/24 at 11:17 A.M., the Administrator said the resident transferred to a facility in another state because he/she wanted to be closer to his/her previous home. On the day of a resident's transfer or discharge, the SSD is responsible for providing the resident with a discharge summary. The discharge summary should be signed by the resident and retained in the resident's medical record. The resident's medical record should show the resident signed off on receiving his/her personal belongings and the appropriate discharge paperwork.
MO00235408
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure one resident's room was free from hazardous chemicals at the bedside (Resident #124). The sample was 30. The census was...
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Based on observation, interview and record review, the facility failed to ensure one resident's room was free from hazardous chemicals at the bedside (Resident #124). The sample was 30. The census was 151.
Review of the Material Safety Data Sheet (MSDS) for Odoban (disinfectant cleaner), dated 2/10/2022, showed:
-Regulatory information: immediate health hazard;
-Hazard statement: may cause respiratory irritation. Causes serious eye irritation.
Review of the MSDS for Raid Ant and Roach Killer, dated 9/6/2016, showed:
-Precautions for safe handling: avoid contact with skin, eyes and clothing, do not enter places where used or stored until adequately ventilated, flammable.
Review of the MSDS for Febreeze Air Effects, dated 2/24/2014, showed:
-Advice on safe handling: use personal protective equipment as required. Keep container closed when not in use.
Review of Resident #124's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/5/24 showed the following:
-Diagnoses of schizoaffective disorder (combination of schizophrenia and mood disorder symptoms), dementia and major depressive disorder;
-Resident is ambulatory and has full function of his/her arms;
-Moderately impaired cognition.
Observation on 7/8/24 at 9:07 A.M., showed the resident's nightstand had one can of Raid bug spray half full, two full cans of Odoban odor spray, and two full spray bottles of Febreeze odor spray.
Observation on 7/9/24 at 7:27 A.M., showed the top of the resident's nightstand had one can of Raid bug spray half full, two full cans of Odoban odor spray, and two full spray bottles of Febreeze odor spray.
Observation on 7/10/24 at 6:58 A.M., showed the top of the resident's nightstand had one can of Raid bug spray half full, two full cans of Odoban odor spray, and two full spray bottles of Febreeze odor spray.
Observation on 7/11/24 at 7:13 A.M., showed the top of the resident's nightstand had one can of Raid bug spray half full, two full cans of Odoban odor spray, and two full spray bottles of Febreeze odor spray.
During an interview on 7/15/24 at 2:38 P.M., Certified Nursing Assistant (CNA) M said all staff are expected to observe residents' belongings to ensure resident does not have harmful chemicals. He/She said chemicals have a potential to be harmful to the resident.
During an interview on 7/15/24 at 2:47 P.M., Licensed Practical Nurse (LPN) L said all staff should check resident rooms for chemicals. He/She said resident rooms are expected to be free from chemicals.
During an interview on 7/16/24 at 11:44 A.M., the Administrator said she expected residents' rooms to be free from chemicals. She expected all staff to observe residents' rooms for harmful chemicals.
CONCERN
(D)
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 ensure one of five sampled residents (Resident #93), diagnosed as having dementia with depression and exhibiting symptoms/behaviors, receiv...
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Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident #93), diagnosed as having dementia with depression and exhibiting symptoms/behaviors, received the appropriate treatment and services to attain or maintain his/her highest practicable physical, mental and psychosocial well-being. The facility failed to follow the recommendations from his/her psychiatric Nurse Practitioner (NP) and there was no Social Service documentation of the resident's behaviors and individualized interventions provided by Social Services. The census was 151.
Review of the facility's policy titled, Physician Orders, revised 10/24/22, showed:
-Purpose: This will ensure that all physician orders are complete and accurate;
-Other orders will include a description complete enough to ensure clarity of the physician's plan of care;
-Documentation pertaining to physician orders will be maintained in the resident's medical record.
Review of Resident #93's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/15/24, showed:
-admission date 7/11/2023;
-Moderate cognitive impairment;
-Moderate depression;
-Set-up for eating, oral hygiene, and toileting. Supervision for showers;
-Diagnoses include high blood pressure, diabetes, high cholesterol, Alzheimer's and depression.
Review of the resident's care plan, dated 7/28/23, showed:
-Focus: Resident has impaired cognitive function related to dementia;
-Goal: Resident will be able to communicate basic needs on a daily basis through the review date;
-Interventions: Ask simple yes/no questions in order to determine resident's needs. Cue, reorient and supervise as needed.
Review of the resident's clinical Visit-Mental Status Exam (MSE), showed the following:
-September 18, 2023, to start donepezil (cognition-enhancing medication) 5 milligrams (mg) daily at nighttime.
Review of the resident's Physician Orders, showed the recommendation for donepezil was not transcribed.
Review of the resident's medical record, showed no Social Service notes related to resident behaviors.
Review of the resident's care plan, dated 12/15/2023, showed:
-Focus: Resident uses antidepressant medication related to depression, poor adjustment to admission, and poor nutrition;
-Goal: Resident will be free from discomfort or adverse reactions related to antidepressant therapy;
-Interventions: Administer antidepressant medications as order by physician. Monitor/document side effects and effectiveness. Monitor/document/report as needed adverse reactions antidepressants therapy.
Review of the resident's clinical Visit MSE, showed the following:
-August 23, 2024, to add Namenda XR (cognition-enhancing medication) 7 mg daily for Alzheimer's.
Review of the resident's Physician Orders showed the recommendation for Namenda XR was not transcribed.
Observation on 7/8/24 at 9:30 A.M., showed the resident at the nurse's station, crying and staff re-directing him/her. Staff walked down the hall with the resident, consoling and attempting to redirect the resident. The resident came out of his/her room crying and said, I just don't understand.
Observation on 7/9/2024 at 8:00 A.M., showed the resident sat in the dining room, very tearful, making statements he/she wanted to leave with his/her daughters.
Observation on 7/10/24 at 1:21 P.M., showed resident near the locked doors on the unit crying, talking very loudly, and appeared to be upset with daughters.
Observation on 7/11/24 at 9:07 A.M., showed the resident at the nurse's station crying, wanting the use the phone to call his/her daughter.
Observation on 7/12/24 at 9:41 A.M., showed the resident on the phone at the nurse's station, saying he/she wanted to leave. The resident was tearful.
During an interview on 7/8/24 10:03 A.M., Licensed Practical Nurse (LPN) D said the resident had frequent crying episodes. The resident can be redirected sometimes.
During an interview on 7/11/24 at 10:58 A.M., LPN J said he/she did not know where to locate the psychiatric NP notes. LPN J was aware there is a new order for a medication. He/She is unaware of where the medication orders originate and never sees the visit notes.
During an interview on 7/11/24 at 11:05 A.M., LPN D said he/she was unaware of a new physician order until there was an instance when he/she had to call to the pharmacy to clarify a medication that was ordered by the psychiatric NP. He/She spoke with another nurse regarding the order for the medication. He/She was informed the psychiatric NP emails the recommendations to the Director of Nursing (DON) and then transcribes the order into the electronic medical record.
During an interview on 7/16/24 at 12:30 P.M., the Administrator there had been a break down in the process with the psychiatric recommendations. Prior to May 2024, the recommendations were sent to the DON, who would send the recommendations to the Unit Managers, who would transcribe the orders into the electronic medical record. At this time, the psychiatric recommendations are only available if requested by the staff and she is unaware if there are any current recommendations.
During an interview on 7/16/24 at 12:30 P.M., the DON said the resident may not have experienced the ongoing behaviors, crying, and pacing if the medications would have been administered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional standards and facility...
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Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional standards and facility policy in two of two medication rooms and three of five medication/treatment carts. The census was 151.
Review of the facility's Medication Storage Policy, dated 1/2021, showed:
-Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications;
-Medications requiring refrigeration or temperatures between 36 degrees Fahrenheit and 46 degrees Fahrenheit are kept in a refrigerator with a thermometer to allow temperature monitoring. A temperature log or tracking mechanism is maintained to verify that the temperature has remained in acceptable limits. The temperature of any refrigerator that stores vaccines should be monitored and recorded twice daily;
-Internally administered medications are stored separately from medications used externally such as lotions, creams, ointments, and suppositories;
-Outdated, contaminated, discontinued or deteriorated medications and those in container that are cracked, soiled, or without secure closures are immediately removed from the stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists;
-Medication storage should be kept clean, well lit, organized and free from clutter.
Review of Medline's Evencare Blood Glucose Monitoring System recommendations, showed:
-Keep the test strips away from direct sunlight and heat. Store the test bottle in a dry, cool place.
-For vial test strips, record the date on the bottle when opened. Discard any unused test strips six months after opening.
Review of Advair Diskus 250/50 patient information, showed:
-Write the date you opened the foil pouch in the first blank line on the diskus label. Write the use by date in the second blank line on the label. Discard after 30 days.
Observations during the survey, showed:
-On 7/9/24 at 10:40 A.M., the first floor medication room locked refrigerator had boxes of medication on the lower shelf, and a bag of Tuberculin dose vials in a bag which was wet from water leaking from the freezer. The temperature was 42 degrees Fahrenheit (F);
-On 7/9/24 at 11:06 A.M., the third floor medication room had an open bottle of Active Liquid Protein that expired 1/2024;
-On 7/11/24 at 9:09 A.M., the second floor nurse medication cart had Nystatin Powder located in the same drawer with eye and oral medications;
-On 7/11/27 at 9:27 A.M., the second floor Certified Medication Technician (CMT) cart had undated Advair Diskus inhaler, an opened bottle of Artificial Tears, dated 7/2023, and an opened stock bottle of iron, dated 4/2023, unable to read the expiration date due to fading;
-On 7/11/24 at 9:45 A.M., the first floor nurse medication cart had a bottle of Evencare accu-check strips not dated and an opened bottle of Milk of Magnesium, no open date and expired March 2024;
On 7/16/24 at 9:57 A.M., the first floor medication room locked refrigerator still contained the wet boxes of medication on the lower shelf, temperature was 28 degrees F, and icicles formed on the bottom side of the freezer. The temperature log did not reflect the second temperature reading on the July flow sheet.
During an interview on 7/9/24 at 10:40 A.M., Certified Medication Technician (CMT) OO, said he/she was unaware water was dripping from the freezer and would notify the Charge Nurse.
During an interview on 7/9/24 at 11:06 A.M., Assistant Director of Nursing (ADON) CC said expired medications should be removed from the medication room and thrown away.
During an interview on 7/11/24 at 9:09 A.M., CMT F said the bottle of nystatin powder should not be in the same cart where the residents' medications are located. The powder should be stored in the nurse's treatment cart.
During an interview on 7/11/24 at 9:27 A.M., CMT G said inhalers must be dated when they are removed from the box, and medications that are no longer being used or expired should be removed from the cart.
During an interview on 7/11/24 at 9:45 A.M., Licensed Practical Nurse (LPN) A said accu-check bottles should be dated when opened and expired medications should be removed from the cart.
During an interview on 7/15/24 at 2:35 P.M., LPN L said the refrigerators should be checked daily and the temperature recorded on the paper on the door. Items stored in the refrigerators were injectables such as insulin pens, the solution used to check for tuberculosis (TB), and vaccines. The temperature must be kept at a certain level, so medications won't go bad.
During an interview on 7/16/24 at 12:30 P.M., the Director of Nursing (DON) said she expected the nurses to check the temperature of the refrigerators regularly. She was unaware that the refrigerators that contain vaccines should be checked twice daily per facility policy. If a refrigerator is unable to keep temperature and is malfunctioning, the nurses should contact maintenance and nursing management. The medication carts are checked weekly. The medications that are expired or no longer ordered for the residents should be removed from the medication rooms and carts. Inhalers, insulins, and accu-check strips should be dated when opened. The medications used for treatments should not be kept in the same cart with other the medications.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0808
(Tag F0808)
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 two residents received mechanically altered 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 ensure two residents received mechanically altered diets in accordance with physician orders (Residents #127 and #15). The census was 151.
Review of the facility's Therapeutic Diets policy, revised 10/24/22, showed:
-Purpose: To ensure that the facility provides therapeutic diets to residents that meet nutritional guidelines and physician orders;
-Policy: Therapeutic diets are diets that deviate from the regular diet and require a physician order. Per the physician order, therapeutic diets are planned, prepared and served in consultation with the Dietitian;
-Procedure:
-The nursing staff is responsible for communicating the physician's order for a therapeutic diet to the dietary department in writing;
-The therapeutic diet will be reflected on the resident's tray card.
-The Dietary Manager will periodically review the resident's tray card and the physician's dietary orders to ensure that the information is consistent.
1. Review of Resident #127's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/22/24, showed:
-Moderate cognitive impairment;
-Independent with eating;
-Diagnoses included malnutrition, dysphagia (difficulty swallowing), diabetes, and cognitive communication deficit;
-Therapeutic diet received.
Review of the resident's care plan, in use at the time of survey, showed:
-Focus: Resident has nutritional problem or potential nutritional problem related to diet restrictions;
-Interventions included: Provide and serve diet as ordered. Regular diet, mechanical soft texture.
Review of the resident's electronic physician order sheet (ePOS), showed an order, dated 6/10/24, for mechanical soft texture diet.
Review of the resident's diet card, undated, showed Regular diet checked at the top of the card.
Observation on 7/8/24 at 4:54 P.M., showed the resident on his/her left side in bed with a plate of whole egg rolls and noodles. The resident used his/her hands to rip up the food and put it in his/her mouth, spitting bits of food out of his/her mouth while he/she chewed. During an interview, the resident said the food was good. He/She was unable to answer questions about the food texture.
Observation on 7/15/24 at 11:44 A.M., showed the resident sat in the dining room with a whole hamburger and crinkle-cut fries. The resident used his/her hands to rip up the hamburger and put it in his/her mouth, spitting bits of food out while he/she chewed.
During an interview on 7/15/24 at 2:48 P.M., Certified Nurse Aide (CNA) R said the resident has been spitting out his/her food while he/she eats. He/She used to receive mechanical soft food, but it was switched to regular texture a month ago and that's when he/she began spitting out his/her food.
During an interview on 7/16/24 at 11:09 A.M., the Speech Therapist said the resident was referred to her in June 2024 and she completed a swallow evaluation. The resident has been having issues with swallowing. He/She has been expelling his/her food, but not always. His/Her diet was downgraded to mechanical soft because he/she does not have enough teeth. She expects the resident to receive a mechanical soft diet. If dietary serves the resident whole foods, nursing staff usually chop up the food for the resident.
During an interview on 7/16/24 at 9:30 A.M., the Dietary Manager (DM) said the resident has been chewing his/her food and spitting it out. He/She is supposed to receive a mechanical diet, not a regular diet. During the interview, the DM reviewed the resident's diet card, which showed regular diet. The DM said the resident's diet card had been changed by someone else, and he did not know who. Dietary staff should not change the diet cards and should always go by physician-ordered diet.
2. Review of Resident #15's medical record, showed:
-Diagnoses included malnutrition, nutritional anemia, dementia, cognitive communication deficit, and diabetes;
-A physician order, dated 5/20/24, for mechanical soft diet, easy to chew.
Review of the resident's quarterly MDS, dated [DATE], showed:
-Moderate cognitive impairment;
-Supervision or touching assistance required for eating;
-Diagnoses included malnutrition, dementia, cognitive communication deficit, stroke, heart failure, kidney failure, and high blood pressure;
-Mechanically altered and therapeutic diet received;
-Signs and symptoms of possible swallowing disorder: Holding food in mouth/cheeks or residual food in mouth after meals.
Review of the resident's care plan, in use at the time of survey, showed:
-Focus: Resident consumes a regular diet;
-Interventions included: Monitor for change in appetite, inform physician and responsible party;
-Focus: Resident has nutritional problem or potential nutritional problem related to anorexia - loss of appetite and unplanned weight loss;
-Interventions included: Provide, serve diets as ordered, regular diet with thin liquids;
-The care plan failed to identify the resident's physician order for mechanical soft diet.
Review of the resident's diet card, undated, showed Mech handwritten across the card.
During an interview on 7/8/24 at 9:45 A.M., the resident said he/she is missing his/her bottom dentures. Staff give him/her chopped up food to make eating easier.
Observation on 7/8/24 at 4:51 P.M., showed the resident sat in the dining room with a plate of whole egg rolls and noodles.
Observation on 7/15/24 at 7:42 A.M., showed the resident sat in the dining room with a whole sausage patty, biscuit, and scrambled eggs on his/her plate.
Observation on 7/15/24 at 11:44 A.M., showed the resident sat in the dining room with a whole hamburger and crinkle-cut fries on his/her plate.
3. During an interview on 7/9/24 at 8:44 A.M., Licensed Practical Nurse (LPN) D said the meals served by dietary are not consistent. Sometimes residents are served whole foods when they are supposed to receive mechanical soft texture. When this happens, he/she has to go to dietary and request the correct food. Dietary and nursing staff are responsible for ensuring residents are served diets as ordered. Yesterday, whole egg rolls were served to residents who were supposed to receive mechanical soft, and he/she had to remove the egg rolls because it was not the right texture.
During an interview on 7/15/24 at 2:48 P.M., CNA R said when dietary sends the meal trays up to the floor, the trays include the resident's diet card. The diet card tells staff what type of diet the resident should receive, including texture, such as mechanical-soft. When nursing staff passes the trays, they check the diet card and make sure trays have the correct foods on them. If the tray has regular texture food when it should be mechanical soft, nursing staff call the kitchen and let dietary staff know. Nursing staff can also chop up the food to make it small for the resident. It is important for residents to be served the correct texture of food to help them with chewing.
During an interview on 7/16/24 at 7:40 A.M., the Wound Nurse said she expects dietary to make sure they properly set up the meal trays before the trays are brought out to the floor. Once the trays are brought out, she expects nursing staff to check the diet card to make sure the tray is correct before passing it out. If the tray is incorrect, nursing should contact dietary. Dietary staff have been sending out the wrong food textures and items, then they get mad when nursing calls them to get the right items. Residents should receive mechanical diets as ordered because they need to have the right texture to prevent choking and address issues with swallowing.
During an interview on 7/15/24 at 10:01 A.M., the DM said he is made aware of changes to a resident's diet when nursing sends him a diet slip. Once he receives a diet slip, he puts the diet order on a dietary card. He expects residents to be served diets as ordered to prevent choking or other health concerns. Whole foods, such as egg rolls, are not considered mechanical texture. If dietary sends out food with the wrong texture, he expects nursing staff to report it to dietary and they will change the food.
During an interview with the Director of Nurses (DON) and Administrator on 7/16/24 at 11:17 A.M., the Administrator said when trays come up to the dining room, she expects nursing staff to check the diet card before passing the trays to make sure the correct foods are served. Diet cards are created by the DM, based on the orders put in the resident's electronic medical record. If nursing staff see the food texture on a plate does not match the food texture on the diet card, they are expected to decline the tray and notify dietary to get the issue fixed. Providing residents with the proper texture of food is important to prevent aspiration.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to maintain medical records that are complete and accurately documented in accordance with acceptable professional standards and...
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Based on observation, interview, and record review, the facility failed to maintain medical records that are complete and accurately documented in accordance with acceptable professional standards and practices and with the facility's policies, when staff revised an assessment completed three months ago for one resident (Resident #45). The sample was 30. The census was 151.
Review of the facility's Falsification and Omission policy, revised 10/24/22, showed:
-Purpose: To ensure entries in the medical records provide an accurate description of the services provided;
-Policy: Entries in a medical record at the facility will be factual and will accurately reflect the services provided to the resident, the condition of the resident, and the resident's response to services provided;
-Procedure:
-The original entry in a record is not to be destroyed or removed from the record;
-Errors in the record may be corrected or amended. See policy Completion and Correction;
-A deficiency in any omitted entry or incorrect entry that is not knowingly omitted or documented incorrectly;
-Willful material falsifications and omissions are prohibited.
Review of the facility's Completion and Correction policy, revised 10/24/22, showed:
-Purpose: To ensure that medical records are complete and accurate;
-Policy: The facility will work to complete and correct medical records in a standardized manner to provide the highest quality and accuracy in documentation;
-Procedure:
-Entries will be recorded promptly as the events or observations occur;
-Entries will be complete, legible, descriptive and accurate;
-Entries will be permanent, either electronically or legibly written in permanent ink and capable of being photocopied or printed;
-No portion of the record is to be obliterated, erased, or destroyed;
-If an error needs to be corrected, draw one line through the entry, designate the entry as an error, and initial next to the change;
-An addendum provides additional information to address a specific situation or incident;
-Clarification is a type of late entry used to clarify a previous entry to avoid incorrect interpretation of information that has been previously documented;
-Designate the information as clarification and state the reason for the clarification referring back to the original entry;
-Electronic Records:
-Correcting an error in an electronic/computerized medical record system follows the same principles as correcting a paper record;
-When correcting or making a change to a signed entry, the original entry must be viewable, the current date and time entered, and the person making the changed identified.
Review of Resident #45's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/26/24, showed the following:
-Cognitively intact;
-Diagnoses included malnutrition, anxiety, depression, psychotic disorder, bipolar disease (mood disorder that can cause intense mood swings);
-Use of feeding tube.
Review of the resident's care plan, in use at the time of survey, showed:
-Focus: Resident has declined to allow staff to administer his/her medication via oral route as directed;
-Goal: Resident will have his/her medications administered as directed;
-Interventions: Encouragement and retraining needed to allow resident to regain taste sensation of medication, monitor his/her intake of medications, if nausea/vomiting persists administer his/her medications via feeding tube and document;
-The care plan did not identify the resident as being able to self-administer his/her medications.
Review of the resident's quarterly Medication Self-Administration Screen, dated 4/23/24, reviewed 7/10/24 at 8:08 A.M., showed:
-No medications listed;
-Interdisciplinary team (IDT) feels resident is safe to self-administer listed medications: No;
-Resident agrees to terms and policies for self-administration: No;
-Date of agreement: Blank;
-Physician order: Resident may not self-administer medications;
-Category: Resident may not self-administer medications.
Review of the resident's electronic physician order sheet (ePOS), reviewed 7/10/24 at 8:35 A.M., showed no orders for the resident to self-administer his/her medications.
Review of the resident's progress note, dated 7/8/24 at 11:43 A.M., showed the resident requested to self-administer medication through the feeding tube . Staff made medical director (MD) aware. MD declined to give order and stated that nurse must give resident his/her medication. The resident and Director of Nursing (DON) made aware.
Observation on 7/11/24 at 7:30 A.M., showed Licensed Practical Nurse (LPN) J prepared medications for the resident at the nurse's station. He/She crushed the resident's medication and placed the medication into a 5 milliliter (ml) medication cup and walked to the resident's room. LPN J filled a graduate (container used to measure liquids) with warm water from the sink in the resident's room, added an unmeasured amount to the medication cup, and handed the resident the cup of fluid containing medications. The resident exposed his/her abdomen and produced the gastrostomy tube (g-tube, a tube surgically inserted into the stomach to provide hydration, nutrition, and medications), removed the stopper and inserted an empty syringe in the g-tube. The resident poured approximately half of the liquid containing medication into the syringe, a large amount of air remained in the syringe. He/She placed the plunger at the end of the syringe and then pushed the liquid containing medications in quickly and with force approximately 9 cubic centimeters (cc) of air also injected into the stomach. The resident removed the syringe from the g-tube slightly to allow the plunger to be removed without resistance. The resident placed the syringe back into the g-tube, poured more of the fluid containing medication into the syringe, a large amount of air remained in the syringe, inserted the plunger, and pushed the medications in quickly and with force. The resident removed the syringe from the g-tube slightly to allow the plunger to be removed without resistance. The resident then poured water from the graduate into the cup containing residual medications. The resident placed the syringe back into the g-tube, poured the remaining fluid in the medication cup and a large amount of air remained in the syringe. He/She inserted the plunger, and pushed the medications in quickly and with force. The resident replaced the stopper and laid back onto his/her bed. LPN J observed the resident administering medication, did not cue the resident to allow the medication to be administered via gravity, did not cue the resident not to push air into the stomach, and did not provide education on the risks of inserting air into the stomach.
During an interview on 7/11/24 at 8:47 A.M., LPN J said the resident will not allow staff to flush, administer the medication, or apply the gauze to the g-tube site. The resident has a history of refusing the medications if staff attempt to provide medications and treatments as ordered. The resident needs constant reminders to not push so much air into the stomach while administering the medications.
Review of the resident's quarterly Medication Self-Administration Screen, dated 4/23/24, reviewed 7/11/24 at 10:54 A.M., showed:
-Document revised by MDS Coordinator on 7/11/24;
-Seven medications listed;
-IDT review summary: Narcotic dependence;
-IDT feels resident is safe to self-administer listed medications; Yes;
-Resident agrees to terms and policies for self-administration: Yes;
-Date of agreement: 1/26/24;
-Physician order: Resident may self-administer medications with supervision;
-Category: Resident may self-administer medication with supervision;
-All fields on the previous assessment, dated 4/23/24, and reviewed 7/10/24 at 8:08 A.M. were revised and the original content no longer visible.
During an interview on 7/16/24 at 10:20 A.M., the MDS Coordinator said this morning, she reviewed the resident's self-administration assessment completed in April 2024. She determined the assessment was incorrect. The resident can safely administer his/her own medications and the MDS Coordinator educated the resident on how to do so. The resident's quarterly self-administration of medication assessment is due. The MDS Coordinator did not revise the assessment completed three months ago on purpose. She meant to generate a new quarterly assessment for self-administration of medication. Staff should document accurately in resident records.
During an interview with the DON and Administrator on 7/16/24 at 11:17 A.M., the DON said the charge nurse is responsible for completing assessments for self-administration. The assessment determines whether a resident is safe or unsafe to self-administer their medications. If the resident is safe to administer their medications, a physician order should be obtained and staff should supervise and cue the resident during the administration. The Administrator said if the resident's condition has changed since their previous assessment, she expects staff to complete a new assessment at that time. It is not appropriate to revise an assessment from months ago.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to follow acceptable standards of practice for infection prevention and control, when staff failed to utilize Enhanced Barrier P...
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Based on observation, interview, and record review, the facility failed to follow acceptable standards of practice for infection prevention and control, when staff failed to utilize Enhanced Barrier Precautions (EBP), an infection control method that uses personal protective equipment (PPE), gowns and gloves, to reduce the spread of multidrug-resistant organisms (MDRO, a germ resistant to many antibiotics), for one resident (Resident #22). In addition, the facility failed to use proper infection control techniques when obtaining blood glucose and administering insulin to one resident (Resident #133). The sample was 30. The census was 151.
Review of the facility's Standard and Enhanced Precautions policy, revised 4/1/24, showed:
-Purpose: To ensure the use of appropriate protective equipment to improve infection control as required in the care of the residents;
-Policy: The facility will utilize current guidance from the Centers for Disease Control (CDC) and the Centers for Medicare and Medicaid Services (CMS) to determine the appropriate PPE to be utilized during the care of residents to minimize the risk for infection or spread of infection;
-EBP refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employees targeted gown and glove use during high contact resident care activities that are associated with a high risk MDRO colonization when contact precautions do not otherwise apply and or transmission such as presence of indwelling devices (urinary catheter, a tube that drains urine from the bladder), feeding tube, tracheostomy tube (a surgically created hole in the windpipe that assists with breathing), vascular catheters (a flexible tube inserted into the blood vessel to access the blood stream), wounds or presence of unhealed pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure to the skin);
-For residents whom EBP are indicated, EBP should be used when performing the following high-contact resident care activities: Dressing, bathing, showering, transferring, providing hygiene care, changing linen, changing briefs or assisting with toileting, vascular catheters, urinary catheter, feeding tube, tracheostomy, and wound care that has a skin opening and requires a dressing;
-EBP are intended to be in place for the duration of a resident's stay in the facility or until the resolution of the wound or discontinuation of the indwelling medical device that placed them at high risk.
1. Review of Resident #22's, quarterly Minimum data set (MDS), a federally mandated assessment instrument completed by facility staff, dated, 5/17/24, showed:
-The resident is rarely understood;
-Has impairment to upper and lower extremities;
-Requires substantial to maximal assist for personal and toileting hygiene;
-Always incontinent of bowel and bladder;
-Nutritional approaches: feeding tube.
Review of a list of residents on EBP provided by the facility showed the resident was not listed.
Observation on 7/9/24 at 11:28 A.M., showed a sign posted on the resident's door related to EBP: STOP, providers and staff must wear gloves and gown for high contact resident care activities. No PPE was located outside the resident's door. The resident had vomited a large amount of emesis that covered his/her sheets and gown. Restorative Aide W and Certified Nursing Assistant (CNA) V entered the resident's room without a protective gown on. Restorative Aide W and CNA V cleaned the resident's face with a washcloth, removed his/her top sheet, and gown. The resident had a feeding tube in place in his/her abdomen. The resident's brief was soiled, Restorative Aide W and CNA V provided peri-care (cleansing of the genitals and buttock area) to the resident and changed the resident's bed pad by turning the resident side to side. The resident's bare knees touched Restorative Aide W's and CNA V's scrub tops while they were turning the resident. The resident was repositioned, a new gown was applied, and the resident was provided a clean top sheet. Restorative Aide W and CNA V did not have a protective gown on during the entire duration of care to the resident.
During an interview on 7/15/24 at 9:24 A.M., CNA QQ said staff are supposed to wear a gown, masks, and gloves when the EBP signs are posted on the resident's door.
During an interview on 7/15/24 at 9:32 A.M. Licensed Practical Nurse (LPN) SS and the facility Wound Nurse said they knew absolutely nothing about EBP. They had seen the signs on the door, but were unsure what criteria and what interventions were involved.
During an interview on 7/15/24 at 9:38 A.M., CNA RR said he/she was aware of the signs of the door, but was not entirely sure what the criteria was for EBP or what it meant.
During an interview on 7/16/24 at 7:56 A.M., the MDS Nurse said she was also the Infection Preventionist (IP). Staff are expected to follow the EBP sign posted on the resident's door. When the sign is posted, staff are to wear the appropriate PPE. The resident has a feeding tube, so staff should have worn a protective gown in addition to gloves while providing care. The purpose of EBP is to prevent the spread of infections to the vulnerable population.
During an interview on 7/16/24 at 11:16 A.M., the Director Of Nursing (DON) said the resident is on EBP because the resident has a feeding tube. It is expected that staff follow the EBP signs when indicated to decrease the spread of infection. A gown should have been worn when staff provided care to the resident.
2. Review of the competency checklist for the Blood Glucose Monitoring (BGM), Subcutaneously, under layers of the skin (SQ) Injections, and Blood Glucose Meter Cleaning, undated, showed:
-Perform hand hygiene;
-Complete the cleaning and disinfecting the blood glucose meter before and after each blood glucose testing event;
-Remove the disinfectant wipe from the container. Use the wipe to clean the surface of the workspace and dispose of the wipe. Place a dry paper on the workspace to use as a barrier;
-Remove gloves and perform hand hygiene;
-Position the resident to expose the finger to be pricked. Determine the resident's preference;
-Clean the area of the finger that will be punctured with an alcohol pad. Allow the finger to air dry;
-Obtain the sample;
-Remove gloves and perform hand hygiene;
-Document the results in medical record;
-Clean injection site with an alcohol wipe, beginning at center of the site moving outward in a circular motion;
-Remove gloves and wash hands;
-Clean the glucose meter and store in a clean, dry drawer or container.
The facility was not able to provide a policy on Insulin Administration.
Review of Resident #133's face sheet, undated, showed diagnoses including diabetes.
Review of the resident's Physicians Order Sheet (POS), dated July, 2024, showed:
-Lispro (fast acting insulin) 100 unit/milliliters (ml), SQ per sliding scale (a scale used to determine the amount of insulin to be administered based off of the result of the blood glucose level);
-There was no order for BGM.
Observation on 7/11/24 at 12:18 P.M., showed Certified Medication Technician (CMT) AA near the nurse's station, pushing the medication cart to the resident room. He/She put on gloves and did not complete hand hygiene, opened a drawer in the medication cart, grabbed the basket containing the glucometer and supplies. CMT AA removed the glucometer, did not clean the glucometer and placed the device on the top of the medication cart, with no barrier in place. With a gloved hand, CMT AA opened the bottle of strips, removed a strip, placing it on the top of the medication cart, where there was no barrier. He/She grabbed the monitor, a strip, a lancet and an alcohol wipe, reviewed the computer screen, placed the strip in the glucometer, and walked into the resident's room. The resident showed CMT AA the finger he/she wanted used to check his/her blood sugar. CMT AA, with the same gloves massaged the finger and then used the lancet to stick the finger. After several unsuccessful attempts to produce blood, he/she wiped the resident's finger with an alcohol wipe and placed the glucometer on the resident's bedside table without a barrier. Returning to the medication cart, he/she discarded the strip in the sharps container (a contained box where sharp objects are placed to prevent harm), changed gloves, but did not perform hand hygiene, collected a lancet, strip and alcohol wipe. CMT AA returned to the resident, placed the strip into the glucometer, selected a different finger, and used the lancet to stick a finger. Blood formed on the resident's finger. CMT AA collected a sample of blood with the glucometer and strip. CMT AA then cleaned the resident's finger with the alcohol pad and returned to the medication cart, placed the glucometer with the used strip on the top of the medication cart. He/She reviewed the computer screen, he/she pulled the soiled strip out of the glucometer, and placed the glucometer in the basket that contained lancets, alcohol pads and a bottle containing strips and discarded the strip into the sharps container. CMT AA did not clean the glucometer. CMT AA removed his/her gloves, did not perform hand hygiene and applied another pair of gloves. The resident's blood glucose result was 398, he/she wiped the top of the bottle of Lispro insulin, filled the syringe with ten units of Lispro insulin and entered the resident's room, informed the resident he/she was going to inject the insulin to the right lower quadrant of the stomach. The resident raised his/her shirt, CMT AA placed his/her hand on the abdomen and then injected the insulin without cleaning the injection site. He/She wiped the injection site with an alcohol wipe and returned to the medication cart and discarded the needle in the sharps container.
During an interview on 7/16/24 at 7:56 A.M., the MDS Nurse said she was also the IP. Anytime a CMT puts on and takes off gloves they should wash their hands. CMTs should not put gloves on at the nurse's station and then proceed to administer medications or treatments to residents. CMTs should use a barrier as a clean surface to place the clean equipment. CMTs should clean the site before and after a finger stick and injections. Glucometers should be cleaned prior to and after use. The importance of the handwashing, hand hygiene and a barrier are to prevent the spread of infection. Staff who perform finger sticks and injections complete competencies. The most recent competency event was within the last three months, but she could not provide the exact date.
During an interview on 7/16/24 at 12:30 P.M., the DON said she expected staff to use proper hand hygiene, and to use the alcohol wipes to clean the site for a finger stick and injection. She expected the glucometer to be cleaned before and after use, and a barrier to be used while performing the finger sticks. The importance of the handwashing, hand hygiene and a barrier are to prevent infection.
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 F0914
(Tag F0914)
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 beds in three shared rooms were equipped with ...
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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 beds in three shared rooms were equipped with curtains to assure full visual privacy for each resident (Residents #37, #126, and an unidentified resident). The census was 151.
1. Review of Resident #37's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/10/24, showed:
-Severe cognitive impairment;
-Diagnoses included Alzheimer's disease.
Observation on 7/8/24 at 10:08 A.M., showed no privacy curtain hung around the resident's bed.
Observation on 7/9/24 at 8:33 A.M., showed no privacy curtain hung around the resident's bed. The resident stood next to his/her bed while Certified Nurse Aide (CNA) E assisted him/her in getting undressed. The resident's roommate sat in a chair on his/her side of the room, in full line of sight of the resident getting undressed.
Observations of the resident's room on 7/11/24 at 8:50 A.M., 7/12/24 at 11:55 A.M., and 7/15/24 at 7:31 A.M., showed no privacy curtain hung by the resident's bed.
2. Review of Resident #126's quarterly MDS, dated [DATE], showed:
-Severe cognitive impairment;
-Diagnoses included dementia.
Observation on 7/8/24 at 10:02 A.M., showed no privacy curtain hung around the first bed in the room. During an interview, the resident said he/she shared a room with another resident. He/She had a curtain around his/her bed, but the roommate did not.
Observations of the resident's room on 7/9/24 at 9:20 A.M., 7/11/24 at 8:48 A.M., 7/12/24 at 9:41 A.M., and 7/15/24 at 7:31 A.M., showed no privacy curtain hung by the resident's roommate's bed.
3. Observations of room [ROOM NUMBER], shared by two unidentified residents, on 7/12/24 at 9:41 A.M. and 7/15/24 at 7:31 A.M., showed no privacy curtain hung by either bed.
4. During an interview on 7/15/24 at 2:48 P.M., CNA R said there should be a curtain hung by each resident's bed to ensure privacy. A couple of resident rooms were missing privacy curtains. Missing privacy curtains should be reported to housekeeping or maintenance.
During an interview on 7/15/24 at 7:39 A.M., Housekeeper KK said each resident's bed should have its own privacy curtain. Housekeeping staff clean resident rooms daily. If they noticed a privacy curtain is missing or soiled, they report it to their supervisor. If the privacy curtain is soiled, maintenance staff will remove the privacy curtain and take it to laundry. He/She is not sure who puts the privacy curtains back up.
During an interview on 7/16/24 at 8:32 A.M., the Housekeeping/Laundry Director said each resident bed should have its own privacy curtain. Housekeeping staff clean resident rooms daily and if they notice a privacy curtain is soiled, they report it to maintenance, who removes the curtain and has it sent to laundry. The privacy curtain should be returned to the resident's room within the same day. The facility is short on privacy curtains, which are currently on order.
During an interview on 7/16/24 at 10:32 A.M., the Maintenance Director said he was not aware of any missing privacy curtains in rooms on the second floor. He expected staff to report missing privacy curtains to him. Each resident's bed should have its own privacy curtain.
During an interview on 7/16/24 at 11:17 A.M., the Administrator said each resident bed should be equipped with a privacy curtain. Nursing and housekeeping staff should report any missing privacy curtains to the Housekeeping/Laundry Director, Central Supply, or the Administrator. An audit was completed last week to identify which privacy curtains were missing and what sizes are needed. The needs have been identified and now it is a matter of ordering the privacy curtains.
MO00238490
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 F0558
(Tag F0558)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide reasonable accommodation of needs and preferen...
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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 reasonable accommodation of needs and preferences by failing to ensure three residents had wheelchairs that were in good condition and properly fit the residents (Resident #1, #87, and #127). The facility also failed to provide side rails to assist one resident with bed mobility, positioning, and transfers (Resident #42) and ensure one resident had his/her call light in reach (Resident #89). In addition the facility failed to provide access to community rooms on the third floor, therefore limiting access for the residents to the TV and vending machines for three residents (Resident #46, #138 and #45). The sample was 30. The census was 151.
Review of the facility's admission Packet, revised 7/2022, showed the facility shall offer personal care, room, board, dietary services and laundry services. The facility will also offer nursing care, activities, restorative and rehabilitative services, and psychosocial care as identified in the resident's plan of care established by the facility to the extent required by the facility standards and in accordance with the policies of the facility.
1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/23/24, showed:
-Cognitively impaired;
-Functional limitations of range of motion (ROM): Impairment to left upper extremity and to both lower extremities;
-Uses a manual wheelchair;
-Diagnoses include aphasia (difficulty speaking) and traumatic brain injury (TBI).
Review of the resident's care plan, in use at the time of survey, showed:
-Focus: The resident has an activity of daily living (ADL) self-care performance deficit related to hemiparesis (muscle weakness to one side of the body) to left side;
-Interventions: The resident requires assistance of one staff member for long distance in his/her wheelchair; The resident requires assistance to reposition his/herself while in his/her wheelchair; The resident requires extensive assist of two staff members with transfers, bed mobility, dressing, grooming, personal hygiene and oral care.
Observation and interview on 7/8/24 at 8:53 A.M., 7/9/23 at 11:05 A.M. and 7/12/24 at 9:30 A.M., showed the resident sat in a manual wheelchair. The resident had a large, thick, gray supportive arm rest positioned under his/her contracted left arm. Where the resident's elbow was positioned on the arm rest, a large hole was present. The arm rest material that resembled vinyl had multiple splits and tears on it. The resident said he/she liked the arm rest and said it would be nice to have one that didn't look so bad and felt more comfortable. The right arm rest on the wheelchair was made of metal and a bright green, worn-through plastic cover that was held together with duct tape. He/She said the arm rests had a been like that for months.
During an interview on 7/12/24 at 8:40 A.M., Certified Nursing Assistant (CNA) RR said the resident's wheelchair arm had been like that for a several weeks. He/She did not know if the issue had been reported to anyone. CNAs on night shift were responsible for cleaning the wheelchairs and informing the appropriate persons for any repairs or issues with the wheelchairs.
During an interview on 7/12/24 at 8:50 A.M., Licensed Practical Nurse (LPN) L said the resident's arm rest had been like that since January, 2024. Everyone was aware of it including therapy, but nothing has been done.
During an interview on 7/15/24 at 10:15 A.M., Occupational Therapist (OT) UU said the resident's supportive arm rest had just been reported to him/her last week and it has to be special ordered. The resident has left sided arm weakness and requires his/her arm to be supported for comfort and mobility. She would expect staff to notify the therapy department when assistive devices are damaged or non-functional.
2. Review of Resident # 87's quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-Uses wheelchair;
-Independent with propelling self 50 feet and making two turns;
-Independent with propelling self 150 feet in a corridor or similar space.
Review of the resident's face sheet, undated, showed diagnoses that included: Pain in right and left leg, spinal stenosis (narrowing of the spinal canal causing pain), difficulty walking, iliotibial band syndrome (a painful condition in which connective tissue rubs against the thigh bone).
Observation and interview on 7/10/24 at 8:31 A.M., 7/12/24 at 8:50 A.M., and 7/15/23 at 9:55 A.M., showed the resident sitting in his/her wheelchair with his/her shoulders forward, self-propelling in the hallway. The resident's knees were positioned above his/her waist and the resident made short, shuffled movement with his/her feet. The resident said the wheelchair was too small for him/her. He/She said his/her bottom, legs and knees hurt while he/she was in the wheelchair. The resident said he/has had the wheelchair for several months.
During an interview on 7/12/24 at 8:50 A.M., LPN L said the resident has had the wheelchair for several months. The wheelchair looked like it didn't fit the resident correctly. Therapy was responsible for wheelchairs fittings. A physician order was not needed for wheelchair adjustments. The resident does complain of knee and back pain. The nurse wasn't sure if therapy was informed.
During an interview on 7/11/24 at 10:00 A.M., OT VV said he/she did not think the wheelchair fit the resident correctly. The wheelchair seat needed to be taller. Assessments of the wheelchairs can be completed without a physician order by the therapy department. A properly fitting wheelchair would provide comfort and better mobility for the resident.
3. Review of Resident #127's quarterly MDS, dated [DATE], showed:
-Room on second floor of facility;
-Moderate cognitive impairment;
-Independent with use of manual wheelchair;
-Diagnoses included cognitive communication deficit, depression, anxiety, generalized muscle weakness, other reduced mobility, muscle wasting and atrophy, and unspecified lack of coordination.
Observation on 7/8/24 at 10:28 A.M., showed the resident seated in a wheelchair in the hallway. The covering on the front of the right armrest torn and split open, leaving approximately four inches of yellow stuffing exposed. During an attempted interview, the resident was unable to respond regarding questions pertaining to his/her wheelchair and comfort.
Observation on 7/9/24 at 12:19 P.M., showed the resident sat in his/her wheelchair in the dining room. The right armrest torn had exposed stuffing. CNA E and CNA PP interacted with the resident.
Observation on 7/11/24 at 8:40 A.M., showed the resident sat in his/her wheelchair in the hallway, talking to LPN F about pain. The resident wore a t-shirt and his/her right arm rubbed against the torn armrest on the right side of his/her wheelchair.
Observation on 7/15/24 at 7:06 A.M., showed the resident sat in his/her wheelchair with the right armrest torn and stuffing exposed.
During an interview on 7/15/24 at 2:48 P.M., CNA R said CNAs clean wheelchairs every day after the resident has laid down. He/She has seen the torn armrest on the resident's wheelchair. When asked if he/she reported this to anyone, CNA R said people probably know. But CNA R did not
4. During an interview on 7/16/24 at 7:40 A.M., the Wound Nurse said CNAs and any staff who interact with the residents should notice if a resident's wheelchair has a torn armrest. Issues with wheelchairs should be reported to Maintenance.
5. During an interview on 7/16/24 at 10:24 A.M., the Regional Maintenance Director said they have a process to where the facility staff can place a request for wheelchair repairs in the TELS Platform (a web based technology designed to assist with building operations). They currently do not have an audit system in place to routinely check resident wheelchairs that are in use. He would expect staff that were completing the weekly wheelchair cleanings to report any damaged wheelchairs that need repair.
6. Review of Resident #42's quarterly MDS, dated [DATE], showed:
-No cognitive impairment;
-Diagnoses include heart failure, high blood pressure, asthma, respiratory failure;
-Receives oxygen therapy;
-Uses wheelchair.
Review of the resident's Physician's Orders Sheet (POS), dated July 2024, showed an order, dated 4/26/24, side rails ¼ for positioning, bed mobility, and transfers.
Review of the resident's side rail assessment, dated 5/24/24, showed:
-Recommendations: Bed rails are indicated and serve as an enabler to promote bed mobility and independence;
-If bed rails are indicated, please specify: Bilateral;
-The resident understands the positive and negative aspects of bed rail use and are aware of risks involved with bed rail use: Yes.
Review of the resident's care plan, in use during survey, showed:
-Focus: Resident has an ADL self-care performance deficit related to rheumatoid arthritis;
-Goal: Will maintain current level of function in ADLs;
-Interventions: Side Rails: 1/4 rails up as per physician's order for safety during care provision, to assist with bed mobility, positioning and transfers. Observe for injury or entrapment related to side rail use.
Observation and interview on 7/11/24 at 9:15 A.M., showed the resident was in bed; alert and oriented. The resident did not have side rails on the bed. The resident said he/she was supposed to have them, but did not receive them yet. When he/she wants to reposition him/herself, he/she will reach over and grab the night table or the table that holds his/her television. His/Her old bed had the side rails, but he/she received a new bed. They had an order for the side rails since admission and he/she was assessed for it. He/She was waiting for the side rails for the new bed.
Observation on 7/15/24 at 11:55 A.M., and 7/16/24 at 8:28 A.M., showed the resident did not have side rails on the bed.
During an interview on 7/16/24 at 10:24 A.M., the Regional Director of Plant Operations said if a resident was ordered side rails, central supply would be able to order it and maintenance would install them. He would have to check on the status of the resident's side rails. At 10:54 A.M., he/she said the most recent work order for the resident was on 6/27/24. It was to put the new bed together. There was no work order for the side rails. The MDS Coordinator had the order for the side rails, but maintenance was not aware of it until today, and the side tails will be installed today. When there is an order for side rails in the electronic medical record, it automatically triggers it in TELS. It is instant and he would have known to install the side rails.
During an interview on 7/16/24 at 11:18 A.M., the Administrator said she would expect side rails to be ordered and installed as ordered. If a resident received a new bed, she would expect the new side rails to have been ordered at that time.
7. Review of Resident #89's annual MDS, dated [DATE], showed:
-No cognitive impairment;
-Diagnoses included heart failure, high blood pressure, diabetes, malnutrition, anxiety, bipolar (disorder associated with mood swings ranging from depressive lows to manic highs), and asthma;
-Receives oxygen.
Review of the resident's care plan, in use during survey, showed:
-Focus: Resident is at risk for falls. Gait/balance problems, incontinence, and psychoactive drug use;
-Interventions: Educated resident to use call light and to request assist of staff for transfers. Verbalized understanding;
-Education provided to use call light for assistance when feeling weak and needing assistance with his/her transfers.
Observation and interview on 7/8/24 at 9:39 A.M., showed the resident in bed, calling out for help. He/She sat up in bed, attempted to get up, but was unsuccessful. The resident said he/she was unable to get up and was not able to hit his/her call light because it was stuck. Observation of the call light showed the cord was wrapped up and underneath the leg of a night table. The resident had active bleeding on his/her abdomen.
During an interview on 7/16/23 at 11:16 A.M., the Administrator said she expected call lights to be accessible. Staff should ensure the call light is in reach and not stuck on something or underneath objects.
8. Review of Resident #46's , quarterly MDS, dated , 7/3/24, showed:
-Moderate cognitive impairment;
-Diagnoses that included depression and schizophrenia (a mood disorder that distorts reality).
Review of the resident's activity quarterly review dated 6/27/24, showed the resident's favorite activity is watching movies.
Review of the resident's care plan, in use at the time of survey, showed:
-Focus: Requires assistance form staff for meeting emotion, intellectual, physical, and social needs;
-Interventions: Ensure that the activities the resident is attending are compatible with known interest and preferences; Establish and record the resident's prior level of activity involvement and interest by talking with the resident.
During observation and interview on 7/15/24 at 10:00 A.M., the resident sat in the hallway and he/she said there really wasn't anything to do. He/She really wanted to watch TV but didn't have one of his/her own. The community dining room, where everyone could watch TV, had been locked for at least three weeks. He/She wasn't sure why it was locked but really liked going in the community room to watch TV.
9. Review of Resident #138's, quarterly MDS, dated , 5/9/24, showed:
-Cognitively intact;
-Diagnoses that included anxiety, depression, and schizophrenia.
Review of the resident's activity quarterly review, dated 5/14/24, showed the resident's favorite activity documented as not applicable (NA).
Review of the resident's care plan, in use at the time of survey did not address the resident's activities.
During an interview on 7/9/24 at 12:05 P.M., the resident said he/she misses going into to the community room to watch TV. The community room has been locked for about three weeks, and the TV in the community was broken by another resident about a month ago.
Observations on 7/10/24 at 8:20 A.M., 7/12/24 at 9:35 A.M., and 7/15/24 at 9:55 A.M. showed a locked resident community room on the Third floor Main hall at the end of the hall.
During an interview on 7/12/24 at 8:40 A.M., CNA RR said the residents on Third floor Main need a TV to watch. If they don't have a TV in their room, there is no other option for them to watch TV. The residents have just been hanging out in the halls with really no where to sit and socialize.
During an interview on 7/9/24 at 12:15 P.M., Certified Medicine Technician (CMT) AA said the community room was the main place the residents could go and watch TV and socialize. The residents really enjoyed being in the community room. The community room has been closed for about two weeks.
During an interview on 7/12/24 at 9:35 A.M., the facility Maintenance Director said the community rooms on third floor were locked because it gets too hot in the room for the residents to sit in. On Three Main, the community room had a large flat screen TV mounted on the wall with a cord dangling. The Maintenance Director was unable to power on the television. He was not aware the TV was not working. He would expect staff to let him know that the TV was not working.
10. Review of Resident #45's quarterly MDS, dated [DATE] showed the following:
-Diagnoses of anorexia (eating disorder), bipolar disorder, and anxiety;
-Cognitively Intact.
Review of the resident's care plan, dated 6/11/24, showed:
-Focus: The resident wishes to stay long term care;
-Goal: Will continue to express satisfaction with living arrangements through review date;
-Interventions: Encourage social interactions and participation in activities with other residents.
During an interview on 7/8/24 at 4:49 P.M., the resident said the door to the day room area where the tables to eat, television, and vending machines are, is normally locked due to the room being too hot. He/She said they would like to be able to use tables to eat and interact with fellow residents.
Observation on 7/8/24 at 4:30 P.M., 7/9/24 at 9:15 A.M., 7/10/24 at 6:54 A.M., and 7/16/24 at 7:09 A.M. of the third floor showed the door to the day room was locked.
During an interview on 7/15/24 at 2:38 P.M., CNA M said the door to the day room has been locked for at least three weeks due to the air conditioning unit being broken and the day room being too hot. He/She said it was not homelike for residents to not have access to communal tables for eating, the television, or vending machines.
During an interview on 7/15/24 at 2:47 P.M., LPN L said the door to the day room was locked most of the time due to the temperature in the room. He/She said residents are not able to eat together due to this and have to eat in their rooms. He/She does not consider this homelike or accommodating.
11. During an interview on 7/16/24 at 11:16 A.M., the Administrator said the community room on Three Main and Three Main South has been locked for about three weeks due to it being too hot for the residents. She was not aware that the TV was broken in the community room on Three Main. Residents should have TV access when they do not have one in their room . The facility is expected to be more accommodating when access is denied to some of the rooms that the residents meet in.
MO00238297
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
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the first floor dining room was free from leak...
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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 first floor dining room was free from leaks (Resident #45), failed to ensure furniture and second floor common areas were clean and in good repair (Residents #86 and #106), failed to provide a homelike environment by serving meals with plastic utensils to residents on the second floor (Residents #106, #15, #50, and #126), failed to ensure the third floor shower room was clean and the toilet was in working order (Residents #87), failed to ensure Resident #120's bedroom wall was free from damage, failed to ensure the Air Conditioning (AC) units were free from dust and debris (Rooms 301, 303, 305, and 307), failed to ensure Resident #45 had a closet door. The sample was 30. The census was 151.
Review of the facility's Maintenance Services policy, revised 10/24/22, showed:
-Purpose: To protect the health and safety of residents, visitors, and facility staff;
-Policy: The maintenance department maintains all areas of the building, grounds, and equipment;
-Procedure: The maintenance department is responsible for maintaining the buildings, grounds, and
equipment in a safe and operable manner at all times. Functions of the Maintenance Department may include, but are not limited to: Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines, maintaining the building free from hazards, ensuring adequate ventilation, establishing priorities in providing repair service, maintaining the paging system in good working order, providing routinely scheduled maintenance service to all areas, and other services that may become necessary or appropriate.
Review of the facility's housekeeping job daily routine, undated, showed:
-Job duties: Pull trash from rooms, check under beds for trash, sweep and mop under beds, wipe down windowsills, clean dressers, wipe down unmade beds, bed rails, sinks, pick up used linen from floor, and clean dining areas.
Review of the facility's floor technician job daily routine, undated, showed:
-Take out all trash, clean and mop utility rooms. Clean out shower rooms. Buff floors once weekly or when needed, sweep and mop hallways with machine.
1. Review of Resident #45's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/23/24, showed the following:
-Cognitively Intact.
Observation on 7/9/24 at 11:43 A.M., showed the ceiling of the dining room leaking in two different areas. The water leaked from vents in the ceiling. Water was collecting into a bucket on the floor, with water on the floor around the bucket. Thirty-three residents were in the dining room at the time.
During an interview on 7/9/24 at 11:43 A.M., Resident #45 said the roof leaks a lot in different areas. The dining room leak started last week and it does not feel homelike.
Observation on 7/16/24 at 9:09 A.M., showed the ceiling of the dining room leaking in two different areas. The water leaked from vents in the ceiling. Water was collecting into a bucket on the floor, with water on the floor around the bucket.
Review of a letter from a roofing company, showed on 07/15/24, they had been onsite to inspect the leak issues which had been an ongoing issue since 4/4/24 due to significant [NAME] damage. Review of the letter showed:
-On site on 7/15/24 to look at leak issues with the current roof system . Existing roof system is poly-vinyl chloride (PVC). Upon inspecting the roof, we found it to have significant [NAME] damage in the field and wall flashings. Would advise the property owner to contact insurance company and set up a time for an adjuster and myself to do a thorough inspection. From the site visit, would recommend full roof replacement to ensure a water tight roof system .
During an interview on 7/16/24 at 10:33 A.M., the Regional Director of Plant Operations said the dining room has leaked before and that the most current leaks started the past week. It is not homelike for residents to be eating while the ceiling is leaking. The facility has put in a drain line to try and help with the issue.
2. Review of Resident #106's quarterly MDS, dated [DATE], showed:
-Cognitively intact.
Observation of the second floor dayroom on 7/8/24 at 5:09 P.M. and 7/9/24 at 9:22 A.M., showed:
-A loveseat missing one of its four legs, causing the loveseat to tilt backward;
-A reclining chair with stained upholstery on the armrests and a rip in the seat, approximately ten inches long, leaving the stuffing exposed;
-Brown circular stains on one ceiling tile and brown stained carpeting underneath the stained ceiling tile. A black baseboard, approximately three feet long, on top of the stained area of carpeting, exposing black spots along the bottom of the wall where the baseboard was missing;
-Dark brown splatter marks of a dried substance along a section of wall, approximately four feet wide.
Observation of the second floor dayroom on 7/11/24 at 8:37 A.M., showed:
-A loveseat missing one of its four legs, causing the loveseat to tilt backward;
-A reclining chair with stained upholstery on the armrests and a rip in the seat, approximately ten inches long, leaving the stuffing exposed;
-Brown circular stains on one ceiling tile. A black baseboard, approximately three feet long, propped against the wall where it was missing on 7/8/24 and 7/9/24;
-Dark brown splatter marks of a dried substance along a section of wall, approximately four feet wide.
Observation of the second floor dayroom on 7/15/24 at 7:25 A.M., showed Resident #86 sat on the loveseat missing one of its four legs. The resident's positioning was leaned back due to the tilt of the loveseat. During an interview, Residents #86 and #106 said the furniture had been this way as long as they could remember and it was not nice to look at.
Observation of the second floor dayroom on 7/16/24 at 7:11 A.M., showed a resident slept on the loveseat missing one of its four legs. Certified Nurse Aide (CNA) EE approached the resident and redirected him/her back to his/her room. During an interview, CNA EE said the residents should not have broken, torn, or ripped furniture. The residents deserve to have good furniture.
During an interview on 7/15/24 at 7:39 A.M., Housekeeper KK said housekeeping staff cleans the dayroom at the end of the hall on a daily basis. The furniture in the dayroom is old. The couch is missing a leg and one of the chairs is torn. Management knows the furniture looks like this.
During an interview on 7/16/24 at 8:32 A.M., Housekeeper JJ said housekeeping is responsible for cleaning the furniture in the dayroom every other day. They should wipe down the walls if there is splatter on them. He/She expected residents to have furniture in good condition.
During an interview on 7/16/24 at 8:34 A.M., the Housekeeping/Laundry Director said housekeeping staff clean the dayrooms every day. They should also clean the furniture in the dayroom. If staff observe a piece of furniture is in need of repair, they should report the issue to Maintenance through TELS (technology-based building management system). If a furniture item is beyond cleaning or repair, the facility should get rid of it.
During an interview on 7/16/24 at 10:31 A.M., the Maintenance Director said this morning, he was told about the second floor couch missing a leg. This is something he would expect staff to report to him. Staff can write a request for repairs, but the facility is trying to get away from written requests in case they get lost. All desktop computers have TELS software, which is the system used by staff to make repair requests.
3. Review of Resident #15's quarterly MDS, dated [DATE], showed:
-Moderate cognitive impairment;
-Supervision or touching assistance required for eating;
-Diagnoses included stroke, dementia, hemiparesis (weakness on one side of the body) or hemiplegia (paralysis on one side of the body), and malnutrition.
Review of Resident #50's quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-Supervision or touching assistance required for eating;
-Diagnoses included malnutrition.
Review of Resident #126's quarterly MDS, dated [DATE], showed:
-Severe cognitive impairment;
-Supervision or touching assistance required for eating;
-Diagnoses included malnutrition.
Observation of the second floor dining room on 7/9/24 at 12:09 P.M., showed 21 residents seated throughout the dining room, eating lunch. Lunch consisted of a slice of meatloaf, mashed potatoes, and mixed vegetables. All residents had plastic spoons to eat their meals; no regular utensils. Several residents dropped food as they attempted to use their plastic spoons to scoop meatloaf. During an interview, Resident #106 said it isn't easy to eat meat with a spoon and he/she thought it was a challenge. It would be nice to have a fork.
Observation of the second floor dining room on 7/12/24 at 11:43 A.M., showed 25 residents seated throughout the dining room, eating lunch. Lunch consisted of a breaded fish patty, spaghetti, and sliced carrots. All meals were served with a plastic fork and a plastic spoon; no regular utensils. During an interview, Resident #15 said he/she could not cut the fish patty with the plastic fork, so he/she ate with his/her hands. Resident #50 said he/she could not cut the fish patty with the plastic utensils. He/She had to pick up the patty to eat it.
Observation of the second floor dining room on 7/15/24 at 7:42 A.M., showed 22 residents seated throughout the dining room, eating breakfast. Breakfast consisted of a sausage patty, scrambled eggs, biscuit, and hot cereal. All residents had plastic spoons to eat their meals; no regular utensils. During an interview, Resident #126 said he/she just has to make due with using a plastic spoon to cut his/her sausage patty.
Observation of the second floor dining room on 7/16/24 at 7:35 A.M., showed 13 residents seated throughout the dining room, waiting for breakfast. All tables were set with one plastic spoon and a napkin.
During an interview on 7/15/24 at 2:48 P.M., CNA R said the second floor is a memory care unit. Residents were served meals with plastic utensils because they try to keep the regular utensils. This has been going on for a couple of years. The residents are given plastic spoons a lot, more than forks. It would be easier for residents to cut up their food with regular, solid utensils instead of plastic utensils. He/She would prefer to have regular utensils with his/her meals.
During an interview on 7/9/24 at 8:44 A.M., Licensed Practical Nurse (LPN) D said residents on the second floor have been served meals with plastic utensils. Yesterday, residents were served egg rolls and noodles with plastic spoons, no forks. It didn't make sense. He/She has been asking dietary about why this is happening for the longest time and doesn't get an answer.
During an interview on 7/16/24 at 12:14 P.M., the Dietary Manager said meals on the second floor were served with plastic utensils because the regular silverware was not coming back to the kitchen. It is a safety issue. If a resident wants regular silverware, dietary can get that for them. Nursing staff tell him not to send real silverware to the second floor. The facility has enough silverware to provide at each meal to all residents in the facility. They ran out of regular spoons, but they came in today. If plastic utensils are going to be used on the second floor, residents should receive forks as well as spoons. It would be helpful to eat certain food items, such as noodles, with a fork. It is not considered homelike to serve meals with plastic utensils.
During an interview on 7/16/24 at 11:17 A.M., the Administrator said it was recently brought to her attention that residents on the second floor were being served meals with plastic utensils. This issue has been going on for a couple of weeks. The issue has been partly due to shortage of supply and partly due to needed education. She would expect all residents to receive all meals with regular utensils.
4. Review of the Resident #87's quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-Uses a manual wheelchair;
-Independent with toilet transfers.
Observations on 7/8/24 at 8:36 A.M. and 7/9/24 at 12:15 P.M., showed the Third floor Main tub room with the door unlocked and partially open. The tub room had a bathroom stall with a door that was unlocked and opened. The toilet had large amounts of toilet paper and fecal material in the bowl that had clogged the toilet. Flies were landing on the toilet paper and fecal material in the toilet bowl.
Observations and interview on 7/10/24 at 8:31 A.M., showed Resident #87 self-propelled him/herself in his/her wheelchair into the Third floor Main tub room and into the bathroom stall. The door was left open by the resident. The resident stood up and urinated into the toilet bowl that was clogged with toilet paper and fecal material. When the resident propelled him/herself out of the tub room, he/said the toilet was sick.
During an interview on 7/9/24 at 12:10 P.M., Certified Medication Technician (CMT) AA said the clogged toilet on Third floor Main tub room has been like that for about a month and thought either housekeeping or maintenance were supposed to fix the issue. He/she did not report the issue because he/she thought someone in the facility administration was already aware.
During an interview on 7/10/24 at 8:21 A.M., Housekeeper Z said the clogged toilet on Third floor Main tub room had been like that for about two weeks and was sure maintenance was aware of the issue. He/she had not reported the clogged toilet to anyone.
During an interview on 7/11/24 at approximately 10:00 A.M., the Maintenance Director said he was not aware of the Third floor tub room until 7/10/24. A clogged community toilet is something he would encourage staff to report right away. A clogged toilet is not a homelike environment.
During an interview on 7/16/24 at 11:16 A.M., the Administrator said she would expect the staff to report a clogged toilet immediately to the Maintenance Director or the Administrator. A clogged toilet is not homelike.
5. Review of Resident #120's, annual MDS, dated [DATE], showed:
-Cognitively intact.
Observation and interview on 7/9/24 at 12:00 P.M., 7/12/24 at 3:31 P.M. and 7/16/24 at 8:10 A.M., showed in the resident's room behind his/her bed, the baseboards were halfway off exposing crumbling drywall and clusters of dark circular spots on the intact drywall. The resident said he/she was visually impaired and cannot see the wall.
During an interview on 7/16/24 at 8:18 A.M., CNA O said he/she thought the resident's walls were like that for one to two weeks. Staff normally let maintenance department know about repairs. He/She did not report the damaged walls to anyone.
During an interview on 7/16/24 at 8:30 A.M., Housekeeper P said he/she cleans rooms on third floor but did not know how long the resident's walls were damaged. He/She would normally report any issues he/she finds to his/her manager. He/She did not report the resident's damaged wall to anyone.
During an interview on 7/16/24 at 10:24 A.M., the Maintenance Director said he was only made aware of the resident's wall on 7/15/24. The staff can place a request for repairs in the computer or if they do not have computer access, then staff are expected to inform their supervisor and that person can add the repair request. Damaged walls were not a homelike environment.
During an interview on 7/16/24 at 11:16 A.M., the Administrator said she expected staff to place a request for repairs in the computer or inform their charge nurse or supervisor of damaged walls in a resident's room. Damaged walls were not a homelike environment.
6. Observation of room [ROOM NUMBER] during the survey, showed:
-On 7/8/24 at 9:10 A.M., the AC unit by the window had dust and debris build up on the outside and inside of the vent;
-On 7/10/24 at 6:53 A.M., the AC unit by the window had dust and debris build up on the outside and inside of the vent;
-On 7/11/24 at 7:09 A.M., the AC unit by the window had dust and debris build up on the outside and inside of the vent.
Observation of room [ROOM NUMBER] during the survey, showed:
-On 7/8/24 at 12:20 P.M., the bathroom had a burned out light bulb. The AC by the window had dust and debris build up on the outside and inside of the vent;
-On 7/10/24 at 7:01 A.M., the bathroom had a burned out light bulb. The AC by the window had dust and debris build up on the outside and inside of the vent;
-On 7/11/24 at 7:10 A.M., the bathroom had a burned out light bulb. The AC by the window had dust and debris build up on the outside and inside of the vent.
Observation of room [ROOM NUMBER] during the survey, showed:
- On 7/8/24 at 9:10 A.M., the floors were sticky with a liquid spill and have various locations of trash and debris. The AC by the window had dust and debris build up on the outside and inside of the vent;
-On 7/10/24 at 6:56 A.M., the floors were sticky with a clear liquid spill. The AC unit by the window had dust and debris build up on the outside and inside of the vent;
-On 7/11/24 at 8:00 A.M., the floors were sticky with a clear liquid spill. The AC unit by the window had dust and debris build up on the outside and inside of the vent.
Observation of room [ROOM NUMBER] during the survey, showed:
-On 7/9/24 at 8:56 A.M., the bathroom had a burned out light bulb. The AC by the window had dust and debris build up on the outside and inside of the vent;
-On 7/10/24 at 6:59 A.M., the bathroom had a burned out light bulb. The AC by the window had dust and debris build up on the outside and inside of the vent;
-On 7/11/24 at 7:13 A.M., the bathroom had a burned out light bulb. The AC by the window had dust and debris build up on the outside and inside of the vent.
During an interview on 7/16/24 at 7:10 A.M., Housekeeper P said housekeepers were expected to clean residents' floors once a day and as needed. The AC unit should be cleaned by maintenance staff.
During an interview on 7/16/24 at 10:27 A.M., the Regional Director of Plant Operations said housekeepers were expected to dust the outside of the AC units and the inside was cleaned every three weeks by maintenance staff. He expected AC units to be clean and free from debris and dust build up. He expected all staff to inform maintenance staff if a resident's bathroom light was burned out. He expected for residents rooms to be clean.
7. Review of Resident #45's quarterly MDS, dated [DATE] showed the following:
-Cognitively Intact.
Observation and interview on 7/8/24 at 12:20 P.M., showed the resident's closet door was missing. A curtain lay on top of boxes on the floor of the closet. The resident said he/she really wants a closet door due to his/her closet being located right next to the door to the hallway. Other residents come and mess with his/her things. The resident placed a curtain over his/her belongings.
Observation on 7/10/24 at 7:01 A.M., showed the resident's closet door was missing. A curtain lay on top of boxes on the floor of the closet.
During an interview on 7/16/24 at 10:29 A.M., the Regional Director of Plant Operations said he was not aware that the resident did not have a closet door. He said it is not homelike to have a missing closet door.
MO00238490
MO00230468
MO00232891
MO00234203
MO00235027
MO00236928
MO00237491
MO00237997
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to perform criminal background checks (CBC) on newly hired employees prior to the employee's start date, in accordance with the facility's pol...
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Based on interview and record review, the facility failed to perform criminal background checks (CBC) on newly hired employees prior to the employee's start date, in accordance with the facility's policy, for three of 10 employees hired since the last survey. The census was 151.
Review of the facility's Staff Screening policy, revised 10/24/22, showed:
-Purpose: To ensure the highest quality of care through the utilization of qualified staff, consultants and volunteers;
-Policy: The Facility will utilize reasonable and prudent criminal background screening and reference checks for prospective staff, contractors/consultants, registry/temporary staff, and volunteers;
-Procedure: Prior to employment or commencement of a contract, the facility will verify and document or obtain a copy, if applicable, of the following information that may include, but not limited to criminal background checks.
1. Review of Certified Nurse Aide (CNA) AAA's employee file, provided for review on 7/10/24, showed:
-Hire date 11/1/23;
-No CBC requested or received;
-Family Care Safety Registry (FCSR) check run on 7/10/24.
2. Review of Dietary Aide (DA) BBB's employee file, provided for review on 7/10/24, showed:
-Hire date 2/17/23;
-No CBC requested or received;
-FCSR check run on 7/10/24.
3. Review of Maintenance Assistant CCC's employee file, provided for review on 7/10/24, showed:
-Hire date 3/7/24;
-No CBC requested or received;
-FCSR check run on 7/10/24.
4. During an interview on 7/15/24 at 10:09 A.M., Human Resources (HR) said when someone applies for a position at the facility, she is responsible for running pre-employment background checks, which includes running a CBC or FCSR. The pre-employment background checks have to be run on a new hire before the employee starts working in the facility. Pre-employment background checks should be retained in the employee files. Sometimes things get hectic and she runs the background checks as she goes and saves them. She did not see the missing background checks when she pulled the employee files for review.
5. During an interview on 7/16/24 at 11:17 A.M., the Administrator said she expects HR to run the appropriate background checks on all new hires prior to the employee starting work in the facility. Pre-employment background checks should be retained in the employee files.
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 five residents who required assistance with ac...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure five residents who required assistance with activities of daily living (ADL) received personal care, nail care, and facial hair hygiene in accordance with their needs and preferences (Residents #37, #22, #88, #51, and #124). The sample was 30. The census was 151.
Review of the facility's Care and Services policy, dated 10/24/22, showed:
-Policy: Residents are provided with the necessary care and services to maintain the highest practicable physical, mental, and social well-being level in an environment that enhances quality of life in the scope of a long-term care facility. Care and services are provided in a manner that consistently enhances self-esteem and self-worth;
-Procedure: The Facility will have sufficient staff to provides services to residents with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being as determined by individualized resident assessments and plans of care;
-The identification of needed care and services begins during the pre-admission process;
-Once admitted , the resident receives an admission assessment where initial care and service needs are identified;
-A resident who displays or is diagnosed with a mental disorder or psychosocial adjustment difficulty will receive appropriate treatment in accordance with assessed behavioral health needs;
-A resident whose assessment did not reveal or who does not have a diagnosis of a mental or psychosocial adjustment difficulty should not display a pattern or decreased social interaction and/or increased withdrawn, angry or depressive behaviors unless the resident's clinical condition demonstrates that development of such pattern was unavoidable;
-The Interdisciplinary Team (IDT) receives and reviews initial assessment information to ensure that members of the IDT interact with residents in a manner that enhances self-esteem and self-worth, such as activities related to bathing, grooming, dining, recreational and social opportunities;
-The IDT facilitates opportunities for residents to exercise choice and self-determination during ADLs;
-The IDT provides care and services to residents with reasonable accommodations of each resident's individual needs and preferences;
-The licensed nurse or designee documents and notifies the resident's physician and responsible party of:
-Change in condition, including progress and/or decline in physical or mental function;
-Resident refusal of care or services;
-Unusual circumstances.
1. Review of Resident #37's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/10/24, showed:
-Severe cognitive impairment;
-Rejection of care behavior not exhibited;
-Partial/moderate assistance for showering/bathing;
-Diagnoses included Alzheimer's disease, anxiety, depression, schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves), need for assistance with personal care, generalized muscle weakness, unsteadiness on feet, lack of coordination, and other sites of candidiasis (fungal infection caused by an overgrowth of yeast).
Review of the resident's care plan, in use at the time of survey, showed:
-Focus: Resident has an ADL self-care performance deficit related to dementia, limited range of motion, and pain;
-Interventions: Resident needs assistance of set up of his/her clothing, toileting, transfers, meals, and snacks;
-Focus: Resident is resistant of care related to Alzheimer's disease and mood;
-Interventions: Encourage as much participation/interaction by the resident as possible during care activities. Give clear explanation of all care activities prior to and as they occur during each contact. If possible, negotiate a time for ADLs so that resident participates in the decision-making process and return at the agreed upon time;
-The care plan failed to identify the resident's individual needs and preferences related to showering/bathing, including need for partial to moderate assistance from staff for showering/bathing.
Review of the resident's electronic physician order sheet (ePOS), showed an order, dated 6/10/24, for Nystatin (antifungal medication) powder 10000 unit/gram, applied to groin, under breast topically every day and evening shift for fungal rash.
Review of the facility's shower schedule, undated, showed the resident scheduled for showers on Monday and Thursday evening shift. All showers must be documented. Report all refusals to the charge nurse.
Review of the resident's shower sheets for June and July 2024, showed:
-On 6/10/24, Certified Nurse Aide (CNA) documented shower completed. Nystatin used under breast and between folds;
-On 6/14/24, CNA documented shower completed. Nystatin under all folds;
-On 6/26/24, CNA documented shower completed. Nystatin applied under breast, stomach;
-On 7/9/24, CNA documented shower completed;
-The resident missed approximately seven showers.
Observation on 7/8/24 at 10:08 A.M., showed the resident sat in a chair in his/her room. A sour, pungent odor permeated from the resident and his/her bed. During an interview, the resident exhibited confusion. He/She said he/she takes showers and responded to further questions in a nonsensical manner.
Observation on 7/9/24 at 8:33 A.M., showed CNA E assisted the resident in getting undressed for a skin assessment. A strong odor permeated from the resident. Powder noted underneath the resident's breasts. During an interview, the resident said he/she only showers when he/she has to go somewhere, otherwise, he/she may only take a shower once or twice a week.
During an interview on 7/9/24 at 8:45 A.M., CNA E said the resident has a strong odor coming from his/her stomach and breast folds. He/She had the odor yesterday and this morning. The resident has yeast under his/her folds and needs a medicated powder and showers. This morning, CNA asked the resident if CNA could assist him/her in having a shower and the resident said he/she already had one, but he/she had not. CNA asked again and the resident agreed to the shower, which was provided this morning. The resident will usually agree to taking a shower if staff come back and ask again later, or if they offer the resident a soda. The resident does not usually refuse showers altogether.
Observation on 7/11/24 at 8:50 A.M., showed Certified Medication Technician (CMT) F opened the door to the resident's room and a sour, pungent odor emitted from the room. The resident seated in a chair next to his/her bed. During an interview, CMT F said he/she smelled a strong odor and did not know where it was coming from.
Observation on 7/12/24 at 11:55 A.M., showed the resident sat in a chair in his/her room. He/She wore the same outfit as the day before. A pungent, sour odor permeated from the resident.
During an interview on 7/15/24 at 2:48 P.M., CNA R said the resident cannot reach everything on his/her body and requires assistance of two staff for showers. The resident has an odor to him/her. If staff give him/her a snack or soda, the resident will take a shower. Showers are provided twice a week and as needed. There is a shower schedule posted at the nurse's station for staff to follow. Showers are scheduled for day and evening shift. The facility is short-staffed at times. When staffing is short, showers do not get done.
During an interview on 7/9/24 at 8:55 A.M., Licensed Practical Nurse (LPN) D said the resident is behavioral, but easy to redirect. He/She likes snacks and snacks will usually help staff to get him/her to do things, like agreeing to take showers. Showers should be provided per the shower schedule and as needed. CNAs document showers on a shower sheet and then give the completed shower sheet to the nurse. If a resident refuses their shower, the CNA should notify the nurse. The nurse will adjust the shower schedule as needed.
2. Review of Resident #22's quarterly MDS, dated [DATE], showed:
-Severe cognitive impairment;
-Diagnoses included aphasia (language disorder), cerebral palsy (congenital disorder of movement, muscle tone, or posture), dementia, quadriplegia (paralysis of all four limbs), and seizure disorder;
-Impairment on both sides of the upper and lower extremities;
-Has a feeding tube;
-Requires substantial/maximal assistance for personal hygiene and showers/bath.
Review of the resident's care plan, in use during survey, showed:
-Focus: Resident has an ADL self-care performance deficit related to cerebral palsy;
-Goal: Resident will maintain current level of function;
-Interventions:
-Bed mobility: Resident is totally dependent on 1-2 staff for repositioning and turning in bed during routine rounds and as necessary;
-Toilet use: Resident is not toileted;
-Transfer: Resident is totally dependent on 2 with mechanical lift, staff for transferring;
-Focus: Resident has contractures (loss of range of motion caused by muscle and tendon shortening), he/she requires total care with mobility from staff. Resident is unable to use call light related to contracture and cognition;
-Goal: Will be free of thrombus formation (the formation of a blood clot within arterial or venous blood vessels, limiting the natural flow of blood), skin-breakdown, and fall related injury;
-Interventions:
-Bolster wrap (provides elevated edges on the bed) to the mattress for positioning while in bed;
-Daily bilateral upper extremity (BUE) splinting of resting hands, begin with 1 hour daily monitor skin integrity clean palm with soap and water daily keep nails trimmed;
-Geri-chair (medical reclining chair) use for positioning while out of bed.
Review of the resident's ePOS, dated July 2024, showed an order dated 1/15/19, for Ketoconazole (antifungal) Shampoo 2%. Apply to scalp topically every day shift every Tuesday, Thursday, and Saturday for dandruff.
Review of the resident's electronic Medication Administration Record (eMAR), dated July 2024, showed Ketoconazole Shampoo 2%. Apply to scalp topically every day shift every Tuesday, Thursday, and Saturday;
-On 7/4/24: blank;
-On 7/6/24: staff documented see progress notes.
Review of the resident's progress notes, showed on 7/6/24 at 12:55 P.M., Ketoconazole Shampoo 2%. Apply to scalp topically every day shift every Tuesday, Thursday, and Saturday. Resident resting in bed.
Observation of the resident, showed:
-On 7/8/24 at 10:44 A.M., the resident in bed, eyes closed. He/She had a dried whitish colored substance on his/her beard;
-On 7/10/24 at 7:41 A.M., the resident in bed. The resident's nails were long. The resident had a full beard. His/Her hair had white flakes throughout the hair;
-On 7/15/24 at 11:00 A.M. and 3:00 P.M., the resident's nails were long with buildup of dirt underneath the nail bed. His/Her hair had white flakes throughout the hair;
-On 7/16/24 at 8:25 A.M., the resident's nails were long with buildup of dirt underneath the nail bed. His/Her hair had white flakes throughout the hair.
Review of the resident's shower sheets, showed no shower sheets had been provided to surveyor for July 2024.
3. Review of Resident 88's quarterly MDS, dated [DATE], showed:
-Mild cognitive impairment;
-Diagnoses included high blood pressure, renal (kidney) failure, hyperlipidemia (high level of lipids in the blood), hemiplegia (partial paralysis on one side), malnutrition, anxiety, depression, and psychotic disorder;
-Range of motion impairment to one side of the upper extremity;
-Requires substantial/maximal assistance with personal hygiene and showers/bath.
Review of the resident's care in plan, in use during survey, showed:
-Focus: Resident has an ADL self-care performance deficit related to impaired balance, limited mobility. Resident prefers to wear adult briefs at all times;
-Goal: No decline in ADL functioning;
-Interventions:
-Encourage out of bed daily;
-Incontinent care as needed;
-Skin assessment as needed;
-Resident is total assist of one staff with his/her ADLs; wheelchair mobility when out of bed, dressing, bathing;
-Extensive assistance of one with his/her meals, toileting, and bed mobility, non-ambulatory;
-Two person assist for transfer may use Hoyer (full body mechanical lift) if needed.
Review of the resident's ePOS, dated July 2024, showed an order dated 1/18/24, for regular diet, regular texture, and regular consistency. Prefers finger foods; any hard, crunchy meats mechanical soft.
Observation and interview of the resident, showed:
-On 7/9/24 at 8:01 A.M., 7/10/24 at 7:39 A.M., 7/11/24 at 9:14 A.M., 7/15/24 at 8:15 A.M., and 7/16/24 at 8:25 A.M., showed the resident had long nails that were approximately one inch in length. There was a thick buildup of dirt that also included red colored buildup underneath the resident's thumb on the right hand. The resident had food crumbs on his/her hands. The resident said staff keep him/her clean and dry and did not have complaints. The resident said he/she had a stroke and his/her left side was affected. He/She eats his/her food with his/her hands;
-On 7/8/24 at 12:22 P.M. and 4:46 P.M., and 7/15/24 at 8:15 A.M., showed the resident was served finger foods. He/She ate meals without utensils using his/her right hand.
During an interview on 7/16/24 at 8:40 A.M. CNA V said if the resident receives a bed bath, they are supposed to do nail care if the resident allows it and if they are not a diabetic. There is an activity aide that comes on weekends and cuts the resident's hair and shave them.
4. During an interview on 7/16/24 at 9:56 A.M., CNA DDD said staff are expected to complete nail care when the residents receive a bed bath. Residents #22 and #88 are easy to provide care for. Resident #22 can do more than what people think because he/she is contracted, but he/she can straighten out his/her legs. He/She is supposed to have his/her hair washed daily. Resident #88 needed to have his/her hair cut and washed. His/her nails are long and need to be cut. It is time for them to be cut. He/She would normally do it during evening shift because it is so hectic during day shift.
5. Review of Resident #51's quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-Impairment to the lower extremities;
-Uses a wheelchair for mobility;
-Maximal staff assistance needed for bathing, dressing, and personal hygiene;
-Diagnoses: heart failure, stroke, vascular disease, kidney disease, diabetes, anxiety, and depression.
Review of the resident's care plan, updated 9/12/24, showed:
-Focus: the resident has a self-care deficit;
-Goal: will improve current level of function;
-Interventions: staff provide extensive assistance of two staff with dressing, mobility, showering and hygiene.
During an interview on 7/8/24 at 9:13 A.M., the resident said he/she had not received routine showers. At times, staff provided a bed bath, he/she preferred a shower. Staff had told him/her there was not enough staff to provide showers.
Review of the resident's shower sheets, showed no documented showers had been provided in June 2024 or July 2024.
During an interview on 7/9/24 at 1:36 P.M., LPN A said the CNAs are responsible to complete the assigned showers, per the shower schedules. Staff have struggled to complete assigned showers and may complete a bed bath. Residents should receive showers twice a week.
During an interview on 7/10/24 at 9:05 A.M., LPN L said all facility residents should receive a shower twice a week. Bed baths should be given if the resident elected one. Staff are often very busy and unable to provide showers to residents. The aides should follow the shower schedule daily. The nurses fill out the daily shower schedule. The aides should notify the nurses if a shower is not completed.
6. Review of Resident #124's quarterly MDS, dated [DATE] showed the following:
-Diagnoses of schizoaffective disorder, dementia, and major depressive disorder;
-Moderately impaired cognition;
-Independent with toileting.
Observation on 7/8/24 at 9:06 A.M., showed the resident in bed sitting on his/her bed. The resident's linen stained with yellow liquid and brown matter. The linen had a urine and bowel movement odor. Eight flies were observed on the resident's linen and flying around the bed.
Observation on 7/9/24 at 7:26 A.M., showed the resident's linen was stained with yellow liquid and brown matter. The linen had a urine and bowel movement odor. Flies were observed on the resident's linen and flying around the bed.
Observation on 7/10/24 at 9:27 A.M., showed the resident's bed linen was observed to have been changed.
During an interview on 7/10/24 at 9:27 A.M., the resident said he/she was glad his/her bed linen had been changed and that it had not been changed for at least three days.
During an interview on 7/15/24 at 2:41 P.M., CNA M said resident bedding should be changed every day. If staff observed the resident's linen to be soiled and covered with flies, the bedding should be changed immediately.
During an interview on 7/15/24 at 2:49 P.M., LPN L said he/she believes staff are not changing the resident's bedding enough if flies were observed on and around the resident's bed and linen. Bedding should be changed at least once a day or when needed.
During an interview on 7/16/24 at 11:37 A.M., the Director of Nursing (DON) and Administrator said they would expect resident's linen to be changed at least two times a week after the resident's shower or bed bath. They would also expect the bedding to be changed on an as needed basis. They would expect staff to immediately change the resident's bedding if it was observed to be soiled with flies on the bed.
7. During an interview on 7/9/24 at 8:45 A.M., CNA E said residents should receive showers at least twice weekly and as needed. If a resident does not want a shower, staff should try again later and offer a bed bath. If a resident refuses a shower, staff should try to offer different things to incentivize, such as offering a soda or something the resident likes. All showers should be documented on shower sheets. The CNA should sign off on the shower sheet and give it to the nurse for them to review. Upon completion, the shower sheets get placed in a folder at the nurse's station.
8. During an interview on 7/9/24 at 1:46 P.M., LPN A said showers are scheduled twice a week. There is a shower schedule for staff to follow on day and evening shift. All showers should be documented on shower sheets. Once the shower is completed, the shower sheet is given to the nurse for review.
10. During an interview on 7/15/24 at 6:36 A.M., LPN II said showers are scheduled on day and evening shift. There is a shower schedule at the nurse's station for staff to follow. CNAs should document all showers on a shower sheet and sign off upon completion. The shower sheet is given to the nurse, who reviews the shower sheet. Completed shower sheets go in a folder at the nurse's station.
11. During an 7/16/24 at 11:18 A.M., the Administrator and DON said showers are scheduled two times a week and a shower schedule is posted at the nurse's station on each floor. Some residents want more or less showers. The CNAs are expected to complete shower sheets and give them to the charge nurse or the DON/Assistant Director of Nursing (ADON) if there are concerns. The shower sheet should be signed by CNA, the nurse reviews it and signs the shower sheet. She would expect staff to trim nails. The DON said it can be done by the CNA unless the resident is a diabetic. They are expected to report if the resident had any skin issues or the reason why it was not completed. If showers and bed care was not completed, staff are expected to report it to nursing. The CNAs can also shave the residents, but it is case by case as generalized shaving is facial care. Aides are expected to shampoo the resident's hair and document it on the shower sheet. If the resident refuses the initial attempt, they can come back 30 minutes later. If the resident continues to refuse, staff are to give them more time. If they are irate, the nurse is expected to document the refusal. Staff are expected to have incentive if applicable to get the resident to shower. They are expected to try different methods.
MO00235408
MO00236928
MO00237997
MO00238490
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
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 fully implement the restorative therapy program for re...
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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 fully implement the restorative therapy program for residents with limited mobility. The facility failed to ensure appropriate services and assistance to maintain or improve mobility for three residents (Residents #88, #4 and #123 ). Resident #88's therapy was discontinued due to insurance and restorative services was not recommended. Resident #88 also had a hand contracture, with therapy recommendations for a hand splint that was not ordered. The sample was 30. The census was 151.
Review of the facility's Restorative Nursing Program policy, dated 10/24/22, showed:
-Purpose: The Restorative Nursing Program provides nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. This program actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning;
-Policy: 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 rehabilitation therapy;
-When restorative needs arise during the course of a longer-term stay;
-In conjunction with formalized rehabilitation therapy;
When a resident is discharged from formalized physical, occupational, or speech rehabilitation therapy;
-The Director of Nursing Services (DNS), or their designee, manages and directs the Restorative Nursing Program. licensed rehabilitation professionals, (physical therapists, occupational therapists, and speech therapists} 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 (AROM);
-Passive range of motion (PROM);
-Splinting or bracing;
-Amputation/Prosthesis management;
-Bladder training or bowel training;
-Bed mobility;
-Transfer training;
-Dressing or grooming;
-Walking;
-Eating or swallowing;
-Communication;
-Procedure: Residents will be reviewed by the Interdisciplinary Team (IDT) upon admission, readmission quarterly, and as needed to identify any decline in activity of daily living (ADL) function. If a decline is identified, the IDT will evaluate whether the resident is an appropriate candidate for restorative services;
-The Attending Physician, Licensed Nurse or Therapist may refer the resident to the rehabilitation department for rehabilitative screening;
-The Licensed Therapist will document whether the resident may benefit from a more detailed rehabilitation evaluation or from unskilled therapy (restorative nursing services that can be provided by caregivers);
-In conjunction with the Attending Physician and staff, therapists will propose a rehabilitation or restorative care plan that provides an appropriate intensity, frequency and duration of interventions to help achieve anticipated goals and expected outcomes;
-If a potential to benefit from rehabilitation therapies (either skilled or unskilled) is identified, the Attending Physician will order a relevant therapy evaluation;
-An order will be obtained from the Attending Physician as indicated for participation in the Restorative Nursing program or for skilled rehabilitation services (physical, occupational, or speech therapy).
1. Review of Resident #88's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/27/24, showed:
-Mild cognitive impairment;
-Diagnoses included coronary artery disease, high blood pressure, renal failure, hemiplegia (partial paralysis on one side), malnutrition, anxiety, depression, psychotic disorder;
-Range of motion impairment to one side of the upper extremity;
-Occupational therapy minutes: 0;
-Physical therapy minutes: 0;
-Number of days each of the following restorative programs was performed (for at least 15 minutes a day) in the last seven calendar days: Range of motion (passive): 0;
-Range of motion (active): 0;
-Splint or brace assistance.
Review of the resident's care plan, in use during survey, showed:
-Focus: Resident has an ADL self-care performance deficit related to impaired balance, limited mobility. Resident prefers to wear adult briefs at all times;
-Goal: No decline in ADL functioning;
-Interventions: Encourage out of bed daily;
-Incontinent care as needed;
-Skin assessment as needed;
-Resident is total assist of one staff with his/her ADLs; wheelchair mobility when out of bed, dressing, bathing;
-Extensive assistance of one with his/her meals, toileting, and bed mobility, non ambulatory;
-Two person assist for transfer may use Hoyer (full mechanical lift) if needed.
Review of the resident's Physician's Orders Sheet (POS), dated July 2024, showed:
-An order, dated 5/2/24, clarification order: Patient will be seen for skilled Occupational Therapy (OT) five times per week (wk) for four weeks and may include therapeutic exercises, therapeutic activities, neuromuscular re-education, self-care training, wheelchair management, contracture management/orthotic scheduling, electrical stimulation (e-stim)/ultrasound modalities, and patient/caregiver education;
-No physician's orders for hand splint.
Observation and interview on 7/9/24, 7/11/24, 7/15/24, and 7/16/24, showed:
-On 7/9/24 at 11:27 A.M., resident lay in bed with eyes closed. The resident's hands were contracted and no hand splint worn;
-On 7/11/24 9:14 A.M., resident lay in bed. He/She said he/she had to be wheeled by staff because he/she cannot operate a wheelchair. He/She had a stroke and his/her left side was affected. He/She cannot use legs/feet to push him/herself in a wheelchair. He/She cannot use his/her hands to roll him/herself, staff have to push him/her. Staff talked to him/her about using a different wheelchair. The resident had not heard anything about it since. He/She had not received therapy or restorative. The resident wore no hand splint;
-On 7/15/24 8:15 AM, the resident was in his/her room, in bed. He/She received a meal. He/she ate with the right hand and used fingers to pick up food without the use of utensils. The resident's left hand was contracted. The resident wore no brace;
-On 7/16/24 at 8:25 A.M., the resident was eating a meal, served on the bedside table. The resident ate the meal with his/her right hand and used fingers to pick up food without the use of utensils. The resident's left hand was contracted. The resident wore no hand splint.
Review of the resident's OT evaluation, dated 4/25/24, showed:
-Diagnoses: Hemiplegia and hemiparesis, contracture of muscle, muscle weakness, unspecified lack of coordination, need for assistance with personal care, contracture left elbow;
-Frequency: Five times a week;
-Duration: Four weeks;
-Certification period: 4/25/24 through 5/23/24;
-Reason for Referral Current Illness: Patient referred to OT due to exacerbation of decrease in functional mobility, decrease in range of motion (ROM), decrease in strength, decreased coordination, decreased neuro-motor control, decreased postural alignment, increased need for assistance from others, paralysis/paresis, reduced dynamic balance, reduced ADL participation, and wheelchair evaluation;
-Functional Limitations Present due to Contracture: Yes;
-Functional Limitations as Result of Contracture(s): Turning in bed, dressing;
-Is skilled therapy needed to address impairment: Yes
-Current Orthotic Device: To further assess and order/fabricate;
-Location of Contracture: Left elbow, wrist and digits;
-Orthotics: Splint/Orthotic recommendations: It is recommended the patient wear a resting hand splint and an elbow extension splint on left elbow and on left hand at all times except bathing and exercise in order to maintain joint integrity and inhibit abnormal positions;
-Clinical Impressions: Patient uses Hoyer lift to transfer. Patient was assessed for safe manual wheelchair mobility. Patient does not currently have a chair and utilizes facility chair. Patient requires ultra light-weight wheelchair due to facility chair not being suitable for patient due to poor positioning, endurance, difficulty with maneuvering. Patient will benefit from an adjustable axle to promote proper propulsion and positioning/postural alignment. Patient cannot use a walker or cane as patient is non-ambulatory. Patient requires manual wheelchair (MWC) to complete ADLs. Patient has asymmetrical posture with, left leaning thoracic, and flaccid left arm. Patient will require a half tray in order to manage flaccid left arm, prevent subluxation (partial dislocation) and improve positioning. Patient requires support to maintain sitting balance and midline. Patient is unable to perform self-repositioning and pressure relieving techniques in wheelchair due to inability to perform wheelchair pushups or stand. Patient will utilize device life-long in order to improve quality of life, and increase interaction with environment. Further skilled OT is indicated to address strength and coordination deficits to increase safety and participation in ADLs.
Review of the resident's Occupational therapy discharge summary, showed:
-Patient was seen for nine days during the 4/25/24 through 5/7/24 progress period;
-Discharge destination: Long term care setting;
-Discharge reason: Change in payer source;
-Discharge recommendation: Home exercise program;
-Restorative program established: Not indicated at this time;
-Functional Maintenance program established: Not indicated at this time.
During an interview on 7/11/24 at 9:39 A.M., therapy staff confirmed the resident had OT last year and this year, but he/she could not continue because the resident's insurance was out of state.
During an interview on 7/15/24 at 2:53 P.M., Restorative Aide W said the resident is not on restorative therapy. The resident was on restorative therapy in the past when Restorative Aide W first started at the facility. The resident was on therapy too long and it was discontinued. The resident went back on Physical therapy (PT)/OT again, but he/she did not go back on restorative after the skilled therapy.
2. Review of Resident #4's quarterly MDS, dated [DATE], showed:
-Severe cognitive impairment;
-Functional range of motion limited to the upper and lower extremity;
-Staff provide full care assistance;
-Did not receive therapy services;
-No restorative therapy received;
-Diagnoses included: Stroke, epilepsy, left sided paralysis, abnormal posture, need for assistance with personal care and dementia.
Review of the care plan, in use during the survey, showed:
-Focus: Limited physical mobility and requires assistance with transfers due to stroke and left sided weakness;
-Goal: Maintain current level of mobility to self propel in his/her wheelchair;
-Interventions: Two staff for transfers, invite to activity programs, encourage physical activity and group exercises. Refer to PT/OT as needed.
Review of the occupational and physical therapy Discharge summary, dated [DATE], showed:
-Discharge recommendations: The resident is a resident of the facility with 24 hour supervision;
-Restorative program: Restorative program established/trained, not indicated at this time;
-Functional maintenance: Functional maintenance program established/trained: not indicated at this time.
During an interview on 7/8/24 at 2:23 P.M., the resident said he/she does not get any therapy services. He/She had a stroke and a contracted right hand, his/her movement can be difficult. Staff provide full care.
3. Review of Resident #123's quarterly MDS, dated [DATE], showed:
-Rarely understood;
-Used wheelchair for mobility;
-Staff provide maximal assistance for toileting, dressing, hygiene and mobility;
-Received no physical, occupational or restorative therapy;
-Diagnoses included quadriplegia (paralysis from the neck down), lack of coordination and dementia.
Review of the care plan, in use at the time of the survey, showed:
-Focus: Self-care deficit;
-Goal: Maintain current level of function;
-Interventions: Needs extensive assistance with personal hygiene, grooming, bathing, dressing and assistance of one staff required for eating.
Review of the occupational and physical therapy Discharge summary, dated [DATE], showed:
-Discharge recommendations: The resident is a resident of the facility with 24 hour supervision;
-Restorative program: restorative program established/trained, not indicated at this time;
-Functional maintenance: functional maintenance program established/trained: Not indicated at this time.
Observation on 7/8/24 at 12:55 P.M., showed the resident awake in his/her chair with contractures to the hands and both upper arms.
Review of the physician's orders sheet on 7/10/24 at 4:15 P.M., showed no orders for restorative therapy.
4. During an interview on 7/15/24 at 2:53 P.M., Restorative Aide W said he/she was pulled to the floor every day to work as a Certified Nurse's Aide (CNA). They do not have enough aides. If it is the first through the tenth of the month, he/she is not pulled to work as a CNA because he/she is responsible for vitals and weights for the entire facility. After the tenth, he/she is pulled as a CNA. They need five aides total, that also includes one for showers, and then he/she would be able to focus on restorative. If a resident refuses restorative three times in a row, he/she will let therapy know.
During an interview on 7/15/24 at 9:37 A.M., OT UU said Resident #88 had out of state insurance and his/her OT was discontinued. The business office would know if the resident's insurance had changed. OT UU thought restorative therapy was recommended. It is documented on the form not indicated, but it a computer issue. It chooses that. Sometimes, the resident participated in therapy, and sometimes he/she did not. Therapy was getting ready to discharge him/her anyway. The restorative aide is pulled a lot. Some of the aides on the floor could do some exercises with the resident. OT UU was asked if doing the exercises with staff in home exercise therapy would be appropriate for restorative therapy. OT UU said Home exercise program as indicated on the record, meant there were exercises the resident could do alone. The resident was shown the exercises as well. OT UU did not know if the resident was ever ordered a hand splint. The resident had been on and off therapy a few times. Therapy would be responsible for ordering the hand splint and nursing would make sure it was on the POS. Therapy would show the resident how to put it on, then it was nursing's responsibility. OT UU did not know if the option for restorative had been revisited for the resident. Resident #123 is mobile, and OT UU did not recall the resident having a stroke, but he/she had severe dementia. Resident #4 refused and did not like anyone touching his/her hand. He/She had been assessed for a new wheelchair, but OT UU did not know what type of wheelchair. OT UU said he/she did not know of any residents currently on a restorative program.
During interviews on 7/12/24 at 9:33 A.M. and on 7/16/24 at 11:18 A.M., the Administrator said there isn't a restorative program right now. They are working on it. The restorative aide is pulled to the floor a couple of times a week. They are trying to attain a program. She did not remember when the last time the facility had a restorative program. In the past 90 days there has not been anything in the program. There is a feeding program. If a resident was not on restorative, they could have some therapy if Medicare Part B services were available. Therapy had not recently recommended any resident to be on the program. She would expect there to be orders for a splint, and expected aides to apply the splint. Therapy will also provide education to the aides on the floor to make sure they know what to do if there is an order for restorative.
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 F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure sufficient number of staff to meet the residents' needs. In addition, the facility failed to provide wound treatments for two reside...
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Based on interview and record review, the facility failed to ensure sufficient number of staff to meet the residents' needs. In addition, the facility failed to provide wound treatments for two residents (Resident #89 and #2) due to lack of nursing staff. The sample size was 30. The census was 151.
Review of the facility's Staffing, Scheduling and Posting policy, revised 10/24/22, showed:
-Purpose: To ensure an adequate number of nursing personnel are available to meet resident needs;
-Procedure:
-The facility will employ sufficient Nursing Staff on an 24 hour basis that meet the appropriate competencies, skill set, and required qualifications to provide nursing and related services to attain or maintain the highest practicable physical, mental and psychosocial well-being for each resident;
-In staffing an adequate number of nursing service personnel, scheduling will be done as needed to meet resident needs and will account for the number, acuity and diagnoses the facilities resident populations;
-Nursing stations will be staffed with nursing personnel when residents are housed in the nursing unit;
-The facility will employ sufficient nursing staff as determined by resident assessments and individual plans of care;
-Nursing staffing will take into account the number, acuity, and diagnosis of the facility's resident population.
-The DON and the Administrator will establish nursing hours and make adjustments to meet resident needs;
-The shift times are established and posted in the scheduling office and in the areas convenient for nursing staff to view;
-Shift times may be adjusted according to the needs of the facility with advance notice;
-Nursing staff may be added to the schedule as required by facility occupancy and workload.
Review of the facility's assessment, dated 12/13/23, showed:
-Average daily census: 125-135; (current census was 151)
-Residents who required assistance of one to two staff persons for activities of daily living (ADL): Dressing: 76; Bathing: 42; Transfers: 66; Eating: 73; and Toileting: 68;
-Residents who are dependent on staff for ADLs: Dressing: Six; Bathing: 44; Transfers: 14; Eating: Two; Toileting: 15.
1. Review of Resident #89's medical record, showed:
-Diagnoses included cellulitis (deep inflammation of the tissues just under the skin) of unspecified part of limb, history of diabetic foot ulcer, acute hematogenous osteomyelitis (infection of the bone and bone marrow) multiple sites, panniculitis (inflammation of the subcutaneous fat);
-An order, dated 5/7/24, for wound to right foot: Cleanse with Vashe (wound cleanser), pat dry, apply Santyl (ointment used to remove damaged tissue) nickel thick edge to edge of wound bed, cover with calcium alginate (provides a moist environment for wound healing) cut to fit, cover with bordered gauze, every day shift;
-An order, dated 5/7/24, for wound to groin: Cleanse with Vashe, pat dry, apply Santyl nickel thick edge to edge to wound bed, cover with calcium alginate cut to fit, cover with ABD (absorbent abdominal) pad, every day shift;
-An order, dated 6/1/24, for wound to sternum (long, flat bone of the chest): Cleanse with wound cleanser, pat dry, apply bordered gauze, every day shift;
-An order, dated 6/30/24, for wound care to abdomen midline: Cleanse with wound Vashe, pat dry then apply silicone bordered gauze, every day shift for wound treatment;
-An order, dated 6/30/24, for wound care to left heel: Cleanse back of left heel with Vashe, pat dry, apply Santyl to wound bed only, apply calcium alginate to wound bed only, then cover with border gauze dressing, every day shift for wound care management;
-On 7/2/24, Licensed Practical Nurse (LPN) L documented unable to carry out wound treatments for right foot, groin, sternum, abdomen, and left heel, physically impossible related to nurse to patient ratio.
2. Review of Resident #2's medical record, showed:
-Diagnoses included other specified disorders of skin and subcutaneous tissue, pressure ulcer of sacral (above the tailbone) region-unstageable (slough (dead tissue) is present, the actual base and condition of the ulcer cannot be determined), other acute osteomyelitis, osteomyelitis of vertebra, sacral and sacrococcygeal (sacral and tailbone) region, pressure ulcer of unspecified site - Stage 4 (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dead tissue) may be present on some parts of the wound bed. Often includes undermining or tunneling), local infection of the skin and subcutaneous tissue, sepsis (presence of bacteria and infectious organisms in the blood stream), and methicillin resistant staphylococcus aureus (MRSA, a bacterium that causes infections in different parts of the body) infection;
-An order, dated 6/9/24, for Santyl ointment 250 units/gram, apply topically every day shift for wound care;
-An order, dated 6/9/24, for wound to left calcaneus (heel bone): Cleanse with Vashe, pat dry, apply Santyl nickel thick edge to edge, cover with calcium alginate cut to fit, cover with ABD, wrap with kerlix (gauze bandage roll), secure with tape, every day shift for wound care;
-An order, dated 6/9/24, for wound to left foot sole distal: Cleanse with Vashe, pat dry, apply Santyl nickel thick edge to edge, cover with calcium alginate cut to fit, cover with ABD, wrap with kerlix, secure with tape, every day shift for wound care;
-An order, dated 6/9/24, for wound to left posterior calcaneus: Paint with betadine (topical antiseptic), cover with ABD pad, wrap with kerlix, secure with tape, every day shift for wound care;
-An order, dated 6/9/24, for wound to right calcaneus: Paint with betadine, cover with ABD pad, wrap with kerlix, secure with tape, every day shift for wound care;
-An order, dated 6/28/24, for wound to coccyx (tailbone): cleanse with Vashe, pat dry, apply Santyl nickel thick edge to edge of wound bed, alginate cut to fit cover super absorbent square, ABD pad, then kerlix, every day shift for wound care;
-An order, dated 6/28/24, for wound to left calf: Vashe, pat dry, cover with calcium alginate cut to fit, cover bordered gauze, every day shift;
-On 7/2/24, LPN L documented unable to carry out wound treatments for left calcaneus, left foot sole, left posterior calcaneus, right calcaneus, coccyx, and left calf, physically impossible related to nurse to patient ratio.
During an interview on 7/10/24 at 9:05 A.M., LPN L said he/she usually works on the third floor. The facility does not have enough staff. He/She was usually the only nurse on the floor. When he/she works on the first floor, he/she is usually the only nurse working on that floor. The first floor needs at least two nurses. He/She gets pulled to work on the first floor about four to five times a month. He/She usually cannot get his/her tasks completed. When there are not enough aides, residents usually don't get their showers. The staffing ratio is not safe. One nurse working with 73 residents is not safe for the residents due to things like increased falls and wound treatments not being done. Wounds have not been cared for. The wound nurse has not been consistent with wound care. On the days he/she documented treatments as not being done, the wound nurse was not working or did not get the treatment done. He/She tells the Assistant Director of Nurses (ADON) and Director of Nurses (DON) when he/she cannot get his/her tasks done.
During an interview on 7/11/24 at 9:23 A.M., the wound care plus nurse practitioner (NP) said she expected staff to administer wound care orders as written. She had educated staff multiple times of the importance of completing wound treatments. She had been told by several staff that wound treatments had not been completed related to poor staffing of nurses. She had changed multiple resident wound dressings that had been heavily soiled from feces or urine.
Review of the facility's staffing sheets, dated 6/1 through 7/9/24 showed no RN coverage for the following dates:
-6/1, 6/2, 6/15, 6/16, 6/17, 6/18, 6/19, 6/20, 6/21, 6/22, 6/23, 6/29, 6/30, 7/6, and 7/7/24.
3. During an interview on 7/9/24 at 1:46 P.M., LPN A said there are times when he/she feels the facility is short-handed. When staffing is short, he/she has to prioritize his/her workload and he/she tries to get his/her assessments done first. Sometimes there is only one nurse working on the first floor and that is not enough. When a call-off occurs, the Staffing Coordinator tries to use agency to fill in the slots.
During an interview on 7/10/24 at 7:02 A.M., LPN J said that there was an instance about two months ago when he/she had to cover both units on the floor plus pass medications due to call-ins. He/She focused on the medications and did not have the time to complete the wound treatments for both units. He/She was unable to recall if the omitted treatments were reported to the oncoming nurse. He/She said that staffing has been challenging over the last few months.
During an interview on 7/15/24 at 6:36 A.M., LPN II said he/she works night shift. The first floor has a higher level of care for medical needs. On night shift, the first floor requires at least one nurse and three Certified Nurse Aides (CNA)s, but ideally, four CNAs. The second floor requires a nurse and at least two CNAs, but ideally, three CNAs. The third floor needs two nurses or a nurse and a Certified Medication Technician (CMT), as well as one CNA on each side. These are the minimum staffing needs that he/she believes would be helpful on night shift.
During an interview on 7/15/24 at 7:06 A.M., CNA E said he/she works day shift on the second floor, a memory care unit. He/She came in early for his/her shift today. He/She comes in early a lot because the facility can be short-handed on nights. The residents on the memory care unit need staff's help with getting cleaned up, changed, and dressed. He/She comes in early to make sure these residents are taken care of, even if staff is shorthanded.
During an interview on 7/15/24 at 11:17 A.M., CMT K said he/she does not feel like the facility has enough staff working across all shifts. He/She gets pulled from passing medications frequently to help the CNAs and is not able to get his/her work done in a timely manner as a result.
During an interview on 7/15/24 at 11:28 A.M. and 2:53 P.M., Restorative Aide (RA) W said she was hired as the facility's RA in September 2023. As the RA, she is responsible for obtaining a full set of vital signs on every resident, approximately 140 people, in the beginning of the month. She is also responsible for obtaining weights on every resident at the beginning of the month. There is no restorative program because she keeps getting pulled to work the floor because the facility is short-staffed. The facility needs to hire another RA so if staffing is short, one RA could be pulled to assist on the floor and the other RA could carry out the restorative program. They do not have enough aides. They need five aides total, that also includes one for showers, and then he/she would be able to focus on restorative.
During an interview on 7/15/24 at 2:48 P.M., CNA R said he/she usually works evening shift on the second floor, a memory care unit. On the evening shift, it would be best to have three CNAs working. The residents on the second floor have more confusion in the evening. The residents need to be helped with eating dinner, going to the bathroom, getting bathed, getting changed, and getting ready for bed. The residents also wander and need to be supervised and redirected from the doors and other rooms. Showers are scheduled for day and evening shift. The facility is short-staffed at times. When staffing is short, showers do not get done.
During an interview on 7/16/24 at 7:06 A.M., CNA EE said the facility is short on staff, especially on nights. He/She often works double shifts to help make sure the shifts are covered. Sometimes showers don't get done because the facility is short staffed. The facility needs another RA. There is only one RA for all the residents and it is not possible to get restorative done.
During an interview on 7/16/24 at 7:00 A.M., CNA DD said the facility is short on staff. Because the facility is short on staff, he/she sometimes has to work seven days in a row to help out.
During an interview on 7/15/24 at 3:08 P.M., the Staffing Coordinator said she is the only Staffing Coordinator for the facility. She works during the week and she is also the only person to contact when there are call-offs on the evenings and weekends. The facility's first floor requires a higher level of care. The first floor needs at least one nurse, but preferably two nurses, three CMTs, and at least four CNAs to work on the day and evening shifts. One nurse and at least three CNAs, preferably four or five CNAs, are needed on night shift for the first floor. The facility's second floor is a locked memory care unit. The second floor needs at least one nurse, one CMT, and two CNAs to work the day and evening shifts. One nurse and one CNA can cover the night shift on the second floor. The facility's third floor is behavioral, and is split into two sections, South and Main. Third floor Main needs one nurse, two CMTs, and two CNAs for day and evening shift. Third floor Main needs one nurse and one CNA for night shift. Third Floor South needs one nurse, one CMT, and at least one CNA, but preferably two CNAs, for day and evening shifts. Third floor South needs one nurse or one CMT, and one CNA for night shift. The third floor usually has three nurses so if one of the nurses gets pulled down to the first or second floor, the remaining nurse on the third floor can cover the South and Main sections. The facility does not employ enough staff to fill the schedule and they are currently hiring. The facility is currently using one agency to fill in slots where needed. The facility is a union building and if staff do not show up for their shift, they have two hours before it is officially considered a no-show, and their shift can be filled by facility staff, or can be posted on the needs list to be filled by agency. Sometimes, there is just not enough staff working.
During an interview on 7/10/24 at 9:36 A.M., the DON said the first floor requires one nurse, preferably two nurses, and three CMTs for day and evening shifts. The second floor requires one nurse and one CMT for day, evening, and night shift. The third floor is split into South and Main sections. Third floor South requires one nurse and two CMTs for day, evening, and night shift, and third floor Main requires one nurse and one CMT for day, evening and night shift. When someone calls off, staff can stay over to fill in, or agency staff can be called. The Staffing Coordinator fills in shifts when needed, and the DON and two ADONs are on call to help as well. The facility has enough staff in numbers, but there is no consistency in implementing systems to ensure tasks are getting done how they should be getting done. If staff have expressed they feel there is not enough staff working, they have not discussed it with her or the Staffing Coordinator, so she does not know how to address these issues if she is not made aware of them.
During an interview with the DON and Administrator on 7/16/24 at 11:17 A.M., the Administrator said the Administrator, Regional Nurse, and Regional Director of Operations are responsible for determining the staffing pattern. The staffing pattern is determined by the census number and fire code needs. The staffing pattern is communicated to the Staffing Coordinator, who is responsible for filling in shifts accordingly. The Staffing Coordinator has the staffing phone on her 24 hours a day, 7 days a week. If she needs time off, there is someone else who can fill in for her. The facility currently uses one contracted agency to assist in filling shifts. The facility is currently hiring. If there is a call-off, the Staffing Coordinator contacts as needed (PRN) facility staff first to see if they can pick up a shift. Part-time staff are also contacted to see if they are available. If one floor has more than enough staff, they will move people to help where needed. All departments and department heads are able to pitch in and help where needed. Anyone certified in an area can assist in that area when the facility is shorthanded. The interdisciplinary team (IDT) has had conversations about staffing shortages. Retention has been an issue at the facility.
MO00230468
MO00230563
MO00233204
MO00235070
MO00235408
MO00237997
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide residents food at a safe and appetizing temper...
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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 residents food at a safe and appetizing temperature for three residents (Residents #30, #58, and #111). The sample was 30. The census was 151.
Review of the facility's food temperatures policy, revised 10/24/22, showed:
-Purpose: To provide the dietary 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;
-Acceptable serving temperatures: Eggs should be greater than 135 degrees Fahrenheit (F), meat entrees should be greater than 135 degrees F, cereal or oatmeal should be 135 degrees F.
1. Review of Resident #30's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/12/24, showed:
-Cognitively Intact.
During an interview on 7/8/24 at 9:14 A.M., the resident said his/her food was cold most of the time when it was delivered to his/her room.
2. Review of Resident #58's quarterly MDS, dated [DATE], showed:
-Moderately impaired cognition.
Observation during the survey, showed the resident resided on the second floor.
During an interview on 7/8/24 at 11:07 A.M., the resident said his/her food was normally delivered to him/her cold.
3. Review of Resident #111's quarterly MDS, dated [DATE], showed:
-Cognitively intact.
During an interview on 7/8/24 at 9:00 A.M., the resident said his/her food was almost always cold by the time it was delivered to his/her room.
4. Observation on 7/11/24 at 11:42 A.M., of lunch trays served on the second floor, showed the following temperatures:
-Waffle measured at 76.8 degrees F and was cold;
-Hash browns measured at 94.4 degrees F and were cold;
-Fried chicken measured at 103 degrees F and was cold.
Observation on 7/15/24 at 7:58 A.M., of breakfast trays served on the second floor, showed:
-Sausage patty measured at 85 degrees F and was cold;
-Eggs measured at 83 degrees F and were cold;
-Oatmeal measured at 110 degrees F and was lukewarm.
6. During an interview on 7/15/24 at 9:44 A.M., [NAME] Q said he/she expected food to be delivered to the residents at the appropriate temperatures. He/She said this was important to ensure the residents received a hot meal.
During an interview on 7/15/24 at 9:47 A.M., the Dietary Manager said he expected residents to receive their food at the required temperatures to avoid illness.
During an interview on 7/15/24 at 2:56 P.M., the Administrator said she expected food to be delivered at the appropriate temperatures.
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 keep the kitchen equipment clean and floors free of dust, grease, and grime. In addition, staff failed to wear a beard net wh...
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Based on observation, interview, and record review, the facility failed to keep the kitchen equipment clean and floors free of dust, grease, and grime. In addition, staff failed to wear a beard net when preparing food. The census was 151.
Review of the facility's weekly cleaning list, dated 1/21/24, showed:
-Weekly cleaning: prep table, floors swept and mopped, cook station floors behind the fryers, walk in freezer, and fans and duct work.
1. Observation 7/8/24 of the kitchen, showed:
-At 8:31 A.M., the walk-in freezer with trash and food debris on the floor in multiple areas;
-At 8:34 A.M., the flour and sugar bulk bins observed to have lids caked with a white powder substance;
-At 8:35 A.M., the deep fryer observed with a sticky, dried grease build-up on the sides;
-At 8:35 A.M., the floor under the tilt skillet observed with a dark liquid with other debris spilled and puddled;
-At 8:36 A.M., a fan in the dish washing room with a dust build-up, blowing on the clean dishes.
2. Observation 7/9/24 of the kitchen, showed:
-At 10:47 A.M., a fan in the dish washing room with dust build-up, blowing on the clean dishes;
-At 10:48 A.M., the walk-in freezer with trash and food debris on the floor in multiple areas;
-At 10:48 A.M., the flour and sugar bulk bins observed to have lids caked with a white powder substance;
-At 10:49 A.M., the deep fryer with a sticky, dried grease build-up on the sides.
the floor under the tilt skillet with a dark liquid with other debris spilled and puddled.
3. Observation 7/10/24 of the kitchen, showed:
-At 6:12 A.M., a fan in the dish washing room with dust build-up blowing on the clean silverware;
-At 6:15 A.M., the floors in the main kitchen had various areas with food spills and food debris. The floors by the tilt skillet with a dark liquid with other debris spilled and puddled;
-At 6:16 A.M., the deep fryer with a sticky, dried grease build-up on the sides;
-At 6:25 A.M., the flour and sugar bulk bins with lids caked with a white powder substance;
-At 6:33 A.M., the walk-in freezer with trash and food debris on the floor in multiple areas.
4. Observation on 7/10/24 at 6:25 A.M., of the breakfast preparation, showed [NAME] MM came up to the prep station to assist [NAME] Q with breakfast preparation. [NAME] MM grabbed the uncovered cooked eggs and started to place them into tins for the steam table. [NAME] MM did not wear a beard net and had a beard approximately 3/4 of an inch long.
Observation on 7/11/24 of the lunch preparation showed:
-At 9:01 A.M., [NAME] MM grabbed a tin of cooked chicken and started to puree the chicken and placed the chicken into a tin for the steam table. [NAME] MM did not wear a beard net and had a beard approximately 3/4 of an inch long;
-At 9:16 A.M., [NAME] MM grabbed a tin of mixed veggies and started to puree the veggies and placed them into a tin for the steam table. [NAME] MM did not wear a beard net and had a beard approximately 3/4 of an inch long.
5. During an interview on 7/15/24 at 9:44 A.M., [NAME] Q said all dietary staff are responsible for cleaning the floors and prep stations in the kitchen across all shifts. The Dietary Manager and cook are responsible for cleaning appliances. [NAME] nets are to be worn anytime a staff member with a beard is around food to avoid hair from contaminating the food.
During an interview on 7/15/24 at 9:47 A.M., the Dietary Manager said all dietary staff are responsible for cleaning the floors in the kitchen and walk in freezer, bulk bin lids, and appliances. The Dietary Manager is responsible for cleaning fans. He would expect for the kitchen and appliances to be clean. [NAME] nets are required to be worn anytime food preparation is in process. He would expect his staff to be wearing a beard net.
During an interview on 7/15/24 at 2:56 P.M., the Administrator said she would expect the kitchen and all appliances to be clean to policy standards. She would expect staff to be wearing a beard net when food preparation is in process.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. The census was 151.
Review of th...
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Based on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. The census was 151.
Review of the facility's Nursing Department, Staffing, Scheduling, and Postings policy, revised 10/24/22, showed the facility must use the services of an RN for at least eight consecutive hours a day, seven days a week, unless a waiver applies.
Review of the facility's staffing sheets, dated 6/1 through 7/9/24 showed no RN coverage for the following dates:
-6/1, 6/2, 6/15, 6/16, 6/17, 6/18, 6/19, 6/20, 6/21, 6/22, 6/23, 6/29, 6/30, 7/6, and 7/7/24;
During an interview on 7/10/24 at approximately 12:00 P.M., the Staffing Coordinator said the facility currently has one as needed (PRN) RN but can utilize agency staff to cover the RN vacancy on the schedule.
During an interview on 7/16/24 at 11:16 A.M., the Administrator said she expected the Staffing Coordinator to schedule RN coverage eight hours a day, seven days a week. The facility is actively recruiting for RNs online and have sign on and referral bonuses in place. RNs are difficult to recruit.
MO00230468
MO00230563
MO00233204
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0801
(Tag F0801)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate certification. This had the potential to af...
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Based on interview and record review, the facility failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate certification. This had the potential to affect all residents who consumed food prepared by the facility. The census was 151.
Review of the facility's Dietary Manager job posting, undated, showed:
-Job Requirements: you are certified by the Association of Nutrition and Food Service Professionals, you completed a dietary manager exam.
During an interview on 7/16/24 at 9:18 A.M., the Dietary Manager said he does not currently have any certifications. He went through the course but never took the test.
During an interview on 7/16/24 at 9:27 A.M., the Administrator said the Registered Dietician comes to the facility once a week and is not employed full-time with the facility. She said the Dietary Manager was hired on 9/29/22 and does not have the appropriate certification at this time. She expected the Dietary Manager to have the required certifications.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0838
(Tag F0838)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to have a complete and thorough facility-wide assessment to determine what resources are necessary to care for the residents competently durin...
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Based on interview and record review, the facility failed to have a complete and thorough facility-wide assessment to determine what resources are necessary to care for the residents competently during both day-to-day operations and emergencies. The facility assessment did not include staffing ratios required per shift to meet the needs of residents, the need for a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, or the facility's use of locked units for residents identified with cognitive impairments and behaviors. The census was 151.
Review of the facility's Facility Assessment, updated 12/13/23, showed:
-Persons involved in completing assessment: Administrator, Director of Nursing (DON), Medical Director, Governing Body Representative (representative from facility's corporation);
-Resident acuity, per major resource utilization guidelines (RUGs), number/average or range of residents:
-Rehabilitation plus extensive services: 72;
-Rehabilitation: 71;
-Extensive services: 1;
-Special care, high: 21;
-Special care, low: 6;
-Clinically complex: 4;
-Behavioral symptoms and cognitive performance: 8;
-Reduced physical function: 26;
-Staffing plan: General staffing plan to ensure sufficient staff to meet the needs of the residents at any given time:
-Licensed Nurses: 1 DON, 2 Assistant Directors of Nursing (ADON), 2 RN or Licensed Practical Nurse (LPN) charge nurse;
-Direct care staff: Ratio for days, evenings and nights, blank;
-Other (e.g., department heads, nurse educator, quality assurance, ancillary staff in maintenance, housekeeping, dietary, laundry: 2 wound nurses;
-No documentation of ratios of direct care staff, restorative therapy staff, Social Services staff, dietary staff, housekeeping and laundry staff necessary on each shift to ensure the needs of residents are met;
-No documentation of the need for a RN at least eight consecutive hours a day, seven days a week;
-No documentation for the use of one locked unit utilized for residents identified with cognitive impairments and/or wandering behaviors, and two locked units utilized for residents identified with behaviors.
During the course of the survey process, problems were identified which included:
-Insufficient nursing staff available to meet the needs of residents, as evidenced by staff interviews, residents with missed treatments, and residents with missed activities of daily living (ADL) care;
-A RN was not scheduled eight consecutive hours a day, seven days a week;
-Lack of a restorative program.
During an interview on 7/16/24 at 11:17 A.M., the Administrator said the facility assessment is developed by the Administrator and reviewed by the facility's Regional office and facility's interdisciplinary team. The facility assessment is updated annually unless needed otherwise. She expects the facility assessment to accurately reflect the facility's general staffing needs, including staff ratios. Facility assessment should include all of the facility's resources as they pertain to the building structure, including the use of locked units on the second and third floors of the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to establish an Antibiotic Stewardship Program (ASP) that included antibiotic use protocols and a system to monitor antibiotic use. The census...
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Based on interview and record review, the facility failed to establish an Antibiotic Stewardship Program (ASP) that included antibiotic use protocols and a system to monitor antibiotic use. The census was 151.
Review of the facility's ASP, revised 10/24/22, showed:
-Purpose: To limit antibiotic resistance in the post-acute care setting, improve treatment efficacy and resident safety, and reduce treatment-related costs;
-Policy: ASP is designed to promote appropriate use of antibiotics while optimizing the treatment of infections, and simultaneously reducing the possible adverse events associated with antibiotic use;
-Procedure:
-The Infection Preventionist (IP), a medical professional that develops ways to detect, prevent and control the spread of infections in residents at the facility, and Medical Director will set standards for the use of antibiotics after reviewing antibiotic trends from the previous quarter and outcome reports;
-These standards will be updated as indicated, but no less than annually;
-The IP, or other similarly qualified healthcare professionals, will educate nursing staff to obtain and communicate pertinent clinical information to physicians to promote appropriate diagnosis and prescribing of antibiotics;
-The Infection Control Committee (ICC) will review infections and monitor antibiotic usage patterns on a regular basis. In addition, the ICC will obtain and review results from microbial cultures, resistant organisms, alerts and antibiotics from the lab for trends of resistance;
-The Consultant Pharmacist will review the antibiotic prescribing practices of active antibiotic orders during his/her monthly drug regimen review;
-The Consultant Pharmacist will prepare a written report documenting potential areas for improvement, irregularities, and recommendations. This report will be shared with the ICC and/or the Quality Assessment and Assurance Committee (QAC).
-The IP will report on number of antibiotics prescribed (days of therapy) and the number of residents treated each month to the Consultant Pharmacist.
-The IP will collect and analyze infection surveillance data and monitor the adherence to the ASP and create a report for the Consultant Pharmacist identifying the number of residents on antibiotics that did not meet criteria for active infection and suggest appropriate overall changes to make it a successful, well-rounded program;
-Tracking:
-The IP will be responsible for review of infection surveillance and multi-drug resistant organisms (MDRO), a germ resistant to many antibiotics, tracking;
-The IP will utilize antibiotic tracking sheet;
-The Consultant Pharmacist will review and report antibiotic usage data collected by IP each month during their drug regimen review process to include the above medication safety criteria;
-The IP will measure and report outcomes and success rate at monthly/quarterly ICC meetings.
Review of a list of residents on antibiotics provided by facility showed ten residents had active orders for antibiotics.
During an interview on 7/9/24 at 2:27 P.M., the facility's Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility, Nurse said she recently took over the ASP and the IP role after the last Director Of Nursing (DON) left. She did not have a current tracking system or surveillance for antibiotics and did not know where the previous tracking and surveillance information the previous DON had was located.
During an interview on 7/11/24 at 8:10 AM., the Wound Nurse said she would like to see some type of antibiotic log or tracking so she could determine a more refined plan of care for residents who have infected wounds. She was not aware if the facility had a current ASP in place.
During an interview on 7/17/24 at 11:16 A.M., the Administrator and the DON said antibiotic stewardship is expected to be utilized by the facility to track and monitor the residents who have orders for antibiotics. The IP is responsible to establish and maintain the ASP.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to establish and maintain a tracking system for Certified Nursing Assistant (CNA) 12 hour training requirements for five out of five sampled C...
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Based on interview and record review, the facility failed to establish and maintain a tracking system for Certified Nursing Assistant (CNA) 12 hour training requirements for five out of five sampled CNAs. The census was 151.
A policy related to CNA 12-hour training was not provided by the facility.
Review of the five sampled CNAs' (CMT HHH, CMT OO, CNA E, CNA T, and CNA M) employee training records showed:
-Multiple dated in-services and education sheets signed by the CNAs. The signed in-service and education sheets did not list the amount of time each in-service had taken.
-No further documentation of tracking the in-services for each CNA provided by the facility.
During an interview on 7/10/24 at 4:10 P.M., CNA T said the facility was always in- servicing and providing education, but didn't think the facility was officially tracking the mandatory 12 hours.
During an interview on 7/16/24 at 11:16 A.M., the Administrator said the facility was always providing education and in-services to the CNAs, but she had failed to organize and track the yearly mandatory 12 hour trainings for the facility CNAs to ensure they are being completed.
MINOR
(C)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to post the nurse staffing information daily in a promine...
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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 post the nurse staffing information daily in a prominent place, readily accessible to residents and visitors. In addition, the daily staffing sheets maintained by the facility did not include the facility name. The census was 151.
Review of the facility's Nursing Department Staffing, Scheduling, and Postings policy, revised 10/24/22, showed:
-Posting requirement:
-The facility will post the following information on a daily basis:
-Facility name;
-The current date;
-The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift;
-Facility census;
-The facility will post the nurse staffing data specified above, on a [NAME] basis at the beginning of each shift;
-Data must be posted in a clear and readable format and in a prominent place readily accessible to residents and visitors.
Review of the daily staffing sheets dated 6/3 through 7/9/24 showed:
-On 6/1, 6/2, 6/8, 6/9, 6/15, 6/16, 6/19, 6/29, 6/30, 7/4, 7/5, 7/6, and 7/7/24, the sheets were not completed and posted.
-On 6/3, 6/4, 6/5, 6/6, 6/7, 6/10, 6/11, 6/12, 6/13, 6/14, 6/17, 6/18, 6/20, 6/21, 6/24, 6/25, 6/27, 6/28, 7/1, 7/2, 7/3, 7/8, and 7/9/24, the sheets did not have the facility name listed.
Observation on 7/9/24 at approximately 12:00 P.M., showed the daily staffing sheet posted at the facility's front desk without the facility name listed.
During an interview on 7/10/24 at approximately 12:00 P.M., the Staffing Coordinator said she is the only staff person that fills out the staff sheets and posts them. The sheets have not been filled out or posted on the days that she is not working. She was not aware that the sheets needed to be filled out and posted daily with the facility name.
During an interview on 7/16/24 at 11:16 A.M., the Administrator said she would expect the staffing sheets to be filled out correctly and posted on a daily basis in a prominent area.
Jan 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
Based on interview and record review, the facility failed to notify one of eight sampled residents, in writing, of a facility-initiated immediate discharge in a language understood by the resident (Re...
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Based on interview and record review, the facility failed to notify one of eight sampled residents, in writing, of a facility-initiated immediate discharge in a language understood by the resident (Resident #8). The census was 156.
Review of the facility policy titled, Transfer and Discharge, revised 10/24/22, 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 provide complete, safe, and appropriate discharge planning and necessary information to the continuing care provider. The facility may transfer or discharge a resident for reasons which include that the health and/or safety of individuals in the facility would otherwise be endangered by the resident's presence. Facility staff is to provide the resident with reasonable advance notice of the transfer or discharge before it occurred. In cases in which 30 days' notice is not possible, the notice of transfer or discharge should be provided to the resident or resident's representative as soon as is practicable. Documentation and education provided to a resident or the resident's representative in preparation for transfer or discharge will be provided in a language that he/she understands.
Review of Resident #8's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/1/23, showed the following:
-Severe cognitive impairment;
-Independent activities of daily living;
-Independent ambulation;
-Always continent of bowel and bladder;
-Diagnoses included dementia, high blood pressure, renal failure, diabetes mellitus, epilepsy, anxiety disorder, depression, other specified disorders of the brain, and personal history of benign neoplasm (tumor) of the brain.
Review of the resident's progress notes, showed the following:
-12/5/23 at 4:20 P.M., social worker (SW) and staff continue to use the translation document the SW created to communicate with the resident. He/She does not speak English and signs. His/Her first language is Spanish;
-12/11/23 at 2:57 P.M., the resident eloped from the unit by walking out behind a family member who was entering the hall. The resident does not speak English. No translator on staff. He/She communicated his/her wants by writing that he/she wanted a taxi on a piece of paper. Staff redirected the resident back on the unit.
Review of the resident's physician's orders, showed an order dated 12/11/23, for Haloperidol Lactate Injection Solution (used to treat certain mental/mood disorders) 5 mg (milligrams)/ml (milliliters), inject 5 mg/ml IM (intramuscularly) every 8 hours as needed (PRN) for agitation.
Review of the resident's care plan, updated 12/11/23, showed the following:
-The resident has a communication problem, language barrier;
-He/She only speaks Spanish;
-Monitor/document for physical/nonverbal indicators of discomfort or distress and follow-up as needed;
-The resident is an elopement risk/wanderer;
-Impaired cognitive function related to dementia.
Review of the resident's care plan, did not show any verbal communication interventions/instructions to address the language barrier or behavioral triggers (e.g. coffee running out before the resident could have a second cup, other residents entering his/her room, etc.).
Review of the resident's progress notes, showed the following:
-12/15/23 at 3:40 P.M., the resident was transported to the hospital due to the following behaviors: throwing objects at staff (shoes, phone, food, etc.), use of vulgar language, profanity towards staff and attempting to elope from the unit. At 11:41 P.M., the resident returned from the hospital in a pleasant mood with no signs of distress noted;
-12/20/23 at 9:15 A.M., the resident was transferred to the hospital via ambulance and the police due to increasing agitation, sexual behaviors, throwing objects and seeking to elope. Redirection by staff was attempted with no improvement. One-on-one supervision was provided via the nurse with no improvement. The resident received a PRN 5 mg Haloperidol IM injection.
Review of the resident's notice of proposed discharge, dated and effective 12/20/23, showed the reason for discharge of the resident to the hospital was that the safety and health of individuals in the facility was endangered by the resident's presence.
Review of the resident's notice of proposed discharge, showed it was all in English.
During an interview on 1/18/24 at 9:47 A.M., Nurse A said he/she had not dealt with the resident on a daily basis. However, he/she had responded to codes announced on two different occasions, due to the resident being combative. The resident was very hard to understand. He/She spoke Spanish combined with a Honduran form of street slang and a lot of it sounded like gibberish. Staff communicated with the resident via communication cards with pictures on them, a communication board and translation booklet. When the resident was agitated, he/she did not take the time to verbally communicate, because the inability to effectively verbally communicate frustrated him/her.
During an interview on 1/18/24 at 2:46 P.M., Certified Nurse Aide (CNA) B said he/she spoke Spanish. The communication issue with the resident was that the resident spoke broken Spanish and attempted to fill in the blanks by using his/her hands to sign (make hand signals). However, his/her method of signing was confusing. Another issue was that when the resident was agitated, he/she did not listen to anyone. Certain things triggered the resident like people going into his/her room or not getting two cups of coffee during breakfast.
During an interview on 1/18/24 at 11:36 A.M., Nurse C said the resident was normally quiet and did not have daily behavioral problems. On 12/4/23, staff told him/her the coffee had run out. The resident began shouting, I want coffee, coffee, coffee! He/she started throwing food on the floor and rubbing it in. The resident was out of control. He/She had snatched everything off the medication cart, attempted to break the computer on it and was swinging at people. At that time, the resident did not have a PRN psychotropic medication. Staff had to try and talk him/her down. Because staff was speaking English, the resident could not understand them. So, they called the police.
During an interview on 1/18/24 at 10:20 A.M., CNA D said the resident spoke very little English and could not understand much of it. So, the resident used hand gestures and pointed at things, in order to communicate his/her needs. Staff also used flash cards with pictures and words in Spanish, when interacting with him/her. The resident tended to get frustrated, because no one could understand what he/she was saying and he/she had to reside on a locked unit. The triggers of a communication barrier and lack of freedom resulted in a tendency to get a little aggressive. His/Her mood was in and out (up and down). The resident would become anxious, wanting to go off the unit and do something. Frustration would build up and he/she would get into an uproar, throwing whatever was in his/her hands and swinging at anyone in his/her way. Verbal redirection was not effective, so CNA D would either give the resident something (e.g. another cup of coffee) or wait for the resident to calm down. The resident knew that if he/she acted up, then he/she would get sent out to the hospital. Consequently, the resident always willingly hopped onto the Emergency Medical Services (EMS) stretcher. He/She was manipulative in that way. On 12/20/23, the resident displayed his/her normal level of aggression. Most likely, he/she thought that a trip to the hospital would grant him/her some freedom and then he/she would return to the facility.
During an interview on 1/18/24 at 10:51 A.M., CNA E said some days, the resident understood what staff said to him/her and other times he/she did not. Consequently, staff mainly communicated with the resident via flashcards which were in Spanish and had pictures on them. On 12/20/23, the resident got upset, when he/she only received one cup of coffee. He/She threw the computers off both medication carts and started tossing everything that he/she could grab.
During an interview on 1/20/24 at 11:45 A.M., the SW said the discharge letter given to the resident on 12/20/23, was in English. One of the EMS workers, who arrived to transport the resident to the hospital, spoke Spanish and read parts of it to the resident. However, the resident's Spanish was so broken that it was not clear how much he/she comprehended.
During an interview on 1/19/24 at 11:36 A.M., the Regional Nurse Consultant (RNC) said the resident had a traumatic brain injury (a form of acquired brain damage from trauma which impacts impulse control and self-awareness), so it was not clear how much the resident understood even in Spanish. The RNC felt with the resident, there was more of a comprehension issue than a language barrier.
During an interview on 1/18/24 at 2:30 P.M., the Assistant Administrator said on 12/20/23, the resident showed a lot of aggression which included throwing things and attempting to hit people, which created an unsafe environment for staff. The resident was throwing things like coffee and the medication cart computers at staff. It was his/her third aggressive behavioral episode within a few days. Staff sent the resident to the hospital with an immediate discharge letter and faxed a copy of it to the hospital to which EMS had been instructed to transport him/her. The letter was in English. In hindsight, the letter should have been in Spanish. However, the resident's Spanish was very broken and the letter was verbally translated for him/her. EMS diverted the resident to a different hospital. When the Assistant Administrator found out the hospital planned to send the resident back to the facility, he reached out to the hospital, tried to put a stop to it and offered assistance with finding placement for the resident elsewhere. He provided the front desk at the facility with a copy of the immediate discharge letter. The Assistant Administrator believed the resident was dangerous to staff. He turned EMS back and did not allow the resident to re-enter the facility.
MO00229309
Nov 2023
4 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
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to ensure one resident (Resident #7) was free from physical abuse. On 9/21/23, Resident #4 hit Resident #7, resulting in small laceration (cut)...
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Based on interview and record review the facility failed to ensure one resident (Resident #7) was free from physical abuse. On 9/21/23, Resident #4 hit Resident #7, resulting in small laceration (cut) to left eye brow, bottom lip and left upper and bruising with some swelling under left eye and bridge of nose. The sample was 10. The census was 146.
Review of the facility's Abuse Prevention and Prohibition Program policy, dated revised: October 24, 2022, showed:
-Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The Facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property;
-The Facility is committed to protecting residents from abuse by anyone, Including but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitors;
-Resident-to-resident altercations must be reported if the altercation is caused by a willful action that results in physical injury, mental anguish or pain;
-The presence of a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate on non-accidental behavior;
-Assessing psychosocial outcome of the victim of abuse may be difficult to determine or incongruent with what would be expected. In these situations, the Investigator should consider how a reasonable person in the resident's circumstances would be impacted by the incident;
-Investigation: The Administrator will provide initial and follow-up written reports of the results of all abuse investigations and consequent actions to the appropriate agencies as outlined in Section IX below:
-If the investigation substantiates the allegation, corrective action will be documented as part of the investigation and implemented to prevent recurrence;
-If the investigation reveals that the initial report was unsubstantiated, the investigation ceases immediately. The Facility will notify residents, family members, facility staff, and the appropriate state agencies of the findings.
1. Review of the facility's investigation, showed:
-Initial Investigation: On 9/21/23 at approximately 7:30 P.M., the Administrator and Director of Nursing was notified that Resident #4 hit Resident #7. No recent behavior noted for Resident #4;
- Initial Intervention: the residents were separated, residents and staff was interviewed. The police and Emergency Medical Services (EMS) was called. Resident #4 was sent out via emergency services. Skin assessment was completed. The Medical Doctor (MD), both resident representatives (RP) and the Department of Health and Senior Services (DHSS) was notified;
-Findings: Resident #4 stated he/she thought Resident #7 went into his/her room and he/she was upset that Resident #7 could not respond and became frustrated and hit Resident #7. Resident #7 and Resident #4 were separated, Resident #4 was placed on 1 to 1 until EMS arrived; A skin assessment was completed by the nurse on Resident #7 with minimal discoloration and a x-ray was completed with no abnormalities found. Resident was interviewed by nurse and reported no pain and felt safe; other residents were interviewed and feel safe in their environment and know who to report to if they are concerned or feel unsafe;
-Final Interventions: Updated care plan; Doctor notified of incident and psych will follow up; Social Worker followed up with Resident #7-no concerns; x-ray completed on Resident #7 with no abnormalities noted; Resident #4 remains out of the building.
-The investigation did not say if the facility found the allegation to be substantiated or not.
Review of the undated statement from resident #7, showed: he/she said I went into his/her room, but I didn't. I'm fine. I'm okay. I don't need anything. I feel fine here.
Review of Resident #7's weekly skin observation, dated 9/21/23, showed:
-Skin issues? Yes was marked;
-Notes: Lateral (outer side) left eye brow small laceration (cut), no bleeding; Left upper cheek small laceration, no bleeding; Under left eye bruising, swelling; Bridge of nose bruising, scant bleeding from nose; Bottom lip small laceration no bleeding.
Review of undated statement from resident #4, showed: he/she came into my room and he/she wouldn't tell me if he/she did or not when I asked him/her. The line for the signature of witness, title was blank.
Review of Resident #4's Notice of Proposed Discharge, dated 9/21/23, showed:
-Discharge effective date was 9/21/23;
-discharged to: St. Louis City Justice Center;
-Reason for discharge: the safety of individuals in the facility is endangered by your presence and the health of individuals in the facility is endangered by your presence was marked.
Review of Staff Member H, written statement, dated 9/21/23, showed, Resident #4 came to the desk asking for ice. Staff Member H gave him/her ice. Resident #7 was walking down the hall, Resident #4 turned around and just started punching him/her in the face. Staff Member H screamed for Resident #4 to stop and got between them to split them up and Staff Member I helped.
Review of Staff Member I, written statement, dated 9/21/23 showed, as he/she came off break and saw Staff Member H was trying to separate the residents and he/she helped separate them.
2. Review of Resident #7's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/3/23, showed:
-Resident had severe cognitive impairment;
-Diagnoses included: medically complex condition, anxiety disorder, depression and schizophrenia.
Review of the care plan in use at the time of survey, showed:
-Focus: The resident has little or no activity involvement related to anxiety and schizophrenia;
-Goal: resident will express satisfaction with type of activities and level of activity involvement when asked through the review date;
-Intervention included: Activity department to participate in 1 to 1 activity of his/her choice twice a week; Resident needs assistance/escort to activity functions; resident to make his/her own name plaque for his/her door during activity time; remind resident that resident may leave activities at any time and is not required to stay for the entire activity; the residents preferred activities are radio and different types of music.
During an interview on 11/7/23 at 2:45 P.M., the resident said, Resident #4 said he/she was going into his/her room and did not go into his/her room and said he/she guessed Resident #4 was calling the tv room his/her room because that was the only room he/she went in. Then, he/she said, Resident #4 attacked him/her for no reason at all. Resident #4, socked him/her in the nose and beat the shit out of him/her. Resident #7 said he/she did not hit Resident #4 back. The staff took him/her off the floor and wanted him/her to go to the hospital, but he/she did not want to go.
Review of the progress notes, showed:
-On 9/21/23 at 11:05 P.M., it was reported that resident allegedly entered another resident's room, resident stated that he/she was hit by another resident. Resident removed from unit for safety, skin assessment completed as entered, Resident denied any pain at that time. Medical Doctor (MD) was notified with new order to send resident out to hospital. Resident refused and further assessed by Emergency medical Service (EMS) alert & oriented times three to four (person, place, time and situation), upper management present. Responsible party aware of refusal. MD on call aware of refusal, neuro checks began;
-On 9/22/23 at 11:19 A.M., Social Worker (SW) was informed resident was physically assaulted by another resident last night. Resident refused to go to the hospital. SW followed up with resident today. Resident appeared in good spirits today. Resident was up walking around the hall. SW asked resident how resident feeling was. Resident stated I am just fine. I didn't go to the hospital. SW stated, how come you did not want to go to the hospital? Resident stated, I am doing good. He/she hit me because he/she said I went into his/her room and I did not;
-On 9/22/23 at 2:02 P.M., SW documented incorrectly. SW informed resident was involved in a resident to resident last night. Resident refused to go to the hospital. SW followed up with resident today. Resident appears in good spirits today. Resident was up walking around the hall. SW asked resident how resident feeling was. Resident stated I am just fine. I didn't go to the hospital. SW stated, how come you did not want to go to the hospital? Resident stated, I am doing good. He/She hit me because he/she said I went into his/her room and I did not;
-On 9/23/23 at 12:56 A.M., resident was in bed. Responding appropriately to verbal stimulus. Resident has bruising around left eye related to altercation with another resident. Voiced no complaints of pain. No swelling observed. Will continue to monitor resident. No agitation noted.
3. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/1/23, showed:
-Resident was cognitively intact;
-No behavioral symptoms were exhibited;
-Diagnoses included: medically complex condition, anxiety disorder, psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions) and schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves).
Review of the care plan, in use at the time of the survey, showed:
-Focus: Resident has a history of aggressive behavior toward others:
-On 6/28/21, the resident became irate with staff and physically knocked items away from staff when he was upset about his belongings;
-On 2/20/2023, the resident hit another resident while in the TV room on the unit;
-Goal: Resident will not harm other/self through next review;
-Interventions: anticipate and meet the resident's need; caregivers to provided opportunity for positive interaction, attention; Stop and talk with him/her as passing by; Encourage the resident to express his feelings appropriately; Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; 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; provide a program of activities that is of interest and accommodates resident's status.
Review of the progress notes, showed:
-On 9/21/23 at 10:59 P.M., the resident reported to staff that another resident was going into his/her room and became frustrated due to another resident allegedly being in his/her room. He/She admitted to hitting a resident. Resident was placed on 1:1 monitoring for safety until emergency services arrived, Medical Doctor (MD) was notified. The guardian was notified and upper management was present;
-On 9/22/23 at 11:14 A.M., Social Worker informed resident physically assaulted another resident last night due to resident believing other resident was going into resident's room. Resident arrested and has not returned as of today;
-On 9/22/23 at 1:28 P.M., SW documented incorrectly. SW was informed resident
was involved in a resident to resident with another resident last night. Resident was placed on 1:1 until emergency services arrived. Resident has not returned to facility as of today.
4. During an interview on 11/7/23 at 12:00 P.M., Licensed Practical Nurse (LPN) J said, he/she was working on another hall when a staff member ran and got him/her and told her something about Resident #4 and #7. When LPN J arrived on the unit, Resident #4 was at his/her door pacing and talking about Resident #7 came into his/her room and Resident #7 should not have come into his/her room. Resident #4 did admit to striking Resident #7. Resident #4 was placed on 1 to 1.
Resident #7 was in the hall a few doors down, there was blood on the floor, but LPN J did not see where the blood came from. Resident #7 had some bruising and swelling on his/her face. LPN J called a stat (for other staff members to respond to unit). Another nurse took Resident #7 off the floor and provided care for him/her. The MD wanted Resident #7 to go to the hospital but the resident refused. Neuro checks was started. 911 was called and the police did arrive within 30 to 45 minutes. Management was notified. The MD and RP for both residents was notified. The RP wanted Resident #4 charged and talked to the police on the phone. When Resident #4 left the building he/she left with the police and EMS.
5. During an interview on 11/7/23 at 2:20 P.M., Certified Medication Technician (CMT) K said, if there was a resident to resident altercation, he/she would diffuse the situation and separate the residents and report the situation to the nurse and if there was no nurse available he/she would call the administrator.
6. During an interview on 11/7/23 at 2:30 P.M., Certified Nurse Aide (CNA) L said, if a resident had an altercation with another resident he/she would redirect the residents and report it to the nurse.
7. During an interview on 11/7/23 at 2:35 P.M., CNA M said, if a resident had an altercation with another resident, he/she would try to calm the resident down and separate the residents, call a Dr. Strong and call the family to try to have them help calm down the resident.
8 During an interview on 11/7/23 at 4:10 P.M., CNA N said, Resident #4 went out earlier in the day and was not him/herself when he/she returned. He/She was not on the floor when the incident occurred. When he/she got to the floor, he/she saw someone cleaning up the blood off the floor. Resident #7 had gotten beaten up and was hurt. He/she had blood on his/her face, and the nurse was there assessing him/her.
9. During an interview on 11/8/23 at 7:05 A.M. CMT Q, said, if a resident had a resident to resident altercation, he/she would break it up and separate the residents, make a report and report it to the Director of Nursing (DON).
10. During an interview on 11/8/23 at 11:00 A.M., the Director of Nursing (DON) said she was at home when the incident occurred. Resident #4 was at the nurse's station. He/She asked for ice and the DON did not know what was said. Resident #4 turned and punched Resident #7. Staff separated the residents. Resident #7 was assessed and he/she had something on his/her eye brow and something on the side of his/her nose. Resident #4 went back to his/her room. Resident #7 went off the floor to the lobby. The Administrator, families and police was called. Resident #4 left with the police. Resident #7 stayed here, he/she refused to go to the hospital, neuro checks were done and facial x-rays were done.
11. During an interview on 11/8/23 at 11:10 A.M., the Administrator said Resident #4 said Resident #7 went into his/her room. Resident #7 did not respond when Resident #4 said something to him/her and Resident #4 got frustrated and hit Resident #7 in the face. The residents were separated. Other residents heard the commotion but no other residents witnessed the incident. Resident #4 was placed on 1 to 1 until EMS arrived. Resident #4 was issued an immediate discharge. The resident left with EMS and the police and has not returned to the facility. Resident #7, staff assessed him and took him/her off the floor. The MD wanted Resident #7 to go to the hospital but he/she refused. X-rays were ordered and were negative.
MO00225109
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
See T2XB12
Based on interview and record review, the facility failed to thoroughly investigate an abuse allegation for one resident (Resident #3), when he/she alleged an African American male Certifie...
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See T2XB12
Based on interview and record review, the facility failed to thoroughly investigate an abuse allegation for one resident (Resident #3), when he/she alleged an African American male Certified Nursing Assistant (CNA), threatened him/her. Appropriate staff and resident interviews were not conducted. The sample was 10. The census was 146.
Review of the facility's abuse policy, dated 10/24/22, showed:
-Purpose includes: To ensure the facility established, operationalized, and maintained an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the investigation of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements;
-The investigator may take some or all of the following steps:
-Reviews all relevant documentation;
-Interviews any witnesses to the alleged incident;
-Interviews the resident (as medically appropriate);
-Interviews facility staff members who have had contact with the resident during the period of the alleged incident;
-Interviews the resident's roommate, family members, and visitors.
Review of Resident #3's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/14/23, showed:
-Cognitively intact;
-Independent in self-care tasks;
-Diagnosis of anti-social personality disorder (condition in which a person consistently shows no regard for right and wrong and ignores the rights and feelings of others).
Review of the resident's care plan, in use at the time of survey, showed:
-Problem: The resident verbalized his/her dissatisfaction with staff performance and was verbally abusive towards staff;
-Desired outcome: The resident will demonstrate effective coping behavior;
-Interventions: The resident was allowed to express his/her feelings, was educated on facility procedures, was given choices about his/her care and staff paired up when providing care.
Review of the facility's initial investigation, received on 9/17/23, showed:
-Date of alleged incident: Unknown;
-Time of alleged incident: Unknown;
-Summary of alleged incident: The resident was sent to the hospital and informed the social worker an African American male CNA, whom worked reception also, told him/her he/she would beat (his/her) ass if the resident pressed his/her call light. No male staff worked as a CNA and reception. Facility investigation was started.
Review of the list of male CNA staff, provided by the facility, showed four African American males CNAs: CNA D, CNA/Certified Medication Technician (CMT) E, CNA F and CNA G.
Review of the facility's investigation, dated 9/17/23, showed:
-Written statements from three, female CNAs and one female CMT;
-No documented interviews with CNA D, CNA/CMT E, CNA F and CNA G;
-No documented interview with the resident's roommate.
During an interview on 11/7/23 at 1:15 P.M., the Administrator said she completed the investigation. She did not interview any African American male CNAs, because they did not fit the description.
Review of written statements, submitted to DHSS on 11/17/23 at 12:55 P.M., by corporate staff, showed two statements by male staff.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** See T2XB11
Based on interview and record review, the facility failed to ensure services provided met professional standards when...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** See T2XB11
Based on interview and record review, the facility failed to ensure services provided met professional standards when one resident (Resident #2) with a head laceration, related to a fall, did not receive neurological checks (neuro checks, an assessment completed by nursing staff to monitor for changes in the resident's neurological (nervous system) status); and failed to ensure one resident (Resident #7 ) received neuro checks after another resident hit him/her in the head with their fist. The sample of residents with head injuries or unwitnessed falls was four. The census was 146.
Review of the facility Neurological Assessment Policy, dated revised 10/24/22, showed:
-Purpose: To provide guidelines for the performance of a neurological assessment on residents;
-Policy: Nursing will perform a neurological assessment in the following circumstances:
--Upon Attending Physician order;
--Following an unwitnessed fall and neither the resident nor anyone else know how he/she got there;
--Following a fall or other accident/injury involving head trauma;
--When indicated by resident's condition;
-Documentation: the following information will be documented in the resident's medical record:
--The date and time the procedure was performed;
--The name and title of the individual(s) who performed the procedure;
--All assessment data obtained during the procedure, including
-Eye opening;
-Verbal response;
-Motor response;
-Pupillary response;
-Limb response;
--If the resident refused the procedure, the reason(s) why and the interventions taken;
--The signature and title of the person recording the data.
1. Review of Resident #2's admission Face Sheet, showed the resident was admitted on [DATE] with diagnoses including muscle wasting and atrophy (a significant shortening of the muscle fibers and a loss of overall muscle mass), reduced mobility, schizoaffective disorder (a mental illness that can affect your thoughts, mood and behavior), aphasia (affects a person's ability to express and understand written and spoken language) and abnormalities of gait (walking) and mobility.
Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/8/23, showed:
-Severe cognitive impairment;
-A history of falls prior to admission;
-Dependent on staff for mobility.
Review of the resident's Witnessed Fall sheet, dated 9/30/23, showed:
-Incident description: Resident alert with confusion. Total care assisted up in wheelchair in dining room. Spoon fed. Encouraged appetite intake and fluids. Resident up in wheelchair. Witness resident suddenly out of wheelchair and laid on the floor on right side. Right side eyebrow area healed scab with scant amount of bleeding. Area cleaned with soap and water. Stopped bleeding. Resident assisted back to wheelchair. Monitor for fall risk. Resident to be monitored up in wheelchair with confusion. Moving all extremities;
-Injury type: No injuries observed at time of incident;
-Level of consciousness: alert;
-Mobility: Wheelchair bound;
-Mental status: Resident confused times three;
-Injuries report post incident: No injuries observed post incident;
-Predisposing environmental factors: None;
-Predisposing physiological factors:
--Confused;
--Incontinent;
--Gait imbalance;
--Impaired memory;
-Predisposing situation factors:
--Wanderer;
-Witnesses: No witnesses found
-Agencies/People notified: Responsible Party, Physician and Director of Nursing (DON) notified on 9/30/23;
-No noted documentation that neuro checks were performed.
Review of the resident's Weekly Skin Observation, dated 9/30/23, showed a small laceration above the right eyebrow, signed by the DON on 11/7/23.
Review of the resident's Fall Risk Assessment, dated 9/30/23 showed:
-Reason for assessment: Recent fall;
-History of falls within last six months: one to two times;
-Medication use: antihypertensives (medication for high blood pressure) and psychotropics (relating to or denoting drugs that affect a person's mental state);
-Memory and recall ability: Never able to recall three out of four of the following: current season, that he/she is in a nursing home, location of room, staff names/faces;
-Vision pattern: Adequate - able to see in adequate light with glasses on;
-Continence in the last 14 days: Total incontinence, bowel and bladder;
-Confined to chair and disoriented;
-Signed by DON on 11/7/23;
-No noted documentation that neuro checks were performed.
Review of the resident's nursing progress notes, showed:
-9/30/23 at 12:18 A.M., Note Text: Found on the Floor: Assigned Certified Nursing Assistant (CNA) informed Nurse during last rounds of finding resident on the floor at foot of his/her bed and lying on his/her right side. Nurse witnessed floor mats adjacent to resident's bed. Small amount of blood noted from resident right side of forehead. Laceration 1.5 cm. Area cleansed. Required one staff in assisting resident from floor to his/her bed and during treatment care. Assisted range of motion (AROM, when the person needs assistance with movement from an external force because of weakness, pain, or changes in muscle tone) and passive range of motion (PROM, when the person is unable or not permitted to move the body part) within normal limits for resident. Responded to his/her name. Did not answer how he/she got on the floor;
-9/30/23 at 6:39 A.M., Note Text: Remains on on-going observation post fall. Resting in bed with eyes closed, unlabored and even breathing. Mats in place at beside;
-9/30/23 at 9:15 A.M., Note Text: Resident up in wheelchair, attempting to lay on floor. Right side of forehead with scabbed area status post (medical term used to refer to a treatment, diagnosis or just an event that a patient has experienced previously) laceration. Scant amount bleeding. Resident to be monitored for fall risk. Right side area washed with soap and water. No further bleeding. Spoon fed. Appetite good. Vital Signs (VS) Blood Pressure (B/P, normal 90/60 through 120/80) 134/60, Pulse, (P, normal 60 to 100) 63, Respirations (R, normal 12 to 18) 19, Temperature (T, normal 97.8 through 99.1) 97.3;
-9/30/23 at 1:13 P.M., Resident taken to shower area and resident suddenly appeared weak. Legs had some partial discoloration. Placed call to 911 per DON. Resident transported to emergency room (ER) for evaluation and treatment. Physician made aware. Responsible party notified;
-9/30/23, no noted documentation of any physical assessments performed, including neuro checks.
During an interview on 11/8/23 at 11:47 A.M., Licensed Practical Nurse (LPN) T said:
-Anytime a resident has a fall, the nurse should assess the resident, alert management, call the physician and responsible party;
-The assessment should include a head to toe inspection, neuro checks, skin assessment, pain level and vital signs;
-Neuro checks should be performed any time there is a head injury or if the fall was unwitnessed, even if the resident says they did not hit their head, just to be safe;
-Neuro checks should be performed per schedule for 3 days;
-All neuro checks should be documented on paper or in the electronic chart, and also noted in the progress notes;
-Neuro checks performed on the paper log should be given to nursing management upon completion. He/She thought they keep them in a folder;
-If a resident had a fall resulting in a laceration above the eyebrow, neuro checks should have been started immediately and continued for the entire scheduled 3 days period;
-The resident was not oriented enough to be able to tell what happened after a fall;
-The resident was sent out due to a change in condition.
During an interview on 11/8/23 at 12:20 P.M., the DON said:
-Neuro checks should be performed every time there is a head injury or after an unwitnessed fall or witnessed fall with resident hitting their head;
-She expected staff to perform neuro checks per policy;
-Neuro checks should have been started immediately and continued to the entire 72 hour schedule or until he/she was sent out to the ER;
-Nurses are only expected to do neuro checks on the paper form;
-She is not sure if all nurses know there is a neuro check form in the electronic medical record;
-She is going to ensure all nursing staff are educated on documenting neuro checks in the electronic medical record and the paper form will be phased out;
-She was unable to find neuro checks for the resident after his/her fall on 9/30/23;
-She does not know if they were done on paper and misplaced or not done at all;
-The resident was sent out for a change in condition, but she is not sure if it was related to the fall.
2. Review of Resident #7's annual MDS, dated [DATE], showed:
-Severe cognitive impairment;
-Diagnoses included anxiety disorder, depression and schizophrenia.
During an interview on 11/7/23 at 2:45 P.M., the resident said another resident socked me in the nose and beat the shit out of me.
Review of the progress notes, dated 9/21/23 at 11:05 P.M., showed it was reported that resident allegedly entered another resident's room, resident stated he/she was hit by another resident. Resident removed from unit for safety, skin assessment completed as entered, Resident denied any pain at that time. Medical Doctor (MD) was notified with new order to send resident out to hospital. Resident refused and further assessed by Emergency Medical Service (EMS). Alert and oriented times three to four (person, place, time and situation), upper management present. Responsible party aware of refusal. MD on call aware of refusal, neuro checks began.
Review of the weekly skin observation, dated 9/21/23, showed:
-Lateral (away from center, side) left eye brow small laceration (cut), no bleeding;
-Left upper cheek small laceration, no bleeding;
-Under left eye bruising swelling;
-Bridge of nose bruising, scant bleeding from nose.
Review of the progress notes, dated 9/22/23 through 9/24/23, showed:
-On 9/22/23 at 12:30 A.M., EMTs (Emergency Medical Technicians) on the floor, stated they were there to pick up the resident. The resident refused to go with them. Resident was alert and oriented times two to four, at his/her baseline, denies pain. VS: B/P 128/78, P 89, R 20, T 98, Oxygen saturation (02 sat, normal 95% to 100%) 98%;
-No other vital signs were documented and there was no documentation showing the resident refused to have his/her VS or neuro checks done.
During an interview on 11/7/23 at 12:00 P.M., LPN J said he/she was working on another hall when a staff member ran and got him/her and told him/her about Resident #7 being hit. When LPN J arrived on the unit, he/she found Resident #7's face was bruised and swollen. Resident #4 said Resident #7 should not be in his/her room and said he/she did hit Resident #7. Another nurse took Resident #7 off the floor and provided care for him/her. The doctor wanted Resident #7 to go to the hospital and EMS was notified, but Resident #7 refused to go. Neuro checks were started. LPN J said Resident #7 did allow the first couple neuro checks to be completed but he/she did not know after that. If a resident refused neuro checks, LPN J would report it to the MD and document it.
3. During an interview on 11/8/23 at 7:20 A.M., LPN Q said if a resident hit another resident in the head, neuro checks would be started. Neuro checks are done initially, then every 15 minutes times four, the schedule for neuro checks are on the paper. Neuro checks are done on paper and in the computer.
4. During an interview on 11/8/23 at 10:20 A.M., LPN S said if a resident got hit in the head by another resident, he/she would notify the MD and the DON and start neuro checks. Neuro checks are done for 24 hours and he/she would do incident follow up for 3 days. Neuro checks are documented in the computer under assessments.
5. During an interview on 11/8/23 at 11:55 A.M., the DON said neuro checks should be completed per the facility policy. Neuro checks should be done when there is an unwitnessed fall or a change in the resident's plane, or when resident or staff cannot determine what got the resident to that plane. Neuro checks should be completed per the schedule on the neuro check form. The DON expected staff to complete the neuro checks per the schedule on the form. Neuro checks can be completed on paper or in the computer. The DON checked the computer and said she did not see any additional neuro checks completed for Resident #7. She expected staff to have completed his/her neuro checks. If the resident refused neuro checks, staff should have documented that on the neuro check form and documented he/she refused in the progress notes.
MO00225141
MO00225214
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 F0728
(Tag F0728)
Could have caused harm · This affected 1 resident
See T2XB11
Based on interview and record review, the facility failed to ensure three Nurse Aides (NA C, NA A and NA B completed a nurse aide training program within four months of their employment wit...
Read full inspector narrative →
See T2XB11
Based on interview and record review, the facility failed to ensure three Nurse Aides (NA C, NA A and NA B completed a nurse aide training program within four months of their employment with the facility. The census was 146.
Review of the facility's Competency Evaluation Policy, revised dated December 2006, showed the following:
-Policy Statement: Nurse aides employed for a period greater that four months must successfully pass a state approved competency evaluation;
-Policy Interpretation and Implementation:
-Persons completing the training program must successfully pass the competency evaluation test within four months (120 days) of their date of employment. Failure to do so will result in the student having to retake the training program. Persons not successfully completing the competency evaluation, within 120 days, will not be permitted to continue their employment until they have successfully passed the competency evaluation;
-Persons may take the competency evaluation three times. Failure to pass the test on the third attempt will require the person to be terminated from employment or reassigned to non-nursing duties.
1. Review of NA C's employee file, showed the following:
-Hire date: 9/14/22;
-No documentation of completing the classroom or onsite training;
-No documentation of completing the CNA examination.
During an interview on 11/8/23 at 8:05 A.M., NA C said he/she completed the CNA program in June, 2023. NA C said he/she needed to take the examination but did not have the fee to pay for the exam. NA C said he/she has been working on the floor as an NA.
2. Review of NA A's employee file, showed the following:
-Hire date: 5/24/23;
-Completion of classroom and onsite training: 6/30/23;
-No documentation of completing the CNA examination.
During an interview on 11/7/23 at 1:20 P.M., NA A said he/she worked at a sister facility as a housekeeper in April of 2023 and came to this facility and started the CNA program in May, 2023 through June, 2023. NA A said he/she was scheduled to take the CNA examination on November 17, 2023. NA A has been working as an NA since June and was sent home today. NA A said he/she was not told why he/she was sent home.
3. Review of NA B's employee file, showed the following:
-Hire date: 5/24/23;
-Completion of classroom and onsite training: 6/30/23;
-No documentation of completing the CNA examination.
During an interview on 11/7/23 at 1:33 P.M. NA B said he/she completed the CNA program at the end of June, 2023. NA B said he/she took the examination but failed it by two points. NA B has not rescheduled to retake the CNA examination. NA B said he/she has been working 40 hours a week as an NA since June.
4. During an interview on 11/8/23 at 10:21 A.M., the Human Resource Manager (HRM) said there is a Corporate Recruiter who does the interviews for the NA program. The NAs are paid at an NA wage, but she is not involved with the testing and not told when the test have been completed. The HRM said the only thing he/she does is get name badges for the NAs.
5. During an interview on 11/8/23 at 9:33 A.M., the Director of Nursing (DON) said the students sign up for the CNA classes through a person in the corporate office. The DON said she does not interact with the students during the program. The students will have a clinical instructor while in the program. The DON did not know the three NAs did not pass the exam. The DON is not kept in the loop and did not know how the CNA program works.
6. During an interview on 11/8/12 at 12:23 P.M., the Administrator said she was not aware the three NAs had not passed the examination. The Administrator said she is ultimately responsible for monitoring the NAs' progress, but the Human Resource Manager should have been monitoring the NAs' progress as well. The Administrator said they have a system failure.
MO00226632
Sept 2023
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
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 resident (Resident #7) was free from physical abuse. On ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one resident (Resident #7) was free from physical abuse. On 9/21/23, Resident #4 hit Resident #7, resulting in small laceration (cut) on his/her left eyebrow, bottom lip and left upper lip, and bruising with some swelling under his/her left eye and bridge of nose. The sample was 10. The census was 146.
The Administrator was notified on 11/17/23, of the past non-compliance. Both residents' physicians, EMS and responsible parties were notified, Resident #4 was immediately discharged with appropriate notice and staff were in-serviced on responding to resident abuse. The deficiency was corrected on 9/28/23.
Review of the facility's Abuse Prevention and Prohibition Program policy, dated revised October 24, 2022, showed:
-Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The Facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property;
-The Facility is committed to protecting residents from abuse by anyone, Including but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitors;
-Resident-to-resident altercations must be reported if the altercation is caused by a willful action that results in physical injury, mental anguish or pain;
-The presence of a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate on non-accidental behavior;
-Assessing psychosocial outcome of the victim of abuse may be difficult to determine or incongruent with what would be expected. In these situations, the Investigator should consider how a reasonable person in the resident's circumstances would be impacted by the incident;
-Investigation: The Administrator will provide initial and follow-up written reports of the results of all abuse investigations and consequent actions to the appropriate agencies as outlined in Section IX below:
-If the investigation substantiates the allegation, corrective action will be documented as part of the investigation and implemented to prevent recurrence;
-If the investigation reveals that the initial report was unsubstantiated, the investigation ceases immediately. The Facility will notify residents, family members, facility staff, and the appropriate state agencies of the findings.
Review of the facility's investigation, showed:
-Initial Investigation: On 9/21/23 at approximately 7:30 P.M., the Administrator and Director of Nursing (DON) was notified that Resident #4 hit Resident #7. No recent behavior noted for Resident #4;
-Initial Intervention: the residents were separated, residents and staff was interviewed. The police and Emergency Medical Services (EMS) was called. Resident #4 was sent out via emergency services. Skin assessment was completed. The Medical Doctor (MD), both resident representatives (RP) and the Department of Health and Senior Services (DHSS) was notified;
-Findings: Resident #4 stated he/she thought Resident #7 went into his/her room and he/she was upset that Resident #7 could not respond and became frustrated and hit Resident #7. Resident #7 and Resident #4 were separated, Resident #4 was placed on 1 to 1 until EMS arrived; A skin assessment was completed by the nurse on Resident #7 with minimal discoloration and a x-ray was completed with no abnormalities found. Resident was interviewed by nurse and reported no pain and felt safe; other residents were interviewed and feel safe in their environment and know who to report to if they are concerned or feel unsafe;
-Final Interventions: Updated care plan; Doctor notified of incident and psych will follow up; Social Worker followed up with Resident #7-no concerns; x-ray completed on Resident #7 with no abnormalities noted; Resident #4 remains out of the building.
Review of the undated statement from Resident #7, showed he/she said I went into his/her room, but I didn't. I'm fine. I'm okay. I don't need anything. I feel fine here.
Review of undated statement from Resident #4, showed he/she (Resident #7) came into my room and he/she wouldn't tell me if he/she did or not when I asked him/her. The line for the signature of witness, title was blank.
Review of Staff Member H's written statement, dated 9/21/23, showed Resident #4 came to the desk asking for ice. Staff Member H gave him/her ice. Resident #7 was walking down the hall, Resident #4 turned around and just started punching him/her in the face. Staff Member H screamed for Resident #4 to stop and got between them to split them up and Staff Member I helped.
Review of Staff Member I's written statement, dated 9/21/23, showed as he/she came off break and saw Staff Member H was trying to separate the residents and he/she helped separate them.
Review of Resident #7's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/3/23, showed:
-Resident had severe cognitive impairment;
-Diagnoses included anxiety disorder, depression and schizophrenia (a mental disorder characterized by continuous or relapsing episodes of psychosis).
Review of the care plan in use at the time of survey, showed:
-Focus: The resident has little or no activity involvement related to anxiety and schizophrenia;
-Goal: resident will express satisfaction with type of activities and level of activity involvement when asked through the review date;
-Intervention included: Activity department to participate in 1 to 1 activity of his/her choice twice a week; Resident needs assistance/escort to activity functions; resident to make his/her own name plaque for his/her door during activity time; remind resident that resident may leave activities at any time and is not required to stay for the entire activity; the residents preferred activities are radio and different types of music.
Review of Resident #7's weekly skin observation, dated 9/21/23, showed:
-Skin issues? Yes was marked;
-Notes: Lateral (outer side) left eye brow small laceration (cut), no bleeding; Left upper cheek small laceration, no bleeding; Under left eye bruising, swelling; Bridge of nose bruising, scant bleeding from nose; Bottom lip small laceration no bleeding.
Review of Resident #7's progress notes, showed:
-On 9/21/23 at 11:05 P.M., it was reported that resident allegedly entered another resident's room, resident stated that he/she was hit by another resident. Resident removed from unit for safety, skin assessment completed as entered, Resident denied any pain at that time. MD was notified with new order to send resident out to hospital. Resident refused and further assessed by EMS. Alert and oriented times three to four (person, place, time and situation), upper management present. Responsible party aware of refusal. MD on call aware of refusal, neuro checks began;
-On 9/22/23 at 11:19 A.M., Social Worker (SW) was informed resident was physically assaulted by another resident last night. Resident refused to go to the hospital. SW followed up with resident today. Resident appeared in good spirits today. Resident was up walking around the hall. SW asked resident how resident feeling was. Resident stated I am just fine. I didn't go to the hospital. SW stated, how come you did not want to go to the hospital? Resident stated, I am doing good. (He/she) hit me because (he/she) said I went into (his/her) room and I did not;
-On 9/22/23 at 2:02 P.M., SW documented incorrectly. SW informed resident was involved in a resident to resident last night. Resident refused to go to the hospital. SW followed up with resident today. Resident appears in good spirits today. Resident was up walking around the hall. SW asked resident how resident feeling was. Resident stated I am just fine. I didn't go to the hospital. SW stated, how come you did not want to go to the hospital? Resident stated, I am doing good. (He/She) hit me because (he/she) said I went into (his/her) room and I did not;
-On 9/23/23 at 12:56 A.M., resident was in bed. Responding appropriately to verbal stimulus. Resident has bruising around left eye related to altercation with another resident. Voiced no complaints of pain. No swelling observed. Will continue to monitor resident. No agitation noted.
Review of Resident #4's quarterly MDS, dated [DATE], showed:
-Resident was cognitively intact;
-No behavioral symptoms were exhibited;
-Diagnoses included anxiety disorder, psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions) and schizophrenia.
Review of the care plan, in use at the time of the survey, showed:
-Focus: Resident has a history of aggressive behavior toward others:
-On 6/28/21, the resident became irate with staff and physically knocked items away from staff when he was upset about his belongings;
-On 2/20/2023, the resident hit another resident while in the TV room on the unit;
-Goal: Resident will not harm other/self through next review;
-Interventions: anticipate and meet the resident's need; caregivers to provided opportunity for positive interaction, attention; Stop and talk with him/her as passing by; Encourage the resident to express his/her feelings appropriately; Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; 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; provide a program of activities that is of interest and accommodates resident's status.
Review of Resident #4's progress notes, showed:
-On 9/21/23 at 10:59 P.M., the resident reported to staff that another resident was going into his/her room and became frustrated due to another resident allegedly being in his/her room. He/She admitted to hitting a resident. Resident was placed on 1:1 monitoring for safety until emergency services arrived, MD was notified. The guardian was notified and upper management was present;
-On 9/22/23 at 11:14 A.M., Social Worker informed resident physically assaulted another resident last night due to resident believing other resident was going into resident's room. Resident arrested and has not returned as of today;
-On 9/22/23 at 1:28 P.M., SW documented incorrectly. SW was informed resident was involved in a resident to resident with another resident last night. Resident was placed on 1:1 until emergency services arrived. Resident has not returned to facility as of today.
Review of Resident #4's Notice of Proposed Discharge, dated 9/21/23, showed:
-Discharge effective date was 9/21/23;
-discharged to: St. Louis City Justice Center;
-Reason for discharge: the safety of individuals in the facility is endangered by your presence and the health of individuals in the facility is endangered by your presence.
During an interview on 11/7/23 at 2:45 P.M., Resident #7 said Resident #4 said he/she was going into his/her room and he/she did not go into the resident's room. He/She guessed Resident #4 was calling the TV room his/her room because that was the only room he/she went in. Resident #4 attacked him/her for no reason at all. Resident #4 socked him/her in the nose and beat the shit out of him/her. Resident #7 said he/she did not hit Resident #4 back. The staff took him/her off the floor and wanted him/her to go to the hospital, but he/she did not want to go.
During an interview on 11/7/23 at 12:00 P.M., Licensed Practical Nurse (LPN) J said he/she was working on another hall when a staff member ran and got him/her and told her something about Residents #4 and #7. When LPN J arrived on the unit, Resident #4 was at his/her door pacing and talking about Resident #7 came into his/her room and Resident #7 should not have come into his/her room. Resident #4 did admit to striking Resident #7. Resident #4 was placed on 1 to 1. Resident #7 was in the hall a few doors down, there was blood on the floor, but LPN J did not see where the blood came from. Resident #7 had some bruising and swelling on his/her face. LPN J called a stat (for other staff members to respond to unit). Another nurse took Resident #7 off the floor and provided care for him/her. The MD wanted Resident #7 to go to the hospital but the resident refused. Neuro checks were started. 911 was called and the police did arrive within 30 to 45 minutes. Management was notified. The MD and RP for both residents was notified. The RP wanted Resident #4 charged and talked to the police on the phone. When Resident #4 left the building, he/she left with the police and EMS.
During an interview on 11/7/23 at 2:20 P.M., Certified Medication Technician (CMT) K said if there was a resident to resident altercation, he/she would diffuse the situation and separate the residents and report the situation to the nurse. If there was no nurse available, he/she would call the Administrator.
During an interview on 11/7/23 at 2:30 P.M., Certified Nurse Aide (CNA) L said if a resident had an altercation with another resident, he/she would redirect the residents and report it to the nurse.
During an interview on 11/7/23 at 2:35 P.M., CNA M said if a resident had an altercation with another resident, he/she would try to calm the resident down and separate the residents, call a Dr. Strong and call the family to try to have them help calm down the resident.
During an interview on 11/7/23 at 4:10 P.M., CNA N said Resident #4 went out earlier in the day and was not him/herself when he/she returned. He/She was not on the floor when the incident occurred. When he/she got to the floor, CNA N saw someone cleaning up the blood off the floor. Resident #7 had gotten beaten up and was hurt. He/She had blood on his/her face, and the nurse was there assessing him/her.
During an interview on 11/8/23 at 7:05 A.M. CMT Q said if a resident had a resident to resident altercation, he/she would break it up and separate the residents, make a report and report it to the DON.
During an interview on 11/8/23 at 11:00 A.M., the DON said she was at home when the incident occurred. Resident #4 was at the nurse's station. He/She asked for ice and the DON did not know what was said. Resident #4 turned and punched Resident #7. Staff separated the residents. Resident #7 was assessed and he/she had something on his/her eyebrow and something on the side of his/her nose. Resident #4 went back to his/her room. Resident #7 went off the floor to the lobby. The Administrator, families and police were called. Resident #4 left with the police. Resident #7 refused to go to the hospital, neuro checks were done and facial x-rays were done.
During an interview on 11/8/23 at 11:10 A.M., the Administrator said Resident #4 said Resident #7 went into his/her room. Resident #7 did not respond when Resident #4 said something to him/her and Resident #4 got frustrated and hit Resident #7 in the face. The residents were separated. Other residents heard the commotion but no other residents witnessed the incident. Resident #4 was placed on 1 to 1 until EMS arrived. Resident #4 was issued an immediate discharge. The resident left with EMS and the police and has not returned to the facility. Staff assessed Resident #7 and took him/her off the floor. The MD wanted Resident #7 to go to the hospital but he/she refused. X-rays were ordered and were negative.
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 F0604
(Tag F0604)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure one resident was free from physical restraint when, Certified Nurse Aide (CNA) D, pinned the resident's wrists to his/h...
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Based on observation, interview and record review, the facility failed to ensure one resident was free from physical restraint when, Certified Nurse Aide (CNA) D, pinned the resident's wrists to his/her chest to provide care (Resident # 13). The sample was 20. The census was 160.
Review of the facility's Restraint policy, revised June 2020, 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 measures shall be used;
-Physical Restraint is defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body;
-The facility honors the resident's right to be free from any restraints that are imposed for reasons other than treatment of the resident's medical symptoms. The facility will ensure restraints will not be imposed for purposes of discipline or convenience;
-Medical symptoms will be evaluated to determine if underlying causes may be eliminated;
-If underlying causes of medical symptoms cannot be eliminated, alternative measures must be tried before a restraint is used;
-If alternative measures are unsuccessful, the least restrictive form of a restraint will be used;
-Unless otherwise specified by the attending physician's order, alternative methods of behavioral control must be attempted and documented in the resident's medical record before a physical restraint is used;
-Restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention and a restraint is required to:
-Treat the medical symptom;
-Protect the resident's safety;
-Help the resident attain the highest level of his/her physical or psychological well-being.
Review of Resident #13's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/19/23, showed:
-Severe cognitive impairment;
-Verbal behavior symptoms directed towards others;
-No physical behaviors;
-Behaviors interfered with the resident's care;
-The resident and others were not at risk for physical injury;
-Rejection of care not exhibited;
-Required one person physical assistance for transfers and dressing;
-Required moderate assistance for toileting hygiene;
-Occasionally incontinent of bowel and bladder;
-Diagnoses included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), manic depression, bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), anxiety disorder and seizure disorder.
Review of the resident's care plan, in use during the survey, showed:
-Focus: The resident had a behavior problem due to bipolar disorder and schizophrenia. He/She elaborated stories or situations;
-Interventions: The resident refused vitals, yelled at staff and attempted to spit on CNA when he/she attempted to clean the resident up. The resident was fighting and kicking staff. The resident was uncooperative and it was difficult to provide care. The resident threw food and milk on the housekeeper. He/She did not want staff in his/her room. Staff left and let the resident calm down (initiated on 6/1/23). Explain all procedures to resident and allow him/her to adjust. Explain why behavior is inappropriate. Intervene as necessary to protect other's safety. Approach/speak in a calm manner. Two care givers to assist with care when possible and in needed situations;
-Focus: The resident was resistant to care of personal needs and medications due to anxiety and dementia. He/She refused assessments, medication, vital signs and treatments;
-Interventions: Allow resident to make decisions about treatment. Encourage participation/interaction during care. If he/she resisted activities of daily living (ADLs), leave and return five to ten minutes later and try again. Give clear explanation of all care activities prior to performing;
-Focus: The resident had potential to be physically aggressive. A history of harm to others and poor impulse control;
-Interventions: The resident attempted to hit CNA, yelled and beat table with water pitcher. He/She poured water on the floor and pulled the cord and keyboard off the nurse cart. Staff redirected the resident back to his/her room (initiated 8/14/23). Administer medication as ordered. Analyze time of day, place, circumstances, triggers, how to de-escalate behaviors and document. Assess and address sensory deficits. Provide physical and verbal cues to alleviate anxiety, give positive feedback, and assist to set goals for more pleasant behavior. Give choices about care and activities. The resident's triggers for physical aggression were (specify). The resident's behaviors were de-escalated by (specify). Psychiatric consult as needed. Intervene before agitation escalates, engage calmly in conversation. If response was aggressive, walk away and approach later;
-Focus: The resident had impaired cognitive function and difficulty making decisions;
-Interventions: Ask yes/no questions. Cue, reorient and supervise as needed;
-Focus: The resident had bowel incontinence;
-Intervention: Encourage resident to sit on toilet to evacuate bowels if possible.
Review of the facility's investigation, dated 8/25/23, showed:
-Findings: CNA D and CNA E, attempted to provide care to the resident. The resident kicked, yelled, bit and screamed at the CNAs. The resident grabbed a TV and hit him/herself on the left side of the head. CNA D and CNA E made sure the resident was safe and left the room so the resident could calm down;
-Resident's roommate was interviewed and said he/she heard noises coming from behind Resident #13's privacy curtain, but did not see anything;
-A written statement, dated 8/25/23, in which CNA D said he/she went into the resident's room to change the resident. The resident was wet and would not let CNA D change him/her. The resident tried to hit CNA D with a TV and it fell on the resident's head. CNA D left the room and asked CNA E to assist him/her. CNA D and CNA E removed the resident's wet clothes and bed linen. The resident would not allow CNA D and CNA E to put nothing else on him/her. The resident was kicking and yelling. He/She scratched CNA D under his/her arm, kicked him/her in the stomach and called him/her the N word;
-A written statement, undated, in which CNA E said the resident screamed racist remarks when he/she and CNA D entered the resident's room. The resident grabbed his/her roommate's TV. The resident attempted to throw the TV and it fell on his/her face. CNA D and CNA E grabbed the TV and the resident held onto the cord. The resident threw the cord in anger. The resident kicked at CNA D and the nurse caught the TV and placed it correctly. The resident scratched at CNA D. The resident continued to be irate and flip from left to right in the bed. CNA D, CNA E and the nurse left the room.
Review of the resident's progress notes, dated 8/25/23 at 7:52 P.M., showed the nurse was called to the resident's room by nursing staff. The resident was very aggressive and combative towards nursing staff. He/She had swung the call light at staff. Nursing staff removed all cords safely. The resident then grabbed roommate's television and pulled it down on top of him/her. The resident yelled and cursed at nursing staff. Staff could not re-direct the resident. The resident removed his/her brief and night gown and played in his/her feces. The resident was allowed time to decompress. The nurse attempted to do a skin assessment on resident. He/She grabbed the nurse's fingers and tried to bite him/her. The nurse could not do a full body/skin assessment, obtain vital signs or initiate neuro checks. The resident's physician and responsible representative were notified of incident/accident. At 8:01 P.M., the resident had a small goose egg shaped area to left side of his/her forehead. The resident continued to be combative towards the nurse.
During interviews on 9/7/23 at 2:48 P.M. and 9/8/23 at 2:28 P.M., CNA D said his/her shift started at 3:00 P.M. on 8/25/23. The nurse told him/her the resident needed to be changed. He/She took the resident's dinner tray to his/her room. The resident did not want to eat and he/she threw the tray at CNA D. CNA D waited 15 minutes, then went back to the resident's room with CNA E at 6:30 P.M. to change him/her. The resident was wearing pants and a gown when CNA D and CNA E entered his/her room. CNA E left the room to get clean linen. The resident grabbed the 32 inch TV off the bedside table to the right of his/her bed. He/She held the TV above his/her head and tried to throw it at CNA D. The TV fell on the resident's head. CNA D grabbed the TV and put it on the bedside table on the other side of the room. CNA E came back into the room. The resident kicked and fought when they tried to remove his/her pants. CNA D stood on the resident's left side, leaned over the resident, crossed the resident's arms, one over the other, across the resident's chest and pinned the resident's wrist to his/her chest. The resident tried to get away from CNA D, but could not free his/her arms. CNA E cleaned the resident off and changed his/her brief. When CNA D released the resident's wrists, he/she scratched CNA D under his/her right arm and kicked him/her in the stomach. The resident would not let staff put a clean gown on him/her. CNA D and CNA E put a cover over the resident and left the room. CNA D did not notice any bruising to the resident's face when the TV fell on him/her. When he/she left the resident's room, he/she noticed discoloration above the resident's left eye. CNA D thought they were in the room for 15 minutes. He/She went to the nurse's station and told Nurse F the resident was combative and tried to throw a TV at him/her. The resident's roommate was in the room, but his/her privacy curtain was closed. The resident was usually combative when staff tried to change him/her. When a resident was agitated or combative, staff were supposed to leave and try again later. They did not leave because they had to remove the wet clothes off the resident. Staff were not supposed to hold the resident's arms, but they could hold the resident's wrist. He/She held the resident long enough for CNA E to change the resident.
During an interview on 9/8/23 at 10:38 A.M., CNA E said on 8/25/23, he/she worked on the resident's hall with CNA D. Before CNA E went to lunch, CNA D told him/her, he/she needed help changing the resident. CNA E and CNA D were doing rounds after dinner and when they entered the resident's room, the resident screamed You are not going to touch me with your dirty hands, you dirty N word! The resident lay in the bed. The resident grabbed the TV off the bedside table and tried to throw it. The TV fell on the resident's face. CNA D grabbed the TV, but the resident was holding the cord. CNA D put the TV on the bedside table. The resident kicked CNA D in the stomach. Nurse F entered the resident's room and tried to re-direct him/her with a snack. Nurse F tried to assess the resident. The resident had feces on his/her hands and his/her pants were pulled down past his/her private area. CNA E left the room after the resident tried to grab his/her injured finger (he/she slammed it in the door earlier in the day). CNA E did not remove the resident's brief, gown or change his/her linen. He/She was not sure if Nurse F and CNA D stayed in the resident's room. He/She went back to the resident's room at 8:00 P.M. and the resident's brief and pants were at the bottom of his/her bed and he/she was naked. When residents were combative, staff were supposed to report it to the nurse. If the resident could not be redirected, staff were supposed to leave and try again later.
During an interview on 9/8/23 at 1:26 P.M., Nurse F said he/she was seated at the nurse station on the resident's hall and CNA D and CNA E said the resident grabbed a TV and would not let them change him/her. He/She entered the resident's room at 7:00 P.M. and the resident was swinging the call light. The resident's gown was hanging on one arm. He/She tried to cover the resident up. The resident was clean when he/she entered the resident's room and the linen had been changed. It appeared as if the resident was having another bowel movement. He/She did not see a brief on the resident's bed. Nurse F left the resident's room. Another resident approached him/her and said Resident #13 had bruises and blood all over him/her. He/She entered the resident's room and CNA D and CNA E were standing in the resident's doorway. The resident had a goose egg on his/her head. He/She tried to assess the resident, but he/she was still combative. Nurse F left the resident's room and told CNA D and CNA E to follow him/her. Nurse F called the Administrator, but she did not answer. The Director of Nursing (DON) arrived at the facility and interviewed the resident's roommate (Resident #17). Nurse F obtained statements from staff. CNA D said the resident grabbed the TV and it fell on him/her. CNA D and CNA E said they changed the resident. He/She continued to check on the resident until his/her shift ended at 11:00 P.M. The resident was always combative and resistant to care. When residents were combative and agitated, staff were supposed to back off and report it to a nurse.
During an interview on 9/11/23 at 11:00 A.M., Resident #17 said CNA D and CNA E came into his/her room to change Resident #13. He/She did not see anyone hit the resident because the privacy curtain was closed. CNA D and CNA E changed Resident #13. Resident #13 was naked when CNA D and CNA E left the room. He/She said the resident did not drop the TV on his/her face. He/She did not hear the TV fall. He/She heard Resident #13 yell, Quit beating on me.
Observation of the resident on 9/11/23 11:05 A.M., showed the resident had bruising under his/her left eye. He/She had yellow and green discoloration to the left cheek with swelling. He/She had an egg shaped contusion to the left temple area, with bruising. When asked about the incident, the resident talked about graduation and boot camp.
During an interview on 9/11/23 at 8:37 A.M., the Administrator said she not aware CNA D restrained the resident. None of the other staff said they saw him/her restrain the resident.
Review of the facility's investigation, dated 9/12/23, showed:
-Investigation: CNA D said he/she held the resident's hands and talked to him/her calmly. He/She did not hold the resident's hands forcibly. The resident hit and scratched him/her while he/she was holding the resident's hand. The resident would not calm down and he/she left the resident's room.
-A written statement, undated, CNA D wrote after meeting with state, he/she recalled having contact with the resident. He/She held the resident's hands to calm him/her down. The resident calmed down when he/she released the resident's hands. The resident was kicking and he/she left the room.
During an interview on 9/11/23 at 12:43 P.M., CNA D said he/she did not hold the resident down. After being reminded of his/her previous interviews, he/she said (He/She) was holding the resident. The resident was calming down when (he/she) released pressure from (his/her) hands. He/She should have stopped and left the room. The resident let the CNAs get his/her bottoms off, but would not let them do anything else. The facility used to provide crisis prevention and intervention (CPI) training. The facility no longer provided the training.
During an interview on 9/12/23 at 1:15 P.M., the DON said the resident had always had behaviors. He/She was resistant to care/treatment and refused medication. The resident's physician was aware the resident refused medication and treatment. Staff were supposed to redirect the resident when he/she exhibited behaviors. If they could not redirect the resident, they should leave, come back and re-approach in a calm manner. If a resident could not move around freely, then it was a restraint. Staff should never restrain a resident. He/She was not sure when staff were last in-serviced on restraints.
MO00223527
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to thoroughly investigate an abuse allegation for one resident (Resident #3), when he/she alleged an African American male Certified Nursing A...
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Based on interview and record review, the facility failed to thoroughly investigate an abuse allegation for one resident (Resident #3), when he/she alleged an African American male Certified Nursing Assistant (CNA), threatened him/her. Appropriate staff and resident interviews were not conducted. The sample was 10. The census was 146.
Review of the facility's abuse policy, dated 10/24/22, showed:
-Purpose includes: To ensure the facility established, operationalized, and maintained an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the investigation of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements;
-The investigator may take some or all of the following steps:
-Reviews all relevant documentation;
-Interviews any witnesses to the alleged incident;
-Interviews the resident (as medically appropriate);
-Interviews facility staff members who have had contact with the resident during the period of the alleged incident;
-Interviews the resident's roommate, family members, and visitors.
Review of Resident #3's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/14/23, showed:
-Cognitively intact;
-Independent in self-care tasks;
-Diagnosis of anti-social personality disorder (condition in which a person consistently shows no regard for right and wrong and ignores the rights and feelings of others).
Review of the resident's care plan, in use at the time of survey, showed:
-Problem: The resident verbalized his/her dissatisfaction with staff performance and was verbally abusive towards staff;
-Desired outcome: The resident will demonstrate effective coping behavior;
-Interventions: The resident was allowed to express his/her feelings, was educated on facility procedures, was given choices about his/her care and staff paired up when providing care.
Review of the facility's initial investigation, received on 9/17/23, showed:
-Date of alleged incident: Unknown;
-Time of alleged incident: Unknown;
-Summary of alleged incident: The resident was sent to the hospital and informed the social worker an African American male CNA, whom worked reception also, told him/her he/she would beat (his/her) ass if the resident pressed his/her call light. No male staff worked as a CNA and reception. Facility investigation was started.
Review of the list of male CNA staff, provided by the facility, showed four African American males CNAs: CNA D, CNA/Certified Medication Technician (CMT) E, CNA F and CNA G.
Review of the facility's investigation, dated 9/17/23, showed:
-Written statements from three, female CNAs and one female CMT;
-No documented interviews with CNA D, CNA/CMT E, CNA F and CNA G;
-No documented interview with the resident's roommate.
During an interview on 11/7/23 at 1:15 P.M., the Administrator said she completed the investigation. She did not interview any African American male CNAs, because they did not fit the description.
Review of written statements, submitted to DHSS on 11/17/23 at 12:55 P.M., by corporate staff, showed two statements by male staff.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure services provided met professional standards when one reside...
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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 services provided met professional standards when one resident (Resident #2) with a head laceration, related to a fall, did not receive neurological checks (neuro checks, an assessment completed by nursing staff to monitor for changes in the resident's neurological (nervous system) status); and failed to ensure one resident (Resident #7 ) received neuro checks after another resident hit him/her in the head with their fist. The sample of residents with head injuries or unwitnessed falls was four. The census was 146.
Review of the facility Neurological Assessment Policy, dated revised 10/24/22, showed:
-Purpose: To provide guidelines for the performance of a neurological assessment on residents;
-Policy: Nursing will perform a neurological assessment in the following circumstances:
--Upon Attending Physician order;
--Following an unwitnessed fall and neither the resident nor anyone else know how he/she got there;
--Following a fall or other accident/injury involving head trauma;
--When indicated by resident's condition;
-Documentation: the following information will be documented in the resident's medical record:
--The date and time the procedure was performed;
--The name and title of the individual(s) who performed the procedure;
--All assessment data obtained during the procedure, including
-Eye opening;
-Verbal response;
-Motor response;
-Pupillary response;
-Limb response;
--If the resident refused the procedure, the reason(s) why and the interventions taken;
--The signature and title of the person recording the data.
1. Review of Resident #2's admission Face Sheet, showed the resident was admitted on [DATE] with diagnoses including muscle wasting and atrophy (a significant shortening of the muscle fibers and a loss of overall muscle mass), reduced mobility, schizoaffective disorder (a mental illness that can affect your thoughts, mood and behavior), aphasia (affects a person's ability to express and understand written and spoken language) and abnormalities of gait (walking) and mobility.
Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/8/23, showed:
-Severe cognitive impairment;
-A history of falls prior to admission;
-Dependent on staff for mobility.
Review of the resident's Witnessed Fall sheet, dated 9/30/23, showed:
-Incident description: Resident alert with confusion. Total care assisted up in wheelchair in dining room. Spoon fed. Encouraged appetite intake and fluids. Resident up in wheelchair. Witness resident suddenly out of wheelchair and laid on the floor on right side. Right side eyebrow area healed scab with scant amount of bleeding. Area cleaned with soap and water. Stopped bleeding. Resident assisted back to wheelchair. Monitor for fall risk. Resident to be monitored up in wheelchair with confusion. Moving all extremities;
-Injury type: No injuries observed at time of incident;
-Level of consciousness: alert;
-Mobility: Wheelchair bound;
-Mental status: Resident confused times three;
-Injuries report post incident: No injuries observed post incident;
-Predisposing environmental factors: None;
-Predisposing physiological factors:
--Confused;
--Incontinent;
--Gait imbalance;
--Impaired memory;
-Predisposing situation factors:
--Wanderer;
-Witnesses: No witnesses found
-Agencies/People notified: Responsible Party, Physician and Director of Nursing (DON) notified on 9/30/23;
-No noted documentation that neuro checks were performed.
Review of the resident's Weekly Skin Observation, dated 9/30/23, showed a small laceration above the right eyebrow, signed by the DON on 11/7/23.
Review of the resident's Fall Risk Assessment, dated 9/30/23 showed:
-Reason for assessment: Recent fall;
-History of falls within last six months: one to two times;
-Medication use: antihypertensives (medication for high blood pressure) and psychotropics (relating to or denoting drugs that affect a person's mental state);
-Memory and recall ability: Never able to recall three out of four of the following: current season, that he/she is in a nursing home, location of room, staff names/faces;
-Vision pattern: Adequate - able to see in adequate light with glasses on;
-Continence in the last 14 days: Total incontinence, bowel and bladder;
-Confined to chair and disoriented;
-Signed by DON on 11/7/23;
-No noted documentation that neuro checks were performed.
Review of the resident's nursing progress notes, showed:
-9/30/23 at 12:18 A.M., Note Text: Found on the Floor: Assigned Certified Nursing Assistant (CNA) informed Nurse during last rounds of finding resident on the floor at foot of his/her bed and lying on his/her right side. Nurse witnessed floor mats adjacent to resident's bed. Small amount of blood noted from resident right side of forehead. Laceration 1.5 cm. Area cleansed. Required one staff in assisting resident from floor to his/her bed and during treatment care. Assisted range of motion (AROM, when the person needs assistance with movement from an external force because of weakness, pain, or changes in muscle tone) and passive range of motion (PROM, when the person is unable or not permitted to move the body part) within normal limits for resident. Responded to his/her name. Did not answer how he/she got on the floor;
-9/30/23 at 6:39 A.M., Note Text: Remains on on-going observation post fall. Resting in bed with eyes closed, unlabored and even breathing. Mats in place at beside;
-9/30/23 at 9:15 A.M., Note Text: Resident up in wheelchair, attempting to lay on floor. Right side of forehead with scabbed area status post (medical term used to refer to a treatment, diagnosis or just an event that a patient has experienced previously) laceration. Scant amount bleeding. Resident to be monitored for fall risk. Right side area washed with soap and water. No further bleeding. Spoon fed. Appetite good. Vital Signs (VS) Blood Pressure (B/P, normal 90/60 through 120/80) 134/60, Pulse, (P, normal 60 to 100) 63, Respirations (R, normal 12 to 18) 19, Temperature (T, normal 97.8 through 99.1) 97.3;
-9/30/23 at 1:13 P.M., Resident taken to shower area and resident suddenly appeared weak. Legs had some partial discoloration. Placed call to 911 per DON. Resident transported to emergency room (ER) for evaluation and treatment. Physician made aware. Responsible party notified;
-9/30/23, no noted documentation of any physical assessments performed, including neuro checks.
During an interview on 11/8/23 at 11:47 A.M., Licensed Practical Nurse (LPN) T said:
-Anytime a resident has a fall, the nurse should assess the resident, alert management, call the physician and responsible party;
-The assessment should include a head to toe inspection, neuro checks, skin assessment, pain level and vital signs;
-Neuro checks should be performed any time there is a head injury or if the fall was unwitnessed, even if the resident says they did not hit their head, just to be safe;
-Neuro checks should be performed per schedule for 3 days;
-All neuro checks should be documented on paper or in the electronic chart, and also noted in the progress notes;
-Neuro checks performed on the paper log should be given to nursing management upon completion. He/She thought they keep them in a folder;
-If a resident had a fall resulting in a laceration above the eyebrow, neuro checks should have been started immediately and continued for the entire scheduled 3 days period;
-The resident was not oriented enough to be able to tell what happened after a fall;
-The resident was sent out due to a change in condition.
During an interview on 11/8/23 at 12:20 P.M., the DON said:
-Neuro checks should be performed every time there is a head injury or after an unwitnessed fall or witnessed fall with resident hitting their head;
-She expected staff to perform neuro checks per policy;
-Neuro checks should have been started immediately and continued to the entire 72 hour schedule or until he/she was sent out to the ER;
-Nurses are only expected to do neuro checks on the paper form;
-She is not sure if all nurses know there is a neuro check form in the electronic medical record;
-She is going to ensure all nursing staff are educated on documenting neuro checks in the electronic medical record and the paper form will be phased out;
-She was unable to find neuro checks for the resident after his/her fall on 9/30/23;
-She does not know if they were done on paper and misplaced or not done at all;
-The resident was sent out for a change in condition, but she is not sure if it was related to the fall.
2. Review of Resident #7's annual MDS, dated [DATE], showed:
-Severe cognitive impairment;
-Diagnoses included anxiety disorder, depression and schizophrenia.
During an interview on 11/7/23 at 2:45 P.M., the resident said another resident socked me in the nose and beat the shit out of me.
Review of the progress notes, dated 9/21/23 at 11:05 P.M., showed it was reported that resident allegedly entered another resident's room, resident stated he/she was hit by another resident. Resident removed from unit for safety, skin assessment completed as entered, Resident denied any pain at that time. Medical Doctor (MD) was notified with new order to send resident out to hospital. Resident refused and further assessed by Emergency Medical Service (EMS). Alert and oriented times three to four (person, place, time and situation), upper management present. Responsible party aware of refusal. MD on call aware of refusal, neuro checks began.
Review of the weekly skin observation, dated 9/21/23, showed:
-Lateral (away from center, side) left eye brow small laceration (cut), no bleeding;
-Left upper cheek small laceration, no bleeding;
-Under left eye bruising swelling;
-Bridge of nose bruising, scant bleeding from nose.
Review of the progress notes, dated 9/22/23 through 9/24/23, showed:
-On 9/22/23 at 12:30 A.M., EMTs (Emergency Medical Technicians) on the floor, stated they were there to pick up the resident. The resident refused to go with them. Resident was alert and oriented times two to four, at his/her baseline, denies pain. VS: B/P 128/78, P 89, R 20, T 98, Oxygen saturation (02 sat, normal 95% to 100%) 98%;
-No other vital signs were documented and there was no documentation showing the resident refused to have his/her VS or neuro checks done.
During an interview on 11/7/23 at 12:00 P.M., LPN J said he/she was working on another hall when a staff member ran and got him/her and told him/her about Resident #7 being hit. When LPN J arrived on the unit, he/she found Resident #7's face was bruised and swollen. Resident #4 said Resident #7 should not be in his/her room and said he/she did hit Resident #7. Another nurse took Resident #7 off the floor and provided care for him/her. The doctor wanted Resident #7 to go to the hospital and EMS was notified, but Resident #7 refused to go. Neuro checks were started. LPN J said Resident #7 did allow the first couple neuro checks to be completed but he/she did not know after that. If a resident refused neuro checks, LPN J would report it to the MD and document it.
3. During an interview on 11/8/23 at 7:20 A.M., LPN Q said if a resident hit another resident in the head, neuro checks would be started. Neuro checks are done initially, then every 15 minutes times four, the schedule for neuro checks are on the paper. Neuro checks are done on paper and in the computer.
4. During an interview on 11/8/23 at 10:20 A.M., LPN S said if a resident got hit in the head by another resident, he/she would notify the MD and the DON and start neuro checks. Neuro checks are done for 24 hours and he/she would do incident follow up for 3 days. Neuro checks are documented in the computer under assessments.
5. During an interview on 11/8/23 at 11:55 A.M., the DON said neuro checks should be completed per the facility policy. Neuro checks should be done when there is an unwitnessed fall or a change in the resident's plane, or when resident or staff cannot determine what got the resident to that plane. Neuro checks should be completed per the schedule on the neuro check form. The DON expected staff to complete the neuro checks per the schedule on the form. Neuro checks can be completed on paper or in the computer. The DON checked the computer and said she did not see any additional neuro checks completed for Resident #7. She expected staff to have completed his/her neuro checks. If the resident refused neuro checks, staff should have documented that on the neuro check form and documented he/she refused in the progress notes.
MO00225141
MO00225214
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
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to follow acceptable standards of practice when staff failed to follow their policy to obtain one resident's wound care orders ti...
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Based on observation, interview and record review, the facility failed to follow acceptable standards of practice when staff failed to follow their policy to obtain one resident's wound care orders timely (Resident #6). The sample was 20. The census was 160.
Review of the facility's Wound Care Policy, revised October 2010, showed:
-Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing;
-Preparation: Verify that there is a physician's order for this procedure;
-Documentation: The following information should be recorded in the resident's medical record: the type of wound care given; any change in the resident's condition; all assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound; if the resident refused the treatment and the reason(s) why;
-Reporting: Notify the supervisor if the resident refuses the wound care; report other information in accordance with facility policy and professional standards of practice.
Review of the facility's Physician Orders Policy, revised 10/24/22, showed:
-Purpose: This will ensure that all physician orders are complete and accurate;
-Treatment orders will include the following: a description of the treatment, including the treatment site, if applicable; the frequency of treatment and duration of order (when appropriate); and the condition/diagnosis for which the treatment is ordered; whenever possible, the licensed nurse receiving the order will be responsible for documenting and implementing the order;
-Medication/treatment orders will be transcribed onto the appropriate resident administration record.
Review of the facility's Medication Orders Policy, revised November 2014, showed:
-Purpose: The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders;
-Treatment Orders: When recording treatment orders, specify the treatment, frequency and duration of the treatment. Example: Apply 4X4 inch Duoderm (hydrocolloid dressing) with border to stage 1 (intact skin with localized area of non-blanchable erythema (superficial redden area)) ulcer on coccyx (tailbone); change every three days and as needed (PRN) per wound care protocol.
1. Review of Resident #6's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/31/23, showed:
-Moderately impaired cognition;
-No rejection of care;
-Required supervision and set up for eating;
-Required limited assistance of one staff for personal hygiene;
-Required extensive assistance of one staff for bed mobility and dressing;
-Required total assistance of one staff for transfers, locomotion, toilet use and bathing;
-Diagnoses included: anemia, heart failure, high blood pressure, Parkinson disease (a brain disorder that causes unintended or uncontrollable movements), malnutrition, bipolar disease and schizophrenia;
-At risk for developing pressure ulcers? No;
-Does the resident have one or more unhealed pressure ulcers at stage one or higher? No
Review of the care plan, in use at the time of the survey, showed:
-Focus: The resident had potential/actual impairment to skin integrity, date initiated 8/24/23;
-Goal: The resident would maintain intact skin;
-Interventions included: Treatment per medical doctor (MD) orders.
Review of the progress notes dated 9/1/23 through 9/7/23, showed:
-On 9/4/23 at 2:25 A.M., status post right hip fracture, incision site pink with no drainage noted. Incision site had 19 staples intact and well approximated.
Observation on 9/7/23 at 8:00 A.M., showed the resident in bed and faced the window. Certified Medication Technician (CMT) B and CMT G were in the room providing care to the resident. The resident had a red dressing with no date on his/her left hip and an open area on his/her coccyx. The open area was irregularly shaped with a white/ash colored center.
Review of the resident's Treatment Administration Record (TAR), dated 9/1/23 through 9/7/23, showed no treatment for the open area on the coccyx.
Review of the progress notes dated 9/1/23 through 9/7/23, showed:
-No documentation showed a wound on the coccyx.
Review of the weekly skin observations, showed the last skin observation dated 8/12/23, no wound on the coccyx was noted.
Review of the shower sheet, dated 9/7/23, showed:
-On the human diagram, an X was mark on the coccyx area;
-Hand written: open area was reported.
Review of the progress notes dated 9/8/23 through 9/10/23, showed, on 9/9/23 at 3:02 P.M., resident resembles Stage II pressure ulcer (a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough, may also present as an intact or open/ruptured blister) to coccyx area, area actively bleeding. Wound cleansed, and dressed with foam protective dressing. MD notified via exchange for wound care orders. Resident verbalized pain 6 out of 10 (on a pain scale, where 0 was no pain and 10 was the worst pain), resident administered PRN Tylenol as ordered. Nurse aides instructed to turn resident every two hours. Upper management aware of findings.
Review of the TAR, dated 9/8/23 through 9/10/23, showed no treatment for the coccyx.
During an interview on 9/11/23 at 8:44 A.M., the resident said he/she had a wound on his/her bottom. He/She had had it for two to three days.
Observation and interview on 9/11/23 at 12:33 P.M., showed the resident in bed. The Director of Nursing (DON) rolled the resident over onto his/her side. The resident had a dressing on his/her coccyx, dated 9/9/23. The DON removed the dressing. The resident had an open area on his/her coccyx. The DON described the wound as a Stage II pressure ulcer, the first layer of skin was off, the wound bed was white and there was slight drainage with no odor. Measurements were 7 centimeters (cm) X 4.5 cm X 0.0. The DON said, she did not know how long the resident had had the wound. Staff would call the MD and get orders. The Wound Nurse Practitioner would see the resident on the next visit. Staff would also notify the resident's responsible party.
During an interview on 9/13/23 at 9:38 A.M., the MDS Nurse said when a certified nurse aide (CNA) provided the resident a shower, they should complete the shower sheet and give it to the Nurse. If the CNA noted a skin issue they would mark it on the sheet. The Nurse should notify the MD and get an order for a treatment.
During an interview on 9/18/23 at 10:30 A.M., the Corporate Nurse said, the 24 hour report sheet was reviewed Monday through Friday for new wounds and to ensure treatment orders were in place. The facility caught Resident #6's wound. His/Her wound was noted on Saturday 9/9/23. The Nurse cleaned the wound and applied a dressing and placed a call to the exchange to get orders. When the 24 hour sheet was reviewed on Monday (9/11/23), the facility was aware the resident had a wound. The MD did not return the call until 9/11/23 with orders for the wound. The Corporate Nurse was not aware the resident had a shower sheet which showed the resident had an open area on 9/7/23. The shower sheet was not part of the facility's audit process, so they would not have seen it on 9/7/23. The CNA should mark any skin issues on the shower sheet and report it to the Nurse. The Nurse should assess the resident, if any skin issues were noted, the Nurse should call the MD and get orders. The Nurse who obtained the orders should document the orders in the medical record and on the TAR. If the Nurse placed a call to the MD and did not get a response back timely, the Nurse should have followed up with another call. Orders for dressings should be on the TAR and the orders should include the location of the dressing and how often the dressing should be changed. The Corporate Nurse said the facility had put another process in place along with auditing the 24 hour report sheets for wounds. The new process was for the DON to review the shower sheets within 24 hours of the resident receiving a shower. The new process started after it was noted Resident #6 had a wound on the shower sheet which was not on the 24 hour report sheet.
During an interview on 9/13/23 at approximately 11:30 A.M., the Administrator said she expected staff to follow the facility's policy and procedures and physician orders.
MO00221712
MO00221782
MO00223442
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 F0728
(Tag F0728)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure three Nurse Aides (NA C, NA A and NA B completed a nurse aide training program within four months of their employment with the facil...
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Based on interview and record review, the facility failed to ensure three Nurse Aides (NA C, NA A and NA B completed a nurse aide training program within four months of their employment with the facility. The census was 146.
Review of the facility's Competency Evaluation Policy, revised dated December 2006, showed the following:
-Policy Statement: Nurse aides employed for a period greater that four months must successfully pass a state approved competency evaluation;
-Policy Interpretation and Implementation:
-Persons completing the training program must successfully pass the competency evaluation test within four months (120 days) of their date of employment. Failure to do so will result in the student having to retake the training program. Persons not successfully completing the competency evaluation, within 120 days, will not be permitted to continue their employment until they have successfully passed the competency evaluation;
-Persons may take the competency evaluation three times. Failure to pass the test on the third attempt will require the person to be terminated from employment or reassigned to non-nursing duties.
1. Review of NA C's employee file, showed the following:
-Hire date: 9/14/22;
-No documentation of completing the classroom or onsite training;
-No documentation of completing the CNA examination.
During an interview on 11/8/23 at 8:05 A.M., NA C said he/she completed the CNA program in June, 2023. NA C said he/she needed to take the examination but did not have the fee to pay for the exam. NA C said he/she has been working on the floor as an NA.
2. Review of NA A's employee file, showed the following:
-Hire date: 5/24/23;
-Completion of classroom and onsite training: 6/30/23;
-No documentation of completing the CNA examination.
During an interview on 11/7/23 at 1:20 P.M., NA A said he/she worked at a sister facility as a housekeeper in April of 2023 and came to this facility and started the CNA program in May, 2023 through June, 2023. NA A said he/she was scheduled to take the CNA examination on November 17, 2023. NA A has been working as an NA since June and was sent home today. NA A said he/she was not told why he/she was sent home.
3. Review of NA B's employee file, showed the following:
-Hire date: 5/24/23;
-Completion of classroom and onsite training: 6/30/23;
-No documentation of completing the CNA examination.
During an interview on 11/7/23 at 1:33 P.M. NA B said he/she completed the CNA program at the end of June, 2023. NA B said he/she took the examination but failed it by two points. NA B has not rescheduled to retake the CNA examination. NA B said he/she has been working 40 hours a week as an NA since June.
4. During an interview on 11/8/23 at 10:21 A.M., the Human Resource Manager (HRM) said there is a Corporate Recruiter who does the interviews for the NA program. The NAs are paid at an NA wage, but she is not involved with the testing and not told when the test have been completed. The HRM said the only thing he/she does is get name badges for the NAs.
5. During an interview on 11/8/23 at 9:33 A.M., the Director of Nursing (DON) said the students sign up for the CNA classes through a person in the corporate office. The DON said she does not interact with the students during the program. The students will have a clinical instructor while in the program. The DON did not know the three NAs did not pass the exam. The DON is not kept in the loop and did not know how the CNA program works.
6. During an interview on 11/8/12 at 12:23 P.M., the Administrator said she was not aware the three NAs had not passed the examination. The Administrator said she is ultimately responsible for monitoring the NAs' progress, but the Human Resource Manager should have been monitoring the NAs' progress as well. The Administrator said they have a system failure.
MO00226632
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 F0925
(Tag F0925)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an effective pest control program to prevent ...
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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 maintain an effective pest control program to prevent roaches, mice and gnats in resident rooms (Residents #19, #16, #10, #5 and #18) and common areas. The census was 160.
Review of the facility's Pest Policy, revised 10/24/22, showed:
-Purpose: To ensure the facility is free of insects, rodents, and other pests that could compromise the health, safety, and comfort of residents, facility staff, and visitors;
-The Administrator arranges for a pest control company (Company) to visit and inspect the facility at least once a year;
-The company representative will inspect the facility and grounds for insects, termites, rodents, and any other pests that may cause damage to the facility;
-Submit a written report to the Administrator detailing its findings;
-Department and area staff are responsible for carrying out these recommendations to prevent pests in their respective areas and keeping documentation in accordance with department and facility policies.
1. Review of Resident #19's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/11/23, showed:
-No cognitive impairment;
-Required limited staff assistance for bed mobility and toileting;
-Occasionally incontinent of urine.
Observation of the resident's room on 9/11/23 at 8:30 A.M., showed his/her bed with a bed pad saturated with a yellowish liquid. A fitted sheet under the bed pad was also wet with a yellowish ring. The bed pad was covered with small black bugs.
During an interview on 9/11/23 at 8:40 A.M., Certified Medication Technician (CMT) C said the small bugs on the pad were gnats and , apparently we have a lot of gnats. CMT C removed the linens from the bed and said he/she would have housekeeping disinfect the bed.
2. Review of Resident #16's annual MDS, dated [DATE], showed:
-Cognitively intact;
-Independent with activities of daily living (self-care activities);
-Always continent of bowel and bladder.
Observation and interview of the resident's room, room [ROOM NUMBER], on 9/11/23 at 3:05 P.M., showed the resident's bed pad was wet with a yellowish liquid and was covered with gnats. A pipe under the sink with a trash can underneath was also observed. A small amount of water was observed in the trashcan and on the floor around the trash can. There were holes in the lower portion of the wall on the right side of the room near the resident's bed. The resident said he/she saw mice come out of a hole in the corner by his/her closet. He/She said the mouse ran along the wall towards the closet door. Other times, the mouse ran across to the other side of the room by the sink. The resident last saw a mouse about two weeks ago.
3. Review of Resident #10's quarterly MDS, dated [DATE], showed the resident had moderately impaired cognition.
Observation and interview of the resident's room, room [ROOM NUMBER], on 9/11/23 at 3:20 P.M., showed a pipe under the sink with a trash can underneath. The resident said, they fixed it a little, but it still leaks, and water still got on the floor. He/She saw cockroaches, gnats and mice in his/her room. He/she saw a mouse yesterday in his/her room under the air conditioner and there was a baby mouse that ran by the front desk. The resident never told anyone about the bugs and mice because they know there are mice.
4. Review of Resident #5's quarterly MDS, dated [DATE], showed the resident had moderately impaired cognition.
During an interview and observation of the resident's room, room [ROOM NUMBER], on 9/11/23 at 7:55 A.M., the resident said he/she saw a mouse in his/her room two days ago. The mouse ran down the wall by his/her headboard and around the corner to go under the air conditioner. The resident had an empty glue trap on top of his/her air conditioner. The resident also said the mouse would run over to the other side of the room by his/her roommate's air conditioner. An empty glue trap was noted on the side of the roommate's air conditioner. Gnats were also observed flying around in the resident's room. The resident said he/she had seen a lot of gnats lately.
Observation on 9/11/23 at 2:57 P.M. showed a mouse on the glue trap next to the air conditioner in the resident's room.
5. Review of Resident #18's admission MDS, dated [DATE], showed the resident was cognitively intact.
Observation and interview of the resident's room, room [ROOM NUMBER], on 9/11/23 at 3:29 P.M., showed an empty glue trap under his/her sink. He/She said he/she saw a mouse run across the floor a couple of weeks ago. There was also an approximately three inch gap between the bottom of the closet doors and the floor. Inside the closet was a blackish discoloration on the bottom of the walls. The resident said when it rained, it rained inside the closet.
6. Observation and interview on 9/7/23 at 8:00 A.M. showed a brownish colored insect, approximately one inch long, ran in the center of room [ROOM NUMBER]. Certified Medication Technician (CMT) B, stepped on the insect and identified the insect as a roach.
Observation on 9/7/23 at 8:15 A.M.,showed a roach, approximately a half inch long, climbed up the wall in the hall near room [ROOM NUMBER].
During an interview on 9/7/23 at 8:25 A.M., CMT B, said he/she saw mice daily around the nurse's station, in the soiled utility room and in some of the residents' rooms; especially those residents who liked to hoard food. He/She also had seen a lot of gnats recently. He/She had not reported any pest sightings because everyone knew.
7. During an interview on 9/11/23 at 8:56 A.M., the Social Services Assistant said the exterminator came weekly and staff were seeing less bugs, which was better. However, staff continued to see mice every now and then. Residents continued to eat in their rooms and had food everywhere. Currently, the gnats and flies were terrible.
During an interview on 9/12/23 at 12:30 P.M., the Maintenance Director, said, he has been at the facility for about three weeks. He was unaware of any issues with roaches. He was aware of issues with gnats and flies. room [ROOM NUMBER] seemed to be the worst room for gnats. The facility sprayed and closed up a hole in the dry wall and the housekeepers were doing their best to keep the rooms clean. A couple of residents reported seeing mice. Pest control visited the facility weekly and they left invoices with recommendations. The Maintenance Director expected the pest company's recommendations to be fixed within a day or two of receiving them.
During an interview on 9/13/23 at approximately 11:30 A.M., the Administrator said, if someone saw a pest, she would expect for staff to log it in the book at the nurse's station and notify management. The pest control company came every week. If they were needed before the next scheduled visit, the company would come more frequently. Last week they were in the building twice. The Administrator was aware of the gnats on the third floor. The residents who had gnats on their bed pads and mattresses received different mattresses. The pest control invoice recommendations went to maintenance and repairs were made within the next couple of days. The timeline for a repair to be completed would depend on the repair needed. The Administrator expected the facility to be clean, comfortable, homelike and pest free.
MO00224259
MO00222840
Aug 2023
1 deficiency
1 IJ (1 facility-wide)
CRITICAL
(L)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Safe Environment
(Tag F0584)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain temperatures in resident accessible areas at ...
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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 maintain temperatures in resident accessible areas at or below 81 degrees Fahrenheit (F) and/or meet the comfort needs of residents for three of three resident floors. On 7/28/23, temperatures in the facility ranged from 82 degrees F to 90 degrees F. Resident #1 who is on oxygen and has Chronic Obstructive Pulmonary Disease (COPD-lung disease) reported he/she was hot. His/her window air conditioner registered 90 degrees, his/her portable air conditioner blew a fuse and with the fans blowing, the room temperature measured 88.8 degrees F. Residents #2 and #3 were in a room with an air conditioner unit, that was unplugged. The plug of the unit appeared burnt and unsafe for use. There were no fans in the room. The temperature in the room measured 88.8 degrees F. Both residents complained of being hot and asked for the air conditioner to be plugged in. Staff were not provided with special instructions related to the elevated temperatures and possible side effects of the heat on the residents. Residents are at risk for serious harm due to the extreme temperatures, in conjunction with their medical conditions (Residents #1, #2, #3, #4, #10, #5, #6, #8, #14, #9 and #15). The facility census was 156.
The administrator was informed on 7/28/23 at 5:05 P.M. of an Immediate Jeopardy (IJ), which began on 7/28/23. The IJ was removed on 7/29/23, as confirmed by surveyor on-site verification.
Review of the facility's Disaster and Fire Manual Extreme High Temperatures Policy, undated, showed:
-Should the temperatures in this facility rise above the following upper limits for relative humidity and temperature, the facility shall be evacuated in coordination with the public health department:
-It's too hot if:
-Humidity is greater than 40% at 80 degrees F;
-Humidity is greater than 5% at 85 degrees F;
-Humidity is at 0% at 90 degrees F or higher;
-Otherwise, the following procedures shall be implemented, as high temperatures create the potential for hazardous conditions:
-Monitor residents for intake and output of fluids. Encourage and offer fluids frequently;
-Shade windows exposed to direct sunlight;
-Monitor residents for signs of discomfort and adverse physical symptoms such as hyperthermia (the condition of having a body temperature greatly above normal), heat stroke (the most serious heat-related illness. It occurs when the body can no longer control its temperature) or heat exhaustion (heavy sweating, Weakness or tiredness, cool, pale, clammy skin; fast, weak pulse, muscle cramps, dizziness, nausea or vomiting, headache, fainting);
-High risk residents will be monitored closely. High-risk residents include those with heart, circulatory or respiratory problems, those taking diuretics (medications that remove water or salt from the body), anticholinergics (drugs that can turn off the system in the body that causes the fight and flight reaction), sedatives (medications that slow the brain's activity) and hypnotics (medications used to induce, extend, or improve the quality of sleep, and to reduce wakefulness during sleep);
-Check resident's temperature and vital signs at least every 4-6 hours;
-Dress residents in lightweight clothing, when possible;
-Monitor air temperatures at least every 2 hours between 8am and 10pm, in resident areas;
-Provisions will be made for an adequate supply of fans for residents' rooms;
-If mechanical problems occur in sections of the building or in resident's rooms, transfer residents to areas of the facility that are better ventilated and cooler in temperature. If complete utility failure occurs and temperatures in the facility become extreme, begin procedure for complete evacuation to alternative facilities.
Review of the facility's policy, Resident Rooms and Environment, Revised October, 2022 showed:
-Purpose: To provide residents with a safe, clean, comfortable and homelike environment;
-Policy: The facility provides residents with a safe, clean, comfortable and homelike environment. Facility staff will provide residents with a pleasant environment and person-centered care that emphasizes the resident's comfort, independence and personal needs and preferences. This shall include ensuring that residents can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk;
-Procedure: Facility staff aim to create a personalized, homelike atmosphere, paying close attention to the following:
*Cleanliness and order;
*Comfortable temperatures.
Review of the local temperatures for the week of 7/24/23 through 7/28/23, showed:
-7/24/23, a temperature of 91 degrees F;
-7/25/23, a temperature of 97 degrees F;
-7/26/23, a temperature of 95 degrees F;
-7/27/23, a temperature of 99 degrees F;
-7/28/23, a temperature of 100 degrees F.
1. During an interview on 7/28/23 at 11:50 P.M., the Human Resources Director said they just found out the temperatures were high in the building that morning. They were pushing fluid hydration with water stations, placed extra fans on all the floors and had shut down the smoking and day rooms on all the floors. They were out buying some more portable air conditioners to place in the areas where the building was hot.
2. Observation of the secured 300 North hall on 7/28/23 at 12:30 P.M., showed the following:
-A portable air conditioning unit at the southwest corner of the hallway;
-Several fans placed along the hallway;
-Several residents seated in wheelchairs and chairs outside their doors;
-The recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 83.4 degrees F.
3. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/1/23, showed:
-Cognitively intact;
-Independent with walking, transfers, dressing and personal hygiene;
-Special treatment: Oxygen therapy;
-Diagnoses of COPD, dependence on supplemental oxygen, high blood pressure and shortness of breath.
Review of the resident's care plan dated 7/25/23, showed the following:
-Focus: The resident has oxygen therapy. He/She has COPD and is prone to pleurisy (an inflammation of the lining of the lungs (pleura) that causes sharp chest pains);
-Goal: He/She will have no sign and symptoms of poor oxygen absorption;
-Interventions: Monitor for signs and symptoms of respiratory distress and report to medical doctor as needed: respirations, pulse oximetry (a test used to measure oxygen level), increased heart rate, restlessness, headaches, lethargy (lack of energy), confusion, hemoptysis (coughing up blood), pleuritic pain (chest pain), skin color. May have oxygen at 2-5 liters as needed. Monitor/document breathing patterns. Report abnormalities to medical doctor.
Observation and interview on 7/25/23 at 12:45 P.M., showed, the resident had a small window air conditioner in his/her room. The room was large with four beds. The illuminated digital display on the air conditioner read 90 degrees F and warm air blew out of it. There was an unplugged portable air conditioner on the floor adjacent to the bed. There were two fans, one on his/her bedside table and one on the floor across from his/her bed. There was an oxygen concentrator (a medical device that gives extra oxygen) in the corner across from his/her bed. The recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 87.6 degrees F. The resident said his/her room had been hot for a long time. He/She complained to staff and they brought the portable air conditioner to the room, but it blew the fuses and staff had to unplug it. The fans did not help cool the room down. Staff offered to move him/her to another room a while ago, but not recently. He/She had COPD and used oxygen and it hurt to breathe in the heat sometimes. As he/she talked, he/she started to wheeze. He/She said he/she needed his/her inhaler.
During an interview on 7/28/23 at 1:05 P.M., Certified Medication Technician (CMT) E said the resident complained about the heat in his/her room several times. They had tried to put a portable air conditioner in there, but it blew the fuses. They could not move him/her to another room, because the residents did not all get along with each other and they did not all like the rooms at the same temperature. They put portable air conditioners and fans in the hallways, but it was still hot in the building sometimes. They closed down the day room because it was too hot in there, but they were not given any special instructions on what to do with residents when the temperatures were warm.
4. Observation of the secured 300 South hall on 7/28/23 at 1:25 P.M., showed the following:
-A portable air conditioning unit at the southwest corner of the hallway. The illuminated digital display of 84 degrees F, showed on front of the air conditioner;
-Several residents sat in wheelchairs and chairs outside their doors;
-There was a cart with a container of water on it, but no cups;
-The recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 88.0 degrees F at the end of the hallway.
5. Review of Resident #2's annual MDS, dated [DATE], showed:
-Moderately cognitively impaired;
-Limited assistance of one staff needed for bed mobility, transfers, dressing and personal hygiene;
-Extensive assistance of one staff needed for toileting;
-Used a wheelchair;
-Special treatment: Oxygen therapy;
-Diagnoses included COPD, shortness of breath, dependence of supplemental oxygen.
Observation and interview on 7/25/23 at 1:35 P.M., showed the resident sat on his/her bed in a brief and a t-shirt eating lunch from his/her bedside table. His/her room felt very warm and the wall mounted air condition/heater (PTAC) was unplugged. The plug appeared to be burnt and unsafe for use. The front of the unit was pulled away and leaned against the wall. The recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 88.8 degrees F. The resident asked the surveyor to plug the air conditioner in and said he/she was Damned hot. A staff member entered the room and the surveyor asked if he/she knew anything about the air conditioner and if it worked. The staff member said he/she did not know anything about the air conditioner; only that it was hot in the room. There was no other cooling devices in the room. The resident said he/she would like a fan, but no one offered one.
6. Review of Resident #3's quarterly MDS, dated [DATE], showed:
-Cognitively impaired;
-Limited assistance of one staff needed for bed mobility, transfers, dressing, toileting and personal hygiene;
-Used a wheelchair;
-Diagnoses included conversion disorder with seizures (condition where a mental health issue disrupts how the brain works) and chronic heart disease.
Observation and interview on 1:40 P.M., showed the resident (Resident #2's roommate) lay in his/her bed in a brief and a t-shirt with no sheets on his/her bed. He/She had no water on his/her bedside table. He/She said he/she was hot and wanted a fan. Staff had not offered him/her a fan.
7. Review of Resident #4's annual MDS, dated [DATE], showed:
-Cognitively intact;
-Independent with walking and transfers;
-Diagnoses included high blood pressure and unspecified asthma.
Observation and interview on 7/28/23 at 12:55 P.M., showed the resident had a small window air conditioner in his/her room. The illuminated digital display of 84 degrees F, showed on the front of the air conditioner. The recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 86 degrees F. There was no fan in the room. The resident said he/she felt hot in the room. He/She would like a fan, but no one asked if he/she wanted one. He/She did not know he/she could ask for one. The room was okay at night, but it was too hot during the day. It would get so hot it made him/her feel sick to his/her stomach and it was hard to breathe sometimes.
8. Review of Resident #10's quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-Limited assistance of one staff needed for transfers;
-Used a wheelchair;
-Special treatment: Oxygen;
-Diagnoses included COPD, chronic respiratory failure with hypoxia (hypoxemic respiratory failure happens when there is not enough oxygen in blood), dependence on supplemental oxygen, shortness of breath, obstructive sleep apnea (sleep disorder where a blockage in the airway keeps air from moving through the windpipe while asleep) and high blood pressure.
Observation and interview on 7/25/23 at 12:35 P.M., showed the resident sat in his/her wheelchair in the hallway close to the portable air conditioner. He/She said it was too hot to stay in his/her room. It had been so hot the last few days he/she felt like throwing up. It was hard to sleep at night. They could not eat or watch television (TV) in the day room so there was nothing to do but sit in the hallway all day. It made everyone angry and it was hard to not get into trouble.
9. Review of Resident #5's quarterly MDS, dated [DATE], showed:
-Cognitively impaired;
-Independent with walking, transfers, dressing and personal hygiene;
-Diagnoses included pulmonary embolism (blockage in a lung artery), schizophrenia (a serious mental illness which affects the way you think, feel and behave) and altered mental status.
Observation and interview on 7/28/23 at 1:40 P.M., showed the resident lay in bed in his/her room. The PTAC was on, but the room felt hot. The recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 89.0 degrees F. There was no other cooling device in the room. The resident said he/she was hot and would like a fan.
10. Review of Resident #6's quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-Independent with walking, transfers, dressing and personal hygiene;
-Diagnoses included hypertensive heart disease without heart failure, acute kidney failure and high blood pressure.
Observation and interview on 7/28/23 at 3:15 P.M., showed there was a small air conditioner in the window of the resident's room. It was set on the highest level. The bed by the window could get air, but the privacy curtain blocked the bed by the door from getting air. The resident's bed was located by the door. The recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 85.4 degrees F. The resident said he/she was hot. No one offered a fan and the resident did not know he/she could ask for one.
11. During an interview on 7/28/23 at 1:15 P.M., Housekeeper F said the temperature could get very hot in the building sometimes. Today was the first time he/she saw them close down the day rooms. The high temperatures could be dangerous for some of the residents.
12. During an interview on 7/28/23 at 3:55 P.M., CMT K said when the temperatures got warm they were supposed to let management or maintenance know and give out ice water. He/She did not have any other instructions to follow if the temperatures rose. He/She did not know where they would get extra fans if the residents wanted them.
13. Observations of the second floor resident areas, showed:
-At 12:36 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 81 degrees F in the entry way;
-At 12:37 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 80.3 degrees F at the nurses' station where a portable fan was in use;
-At 12:34 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 83.9 degrees F in the hallway outside room [ROOM NUMBER] where a portable fan was in use;
-At 12:48 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 84 degrees F in the day room by room [ROOM NUMBER]. Six residents sat in the day room and were positioned in front of a portable cooling unit and watched TV;
-At 12:55 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 85.8 degrees F in the dining room where three residents sat;
-At 12:56 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 83.9 in front of the portable unit in the dining room;
-At 1:03 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 85.5 degrees F by the second floor hydration station;
-At 1:04 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 85.3 degrees F in the hallway outside room [ROOM NUMBER].
14. Review of Resident #8's admission MDS, dated [DATE], showed:
-Moderate cognitive impairment;
-Independent with walking and transfers, required limited staff assistance with dressing and personal hygiene;
-Diagnoses included stroke, high blood pressure and dementia.
Observation and interview of the resident on 7/28/23 at 12:40 P.M., showed:
-Room temperature of 82 degrees F and the door to the room was open to the hallway;
-The resident sat in a chair in his/her room;
-The resident said he/she was hot;
-He/She had not been able to get the PTAC to work;
-The PTAC was on cool/high fan and set to 66 degrees F;
-No other cooling devices were in the room.
15. Observation and interview of Resident #14 on 7/28/23 at 1:16 P.M., showed:
-The resident sat in the Day Room and watched TV;
-The temperature in the room was 86.5 degrees F;
-The resident said all of the thermometers were broken;
-He/She was hot;
-He/She tried to stay in his/her room to stay cool.
16. Observation and interview of Resident #9 on 7/28/23 at 1:14 P.M., showed:
-The resident sat in his/her wheelchair next to the window in the second floor Day Room by room [ROOM NUMBER];
-The resident wore a long sleeved shirt, flannel pants, socks and shoes;
-The recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 89.5 degrees F;
-He/She said he/she was hot, but would deal with it.
17. During an interview on 7/28/23 at 12: 57 P.M., Certified Nurse Aide (CNA) L and CNA M both said they had not received any special instructions on how to care for residents in excessive heat.
18. Observations of the first floor resident areas, showed:
-At 1:29 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 86 degrees F in the hallway by room [ROOM NUMBER];
-At 1:30 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 85.2 at the nurses' station on the south hall.
19. Review of Resident #15's quarterly MDS, dated [DATE], showed:
-No cognitive impairment;
-Independent with walking, transfers and person hygiene;
-Diagnoses included diabetes, stroke and depression.
Observation and interview on 7/28/23 at 4:08 P.M., showed:
-The recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 84.6 degrees F in the resident's room;
-He/She said he/she was most comfortable in his/her room;
-It has been hot in the facility since April or May. Portable units and fans had been purchased about a month ago.
20. During an interview on 7/28/23 at 3:53 P.M., a resident who wished to remain anonymous said the main dining room was cooler than on his/her hall. It had been uncomfortably warm in the facility for sometime.
21. During an interview on 7/28/23 at 2:30 P.M., the Administrator said One Main Hall and Three South Hall were audited for temperatures and were found to be at 82 degrees F. Staff were putting fans up there and portable air units were being purchased. Hydration stations were also set up. Staff were to begin interviewing residents regarding their comfort and provide interventions. This was the first time they had temperatures which were higher than what the facility's policy allows. Temperatures have been taken on all resident halls and One Main and Three South are the only two that were out of range. Residents on the Third floor kept turning their PTAC units off. Staff were to monitor hourly on the floors which were out of range. She had asked that all halls be monitored hourly.
22. During an interview on 7/28/23 at 3:30 P.M., CMT I said no one told him/her to do anything differently for the residents when the temperatures were hotter. It could get very warm in some areas of the building.
23. During an interview on 7/28/23 at 3:35 P.M., the Dietary Manager said he fixed an air conditioning unit on the Second floor about a month ago. The room units were not working. He took them out, washed them and changed the filters. The temperature in the kitchen had been extremely high over the last three days. Yesterday he overheard staff and residents complain about it being too hot. Yesterday was the hottest day yet. They offered residents ice cream and soda to help stay cool. They also made sure water and ice were available on each floor.
24. Observation in the main dining room on 7/28/23 at 3:50 P.M., showed:
-Six residents sat at tables and watched TV;
-The recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 85.8 degrees F in the middle of the room;
-The recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 81.3 degrees F in the very back of the room.
25. During an interview on 7/28/23 at 3:57 P.M., CMT H said it was hot on the third floor yesterday. He/She was hot, so the residents must've been too. He/She had not received any specific guidance related to excessive heat.
26. During an interview on 7/28/23 at 4:12 P.M., CMT J said everyone complained about the air. It was warm in the building. If it was hot outside, it was hot inside. It has been warm inside the building all week. He/She had not received any specific guidance related to excessive heat.
27. Observation of the second floor dining room on 7/28/23 at 4:17 P.M., showed 23 residents sat at tables and watched TV. The recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 85.4 degrees F.
28. Observations of the first floor on 7/28/23, showed:
-At 6:54 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 82 degrees F by the main nurses' station;
-At 6:55 P.M., The recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 82.4 degrees F by the portable cooling unit in the hallway outside of room [ROOM NUMBER];
-At 6:56 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 82.3 degrees F in the hallway outside room [ROOM NUMBER].
29. Observations of the second floor on 7/28/23, showed:
-At 4:19 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 86.3 degrees F in the hallway outside room [ROOM NUMBER];
-At 4:20 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 86.6 degrees F in the hallway near a fan outside room [ROOM NUMBER];
-At 4:21 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 86.4 degrees F in the Day Room near room [ROOM NUMBER];
-At 4:23 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 85.3 degrees F in the hallway outside room [ROOM NUMBER];
-At 6:57 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 83.0 degrees F at the nurses' station;
-At 6:58 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 81.7 degrees F in the dining room;
-At 7:00 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 82.3 degrees F in the hallway by room [ROOM NUMBER];
-At 7:01 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 84.2 degrees F in the day room near room [ROOM NUMBER], where six residents sat and watched TV;
-At 7:03 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 83.9 degrees F in the hallway by room [ROOM NUMBER];
-At 7:04 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 85.6 degrees F in the day room near room [ROOM NUMBER], where Resident #14 sat and watched TV.
30. Observations for the secured South 300 floor on 7/28/23, showed the following:
- At 4:15 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 85.6 degrees F in room [ROOM NUMBER];
-At 4:20 P.M., the the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 84.5 degrees F in the hallway, adjacent to the nurse's station;
-At 6:45 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 85.0 degrees F in room [ROOM NUMBER];
- At 6:50 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 83.6 degrees F in the hallway, adjacent to the day room.
31. Observations for the secured North 300 floor on 7/28/23, showed the following:
-At 4:25 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 87.8 degrees F in the hallway outside room [ROOM NUMBER];
-At 7:10 P.M., the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 86.0 degrees F in the hallway, adjacent to the nurse's station on the southwest hall;
-At 7:15 P.M., the the recorded temperature on the surveyor's digital electronic thermometer, showed a temperature of 85 degrees F in the southeast, hallway adjacent to the smoking area.
32. During an interview on 7/28/23 at 7:28 P.M., the Corporate Nurse said more portable cooling units had arrived and were being put on the resident halls. The HVAC (heating, ventilation and air conditioning) company was picking up parts and expected to arrive at the facility within 30 minutes.
33. During an interview on 7/28/23 at 7:30 P.M., the Regional Director of Maintenance said one side of the building was cooled by PTACs. The other side used individual window air conditioners. They used roof top units for the common areas and a condenser unit and air handler for the ground floor. When the temperature reached 100 degrees outside it was difficult for the system to cool the building. They brought in portable units to cool down the common areas and were bringing in more. They did not always know if there was a problem in the building unless staff reported it. Then they could go out and buy more units. He did not know there was a problem in the building until that day. Staff needed to be educated to report to Administration and Maintenance when there were problems with the cooling and heating systems. The individual air conditioners in the resident rooms may have been too small to cool the entire room. There might be a problem with the privacy curtains preventing the air from circulating in the room. They could buy fans for the residents, but they needed to know if the residents wanted or needed fans.
NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level L. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements.
At the time of exit, the severity of the deficiency was lowered to the F level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).
MO00222139
MO00222158
Jul 2023
4 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
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify and/or document the physician was notified when one resident...
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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 and/or document the physician was notified when one resident refused his/her medications (Resident #21) and failed to administer and notify and/or document the physician was notified when a medication was not available for one resident (Resident #10). The sample was 35. The census was 151.
Review of the facility's Monitoring of Medication Administration Policy, dated 1/20, showed:
-The consultant pharmacist, designated nursing staff or pharmacy designee, performs quality assurance evaluations to determine that:
-Medications are administered at the frequency and times indicated in the prescriber orders;
-Stop order policies, where utilized are observed;
-Refusal or inability of the resident to take medication is evaluated, documented and responded to appropriately;
-The policy failed to address when staff should notify the physician.
1. Review of Resident #21's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/9/23, showed:
-Short and long term memory problem;
-Cognitive skills for daily decision making: severely impaired-never/rarely made decisions;
-No rejection of care;
-Diagnoses included schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves).
Review of the care plan, in use at the time of survey, showed:
-Focus: revision date was 2/24/22, has poor decision making skills/very paranoid;
-Interventions: Administer medications as ordered;
-Focus: revision date was 6/20/23, has behavior problem related to schizophrenia and delusions. Resident will call different hotlines to report that he/she is being held captive and not being fed;
-Intervention: Administer medications as ordered;
-Focus: has behavior problem related to resisting care (refusing therapy) declining vs. to be obtained and skin assessments, declines weights and vital signs, declines sleeping in a bed, sleeps in bathroom in a chair, covers toilet and window with blankets and towels, leaves water running in the bathroom sink, pulls mattress out of the room into the hallway, pushes it up against the wall, will place up against the window if mattress is placed in room, refuses to turn call light off and will not allow staff to turn call light off, eats in the bathroom, steals house phone from the nurses desk and will not allow others to use it, aggressive and uses curse words with staff members, kicked staff member in stomach, writes/colors on walls in room and common area;
-Intervention: Administer medications as ordered;
-Focus: revision date 4/29/23, paranoid behavior related to putting a chair behind his/her door during the night/pushing chair/bedside table and bed behind door;
-Intervention: Administer medications as ordered;
-Focus, date initiated 3/2/23, has episodes of delusions;
-Interventions: Administer medications per orders.
Review of the Medication Administration Record (MAR) dated 5/1/23 through 5/31/23, showed:
-An order for: olanzapine 5 milligrams (mg), give 1 daily at bedtime for schizophrenia, start date was 2/18/22, hold 5/17/23 through 5/18/23;
-Documentation on 5/2 through 5/6, 5/8 through 5/10, 5/14 and 5/16, showed a 2 was documented. A 2 meant=refused;
-An order of olanzapine 5 mg, give 1 daily at bedtime for schizophrenia, start date was 5/31/23;
-Documentation on 5/31/23, showed a 2 was documented;
Review of the progress notes, dated 5/13/23 through 5/31/23, showed:
-On 5/13/23 at 5:31 P.M., the nurse went to the patient's room to answer his/her call light. When the nurse entered the room, patient ran from the bathroom and kicked the nurse in the stomach. As this nurse was attempting to catch his/her balance patient slammed the nurse's hand with the bathroom door. Patient then proceed to pull the nurse's hair. The nurse was able to exit the patient's room without injury. Patient then proceeded to throw water on another. 911 immediately called for transport to the hospital. Patient refused to take as needed to help with his/her frequent behaviors;
-On 5/16/23 at 9:21 P.M., patient yelling, trying to attack staff, stated he/she wanted to use the phone but would not wait for staff to give him/her the phone. Came behind nurse desk and snatched the phone out of the drawer and refused to give it back to the nurse. Report called to the hospital Registered Nurse (RN) to ensure patient could be seen tonight and not sent back, permission granted and patient sent out by ambulance;
-There was no documentation showing the physician was notified the resident refused medication.
Review of the MAR, dated 6/1/23 through 6/30/23, showed:
-An order of olanzapine 5 mg, give 1 daily at bedtime for schizophrenia, start date was 5/31/23 and discontinued on 6/17/23;
-Documentation on 6/1, 6/2, 6/4, 6/6 through 6/16, showed a 2 was documented;
-An ordered for olanzapine 2.5 mg, give 1 daily at bedtime for schizophrenia, start date was 6/17/23;
-Documentation on 6/17 through 6/25 and 6/27 through 6/30, showed a 2 was documented;
- An order for divalproex sodium 250 mg, take 1 twice daily for psychosis, start date was 5/31/23;
-Documentation at 9:00 A.M. on 6/2, 6/3, 6/6, 6/8 through 6/18, 6/20 through 6/25, 6/28 through 6/30, a 2 was documented; at 5:00 P.M. on 6/1 through 6/9, 6/11 through 6/16, 6/18, 6/19, 6/21 through 6/25 and 6/27 through 6/30, showed a 2 was documented.
Review of the progress notes, dated 6/1/23 through 6/30/23, showed:
-On 6/6/23 at 6:48 A.M., resident was living inside of the bathroom in room;
-On 6/7/23 at 6:31 A.M., observed during night up at intervals continues staying in bathroom inside room;
-There was no documentation showing the physician was notified the resident refused their medication.
Review of the MAR, dated 7/1/23 through 7/4/23, showed:
-An ordered for olanzapine 2.5 mg, give 1 daily at bedtime for schizophrenia, start date was 6/17/23;
-Documentation on 7/1 through 7/3, showed a 2 was documented;
- An order for divalproex sodium 250 mg, take 1 twice daily for psychosis, start date was 5/31/23;
-Documentation on 7/1 through 7/3 at 9:00 A.M. and 5:00 P.M., showed a 2 was documented.
Review of the progress notes, dated 7/1/23 through 7/4/23, showed:
-On 7/4/23 at 4:20 A.M., at approximately 4:00 A.M., resident went to the alarmed door that is right before dining room and was able to get the door open setting off the alarm, when asked how he/she was able to get the door open the resident stated with my fingernail. Resident stated that he/she was leaving but would not state where he/she wanted to go and became very loud and unable to redirect away from the door. Resident verbally aggressive and spraying air freshener towards the face of staff; at 4:15 A.M. the nurse practitioner (NP) was contacted and gave order to send the resident to the emergency room for evaluation and treatment;
-There was no documentation showing the physician was notified the resident refused his/her medications.
During an interview on 7/14/24 at 1:45 P.M., the Assistant Director of Nursing (ADON) said the resident will not take medications, the doctors are aware he/she will not take medications and it is care planned.
During an interview on 7/14/23 at 5:06 P.M. the Director of Nursing (DON) said it should be documented that he/she would not take his/her medications.
2. Review of Resident #10's quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-No rejection of care;
-Diagnoses included anxiety and depression;
Review of the care plan, in use at the time of survey, showed:
-Focus: revision date was 7/12/22, prefers not to eat breakfast, states he/she wishes to lose weight;
-The care plan did not address the use of Ozempic for weight management.
During an interview on 7/12/23 at 11:24 A.M., the resident said he/she has not been getting his/her Ozempic. The facility was having a hard time getting the medication, but the medication is here and they don't always give it to him/her. I was supposed to have got an injection yesterday, Wednesday, and I still haven't gotten it. The staff say I don't get it anymore but when the doctor comes, he/she will ask me if I am getting it. How can it be discontinued when the doctor says I am still getting it?
Review of the MAR, dated 6/1/23 through 6/30/23, showed:
-An order for Ozempic 0.5 mg subcutaneously (under the skin) every Wednesday morning for weight management, start date was 5/17/23, hold 6/15/23 to 6/18/23;
-Documentation showed on 6/7 and 6/21 the MAR was blank; On 6/14 and 6/28, a 9 (other/see progress notes) was documented.
Review of the progress notes, dated 6/1/23 through 6/30/23, showed:
-On 6/5/23 at 8:54 A.M., Resident stated he/she received Ozempic injection on Saturday and did not need it today;
-On 6/15/23 at 4:40 A.M., Ozempic medication placed on hold x 3 days for pharmacy to deliver.
Review of the MAR, dated 7/1/23 through 7/14/23, showed:
-An order for Ozempic 0.5 mg subcutaneously every Wednesday morning for weight management, start date was 5/17/23;
-Documentation showed on 7/12/23, the MAR was blank.
During an interview on 7/14/24 at 1:45 P.M., the ADON the resident can tell you if he/she got their medication. If he/she said they did not get their medication, they did not get their medication. The Ozempic has been on back order and it should be documented and the doctors should be aware.
During an interview on 7/14/23 at 5:06 P.M. the DON said he/she thought the resident was only supposed to have it four times, then it was done. If a medication is listed on the MAR and there was no stop date, the medication should be continued.
3. During an interview on 7/13/23 at 8:15 A.M., Registered Nurse (RN) L said if a resident refused a medication, he/she would explain the risk to the resident and document the resident refused their medication and notify the physician. He/She would also make staff aware the resident refused their medication so they could monitor the resident. The physician would be notified for every dose of medication refused.
4. During an interview on 7/14/24 at 1:45 P.M., the ADON said a blank on the MAR would mean the medication/item was not documented. If a resident refused to take their medication, the Certified Medication Technician (CMT) should tell the ADON and the ADON will talk with the resident and notify staff to keep an eye out on the resident and document it on the MAR and in the progress note. If the resident has refused their medication for three days, the physician would be notified and documented in the progress notes. If a resident refused to take their medication it should be on their care plan.
5. During an interview on 7/14/23 at 3:35 P.M., the MDS Nurse said if a resident refused a medication it should be documented in the progress notes, and the physician should be notified after three missed doses. If a resident consistently refused a medication, it should be on their care plan. If a resident refused a medication once, it should be care planned because it will happen again.
6. During an interview on 7/14/23 at 5:06 P.M. the DON said a blank on the MAR means that item was not documented or the medication was not given. If a 9 was documented, there should be a corresponding progress note. If a resident refused a medication, the CMT should notify the nurse and the nurse will notify the physician. The physician should be notified for each dose of missed medication and it should be documented. If the resident continues to refuse their medication the physician should be notified to see what else they may want to do. The DON expected staff to follow physician orders and the facility's policies and procedures and if they are unable to follow the policies and procedures, she expected them to move up the chain of command.
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
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a safe, clean, comfortable and homelike enviro...
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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 a safe, clean, comfortable and homelike environment when temperatures inside the facility caused the residents on the third floor South hall, the first floor South hall and residents who attended activities on the ground floor activities room to feel uncomfortable and complain of feeling hot. The facility also failed to provide clean bed and bath linens in a timely manner, delaying person centered care needs and assistance from staff. This could impact all residents who needed to be changed, wanted to shower or needed clean bedding. The sample was 35. The census was 151.
Review of the facility's policy, Extreme Weather, revised October 2022, showed:
-Purpose: To provide residents, visitors and staff with a comfortable and safe environment during extreme weather;
-Policy: The facility responds to extreme weather in a prompt manner to protect the health and safety of residents;
-Procedure: The maintenance department maintains a log of Facility temperatures. If the temperature is above 81 degrees Fahrenheit (F) or below 71 degrees Fahrenheit, the Maintenance Department will take and document measures to remedy the situation.
Review of the facility's policy, Resident Rooms and Environment, Revised October, 2022 showed:
-Purpose: To provide residents with a safe, clean, comfortable and homelike environment;
-Policy: The facility provides residents with a safe, clean, comfortable and homelike environment. Facility staff will provide residents with a pleasant environment and person-centered care that emphasizes the resident's comfort, independence and personal needs and preferences. This shall include ensuring that residents can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk;
-Procedure: Facility staff aim to create a personalized, homelike atmosphere, paying close attention to the following:
*Cleanliness and order;
*Comfortable temperatures.
1. During an observation and interview on 7/2/23 at 8:30 A.M., upon entering the facility, the temperature felt warm. Receptionist D said, The air conditioning is out. It has been out since last night around 4:00 P.M. when the storm hit. It knocked the power out and the generator kicked on. When the power came back on, the air conditioner did not come back on. He/She did not call anyone yesterday because he/she did not notice it until about 7:00 P.M. when it started to become very hot and it was time for him/her to leave work. It was still out when he/she came back to work this morning at 7:00 A.M. He/She did not notify anyone the night before because he/she did not realize the air conditioning was off until right before his/her shift ended at 7:00 P.M. and it started to get hot. He/She had a fan blowing on him/her and was perspiring. The air temperature in the hallway measured 82.3 degrees F.
During an interview on 7/2/23 at 9:00 A.M., the Director of Nursing (DON) said no one called her and told her the air conditioning was out in the building the night before. She was not aware there was a problem with the air conditioning until the Surveyor reported the issue. Staff should have notified Maintenance and Administration about the air conditioner when the building lost power and the air conditioner did not turn back on. No one complained to her about the building being too hot.
Observations on 7/2/23 between 10:50 A.M and 1:30 P.M., of the third floor, 300 Hall South, secured unit, located on the South side of the building showed:
-In the television room, at the end of the Southwest hall, showed two residents seated inside the room. The recorded temperature on an electronic thermometer, showed a temperature of 82.3 degrees F.;
-In the designated smoking area located at the end of the Southeast hall, showed three residents seated inside the room. An unplugged portable air conditioning unit was located in the room. There were fans in the windows but they were turned off. The recorded temperature on an electronic thermometer, showed a temperature of 87.2 degrees F.
Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/22/23, showed the resident was cognitively intact.
During an interview on 7/2/23 at 11:20 A.M., the resident said the designated smoking area is always hot. They are not allowed to turn on the window fans unless the staff are in the room. He/She thought the portable air conditioner was broken because it had not been plugged in all week. It was always hot in the smoking room, the television room at the other end of the hall and his/her room when the temperatures were hot outside. He/She complained to staff but it did not do any good.
Review of Resident #4's admission MDS, dated [DATE], showed the resident was cognitively intact.
During an interview on 7/2/23 at 11:25 A.M., the resident said the 300 hall designated smoking room was always hot along with the television room and the hallway. He/she complained about the temperatures but no one did anything about it.
Review of Resident #3's admission MDS dated [DATE], showed the resident was cognitively intact.
During an interview on 7/2/23 at 11:30 A.M., the resident said it gets very hot in the 300 smoking room, the hallway and his/her room when the temperatures are hot outside. He/She has complained about the temperatures but the staff tell him/her it not their job to take care of the air conditioning.
During an interview on 7/2/23 at 11:50 A.M., on the 300 Hall South, Certified Nurse Aide (CNA) N said he/she could not do anything about the temperature in the smoking room because that was just the way it was. The temperatures were cooler today but when it was hotter outside, the temperatures inside the building were excruciating. The residents were always complaining about the heat. The air conditioning did not work well on the third floor.
During an interview on 7/2/23 at 11:54 A.M., on the 300 Hall South, Receptionist D said the temperatures were always hot up on the third floor in the halls and around the nurse's station when it was hot outside. There was nothing the staff could do about it.
Review of Resident #10's annual MDS dated [DATE], showed the resident was cognitively intact
During an observation of room [ROOM NUMBER] and interview on 7/2/23 at 1:15 P.M., Resident #10, who resided in room [ROOM NUMBER], said when the temperatures get hot, he/she feels like he/she is going to cook in his/her room. He/She has complained to staff several times but nothing changed. The recorded temperature on an electronic thermometer, showed a temperature of 80.1 degrees F.
Review of Resident #9's admission MDS, dated [DATE], showed the resident was cognitively intact.
During an observation and interview on 7/2/23 at 1:20 P.M., of room [ROOM NUMBER], showed the room felt very warm. The resident was perspiring. He/She lay in bed with a fan on the bedside table, blowing directly on him/her. The resident said when the temperatures are warm outside, his/her room gets very hot. He/She had to borrow a fan from one of the other residents. The air temperature in the room measured 81.1 degrees F.
During an interview on 7/2/23 at 11:40 A.M., Activities Staff Person M said when the temperature gets hot outside, the portable air conditioners do not work well in the activities room and it gets very warm. The residents often complain about the temperature in the room.
Review of Resident #8's admission MDS, dated [DATE], showed the resident was cognitively intact.
During an interview on 7/2/23 at 1:30 P.M., the resident said when the temperature gets hot outside, the activities room gets stifling hot. That is why he/she and several other residents will no longer attend activities when the temperatures are hot.
During an interview on 7/2/23 at 9:10 A.M., the Maintenance Director said he was not aware there was a problem with the air conditioner until he came into work on 7/2/23. He expected staff to call him when the air conditioner went out the night before. He just needed to reset the circuit breaker to start the air conditioner back up. No one made any complaints to him about the building being hot prior to that morning. They recently made some repairs on the air conditioner. He only started working as the Maintenance Director on 6/30/23.
During an interview on 7/2/23 at 1:00 P.M., the Regional Director of Maintenance said they recently made several repairs to the air conditioner, including the compressor. He had not heard about any complaints from staff or residents about the building being too hot when the weather was hot outside.
During interviews on 7/2/23 at 11:10 A.M. and at 2:00 P.M., the Human Resources Director said no one called him to let him know the air conditioner was out in the building overnight. He expected staff to call someone in Maintenance or Administration if the air conditioning was not working. No one reported to him the residents were complaining of heat when the temperatures were high. The air conditioner in the third floor South smoking room worked but one of the residents kept unplugging it. Additional portable air conditioning units had been purchased or rented to help cool resident rooms, hallways and other areas throughout the building.
Review of the National Weather Service website at weather on 7/4/23, showed:
-On 6/1/23, the high temperature was 92 degrees F.;
-On 6/2/23, the high temperature was 93 degrees F.;
-On 6/3/23, the high temperature was 94 degrees F.;
-On 6/4/23, the high temperature was 93 degrees F.;
-On 6/14/23, the high temperature was 90 degrees F;
-On 6/15 23, the high temperature was 92 degrees F;
-On 6/20/23, the high temperature was 90 degrees F;
-On 6/23/23, the high temperature was 91 degrees F;
-On 6/24/23, the high temperature was 97 degrees F;
-On 6/25/23, the high temperature was 96 degrees F;
-On 6/28/23, the high temperature was 93 degrees F;
-On 6/30/23, the high temperature was 96 degrees F.;
-On 7/1/23, the high temperature was 95 degrees F.
During an interview on 7/17/23 at 10:30 A.M., the Administrator said someone should have notified her or Maintenance when the air conditioner went out on on 7/1/23. Staff should monitor the third floor smoking room and plug in the air conditioner when it is hot. She did not know the residents were complaining of heat in the activities room and first floor areas. Staff should monitor these areas and reporting it if there are concerns about the temperatures.
2. Review of the facility policy, Laundry-Route and Process, dated 10/24/22, showed:
-Purpose: To ensure that the facility provides a sufficient supply of clean linens for all residents;
-Policy: The facility processes and routes laundry on a daily basis to provide linens for each resident;
-Laundry staff is responsible for carrying out duties related to the cleaning of linen;
-Linens are sorted, washed and dried;
-Clean, folded linen is placed on laundry cart;
-The clean laundry on the cart is taken to the clean linen storage/supply room;
-This cycle is repeated until all laundry is done for the day or until the end of the staff shift.
Observation on 7/2/23 at 12:45 P.M., of the linen closet on the 200 Hall, showed three sheets and four pillowcases. There were no towels or washcloths.
Observation on 7/2/23 at 12:55 A.M., of the linen closet on the 300 Hall, North Side, showed no towels or washcloths in the closet.
Observation of the laundry room at 1:15 P.M., showed no laundry carts of towels or sheets ready to go to the floors.
Review of Resident #5's quarterly MDS dated [DATE], showed the resident was cognitively intact.
During an interview on 7/2/23 at 10:50 A.M., the resident said he/she had to use the same towel for four days. This was normal because they never had clean towels or washcloths for the residents to use.
Review of Resident #6's admission MDS dated [DATE], showed the resident was moderately cognitively impaired.
During an interview on 7/2/23 at 1:35 P.M., the resident said he/she often has to wait to get up for breakfast in the morning because the staff do not have clean linens to wash him/her up.
Review of Resident #8's admission MDS dated [DATE], showed the resident was cognitively intact.
During an interview on 7/2/23 at 1:40 P.M., the resident said there is always a problem with getting linens. If you got a clean towel or wash cloth you had to keep if for days because you were not going to get another one for a while. Residents would take several of them from the closet and store them in their rooms because they knew they were not going to be any more put back in the closet for a while.
During an interview on 7/2/23 at 10:55 A.M., third floor North Nurse K said staff do not have enough linen. It should be in the linen closets when they come in so they can start getting the residents up but it is never there. They always have to go try to find their own in the laundry room or on other floors. They cannot start getting the residents ready for the day until they have their supplies. Sometimes they have to wait a couple of hours until it is ready. He/She believes it is because of staffing.
During an interview on 7/2/23 at 11:20 A.M., second floor Certified Nurse Aide (CNA) L said they never have enough linen. They have to go to other floors when they first get to work to try and find enough to get through their shift. It does not do any good to go to the laundry room, because the laundry staff are not washing the linens. Sometimes they have to hide enough so they will be able to take care of all their residents because they do not know when they will get more linens.
During an interview on 7/2/23 at 12:50 P.M., CNA H said there was enough laundry that day but usually there is not enough. He/She works the 7:00 A.M. - 3:00 P.M. shift and usually three to four days there will not be enough laundry after he/she arrives to work. CNA H will have to wait anywhere from 2 to 8 hours for laundry to bring up clean sheets and towels. Sometimes he/she can go down to the laundry but often there is no laundry staff so it is not done. Then the residents have to wait to take showers or get cleaned up. He/She sometimes tears up sheets to make washcloths to wash them up because he/she feels bad about the residents not being able to clean themselves up.
During an interview on 7/3/23 at 9:15 A.M., Laundry Supervisor E said they send laundry up to the halls several times a day. There are times when staff call in and they run short but that does not happen all the time. They have plenty of linens. Laundry Supervisor E did not know what is happening to the linens that are going up to the floors. He/She thought maybe some of the staff might be throwing it away rather than rinsing it out to send to the laundry.
During an interview on 7/2/23 at 3:00 P.M., the DON said she expected laundry to be delivered to the halls twice a day at the beginning of the shifts so the staff would be able to get the residents up and showered before breakfast and to bed after dinner. This was important for general patient care. Residents needed to have clean bedding to prevent skin breakdown. She believed some of the staff might be throwing it away to avoid having to rinse it out.
During an interview on 7/2/23 at 3:05 P.M., the Human Resources Director said they had ordered plenty of linen. There was no reason not to have linen on the halls. He believed some of the staff might be stashing it to make sure they had enough for their shift.
During an interview on 7/17/23 at 10:35 A.M., the Administrator said laundry is responsible for making sure linens are on the floor for staff but staff should call laundry if they are running low on linens during their shift.
MO00220949
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
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure five residents (Residents #2, #19, #20, #3 and #16) out of 3...
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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 five residents (Residents #2, #19, #20, #3 and #16) out of 34 sampled residents remained free from abuse related to resident to resident physical altercations. The facility census was 151.
Review of the facility's Resident Rights policy, revised December 2016, showed: Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the right to be free from abuse, neglect, misappropriation of property and exploitation.
Review of the facility's Abuse Prevention and Prohibition Program policy, revised October 24, 2022, showed:
-Policy: Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual or physical abuse, neglect, mistreatment or misappropriation of resident property;
-The Facility is committed to protecting residents from abuse by anyone, including but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors and friends;
-The facility screens for potentially abusive residents during the pre-screening process;
-The facility involves a qualified psychiatrist and other mental health professional to help facility staff manage difficult or aggressive residents;
-Prevention: Staff, residents and families will be able to report concerns, incidents and grievances without fear of retribution or retaliation;
-Supervisors shall immediately intervene, correct and report identified situations where abuse, neglect or misappropriation of resident property is at risk for occurring;
-Staff is instructed to report any signs of stress from family and other individuals involved with the resident that may lead to abuse, neglect or misappropriation of resident property and intervene as appropriate;
-Residents identified by staff as being self-injurious or exhibiting abusive behavior that requires professional services not provided in the facility (e.g., mental health services will be reviewed by the interdisciplinary team (IDT)) and/or physician;
-Resident assessments and care planning are performed to monitor resident needs and address behaviors that may lead to conflict;
-Resident to Resident altercations must be reported if the altercation is caused by a willful action that results in physical injury, mental anguish or pain;
-The presences of a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate on non-accidental behavior;
-The Administrator will provide initial and follow up written reports of the results of all abuse investigations and consequent actions to the appropriate agencies as outlined in section IX below:
-If the investigation substantiates the allegation, corrective action will be documented as part of the investigation and implemented to prevent reoccurrences;
-If the investigation reveals the initial report was unsubstantiated, the investigation ceases immediately, the facility will notify residents, family members, facility staff and appropriate agencies of the findings;
-The facility will reassess the resident following the abuse incident to determine if the resident's medical, nursing, physical, mental or psychosocial needs or preferences have changed as a result of the abuse and initiate or update the care plan as indicated.
1. Review of Resident #2's admission Record, showed the resident was admitted to the facility on [DATE], with diagnoses that included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), schizophrenia (breakdown in relation between thought, emotion and behavior leading to faulty perception, inappropriate actions and feelings), generalized anxiety disorder, unsteadiness on feet and cognitive communication deficit (difficulty with any part of communication (memory, attention, organization, planning, and problem solving) that is affected by a disruption of the cognitive processes).
Review of the resident's care plan, in use at the time of the investigation, showed:
-Focus: Resident has impaired cognitive function, dementia, difficulty making decisions, impaired decision making and short term memory loss;
-Goal: Resident will be able to communicate basic needs on a daily basis through the review date, resident will remain oriented to person, place, situation, and time, resident will maintain current level of cognitive function;
-Interventions:
-Ask simple yes/no questions in order to determine the resident's needs;
-Communication: Use Resident's preferred name. Identify yourself at each interaction;
-Resident needs supervision/assistance with decision making;
-Use task segmentation to support short term memory deficits. Break tasks into one step at a time;
-Focus: Resident has the potential to have physically aggressive episodes related to anger, dementia, and poor impulse control. Resident had an occurrence with another resident on 2/16/23, 6/1/23 and 6/19/23. Revised: 6/23/23;
-Goals: The resident will demonstrate effective coping skills, the resident will not harm self or others, the resident will seek out staff/caregiver when agitation occurs, the resident will verbalize understanding of need to control physically aggressive behavior;
-Interventions:
-2/16/23, Residents separated. Physician, responsible party, all nursing administration and Division of Health and Senior Services (DHSS) notified. Skin and pain assessments performed. Resident placed on one on one (1:1, one staff member providing support specifically to one individual) with staff. EMS called for transport to emergency room (ER) for evaluation and treatment. Resident was moved to another floor. Date Initiated: 2/22/23;
-6/1/23, Resident had an altercation with his/her roommate. Administrator, Director of Nursing (DON), physician, responsible party and DHSS notified. Residents and staff interviewed and skin assessment performed. Resident placed on 1:1 with staff. Psychiatrist and social worker to follow up with resident. Date Initiated: 6/12/23;
-6/19/23, Resident in a physical altercation with another resident. Residents separated, staff interviewed and residents interviewed. Administrator, DON, physician and DHSS notified. Skin assessment completed. Resident was sent out to hospital via emergency medical services (EMS). Social Services Director (SSD) and psychiatric services followed up with resident. Date Initiated: 6/23/23;
-Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document;
-Monitor, document, /report as needed (PRN) any signs or symptoms of resident posing danger to self and others;
-Psychiatric/Psychogeriatric consult as indicated;
-Resident's triggers for physical aggression are others being in his/her area, too close to him/her or intruding on his/her privacy. Resident's behaviors are de-escalated by monitoring his/her area;
-No new interventions after each physical altercation to prevent further incidents or keep the resident or other residents safe. Resident was already receiving psychiatric services prior to the incident.
Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/2/23, showed:
-Moderately cognitively impaired;
-Independent with activities of daily living (ADLs);
-No behaviors.
Review of the resident's June 2023 through July 2023 progress notes, showed:
-6/19/23 at 7:04 P.M., Writing nurse checking on resident following resident to resident altercation. Resident remains irate. DON and Administrator notified. 1:1 also immediately implemented. No injury noted. No complaints of pain. Resident refused skin assessment. Responsible party made aware and would like to send resident to the hospital. Statement also taken;
-6/19/23 at 10:36 P.M., Resident returned within 1 hour from emergency room (ER) with no new diagnosis. No x-rays were done. Writing nurse notified DON. Resident continues to have irate behaviors along with hallucinations. Resident pacing up and down the hall having verbal altercations with staff and other residents. Writing nurse continues to redirect and continues 1:1 with resident. New order to send resident back to ER;
-6/20/23 at 1:30 A.M., Resident transferred to hospital for psychiatric evaluation. Aggressive bizarre behavior while police were on the premises to accompany emergency medical technicians (EMT) with transfer. Resident exhibiting paranoia. Police officer had to assist EMT to place on stretcher inside of ambulance. Once the resident was inside the ambulance, one police officer remained in the back of the ambulance to transport to the hospital;
-6/20/23 1:30 P.M., Social services had a one on one discussion with the resident regarding his/her behavior. He/She said he/she didn't like what the other resident said to him/her and they started fighting. He/She said the other resident threw the chair at him/her. The resident said he/she doesn't know how to control his/her anger issues at times. The police could not even get him/her calm. Since he/she went to the hospital, he/she feels better. He/She just doesn't know what happened. Both residents apologized to each other.
Review of the resident's mental status exam (MSE) notes, showed:
-On 6/9/23, Symptoms: Patient is out in day room. Calm on approach. Listening to the radio. Content and pleasant. Cognition: appeared to comprehend, shared information and responded appropriately to questions. Insight and judgement: impaired as evidenced by decisions of recent past. General: patient aware, alert and oriented. Observation: disheveled and cooperative. Thought process: some latency (delay) in thought process, mood appropriate, and affect appropriate;
-On 6/16/23, Symptoms: Patient is calm at this time. Denies any hallucinations. Oriented times three. Appears content. Cognition: appeared to comprehend, shared information and responded appropriately to questions. Insight and judgement: impaired as evidenced by decisions of recent past. General: patient aware, alert and oriented. Observation: groomed, neat, clean appearance. Cooperative. Thought process: mood appropriate and affect appropriate;
-On 6/23/23, Symptoms: Staff requested patient be seen weekly at this time. Patient is calm and pleasant. No agitation reported. Out in common area with peers. Oriented to self and situation. No acute agitation. Cognition: appeared to comprehend, shared information and responded appropriately to questions. Insight and judgement: impaired as evidenced by decisions of recent past. General: patient aware, alert and oriented. Observation: groomed, neat, clean appearance. Cooperative. Thought process: mood appropriate and affect appropriate;
-On 7/12/23, Symptoms: Patient stated he/she is feeling good and denies any distress, but staff stated he/she is not sleeping well. He/She spoke about enjoying activities at the facility. Affect is currently pleasant. Memory is limited. Poor informant. Cognition: had difficulty responding to generalized and/or open-ended questions. Insight and judgement: impaired as evidenced by decisions of recent past. General: patient aware. Observation: groomed, neat, clean appearance. Labile (emotions that are easily aroused or freely expressed, and that tend to alter quickly and spontaneously; emotionally unstable), agitated at times;
-No mention of resident behaviors or resident to resident altercations.
During an interview on 7/12/23 at 10:26 A.M., Resident #2 said Resident #20 was smarting off and he/she didn't like what was said. They started fighting. The other resident pushed him/her down and threw a chair at him/her. The resident wanted to defend himself/herself. His/her family member saw it all and they knew the resident didn't start it. It was not the resident's fault.
2. Review of Resident #19's admission Record, showed the resident was admitted to the facility on [DATE], with diagnoses that included paranoid schizophrenia (characterized by predominantly positive symptoms of schizophrenia, including delusions and hallucinations) and generalized anxiety disorder.
Review of the resident's quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-Independent with ADLs;
-No behaviors.
Review of the resident's June 2023 through July 2023 progress notes, showed:
-6/19/23 at 7:06 P.M., writing nurse checking on resident following resident to resident altercation. Resident remains irate. DON and Administrator notified. 1:1 also immediately implemented. No injury, no complaints of pain, and resident refused skin assessment. Message left for responsible party. Statement also taken;
-6/19/23 at 10:34 P.M., writing nurse spoke with ER doctor. He/She stated that facility needed to reach out to psychiatrist for PRN order. Resident has appeared to have behaviors;
-6/20/23 at 12:10 A.M., Resident returned from ER via stretcher, accompanied by two attendants. Was seen in ER related to aggressive behavior and Schizophrenia. No new orders written. On 15 minute checks. Observed in room, then sitting in chair outside of room. No behaviors observed at this time;
-6/20/23 at 1:23 P.M., Social Worker (SW) had a one on one discussion with the resident regarding his/her behaviors. He/She said that the resident threw a chair at him/her. SW asked if he/she knew what happened to have made him/her react. He/She doesn't know what happened and they just started fighting. SW informed resident to stay clear from the other resident. He/She apologized to the other resident, and they didn't have any issues anymore.
Review of the resident's care plan, in use at the time of the investigation and last revised on 6/23/23, showed:
-Focus: The resident is/has potential to be physically aggressive related to anger, depression, and poor impulse control. Resident hit another resident for changing channels on TV. Other resident offered to be hit by him/her. Resident hit other resident under the right eye. 6/19/23, resident was in a physical altercation with another resident;
-Goal: The resident will demonstrate effective coping skills through the review date; the resident will not harm self or others through the review date; The resident will seek out staff/caregiver when agitation occurs. The resident will verbalize understanding of need to control physically aggressive behavior;
-Interventions:
-6/19/2023, Residents separated, staff interviewed, and residents interviewed. Resident was put on a 1:1 immediately. Administrator, DON, DHSS notified. Skin assessment completed. Physician notified of incident. Resident was sent out via EMS to hospital. SSD followed up with resident. Psych will follow up with resident. Date Initiated: 6/23/23;
--Both residents separated, both skin and pain assessments performed. Date Initiated: 4/6/23;
-No new interventions after each incident to prevent further incidents or keep the resident or other residents safe. Resident was already receiving psychiatric services prior to the incident.
Review of the resident's MSE notes, showed:
-On 6/16/23, Symptoms: Patient is calm at this time. Smoking in common area. Denies any acute agitation. Stated his/her mood is pretty good. Has some issues with anger with certain staff. Cognition: appeared to comprehend, shared information and responded appropriately to questions. Insight and judgement: impaired as evidenced by decisions of recent past. General: patient aware, alert and oriented. Observation: cooperative. Thought process: mood appropriate and affect appropriate;
-On 6/23/23, Symptoms: Patient said he/she is sleeping well. No hallucinations. Has been agitated on and off. Cognition: appeared to comprehend, shared information and responded appropriately to questions. Insight and judgement: impaired as evidenced by decisions of recent past. General: patient aware, alert and oriented. Observation: groomed, neat, clean appearance. Normal speech rate and rhythm. Thought process: affect appropriate. Assessment: patient has had recent agitation and episodes or irritability. Recently started Aristada (antipsychotic) IM (intramuscular) injections monthly. Will give more time to assess. No current acute agitation;
-On 7/12/23, Symptoms: Patient is resting in bed. He/She is withdrawn and speech non expansive at this time. He/She had recent history of agitation. Easily irritable. No acute distress at this time. Guarded at this time overall, limited informant. Cognition: appeared to comprehend, shared information and responded appropriately to questions. Insight and judgement: impaired as evidenced by decisions of recent past. General: patient aware, alert and oriented. Observation: impoverished/paucity (small or insufficient quantities or amounts). Thought process: flattened (a lack of expression). Assessment: continue current medications. Staff to contact me with any behavioral concerns. PRN Haldol (antipsychotic) for agitation is an active order;
-No mention of resident's behaviors or resident to resident physical altercations.
Review of the facility's investigation, dated 6/19/23, showed:
-Findings: On 6-19-23 at approximately 6:00 P.M., Certified Nurse Aide (CNA) S was on 3 Main and out of his/her eye saw Resident #2 and Resident #19 fighting. CNA S quickly went down to the smoke room to separate the residents. Administrator and DON were notified immediately. Resident #19 said he/she didn't know what happened, they were in an argument then started fighting. Resident #2 said he/she didn't like what Resident #19 said to him/her and they started fighting. Skin assessment was completed on Resident #2 with two nodules noted to the left elbow and right antecubital (the region of the arm in front of the elbow). Resident #2 was sent out per request of the responsible party. Resident #2 returned within an hour and began exhibiting paranoia behavior. Resident #2 was sent out again via EMS for a psychological evaluation. Resident #19 was sent out via EMS for a psychological evaluation and returned later that night. Psych will follow up with Resident #19 on their next visit. Residents were interviewed and feel safe in their environment and know who to report to if they are concerned or feel unsafe;
-Final Intervention:
--Updated care plan;
--Physician notified of incident;
--Resident #19 was sent out via EMS for psychiatric evaluation;
--Resident #2 was sent out via EMS for psychiatric evaluation;
--SSD followed up with both residents;
--Psych will follow up with both residents.
Review of the Resident #2's statement, undated, showed he/she did not like what Resident #19 said to him/her and they started fighting. Resident #19 pushed Resident #2 and then threw a chair at Resident #2. Resident #2's family member was present when the altercation occurred and said Resident #19 started it.
Review of Resident #19's statement, undated, showed he/she did not know what happened. Resident #19 and Resident #2 had a disagreement then just started fighting. Both residents apologized to each other.
Review of Resident #2's family member's hand written statement, undated, showed when he/she arrived in the smoke room, Resident #19 was cursing Resident #2 calling him/her a punk ass bitch and just kept messing with Resident #2. Resident #2 asked Resident #19 to not curse him/her. Resident #19 then pushed Resident #2 in his/her chest and they got to wrestling and throwing chairs. Resident #19 then started punching Resident #2 and they ended up on the floor. Resident #19 hit Resident #2 with the chair and broke it. Then a male employee rushed in and broke them up. Staff took Resident #2 off the floor and then he/she took Resident #2 out in front of the building.
Review of the hand written statement from CNA S, undated, showed CNA S was at the 3 main nurse's station in the corner of his/her eye saw Resident #2 stride across the smoke room floor. CNA S quickly went down to the smoke room and Resident #19 had a chair in his/her hands. Resident #2 was getting up and was trying to pick up a chair. CNA S intervened and separated the resident. Resident #2's family member saw the whole fight. He/she said Resident #19 started the fight.
During an interview on 7/14/23 at 11:20 A.M., Resident #19 said he/she did not know how the fight started. They were having words and the next thing they were fighting. He/she pushed Resident #2 and threw a chair at him/her. Both residents apologized to each other and things are ok now. He/She was just mad at the time.
During an interview on 7/14/23 at 1:30 P.M., CNA S said he/she was standing at the nurse's station and saw Resident #2 fly across the room. Resident #19 was standing there holding a chair, the seat was missing. He/she did not know for sure if Resident #19 hit Resident #2 with the chair, but Resident #2 slid across the floor. Resident #2's family member was standing there when it happened. Resident #2 did not back down, he/she was upset and wanted revenge. CNA S separated the residents and took Resident #2 and his/her family member out to smoke and calm down. He/She had never seen Resident #2 like that before. Staff kept the residents separated for a couple hours to calm down. There is not a list or any place that shows resident triggers. Nurse's deal with the interventions, CNAs do not. As a CNA, he/she just separates the residents and try to calm them down by taking them to smoke, talk to them, get them a soda, get them off the floor/get a change of view.
3. Review of Resident #20's admission Record, showed the resident was originally admitted to the facility on [DATE], with diagnoses that included schizophrenia, depression and epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures).
Review of the resident's quarterly MDS, dated [DATE], showed:
-Moderately cognitively impaired;
-Required supervision of one staff with ADLs;
-No behaviors.
Review of the resident's June 2023 through July 2023 progress notes, showed:
-6/7/23 at 1:30 P.M., Resident reported altercation with another resident. Skin assessment done, no abnormal findings. Reported to DON and Administrator;
-7/10/23 at 12:30 P.M., Resident was involved in a resident to resident altercation. No abnormalities found when skin assessment was performed. All parties notified. Resident denied wanting to go to hospital. Resident separated from other resident and placed on 15 minute checks per Administrator. Staff to monitor resident and document further behaviors.
Review of the resident's Care Plan, in use at the time of the investigation and last revised on 5/7/23, showed:
-Focus: Resident has alteration in thought process related to Schizophrenia. 4/6/23--changing channels in TV room while others watched TV. Another resident spoke to him/her to stop. He/she offered the other resident to hit him/her, which other resident did hitting him/her under the right eye.
-Goal: Resident will remain safe and his needs will be met daily through next review date. Date Initiated:
-Interventions:
-Both residents were separated. Skin and pain assessment performed on 4/6/23;
-Resident sent to ER for evaluation. Notified physician, responsible party, Administrator and DON on 4/6/23;
-Administer medications as ordered. Monitor and document for side effects and
effectiveness;
-Anticipate and meet the resident's needs;
-Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as passing by;
-Encourage the resident to express feelings appropriately;
-Monitor behavior episodes and attempt to determine underlying cause;
-Provide a program of activities that is of interest and accommodates residents
status;
-Reward the resident for positive behavior;
-No new interventions after each incident to prevent further incidents or keep the resident or other residents safe. Resident was already receiving psychiatric services prior to the incident.
Review of the resident's MSE notes, showed:
-On 6/16/23: Symptoms: Patient is disheveled. Said he/she feels locked down and prays a lot. Fleeting suicidal ideation, denies intent. Mood dysphoric (a consistent state of profound unhappiness and dissatisfaction). Cognition: appeared to comprehend, shared information and responded appropriately to questions. Insight and judgement: impaired as evidenced by decisions of recent past. General: patient aware, alert and oriented. Observation: disheveled, withdrawn, paucity. Thought process: depressed, blunted (a decreased ability to express emotion through your facial expressions, tone of voice, and physical movements);
-On 7/12/23: Symptoms: Patient is dysphoric. He/She is very paranoid. Speaks about being robbed, endorses lots of crying. Wished he/she could live at another facility. Suicidal ideation at times. Cognition: appeared to comprehend, shared information and responded appropriately to questions. Insight and judgement: impaired as evidenced by decisions of recent past. General: patient aware, alert and oriented. Observation: patient is aware, alert and oriented. Thought process: depressed, blunted;
-No mention of resident behaviors or resident to resident physical altercations.
Review of the facility's investigation, dated 6/19/23, showed:
-Findings: On 6/7/23 at approximately 1:30 P.M., Resident #20 approached the Assistant Director of Nursing (ADON) and said that Resident #19 had hit him/her. ADON asked Resident #19 about the incident and Resident #19 said Yeah, I beat (his/her) ass and I will do it again. Resident #19 was placed on 1:1 observation and the ADON notified the Administrator and DON. Resident #19 was sent out to the hospital via EMS. Skin assessment was completed on Resident #20 with no abnormalities found. Residents were interviewed and they feel safe in their environment, and know who to report to if they are concerned or feel unsafe. Incident was substantiated based on resident admitting that he/she pushed the other resident due to name calling. He/She understood and should not have done that. Residents are being counseled by SSD and follow up for psychiatric services;
-Final intervention:
--Updated care plan;
--Physician notified of incident;
--SSD followed up with Resident #19;
--Psych will follow up with Resident #19.
Review of the ADON's hand written statement, undated, showed: Resident #20 approached this nurse and reported Resident #19 hit him/her. When investigated, Resident #19 said Yeah I beat (his/her) ass, I'll do it again. Staff also reported Resident #19 threatened them and said I'll have my cousin come up here and beat y'alls ass. Incident reported to Administrator.
During an interview on 7/14/23 at 1:45 P.M., the ADON said she was in her office on the third floor when Resident #20 told her that someone hit him/her. Pain and skin assessments were performed. Resident #19 is a younger resident and does not want to be in a facility. Resident #20 picks on and irritates other residents and Resident #19 is a firecracker. Resident #19 said Resident #20 kept antagonizing and taunting him/her and he/she just got fed up with it. They did exchange punches. Resident #19 had no injury and Resident #20 had an open area to his/her face. The ADON cleaned it and applied triple antibiotic ointment. All physicians and families were notified. Staff separated the residents, the nurse was notified, skin assessments and pain assessments were completed, witness statements were taken, both were placed on checks until one could leave the floor or be sent out. Residents are usually on 15 minute checks until the aggressor is sent out, then the nurse continues 15 minute checks on the other resident until the shift is completed. When the aggressor is sent back, staff do frequent checks and use redirection. For the most part, everyone up on the third floor pretty much can be calmed by buying them a can of soda.
4. Review of Resident #3's admission MDS dated [DATE], showed:
-Cognitively intact;
-Independent with ADLs;
-Diagnoses included: traumatic brain injury (TBI, is an injury that affects how the brain works), anxiety, depression, bipolar disease (a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression)), and post-traumatic stress disorder (PTSD, mental health condition that's triggered by a terrifying event, either experiencing it or witnessing it).
Review of the care plan in use at the time of survey, showed:
-Focus: Resident uses psychotropic (medication that affect a person's mental state) and antidepressant medications related to generalize anxiety disorder (GAD), bipolar and depression;
-Goal: Will be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment;
-Interventions included: monitor/record occurrence of target behavior symptoms pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others and document;
-Focus: Resident has a mood problem related to refusing his/her medications at times;
-Goal: Will have improved mood state;
-Interventions included: Monitor/record/report to Medical Doctor (MD) PRN mood patterns signs and symptoms of depression, anxiety, sad mood as per facility behavior monitoring protocols; Monitor/record/report to MD PRN risk for harming others: increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone, possession of weapons or objects that could be used as weapons; Notify MD/Responsible Party (RP)/Nursing Administration of refusal of medications and treatments; Psych consult as needed;
-No new interventions after each physical altercation to prevent fur
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 F0740
(Tag F0740)
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 follow their policy when staff failed to monitor residents' behavio...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy when staff failed to monitor residents' behavior and/or implement interventions to address the resident behaviors and also update the care plan after resident to resident altercations for eight residents (Residents #3, #16, #28, #27, #2, #19, #20 and #13). The sample was 35. The census was 151.
Review of the facility's Behavior Management policy, undated, showed:
-Policy: The concept of behavior management is an interdisciplinary process. The key components of this process are:
-Identifying residents whose behaviors may pose a risk to self or others;
-Developing individual and practical care strategies based on assessed needs;
-Implementing the behavior management program; and
-Ongoing assessment, monitoring, and evaluation of the effectiveness of the behavior management program including the effectiveness of psychoactive drugs;
-It is important to understand that behavior management is not behavior modification. Behavior management means the interdisciplinary team (IDT) seeks to accommodate the resident with behavioral problems as much as practical in the facility;
-When a resident displays adverse behavioral symptoms (e.g. crying, yelling, hitting, biting, etc.), Licensed Nursing Staff will assess the behavioral symptoms to determine possible causal factors, contact the attending physician, and implement non-drug interventions to alleviate the behavioral symptoms before initiating any psychotherapeutic agent(s);
-When a resident exhibits adverse behavioral symptoms (e.g. crying, yelling, hitting, biting, etc.), Licensed Nursing staff will document the behaviors in the medical record, noting the time the behavior(s) occur, antecedent events, possible casual factors and interventions attempted;
-Upon observing the adverse behavioral symptoms, staff will do the following as indicated:
-Ensure the safety of the resident as well as other residents;
-Document notification of the attending physician;
-Document notification of the resident's family and/or responsible party (RP) about the change in behaviors and the attending physician's response;
-Document the incident on the 24 hour report;
-The Charge Nurse will assign a staff member(s) to monitor/shadow the resident as needed;
-Nursing Staff will continue to monitor the resident's behavior to determine what event(s) if any, precipitated the behavior and document the following information as indicated:
-Date and time of the behavior;
-Location of the resident when the behavior occurred;
-Description of the behavior (e.g. what the resident said or did and if the behavior intensified);
-Non-verbal cues (e.g. darting eyes may indicate anxiety or fear, crossed arms may signal withdrawal or fear, and tears may indicate sadness, frustration or fear); what seemed to cause the behavior; and any interventions used and their effect;
-In assessing the resident for potential causal factors, Licensed Nursing Staff will consider the following factors and document their findings in the medical record:
-Physical conditions (e.g. pain or discomfort, hunger or thirst, fatigue, toileting needs, incontinence);
-Environmental conditions (e.g. inappropriate room temperatures, noise, overcrowding);
-Psychosocial or emotional stressors (e.g., change in resident's customary routine, loneliness, frustration, fear of unknown, possible abuse by staff or other residents, incompatibility with roommate, inability to communicate needs, lack of support system, loss of control due to changes in physical condition, financial concerns);
-In the evaluation of outcomes, Licensed Nursing Staff will do the following:
-Document observations, interventions and outcome;
-Document the resident's progress or lack of progress on the shift/weekly nursing notes and the interdisciplinary notes;
-A Licensed Nurse will summarize the results of the medication and the behaviors on the monthly behavioral summary form;
-Nursing Staff will document the resident's response to medications, including behaviors and side effects on the Medication Administration Record (MAR);
-Update the plan of care as indicated.
1. Review of Resident #3's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/19/23, showed:
-Cognitively intact;
-Independent with activities of daily living (ADLs, grooming, dressing, bathing, ambulation);
-Diagnoses included: traumatic brain injury (TBI, is an injury that affects how the brain works), anxiety, depression, bipolar disease (a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression)), and post-traumatic stress disorder (PTSD, mental health condition that's triggered by a terrifying event, either experiencing it or witnessing it).
Review of the Social Services progress notes, showed on 6/27/23 at 8:41 A.M., the resident attacked another resident. He/She said he/she woke up in a bad mood and missed his/her smoke break so he/she was frustrated.
Review of the progress notes, dated 6/27/23 at 11:16 A.M., showed at 6:45 A.M., the nurse was called to the floor for a resident altercation. Upon entering unit, both parties were standing near the nurse's station. The resident was cursing and yelling at both the other resident and staff, unable to calm down. The resident became aggressive towards staff. The nurse immediately separated both residents and the nurse called 911 for transport to the emergency room (ER) for aggressive behavior. The nurse stayed 1:1 (one designated staff assigned to one resident for monitoring) with the resident until the emergency medical service (EMS, ambulance) transported to the hospital. With his/her aggressive behavior, he/she spoke out names calling staff liars and bitches. When asked why he/she hit the resident, he/she said he/she did not hit the other resident and was protecting himself/herself. The resident was unable to say how he/she was protecting himself/herself. Certified Medication Technician (CMT) called for EMS to transport. Resident quickly got his/her hoodie on and changed from his/her walker to his/her cane.
Review of the care plan, in use at the time of survey and last revised on 5/25/23, showed:
-Focus: Resident uses psychotropic and antidepressant medications related to generalize anxiety disorder (GAD), bipolar and depression;
-Goal: will be/remain free of psychotropic (antidepressants, antianxiety medications, antipsychotics, and stimulants) drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment;
-Interventions included: Monitor/record occurrence of for target behavior symptoms pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others etc. and document;
-Focus: Resident has a mood problem related to refusing his/her medications at times;
-Goal: Will have improved mood state;
-Interventions included:
-Monitor/record/report to Medical Doctor (MD) as needed (PRN) mood patterns signs and symptoms of depression, anxiety, sad mood as per facility behavior monitoring protocols;
-Monitor/record/report to MD PRN risk for harming others: increased anger, labile mood (rapid changes in mood) or agitation, feels threatened by others or thoughts of harming someone, possession of weapons or objects that could be used as weapons;
-Notify MD/RP/Nursing Administration of refusal of medications and treatments;
-The care plan failed to show new interventions to address the incident on 6/27/23.
Review of the Social Service (SS) Assessments, showed a quarterly assessment dated [DATE] was in progress, no other social service assessments were completed.
Review of the SS notes, showed there was no other documentation following the incident on 6/27/23.
Review of the June 2023 MAR, showed:
-An order dated 4/13/23, for behavior monitoring-monitor the resident for behaviors as follows: (enter the specific behaviors) Document Y if resident exhibited behaviors during the shift. Enter a progress note with the resident's specific behaviors and interventions. Document N if the resident didn't exhibit behaviors. Every shift for monitoring;
-Day shift on 6/5, 6/9, 6/15, 6/16 and 6/24/23 left blank;
-Evening shift on 6/9 and 6/15/23 left blank;
-Night shift on 6/2, 6/9, 6/14, 6/15, 6/22 and 6/26/23 left blank.
Review of the electronic medical record (EMR), showed there was no monthly behavioral summary.
During an interview on 7/14/23 at 11:10 A.M., CMT O said the resident had a bad morning, usually he/she was not up that early. He/she was yelling at other residents and the certified nurse aide (CNA) was trying to get the resident to calm down but the resident kept escalating up. He/she was very aggressive. The CMT thought the resident was going to hurt someone. He/She was yelling because another resident had blood on the floor. The resident attacked another resident. The resident went from 0 to 10 real fast. Dr. Strong was called (code used to call more staff to the unit) and the residents were separated. CMT O said if a resident was displaying behaviors, the staff will try to talk to the resident to see what is causing the problem. If needed, staff will separate the residents. If there was an altercation between residents staff don't get in the middle of them. Typically staff remove one of the residents, usually it is not the aggressor, and try to talk that resident into going back to their room. The CMT was not aware of any new interventions put into place after the incident on 6/27/23 occurred to prevent future occurrences.
During an interview on 7/14/23 at 1:45 P.M., the Assistant Director of Nursing (ADON) said a blank on the MAR would mean that item was not documented.
2. Review of Resident #16's quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-Independent with ADLs;
-Diagnoses included: Alzheimer's disease and dementia.
Review of the SS progress notes, showed on 6/27/23 at 8:41 A.M., the resident had an altercation with another resident and was attacked.
Review of the progress notes, showed on 6/26/23 at 11:03 A.M., late entry, at 6:45 A.M., the nurse was called to the floor due to a resident altercation. Upon entering the unit, both residents were standing in the nursing area. The aggressor resident was yelling, cursing and being very belligerent towards both the resident and staff. Both parties immediately separated. The resident was noted with blood to his/her neck and ear on the right side. Skin assessment performed with noted left lateral forehead redness, approximately 4 X 2 inches. Stated he/she was in no pain. Staff assisted escorting him/her to his/her room and applying a cold cloth to his/her ear, noted a small hematoma (bruise) to his/her inner cartilage, mastoid (bone behind the ear) area with laceration approximately ½ inch. When asked what occurred the resident said he/she was standing in the hall when Resident #3 hit him/her throwing him/her on the ground.
Review of the care plan, in use at the time of survey, showed the care plan was not updated to address the incident that occurred on 6/27/23 nor were any new interventions put into place to prevent the incident for reoccurring.
Further review of the SS notes, showed there were no follow up notes following the incident on 6/27/23.
Review of the June 2023 MAR, showed there was no order for behavior monitoring.
Review of the EMR, showed there was no monthly behavioral summary.
3. Review of Resident #28's quarterly MDS, dated [DATE], showed:
-Moderately impaired cognition;
-Independent with transfers and walking in room and in the corridor;
-Diagnoses included: dementia, bipolar disease and schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves).
Review of a progress note, dated 7/9/23, showed at 7:40 A.M., late entry, it was reported by the charge nurse that the resident hit his/her roommate in the mouth due to touching the curtain and hitting his/her head with the curtain. Per the other roommate whom observed the interaction between the two, Resident #27 lost his/her balance falling towards the curtain. Resident #28 walked to the other resident side and hit him/her in the mouth and went back to bed. Resident #28 was moved to another room to avoid further occurrences.
Review of the Mental Status Exam (MSE) note, dated 7/12/23, showed symptoms: Patient was calm on approach, staff note he/she had history of agitation. Patient was in no acute distress, currently participates in activities, redirectable overall;
-Assessment: See new order. (Increase Zoloft (antidepressant) to 50 milligrams (mg) daily for anxiety). Staff to report any issues with increased anxiety or agitation. Continue to monitor.
Review of the care plan, in use at the time of survey and last revised on 4/25/23, showed:
-Focus: Resident has a history of exhibiting behavior problems such as being physically aggressive towards others. Resident has diagnoses of schizophrenia, intellectual disability, bipolar disorder;
-Goal: Resident's behaviors will be managed with medication intervention;
-Interventions: Anticipate and meet resident needs; explain/reinforce why behavior is inappropriate and/or unacceptable to resident;
-Focus: Resident has potential to be physically aggressive to others related to anger, dementia, depression, poor impulse control. Resident hit another resident on 3/27/23;
-Goal: Resident will demonstrate effective coping skills through review date, resident will not harm self or others through next review date, resident will seek out staff/caregiver when agitation occurs through the review date, resident will verbalize understanding of need to control physically aggressive behavior;
-Interventions: Resident was separated from roommate, staff and residents interviewed, notified: primary care provider (PCP), Administrator, Director of Nursing (DON) and Department of Health and Senior Services (DHSS), skin assessment completed, placed on 1:1, date initiated and revision date was 3/28/23;
-The care plan was not updated after the incident on 7/9/23.
Review of the SS notes, showed the last note was written on 12/7/22. There was no other follow up documentation.
Review of the MAR dated 7/1/23 through 7/11/23, showed there was no order for behavior monitoring.
Review of the EMR, showed the last monthly behavior summary was completed on 2/4/2018.
During an interview on 7/14/23 at 12:00 P.M., Licensed Practical Nurse (LPN) P said he/she was not aware of either resident having a prior history of an altercation. He/She would know if a resident had a behavior and what may trigger a behavior by looking at the resident's care plan. The care plan also has interventions to help prevent behaviors. Either SS staff or the MDS Nurse would be responsible for updating the care plan with a new intervention after a resident to resident altercation. The nurses would be responsible for updating SS and the MDS Nurse, but they would also be aware because the nurse has to document the incident in the progress notes. After an incident occurs, staff should document behaviors in the progress notes for three to five days. Behaviors are also documented on the drop down box on the MAR.
4. Review of Resident #27's quarterly MDS, dated [DATE], showed:
- Cognitively intact;
-Independent with ADLs;
-Diagnoses included: progressive neurological condition, dementia and schizophrenia.
Review of the progress notes, showed on 7/9/23 at 7:40 A.M., late entry, reported by charge nurse of the resident being hit in his/her mouth by his/her roommate. Per other roommate who observed occurrence stated Resident #27 stood up, lost his/her balance falling towards the curtain causing the curtain to hit his/her roommate in his/her head. Resident #28 walked around to the resident hitting him/her in the mouth.
Review of the care plan, in use at the time of the survey, showed it was not updated to address the incident that occurred on 7/9/23.
Review of the Social Service Quarterly Assessment, dated 7/7/23, showed: Is behavior tracking in place? Yes.
Review of the MAR, dated 7/1/23 through 7/11/23, showed no order for behavior monitoring.
Review of the EMR, showed there were not monthly behavioral summaries.
5. Review of Resident #2's admission Record, showed the resident was admitted to the facility on [DATE], with diagnoses that included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), schizophrenia (breakdown in relation between thought, emotion and behavior leading to faulty perception, inappropriate actions and feelings), generalized anxiety disorder, unsteadiness on feet, and cognitive communication deficit (difficulty with any part of communication (memory, attention, organization, planning, and problem solving) that is affected by a disruption of the cognitive processes).
Review of the resident's quarterly MDS, dated [DATE], showed:
-Moderate cognitive impairment;
-Independent with ADLs;
-No behaviors.
Review of the resident's May 2023 through July 2023 progress notes, showed:
-6/1/23 at 5:20 A.M., Resident involved in altercation with roommate. Resident said the roommate touched him/her and threw him/her onto floor. Assessed holding left elbow and rubbing left side. No noted bruising or swelling at the time of assessment. Complaints of discomfort. PRN pain medication given. Resident went to room and laid down. Resident monitored;
-6/9/23 at 11:55 A.M., IDT Risk: Resident was accused of choking his/her roommate. Resident was put on 1:1 immediately. The Administrator and DON were notified. Physician notified. Resident was interviewed stating his/her roommate was coming on his/her side of the room and messing with the resident's items. Resident told the roommate to stop touching his/her items. Roommate then came to him/her hitting the resident on his/her arm. Resident said that he/she never touched his/her roommate. Skin assessment performed with no concerns found. Other residents interviewed with feel safe in their environment;
-6/15/23 at 10:43 A.M., Social Worker had a one on one discussion with the resident regarding his/her resident to resident altercation. The resident said the roommate was invading his/her privacy. He/She denied hitting the other resident. Social Worker informed the resident if he/she was having any problems to report it to staff;
-6/19/23 at 7:04 P.M., Writing nurse checking on resident following resident to resident altercation. Resident remains irate. DON and Administrator notified. 1:1 also immediately implemented. No injury noted. No complaints of pain. Resident refused skin assessment. RP made aware and would like to send resident to the hospital. Statement also taken;
-6/19/23 at 10:36 P.M., Resident returned within one hour from ER with no new diagnosis. No x-rays were done. Writing nurse notified DON. Resident continues to have irate behaviors along with hallucinations. Resident pacing up and down the hall having verbal altercations with staff and other residents. Writing nurse continues to redirect and continues 1:1 with resident. New order to send resident back to ER;
-6/20/23 at 1:30 A.M., Resident transferred to hospital for psychiatric evaluation. Aggressive bizarre behavior while police were on the premises to accompany EMT with transfer. Resident exhibiting paranoia. Police officer had to assist EMT to place on stretcher inside of ambulance. Once the resident was inside the ambulance, one police officer remained in the back of the ambulance to transport to the hospital;
-6/20/23 1:30 P.M., SS had a one on one discussion with the resident regarding his/her behavior. The resident said he/she didn't like what the other resident said to him/her and they started fighting. He/She said the other resident threw the chair at him/her. He/She doesn't know how to control his/her anger issues at times. He/She said the police could not even get him/her calm. The resident said since he/she went to the hospital, he/she feels better. He/She said he/she just doesn't know what happened. Both residents apologized to each other.
Review of the resident's care plan, in use at the time of the investigation and last revised on 6/23/23, showed:
-Focus: Resident has the potential to have physically aggressive episodes related to anger, dementia, and poor impulse control. Resident had an occurrence with another resident on 2/16/23, 6/1/23 and 6/19/23;
-Goals: The resident will demonstrate effective coping skills. The resident will not harm self or others. The resident will seek out staff/caregiver when agitation occurs. The resident will verbalize understanding of need to control physically aggressive behavior;
-Interventions:
-6/1/23, Resident had an altercation with his/her roommate. Administrator, DON, physician, RP and DHSS notified. Residents and staff interviewed and skin assessment performed. Resident was placed on 1:1 with staff. Psychiatrist and Social Worker to follow up with resident. Date Initiated: 6/12/23;
-6/19/23: Resident in a physical altercation with another resident. Residents separated, staff interviewed and residents interviewed. Administrator, DON, physician and DHSS notified. Skin assessment completed. Resident was sent out to hospital via EMS. Social Services Director (SSD) and psychiatric services followed up with resident. Date Initiated: 6/23/23;
-Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. Monitor, document PRN any signs or symptoms of resident posing danger to self and others.
-Psychiatric/Psychogeriatric consult as indicated;
-Resident's triggers for physical aggression are others being in his/her area, too close to him/her or intruding on his/her privacy. Resident's behaviors is de-escalated by monitoring his/her area;
-Residents separated (no date). Physician, responsible party, all nursing administration and DHSS notified. Skin and pain assessments performed. Resident placed 1:1 care. EMS called for transport to ER for evaluation and treatment. Resident was moved to another floor. Date Initiated: 2/22/23;
-Focus: Resident has impaired cognitive function, dementia, difficulty making decisions, impaired decision making and short term memory loss;
-Goals: Resident will be able to communicate basic needs on a daily basis. Resident will remain oriented to person, place, situation. Resident will maintain current level of cognitive function.
-Interventions:
-Ask simple yes/no questions in order to determine the resident's needs;
-Communication: Use Resident's preferred name. Identify yourself at each interaction;
-Resident needs supervision/assistance with decision making;
-Use task segmentation to support short term memory deficits. Break tasks into one step at a time.
Review of the resident's MSE notes, showed:
-On 6/9/23, Symptoms: Patient is out in day room. Calm on approach. Listening to the radio. Content and pleasant. Cognition: appeared to comprehend, shared information and responded appropriately to questions. Insight and judgement: impaired as evidenced by decisions of recent past. General: patient aware, alert and oriented. Observation: disheveled and cooperative. Thought process: some latency (delay) in thought process, mood appropriate, and affect appropriate;
-On 6/16/23, Symptoms: Patient is calm at this time. Denies any hallucinations. Oriented times three. Appears content. Cognition: appeared to comprehend, shared information and responded appropriately to questions. Insight and judgement: impaired as evidenced by decisions of recent past. General: patient aware, alert and oriented. Observation: groomed, neat, clean appearance. Cooperative. Thought process: mood appropriate and affect appropriate;
-On 6/23/23, Symptoms: Staff requested patient be seen weekly at this time. Patient is calm and pleasant. No agitation reported. Out in common area with peers. Oriented to self and situation. No acute agitation. Cognition: appeared to comprehend, shared information and responded appropriately to questions. Insight and judgement: impaired as evidenced by decisions of recent past. General: patient aware, alert and oriented. Observation: groomed, neat, clean appearance. Cooperative. Thought process: mood appropriate and affect appropriate;
-On 7/12/23: Symptoms: Patient said he/she is feeling good and denies any distress, but staff stated he/she is not sleeping well. He/She spoke about enjoying activities at the facility. Affect is currently pleasant. Memory is limited. Poor informant. Cognition: had difficulty responding to generalized and/or open-ended questions. Insight and judgement: impaired as evidenced by decisions of recent past. General: patient aware. Observation: groomed, neat, clean appearance. Labile (emotions that are easily aroused or freely expressed, and that tend to alter quickly and spontaneously; emotionally unstable), agitated at times;
-No mention of resident behaviors or resident to resident altercations.
Review of the June 2023 MAR, showed there was no order for behavior monitoring.
Review of the July 2023 MAR, showed there was no order for behavior monitoring.
Review of the EMR, showed there were no monthly behavioral summaries.
6. Review of Resident #19's admission Record, showed the resident was admitted to the facility on [DATE], with diagnoses that included paranoid schizophrenia (characterized by predominantly positive symptoms of schizophrenia, including delusions and hallucinations), generalized anxiety disorder.
Review of the resident's quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-Independent with ADLs;
-No behaviors.
Review of the resident's June 2023 through July 2023 progress notes, showed:
-6/19/23 at 7:06 P.M., writing nurse checking on resident following resident to resident altercation. Resident remains irate. DON and Administrator notified. 1:1 also immediately implemented. No injury, no complaints of pain, and resident refused skin assessment. Message left for RP. Statement also taken;
-6/19/23 at 10:34 P.M., writing nurse spoke with ER doctor. He/She said the facility needed to reach out to psychiatrist for PRN order. Resident has appeared to have behaviors;
-6/20/23 at 12:10 A.M., Resident returned from ER via stretcher, accompanied by two attendants. Was seen in ER related to aggressive behavior and schizophrenia. No new orders written. On 15 minute checks. Observed in room, then sitting in chair outside of room. No behaviors observed at this time;
-6/20/23 at 1:23 P.M., Social Worker had a one on one discussion with the resident regarding his/her behaviors. He/She said the resident threw a chair at him/her. Social Worker asked if he/she knew what happened to have made him/her to react. The resident said he/she doesn't know what happened and they just started fighting. Social Worker informed resident to stay clear from the other resident. He/She said he/she apologized to the other resident, and they didn't have any issues anymore.
Review of the resident's Care Plan, in use at the time of the investigation and last revised on 6/23/23, showed:
-Focus: The resident is/has potential to be physically aggressive related to anger, depression, and poor impulse control. Resident hit another resident for changing channels on TV and resident offering the other resident to be hit by him/her. Resident hit other resident under the right eye. 6/19/23 resident was in a physical altercation with another resident;
-Goal: The resident will demonstrate effective coping skills. The resident will not harm self or others. The resident will seek out staff/caregiver when agitation occurs. The resident will verbalize understanding of need to control physically aggressive behavior;
-Interventions:
-Both residents separated, both skin and pain assessments performed. Date Initiated: 4/6/23;
-Resident was sent ER for evaluation. Physician, RP, Administrator and DON notified. Date Initiated: 5/7/23;
-6/19/2023: Residents separated, staff interviewed, and residents interviewed. Resident was put on a 1:1 immediately. Administrator, DON, DHSS notified. Skin assessment completed. Physician notified of incident. Resident was sent out via EMS to hospital. SSD followed up with resident. Psych will follow up with resident;
-No new interventions after each incident to prevent further altercations or to keep the resident and other residents safe. Resident was already receiving psychiatric services prior to the incidents.
Review of the resident's MSE notes, showed:
-On 6/16/23: Symptoms: Patient is calm at this time. Smoking in common area. Denies any acute agitation. Stated his/her mood is pretty good. Has some issues with anger with certain staff. Cognition: appeared to comprehend, shared information and responded appropriately to questions. Insight and judgement: impaired as evidenced by decisions of recent past. General: patient aware, alert and oriented. Observation: cooperative. Thought process: mood appropriate and affect appropriate;
-On 6/23/23: Symptoms: Patient said he/she is sleeping well. No hallucinations. Has been agitated on and off - having Cognition: appeared to comprehend, shared information and responded appropriately to questions. Insight and judgement: impaired as evidenced by decisions of recent past. General: patient aware, alert and oriented. Observation: groomed, neat, clean appearance. Normal speech rate and rhythm. Thought process: affect appropriate. Assessment: patient has had recent agitation and episodes or irritability. Recently started Aristada (antipsychotic) IM (intramuscular) injections monthly. Will give more time to assess. No current acute agitation;
-On 7/12/23: Symptoms: Patient is resting in bed. He/She is withdrawn and speech non expansive at this time. He/She had recent history of agitation. Easily irritable. No acute distress at this time. Guarded at this time overall, limited informant. Cognition: appeared to comprehend, shared information and responded appropriately to questions. Insight and judgement: impaired as evidenced by decisions of recent past. General: patient aware, alert and oriented. Observation: impoverished/paucity (small or insufficient quantities or amounts). Thought process: flattened (a lack of expression). Assessment: continue current medications. Staff to contact me with any behavioral concerns. PRN Haldol (antipsychotic) for agitation is an active order;
-No mention of resident behaviors or resident to resident physical alte[TRUNCATED]
Mar 2023
5 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
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** See the deficiencies cited at Event ID MEES12.
Based on observation, interview and record review, the facility failed to provide...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** See the deficiencies cited at Event ID MEES12.
Based on observation, interview and record review, the facility failed to provide nutritional support, provide meal preferences and follow their weight policy guidelines and physician orders for Resident #12, who had an unplanned weight loss. The facility also failed to re-weigh Resident #30 when the resident had a substantial weight gain. The sample was 26. The census was 136.
Review of the facility's Nutritional (Impaired)/Unplanned Weight Loss, Revised September, 2017, showed:
Assessment and Recognition:
- The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time;
-The staff and physician will define the individual's current nutritional status (weight, food/fluid intake, and pertinent laboratory values) and identify individuals with anorexia (lack or loss appetite for food), weight loss or gain, and significant risk for impaired nutrition; for example, high risk residents with acute symptoms such as vomiting, diarrhea, fever and infection, or those taking medications that may be causing weight gain or increasing the risk of anorexia or weight loss;
-The physician will consider whether any assessment including additional diagnostic testing is indicated to help clarify the severity or consequences of weight loss and/or impaired nutrition;
-No lab tests are sensitive or specific enough for defining nutritional status that they should be ordered for everyone. Lab tests should be ordered if they are likely to substantially help establish current status or prognosis, causes or choices of interventions; otherwise, routine ordering to assess or follow nutritional status is not generally indicated;
-The staff will report to the physician significant weight gains or losses or any abrupt or persistent change in baseline appetite or food intake.
Cause and identification:
-The physician will review for medical causes of weight gain, anorexia and weight loss before ordering interventions;
-For individuals with recent or rapid weight gain or loss (for example, more than a pound a day), the staff will review for possible fluid and electrolyte imbalance as a cause;
-Conditions such as heart failure and renal failure can cause rapid weight gain and fluid deficits can result in rapid weight loss (2.2 pounds (lbs.) gained or lost for each liter of fluid excess or deficit).The physician, with the help of the multidisciplinary team, will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss;
-The physician will help identify medical conditions (cancer, cardiac or renal disease, depression, dental problems, etc.) and medications that may be causing weight gain or loss or increasing risk for either gaining or losing weight;
-Many categories of diseases and medications can affect appetite directly or indirectly by affecting taste or causing lethargy, confusion, and dry mouth;
-The physician will review carefully, and rule out medical causes of, oral or swallowing problems before authorizing other consults or interventions to modify diet consistency;
-Sometimes, an extensive workup may not be appropriate or knowing the cause may not change the interventions. Nevertheless, a systematic review for causes based on an individual's history, comorbidities (having more that one diseases at the same time) risk factors, may be appropriate even if an extensive workup is not. Persistent change from baseline appetite or food intake;
-The physician will review and rule out medical causes of oral or swallowing problems before authorizing other consults or interventions to modify diet consistency;
-A physician should define and differentiate basic causes of apparent swallowing or choking problems; other disciplines may be trained to treat symptoms but not to identify a differential diagnosis;
-The physician (or staff, based on a discussion with the physician) will document relevant medical information regarding the nature, severity, causes, and consequences of impaired nutritional status, especially in complex situations such as where multiple causes coexist.
Treatments:
-The staff and physician will identify pertinent interventions based on identified causes and overall resident condition, prognosis, and wishes;
-Treatment decisions should consider all pertinent evidence and relevant issues (e.g., food intake, resident wishes, overall condition and prognosis, etc.), and should not be based solely on lab or diagnostic test results (albumin (protein in the blood), cholesterol, swallowing studies.);
-The physician will authorize appropriate interventions, as indicated;
-This may include tapering, stopping, or switching medications known to be associated with undesirable weight gain or anorexia or weight loss.
Treatment and management:
-The physician will document if cause-specific interventions could not be identified or are not feasible;
-The staff and physician will review and consider existing dietary restrictions and modified consistency diets;
-Dietary restrictions are not always essential, and they may even be unnecessary or harmful. In some instances, the risk of continued weight loss and hydration deficits may outweigh other considerations that such restrictions are meant to address;
-The physician will limit prescribing of appetite stimulants to situations in which underlying causes cannot be identified or treated, other pertinent interventions have not worked or are not feasible, these medications have a valid indication, and improving appetite and weight is consistent with the individual's condition, prognosis, and wishes;
-A pertinent assessment and meaningful review of possible medical and non-medical causes of altered nutritional status should precede the use of such medications.
Monitoring:
-The physician and staff will monitor nutritional status, an individual's response to interventions, and possible complications of such interventions (for example, additional weight gain or loss, nausea, or vomiting);
-When medical conditions or medication-related adverse consequences are causing or contributing to altered nutritional status, the physician and staff will collaborate in adjusting interventions, taking into account the status of those causes and the resident responses, goals, wishes, prognosis, and complications.
Review of the facility's Assessment and Management of Residents' Weights policy, revised June, 2020, showed:
Purpose: To ensure that each resident maintains acceptable parameters of weight and nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible based on the resident's comprehensive assessment. To ensure that a resident receives a therapeutic diet when there is a nutritional problem;
Policy: Weights are obtained upon admission and/or re-admission, then weekly for four weeks and monthly thereafter. Additional weights may be obtained at the discretion of the licensed nurse or the interdisciplinary team (IDT);
Procedure:
-A licensed nurse or designee will weigh residents:
-Admissions and re-admissions will be weighed on the shift they arrive;
-Hospital weight will not serve as admission or re-admission weight;
-Adaptive or assistive equipment used during measurement will be documented;
-If the weight is less than or greater than 5 lbs. (pounds) from the previous weight, immediately re-weigh and have a licensed nurse verify the accuracy of the weight;
-Weights will be entered into the clinical record on that shift.
1. Review of Resident #12's, admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/6/23, showed:
-admission date, 12/2/22;
-Requires supervision, oversight, encouragement or cueing with eating;
-Diagnosis included anemia (low red blood cells in the blood), heart failure, gastroesophageal reflux disease (a chronic digestive disease that occurs when stomach acid flows into the esophagus (a canal in the body that transports food from the mouth to the stomach) and causes irritation of the lining), diabetes, anxiety, depression and schizophrenia (a mental disorder where reality is perceived abnormally);
-No rejection in care.
Review of the residents care plan, in use at the time of survey, showed:
Problem: The resident has a nutritional problem or potential nutritional problem related to diet restrictions and obesity;
Interventions: Provide diet as served; Registered Dietician (RD) to evaluate and make dietary changes and recommendations as needed (PRN); Weigh at the same time of the day and record.
Review of the resident's progress notes showed:
-On 1/23/23 at 12:30 P.M.; resident sent to the hospital for right ankle being swollen and increased pain;
-On 1/27/23 at 10:12 P.M. returned from the hospital per stretcher. Resident had repair of an ankle fracture related to an unwitnessed fall.
Review of the resident's physician order sheets (POS) dated March 2023, showed:
-An order, dated 1/27/23, for weights to be done and recorded monthly;
-An order, dated 1/27/23, for regular diet, mechanical soft, regular consistency.
Review of the resident's weights, showed:
-12/16/22: 143.2 lbs;
-1/5/23: 140.0 lbs;
-No re-admission weight;
-February 2023: no weight;
-3/8/23: 132.8 lbs.
Review of the resident's RD nutritional assessment dated [DATE], showed:
-At risk for weight loss;
-Supplements: ferrous sulfate (iron);
-Eating patterns: blank;
-Food groups or foods refused; meat: blank; dairy: blank; fruit and vegetables: blank; bread or cereal: blank; fluids: blank;
-Food preferences: blank.
Observation and interview on 3/28/23 at approximately 11:00 A.M., showed the resident in bed. He /She appeared pale and spoke in a very soft, weak voice. He/She had on a hospital gown with dried food particles on it. The resident said the food was gross, he/she just tries to eat what they give him/her. He/She is never offered anything different when he/she doesn't eat. Staff just take the food tray away. The resident said he/she loves cola to drink, fresh fruits and vegetables but never receives any on his/her tray.
During an interview on 3/28/23 at 11:23 A.M. and 3/30/23 at 9:00 A.M., Certified Nursing Assistant (CNA) A said that the second floor was a dementia unit and no menu or menu choices are provided to that resident population. There used to be a menu posted but it is no longer there. If a resident refuses to eat, the staff should be providing something else in place but sometimes that will take a while to get from the kitchen. He/She has noticed residents losing weight on the second floor and has been trying to feed those residents. The restorative aide is the person responsible for obtaining weights and informing the nurse if there is a weight loss or gain.
Observation and interview on 3/30/23 at approximately 9:00 A.M., showed the resident in his/her bed with his/her tray table partially pushed away from him/her. He/She ate the toast and oatmeal but did not consume the scrambled eggs. He/She said he/she does not like eggs.
2. Review of Resident #30's quarterly MDS, dated [DATE], showed:
-admission date: 12/6/22;
-Cognitively impaired;
-Required limited assistance with eating;
-Diagnoses that included heart disease, anemia and stroke.
Review of the resident's care plan, in use at the time of survey, showed:
Focus: Resident has a nutritional problem or potential nutritional problem related to anorexia, weight loss and loss of appetite;
Interventions: Provide and serve supplements as ordered; Provide, serve and assist with meals; RD to evaluate and make dietary recommendations PRN.
Review of the resident's weights, showed:
-1/9/23:130.0 lbs.;
-2/22/23: 126.2 lbs.;
-3/8/23: 191.2 lbs.;
-No re-weight obtained.
3. During an interview on 3/30/23 at 8:46 A.M. and 3/31/23 at 9:19 A.M., the facility RD said he/she reviews the weights when he/she comes into the building. He/She was not able to see all the residents who needed to be seen the last time he/she visited the facility. Ideally the facility nursing staff should notify the dietician when a resident has had some weight loss, and he/she would provide some type of recommendations, and the facility nursing staff would then call the physician for orders. The resident's preferences should be listed on the resident's meal card and the dietary manager usually will interview the resident for specific preferences. The RD can also obtain meal preferences and pass them onto the dietary manager. All residents are expected to be offered alternatives if they do not like what is on the menu. The residents should be re-weighed immediately when a weight discrepancy is found. Resident #30's weight gain was likely an error in obtaining the weight.
4. During an interview on 3/30/23 at 10:35 A.M., the Dietary Manager said he interviews all the new admissions for meal preferences. He did not have any meal preferences listed for Resident #12 and was not aware he/she had any preferences. The resident was probably admitted before he started working at the facility. There are no menus posted for the residents. Staff should call the kitchen and request a second choice or a cheese sandwich. Second choices include chicken tenders and hamburgers. The second choices are offered every other week (rotating) because when one resident sees, for an example, a hamburger, then the whole floor wants a hamburger. Residents with weight loss are discussed in the morning meetings with members of the management team.
5. During interviews on 3/30/23 at 10:45 A.M. and 1:45 P.M. the Director of Nursing (DON) said weights are expected to be completed by nursing staff on admission, readmission and by the fifth of every month. The nursing management team reviews the monthly weights. Nursing staff are expected to contact the dietician and physician (MD) for further orders, such as supplements. Staff are expected to offer alternatives to residents who are not eating. Staff are expected to re-weigh the resident immediately if possible, when a discrepancy is noted. The dietary manager is responsible to interview the residents for food preferences. For Resident #30, the DON thought the resident was probably weighed with the leg rests on the wheelchair.
6. During an interview on 3/31/23 at 9:08 A.M., with Regional Nurse Consultant said the DON and the dietician are expected to review the monthly weights.
MO00214071
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
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** See the deficiencies cited at Event ID MEES12.
Based on observation, interview and record review, the facility failed to follow ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** See the deficiencies cited at Event ID MEES12.
Based on observation, interview and record review, the facility failed to follow their policy when staff failed to maintain continuous positive airway pressure (CPAP, machine that uses mild air pressure to keep breathing airways open while you sleep) and bilevel positive airway pressure (BiPap, a machine that delivers two levels of air pressure to keep breathing airways open while you sleep) equipment by not providing distilled water for the humidifier chamber for two of two sampled residents (Resident #28 and Resident #17). The census was 136.
Review of the facility's CPAP/BiPap Support policy, dated 3/2015, showed the following:
-Purpose:
1. To provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen;
2. To improve arterial oxygenation in residents with respiratory insufficiency, obstructive sleep apnea (occurs when your breathing is interrupted during sleep, for longer than 10 seconds at least 5 times per hour (on average) throughout your sleep period) or restrictive/obstructive lung disease;
3. To promote resident comfort and safety;
-Humidifier:
a. Use clean, distilled water only in the humidifier chamber.
1. Review of Resident #28's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/20/23, showed the following:
-Clear speech;
-Ability to express ideas and wants: Understood;
-Ability to understand others: Understood;
-Mildly cognitively impaired;
-Diagnoses included chronic obstructive pulmonary disease (COPD, lung disease), dependence on oxygen and shortness of breath.
Review of the resident's care plan, dated 2/8/23, showed the following:
-Focus: The resident has oxygen therapy. CPAP as ordered. The resident needed to be encouraged to place his/her CPAP on while resting in bed;
-Interventions: Remind and assist with nasal cannula with proper placement;
-Give medications as ordered by physicians;
-No documentation on how to use or clean equipment.
Review of the resident's electronic physician's order sheet (ePOS), showed an order, dated 9/21/21, for CPAP used daily when at sleep.
Review of the resident's electronic medication administration record (eMAR), showed an order, dated 9/26/21, to clean CPAP with soap and water. Remove tubing and allow to soak in warm water. Allow to air dry. Wipe face mask and head gear with soap and water, allow to air dry.
Observation on 3/28/23 at 1:00 P.M. showed the following:
-A CPAP machine on the floor beside the bed with an empty humidifier chamber;
-An empty gallon container of distilled water on the table in front of the bed.
Observation on 3/29/23 at 10:15 A.M, showed the following:
-A CPAP machine on the table in front of the bed. The humidifier chamber was empty;
-An empty gallon of distilled water on the table in front of the bed.
During an interview on 3/29/23 at 10:20 A.M., the resident said he/she had not been given distilled water for over a month. He/she asked different staff and had been told they did not have any or they did not have time to get it for him/her. He/she was using tap water for it, but he/she knew this was not good for it.
2. Review of Resident #17's annual MDS, dated [DATE], showed the following:
-Clear speech;
-Ability to express ideas and wants: Understood;
-Ability to understand others: Understood;
-Mildly cognitively impaired;
-Diagnoses included obstructive sleep apnea and shortness of breath.
Review of the resident's ePOS, showed an order, dated 12/14/17, for BiPap on at bedtime.
Review of the resident's care plan, dated 2/17/23, showed the following:
-Focus: The resident has been prescribed BiPap with settings;
-Interventions: Educate resident on the purpose of BiPap machine. BiPap at night. Encourage resident to use BiPap. If resident refuses to use BiPap machine at night, document amount of time was worn, tolerance of machine during treatment, oxygen saturation, condition of resident's skin changes in level of consciousness, education provided and his/her response. Inform physician/nurse practitioner;
-No documentation on how to use or clean equipment.
Observation on 3/28/23 at 1:05 P.M., showed the resident's BiPap machine on his/her dresser, with an empty humidifier chamber.
Observation on 3/29/23 at 10:20 A.M., showed the resident's BiPap machine on his/her dresser, with an empty humidifier chamber.
During an interview on 3/29/23 at 12:00 P.M., the resident said staff often run out of distilled water or give the last gallon to his/her roommate. He/She was having problems with his/her roommate and he/she would not share the water. If they do not have the distilled water, he/she will just run the machine without any water or will not use it at all.
During an interview on 3/29/23 at 10:00 A.M., Certified Medication Technician (CMT) C said they kept distilled water in the supply room adjacent to the nurse's station. When asked if he/she could show the surveyor extra water, he/she was unable to locate any. CMT C said if they ran low, they usually filled out a central supply list, and someone from central supply would pick it up and bring up what they needed. He/She did not know when the water was last ordered. CMT C thought he/she had given the residents a gallon of distilled water a couple of weeks ago.
Review of the central supply lists provided by the facility on 3/30/23, showed:
-Staff should have the list ready by 10:00 A.M.;
-An area designating the floor requesting items;
-An area for the date items were requested;
-A note to check their supply closet first before ordering;
-A check list of items staff could request;
-An area labeled miscellaneous where staff could write items not labeled on the list, such as distilled water;
-Lists filled out by staff from Resident #28 and Resident #17's floor, showed no requests for distilled water from February 2023 through March 2023.
During an interview on 3/30/23 at 8:25 A.M., the Central Supply Clerk said he/she did not remember the staff on the residents' floor requesting distilled water recently but someone could have come down and gotten it themselves. Usually they put it on the supply list and she picked the list up in the morning and brought the supplies up later in the day. She had several gallons of distilled water in the supply room. She did not know why staff would not provide it to the residents if they needed it.
During an interview on 3/30/23 at 11:30 A.M., the Director of Nursing said she expected nursing staff to know there was no distilled water on the unit for the residents and to have ordered more from central supply when it ran low. If the residents were asking for distilled water, then staff should have known there was not any in the storage room. The residents should not use tap water for the CPAPs and BiPaps because this could damage the equipment. The staff should have stored the distilled water at the nurse's stations with the residents' names on it.
During an interview on 3/30/23 at 11:30 A.M., the Administrator said the staff should have provided the residents with distilled water for their CPAP and BiPap machines. If they ran out, they should have ordered more from central supply.
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
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** See the deficiencies cited at Event ID MEES12.
Based on observation, interview and record review, the facility failed to provide...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** See the deficiencies cited at Event ID MEES12.
Based on observation, interview and record review, the facility failed to provide a safe, clean and comfortable, homelike environment. The facility failed to unclog sinks in resident rooms, failed to fix broken closet doors, water fountains, shower faucets and repair damaged ceiling tiles. The sample size was 26. The census was 136.
1. Review of Resident #34's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/8/23, showed the resident was cognitively intact.
Observation of Resident #34's room on 3/28/23 at 9:00 A.M., showed when he/she turned the cold water handle in his/her sink, no water came out.
During an interview, the resident said he/she reported the cold water problem to staff a few times but nothing had been done.
2. Review of Resident #32's quarterly MDS, dated [DATE], showed the resident was admitted on [DATE] and was cognitively intact.
Observation of Resident #32's room on 3/29/23 at 10:25 A.M., showed the sink was half full of standing water. The water was a brownish color and would not drain out of the sink.
During an interview on 3/29/23 at 10:25 A.M., the resident said the sink had been stopped up since he/she had arrived at the facility. He/She wished he/she could wash his/her hands or brush his/her teeth in his/her room.
3. Observation of room [ROOM NUMBER] on 3/29/23 at 10:35 A.M., showed the sink was stopped up and filled with brownish water. The water would not drain out of the sink.
4. Observation of room [ROOM NUMBER] on 3/29/23 at 10:38 A.M., showed both closet doors off the track and pushed back against the front of the closet.
5. Review of Resident #28's quarterly MDS, dated [DATE], showed the resident was cognitively intact.
Observation of Resident #28's room on 3/29/23 at 10:40 A.M., showed the closet door adjacent to the entry door, with the sliding vinyl door torn from the hanging latches.
During an interview on 3/29/23 at 10:40 A.M., the resident said he/she was moved to this room a couple of months ago and the closet door was like that when he/she was moved to the room. He/She made complaints about it to staff, but it did not do any good because nothing was done.
6. Observation on 3/29/23 at 11:45 A.M., showed the 300 hall men's shower room had a push button sink faucet. Upon pushing down on the button, water did not exit from the spout. Water exited from the sink's push button and ran around the sink.
7. Observation on 3/29/23 at 11:55 A.M., showed the 300 hall men's bathroom had a push button sink faucet. Upon pushing down on the button, water did not exit from the spout. Water exited from the sink's push button and ran around the sink.
8. Observation on 3/29/23 at 12:00 P.M., of room [ROOM NUMBER], showed the sink half-full of brownish water.
During an interview on 3/29/23 at 12:05 P.M., Certified Nurse's Aide (CNA) I said this resident's room sink had been stopped up for months. CNA I had filled out a request for maintenance several times and put it in the box, but no one had fixed it yet.
9. Observation of the staff lounge area on 3/30/23 at 6:45 A.M., showed a 1 1/2 foot by 1 1/2 foot missing ceiling tile, adjacent to the entry wall, which exposed pipes in the ceiling. The door was open to the hallway and accessible to residents.
During an interview on 3/30/23 at 12:30 P.M., Certified Nurses Aide K said the tile had been missing in the staff lounge for weeks.
10. Review of Resident #35's quarterly MDS, dated [DATE], showed the resident was cognitively intact.
Observation and interview on 3/30/23 at 7:35 A.M., showed the resident stood near the sink in his/her room. The sink basin was filled approximately halfway with water. The water was brownish in color. The resident said maintenance would come fix the sink and then it would back up again. This had been happening for four to five months. Administration knows there are problems with the sinks backing up but do not make the necessary repairs. They plunge the sink or they move people from room to room, but it does not change the problems with the plumbing. The sinks keep backing up again. He/She pointed to a blanket over his/her window. The blanket was wet all along the bottom of the window. The paint was peeling around the window where the water had damaged the wood. The resident said the window leaked when it rained and he/she used the blanket to keep the water from getting on his/her floor. He/She had been telling maintenance for over a year that water was leaking in his/her window.
11. Observation on 3/30/23 at 7:00 A.M. of the first floor resident use shower room, adjacent to room [ROOM NUMBER], showed two shower stalls. The handle in the shower stall closest to the back wall was broken off, which would not allow the water to be turned on.
Review of Resident #33's quarterly MDS, dated [DATE], showed the resident was cognitively intact.
During an interview the resident said the shower handle had been broken for months. It was frustrating because there were a lot of residents on the first floor and only one person could use the shower room at a time.
Review of a repair requisition located in the request bin, on the 100 hall nurses' station on 3/30/23 at 7:25 A.M., showed a request for a repair dated 11/17/22, for the south wing restroom with the two showers, to increase the water pressure and please repair the shower handle. It had been broken for years and it would be good if it worked again.
12. Observation on 3/30/23 at 7:45 A.M., showed the water fountain by the 100 hall nurses' station out of order and covered with a black plastic bag.
During an interview on 3/30/23 at 7:50 A.M., a resident who wished to remain anonymous, said the water fountain had not been working for months.
13. Observation on 3/30/23 at 10:20 A.M., of room [ROOM NUMBER]'s door, showed a 12 inch by 2 inch piece of missing wood at the top of the door, with exposed screws.
14. Observation on 3/30/23 at 10:15 A.M., of the 300 hallway, adjacent to room [ROOM NUMBER], showed a 1 1/2 foot by 1 1/2 foot ceiling tile was covered with rust-colored discoloration and blackened and greenish areas. The ceiling tile bulged down the middle with water damage and had cracks along the sides.
15. During an interview on 3/29/23 at 11:00 A.M., Housekeeper J said he/she has reported the stopped up sinks to maintenance. He/She did not know why they have not been fixed. He/She reports things when he/she sees the maintenance person on the floor. Sometimes if an issue is small, he/she just tries to fix it him/herself. There is just so much the maintenance person can do alone.
16. During an interview on 3/29/23 at 11:05 A.M., Certified Medication Technician (CMT) C said he/she fills out a repair slip for maintenance and they are supposed to come around and get them, but they don't always get around to collect them. They fix the sinks and then they get stopped up again. This continues to be a problem.
17. During an interview on 3/29/23 at 8:45 A.M. the Maintenance Director said he started working at the facility at the end of January. He conducts environmental rounds daily. He is the only maintenance person for the entire building. He makes repairs as residents tell him they need them. He tried to get to them as soon as he could. They have been doing a lot of work on the third floor with fixing rooms and painting. They needed to repair all the pipes on that floor and that is why some of the sinks keep backing up. They obtained bids for the repairs but have not had the work done yet. It is an old building and things keep breaking down.
18. During an interview on 3/30/23 at 1:35 P.M., the Regional Director of Maintenance said there had been some leaking pipes that were fixed and that is why some of the ceiling tiles had not been replaced yet. He did not know why the sinks had not been fixed yet. No one told him they were stopped up. He did not know the shower handle was broken but should be fixed or taken out if it did not work. The building was old and needed a lot of repairs. The Maintenance Director had only been there a couple of months and they were trying to hire more staff to assist him. He expected repairs to be made as soon as possible.
MO00213151
MO00214071
MO00215524
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
Grievances
(Tag F0585)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** See the deficiencies cited at Event ID MEES12.
Based on interview and record review, the facility failed to maintain an effectiv...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** See the deficiencies cited at Event ID MEES12.
Based on interview and record review, the facility failed to maintain an effective grievance process for residents to voice grievances and prompt facility efforts to resolve grievances. The facility's policy failed to identify a grievance official responsible for overseeing grievances. The facility failed to follow the policy by not making the information regarding how to file a grievance or complaint visible and available to all residents residing in the facility. The facility also failed to maintain the results of grievances filed for a minimum of three years. The census was 136.
Review of the facility's Grievance Program, dated 4/2017, showed the following:
-Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances;
-Policy Interpretation and Implementation:
1. Any resident, family member or appointed resident representative may file a grievance or complaint of care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility. Grievances also may be voiced or filed regarding care that has not been furnished;
2. Residents, family and resident representatives have the right to voice or file grievances without discrimination or reprisal in any form and without fear of discrimination or reprisal;
3. All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response;
4. Upon admission, residents are provided with written information on how to file a grievance or complaint. A copy of our grievance/complaint procedure is posted on the resident bulletin board;
5. Grievances and/or complaints may be submitted orally or in writing and may be filed anonymously;
6. The contact information for the individual(s) with whom a grievance may be filed is provided to the resident and/or representative upon admission;
7. The administrator has delegated the responsibility of grievance and/or complaint investigation to the Grievance Officer who is (this area was left blank) and can be contacted by (this area was left blank);
8. Upon receipt of a grievance and/or complaint, the Grievance Officer will review and investigate the allegations and submit a written report of such findings to the Administrator within five working days of receiving the grievance and/or complaint;
9. The Grievance Officer will coordinate actions with the appropriate state and federal agencies, depending on the nature of the allegations. All alleged violations of neglect, abuse and/or misappropriation of property will be reported and investigated under guidelines for reporting abuse, neglect and misappropriation of property, as per state law;
10. The Grievance Officer, Administrator and staff will take immediate action to prevent further potential violations of resident rights while the alleged violation is being investigated;
11. The Administrator will review the findings with the Grievance Officer to determine what corrective actions, if any need to be taken;
12. The resident or person filing the grievance and/or complaint on behalf of the resident will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct any identified problems;
a. The Administrator or his designee will make such reports within (left blank) working days of the filing of the grievance or complaint within the facility;
b. A written summary of the investigation will also be provided to the resident, and a copy will be filed in the business office;
13. If the grievance was filed anonymously, the Grievance Officer will inform the resident that a grievance has been filed anonymously on his or her behalf and the steps that will be taken to investigate the grievance(s) and report the findings. The Grievance Officer will reiterate to the resident that it is against facility policy and federal regulations to discriminate or sanction a resident who has filed or verbalized a complaint against the facility and that his or her rights to be free of discrimination or reprisal will be protected;
14. The results of all grievances filed, investigated and reported will be maintained on file for a minimum of three years from the issuance of the grievance decision;
15. This policy will be provided to the resident or the resident's representative upon request.
1. Review of the facility's grievance log on 3/30/23, showed the following:
-On 3/28/23, a grievance filed with no documentation of follow up, resolution of grievance, notification to resident, nurses' or Administrator's signature;
-On 1/23/23, a grievance filed with no documentation, nurses' or Administrator's signature;
-No documentation of any other grievances filed in 2023;
-On 12/19/22, a grievance filed with no documentation of follow up, resolution of grievance, notification to resident, nurses' or administrators signature;
-On 12/13/22, a grievance filed with no documentation nurses' or Administrator's signature;
-On 12/17/22, a grievance filed with no documentation of follow up, resolution of grievance, notification to resident; another grievance filed with no documentation, nurses' or Administrator's signature;
-On 12/27/22, three grievances filed with no documentation, nurses' or Administrator's signature;
-On 10/11/22, a grievance filed with no documentation of resolution of grievance, notification to resident, no documentation of nurses' or Administrator's signature;
-No documentation of any other grievances prior to 10/22.
2. Review of Resident #32's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/19/23 showed:
-Clear speech;
-Ability to express ideas and wants: Understood;
-Ability to understand others: Understood;
-Cognitively intact.
During an interview on 3/30/23 at 12:40 P.M., the resident said he/she had never been told about a grievance procedure or told about a number he/she could call. He/She did not know how to fill out a grievance form. He/She would talk to a staff member if he/she had a problem.
3. Review of Resident #28's quarterly MDS, dated [DATE], showed:
-Clear speech;
-Ability to express ideas and wants: Understood;
-Ability to understand others: Understood;
-Mildly cognitively impaired.
During an interview on 3/30/23 at 12:50 P.M., the resident said no one had told him/her about filling out a form or how to formally file a grievance. He/She could talk to staff if he/she had a problem. There were certain staff who would follow through on helping him/her with issues and there were some that would not do anything. It was worse on weekends and nights and with agency staff. No one ever gave him/her anything back in writing.
4. Review of Resident #33's quarterly MDS, dated [DATE], showed:
-Clear speech;
-Ability to express ideas and wants: Understood;
-Ability to understand others: Understood;
-Cognitively intact.
During an interview on 3/30/23 at 1:10 P.M., the resident said he/she did not know about any grievance system. If he/she had a problem, he/she would talk to a staff member he/she trusted. He/she did not always get his/her concerns resolved. No one ever gave him/her anything back in writing.
5. Review of Resident #31's quarterly MDS, dated [DATE], showed:
-Clear speech;
-Ability to express ideas and wants: Understood;
-Ability to understand others: Understood;
-Cognitively intact.
During an interview on 3/30/23 at 1:30 P.M., the resident said he/she is the vice president of the resident council. If a resident had a concern, they would come to him/her. Residents know this because staff tell them. He/She did not know if all staff knew to tell the residents or how residents on locked floors would be able to report their concerns to him/her (Resident #31). There are no forms to fill out or particular staff to go to if they had a concern. No one ever brings anything in writing back to him/her. The activity director sets up and attends their resident council meetings and records their concerns, and he/she can ask for any staff member to attend if he/she has a concern with that department. No one ever gets back with him/her about the concerns brought up in the meeting, and very few complaints are ever resolved.
6. During an interview on 3/30/23 at 12:45 P.M., Certified Medication Technician (CMT) C said if a resident had a concern, he/she would just call social services and they would come talk to the resident. The staff would work with them on the weekends or if social services were not in the building. He/She did not know anything about a grievance form.
7. During an interview on 3/30/23 at 12:55 P.M., CMT D said he/she worked at the facility for about two months. If a resident had a grievance, he/she would give them a phone number listed on the paper. He/She pointed to a compliance and ethics information poster on the wall. He/She said there is a number they could search for on the Internet, or ask the Administrator. He/She did not know about a form the residents could fill out.
8. During an interview on 3/30/23 at 1:00 P.M., Nurse F said if a resident had a grievance, they would notify the nurse or nurse management on duty. That person would get the resident the paperwork to fill out. Administration had two days to get back with the resident with the response to the grievance.
9. During interviews on 3/30/23 at 12:35 P.M. and 1:00 P.M., the social worker said there is not a specific Grievance Officer. Usually if a resident had a grievance, the staff would call her and she would go talk to the resident. She is the only social worker for all of the residents and she does her best to get to everyone. She would talk to them and help them fill out the grievance form or have a mediation session. She would get both sides of the story and forward it to the Administrator who would take care of it from her end. She would document the information in the resident's electronic medical record. She only had grievance records from December until now because the previous Administrator took the old records.
10. During an interview on 4/6/23 at 10:35 A.M., the Regional Nurse Consultant said any staff can give a resident a grievance form. The grievances are brought to the morning meeting and given to the department they are about. The department would answer the grievance and give it back to the Administrator. The Administrator would sign it and give a copy back to the resident and place a copy in the grievance log. There is also a poster, posted throughout the facility, with a hotline number that goes to their corporate lawyers. The residents and families can call this number and the lawyers will relay this concern back to the Administrator. The residents and families all know about this. They have given them this information in Resident Council. This information is not in the policy because the policy is just general information.
MO00215234
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 F0742
(Tag F0742)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** See the deficiencies cited at Event ID MEES12.
Based on observation, interview and record review, the facility failed to ensure ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** See the deficiencies cited at Event ID MEES12.
Based on observation, interview and record review, the facility failed to ensure residents received appropriate person-centered care and met the highest practicable psychosocial well-being when the facility failed to ensure mental health services were provided for five sampled residents who displayed behaviors and/or hallucinations (Residents #28, #29, #21, #17 and #19). The resident sample was 26. The census was 136.
Review of the facility's Psychotherapeutic Drug Management policy, revised June 2020, showed:
-Purpose: To implement the most desirable and effective interventions to change, modify, decrease, or eliminate behaviors that are distressing to the resident, and/or are decreasing or negatively impacting the residents' quality of life;
-To help promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being, promote resident safety and security, and to enhance the resident's ability to interact positively with his/her environment;
-To ensure the resident receives only those medications, in doses and for the duration clinically indicated to treat the resident's assessed conditions;
-To ensure non-pharmacological interventions are considered and used when indicated, instead of, or in addition to, medication;
-To ensure clinically significant adverse consequences are minimized;
-To ensure that any potential contribution the medication regimen has to an unanticipated decline or newly emerging or worsening symptoms is recognized and evaluated, and the regimen is modified when appropriate;
-The Facility supports the goal of determining the underlying cause of behavioral symptoms so the appropriate treatment of environmental, medical, and/or behavioral interventions, as well as psychopharmacological medications can be utilized to meet the needs of the individual resident;
-The Facility will make every effort to comply with state and federal regulations related to the use of psychopharmacological medications in the long-term care facility to include regular review for continued need, appropriate dosage, side effects, risks and/or benefits;
-Efforts to reduce dosage or discontinue of psychopharmacological medications will be ongoing, as appropriate, for the clinical situation;
-Psychotherapeutic drugs will only be utilized with a physician order and will never be used for the convenience of staff;
-The facility will utilize individualized, non-pharmacological approaches to care (e.g., purposeful and meaningful activities). Meaningful activities are those that address the resident's customary routines, interests, preferences, and choices to enhance the resident's wellbeing;
-Psychiatrist/Mental Health Responsibility: Provides consultation services;
-Assists the Facility and the attending medical practitioner in establishing appropriate guidelines for use, dosage and monitoring of psychotropic medications;
-Provides in-service training to nursing, medical, and other staff as appropriate.
-Participates in the development of the resident's individualized behavior management plan;
-Nursing responsibility: Consider other factors that may be causing expressions or indications of distress before initiating a psychotropic medication, such as an underlying medical condition (e.g., urinary tract infection, dehydration, delirium), environmental (lighting, noise) or psychosocial stressors;
-Will monitor psychotropic drug use daily noting any adverse effects. (i.e., EPS, Tardive dyskinesia, excessive dose or distressed behavior);
-Monitoring should also include evaluation of the effectiveness of non-pharmacological approaches prior to administering as needed (PRN) medications;
-Will monitor the presence of target behaviors on a daily basis charting by exception (i.e., charting only when the behaviors are present);
-Reviews the use of the medication with the physician and the interdisciplinary team at least quarterly to determine the continued presence of target behaviors and or the presence of any adverse effects of the medication use;
-Implements and updates the care plan as indicated;
-Social Services Responsibility: The Social Worker or designee will complete an initial Social Service Assessment that takes into account the factors that may contribute to the resident's behaviors;
-Information will be collected from the resident and from the resident's surrogate, family and friends as applicable;
-The assessment will include the resident's past psychosocial history and spiritual needs;
-The Social Worker will complete a progress note at least quarterly describing the resident's behaviors, use of psychotropic medication, and the effect of the medication in controlling behaviors;
-The Social Worker will participate in development of the resident's Care Plan and provide social service visits to identify new needs and address ongoing needs.
1. Review of Resident #28's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/20/23, showed the following:
-Mood: Symptoms present:
Feeling down and depressed: Yes;
Trouble falling asleep or staying asleep: Yes;
Sleeping too much: Yes;
Feeling Tired or having little energy: Yes;
Poor appetite or overeating: Yes;
-Mildly cognitively impaired;
-Special therapies: Psychological Therapy: Any licensed Mental Health Professional: Record # of Days: 0
-Diagnoses included schizophrenia (mental disorder in which reality is interpreted abnormally), major depressive disorder and anxiety disorder.
Review of the resident's care plan, in use during survey, showed:
-Focus: Resident has alteration in thought process related to schizophrenia;
-Interventions:Administer medications as ordered. Monitor/document for side effects and effectiveness;
-Anticipate and meet the resident's needs;
-Caregivers to provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by;
-Praise any indication of the resident's progress/improvement in behavior;
-Social service to speak with resident regarding behavior and draw up contract;
-Staff to redirect resident and remind him/her behavior is not tolerated;
-Focus: Resident uses antidepressant medication related to depression;
-Interventions: Administer medications as ordered by physician;
-Monitor/document/report as needed adverse reactions to antidepressant therapy, change in behavior/mood/cognition/suicidal thoughts;
-Focus: The resident has a mood problem:
-Interventions: Assist the resident with developing/provide the resident with a program of activities that is meaningful and of interest to him/her. Encourage and provide opportunities for exercise, physical activity;
-Encourage resident to express feelings;
-Monitor/document/report as needed any risk for harm to self, suicidal plan, past attempt at suicide risky actions, intentionally harm or trying to harm self, refusing to eat or drink, refusing meds or therapies, sense of hopelessness or helplessness, impaired judgement or safe awareness;
-Monitor/record/report to MD as needed any acute episode, feelings of sadness, loss of pleasure and interest in activities, feelings of worthlessness or guilt, change in appetite/eating habits, change in sleep patterns, diminished ability to concentrate, change in psychomotor skills;
-Monitor/record/report to MD as needed risk for harming others; increased anger, labile (easily altered) mood or agitation, feels threatened by others or thoughts of harming someone.
Review of the resident's progress notes, showed:
-On 12/8/22 at 12:27 A.M., the resident returned from the hospital. He/She was diagnosed with anxiety during the visit. At 5:15 P.M., a physician's note: The resident was post hospitalization for anxiety and severe hypokalemia (low potassium level) and the nursing administration requested the resident be evaluated for respiratory issues. The resident had a normal mood, normal affect, was cooperative but was anxious and upset due to son's death. Plan: Nursing notified and administering medication and calling psychiatrist for anti-anxiety medication;
-On 12/29/22 at 7:42 A.M., a physician's note: Resident anxious and upset due to death of son this A.M. Plan: Nursing notified and administering medication and calling psychiatrist for anti-anxiety medication;
-On 1/10/23 at 10:05 A.M., the resident wanted his/her order of Lorazepam (a medication used to treat agitation) changed from 0.5 milligrams (mg) to 1 mg. Staff called the psych doctor who said they had not started seeing patents yet and the Director of Nursing would have to finalize some stuff before they could begin seeing patients;
-On 1/18/23 at 8:46 A.M., the resident reported he/she was seeing and hearing his/her dead son. He/She denied being able to hear what he/she said and thought it might go away if he/she could get his/her dose of Ativan raised. Staff informed the resident psych would be informed. At 1:15 P.M., staff contacted psych and were waiting for a call back. At 1:50 P.M., the staff administered Nitrostat sublingual for chest pain. At 2:11 P.M., staff administered Nitrostat sublingual for chest discomfort. At 2:32 P.M., staff administered Nitrostat sublingual for chest pain. At 3:45 P.M., staff contacted the resident's physician regarding the resident still seeing and unable to hear his/her son. The resident was requesting to go to the hospital because his/her dose of Ativan was not raised and the psych provider had not seen him/her. The physician gave a verbal order to send the resident to the hospital for evaluation and treatment. At 4:07 P.M., staff contacted an ambulance company for a non-emergency transfer to the hospital. At 5:19 P.M., the emergency medical services (EMS) arrived to transport the resident to the hospital. At 9:03 P.M., the hospital called and informed the staff the resident did not meet the requirements for admissions and would be returning to the facility.
Review of the resident's hospital after visit summary, dated 1/18/23, showed the following:
-The resident was evaluated in the emergency department for a mental health problem;
-Recommended he/she follow up closely with his/her primary psychiatrist so they could help with his/her future care;
-If he/she developed thoughts of harming him/herself or anyone else or realized he/she heard voices that no one else could hear, he/she should come back to the hospital.
Review of the resident's progress notes, showed the following:
-On 1/19/23 at 12:26 A.M., a late entry from physician: The resident had a recent hospitalization for suicide ideations. He/She had three immediate family member deaths in the last few months, most recently his/her brother. The resident stated he/she is feeling better and currently denied suicidal ideations. Resident stated his/her anxiety medication was reduced recently and he/she has been more stressed in general along with recent family deaths. Advised resident to speak with nurse and primary care physician about increased stress and medication management. At 1:57 P.M., a late entry from physician: Nursing staff requested resident be seen for shortness of breath with anxiety. Cooperative but anxious and upset due to son's death. Plan of care: Discussed with the nursing staff continue to monitor and treat pulmonary need and collaborate with primary care physician as needed;
-On 1/20/23 at 1:06 P.M., the physician visited the resident today. The new orders were as follows: Start Amitriptyline 50 milligrams by mouth every evening for anxiety and insomnia;
-On 3/9/23 at 1:15 P.M., staff called the psych nurse practitioner in regard to the resident's Lorazepam order. The nurse practitioner said the resident needed a new script and he would need to see the resident before writing a new script. He would be in the next week;
-No documentation of psych notes.
Review of the resident's physician's orders sheet (POS), dated March 2023, showed:
-An order, dated 12/7/22, for buspirone hydrochloride 15 mg (a medication used to treat depression and anxiety);
-An order, dated 12/19/22, for Lorazepam 0.5 mg;
-An order, dated 12/20/22, for Citalopram Hydrobromide tablet 20 mg (a medications used to treat depression);
-An order, dated 1/20/23, for Amitriptyline HCL tablet 50 mg.
During interviews on 3/28/23 at 10:00 A.M. and on 3/29/23 at 10:15 A.M., the resident said he/she had several family members die last year. He/She was hardest hit when his/her son died in November. No one talked to him/her about it. In January, he/she finally broke down and started seeing him. The staff sent him/her to the hospital but the hospital sent him/her right back. The only people who talked to him/her about how he/she was feeling was the ambulance people. No one at the hospital or the facility addressed it with him/her when he/she got back or since then. Sometimes, he/she got really depressed when he/she thought about it. He/She was having a really hard time dealing with the loss and there was no one to talk to about it. The resident asked several times to speak to a psychiatrist but they would tell him/her they made him/her an appointment and then it would be canceled. He/She had not met with anyone from psych since the deaths. The resident felt like his/her medication needed to be changed but he/she had to see the psychiatrist for this to happen. It felt like no one cared about him/her.
During an interview on 3/30/23 at 10:45 A.M., Certified Medication Technician (CMT) C said the resident does get depressed at times because he/she had lost several family members in a short period of time. The staff try to talk to him/her when he/she was down and they will call the social worker if she was available. The resident has not seen a psych doctor since he/she was sent to the hospital in January. He/She has asked to see someone a couple of times but no one came until yesterday afternoon. The staff do their best to try and talk to the residents and calm them down.
During an interview on 3/29/23 at 12:35 P.M., the Social Services Director (SSD) said she thought the resident went to the hospital in January for breathing issues. She did not know the resident had told staff he/she was seeing and grieving for his/her dead son. The staff should have told her about this. The resident should have seen someone when he/she came back from the hospital. The facility changed psych groups in January and the new therapists would not be seeing residents until mid April. No one had seen a psychiatrist since January. The SSD has been working on trying to find therapists who will come out and see the residents but it is difficult to get people out there and there are insurance issues. The group that used to come prior to January stopped coming due to billing issues. She tried to see as many residents as she could. She did not always document who she saw because she there was so much to do and so many people to see.
During an interview on 3/30/23 at 9:00 A.M., the Administrator said someone should have made the Social Worker aware the resident had been sent to the hospital after making statements he/she was seeing his/her dead son. The staff usually go over residents who went to the hospital overnight in the morning clinical meeting. She did not know why this got missed. She is not aware of any grief services provided at the facility.
2. Review of Resident #29's medical record, showed:
-admitted on [DATE];
-Diagnoses included schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety.
Review of the resident's care plan, in use during survey, showed:
-Focus: He/She has a behavior problem related to descriptive account of occurrence involving him/herself and others;
-Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness;
-Educate him/her on successful coping and interaction strategies;
-Encourage him/her to express feelings appropriately;
-Explain all procedures before starting and allow the resident to adjust to changes;
-Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident;
-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;
-Monitor behavior episodes and attempt to determine underlying cause;
-Focus: Resident has a behavior problem as he/she often calls 911 for placement to another facility;
-Intervention: Anticipate and meet the resident's needs;
-Encourage him/her to express feelings appropriately;
-Explain all procedures to him/her before starting and allow the resident to adjust to changes;
-Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident;
-Focus: Resident has a mood problem due to diagnoses of schizophrenia, anxiety and dementia with behaviors;
-Interventions: Assist him/her to identify strengths, positive coping skills and reinforce these;
-Encourage him/her to express feelings;
-Monitor/record/report to MD as needed (PRN) mood patterns signs and symptoms of depression, anxiety, sad mood as per facility behavior monitoring protocols;
-Psych consults as needed.
Review of the resident's progress notes, showed:
-On 3/10/23 at 6:16 P.M., resident was admitted from other entity via ambulance. Resident is alert. Oriented to person, place, time, situation. Mood is withdrawn. Behaviors: resistance to care;
-On 3/23/23 at 12:32 P.M., resident reported to this nurse that he/she is hallucinating because a medication he/she was on for 40 years is not being given anymore. No report of self-harm or wanting to harm him/herself. Call placed to physician to report findings. Resident is his/her own power of attorney (POA) and wants to go to the hospital for evaluation. Resident will be sent to hospital for evaluation;
-At 12:44 P.M., physician made aware and is ok for resident to be sent to hospital for evaluation;
-At 3:08 P.M., gave report to nurse at hospital, faxed over orders and face sheet, due to nurse stating it wasn't received from emergency medical technician (EMT);
-On 3/24/23 at 11:30 A.M., Late Entry: Behavior Note: This writer and MDS went up and spoke to resident about his/her current stay. Resident stated that he/she was not happy here and he/she wanted to leave. It was explained that he/she was his/her own person, and he/she is able to leave at any time. Resident stated that he/she has nowhere to go and his/her family is screwed up. Resident was told that we would send a referral to other places. Resident was agreeable to referral being sent to other places;
-On 3/24/23 at 8:07 P.M., resident called 911. Writer spoke to resident and officer and explained that he/she is wanting to be placed in a different facility. No further information was needed;
-On 3/25/23 at 11:01 A.M., spoke with resident is his/her room. Resident calm, and cooperative. Per resident he/she has been on a anti-psychotropic medication for approximately 40 years and per the resident is the only medication that really helps him/her. He/She was able to tell this writer the name of the medication, write it out and also the dose and how frequently he/she takes the medication. This medication was checked against his/her referral medication list and it was there. The psych nurse practitioner (NP) was contacted and this information was relayed and obtained an order to restart the medication. Pharmacy was contacted to ensure that the medication was available. The medication was delivered later the same afternoon and is being administered per schedule;
-On 3/27/23 at 8:57 A.M., Behavior note: Resident called police this morning and stated, I am fearing for my life. He/She called during breakfast; everyone was in the dining room but him/her. Two officers reported to the floor. This nurse was trying to see what was going on and who called. They stated what was said and the person did not give a name. He/She then comes around the corner and starts talking to them. This nurse assured nothing has gone on so far this shift because they were eating breakfast. Police continued to talk to resident;
-No documentation of psych notes.
Review of the resident's POS, dated March 2023, showed:
-An order, dated 3/25/23, for Perphenazine Oral Tablet 4 mg. Give 4 mg by mouth two times a day related to schizophrenia.
Review of the resident's behavior monitoring and intervention log, dated 3/13/23 through 3/29/23, showed:
-On 3/19/23, staff documented no behaviors;
-On 3/20/23, staff documented no behaviors;
-No further documentation regarding the resident's behaviors.
During an interview on 3/29/23 at 8:45 A.M., the resident said he/she wanted to leave the facility and called the police recently. He/She complained about staff and he/she had not received his/her medication for schizophrenia. The resident had been on the medication for 40 years. He/She reported it to staff and the police when he/she called them. The resident said he/she started receiving the medication in the past week and he/she felt fine. He/She was told by the DON the medication was missed and either it was missed by the hospital or the facility. The resident said he/she just wanted his/her medication to help with the hallucinations. The resident had not seen the psych doctor, and only spoke to the Social Worker about moving to another facility.
During an interview on 3/29/23 at 12:20 P.M., the SSD said the resident did not like the facility as soon as he/she was admitted . He/She has behaviors and called the police four times. The resident had not been seen by the psych doctor since he/she had been admitted . She recently assisted the resident by sending referrals to two facilities.
During an interview on 4/6/23 at 10:15 A.M., the DON and Regional Nurse Consultant said the resident was ordered the medication on 3/25/23. It was missed by the facility when he/she was admitted , but they did not receive all the information from the previous facility. The DON pulled the transfer paper and checked the medications. The resident was referred to psych; however, he/she kept getting sent out to the hospital, so the resident was not seen by psych. The resident went to the hospital on 3/14/23 and a referral for psych was made after he/she returned. On 3/25/23, another referral was made after the resident was ordered Perphenazine. They notified psych because the hospital did not do anything. It is not documented in the medical record, but they communicate with psych through phone calls and texts.
3. Review of the Resident 21's medical record, showed his/her diagnoses included bipolar disorder (a mental disorder that changes a person's mood, energy level and ability to function), current episode manic (extreme mood swings) or severe with psychotic (abnormal thinking and perceptions) features, epilepsy (brain disorder that causes recurrent seizures), schizophrenia, generalized anxiety disorder, insomnia and Parkinson's disease (a brain disorder that causes uncontrollable movements or stiffness).
Review of the resident's care plan, in use at the time of survey, showed:
Focus: The resident has a behavior problem related to bipolar and schizophrenia;
Interventions: Administer medication as ordered; Explain and reinforce why behavior is inappropriate and/or unacceptable to the resident; Intervene as necessary to protect the right and safety of others; Monitor behavior episodes and attempt to determine underlying cause.
Focus: The resident has a mood problem related to schizophrenia;
Interventions: Administer medications as ordered; Assist the resident, family and caregivers to identify strengths and positive coping skills; Encourage the resident to express his/her feelings; Psychiatric consults as needed;
Focus: The resident has a psychosocial well-being problem related to anxiety and ineffective coping;
Interventions: Allow the resident time to answer questions and to verbalize feelings and perceptions and fear; Assist, encourage and support the resident to set realistic goals; Initiate referral as needed to increase social relationships; When conflict arises, remove resident to a calm safe environment and allow him/her share feelings.
Review of the resident's POS dated March 2023, showed:
-An order, dated 3/8/23, for Venlafaxine oral tablet 75 mg ( a medication used to treat depression and anxiety);
-An order, dated 3/8/23, for Abilify oral tablet 5 mg (a medication used to treat schizophrenia);
-An order, dated 2/11/23, for Memantine oral tablet 5 mg (a medication used to treat moderate to severe confusion related to Alzheimer's disease);
-An order, dated 2/10/23, for Depakote sprinkles oral capsule delayed release 125 mg (a medication used to treat seizures and bipolar disorder).
Review of the resident's progress notes, showed:
On 3/4/23 at 6:55 P.M., the resident is becoming louder and more agitated, cursing and threatening staff and other residents. Haldol (a medication to treat schizophrenia) Injection given;
On 3/5/23 at 3:45 A.M., unable to get the resident's vital signs due to combative behavior;
On 3/5/23 at 4:45 A.M., the resident was throwing things, dismantling the bed, yelling, banging on bed and making racial slurs. The nurse went to prepare a Haldol injection and returned and the resident was found on the floor. He/She refused to get up or let staff provide assistance. The resident continued to be belligerent and combative with staff. The resident did not want to be touched. Pain and skin assessment completed. Assisted resident off of the floor and Haldol intramuscular (IM) given. Resident one on one until he/she calms down.
On 3/5/23 at 3:45 A.M., 4:00 A.M. and 4:15 A.M. unable to complete neurological (neuro) checks due to the resident's combative behavior;
On 3/5/23 at 4:27 A.M., the resident is going into other residents' rooms and throwing water on them. One on one continued for safety measures;
On 3/5/23 at 7:53 A.M., the resident's physician was texted about resident being agitated, combativeness and being found on the floor. No response received;
On 3/6/23 at 1:02 A.M., the resident refusing vital signs and neuro checks;
On 3/16/23 at 4:56 A.M., the resident refused assessment and vital signs. The resident is speaking loudly. He/She is resistant to care and becomes combative when care is attempted;
On 3/20/23 at 2:52 P.M., the resident is very anxious and combative with staff. Ativan by mouth given and the resident spit medication out;
On 3/22/23 at 1:31 P.M., the resident threw his/her lunch on the floor. While housekeeping staff was cleaning in the room, the resident pushed his/her bedside table to hit the housekeeper in the back;
On 3/22/23 at 3:52 P.M., the resident is filling a cup of water and throwing it all over his/her room, calling it holy water;
On 3/23/23 at 1:37 A.M., the resident is yelling out, refusing care and is combative with staff;
On 3/27/23 at 2:10 A.M., the resident is refusing all care and is cursing and yelling at staff. Attempted to re-direct resident with no success;
On 3/29/23 at 10:10 A.M., this nurse contacted physician for a psych consult order due to diagnosis.
Review of the resident's record, showed no documentation of psychiatric progress notes and no social service notes.
Observation and interview on 3/29/23 at 11:25 A.M., showed the resident sitting on his/her bed, reading the Bible. His/Her eyeglasses were broken into pieces on his/her bed. The resident screamed get out as an attempt was made to speak with him/her.
During an interview on 3/29/23 at 11:30 A.M., Licensed Practical Nurse (LPN) G said the resident does not like other people in his/her room. The resident is very difficult to redirect. Staff just tries to let (him/her) be. The resident refuses medications most of the time. He/She throws his/her food on the floor. He/She rejects care from staff and can become combative. The resident has been having behaviors for as long as he/she had been employed at the facility which was over a month. LPN G didn't know if the resident was receiving psych services.
Observation on 3/30/23 at 12:45 P.M., showed the resident had thrown his/her lunch and drink on the floor. The resident was calmly sitting on his/her bed and refusing to answer any questions.
During an interview on 3/30/23 at 12:47 P.M., Certified Medication Technician (CMT) C said the resident has had behaviors since his/her admission. The resident has good days and bad days. The resident does not take his/her medications on a regular basis.
During an interview on 3/29/23 at approximately 12:00 P.M., the SSD said the resident was having a lot of behaviors and should have been seen by the psychiatrist. She did not think the resident being seen by the primary care physician was enough to meet the resident's mental needs.
During an interview on 3/30/23 at 1:35 P.M., the Regional Nurse Consultant said the resident was having extreme behaviors and should have had a psych evaluation.
4. Review of Resident #17's medical record, showed his/her diagnoses included paranoid schizophrenia, psychotic disturbance, major depressive disorder, bipolar disorder, pseudobulbar affect (episodes of sudden uncontrollable and inappropriate laughing or crying) and anxiety disorder.
Review of the resident's progress notes, showed:
-On 11/28/22 at 2:29 P.M., the resident experienced crying episodes. He/She cursed at staff and punched the bathroom door. He/She cried over not receiving a soda. Staff calmed him/her down. He/She sat near the nurse's station. Staff continued to monitor;
-On 12/1/22 at 11:44 A.M., the resident had a crying episode. He/She said he/she does not get any attention. Staff told him/her they were there to assist with all his/her needs, educate him/her on call light use and how to call for assistance if he/she needed to vent and assist with ADLs. The resident said okay;
-On 12/26/22 at 9:44 A.M., the resident was observed hitting another resident by housekeeping staff. He/She was separated from all residents and monitored. Staff notified the Administrator and the Assistant Director of Nursing (ADON). The resident was sent to the hospital for further evaluation, via ambulance. At 7:37 P.M., he/she returned to facility by EMS. His/Her mood was calm with no signs of distress noted. He/She was transferred to a different room and 15 minute checks were put in place;
-On 12/29/22 at 12:10 P.M., staff spoke with a liaison for residents with mental health issues. Staff told the liaison the resident was in a nursing home, received 24 hour monitoring and had a psychiatrist and a guardian for decision making. Staff said the liaison was satisfied to be informed of the resident's safety and supervision;
-On 1/3/23 at 10:11 A.M., the resident was very tearful an
Feb 2023
2 deficiencies
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 F0567
(Tag F0567)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility staff failed to obtain written authorization from the resident and/or financial guardian for money withdrawn for seven residents (Resident #1, #6, #7...
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Based on record review and interview, the facility staff failed to obtain written authorization from the resident and/or financial guardian for money withdrawn for seven residents (Resident #1, #6, #7, #8, #9, #10 and #11) out of a sample of 11. Also, the facility failed to withdraw the correct monthly surplus for room and board which did not allow the resident/financial guardian the right to manage all of his/her financial affairs for eight of the 11 sampled residents (Resident #1, #3, #4, #5, #6, #7, #9 and #11). The facility census was 129.
1. Record review of the facility maintained Resident Trust Statement for the period 04/01/22 through 02/15/23, showed the following withdrawals from Resident #1's account:
Date Amount Description
09/26/22 $125.00 Personal Needs
09/29/22 $100.00 Personal Needs
Record review on 02/15/23 of the facility maintained paperwork for Resident #1's Resident Trust Statement, showed no written authorization by Resident #1 and/or financial guardian for the withdrawals.
During an interview on 02/15/23 at 12:21 P.M., Resident #1 said he/she usually only withdraws around $25.00, except one time when he/she did withdraw $600.00 for a computer several years ago. Resident #1 said he/she did not withdraw the $125.00 on 09/26/22, nor the $100.00 on 09/29/22.
2. Record review of the facility maintained Resident Trust Statement for the period 04/01/22 through 02/15/23, showed the following withdrawal from Resident #6's account:
Date Amount Description
07/05/22 $56.00 Personal Needs
Record review on 02/15/23 of the facility maintained paperwork for Resident #6's Resident Trust Statement, showed no written authorization by Resident #6 and/or his/her financial guardian for the withdrawal.
3. Record review of the facility maintained Resident Trust Statement for the period 04/01/22 through 02/15/23, showed the following withdrawal from Resident #7's account:
Date Amount Description
09/26/22 $100.00 Personal Needs
Record review on 02/15/23 of the facility maintained paperwork for Resident #7's Resident Trust Statement, showed no written authorization by Resident #7 and/or his/her financial guardian for the withdrawal.
During an interview on 02/15/23 at 12:55 P.M., Resident #7 said he/she never withdraws $100.00. The most he/she has withdrawn was either $40.00 or $50.00 and did not withdraw $100.00.
4. Record review of the facility maintained Resident Trust Statement for the period 06/01/22 through 02/15/23, showed the following withdrawal from Resident #8's account:
Date Amount Description
09/26/22 $50.00 Personal Needs
Record review on 02/15/23 of the facility maintained paperwork for Resident #8's Resident Trust Statement, showed no written authorization by Resident #8 and/or his/her financial guardian for the withdrawal.
During an interview on 02/15/23 at 1:08 P.M., Resident #8 said he/she usually withdraws no more than $10.00 at a time but has withdrawn $20.00 or $30.00 in the past. Resident #8 said he/she did not withdraw $50.00 at one time.
5. Record review of the facility maintained Resident Trust Statement for the period 05/01/22 through 02/15/23, showed the following withdrawals from Resident #9's account:
Date Amount Description
09/26/22 $100.00 Personal Needs
10/03/22 $50.00 Personal Needs
10/07/22 $100.00 Personal Needs
Record review on 02/15/23 of the facility maintained paperwork for Resident #9's Resident Trust Statement, showed no written authorization by Resident #9 and/or his/her financial guardian for the withdrawals.
During an interview on 02/15/23 at 1:05 P.M., Resident #9 said he/she usually withdraws $20.00. He/she did not withdraw $100.00.
6. Record review of the facility maintained Resident Trust Statement for the period 06/01/22 through 02/15/23, showed the following withdrawal from Resident #10's account:
Date Amount Description
09/29/22 $100.00 Personal Needs
Record review on 02/15/23 of the facility maintained paperwork for Resident #10's Resident Trust Statement, showed no written authorization by Resident #10 and/or his/her financial guardian for the withdrawal.
During an interview on 02/15/23 at 1:00 P.M., Resident #10 said he/she usually withdraws money in increments of eight and has never withdrawn $100.00.
7. Record review of the facility maintained Resident Trust Statement for the period 06/01/22 through 02/15/23, showed the following withdrawals from Resident #11's account:
Date Amount Description
09/26/22 $100.00 Personal Needs
09/26/22 $100.00 Personal Needs
09/29/22 $100.00 Personal Needs
09/30/22 $114.00 Personal Needs
Record review on 02/15/23 of the facility maintained paperwork for Resident #11's Resident Trust Statement, showed no written authorization by Resident #11 and/or his/her financial guardian for the withdrawals.
During an interview on 02/27/23 at 11:19 A.M. and 11:24 A.M., both of Resident #11's Financial Guardians said there would have been no reason the money would have been withdrawn for the listed withdrawals.
8. During an interview on 02/15/23 at 12:08 P.M., the Business Office Manager said he/she was unable to locate any written withdrawal authorizations/receipts prior to his/her start date of 10/03/22.
9. Record review of the facility maintained Resident Trust Statement for the period 04/01/22 through 02/15/23, showed the incorrect withdrawals from Resident #1's account for room & board.
Date Month Amount Withdrawn
04/01/22 04/2022 $561.00
05/16/22 05/2022 $561.00
06/03/22 06/2022 $561.00
07/01/22 07/2022 $561.00
08/03/22 08/2022 $561.00
09/02/22 09/2022 $561.00
10/03/22 10/2022 $561.00
11/03/22 11/2022 $561.00
12/02/22 12/2022 $561.00
01/03/23 01/2023 $623.00
02/03/23 02/2023 $623.00
Record review on 02/27/23 of the Medicaid Category History Screen provided by Missouri HealthNet Division on 02/14/23 and the Cost Settlement Summary Report (CSSR) provided on 02/06/23, showed Resident #1's Care Cost Surplus amount for room & board should be $513.05 for 04/2022 - 02/2023.
10. Record review of the facility maintained Resident Trust Statement for the period 04/01/22 through 02/15/23, showed the incorrect withdrawals from Resident #3's account for room & board.
Date Month Amount Withdrawn
04/01/22 04/2022 $787.00
05/16/22 05/2022 $787.00
06/14/22 06/2022 $787.00
07/13/22 07/2022 $787.00
08/09/22 08/2022 $787.00
09/13/22 09/2022 $787.00
10/17/22 10/2022 $787.00
11/28/22 11/2022 $787.00
01/03/23 12/2022 $787.00
01/10/23 01/2023 $979.00
Record review on 02/27/23 of the Medicaid Category History Screen provided by Missouri HealthNet Division on 02/17/23 and the CSSR provided on 02/06/23, showed Resident #3's Care Cost Surplus amount for room & board should be $726.07 for 04/2022 - 12/2022 and 02/2023 and $691.48 for 01/2023.
11. Record review of the facility maintained Resident Trust Statement for the period 04/01/22 through 02/15/23, showed the incorrect withdrawals from Resident #4's account for room & board.
Date Month Amount Withdrawn
04/01/22 04/2022 $717.00
05/16/22 05/2022 $717.00
06/14/22 06/2022 $717.00
07/13/22 07/2022 $717.00
08/09/22 08/2022 $717.00
09/13/22 09/2022 $717.00
10/17/22 10/2022 $717.00
11/28/22 11/2022 $717.00
01/10/23 01/2023 $784.00
Record review on 02/27/23 of the Medicaid Category History Screen provided by Missouri HealthNet Division on 02/17/23 and the CSSR provided on 02/06/23, showed Resident #4's Care Cost Surplus amount for room & board should be $665.00 for 04/2022 - 12/2022 and 02/2023 and $518.61 for 01/2023.
12. Record review of the facility maintained Resident Trust Statement for the period 04/01/22 through 02/15/23, showed the incorrect withdrawals from Resident #5's account for room & board.
Date Month Amount Withdrawn
04/01/22 04/2022 $329.00
01/03/23 01/2023 $376.00
02/03/23 02/2023 $376.00
Record review on 02/27/23 of the Medicaid Category History Screen provided by Missouri HealthNet Division on 02/17/23 and the CSSR provided on 02/06/23, showed Resident #5's Care Cost Surplus amount for room & board should be $229.00 for 04/2022 - 02/2023.
13. Record review of the facility maintained Resident Trust Statement for the period 04/01/22 through 02/15/23, showed the incorrect withdrawals from Resident #6's account for room & board.
Date Month Amount Withdrawn
04/01/22 04/2022 $1,171.00
05/16/22 05/2022 $1,171.00
06/14/22 06/2022 $1,171.00
07/01/22 07/2022 $1,171.00
08/03/22 08/2022 $1,171.00
09/02/22 09/2022 $1,171.00
10/03/22 10/2022 $1,171.00
11/03/22 11/2022 $1,171.00
12/02/22 12/2022 $1,171.00
01/03/23 01/2023 $1,283.00
02/03/23 02/2023 $1,283.00
Record review on 02/27/23 of the Medicaid Category History Screen provided by Missouri HealthNet Division on 02/17/23 and the CSSR provided on 02/06/23, showed Resident #6's Care Cost Surplus amount for room & board should be $999.09 for 04/2022 - 02/2023.
14. Record review of the facility maintained Resident Trust Statement for the period 04/01/22 through 02/15/23, showed the incorrect withdrawals from Resident #7's account for room & board.
Date Month Amount Withdrawn
04/01/22 04/2022 $632.00
06/03/22 06/2022 $632.00
07/01/22 07/2022 $632.00
01/10/23 01/2023 $698.00
Record review on 02/27/23 of the Medicaid Category History Screen provided by Missouri HealthNet Division on 02/17/23 and the CSSR provided on 02/06/23, showed Resident #7's Care Cost Surplus amount for room & board should be $498.05 for 04/2022 - 02/2023.
15. Record review of the facility maintained Resident Trust Statement for the period 06/01/22 through 02/15/23, showed the incorrect withdrawals from Resident #9's account for room & board.
Date Month Amount Withdrawn
06/03/22 06/2022 $336.00
07/01/22 07/2022 $336.00
08/03/22 08/2022 $336.00
09/02/22 09/2022 $336.00
10/03/22 10/2022 $336.00
11/03/22 11/2022 $336.00
12/02/22 12/2022 $336.00
01/03/23 01/2023 $381.00
02/03/23 02/2023 $381.00
Record review on 02/27/23 of the Medicaid Category History Screen provided by Missouri HealthNet Division on 02/17/23 and the CSSR provided on 02/06/23, showed Resident #9's Care Cost Surplus amount for room & board should be $298.03 for 06/2022 - 02/2023.
16. Record review of the facility maintained Resident Trust Statement for the period 06/01/22 through 02/15/23, showed the incorrect withdrawals from Resident #11's account for room & board.
Date Month Amount Withdrawn
06/03/22 06/2022 $747.00
07/01/22 07/2022 $747.00
08/03/22 08/2022 $747.00
09/02/22 09/2022 $747.00
10/03/22 10/2022 $747.00
11/03/22 11/2022 $747.00
12/02/22 12/2022 $747.00
01/03/23 01/2023 $822.00
02/03/23 02/2023 $822.00
Record review on 02/27/23 of the Medicaid Category History Screen provided by Missouri HealthNet Division on 02/17/23 and the CSSR provided on 02/06/23, showed Resident #11's Care Cost Surplus amount for room & board should be $688.09 for 06/2022 - 02/2023.
17. During an interview on 02/15/23 at 10:52 A.M., the Regional Business Office Manager said he/she was not sure why the previous facility Business Office Manager withdrew the incorrect amount for room & board.
MO00214881
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 record review and interview, the facility failed to ensure six residents (Residents #1, #7, #8, #9, #10 and #11) were free from misappropriation of resident property when the former Acting Bu...
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Based on record review and interview, the facility failed to ensure six residents (Residents #1, #7, #8, #9, #10 and #11) were free from misappropriation of resident property when the former Acting Business Office Manager withdrew resident funds to use for his/her personal use. The facility census was 129.
1. During an interview on 03/02/23 at 10:28 A.M., the Administrator said the former acting BOM (who worked as the BOM at a sister facility) handled resident funds at the facility from 09/01/22 until the current BOM started on 10/03/22. The former acting BOM then trained the current BOM.
2. Record review of the facility maintained Resident Trust Statement for the period 04/01/22 through 02/15/23, showed the following withdrawals from Resident #1's account:
Date Amount Description
09/26/22 $125.00 Personal Needs
09/29/22 $100.00 Personal Needs
Record review of the facility maintained paperwork for Resident #1's Resident Trust Statement, showed no written authorization for the 09/26/22 and 09/29/22 withdrawals by Resident #1.
Record review of the facility maintained Resident Trust Statement for the period 04/01/22 through 02/15/23, showed the following withdrawal from Resident #1's account:
Date Amount Description
10/07/22 $125.00 Personal Needs
Record review of the facility maintained Resident Trust signature page, dated 10/07/22, showed Resident #1's written authorization for a withdrawal of $25.00 from Resident #1's Resident Trust Account.
Record review of the facility maintained paperwork shows the facility uses a computer system known as Resident Fund Management Service (RFMS) to withdraw resident funds. Review showed $125.00 was entered into RFMS instead of $25.00 for the withdrawal.
During an interview on 02/15/23 at 12:21 P.M., Resident #1 said he/she usually only withdraws approximately $25.00, except for one time several years ago when he/she purchased a computer for $600. Resident #1 said he/she did not withdraw the $125.00 on 09/26/22, $100.00 on 09/29/22, nor $125.00 on 10/07/22.
Review of the Resident Trust signature page showed the current BOM documented the total of all daily withdrawals for the unit for 10/05/22 was $217.00.
During an interview on 02/15/22 at 1:45 P.M., the current BOM said:
-He/she remembered giving $25.00 to Resident #1 for the 10/07/22 withdrawal;
-At the time of the withdrawal, the current BOM was newly employed at the facility and did not yet have access to RFMS- and did not obtain access until 10/10/22.
-The current BOM would go to each unit to ask residents how much petty cash they would like- he/she would document the resident name and dollar amount requested, and then the resident signed their written authorization on the sheet.
-The authorized withdrawal sheet is taken back to the office to enter into RFMS and then a check is cut to replenish resident petty cash, however the current BOM gave the sheet to the former Acting BOM since he/she did not have access to RFMS.
-The authorized withdrawal sheet for the 10/05/22 daily unit withdrawals (posted on 10/07/22) totaled $217.00. The former Acting BOM took the sheet to the sister facility where he/she worked and entered $477.00 into RFMS. He/she only gave $217.00 to the current BOM to replenish resident petty cash, which was $260.00 less than the amount withdrawn.
-The dollar amounts entered into RFMS did not match the authorized withdrawal amounts.
3. Record review of the facility maintained Resident Trust Statement for the period 04/01/22 through 02/15/23, showed the following withdrawals from Resident #7's account:
Date Amount Description
09/26/22 $100.00 Personal Needs
Record review of the facility maintained paperwork for Resident #7's Resident Trust Statement, showed Resident #7 did not give written authorization for the 09/26/22 withdrawal.
Record review of the facility maintained Resident Trust Statement for the period 04/01/22 through 02/15/23, showed the following withdrawal from Resident #7's account:
Date Amount Description
10/07/22 $100.00 Personal Needs
Record review of the facility maintained Resident Trust signature page dated 10/05/22, showed Resident #7's written authorization for the withdrawal of $40.00 from Resident #7's Resident Trust Account, however review showed a 1 inserted between the dollar sign and 40 making the withdrawal appear as $140.00 instead of $40.00.
Record review of the facility maintained paperwork showed $100.00 was entered into RFMS instead of $40.00 for the 10/07/22 withdrawal.
During an interview on 02/15/23 at 12:55 P.M., Resident #7 said he/she never withdraws $100.00. The most he/she has withdrawn was either $40.00 or $50.00 and did not withdraw $100.00.
Review of the facility maintained Resident Trust signature page, dated 10/05/22, showed the BOM documented in handwriting the total of all daily withdrawals for the unit was $217.00.
During an interview on 02/15/22 at 1:45 P.M., the current BOM said:
-He/she remembered giving $40.00 to Resident #7 for the 10/07/22 withdrawal.
-He/she did not have access to RFMS until 10/10/22.
-The authorized withdrawal sheet for the 10/05/22 daily unit withdrawals (posted on 10/07/22) totaled $217.00 prior to the former Acting BOM taking the paperwork to a sister facility to enter into RFMS. The former Acting BOM entered $477.00 into RFMS but only gave $217.00 to the current BOM to replenish resident petty cash, which was $260.00 less than the amount withdrawn.
-The dollar amounts entered into RFMS did not match the authorized withdrawal amounts.
4. Record review of the facility maintained Resident Trust Statement for the period 06/01/22 through 02/15/23, showed the following withdrawal from Resident #8's account:
Date Amount Description
09/26/22 $50.00 Personal Needs
Record review of the facility maintained paperwork for Resident #8's Resident Trust Statement, showed Resident #8 did not give written authorization for the 09/26/22 withdrawal.
Record review of the facility maintained Resident Trust Statement for the period 06/01/22 through 02/15/23, showed the following withdrawal from Resident #8's account:
Date Amount Description
10/07/22 $110.00 Personal Needs
Record review of the facility maintained Resident Trust signature page, dated 10/05/22, showed Resident #8's written authorization for a withdrawal of $10.00 from Resident #8's Resident Trust Account, however review showed a 1 inserted between the dollar sign and 10 making the withdrawal appear as $110.00 for Resident #8.
Record review of the facility maintained paperwork showed $110.00 entered into RFMS instead of $10.00 for the 10/07/22 withdrawal.
During an interview on 02/15/23 at 1:08 P.M., Resident #8 said he/she usually withdraws no more than $10.00 at a time, but has occasionally withdrawn $20.00 or $30.00. Resident #8 said he/she never withdraws $50.00 at one time.
Review of the facility maintained Resident Trust signature page, dated 10/05/22, showed the BOM documented in handwriting the total of all daily withdrawals for the unit was $217.00.
During an interview on 02/15/22 at 1:45 P.M., the current BOM said:
-He/she remembered giving $10.00 to Resident #8 for the 10/07/22 withdrawal.
-The current BOM did not have access to RFMS until 10/10/22.
-The authorized withdrawal sheet for the 10/05/22 daily unit withdrawals (posted on 10/07/22), totaled $217.00 prior to the former Acting BOM taking the paperwork to a sister facility to enter into RFMS. The former Acting BOM entered $477.00 into RFMS but only gave $217.00 to the current BOM to replenish resident petty cash, which was $260.00 less than the amount withdrawn.
-The dollar amounts entered into RFMS did not match the authorized withdrawal amounts.
5. Record review of the facility maintained Resident Trust Statement for the period 06/01/22 through 02/15/23, showed the following withdrawals from Resident #9's account:
Date Amount Description
09/26/22 $100.00 Personal Needs
10/03/22 $50.00 Personal Needs
10/07/22 $100.00 Personal Needs
Record review of the facility maintained paperwork for Resident #9's Resident Trust Statement, showed Resident #9 did not give written authorization for any of the withdrawals.
Record review of the facility maintained Resident Trust Statement for the period 06/01/22 through 02/15/23, showed the following withdrawal from Resident #9's account:
Date Amount Description
10/07/22 $110.00 Personal Needs
Record review of the facility maintained Resident Trust signature page dated 10/06/22, showed Resident #9's written authorization next to $10.00, however review showed a 1 inserted between the dollar sign and 10 making the withdrawal appear as $110.00 for Resident #9.
Record review of the facility maintained paperwork showed $110.00 was entered into RFMS instead of $10.00 for the 10/07/22 withdrawal.
During an interview on 02/15/23 at 1:05 P.M., Resident #9 said he/she usually withdraws around $20.00 and $100.00 is too much and he/she did not withdraw $100.00.
Record review of the Resident Trust signature page, dated 10/06/22, showed the BOM documented in handwriting the total of all daily withdrawals for the unit was $245.00.
During an interview on 02/15/22 at 1:45 P.M., the current BOM said:
-He/she remembered giving $10.00 to Resident #9 for the 10/07/22 withdrawal.
-The current BOM did not have access to RFMS until 10/10/22.
-The authorized withdrawal sheet for the 10/06/22 daily unit withdrawals (posted on 10/07/22), totaled $245.00 prior to the former Acting BOM taking the paperwork to a sister facility to enter into RFMS. The former Acting BOM entered $345.00 into RFMS but only gave $245.00 to the current BOM to replenish resident petty cash, which was $100.00 less than the amount withdrawn.
-The dollar amounts entered into RFMS did not match the authorized withdrawal amounts.
6. Record review of the facility maintained Resident Trust Statement for the period 06/01/22 through 02/15/23, showed the following withdrawal from Resident #10's account:
Date Amount Description
09/29/22 $100.00 Personal Needs
Record review on 02/15/23 of the facility maintained paperwork for Resident #10's Resident Trust Statement, showed Resident #10 did not give written authorization for the 09/29/22 withdrawal.
Record review of the facility maintained Resident Trust Statement for the period 06/01/22 through 02/15/23, showed the following withdrawal from Resident #10's account:
Date Amount Description
10/07/22 $140.00 Personal Needs
Record review of the facility maintained Resident Trust signature page dated 10/05/22, showed Resident #10's written authorization for the withdrawal of $40.00 from Resident #10's Resident Trust Account, however review showed a 1 inserted between the dollar sign and 40 making the withdrawal appear as $140.00 instead of $40.00.
Record review of the facility maintained paperwork showed $140.00 was entered into RFMS instead of $40.00 for the 10/07/22 withdrawal.
During an interview on 02/15/23 at 1:00 P.M., Resident #10 said he/she usually withdraws in increments of eight and has never withdrawn $100.00.
Review of the facility maintained Resident Trust signature page, dated 10/05/22, showed the BOM documented in handwriting the total of all daily withdrawals for the unit was $300.00.
During an interview on 02/15/22 at 1:45 P.M., the current BOM said:
-He/she remembered giving $40.00 to Resident #10 for the 10/07/22 withdrawal.
-The current BOM did not have access to RFMS until 10/10/22.
-The authorized withdrawal sheet for the 10/05/22 daily unit withdrawals (posted on 10/07/22), totaled $300.00 prior to the former Acting BOM taking the paperwork to a sister facility to enter into RFMS. The former Acting BOM entered $500.00 into RFMS but only gave $300.00 to the current BOM to replenish resident petty cash, which was $200.00 less than the amount withdrawn.
-The dollar amounts entered into RFMS did not match the authorized withdrawal amounts.
7. Record review of the facility maintained Resident Trust Statement for the period 06/01/22 through 02/15/23, showed the following withdrawals from Resident #11's account:
Date Amount Description
09/26/22 $100.00 Personal Needs
09/26/22 $100.00 Personal Needs
09/29/22 $100.00 Personal Needs
09/30/22 $114.00 Personal Needs
Record review on 02/15/23 of the facility maintained paperwork for Resident #11's Resident Trust Statement, showed Resident #11 did not give written authorization for any of the withdrawals.
Record review of the facility maintained Resident Trust Statement for the period 06/01/22 through 02/15/23, showed the following withdrawal from Resident #11's account:
Date Amount Description
10/07/22 $125.00 Personal Needs
Record review of the facility maintained Resident Trust signature page dated 10/05/22, showed Resident #11's written authorization for the withdrawal of $25.00 from Resident #11's Resident Trust Account, however review showed a 1 inserted between the dollar sign and 25 making the withdrawal appear as $125.00 instead of $25.00.
Record review of the facility maintained paperwork showed $125.00 was entered into RFMS instead of $25.00 for the 10/07/22 withdrawal.
During an interview on 02/27/23 at 11:19 A.M. and 11:24 A.M., both of Resident #11's financial guardians said there would have been no reason the money would have been withdrawn for the listed withdrawal.
Review of the facility maintained Resident Trust signature page, dated 10/05/22, showed the BOM documented in handwriting the total of all daily withdrawals for the unit was $300.00
During an interview on 02/15/22 at 1:45 P.M., the current BOM said:
-He/she remembered giving $25.00 to Resident #11 for the 10/07/22 withdrawal.
-The current BOM did not have access to RFMS until 10/10/22.
-The authorized withdrawal sheet for the 10/05/22 daily unit withdrawals (posted on 10/07/22), totaled $300.00 prior to the former Acting BOM taking the paperwork to a sister facility to enter into RFMS. The former Acting BOM entered $500.00 into RFMS but only gave $300.00 to the current BOM to replenish resident petty cash, which was $200.00 less than the amount withdrawn.
-The dollar amounts entered into RFMS did not match the authorized withdrawal amounts.
8. During an interview on 02/15/23 at 12:08 P.M., the current BOM said he/she was unable to locate any written withdrawal authorizations/receipts prior to his/her start date of 10/03/22.
9. Record review of the facility maintained email showed the current BOM did not have access to RFMS. Review showed the former Acting BOM sent an email asking to add the current BOM to the RFMS system on 10/07/22 at 8:21 A.M. Review showed the current BOM did not receive access to RFMS until 10/10/22 at 7:05 P.M.
10. Record review on 02/15/23 of the facility maintained Operator Petty Cash Account showed Check #3755 in the amount of $2,247.00 to replenish resident trust for multiple days, which included the overage amounts of resident funds that were not authorized by the residents on 10/05/22 and 10/06/22. Review showed the former Acting BOM signature as Authorized Signature on the front of the check and the former acting BOM signature on the back of the check to cash the check.
11. During an interview on 02/15/23 at 1:45 P.M., the current BOM said the former Acting BOM was training him/her and took the cash withdrawal signature pages back to a sister facility to enter into RFMS and get cash due to the current BOM not having access to RFMS. The current BOM asked the former Acting BOM two times for the backup documentation for the resident cash replenishment. The former Acting BOM would not provide the documentation until the current BOM went to the sister facility and was given the originals, which showed a 1 included in a different color of ink on some of the withdrawal sheets. The current BOM said RFMS showed the amounts keyed into the system, which included more than the amounts the residents originally requested.
12. During an interview on 02/23/23 at 10:32 A.M., the Regional Business Office Manager said funds went back into the residents' accounts that had a number 1 added to the amount after the resident gave written authorization.
13. During an interview on 02/22/23 at 2:03 P.M., the former Acting BOM said he/she did train the current BOM at the facility. He/she did not change the amounts in RFMS and did not keep any cash.
MO00214881
Jan 2023
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
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to report an allegation of a resident to resident altercation to the...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to report an allegation of a resident to resident altercation to the Department of Health and Senior Services (DHSS) within the required timeframe. This affected two of four sampled residents (Resident #2 and #4). The census was 130.
Review of the facility Abuse Investigation and Reporting policy, revised July 2017, showed the following:
-Policy Statement: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigation will also be reported;
-Policy Interpretation and Implementation:
-Role of Administrator:
-If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual;
-Reporting:
1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility administrator, or his/her designee, to the following persons or agencies:
a. The state licensing/certification agency responsible for surveying/licensing the facility:
b. The local/state ombudsman;
c. The resident representative (sponsor) of record;
d. Adult Protective Services (where state law provides jurisdiction in long-term care);
e. Law enforcement officials;
f. The resident's attending physician;
g. The facility medical director;
2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but no later than:
a. Two (2) hours if the alleged violation involves abuse or had resulted in serious bodily injury;
b. Twenty-four (24) hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury;
3. Verbal/written notices to agencies may be submitted via special carrier, fax, e-mail or by telephone.
Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/20/22, showed the following:
-No cognitive impairment;
-No moods or behaviors;
-Independent with activities of daily living (ADLs);
-Diagnoses of high blood pressure, diabetes, anxiety and schizophrenia (a serious mental disorder in which people interpret reality abnormally).
Review of the resident's behavior notes, dated 12/21/22 at 11:14 P.M., showed the resident attacked another resident near the nurse's station. Several staff members were able to get the resident to release the hold he/she had on the other resident. After removing the resident, he/she continued to advance toward the area where the other resident was taken. The staff was unable redirect the resident. The resident said, he/she ain't gone never see day light again. Where (he/she) at? The resident was attempting to elope, cursing at staff and talking to him/herself. The resident is visibly agitated, shaking, pacing and still searching for the other resident.
Review of the resident's medical record, showed no documentation the altercation was reported to the Director of Nursing (DON) or the Administrator.
During an interview on 1/17/23 at 12:35 P.M., the resident said he/she did not remember the altercation and he/she was doing fine.
Review of Resident #4's quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-No mood or behaviors;
-Independent with ADLs;
-Diagnoses of anemia, anxiety, psychotic disorder and schizophrenia.
Review of the resident's behavior note, dated 12/21/22 at 11:26 P.M., showed the resident was involved in a resident-to-resident altercation near the nurse station. The staff was able to separate both parties involved. There were no injuries noted and the resident is currently in his/her room with the call light in reach.
Review of the resident's medical record, showed no documentation the altercation was reported to the DON or the administrator.
During an interview on 1/18/23 at 9:00 A.M., the resident was very confused and talked about random things.
During an interview on 1/18/23 at 12:03 P.M., Certified Nurse Aide (CNA) A said he/she was charting at the nursing station. Resident #4 came to the nursing station for a snack. Resident #2 came up behind Resident #4 while Resident #4 was talking. CNA A said Resident #4 will talk about random things which make no sense. Resident #2 gets confused and thought Resident #4 was talking to him/her. Resident #4 got a snack and walked away from the nursing station. Resident #2 went after Resident #4 and tried to hit him/her. Resident #4 put up his/her hands to block the hit and grabbed Resident #2's hands. CNA A said at that point, staff intervened. CNA A assumed the altercation was reported to the DON.
During an interview on 1/18/23 at 11:30 A.M., the DON, Administrator, Regional Nurse Manager and Director of Operations said the following:
-They expected the facility's abuse investigation and reporting policy to be followed;
-The DON said she was not employed with the facility at the time of the altercation, but expected the DON to be notified immediately so an investigation could be started and the altercation could be reported to the hotline within the required timeframe;
-The Regional Nurse said the Administrator was not with the facility, but did not know why the altercation was not reported to management.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to thoroughly and timely investigate a resident to resident altercat...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to thoroughly and timely investigate a resident to resident altercation. This affected two of four sampled residents (Residents #2 and #4). The census was 130.
Review of the facility Abuse Investigation and Reporting policy, revised July 2017, showed the following:
-Policy Statement: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigation will also be reported;
-Policy Interpretation and Implementation:
-Role of Administrator:
-If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual;
-Role of the Investigator:
1. The individual conducting the investigation will, at a minimum:
a. Review the completed documentation forms;
b. Review the resident's medical record to determine events leading up to the incident;
c. Interview the person(s) reporting the incident;
d. Interview any witnesses to the incident;
e. Interview the resident (as medically appropriate);
f. Interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition;
g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident;
h. Interview the resident's roommate, family members, and visitors;
i. Interview other residents to whom the accused employee provides care or services; and
j. Review all events leading up to the alleged incident.
2. The investigator will consult daily with the administrator concerning the progress/findings of the investigation;
3. Upon conclusion of the investigation, the investigator will record the results of the investigation on approved documentation forms and provide the completed documentation to the administrator.
Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/20/22, showed the following:
-No cognitive impairment;
-No moods or behaviors;
-Independent with activities of daily living (ADLs);
-Diagnoses of high blood pressure, diabetes, anxiety and schizophrenia (a serious mental disorder in which people interpret reality abnormally).
Review of the resident's behavior notes, dated 12/21/22 at 11:14 P.M., showed the resident attacked another resident near the nurse's station. Several staff members were able to get the resident to release the hold he/she had on the other resident. After removing the resident, he/she continued to advance toward the area where the other resident was taken. The staff was unable redirect the resident. The resident said, he/she ain't gone never see day light again. Where (he/she) at? The resident was attempting to elope, cursing at staff and talking to him/herself. The resident is visibly agitated, shaking, pacing and still searching for the other resident.
Review of the resident's medical record, showed no documentation the altercation was reported to the Director of Nursing (DON) or the Administrator.
During an interview on 1/17/23 at 12:35 P.M., the resident said he/she did not remember the altercation and he/she was doing fine.
Review of Resident #4's quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-No mood or behaviors;
-Independent with ADLs;
-Diagnoses of anemia, anxiety, psychotic disorder and schizophrenia.
Review of the resident's behavior note, dated 12/21/22 at 11:26 P.M., showed the resident was involved in resident-to-resident altercation near the nurse station. The staff was able to separate both parties involved. There were no injuries noted and the resident is currently in his/her room with the call light in reach.
Review of the resident's medical record, showed no documentation the altercation was reported to the DON or the administrator.
During an interview on 1/18/23 at 9:00 A.M., the resident was very confused and talked about random things.
During an interview on 1/18/23 at 12:03 P.M., Certified Nurse Aide (CNA) A said he/she was charting at the nursing station. Resident #4 came to the nursing station for a snack. Resident #2 came up behind Resident #4 while Resident #4 was talking. CNA A said Resident #4 will talk about random things which make no sense. Resident #2 gets confused and thought Resident #4 was talking to him/her. Resident #4 got a snack and walked away from the nursing station. Resident #2 went after Resident #4 and tried to hit him/her. Resident #4 put up his/her hands to block the hit and grabbed Resident #2's hands. CNA A said at that point, staff intervened. CNA A assumed the altercation was reported to the DON.
During an interview on 1/18/23 at 11:30 A.M., the DON, Administrator, Regional Nurse Manager and Director of Operations said the following:
-They expected the facility's abuse investigation and reporting policy to be followed;
-The DON said she was not employed with the facility at the time of the altercation, but expected the DON to be notified immediately so an investigation could be started and the altercation could be reported to the hotline within the required timeframe;
-The Regional Nurse said the administrator was not with the facility, but did not know why the altercation was not reported to management so it could be investigated. The administrator is responsible for conducting the investigation in a timely manner.
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 F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide nutritional support, provide meal preferences ...
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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 nutritional support, provide meal preferences and follow their weight policy guidelines and physician orders for Resident #12, who had an unplanned weight loss. The facility also failed to re-weigh Resident #30 when the resident had a substantial weight gain. The sample was 26. The census was 136.
Review of the facility's Nutritional (Impaired)/Unplanned Weight Loss, Revised September, 2017, showed:
Assessment and Recognition:
- The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time;
-The staff and physician will define the individual's current nutritional status (weight, food/fluid intake, and pertinent laboratory values) and identify individuals with anorexia (lack or loss appetite for food), weight loss or gain, and significant risk for impaired nutrition; for example, high risk residents with acute symptoms such as vomiting, diarrhea, fever and infection, or those taking medications that may be causing weight gain or increasing the risk of anorexia or weight loss;
-The physician will consider whether any assessment including additional diagnostic testing is indicated to help clarify the severity or consequences of weight loss and/or impaired nutrition;
-No lab tests are sensitive or specific enough for defining nutritional status that they should be ordered for everyone. Lab tests should be ordered if they are likely to substantially help establish current status or prognosis, causes or choices of interventions; otherwise, routine ordering to assess or follow nutritional status is not generally indicated;
-The staff will report to the physician significant weight gains or losses or any abrupt or persistent change in baseline appetite or food intake.
Cause and identification:
-The physician will review for medical causes of weight gain, anorexia and weight loss before ordering interventions;
-For individuals with recent or rapid weight gain or loss (for example, more than a pound a day), the staff will review for possible fluid and electrolyte imbalance as a cause;
-Conditions such as heart failure and renal failure can cause rapid weight gain and fluid deficits can result in rapid weight loss (2.2 pounds (lbs.) gained or lost for each liter of fluid excess or deficit).The physician, with the help of the multidisciplinary team, will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss;
-The physician will help identify medical conditions (cancer, cardiac or renal disease, depression, dental problems, etc.) and medications that may be causing weight gain or loss or increasing risk for either gaining or losing weight;
-Many categories of diseases and medications can affect appetite directly or indirectly by affecting taste or causing lethargy, confusion, and dry mouth;
-The physician will review carefully, and rule out medical causes of, oral or swallowing problems before authorizing other consults or interventions to modify diet consistency;
-Sometimes, an extensive workup may not be appropriate or knowing the cause may not change the interventions. Nevertheless, a systematic review for causes based on an individual's history, comorbidities (having more that one diseases at the same time) risk factors, may be appropriate even if an extensive workup is not. Persistent change from baseline appetite or food intake;
-The physician will review and rule out medical causes of oral or swallowing problems before authorizing other consults or interventions to modify diet consistency;
-A physician should define and differentiate basic causes of apparent swallowing or choking problems; other disciplines may be trained to treat symptoms but not to identify a differential diagnosis;
-The physician (or staff, based on a discussion with the physician) will document relevant medical information regarding the nature, severity, causes, and consequences of impaired nutritional status, especially in complex situations such as where multiple causes coexist.
Treatments:
-The staff and physician will identify pertinent interventions based on identified causes and overall resident condition, prognosis, and wishes;
-Treatment decisions should consider all pertinent evidence and relevant issues (e.g., food intake, resident wishes, overall condition and prognosis, etc.), and should not be based solely on lab or diagnostic test results (albumin (protein in the blood), cholesterol, swallowing studies.);
-The physician will authorize appropriate interventions, as indicated;
-This may include tapering, stopping, or switching medications known to be associated with undesirable weight gain or anorexia or weight loss.
Treatment and management:
-The physician will document if cause-specific interventions could not be identified or are not feasible;
-The staff and physician will review and consider existing dietary restrictions and modified consistency diets;
-Dietary restrictions are not always essential, and they may even be unnecessary or harmful. In some instances, the risk of continued weight loss and hydration deficits may outweigh other considerations that such restrictions are meant to address;
-The physician will limit prescribing of appetite stimulants to situations in which underlying causes cannot be identified or treated, other pertinent interventions have not worked or are not feasible, these medications have a valid indication, and improving appetite and weight is consistent with the individual's condition, prognosis, and wishes;
-A pertinent assessment and meaningful review of possible medical and non-medical causes of altered nutritional status should precede the use of such medications.
Monitoring:
-The physician and staff will monitor nutritional status, an individual's response to interventions, and possible complications of such interventions (for example, additional weight gain or loss, nausea, or vomiting);
-When medical conditions or medication-related adverse consequences are causing or contributing to altered nutritional status, the physician and staff will collaborate in adjusting interventions, taking into account the status of those causes and the resident responses, goals, wishes, prognosis, and complications.
Review of the facility's Assessment and Management of Residents' Weights policy, revised June, 2020, showed:
Purpose: To ensure that each resident maintains acceptable parameters of weight and nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible based on the resident's comprehensive assessment. To ensure that a resident receives a therapeutic diet when there is a nutritional problem;
Policy: Weights are obtained upon admission and/or re-admission, then weekly for four weeks and monthly thereafter. Additional weights may be obtained at the discretion of the licensed nurse or the interdisciplinary team (IDT);
Procedure:
-A licensed nurse or designee will weigh residents:
-Admissions and re-admissions will be weighed on the shift they arrive;
-Hospital weight will not serve as admission or re-admission weight;
-Adaptive or assistive equipment used during measurement will be documented;
-If the weight is less than or greater than 5 lbs. (pounds) from the previous weight, immediately re-weigh and have a licensed nurse verify the accuracy of the weight;
-Weights will be entered into the clinical record on that shift.
1. Review of Resident #12's, admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/6/23, showed:
-admission date, 12/2/22;
-Requires supervision, oversight, encouragement or cueing with eating;
-Diagnosis included anemia (low red blood cells in the blood), heart failure, gastroesophageal reflux disease (a chronic digestive disease that occurs when stomach acid flows into the esophagus (a canal in the body that transports food from the mouth to the stomach) and causes irritation of the lining), diabetes, anxiety, depression and schizophrenia (a mental disorder where reality is perceived abnormally);
-No rejection in care.
Review of the residents care plan, in use at the time of survey, showed:
Problem: The resident has a nutritional problem or potential nutritional problem related to diet restrictions and obesity;
Interventions: Provide diet as served; Registered Dietician (RD) to evaluate and make dietary changes and recommendations as needed (PRN); Weigh at the same time of the day and record.
Review of the resident's progress notes showed:
-On 1/23/23 at 12:30 P.M.; resident sent to the hospital for right ankle being swollen and increased pain;
-On 1/27/23 at 10:12 P.M. returned from the hospital per stretcher. Resident had repair of an ankle fracture related to an unwitnessed fall.
Review of the resident's physician order sheets (POS) dated March 2023, showed:
-An order, dated 1/27/23, for weights to be done and recorded monthly;
-An order, dated 1/27/23, for regular diet, mechanical soft, regular consistency.
Review of the resident's weights, showed:
-12/16/22: 143.2 lbs;
-1/5/23: 140.0 lbs;
-No re-admission weight;
-February 2023: no weight;
-3/8/23: 132.8 lbs.
Review of the resident's RD nutritional assessment dated [DATE], showed:
-At risk for weight loss;
-Supplements: ferrous sulfate (iron);
-Eating patterns: blank;
-Food groups or foods refused; meat: blank; dairy: blank; fruit and vegetables: blank; bread or cereal: blank; fluids: blank;
-Food preferences: blank.
Observation and interview on 3/28/23 at approximately 11:00 A.M., showed the resident in bed. He /She appeared pale and spoke in a very soft, weak voice. He/She had on a hospital gown with dried food particles on it. The resident said the food was gross, he/she just tries to eat what they give him/her. He/She is never offered anything different when he/she doesn't eat. Staff just take the food tray away. The resident said he/she loves cola to drink, fresh fruits and vegetables but never receives any on his/her tray.
During an interview on 3/28/23 at 11:23 A.M. and 3/30/23 at 9:00 A.M., Certified Nursing Assistant (CNA) A said that the second floor was a dementia unit and no menu or menu choices are provided to that resident population. There used to be a menu posted but it is no longer there. If a resident refuses to eat, the staff should be providing something else in place but sometimes that will take a while to get from the kitchen. He/She has noticed residents losing weight on the second floor and has been trying to feed those residents. The restorative aide is the person responsible for obtaining weights and informing the nurse if there is a weight loss or gain.
Observation and interview on 3/30/23 at approximately 9:00 A.M., showed the resident in his/her bed with his/her tray table partially pushed away from him/her. He/She ate the toast and oatmeal but did not consume the scrambled eggs. He/She said he/she does not like eggs.
2. Review of Resident #30's quarterly MDS, dated [DATE], showed:
-admission date: 12/6/22;
-Cognitively impaired;
-Required limited assistance with eating;
-Diagnoses that included heart disease, anemia and stroke.
Review of the resident's care plan, in use at the time of survey, showed:
Focus: Resident has a nutritional problem or potential nutritional problem related to anorexia, weight loss and loss of appetite;
Interventions: Provide and serve supplements as ordered; Provide, serve and assist with meals; RD to evaluate and make dietary recommendations PRN.
Review of the resident's weights, showed:
-1/9/23:130.0 lbs.;
-2/22/23: 126.2 lbs.;
-3/8/23: 191.2 lbs.;
-No re-weight obtained.
3. During an interview on 3/30/23 at 8:46 A.M. and 3/31/23 at 9:19 A.M., the facility RD said he/she reviews the weights when he/she comes into the building. He/She was not able to see all the residents who needed to be seen the last time he/she visited the facility. Ideally the facility nursing staff should notify the dietician when a resident has had some weight loss, and he/she would provide some type of recommendations, and the facility nursing staff would then call the physician for orders. The resident's preferences should be listed on the resident's meal card and the dietary manager usually will interview the resident for specific preferences. The RD can also obtain meal preferences and pass them onto the dietary manager. All residents are expected to be offered alternatives if they do not like what is on the menu. The residents should be re-weighed immediately when a weight discrepancy is found. Resident #30's weight gain was likely an error in obtaining the weight.
4. During an interview on 3/30/23 at 10:35 A.M., the Dietary Manager said he interviews all the new admissions for meal preferences. He did not have any meal preferences listed for Resident #12 and was not aware he/she had any preferences. The resident was probably admitted before he started working at the facility. There are no menus posted for the residents. Staff should call the kitchen and request a second choice or a cheese sandwich. Second choices include chicken tenders and hamburgers. The second choices are offered every other week (rotating) because when one resident sees, for an example, a hamburger, then the whole floor wants a hamburger. Residents with weight loss are discussed in the morning meetings with members of the management team.
5. During interviews on 3/30/23 at 10:45 A.M. and 1:45 P.M. the Director of Nursing (DON) said weights are expected to be completed by nursing staff on admission, readmission and by the fifth of every month. The nursing management team reviews the monthly weights. Nursing staff are expected to contact the dietician and physician (MD) for further orders, such as supplements. Staff are expected to offer alternatives to residents who are not eating. Staff are expected to re-weigh the resident immediately if possible, when a discrepancy is noted. The dietary manager is responsible to interview the residents for food preferences. For Resident #30, the DON thought the resident was probably weighed with the leg rests on the wheelchair.
6. During an interview on 3/31/23 at 9:08 A.M., with Regional Nurse Consultant said the DON and the dietician are expected to review the monthly weights.
MO00214071
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
Respiratory Care
(Tag F0695)
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 their policy when staff failed to maintain cont...
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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 their policy when staff failed to maintain continuous positive airway pressure (CPAP, machine that uses mild air pressure to keep breathing airways open while you sleep) and bilevel positive airway pressure (BiPap, a machine that delivers two levels of air pressure to keep breathing airways open while you sleep) equipment by not providing distilled water for the humidifier chamber for two of two sampled residents (Resident #28 and Resident #17). The census was 136.
Review of the facility's CPAP/BiPap Support policy, dated 3/2015, showed the following:
-Purpose:
1. To provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen;
2. To improve arterial oxygenation in residents with respiratory insufficiency, obstructive sleep apnea (occurs when your breathing is interrupted during sleep, for longer than 10 seconds at least 5 times per hour (on average) throughout your sleep period) or restrictive/obstructive lung disease;
3. To promote resident comfort and safety;
-Humidifier:
a. Use clean, distilled water only in the humidifier chamber.
1. Review of Resident #28's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/20/23, showed the following:
-Clear speech;
-Ability to express ideas and wants: Understood;
-Ability to understand others: Understood;
-Mildly cognitively impaired;
-Diagnoses included chronic obstructive pulmonary disease (COPD, lung disease), dependence on oxygen and shortness of breath.
Review of the resident's care plan, dated 2/8/23, showed the following:
-Focus: The resident has oxygen therapy. CPAP as ordered. The resident needed to be encouraged to place his/her CPAP on while resting in bed;
-Interventions: Remind and assist with nasal cannula with proper placement;
-Give medications as ordered by physicians;
-No documentation on how to use or clean equipment.
Review of the resident's electronic physician's order sheet (ePOS), showed an order, dated 9/21/21, for CPAP used daily when at sleep.
Review of the resident's electronic medication administration record (eMAR), showed an order, dated 9/26/21, to clean CPAP with soap and water. Remove tubing and allow to soak in warm water. Allow to air dry. Wipe face mask and head gear with soap and water, allow to air dry.
Observation on 3/28/23 at 1:00 P.M. showed the following:
-A CPAP machine on the floor beside the bed with an empty humidifier chamber;
-An empty gallon container of distilled water on the table in front of the bed.
Observation on 3/29/23 at 10:15 A.M, showed the following:
-A CPAP machine on the table in front of the bed. The humidifier chamber was empty;
-An empty gallon of distilled water on the table in front of the bed.
During an interview on 3/29/23 at 10:20 A.M., the resident said he/she had not been given distilled water for over a month. He/she asked different staff and had been told they did not have any or they did not have time to get it for him/her. He/she was using tap water for it, but he/she knew this was not good for it.
2. Review of Resident #17's annual MDS, dated [DATE], showed the following:
-Clear speech;
-Ability to express ideas and wants: Understood;
-Ability to understand others: Understood;
-Mildly cognitively impaired;
-Diagnoses included obstructive sleep apnea and shortness of breath.
Review of the resident's ePOS, showed an order, dated 12/14/17, for BiPap on at bedtime.
Review of the resident's care plan, dated 2/17/23, showed the following:
-Focus: The resident has been prescribed BiPap with settings;
-Interventions: Educate resident on the purpose of BiPap machine. BiPap at night. Encourage resident to use BiPap. If resident refuses to use BiPap machine at night, document amount of time was worn, tolerance of machine during treatment, oxygen saturation, condition of resident's skin changes in level of consciousness, education provided and his/her response. Inform physician/nurse practitioner;
-No documentation on how to use or clean equipment.
Observation on 3/28/23 at 1:05 P.M., showed the resident's BiPap machine on his/her dresser, with an empty humidifier chamber.
Observation on 3/29/23 at 10:20 A.M., showed the resident's BiPap machine on his/her dresser, with an empty humidifier chamber.
During an interview on 3/29/23 at 12:00 P.M., the resident said staff often run out of distilled water or give the last gallon to his/her roommate. He/She was having problems with his/her roommate and he/she would not share the water. If they do not have the distilled water, he/she will just run the machine without any water or will not use it at all.
During an interview on 3/29/23 at 10:00 A.M., Certified Medication Technician (CMT) C said they kept distilled water in the supply room adjacent to the nurse's station. When asked if he/she could show the surveyor extra water, he/she was unable to locate any. CMT C said if they ran low, they usually filled out a central supply list, and someone from central supply would pick it up and bring up what they needed. He/She did not know when the water was last ordered. CMT C thought he/she had given the residents a gallon of distilled water a couple of weeks ago.
Review of the central supply lists provided by the facility on 3/30/23, showed:
-Staff should have the list ready by 10:00 A.M.;
-An area designating the floor requesting items;
-An area for the date items were requested;
-A note to check their supply closet first before ordering;
-A check list of items staff could request;
-An area labeled miscellaneous where staff could write items not labeled on the list, such as distilled water;
-Lists filled out by staff from Resident #28 and Resident #17's floor, showed no requests for distilled water from February 2023 through March 2023.
During an interview on 3/30/23 at 8:25 A.M., the Central Supply Clerk said he/she did not remember the staff on the residents' floor requesting distilled water recently but someone could have come down and gotten it themselves. Usually they put it on the supply list and she picked the list up in the morning and brought the supplies up later in the day. She had several gallons of distilled water in the supply room. She did not know why staff would not provide it to the residents if they needed it.
During an interview on 3/30/23 at 11:30 A.M., the Director of Nursing said she expected nursing staff to know there was no distilled water on the unit for the residents and to have ordered more from central supply when it ran low. If the residents were asking for distilled water, then staff should have known there was not any in the storage room. The residents should not use tap water for the CPAPs and BiPaps because this could damage the equipment. The staff should have stored the distilled water at the nurse's stations with the residents' names on it.
During an interview on 3/30/23 at 11:30 A.M., the Administrator said the staff should have provided the residents with distilled water for their CPAP and BiPap machines. If they ran out, they should have ordered more from central supply.
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
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a safe, clean and comfortable, homelike enviro...
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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 a safe, clean and comfortable, homelike environment. The facility failed to unclog sinks in resident rooms, failed to fix broken closet doors, water fountains, shower faucets and repair damaged ceiling tiles. The sample size was 26. The census was 136.
1. Review of Resident #34's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/8/23, showed the resident was cognitively intact.
Observation of Resident #34's room on 3/28/23 at 9:00 A.M., showed when he/she turned the cold water handle in his/her sink, no water came out.
During an interview, the resident said he/she reported the cold water problem to staff a few times but nothing had been done.
2. Review of Resident #32's quarterly MDS, dated [DATE], showed the resident was admitted on [DATE] and was cognitively intact.
Observation of Resident #32's room on 3/29/23 at 10:25 A.M., showed the sink was half full of standing water. The water was a brownish color and would not drain out of the sink.
During an interview on 3/29/23 at 10:25 A.M., the resident said the sink had been stopped up since he/she had arrived at the facility. He/She wished he/she could wash his/her hands or brush his/her teeth in his/her room.
3. Observation of room [ROOM NUMBER] on 3/29/23 at 10:35 A.M., showed the sink was stopped up and filled with brownish water. The water would not drain out of the sink.
4. Observation of room [ROOM NUMBER] on 3/29/23 at 10:38 A.M., showed both closet doors off the track and pushed back against the front of the closet.
5. Review of Resident #28's quarterly MDS, dated [DATE], showed the resident was cognitively intact.
Observation of Resident #28's room on 3/29/23 at 10:40 A.M., showed the closet door adjacent to the entry door, with the sliding vinyl door torn from the hanging latches.
During an interview on 3/29/23 at 10:40 A.M., the resident said he/she was moved to this room a couple of months ago and the closet door was like that when he/she was moved to the room. He/She made complaints about it to staff, but it did not do any good because nothing was done.
6. Observation on 3/29/23 at 11:45 A.M., showed the 300 hall men's shower room had a push button sink faucet. Upon pushing down on the button, water did not exit from the spout. Water exited from the sink's push button and ran around the sink.
7. Observation on 3/29/23 at 11:55 A.M., showed the 300 hall men's bathroom had a push button sink faucet. Upon pushing down on the button, water did not exit from the spout. Water exited from the sink's push button and ran around the sink.
8. Observation on 3/29/23 at 12:00 P.M., of room [ROOM NUMBER], showed the sink half-full of brownish water.
During an interview on 3/29/23 at 12:05 P.M., Certified Nurse's Aide (CNA) I said this resident's room sink had been stopped up for months. CNA I had filled out a request for maintenance several times and put it in the box, but no one had fixed it yet.
9. Observation of the staff lounge area on 3/30/23 at 6:45 A.M., showed a 1 1/2 foot by 1 1/2 foot missing ceiling tile, adjacent to the entry wall, which exposed pipes in the ceiling. The door was open to the hallway and accessible to residents.
During an interview on 3/30/23 at 12:30 P.M., Certified Nurses Aide K said the tile had been missing in the staff lounge for weeks.
10. Review of Resident #35's quarterly MDS, dated [DATE], showed the resident was cognitively intact.
Observation and interview on 3/30/23 at 7:35 A.M., showed the resident stood near the sink in his/her room. The sink basin was filled approximately halfway with water. The water was brownish in color. The resident said maintenance would come fix the sink and then it would back up again. This had been happening for four to five months. Administration knows there are problems with the sinks backing up but do not make the necessary repairs. They plunge the sink or they move people from room to room, but it does not change the problems with the plumbing. The sinks keep backing up again. He/She pointed to a blanket over his/her window. The blanket was wet all along the bottom of the window. The paint was peeling around the window where the water had damaged the wood. The resident said the window leaked when it rained and he/she used the blanket to keep the water from getting on his/her floor. He/She had been telling maintenance for over a year that water was leaking in his/her window.
11. Observation on 3/30/23 at 7:00 A.M. of the first floor resident use shower room, adjacent to room [ROOM NUMBER], showed two shower stalls. The handle in the shower stall closest to the back wall was broken off, which would not allow the water to be turned on.
Review of Resident #33's quarterly MDS, dated [DATE], showed the resident was cognitively intact.
During an interview the resident said the shower handle had been broken for months. It was frustrating because there were a lot of residents on the first floor and only one person could use the shower room at a time.
Review of a repair requisition located in the request bin, on the 100 hall nurses' station on 3/30/23 at 7:25 A.M., showed a request for a repair dated 11/17/22, for the south wing restroom with the two showers, to increase the water pressure and please repair the shower handle. It had been broken for years and it would be good if it worked again.
12. Observation on 3/30/23 at 7:45 A.M., showed the water fountain by the 100 hall nurses' station out of order and covered with a black plastic bag.
During an interview on 3/30/23 at 7:50 A.M., a resident who wished to remain anonymous, said the water fountain had not been working for months.
13. Observation on 3/30/23 at 10:20 A.M., of room [ROOM NUMBER]'s door, showed a 12 inch by 2 inch piece of missing wood at the top of the door, with exposed screws.
14. Observation on 3/30/23 at 10:15 A.M., of the 300 hallway, adjacent to room [ROOM NUMBER], showed a 1 1/2 foot by 1 1/2 foot ceiling tile was covered with rust-colored discoloration and blackened and greenish areas. The ceiling tile bulged down the middle with water damage and had cracks along the sides.
15. During an interview on 3/29/23 at 11:00 A.M., Housekeeper J said he/she has reported the stopped up sinks to maintenance. He/She did not know why they have not been fixed. He/She reports things when he/she sees the maintenance person on the floor. Sometimes if an issue is small, he/she just tries to fix it him/herself. There is just so much the maintenance person can do alone.
16. During an interview on 3/29/23 at 11:05 A.M., Certified Medication Technician (CMT) C said he/she fills out a repair slip for maintenance and they are supposed to come around and get them, but they don't always get around to collect them. They fix the sinks and then they get stopped up again. This continues to be a problem.
17. During an interview on 3/29/23 at 8:45 A.M. the Maintenance Director said he started working at the facility at the end of January. He conducts environmental rounds daily. He is the only maintenance person for the entire building. He makes repairs as residents tell him they need them. He tried to get to them as soon as he could. They have been doing a lot of work on the third floor with fixing rooms and painting. They needed to repair all the pipes on that floor and that is why some of the sinks keep backing up. They obtained bids for the repairs but have not had the work done yet. It is an old building and things keep breaking down.
18. During an interview on 3/30/23 at 1:35 P.M., the Regional Director of Maintenance said there had been some leaking pipes that were fixed and that is why some of the ceiling tiles had not been replaced yet. He did not know why the sinks had not been fixed yet. No one told him they were stopped up. He did not know the shower handle was broken but should be fixed or taken out if it did not work. The building was old and needed a lot of repairs. The Maintenance Director had only been there a couple of months and they were trying to hire more staff to assist him. He expected repairs to be made as soon as possible.
MO00213151
MO00214071
MO00215524
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
Grievances
(Tag F0585)
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 maintain an effective grievance process for residents to voice grie...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain an effective grievance process for residents to voice grievances and prompt facility efforts to resolve grievances. The facility's policy failed to identify a grievance official responsible for overseeing grievances. The facility failed to follow the policy by not making the information regarding how to file a grievance or complaint visible and available to all residents residing in the facility. The facility also failed to maintain the results of grievances filed for a minimum of three years. The census was 136.
Review of the facility's Grievance Program, dated 4/2017, showed the following:
-Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances;
-Policy Interpretation and Implementation:
1. Any resident, family member or appointed resident representative may file a grievance or complaint of care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility. Grievances also may be voiced or filed regarding care that has not been furnished;
2. Residents, family and resident representatives have the right to voice or file grievances without discrimination or reprisal in any form and without fear of discrimination or reprisal;
3. All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response;
4. Upon admission, residents are provided with written information on how to file a grievance or complaint. A copy of our grievance/complaint procedure is posted on the resident bulletin board;
5. Grievances and/or complaints may be submitted orally or in writing and may be filed anonymously;
6. The contact information for the individual(s) with whom a grievance may be filed is provided to the resident and/or representative upon admission;
7. The administrator has delegated the responsibility of grievance and/or complaint investigation to the Grievance Officer who is (this area was left blank) and can be contacted by (this area was left blank);
8. Upon receipt of a grievance and/or complaint, the Grievance Officer will review and investigate the allegations and submit a written report of such findings to the Administrator within five working days of receiving the grievance and/or complaint;
9. The Grievance Officer will coordinate actions with the appropriate state and federal agencies, depending on the nature of the allegations. All alleged violations of neglect, abuse and/or misappropriation of property will be reported and investigated under guidelines for reporting abuse, neglect and misappropriation of property, as per state law;
10. The Grievance Officer, Administrator and staff will take immediate action to prevent further potential violations of resident rights while the alleged violation is being investigated;
11. The Administrator will review the findings with the Grievance Officer to determine what corrective actions, if any need to be taken;
12. The resident or person filing the grievance and/or complaint on behalf of the resident will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct any identified problems;
a. The Administrator or his designee will make such reports within (left blank) working days of the filing of the grievance or complaint within the facility;
b. A written summary of the investigation will also be provided to the resident, and a copy will be filed in the business office;
13. If the grievance was filed anonymously, the Grievance Officer will inform the resident that a grievance has been filed anonymously on his or her behalf and the steps that will be taken to investigate the grievance(s) and report the findings. The Grievance Officer will reiterate to the resident that it is against facility policy and federal regulations to discriminate or sanction a resident who has filed or verbalized a complaint against the facility and that his or her rights to be free of discrimination or reprisal will be protected;
14. The results of all grievances filed, investigated and reported will be maintained on file for a minimum of three years from the issuance of the grievance decision;
15. This policy will be provided to the resident or the resident's representative upon request.
1. Review of the facility's grievance log on 3/30/23, showed the following:
-On 3/28/23, a grievance filed with no documentation of follow up, resolution of grievance, notification to resident, nurses' or Administrator's signature;
-On 1/23/23, a grievance filed with no documentation, nurses' or Administrator's signature;
-No documentation of any other grievances filed in 2023;
-On 12/19/22, a grievance filed with no documentation of follow up, resolution of grievance, notification to resident, nurses' or administrators signature;
-On 12/13/22, a grievance filed with no documentation nurses' or Administrator's signature;
-On 12/17/22, a grievance filed with no documentation of follow up, resolution of grievance, notification to resident; another grievance filed with no documentation, nurses' or Administrator's signature;
-On 12/27/22, three grievances filed with no documentation, nurses' or Administrator's signature;
-On 10/11/22, a grievance filed with no documentation of resolution of grievance, notification to resident, no documentation of nurses' or Administrator's signature;
-No documentation of any other grievances prior to 10/22.
2. Review of Resident #32's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/19/23 showed:
-Clear speech;
-Ability to express ideas and wants: Understood;
-Ability to understand others: Understood;
-Cognitively intact.
During an interview on 3/30/23 at 12:40 P.M., the resident said he/she had never been told about a grievance procedure or told about a number he/she could call. He/She did not know how to fill out a grievance form. He/She would talk to a staff member if he/she had a problem.
3. Review of Resident #28's quarterly MDS, dated [DATE], showed:
-Clear speech;
-Ability to express ideas and wants: Understood;
-Ability to understand others: Understood;
-Mildly cognitively impaired.
During an interview on 3/30/23 at 12:50 P.M., the resident said no one had told him/her about filling out a form or how to formally file a grievance. He/She could talk to staff if he/she had a problem. There were certain staff who would follow through on helping him/her with issues and there were some that would not do anything. It was worse on weekends and nights and with agency staff. No one ever gave him/her anything back in writing.
4. Review of Resident #33's quarterly MDS, dated [DATE], showed:
-Clear speech;
-Ability to express ideas and wants: Understood;
-Ability to understand others: Understood;
-Cognitively intact.
During an interview on 3/30/23 at 1:10 P.M., the resident said he/she did not know about any grievance system. If he/she had a problem, he/she would talk to a staff member he/she trusted. He/she did not always get his/her concerns resolved. No one ever gave him/her anything back in writing.
5. Review of Resident #31's quarterly MDS, dated [DATE], showed:
-Clear speech;
-Ability to express ideas and wants: Understood;
-Ability to understand others: Understood;
-Cognitively intact.
During an interview on 3/30/23 at 1:30 P.M., the resident said he/she is the vice president of the resident council. If a resident had a concern, they would come to him/her. Residents know this because staff tell them. He/She did not know if all staff knew to tell the residents or how residents on locked floors would be able to report their concerns to him/her (Resident #31). There are no forms to fill out or particular staff to go to if they had a concern. No one ever brings anything in writing back to him/her. The activity director sets up and attends their resident council meetings and records their concerns, and he/she can ask for any staff member to attend if he/she has a concern with that department. No one ever gets back with him/her about the concerns brought up in the meeting, and very few complaints are ever resolved.
6. During an interview on 3/30/23 at 12:45 P.M., Certified Medication Technician (CMT) C said if a resident had a concern, he/she would just call social services and they would come talk to the resident. The staff would work with them on the weekends or if social services were not in the building. He/She did not know anything about a grievance form.
7. During an interview on 3/30/23 at 12:55 P.M., CMT D said he/she worked at the facility for about two months. If a resident had a grievance, he/she would give them a phone number listed on the paper. He/She pointed to a compliance and ethics information poster on the wall. He/She said there is a number they could search for on the Internet, or ask the Administrator. He/She did not know about a form the residents could fill out.
8. During an interview on 3/30/23 at 1:00 P.M., Nurse F said if a resident had a grievance, they would notify the nurse or nurse management on duty. That person would get the resident the paperwork to fill out. Administration had two days to get back with the resident with the response to the grievance.
9. During interviews on 3/30/23 at 12:35 P.M. and 1:00 P.M., the social worker said there is not a specific Grievance Officer. Usually if a resident had a grievance, the staff would call her and she would go talk to the resident. She is the only social worker for all of the residents and she does her best to get to everyone. She would talk to them and help them fill out the grievance form or have a mediation session. She would get both sides of the story and forward it to the Administrator who would take care of it from her end. She would document the information in the resident's electronic medical record. She only had grievance records from December until now because the previous Administrator took the old records.
10. During an interview on 4/6/23 at 10:35 A.M., the Regional Nurse Consultant said any staff can give a resident a grievance form. The grievances are brought to the morning meeting and given to the department they are about. The department would answer the grievance and give it back to the Administrator. The Administrator would sign it and give a copy back to the resident and place a copy in the grievance log. There is also a poster, posted throughout the facility, with a hotline number that goes to their corporate lawyers. The residents and families can call this number and the lawyers will relay this concern back to the Administrator. The residents and families all know about this. They have given them this information in Resident Council. This information is not in the policy because the policy is just general information.
MO00215234
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 F0742
(Tag F0742)
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 received appropriate 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 ensure residents received appropriate person-centered care and met the highest practicable psychosocial well-being when the facility failed to ensure mental health services were provided for five sampled residents who displayed behaviors and/or hallucinations (Residents #28, #29, #21, #17 and #19). The resident sample was 26. The census was 136.
Review of the facility's Psychotherapeutic Drug Management policy, revised June 2020, showed:
-Purpose: To implement the most desirable and effective interventions to change, modify, decrease, or eliminate behaviors that are distressing to the resident, and/or are decreasing or negatively impacting the residents' quality of life;
-To help promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being, promote resident safety and security, and to enhance the resident's ability to interact positively with his/her environment;
-To ensure the resident receives only those medications, in doses and for the duration clinically indicated to treat the resident's assessed conditions;
-To ensure non-pharmacological interventions are considered and used when indicated, instead of, or in addition to, medication;
-To ensure clinically significant adverse consequences are minimized;
-To ensure that any potential contribution the medication regimen has to an unanticipated decline or newly emerging or worsening symptoms is recognized and evaluated, and the regimen is modified when appropriate;
-The Facility supports the goal of determining the underlying cause of behavioral symptoms so the appropriate treatment of environmental, medical, and/or behavioral interventions, as well as psychopharmacological medications can be utilized to meet the needs of the individual resident;
-The Facility will make every effort to comply with state and federal regulations related to the use of psychopharmacological medications in the long-term care facility to include regular review for continued need, appropriate dosage, side effects, risks and/or benefits;
-Efforts to reduce dosage or discontinue of psychopharmacological medications will be ongoing, as appropriate, for the clinical situation;
-Psychotherapeutic drugs will only be utilized with a physician order and will never be used for the convenience of staff;
-The facility will utilize individualized, non-pharmacological approaches to care (e.g., purposeful and meaningful activities). Meaningful activities are those that address the resident's customary routines, interests, preferences, and choices to enhance the resident's wellbeing;
-Psychiatrist/Mental Health Responsibility: Provides consultation services;
-Assists the Facility and the attending medical practitioner in establishing appropriate guidelines for use, dosage and monitoring of psychotropic medications;
-Provides in-service training to nursing, medical, and other staff as appropriate.
-Participates in the development of the resident's individualized behavior management plan;
-Nursing responsibility: Consider other factors that may be causing expressions or indications of distress before initiating a psychotropic medication, such as an underlying medical condition (e.g., urinary tract infection, dehydration, delirium), environmental (lighting, noise) or psychosocial stressors;
-Will monitor psychotropic drug use daily noting any adverse effects. (i.e., EPS, Tardive dyskinesia, excessive dose or distressed behavior);
-Monitoring should also include evaluation of the effectiveness of non-pharmacological approaches prior to administering as needed (PRN) medications;
-Will monitor the presence of target behaviors on a daily basis charting by exception (i.e., charting only when the behaviors are present);
-Reviews the use of the medication with the physician and the interdisciplinary team at least quarterly to determine the continued presence of target behaviors and or the presence of any adverse effects of the medication use;
-Implements and updates the care plan as indicated;
-Social Services Responsibility: The Social Worker or designee will complete an initial Social Service Assessment that takes into account the factors that may contribute to the resident's behaviors;
-Information will be collected from the resident and from the resident's surrogate, family and friends as applicable;
-The assessment will include the resident's past psychosocial history and spiritual needs;
-The Social Worker will complete a progress note at least quarterly describing the resident's behaviors, use of psychotropic medication, and the effect of the medication in controlling behaviors;
-The Social Worker will participate in development of the resident's Care Plan and provide social service visits to identify new needs and address ongoing needs.
1. Review of Resident #28's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/20/23, showed the following:
-Mood: Symptoms present:
Feeling down and depressed: Yes;
Trouble falling asleep or staying asleep: Yes;
Sleeping too much: Yes;
Feeling Tired or having little energy: Yes;
Poor appetite or overeating: Yes;
-Mildly cognitively impaired;
-Special therapies: Psychological Therapy: Any licensed Mental Health Professional: Record # of Days: 0
-Diagnoses included schizophrenia (mental disorder in which reality is interpreted abnormally), major depressive disorder and anxiety disorder.
Review of the resident's care plan, in use during survey, showed:
-Focus: Resident has alteration in thought process related to schizophrenia;
-Interventions:Administer medications as ordered. Monitor/document for side effects and effectiveness;
-Anticipate and meet the resident's needs;
-Caregivers to provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by;
-Praise any indication of the resident's progress/improvement in behavior;
-Social service to speak with resident regarding behavior and draw up contract;
-Staff to redirect resident and remind him/her behavior is not tolerated;
-Focus: Resident uses antidepressant medication related to depression;
-Interventions: Administer medications as ordered by physician;
-Monitor/document/report as needed adverse reactions to antidepressant therapy, change in behavior/mood/cognition/suicidal thoughts;
-Focus: The resident has a mood problem:
-Interventions: Assist the resident with developing/provide the resident with a program of activities that is meaningful and of interest to him/her. Encourage and provide opportunities for exercise, physical activity;
-Encourage resident to express feelings;
-Monitor/document/report as needed any risk for harm to self, suicidal plan, past attempt at suicide risky actions, intentionally harm or trying to harm self, refusing to eat or drink, refusing meds or therapies, sense of hopelessness or helplessness, impaired judgement or safe awareness;
-Monitor/record/report to MD as needed any acute episode, feelings of sadness, loss of pleasure and interest in activities, feelings of worthlessness or guilt, change in appetite/eating habits, change in sleep patterns, diminished ability to concentrate, change in psychomotor skills;
-Monitor/record/report to MD as needed risk for harming others; increased anger, labile (easily altered) mood or agitation, feels threatened by others or thoughts of harming someone.
Review of the resident's progress notes, showed:
-On 12/8/22 at 12:27 A.M., the resident returned from the hospital. He/She was diagnosed with anxiety during the visit. At 5:15 P.M., a physician's note: The resident was post hospitalization for anxiety and severe hypokalemia (low potassium level) and the nursing administration requested the resident be evaluated for respiratory issues. The resident had a normal mood, normal affect, was cooperative but was anxious and upset due to son's death. Plan: Nursing notified and administering medication and calling psychiatrist for anti-anxiety medication;
-On 12/29/22 at 7:42 A.M., a physician's note: Resident anxious and upset due to death of son this A.M. Plan: Nursing notified and administering medication and calling psychiatrist for anti-anxiety medication;
-On 1/10/23 at 10:05 A.M., the resident wanted his/her order of Lorazepam (a medication used to treat agitation) changed from 0.5 milligrams (mg) to 1 mg. Staff called the psych doctor who said they had not started seeing patents yet and the Director of Nursing would have to finalize some stuff before they could begin seeing patients;
-On 1/18/23 at 8:46 A.M., the resident reported he/she was seeing and hearing his/her dead son. He/She denied being able to hear what he/she said and thought it might go away if he/she could get his/her dose of Ativan raised. Staff informed the resident psych would be informed. At 1:15 P.M., staff contacted psych and were waiting for a call back. At 1:50 P.M., the staff administered Nitrostat sublingual for chest pain. At 2:11 P.M., staff administered Nitrostat sublingual for chest discomfort. At 2:32 P.M., staff administered Nitrostat sublingual for chest pain. At 3:45 P.M., staff contacted the resident's physician regarding the resident still seeing and unable to hear his/her son. The resident was requesting to go to the hospital because his/her dose of Ativan was not raised and the psych provider had not seen him/her. The physician gave a verbal order to send the resident to the hospital for evaluation and treatment. At 4:07 P.M., staff contacted an ambulance company for a non-emergency transfer to the hospital. At 5:19 P.M., the emergency medical services (EMS) arrived to transport the resident to the hospital. At 9:03 P.M., the hospital called and informed the staff the resident did not meet the requirements for admissions and would be returning to the facility.
Review of the resident's hospital after visit summary, dated 1/18/23, showed the following:
-The resident was evaluated in the emergency department for a mental health problem;
-Recommended he/she follow up closely with his/her primary psychiatrist so they could help with his/her future care;
-If he/she developed thoughts of harming him/herself or anyone else or realized he/she heard voices that no one else could hear, he/she should come back to the hospital.
Review of the resident's progress notes, showed the following:
-On 1/19/23 at 12:26 A.M., a late entry from physician: The resident had a recent hospitalization for suicide ideations. He/She had three immediate family member deaths in the last few months, most recently his/her brother. The resident stated he/she is feeling better and currently denied suicidal ideations. Resident stated his/her anxiety medication was reduced recently and he/she has been more stressed in general along with recent family deaths. Advised resident to speak with nurse and primary care physician about increased stress and medication management. At 1:57 P.M., a late entry from physician: Nursing staff requested resident be seen for shortness of breath with anxiety. Cooperative but anxious and upset due to son's death. Plan of care: Discussed with the nursing staff continue to monitor and treat pulmonary need and collaborate with primary care physician as needed;
-On 1/20/23 at 1:06 P.M., the physician visited the resident today. The new orders were as follows: Start Amitriptyline 50 milligrams by mouth every evening for anxiety and insomnia;
-On 3/9/23 at 1:15 P.M., staff called the psych nurse practitioner in regard to the resident's Lorazepam order. The nurse practitioner said the resident needed a new script and he would need to see the resident before writing a new script. He would be in the next week;
-No documentation of psych notes.
Review of the resident's physician's orders sheet (POS), dated March 2023, showed:
-An order, dated 12/7/22, for buspirone hydrochloride 15 mg (a medication used to treat depression and anxiety);
-An order, dated 12/19/22, for Lorazepam 0.5 mg;
-An order, dated 12/20/22, for Citalopram Hydrobromide tablet 20 mg (a medications used to treat depression);
-An order, dated 1/20/23, for Amitriptyline HCL tablet 50 mg.
During interviews on 3/28/23 at 10:00 A.M. and on 3/29/23 at 10:15 A.M., the resident said he/she had several family members die last year. He/She was hardest hit when his/her son died in November. No one talked to him/her about it. In January, he/she finally broke down and started seeing him. The staff sent him/her to the hospital but the hospital sent him/her right back. The only people who talked to him/her about how he/she was feeling was the ambulance people. No one at the hospital or the facility addressed it with him/her when he/she got back or since then. Sometimes, he/she got really depressed when he/she thought about it. He/She was having a really hard time dealing with the loss and there was no one to talk to about it. The resident asked several times to speak to a psychiatrist but they would tell him/her they made him/her an appointment and then it would be canceled. He/She had not met with anyone from psych since the deaths. The resident felt like his/her medication needed to be changed but he/she had to see the psychiatrist for this to happen. It felt like no one cared about him/her.
During an interview on 3/30/23 at 10:45 A.M., Certified Medication Technician (CMT) C said the resident does get depressed at times because he/she had lost several family members in a short period of time. The staff try to talk to him/her when he/she was down and they will call the social worker if she was available. The resident has not seen a psych doctor since he/she was sent to the hospital in January. He/She has asked to see someone a couple of times but no one came until yesterday afternoon. The staff do their best to try and talk to the residents and calm them down.
During an interview on 3/29/23 at 12:35 P.M., the Social Services Director (SSD) said she thought the resident went to the hospital in January for breathing issues. She did not know the resident had told staff he/she was seeing and grieving for his/her dead son. The staff should have told her about this. The resident should have seen someone when he/she came back from the hospital. The facility changed psych groups in January and the new therapists would not be seeing residents until mid April. No one had seen a psychiatrist since January. The SSD has been working on trying to find therapists who will come out and see the residents but it is difficult to get people out there and there are insurance issues. The group that used to come prior to January stopped coming due to billing issues. She tried to see as many residents as she could. She did not always document who she saw because she there was so much to do and so many people to see.
During an interview on 3/30/23 at 9:00 A.M., the Administrator said someone should have made the Social Worker aware the resident had been sent to the hospital after making statements he/she was seeing his/her dead son. The staff usually go over residents who went to the hospital overnight in the morning clinical meeting. She did not know why this got missed. She is not aware of any grief services provided at the facility.
2. Review of Resident #29's medical record, showed:
-admitted on [DATE];
-Diagnoses included schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety.
Review of the resident's care plan, in use during survey, showed:
-Focus: He/She has a behavior problem related to descriptive account of occurrence involving him/herself and others;
-Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness;
-Educate him/her on successful coping and interaction strategies;
-Encourage him/her to express feelings appropriately;
-Explain all procedures before starting and allow the resident to adjust to changes;
-Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident;
-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;
-Monitor behavior episodes and attempt to determine underlying cause;
-Focus: Resident has a behavior problem as he/she often calls 911 for placement to another facility;
-Intervention: Anticipate and meet the resident's needs;
-Encourage him/her to express feelings appropriately;
-Explain all procedures to him/her before starting and allow the resident to adjust to changes;
-Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident;
-Focus: Resident has a mood problem due to diagnoses of schizophrenia, anxiety and dementia with behaviors;
-Interventions: Assist him/her to identify strengths, positive coping skills and reinforce these;
-Encourage him/her to express feelings;
-Monitor/record/report to MD as needed (PRN) mood patterns signs and symptoms of depression, anxiety, sad mood as per facility behavior monitoring protocols;
-Psych consults as needed.
Review of the resident's progress notes, showed:
-On 3/10/23 at 6:16 P.M., resident was admitted from other entity via ambulance. Resident is alert. Oriented to person, place, time, situation. Mood is withdrawn. Behaviors: resistance to care;
-On 3/23/23 at 12:32 P.M., resident reported to this nurse that he/she is hallucinating because a medication he/she was on for 40 years is not being given anymore. No report of self-harm or wanting to harm him/herself. Call placed to physician to report findings. Resident is his/her own power of attorney (POA) and wants to go to the hospital for evaluation. Resident will be sent to hospital for evaluation;
-At 12:44 P.M., physician made aware and is ok for resident to be sent to hospital for evaluation;
-At 3:08 P.M., gave report to nurse at hospital, faxed over orders and face sheet, due to nurse stating it wasn't received from emergency medical technician (EMT);
-On 3/24/23 at 11:30 A.M., Late Entry: Behavior Note: This writer and MDS went up and spoke to resident about his/her current stay. Resident stated that he/she was not happy here and he/she wanted to leave. It was explained that he/she was his/her own person, and he/she is able to leave at any time. Resident stated that he/she has nowhere to go and his/her family is screwed up. Resident was told that we would send a referral to other places. Resident was agreeable to referral being sent to other places;
-On 3/24/23 at 8:07 P.M., resident called 911. Writer spoke to resident and officer and explained that he/she is wanting to be placed in a different facility. No further information was needed;
-On 3/25/23 at 11:01 A.M., spoke with resident is his/her room. Resident calm, and cooperative. Per resident he/she has been on a anti-psychotropic medication for approximately 40 years and per the resident is the only medication that really helps him/her. He/She was able to tell this writer the name of the medication, write it out and also the dose and how frequently he/she takes the medication. This medication was checked against his/her referral medication list and it was there. The psych nurse practitioner (NP) was contacted and this information was relayed and obtained an order to restart the medication. Pharmacy was contacted to ensure that the medication was available. The medication was delivered later the same afternoon and is being administered per schedule;
-On 3/27/23 at 8:57 A.M., Behavior note: Resident called police this morning and stated, I am fearing for my life. He/She called during breakfast; everyone was in the dining room but him/her. Two officers reported to the floor. This nurse was trying to see what was going on and who called. They stated what was said and the person did not give a name. He/She then comes around the corner and starts talking to them. This nurse assured nothing has gone on so far this shift because they were eating breakfast. Police continued to talk to resident;
-No documentation of psych notes.
Review of the resident's POS, dated March 2023, showed:
-An order, dated 3/25/23, for Perphenazine Oral Tablet 4 mg. Give 4 mg by mouth two times a day related to schizophrenia.
Review of the resident's behavior monitoring and intervention log, dated 3/13/23 through 3/29/23, showed:
-On 3/19/23, staff documented no behaviors;
-On 3/20/23, staff documented no behaviors;
-No further documentation regarding the resident's behaviors.
During an interview on 3/29/23 at 8:45 A.M., the resident said he/she wanted to leave the facility and called the police recently. He/She complained about staff and he/she had not received his/her medication for schizophrenia. The resident had been on the medication for 40 years. He/She reported it to staff and the police when he/she called them. The resident said he/she started receiving the medication in the past week and he/she felt fine. He/She was told by the DON the medication was missed and either it was missed by the hospital or the facility. The resident said he/she just wanted his/her medication to help with the hallucinations. The resident had not seen the psych doctor, and only spoke to the Social Worker about moving to another facility.
During an interview on 3/29/23 at 12:20 P.M., the SSD said the resident did not like the facility as soon as he/she was admitted . He/She has behaviors and called the police four times. The resident had not been seen by the psych doctor since he/she had been admitted . She recently assisted the resident by sending referrals to two facilities.
During an interview on 4/6/23 at 10:15 A.M., the DON and Regional Nurse Consultant said the resident was ordered the medication on 3/25/23. It was missed by the facility when he/she was admitted , but they did not receive all the information from the previous facility. The DON pulled the transfer paper and checked the medications. The resident was referred to psych; however, he/she kept getting sent out to the hospital, so the resident was not seen by psych. The resident went to the hospital on 3/14/23 and a referral for psych was made after he/she returned. On 3/25/23, another referral was made after the resident was ordered Perphenazine. They notified psych because the hospital did not do anything. It is not documented in the medical record, but they communicate with psych through phone calls and texts.
3. Review of the Resident 21's medical record, showed his/her diagnoses included bipolar disorder (a mental disorder that changes a person's mood, energy level and ability to function), current episode manic (extreme mood swings) or severe with psychotic (abnormal thinking and perceptions) features, epilepsy (brain disorder that causes recurrent seizures), schizophrenia, generalized anxiety disorder, insomnia and Parkinson's disease (a brain disorder that causes uncontrollable movements or stiffness).
Review of the resident's care plan, in use at the time of survey, showed:
Focus: The resident has a behavior problem related to bipolar and schizophrenia;
Interventions: Administer medication as ordered; Explain and reinforce why behavior is inappropriate and/or unacceptable to the resident; Intervene as necessary to protect the right and safety of others; Monitor behavior episodes and attempt to determine underlying cause.
Focus: The resident has a mood problem related to schizophrenia;
Interventions: Administer medications as ordered; Assist the resident, family and caregivers to identify strengths and positive coping skills; Encourage the resident to express his/her feelings; Psychiatric consults as needed;
Focus: The resident has a psychosocial well-being problem related to anxiety and ineffective coping;
Interventions: Allow the resident time to answer questions and to verbalize feelings and perceptions and fear; Assist, encourage and support the resident to set realistic goals; Initiate referral as needed to increase social relationships; When conflict arises, remove resident to a calm safe environment and allow him/her share feelings.
Review of the resident's POS dated March 2023, showed:
-An order, dated 3/8/23, for Venlafaxine oral tablet 75 mg ( a medication used to treat depression and anxiety);
-An order, dated 3/8/23, for Abilify oral tablet 5 mg (a medication used to treat schizophrenia);
-An order, dated 2/11/23, for Memantine oral tablet 5 mg (a medication used to treat moderate to severe confusion related to Alzheimer's disease);
-An order, dated 2/10/23, for Depakote sprinkles oral capsule delayed release 125 mg (a medication used to treat seizures and bipolar disorder).
Review of the resident's progress notes, showed:
On 3/4/23 at 6:55 P.M., the resident is becoming louder and more agitated, cursing and threatening staff and other residents. Haldol (a medication to treat schizophrenia) Injection given;
On 3/5/23 at 3:45 A.M., unable to get the resident's vital signs due to combative behavior;
On 3/5/23 at 4:45 A.M., the resident was throwing things, dismantling the bed, yelling, banging on bed and making racial slurs. The nurse went to prepare a Haldol injection and returned and the resident was found on the floor. He/She refused to get up or let staff provide assistance. The resident continued to be belligerent and combative with staff. The resident did not want to be touched. Pain and skin assessment completed. Assisted resident off of the floor and Haldol intramuscular (IM) given. Resident one on one until he/she calms down.
On 3/5/23 at 3:45 A.M., 4:00 A.M. and 4:15 A.M. unable to complete neurological (neuro) checks due to the resident's combative behavior;
On 3/5/23 at 4:27 A.M., the resident is going into other residents' rooms and throwing water on them. One on one continued for safety measures;
On 3/5/23 at 7:53 A.M., the resident's physician was texted about resident being agitated, combativeness and being found on the floor. No response received;
On 3/6/23 at 1:02 A.M., the resident refusing vital signs and neuro checks;
On 3/16/23 at 4:56 A.M., the resident refused assessment and vital signs. The resident is speaking loudly. He/She is resistant to care and becomes combative when care is attempted;
On 3/20/23 at 2:52 P.M., the resident is very anxious and combative with staff. Ativan by mouth given and the resident spit medication out;
On 3/22/23 at 1:31 P.M., the resident threw his/her lunch on the floor. While housekeeping staff was cleaning in the room, the resident pushed his/her bedside table to hit the housekeeper in the back;
On 3/22/23 at 3:52 P.M., the resident is filling a cup of water and throwing it all over his/her room, calling it holy water;
On 3/23/23 at 1:37 A.M., the resident is yelling out, refusing care and is combative with staff;
On 3/27/23 at 2:10 A.M., the resident is refusing all care and is cursing and yelling at staff. Attempted to re-direct resident with no success;
On 3/29/23 at 10:10 A.M., this nurse contacted physician for a psych consult order due to diagnosis.
Review of the resident's record, showed no documentation of psychiatric progress notes and no social service notes.
Observation and interview on 3/29/23 at 11:25 A.M., showed the resident sitting on his/her bed, reading the Bible. His/Her eyeglasses were broken into pieces on his/her bed. The resident screamed get out as an attempt was made to speak with him/her.
During an interview on 3/29/23 at 11:30 A.M., Licensed Practical Nurse (LPN) G said the resident does not like other people in his/her room. The resident is very difficult to redirect. Staff just tries to let (him/her) be. The resident refuses medications most of the time. He/She throws his/her food on the floor. He/She rejects care from staff and can become combative. The resident has been having behaviors for as long as he/she had been employed at the facility which was over a month. LPN G didn't know if the resident was receiving psych services.
Observation on 3/30/23 at 12:45 P.M., showed the resident had thrown his/her lunch and drink on the floor. The resident was calmly sitting on his/her bed and refusing to answer any questions.
During an interview on 3/30/23 at 12:47 P.M., Certified Medication Technician (CMT) C said the resident has had behaviors since his/her admission. The resident has good days and bad days. The resident does not take his/her medications on a regular basis.
During an interview on 3/29/23 at approximately 12:00 P.M., the SSD said the resident was having a lot of behaviors and should have been seen by the psychiatrist. She did not think the resident being seen by the primary care physician was enough to meet the resident's mental needs.
During an interview on 3/30/23 at 1:35 P.M., the Regional Nurse Consultant said the resident was having extreme behaviors and should have had a psych evaluation.
4. Review of Resident #17's medical record, showed his/her diagnoses included paranoid schizophrenia, psychotic disturbance, major depressive disorder, bipolar disorder, pseudobulbar affect (episodes of sudden uncontrollable and inappropriate laughing or crying) and anxiety disorder.
Review of the resident's progress notes, showed:
-On 11/28/22 at 2:29 P.M., the resident experienced crying episodes. He/She cursed at staff and punched the bathroom door. He/She cried over not receiving a soda. Staff calmed him/her down. He/She sat near the nurse's station. Staff continued to monitor;
-On 12/1/22 at 11:44 A.M., the resident had a crying episode. He/She said he/she does not get any attention. Staff told him/her they were there to assist with all his/her needs, educate him/her on call light use and how to call for assistance if he/she needed to vent and assist with ADLs. The resident said okay;
-On 12/26/22 at 9:44 A.M., the resident was observed hitting another resident by housekeeping staff. He/She was separated from all residents and monitored. Staff notified the Administrator and the Assistant Director of Nursing (ADON). The resident was sent to the hospital for further evaluation, via ambulance. At 7:37 P.M., he/she returned to facility by EMS. His/Her mood was calm with no signs of distress noted. He/She was transferred to a different room and 15 minute checks were put in place;
-On 12/29/22 at 12:10 P.M., staff spoke with a liaison for residents with mental health issues. Staff told the liaison the resident was in a nursing home, received 24 hour monitoring and had a psychiatrist and a guardian for decision making. Staff said the liaison was satisfied to be informed of the resident's safety and supervision;
-On 1/3/23 at 10:11 A.M., the resident was very tearful and emotional. Staff redirected him/her.
Review o
Jan 2022
19 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent and implement ...
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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 adequate supervision to prevent and implement appropriate interventions for one resident who experienced a fall resulting in a fractured wrist and shoulder (Resident #8) due to the staff leaving the resident's side. In addition, the facility failed to provide adequate supervision for an elopement (leaving the premises or a safe area without authorization and/or any necessary supervision to do so) from a secured unit (Resident #32). In addition, the facility failed to provide oversight for one resident with a history of falls (Resident #82). The facility failed to ensure the residents environment remained free of accident hazards when staff failed to ensure the soiled utility room, where hazardous material is stored, was locked and inaccessible to residents. Also, the facility failed to complete a smoking assessment for one resident (Resident #43). The sample was 24. The census was 121.
1. Review of the facility's Fall Evaluation and Prevention policy, revised 8/2020, showed:
-Purpose: 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;
-Policy: The facility will evaluate residents for their fall risk and develop interventions for prevention. The goal is to prevent falls if possible and avoid any injury related to falls. The care plan should only specify a few interventions at a time so that the staff can determine what intervention is not successful and needs to be changed;
-Intervention suggestions for fall prevention included place bed in lowest position and lock wheels;
-Education of staff related to fall prevention, includes:
-Providing a safe environment for residents;
-Cause and risk factors for falls as well as the interventions to manage risk;
-Safe transferring techniques;
-Use of assistive devices.
Review of Resident #8's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 10/5/21, showed:
-No cognitive impairment;
-Total dependence of two (+) person physical assist required for bed mobility, transfers, locomotion;
-Total dependence of one person physical assist required for toilet use;
-Required extensive assistance of one person physical assist for personal hygiene;
-No upper or lower impairment;
-Diagnoses included end stage renal disease (ESRD, kidney disease), high blood pressure, seizures, anxiety, depression, bipolar disorder (a mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks), schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves), insomnia, restlessness and agitation and repeated falls;
-One fall with injury since last assessment.
Review of the resident's quarterly fall risk assessment, dated 11/23/21, showed the resident identified as moderate risk for falling.
Review of the resident's progress notes, dated 12/18/21, showed:
-At 7:12 A.M., at 4:52 A.M., nurse called to room by CNA. Observed resident on bed, right side, dangling off bed. CNA stated he/she went to wet his/her towels and the resident rolled. Resident assessed, bed lowered, and resident was able to roll back onto bed. Range of motion to upper extremities, complained of discomfort when resident's left arm extended. Given Tramadol (pain medication). Scheduled for dialysis this morning, leave of absence to dialysis;
-At 11:01 A.M., it was reported the resident was hanging on the side of the bed and complained of his/her left elbow hurting. Resident went out to dialysis. Physician notified of incident and that resident received Tramadol for pain. Received call from dialysis and informed that resident requested to go to the emergency room (ER) for complaint of left arm and hip pain. Resident transferred to ER from dialysis. Time of call was 9:11 A.M;
-At 3:13 P.M., report received from ER. Resident had fracture to left shoulder and left wrist. Resident will return to facility with left shoulder splint. Resident also has urinary tract infection (UTI) and will be on antibiotics;
-At 5:40 P.M., the resident returned to the facility from the hospital with a fractured left shoulder and left wrist. Sling in place. Resident stable with minimal pain. Physician notified of resident's return and medications verified.
Review of the facility's investigation form, signed by the DON on 12/19/21, showed:
-Date and time of occurrence: 12/18/21, 6:59 A.M.;
-Detailed description of original allegation/event: Staff nurse was called to room by assigned CNA. While activities of daily living (ADL) care was being provided, the CNA walked to wet a towel when this resident rolled onto the right side, dangling out of the bed;
-Assessment of resident/description of injury: Left arm pain;
-Resident interview summary: Resident reported he/she tried to turn while the CNA went to walk away;
-Immediate resident protection initiated: Resident's bed was moved along the side of the wall. Half side rails were intact and floor mat on the floor;
-Summary of investigation findings: Resident rolled onto right side of bed, dangled along the side of the bed. Was assisted onto the bed. While staff was assessing this resident's range of motion, resident complained of pain to left arm. Pain management was given prior to this resident leaving for scheduled dialysis appointment.
Review of the resident's care plan, showed:
-Focus: On 6/1/20, resident lowered to floor by staff. Resident has history of leaning to left side while in bed. On 8/11/21, rolled out of bed onto the floor, attempted to get money off of the floor. Noted bruise to head;
-Goals: Resident will call when he/she needs assistance with ADLs. He/she will remain free from injury related to poor ADL mechanics;
-Interventions included bed in lowest position, side rails removed, mat placed on floor to left side. Two person assist with transfers;
-Focus: Resident has limited physical mobility related to weakness, has poor trunk control, history of leaning to left side of bed, history of refusing to get out of bed;
-Goals: Resident will remain free of complications related to immobility, including fall related injury through next review date. Resident will maintain current level of mobility transfer with two assistance using a gait belt from surface to surface. He/she refuses to transfer using a Hoyer lift;
-Interventions included: Hoyer lift (mechanical lift) for transfers. Staff position resident for proper alignment while in bed. Resident requires assistance of two staff members and a gait belt for transfers.
-Focus: 12/18/21 fractured to left proximal humerus (portion of the arm bone between shoulder and elbow, closest to the shoulder) and left distal radius (end portion of the forearm, closest to the wrist) fracture;
-Interventions included: No weight bearing status to left arm, maintain left shoulder in sling. Bed in lowest position when not providing care. Don't leave unattended with side rails down. Left hand brace. Mat to left side of bed. Two person assist with transfers.
-Focus: Resident is at risk for falls. Resident keeps bed in a high position and needs reminders to call for help;
-Goals: Resident will be free of injury related to falls;
-Interventions: Educate on fall risk as needed. Two quarter-length side rails to aide in bed mobility and repositioning. Encourage resident to keep bed in low and locked position. Two person assist with transfers;
-The care plan did not specify type of staff assistance and number of staff required for personal care and toileting.
Observation on 1/18/22 at 1:01 P.M., showed the resident on a stretcher, wheeled into his/her room by two staff. Staff used a sliding board to transfer the resident from the stretcher to his/her bed. Staff raised a quarter-length side rail on the left side of the resident's bed, and left the room. The right side of the resident's bed was flush to the wall. The resident's bed was positioned approximately 3 feet above the floor. No fall mat was on the floor. The resident's left wrist was in a brace. During an interview, the resident said he/she fell out of bed recently because the bed was too high. When he/she fell, his/her left wrist hit the air-conditioning unit.
Observation on 1/19/22 at 12:54 P.M., showed the resident lay on his/her back in bed with a quarter-length side rail raised on the left side of the bed. The resident's bed was positioned approximately 3 feet above the floor. No fall mat was on the floor.
Observation on 1/20/22 at 12:28 P.M., showed the resident seated upright in bed with a quarter-length side rail raised on the left side of the bed. The resident's bed was positioned approximately 3 feet above the floor. No fall mat was on the floor.
During an interview on 1/25/22 at 7:19 A.M., the DON and administrator said prior to Resident #8's fall on 12/18/21, the resident required one person to assist with personal care. The DON said she investigated the resident's fall. During the investigation, the DON discovered the CNA walked away from the resident while the resident's bed was raised in a high position. Before providing care, CNAs should gather all materials needed before they enter the resident's room. If the CNA forgot something, they should have called for another employee to come help them. At minimum, the resident's bed should have been lowered when the CNA walked away.
2. Review of the facility policy, titled Elopement Prevention, revised 7/2021, defined elopement as having occurred when a resident left the facility without the expressed knowledge or approval of the facility or an authorized representative of the facility. The Centers for Medicare and Medicaid Services (CMS) defined elopement as leaving the facility premises or a safe area without authorization such as an order for discharge or leave of absence. Residents identified as being at risk for elopement were to have an individualized plan of care developed and implemented which attempted to reduce their elopement or flight risk. In response to an actual elopement attempt, if staff placed the resident on increased supervision, then they were to document safety checks in the clinical record/electronic medical record (EMR) each shift for the duration of the increased supervision.
Review of Resident #32's wandering/elopement assessment, dated 8/2/21, showed the resident was assessed as having the potential/being at low risk for wandering or elopement.
Review of the resident's undated diagnosis sheet, included the following diagnoses: schizophrenia, paranoid schizophrenia (a subtype of schizophrenia characterized by the presence of auditory hallucinations or prominent delusional thoughts about persecution or conspiracy), restlessness and agitation, sexual disorders, mood [affective] disorder (a mental health disorder in which a person experiences long periods of extreme happiness, extreme sadness or both), intellectual disabilities, problems related to lifestyle (self-damaging behavior) and sexual dysfunction not due to a substance or known physiological condition.
Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/4/21, showed the following:
-Cognitively intact;
-Psychosis: hallucinations;
-Wandering behavior occurred one to three days;
-Required supervision of one for locomotion off of the unit;
-No mobility devices.
Review of the resident's care plan, showed no identified elopement risk or preventative interventions.
Review of the resident's progress note, dated 1/5/22 at 10:10 P.M., showed the resident kept going to the door, saying he/she was going to leave. Staff redirected the resident to his/her room several times. The resident went back to the door, so the nurse called the resident's parent to inform him/her of the resident's behavior. The resident told the responsible party that the resident no longer wanted to be at the facility. The resident agreed to go back to his/her room. At 11:13 P.M., the administrator received a call from staff saying the resident was returned to the facility by his/her parent, who said the resident described getting out of the locked unit behind a worker. The resident, who was alert and oriented times two (to person and place), did not exhibit any signs of distress and had no bruises, scratches or discolored skin.
Review of MapQuest.com showed the resident walked 1.2 miles to the store.
Review of the weather history for 1/5/22 at 9:51 P.M., showed the temperature was 21 degrees Fahrenheit.
Further review of the resident's care plan, updated 1/6/22, showed the following:
-The resident had a guardian;
-Psychiatric consult as needed;
-At risk for falls related to potential adverse effects from taking medications to manage symptoms of schizophrenia and hypersexuality (pathologically increased sexual behaviors/obsessive fixation on sex);
-The resident could be resistant to care and required redirection from making sexual remarks toward staff;
-1/6/22, episode of elopement related to the resident being anxious (stating he/she wanted to get out of the facility).
Review of the facility's investigation form, dated 1/11/22, showed on 1/5/22 at about 10:00 P.M., certified medication technician (CMT) R last saw the resident at or around 10:00 P.M. No alarm sounded on the unit, indicating that someone left the unit. The night supervisor saw a woman walking into the facility and asked if she needed help, the woman said that between 10:31 P.M. and 10:38 P.M., a store clerk had called and put the resident on the phone. The resident asked to be picked up. The woman was returning him/her to the facility. She said the resident appeared to be anxious. The two CMTs later said they heard the resident speaking about wanting a girlfriend. They denied hearing the resident mention that he/she wanted to leave the facility or saying he/she was going to leave. The certified nurse aide (CNA) on duty in the unit did not interact with the resident during the entire shift. The resident said he/she was mad, because the the girls were breaking his/her heart, he/she needed to get out and clear his/her mind. After eloping, the resident got cold while walking, went to Walgreens and asked the store clerk to call his/her parent. The resident said he/she did not tell anyone he/she hated the facility and was going to leave, that the elopement was unplanned.
During an interview on 1/20/22 at 2:45 P.M., CMT Q said on the night in question, the other CMT left for the night at 8:00 P.M. A little before 10:00 P.M., the resident started going back and forth, to the doors leading out of the unit. He/she did it three times. The resident was saying that he/she wanted leave the facility and go home. Staff tried to redirect him/her, but the resident said he/she did not want to be there anymore. It was the first time, in CMT Q's three months working at the facility, that CMT Q heard the resident express the desire to leave. At 9:45 P.M., staff got the resident's family member on the phone, to assist in their efforts to redirect the resident, by allowing the resident to speak to him/her. CMT Q last saw the resident at around 10:15 P.M. After walking the resident to his/her room, CMT Q went to the bathroom and then sat at the nursing station for the remainder of his/her shift. He/she was gathering his/her things, preparing to go home, when the nursing supervisor escorted the resident back onto the unit at around 11:05 P.M.
During an interview on 1/19/22 at 1:05 P.M., Nurse R said he/she was not familiar with the resident. On the night in question, there were four staff members on duty in the unit: Nurse R, two CMTs and a CNA. The resident kept coming up to the nurse's station to talk and asking about dinner. After dinner, at around 8:00 P.M., the resident started going to the doors leading out of the unit. He/she did that two or three times, looking out through the windows in the doors. The last time he/she went to the doors, he/she did not seem to want to come away from them. Someone suggested having the resident talk to his/her parent. At that point, he/she was not upset. Nurse R only heard the resident say something about leaving to his/her family member over the phone. Nurse R heard the resident say that he/she wanted to go home. After that phone call, the resident went to his/her room. That was the last time Nurse R saw the resident, prior to his/her elopement. Nurse R sat at the nurse's station with CMT Q throughout the remainder of the shift and charted. Nurse R had only gotten up once to use the bathroom at around 9:00 P.M. Nurse R was shocked when the night supervisor returned the resident to the unit, saying his/her family member picked the resident up from a store. Nurse R had not seen the resident leave the unit and did not know he/she was gone.
During an interview on 1/18/22 at 2:15 P.M., the resident said he/she was upset on the night of his/her elopement, but did not recall expressing to staff the intent to leave. He/she just saw a female staff person (name unknown) leaving and followed her out of the locked unit. The resident was able to get to the first floor unobserved and walked past the security guard seated at the receptionist desk (when the guard was looking down) and exited the facility via the front door.
During an interview on 1/28/22 at 2:56 P.M., the Director of Nursing (DON) said when a resident expressed the intent to leave a secure unit and engaged in behaviors such as repeatedly going to the doors leading out of the unit despite redirection, staff were expected to put the resident on 15 minute checks and notify the receptionist at the front desk. There should be photographs of all residents, identified as being at risk for elopement, posted at the receptionist desk. The increased level of supervision should continue, as long as the behaviors and expressed desire to leave continued.
During an interview on 1/25/22 at 8:13 A.M., the administrator said the facility alarms and door locks were tested and were fully functional. When a resident on a secured unit expressed the intent to leave and/or repeatedly went to the doors leading out of the unit, it was the responsibility of staff on the unit to ensure the resident did not continue to stand by the doors and maintain line-of-sight supervision or increase monitoring to 15 minute checks. One out of the four staff on duty on the unit said the resident was at the door, saying he/she wanted to leave. None of them admitted to the resident exiting the unit behind them. They each said they had gone to the bathroom and consequently did not see the resident elope or know the resident was missing, until his/her return to the unit. Seated at the receptionist desk near the facility entrance was a security guard, contracted via a private security company, who was so hard of hearing that one had to stand in front of him/her and shout in order to be heard. The security guard did not see the resident walk out of the facility. As a contracted security guard, he/she would not have known if someone leaving was a visitor or resident, since there was no cut off time at night for visitation and there was not enough time to thumb through the elopement book every time someone left. After the resident eloped, the facility began posting pictures at the receptionist desk of residents at risk for elopement. The resident was at risk for harm, out in the community unsupervised, due to his/her cognitive impairment and mental health issues.
During an interview on 1/24/22 at 2:54 P.M., Psychiatric Nurse Practitioner (NP) S said he/she was new to the facility and had not yet met the resident due to the facility Covid lockdown and NP S recently contracting Covid. NP S had performed a chart review. Part of the resident's cognitive impairment impacted his/her impulsivity, judgment, personality and the reward system in the brain. Consequently, the resident had no insight and poor judgment. He/she also had a history of sexually inappropriate behavior. The resident was very much so at risk for harm out in the community unsupervised due to the cognitive impairments and poor judgment posing a risk for him/her engaging in risky and/or impulsive behaviors. The resident was childlike and consequently could be induced to do things that the average person would not do. The resident's behaviors of saying he/she wanted to leave and repeatedly going to the doors leading out of the unit warranted one-to-one staff supervision.
3. Review of Resident #82's medical record, showed:
-admission date of 6/16/21;
-Diagnoses included stroke, hemiplegia (paralysis of one side of the body), depression and anxiety;
-A quarterly fall risk assessment, dated 9/16/21, showed the resident identified as high risk for falling.
Review of the resident's quarterly MDS, dated [DATE], showed:
-Moderate cognitive impairment;
-Required extensive assistance of one person physical assist for bed mobility;
-Total dependence of two (+) person physical assist for transfers;
-Upper and lower extremities impaired on one side;
-Two or more falls since last assessment.
Review of the resident's care plan, showed:
-Focus: Resident is at risk for falls. Gait/balance problems, diagnosis of stroke with left side weakness. Resident is non-ambulatory. On 6/29/21, noted on the floor with no injuries. On 9/27/21, reported he/she fell out of bed. On 10/2/21, noted on mat next to bed with no injuries;
-Goals: Resident will not have significant injuries related to falls through next review;
-Interventions included mat to right side of bed.
Observation on 1/18/22 at 12:14 P.M., showed the resident seated upright in bed. No fall mats were on the floor. During an interview, the resident said he/she is paralyzed on the left side and requires staff to assist with transfers. He/she has had a million falls, and none resulted in injury.
Observation on 1/18/22 at 1:23 P.M., 1/19/22 at 12:45 P.M., 1/20/22 at 12:39 P.M. and 5:56 P.M., and 1/21/21 at 7:27 A.M., showed the resident in bed. No fall mats were on the floor.
During an interview on 1/24/22 at 10:08 A.M., CNA G said he/she works at the facility full time and knows the residents well. He/she requires one staff to physically assist with transfers and he/she requires total care for other ADLs. CNA G was not sure if the resident had a history of falls or requires fall interventions, such as a fall mat. The resident is always in bed when he/she is not at dialysis. He/she requires two people to assist with repositioning and personal care. Before providing personal care, staff should gather all items needed in advance, such as a water basin, towels, soap, clothes and bags. During care, they might have to raise a resident's bed in order for staff to reach them. When care is completed, staff should lower the resident's bed. Staff should not leave a resident in a bed raised in a high position because the resident could roll and fall. If a resident is at risk for falls, staff should place a fall mat next to their bed when they are finished providing care. Residents have care plans in their electronic medical record, but CNAs are informed of fall interventions when they receive report from the nurse.
During an interview on 1/24/22 at 9:16 A.M., Nurse B said Resident #82 requires staff assistance with transfers and ADL care. He/she had a fall from his/her wheelchair, but the nurse could not recall if there were any other falls. The resident has side rails as a fall intervention. He/she has a history of falls, usually because he/she rolls over when trying to reach something. The resident does not get out of bed too much. He/she requires one staff person to assist him/her with personal care and bed baths. When staff is going to provide care, they should prepare everything in advance and gather their supplies, such as towels and ointments. If everything is ready in advance, staff would have no reason to leave a resident unattended. If staff need assistance or additional items during care, they should call for help. It would not be appropriate to walk away while a resident is in a bed raised in a high position. The resident's fall interventions include a fall mat, side rails, and keeping the bed in a low position. Interventions are reflected on a resident's care plan. Fall interventions and care needs are communicated to CNAs during report.
During an interview on 1/27/22 at 12:04 P.M., the resident's physician/facility medical director said he expected staff to always put a resident in a safe position before leaving the room. The aide should have ensured the resident was in a secure position before leaving. His expectation is for staff to follow the resident's care plan for interventions, put in place by the facility.
4. During an interview on 1/25/22 at 7:19 A.M., the DON and administrator said following a resident's fall, the interdisciplinary team (IDT) gets together to discuss appropriate interventions. Old interventions are assessed to see what worked and what did not. They try to identify the root cause of a resident's fall so they can put the proper interventions in place. Fall interventions are documented on the resident's care plan and should be resident-specific. The care plan is updated by the MDS coordinator or nurses. Fall interventions are communicated to department heads during the weekly IDT meetings, and when the charge nurse gets report before each shift.
5. Review of the facility's Sharp Object Disposal policy, reviewed 7/2014, showed:
-General: All sharps including needles, syringes, scalpels, and razors are disposed of in an appropriate sharps container;
-Guidelines:
1. All sharps are dropped into the sharps container needle first. Never cut or recap a needle;
2. Never place your hand in a sharps container;
3. When a sharps receptacle is ¾ full, the nurse is responsible for alerting the responsible department to replace the container, or to replace the container themselves;
4. When the new sharps receptacle is replaced, make sure it is secured into place and the opening is facing outward;
5. If the nurse is responsible for removing the filled sharps receptacle, place the receptacle in the designated place for appropriate storage based on state and federal guidelines.
Review of the facility's census report, dated 1/18/22, showed 39 residents occupied the first floor.
Observation of the first floor on 1/18/22 at 11:59 A.M., showed the soiled utility room door open with no staff present. Three uncovered trashcans were filled with soiled linens. A red biohazard tub was open and filled with an overflow of full sharps containers, approximately 6 inches above the top of the biohazard tub opening.
Observation of the first floor on 1/19/22, showed:
-At 6:44 A.M., the soiled utility room door open with no staff present. Two trash bags were filled with soiled linens and four full sharps containers in an open biohazard tub;
-At 12:42 P.M., the soiled utility room door open with no staff present. Three uncovered trashcans were filled with soiled linens. A red biohazard tub was open and filled with full sharps containers. The top sharps container was uncovered and filled with syringes and other materials;
-At 12:46 P.M., CNA G entered the soiled utility room and dropped soiled linens into a trashcan. He/she pulled the door as he/she exited the room and left the door ajar;
-At 12:52 P.M., CNA H opened the soiled utility room door and allowed a resident to enter the room while the CNA supervised. The resident exited and CNA shut the door all the way.
Observation of the first floor on 1/20/22 at 12:21 P.M., showed the soiled utility room with two uncovered trashcans filled with soiled linens. A red biohazard tub was open and filled with an overflow of full sharps containers, approximately eight inches above the top of the biohazard tub opening. CNA G entered the soiled utility room and dropped soiled linens into a trashcan. He/she exited the room and left the door ajar. At 12:38 P.M., CNA G entered the soiled utility room and dropped off soiled linens. He/she closed the door upon exiting the room.
During an interview on 1/24/22 at 10:08 A.M., CNA G said the soiled utility room is hazardous because it is where used sharps and soiled linens go. The soiled utility room should be locked at all times and inaccessible to residents due to safety reasons. Upon exiting the soiled utility room, staff should make sure the door closes behind them.
During an interview on 1/24/22 at 9:16 A.M., Nurse B said used razors and syringes are placed in sharps containers. When sharps containers are full, the nurses put them in a red biohazard tub in the soiled utility room. Sharps containers should be locked. Residents should not have access to the soiled utility room due to the hazardous materials stored in the room. Staff must ensure the door to the soiled utility room closes behind them.
During an interview on 1/25/22 at 7:19 A.M., the DON and administrator said used razors and syringes are disposed of in sharps containers. When the sharps container is full, it should be locked and placed in a biohazard box in the soiled utility room. The soiled utility room should be accessible to residents. Staff should ensure the soiled utility room is locked behind them.
5. Review of Resident #43's medical record, showed diagnoses included paranoid schizophrenia and nicotine dependence.
Review of the resident's Smoking Assessment, dated 9/17/21, showed the resident was safe to smoke with supervision.
Review of the resident's care plan, updated on 10/29/21, showed:
-Focus: The resident enjoys smoking and has the potential for smoking related injuries such as burns to his/her skin and clothes. He/she has wet lungs (Acute respiratory distress syndrome (ARDS) is a medical condition in which the lungs are not working properly and oxygen blood levels are too low) frequently and has refused all smoking substitutes offered;
-Goal: The resident will remain free from injury related to smoking through the next review;
-Interventions: Resident is a supervised smoker and will only smoke in the designated areas on the unit. Instruct him/her about the policy on smoking. Observe clothing and skin for signs of cigarette burns and notify charge nurse immediately if it is suspected that the resident violated the facility smoking policy.
Review of the resident's quarterly MDS, dated [DATE], showed:
-admitted on [DATE];
-Moderate cognitive impairment;
-Exhibited delusions, verbal behaviors and rejection of care one to three days per week;
-Required limited assistance of one staff for locomotion on the unit.
Review of the resident's medical electronic record, last reviewed on 1/25/22 at approximately 1:00 P.M., showed the Smoking Assessment 39 days overdue-due 12/17/21.
During an interview on 1/25/22 at 1:50 P.M., the administrator and DON said smoking assessments should be done upon admission, annually and quarterly. The administrator provided a Smoking Assessment for the resident with a handwritten date of 1/13/22.
MO00195525
CONCERN
(D)
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 observation and interview, the facility failed to maintain resident dignity by failing to sit while assisting two (Resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain resident dignity by failing to sit while assisting two (Residents #93 and #115) of 28 sampled residents with meals. The census was 121.
Review of the facility's Resident's Right policy, revised 8/2021, showed:
-Policy Statement: Employees shall treat all residents with kindness, respect and dignity;
-Policy Interpretation and Implementation:
-Federal and State laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:
-A dignified existence;
-Be treated with respect, kindness and dignity.
1. Review of Resident #93's quarterly Minimum Data Set, (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/13/21, showed:
-admitted on [DATE];
-Exhibited moderate cognitive impairment;
-No behaviors;
-Required supervision and set up from staff for eating.
Review of the resident's care plan, updated on 12/13/21, in use during the survey, showed:
-Focus: The resident has an activities of daily living deficit related to activity intolerance and impaired balance;
-Goal: The resident will maintain current level of function in activities of daily living through the review date;
-Interventions: The resident is able to feed him/herself with set-up help.
Observation on 1/19/22 at 12:59 P.M., showed the resident sat up in bed. Certified Medication Technician (CMT) K stood beside the resident's bed and fed him/her lunch.
Observation on 1/20/22 at 12:53 P.M., showed the resident sat in bed. CMT K stood beside the resident's bed and fed him/her lunch.
2. Review of Resident #115's quarterly MDS dated [DATE] and reviewed on 1/25/22 at 7:34 A.M. showed:
- Diagnoses included dementia, hemiplegia (the functional use of the upper limbs only), seizure disorder, anxiety, depression, and psychotic disorder.
-BIMS score of 9 showing moderate cognitive impairment.
Review of the resident's care plan, in use during the survey, showed:
-Resident prefers to eat his meals in bed;
-Resident is on a pureed diet;
-Resident required full assistance with all meals;
-Resident will drink supplements if offered;
-Recommendation for the resident to receive supercereal with breakfast.
Observation of the lunch meal on 1/20/22 at 12:56 P.M. showed Certified Nursing Assistant (CNA) A assisting the resident in eating his/her tray of food. CNA A stood next to the resident's bed while feeding the resident. An empty chair was visualized near the head of the resident's bed.
Observation of the breakfast meal on 1/24/22 at 8:43 A.M., showed CNA A standing to feed the resident while he/she lay in bed. An empty chair was visualized at the head of the resident's bed.
3. During an interview on 1/25/22 at 8:50 A.M., Nurse M said it was the staff's preference to either sit or stand while feeding residents. Eye contact was important when feeding residents.
4. During an interview on 1/25/22 at 8:55 A.M., CNA L said it was best to feed residents while standing. This was how he/she fed his/her children.
5. During an interview on 1/25/22 at 11:51 A.M., the administrator and Director of Nursing (DON) said staff should sit while feeding residents to maintain their dignity. It was not appropriate to stand while feeding residents.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0563
(Tag F0563)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure the rights of one resident (Resident #55) out of 24 sampled residents, for unrestricted visitation, when the facility prevented the ...
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Based on interview and record review, the facility failed to ensure the rights of one resident (Resident #55) out of 24 sampled residents, for unrestricted visitation, when the facility prevented the resident's care and financial power-of-attorney (POA, a person with the legal authority to make decisions regarding another person's medical care and financial matters) from entering the facility, contacting the resident by phone and did not set up visits via a virtual video teleconferencing platform. The census was 121.
Review of the facility's policy titled, Resident's Rights, effective 9/2015, showed federal and state laws guaranteed certain basic rights to all residents of the facility. Those rights included the right to visit and be visited by others from outside the facility, access to a telephone, communication with and access to people and services, both inside and outside of the facility and to be supported by the facility in exercising his/her rights.
Review of the resident's undated face sheet, showed he/she had a care and financial POA. The face sheet showed special instructions for staff that the POA was not allowed in the facility at all.
Review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/3/21, showed the following:
-Severe cognitive impairment;
-Verbal behavioral symptoms directed at others occurred 1-3 days;
-Wandering occurred four to six days, but less than daily;
-Wheelchair mobility;
-Diagnoses including dementia, manic depression and repeated falls.
Review of the resident's undated care plan,showed the following:
-The resident is not cognitively stable and is not capable of using a call light for assistance;
-Poor safety awareness and decreased comprehension;
-Activities of daily living (ADL) self-care performance deficit related to confusion and dementia;
-The resident has a diagnosis of dementia, has a history of resistance to care, as well as a history of agitated, delusional, hyperactive behaviors.
Further review of the resident's care plan, did not show any documented reason for or exceptions to the special instructions for staff not to allow the POA inside the facility.
Review of the resident's undated clinical physician orders, showed undated special instructions showing the resident's POA was not allowed in the facility at all.
During an interview on 1/21/22 at 11:08 A.M., the social services director said she was unaware of any special instructions directing staff not to allow the POA in the facility. He/she had not set up any virtual visits between the resident and POA.
During an interview on 1/28/22 at 2:56 P.M., the Director of Nursing said it was her understanding that the restriction of the POA not being allowed in the facility was confined to the day that staff asked the POA to leave, due to unsafe behavior.
During an interview on 1/27/22 at 12:07 P.M., the Medical Director/primary care physician said the special instructions on the resident's physician's orders directing staff not to allow the resident's POA to visit was not an order issued by him. Facilities never contacted physicians for issues of that nature.
During an interview on 1/25/22 at 8:54 A.M., the POA said on the day of the incident, he/she had put a small .38 caliber gun in the left pocket of his/her jeans, while moving and forgot about it. In the lobby of the facility, the POA reached into a back pocket and the receptionist saw the gun in the front pocket. The POA never took it out of his/her pocket. The receptionist saw the outline of it and asked, Is that a gun in your pocket? The POA said yes, and the receptionist told the POA to leave. He/she was not given the option of returning without the gun. The social worker called and said the POA was not allowed to return to the facility. Staff also did not allow him/her to speak to the resident on the phone. The POA had not spoken to the resident since July 2021. No one attempted to set up virtual visits. Staff refused to bring the resident downstairs, so that the POA could stand at a window and see the resident, in order to make sure the resident was alright and still wearing both his/her glasses and hearing aids.
During an interview on 1/28/21 at 2:19 P.M., the administrator said she was unaware of the special instructions on the resident's face sheet and physician's orders directing staff not to allow the POA in the facility. Those special instructions were never a physician's order. The administrator said there was an incident in which the POA came up to the facility for a visit with the resident, a gun fell out of his/her pocket and he/she pushed it back in. During the interview, the administrator reviewed social service notes and found an entry from the former social worker dated 11/5/21, documenting a call to the POA to discuss the incident and the social worker telling the POA that the POA was not allowed to enter the building, due to the threatening behavior. The administrator said she did not understand why the special instruction that the POA was not to enter the facility was placed on the resident's face sheet and physician's orders for an isolated incident. Other than the incident with the gun, she had no problem with the POA. During the interview, the administrator removed the special instructions from the face sheet and physician's orders. The administrator was not aware of any attempt made by staff to set up virtual visits between the POA and resident.
MO00194059
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure residents' responsible parties were notified in the event of a significant change for 1 of 24 sampled residents (Reside...
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Based on observation, interview and record review, the facility failed to ensure residents' responsible parties were notified in the event of a significant change for 1 of 24 sampled residents (Resident #55). The census was 121.
Review of the facility's Notification of Change policy, revised November 2017, showed the following:
-In an emergency situation, the physician is contacted at the same time or will be notified following 911 and once the resident is transferred to the hospital;
-In a non-emergent, but acute medical situation (including critical lab values and other diagnostic results) the physician will be paged and if there is no return call in 15 minutes the physician will be notified again. If there is no return call in 5 minutes the Medical Director will be notified;
-In a non-emergent, non-acute medical situation, such as normal labs, the physician can be contacted at their convenience;
-Any questions about how to notify the physician should be directed to the Director of Nurses (DON), Assistant Director of Nurses (ADON), or nursing supervisor.
Review of Resident #55's progress note, dated 6/18/21, showed the following:
-Resident was found in the fetal position on the bed moaning in pain;
-Blood-tinged stool could be seen on the floor of the resident's room;
-On call MD was contacted and gave orders to send resident out to the hospital for evaluation;
-Emergency medical services (EMS) arrived around 9 P.M. that evening;
-Staff did not document contacting the resident's responsible party.
Further review of the resident's progress note, dated 11/4/21 at 9:41 P.M., showed the following:
-Resident was found sitting on the floor in his/her room stating he/she had slipped and fallen.
-Resident was assisted up off of the floor and onto his/her bed;
-Vital signs were taken and found to be within normal range;
-On call physician was attempted to be contacted but could not be reached;
-Twenty minutes later the on call line was phoned again to contact a physician;
-Staff did not document successfully contacting the physician or contacting the resident's responsible party.
During an interview on 1/20/22 at 4:32 P.M., the resident's responsible party said no one from the facility informed him/her of an incident in mid-2021 that led to the resident being hospitalized . He/she said he/she was contacted by the hospital to come pick the resident up, but was never informed by the facility that the resident was sent out for evaluation or that any incident had occurred.
During an interview on 1/25/22 at 1:59 P.M., the director of nursing (DON) and administrator said they expected nursing staff to notify a resident's responsible party in the event of a fall or hospitalization. They expected staff to notify a resident's first emergency contact, even if the resident was their own responsible party.
MO00194059
CONCERN
(D)
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** Based on observation, interview, and record review, the facility failed to provide bathing and grooming assistance for two resid...
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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 bathing and grooming assistance for two residents dependent on staff for assistance with hygiene maintenance (Residents #82 and #45). The sample was 24. The census was 121.
1. Review of Resident #82's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/10/21, showed:
-admission date of 6/16/21;
-Moderate cognitive impairment;
-No behaviors exhibited;
-Required extensive assistance of one person physical assist for bed mobility, dressing, toilet use and personal hygiene;
-Total dependence of two (+) person physical assist for transfers;
-Upper and lower extremity impairment on one side;
-Diagnoses included stroke, coronary artery disease (CAD, heart disease), kidney failure, hemiplegia (paralysis affecting one side of the body), anxiety, depression and psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions).
Review of the facility's shower schedule, undated, showed the resident's scheduled showers were on Monday, Wednesday, and Friday during the evening shift.
Review of the resident's shower sheets from December 2021, showed:
-Bed baths or showers completed 12/1/21 and 12/29/21. Staff documented the resident does not need his/her toenails cut;
-No documentation of other bed baths or showers offered or provided.
Review of the resident's shower sheets from 1/1/22 through 1/21/22, showed:
-Bed bath or shower completed 1/17/22. Staff documented the resident does not need his/her toenails cut;
-No documentation of other bed baths or showers offered or provided.
Review of the resident's care plan, showed:
-Focus: Resident has an activities of daily living (ADL) self-care performance deficit related to impaired balance, limited mobility;
-Goal: No decline in ADL functioning through next review;
-Interventions included one assist with transfers;
-No documentation regarding the frequency of bathing/showering or hygiene preferences.
Observation on 1/18/22 at 12:14 P.M., showed the resident on his/her back in bed, dressed in a hospital gown. His/her fingernails were long on both hands. His/her right big toenail measured approximately 1.25 centimeters (cm) above the top of the toe. During an interview, the resident said he/she had a stroke and is paralyzed on the left side. He/she cannot get out of bed without staff assistance and needs staff assistance with showers and personal care. His/her fingernails and toenails are long and he/she knows staff see them, but they haven't done anything about it. He/she does not want long fingernails or toenails. He/she received a shower this week, but it had been a long time since he/she was bathed before that.
Observation on 1/19/22 at 12:45 P.M. and 1/20/22 at 12:39 P.M., showed the resident seated upright in bed with a hospital gown on. His/her fingernails were long and the right big toenail visibly protruded from underneath the sheet over the resident's legs.
During an interview on 1/20/22 at 12:39 P.M., the resident said staff gave him/her a shower the previous day. When staff put him/her back in bed, the resident told staff about his/her long fingernails and toenails. The employee saw the resident's big toenail was about half an inch long and said they would be right back to trim them. The employee left the room and never came back. Resident could not recall the employee's name.
During an interview on 1/24/22 at 10:08 A.M., certified nurses aide (CNA) G said the resident requires total assistance with bathing and one person to assist with transfers. He/she does not refuse care. Residents should be bathed or showered twice a week and as needed. While providing bathing assistance, staff should observe the resident's feet, skin and nails. CNAs can provide nail care for all residents unless they are diabetic. Diabetic residents receive nail care from the nurse. CNAs document bathing assistance on shower sheets. If a resident refuses bathing assistance, it should be documented on a shower sheet.
During an interview on 1/24/22 at 9:16 A.M., Nurse B said residents should be bathed or showered twice a week and as needed. CNAs should follow the shower schedule and when they provide bathing assistance, they should observe a resident's skin, feet and nails. CNAs can trim a resident's nails, unless the resident is diabetic. If the resident is diabetic, nail care is performed by the nurse. The resident requires one staff to assist him/her with transfers and bathing. He/she does not refuse care. If a resident refuses bathing assistance, staff should document the resident's refusal on a shower sheet.
2. Review of Resident #45's annual MDS, dated [DATE], showed:
-admission date of 7/16/18;
-Severe cognitive impairment;
-No behaviors exhibited;
-Total dependence of two (+) person physical assist for bed mobility, transfers, dressing toilet use and personal hygiene;
-Upper extremity impaired on one side;
-Lower extremities impaired on both sides;
-Diagnoses included traumatic brain injury, deep venous thrombosis (DVT, blot clot formed in a deep vein), diabetes, aphasia (impairment of expression and understanding of language), seizures, dementia, quadriplegia (paralysis affecting all four limbs), and osteomyelitis (bone infection).
Review of the facility's shower schedule, undated, showed the resident's scheduled showers were on Tuesday, Thursday, and Saturday during the day shift.
Review of the resident's shower sheets from December 2021, showed:
-Bed baths or showers completed 12/2/21, 12/14/21, and 12/16/21;
-Bed bath or shower refused 12/23/21;
-No documentation of other bed baths or showers offered or provided.
Review of the resident's shower sheets from 1/1/22 through 1/21/22, showed:
-Bed baths or showers completed 1/17/22 and 1/20/22. No documentation regarding nail care provided;
-No documentation of other bed baths or showers offered or provided.
Review of the resident's care plan, showed:
-Focus: Requires total care with ADLs, diagnosis of quadriplegia, has history of resistance and aggressive behaviors at times during care;
-Goal: Staff will anticipate resident's needs as needed, will be well groomed through next review;
-Interventions included:
-Inform resident of care to be provided prior, if becomes combative or resistant, leave alone and return later when calmer;
-Total care with all ADL functioning;
-Bathing/showering: Check nail length and trip and clean on bath day and as necessary. Report any changes to the nurse;
-Contractures (tightening of muscles): The resident has contractures to bilateral lower extremities and feet and right arm. Provide skin care daily/as needed to keep clean and prevent skin breakdown;
-No documentation regarding the frequency of bathing/showering.
Observation on 1/18/22 at 12:10 P.M., showed the resident lay on his/her back in bed, dressed in a hospital gown. His/her right hand was contracted in a C-shape. His/her left hand had long fingernails, with the middle fingernail approximately 0.75 centimeters (cm) long. During an interview, the resident said he/she needs assistance from staff for bathing, dressing and getting him/her out of bed. He/she cannot move his/her legs. The resident was unable to recall the last time he/she was bathed or showered.
Observation on 1/19/22 at 12:45 P.M. and 1/20/22 at 12:42 P.M., showed the resident seated upright in bed, dressed in a hospital gown with streaks of dried food and crumbs across his/her chest. The fingernails on the resident's left hand were long with the middle fingernail approximately 0.75 cm in length.
Observation and interview on 1/20/22 at 5:57 P.M., showed the resident lay on his/her back in bed, dressed in a hospital gown with a sheet covering his/her legs. CNA N donned gloves and pulled the sheet off the resident's legs. The resident's legs bent at the knee, at approximately a 130-degree angle. The skin on both shins and calves appeared dry and flaky, with chunks of flakes on the sheet underneath the resident's legs. The entire bottom of both feet were covered with dozens of pencil-tip sized red areas covered with scabs. There were rust-colored streaks on the sheet underneath the resident's feet. CNA N said the resident's feet and legs looked dry, and he/she has always had sores on his/her feet. He/she thinks the nurse puts moisturizer on the resident's feet, but it doesn't look like it has been done recently. Residents should be bathed or showered every two days. CNAs document showers or bed baths on shower sheets. Because the resident's legs are dry, staff should put moisturizer on them after the resident is bathed. The resident is total care and likes bed baths or showers.
During an interview on 1/24/22 at 10:08 A.M., CNA G said Resident #45 requires total assistance from staff with all ADLs, including bathing. He/she does not refuse bathing assistance and likes to be shaved, but might say no to being shaved on occasion. While providing bathing assistance, staff should observe the resident's feet, skin, and nails. CNAs can provide nail care for all residents unless they are diabetic. Diabetic residents receive nail care from the nurse. CNAs document bathing assistance on shower sheets. If a resident refuses bathing assistance, it should be documented on a shower sheet.
3. During an interview on 1/24/22 at 9:16 A.M., Nurse B said residents should be bathed or showered twice a week and as needed. CNAs should follow the shower schedule and when they provide bathing assistance, they should observe a resident's skin, feet and nails. CNAs can trim a resident's nails, unless the resident is diabetic. If the resident is diabetic, nail care is performed by the nurse. Resident #45 requires total care from staff for all of his ADLs. His/her legs are contracted and Nurse has not seen him/her out of bed during the last several months.
4. During an interview on 1/25/22 at 7:06 A.M., the administrator and DON said they would prefer bed baths or showers to occur three times a week. Nursing staff is responsible for providing bathing assistance and they should follow the shower schedule as a guideline. If a resident refuses one day, staff should re-approach them later and try to determine a date or time that works for them. If the resident continues to refuse, the aide should get the nurse or Social Services involved to see if they can assist. When providing bathing assistance, staff should look at the resident's skin, feet and nails. CNAs can provide basic nail care and nurses can provide nail care for residents with diabetes or thick nails. The administrator was not aware residents were not provided with bathing assistance in accordance with the shower schedule.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one resident identified...
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Based on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one resident identified with a rash on his/her feet. The facility failed to clarify physician orders for treatment, to administer treatments as needed, and to notify the physician upon a change in condition when the resident developed an abrasion on his/her feet (Resident #45). The sample was 24. The census was 121.
Review of the facility's Non-Pressure Skin Evaluation policy, revised 12/2019, showed:
-General: To provide guidance on the evaluation of skin tears, bruises, and rashes;
-Responsible party: Licensed Nursing Staff, Wound Care Coordinator, Treatment Nurse;
-Policy: When a resident is identified as having a skin tear, bruise, rash, or other skin condition, the appropriate documentation is completed including notification of physician and resident representative per facility guideline. Once the documentation is completed, a corresponding care plan is developed, if needed;
-Procedure:
-Skin tear:
-When a resident is identified with a skin tear, the physician and resident representative are notified, and the appropriate documentation is completed;
-Follow the policy and procedure of the treatment guidelines;
-Document treatment in the electronic health record (EHR);
-Update plan of care to reflect current skin management needs;
-Rashes:
-When a resident is identified with a rash, the physician and resident representative are notified, and the appropriate documentation is completed;
-The Director of Nursing (DON) or designee and the Wound Care Coordinator or designee, will collaborate on rashes to determine if the Wound Care department will follow in Wound Rounds;
-Only rashes that are followed by the Wound Care department, such as fungal and rashes with drainage, will be monitored using the Wound Rounds system;
-Document treatment in EHR;
-Update plan of care to reflect current skin management needs;
-Types of rashes could include:
-Infectious: ringworm, impetigo, fungal, virus, parasites;
-Noninfectious: eczema, contact dermatitis, drug erupts, hives.
Review of Resident #45's medical record, showed:
-admission date 7/16/18;
-Diagnoses included traumatic brain injury, deep venous thrombosis (DVT, blot clot formed in a deep vein), diabetes, aphasia (impairment of expressing and understanding language), seizures, dementia, quadriplegia (paralysis affecting all four limbs) and osteomyelitis (bone infection);
-No weekly nurse's skin assessments documented in October 2021.
Review of the resident's physician order sheet (POS), showed an order, dated 10/26/21, for triamcinolone acetonide cream (topical steroid) 0.1%, apply to affected area topically every 8 hours as needed for affected area, dry flaking skin. The order did not specify the affected area;
Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/8/21, showed:
-Severe cognitive impairment;
-No behaviors exhibited;
-Total dependence of two (+) person physical assist required for bed mobility, transfers, dressing toilet use, and personal hygiene;
-Upper extremity impaired on one side;
-Lower extremities impaired on both sides;
-At risk of developing pressure ulcers;
-No skin issues;
-Skin and ulcer treatments include pressure-reducing device for bed, applications of ointments/medications other than to feet.
Review of the resident's pressure ulcer risk assessment, dated 11/10/21, showed the resident identified as high risk for developing pressure ulcers.
Further review of the resident's medical record, showed:
-Shower sheets completed 11/2/21, 11/4/21, 11/6/21, 11/9/21, 11/11/21, 11/13/21, 11/16/21, and 11/30/21, showed no skin issues identified;
-No weekly nurse's skin assessments documented in November 2021;
-A medication administration record (MAR) and treatment administration (TAR) for November 2021, showed triamcinolone acetonide cream not documented as administered;
-Shower sheets completed 12/2/21, 12/14/21, 12/16/21, and 12/18/21, showed no skin issues identified;
-No weekly nurse's skin assessments documented in December 2021;
-The MARs and TAR for December 2021, showed triamcinolone acetonide cream not documented as administered.
Review of the resident's progress note, dated 1/4/22 at 7:49 A.M., showed Nurse P documented noting several tiny blood tinged stains on the resident's sheets. Upon assessing, nurse noted both feet with redness, scaly sores present, and small amount of bloody drainage. Right heel with multiple areas and scab formation. Oncoming nurse and Director of Nurses (DON) notified.
Further review of the resident's medical record, showed no physician notification of the scabbed areas, identified on 1/4/22.
Review of the resident's weekly nurse's skin assessment, dated 1/5/22, showed Nurse B documented the resident identified with an abrasion to the right heel, might be caused from friction from bed sheets. Dry skin to bilateral feet, and rash to bottom of both feet.
Review of the facility's general wound report, dated 1/5/22, showed the resident was not listed.
Further review of the resident's medical record, showed:
-No measurements of the abrasion noted on 1/5/22;
-No physician notification of the abrasion noted on 1/5/22;
-No weekly nurse's skin assessments documented after 1/5/22;
-A shower sheet, dated 1/17/22, showed no skin issues identified;
-The MAR and TAR for January 2022, showed triamcinolone acetonide cream not documented as administered 1/1/22 through 1/19/22.
Review of the resident's care plan, showed:
-Focus: Resident has rash area to his/her right foot. 10/1/19 rash to left foot, diagnosis of varicosities of extremities;
-Goal: Resident will have no signs or symptoms of infection of the rash through the review date;
-Interventions: Monitor skin rashes for increased spread or signs of infection. Treatment as ordered, inform physician if treatment plan is unsuccessful;
-Focus: Resident requires total care with activities of daily living (ADLs), diagnosis of quadriplegia and history of resistance and aggressive behaviors at times during care;
-Goal: Staff will anticipate resident's needs as needed, will be well groomed through next review;
-Interventions included: Total care with all ADL functioning. Resident is totally dependent on 1-2 staff for repositioning and turning in bed at least two hours and as necessary. The resident has contractures (tightening of muscles) to bilateral lower extremities and feet. Provide skin care daily/as needed to keep clean and prevent skin breakdown. Skin inspection daily, observe for redness, open areas, scratches, cuts, bruises, and report changes to the nurse.
Observation on 1/18/22 at 12:10 P.M., showed the resident lay in bed on his/her back. During an interview, the resident said he/she needs assistance from staff for bathing, dressing, and getting him/her out of bed. He/she cannot move his/her legs.
Observation and interview on 1/20/22 at 5:57 P.M., showed the resident on his/her back in bed, dressed in a hospital gown with a sheet covering his/her legs. The resident agreed to a skin assessment of his/her legs and feet. Certified nurse aide (CNA) N donned gloves and pulled the sheet off the resident's legs. The resident's legs bent at the knee, at approximately a 130-degree angle. The skin on both shins and calves appeared dry and flaky, with chunks of flakes on the sheet underneath the resident's legs. The entire bottom of both feet were covered with dozens of pencil-tip sized red areas covered with scabs. A pencil eraser-sized, round scab on the resident's left heel, and two pencil eraser-sized scabs on the resident's right heel, with dried blood smeared on both heels. Rust-colored streaks on the sheet underneath the resident's feet. CNA N said the resident's feet and legs looked dry, and he/she has always had sores on his/her feet. The CNA was not sure what the sores were. He/she thinks the nurse puts moisturizer on the resident's feet, but it doesn't look like it has been done recently. Residents should be bathed or showered every two days. CNAs document showers or bed baths on shower sheets. They should notify the nurse of any new skin issue identified and mark any skin issues on the shower sheet. Because the resident's legs are dry, staff should put moisturizer on them after the resident is bathed. The resident needs total care and likes bed baths or showers.
Observation and interview on 1/20/22 at 6:14 P.M., showed the resident on his/her back in bed with a sheet covering his/her legs. Assistant Director of Nurses (ADON) O said it was her first day working at the facility and she did not know the resident. ADON O donned gloves and pulled the sheet off the resident's legs. She could not identify the scabbed areas to the bottom of the resident's feet. She expected CNAs to provide bathing assistance twice a week. The CNAs should note any skin issues on the resident's shower sheet and notify the nurse of any new areas. She expected nurses to perform skin assessments every week and document their findings in the medical record. If the nurse observed a new skin area, they should notify the physician and obtain orders for treatment. Physician communication should be documented in the resident's medical record.
During an interview on 1/24/22 at 9:16 A.M., Nurse B said residents should be bathed or showered twice a week and as needed. CNAs should follow the shower schedule and when they provide bathing assistance, they should observe a resident's skin and feet, and note any abnormalities on the shower sheet. CNAs should also notify the nurse of any new skin issues. Typically, nurses should perform skin assessments on a weekly basis, but there is no current schedule or mechanism in place for nurses to complete and document their skin assessments. Resident #45 requires total care from staff for all of his ADLs. His/her legs are contracted and Nurse B has not seen him/her out of bed during the last several months. When Nurse B identified the abrasion on the resident's heel on 1/5/22, he/she did not obtain measurements because the area was not open and there was no drainage. He/she thinks he/she spoke to the physician about the area, and the physician said to apply cream. The resident already has an order in place for triamcinolone acetonide, as needed. The physician order should specify where the cream should be applied so other nurses will know, and the cream should be applied to the resident's feet. Based on the resident's current condition of a scabbed rash on his/her feet, staff should have been applying triamcinolone acetonide cream to the area. Treatment administration should be documented on the TAR. Nurse B did not find his/her communication with the physician in the resident's EHR. Some notes from the EHR disappear. Nurse also notified the treatment nurse about the resident's new area to his/her heel.
During an interview on 1/25/22 at 7:06 A.M., the administrator and DON said they would prefer bed baths or showers to occur three times a week. Nursing staff is responsible for providing bathing assistance and they should follow the shower schedule as a guideline. When providing bathing assistance, staff should look at the resident's skin, feet, and nails. If there are any skin issues, staff should notify the nurse and document their findings on the resident's shower sheet.
During an interview on 1/28/22 at 9:32 A.M., the administrator and DON said they expect all skin issues, including rashes and dryness, to be documented on resident shower sheets. Resident #45's physician order for triamcinolone acetonide, as needed, should have been applied when staff noted the rash on his/her feet. Skin treatments should be applied consistently, until the area clears up. The order for triamcinolone acetonide should specify to which area the medication should be applied. Nurses should clarify orders like this with the physician. When a nurse becomes aware of new skin issues, they should notify the resident's physician to obtain treatment orders. When Resident #45 was noted with a new abrasion to his/her right heel on 1/5/22, the nurse should have obtained measurements of the abrasion and provided more detail as to its appearance. The administrator and DON expected the nurses to notify the physician and wound nurse of the new skin area to obtain treatment orders, and the notification should have been documented in the resident's medical record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to adequately support the nutritional status of 1 of 24 sampled residents by not following RD (Registered Dietician) recommendati...
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Based on observation, interview, and record review the facility failed to adequately support the nutritional status of 1 of 24 sampled residents by not following RD (Registered Dietician) recommendations and physician orders (Resident #115). The facility census was 121.
Review of Resident #115's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, updated 12/20/21, showed:
-Moderate cognitive impairment.
-Resident dependent on staff for all Activities of Daily Living (ADLs).
-Diagnoses included dementia, hemiplegia (the functional use of the upper limbs only), seizure disorder, anxiety, depression, and psychotic disorder.
Review of the resient's care plan, updated on 12/20/21 and in use during the survey, showed:
-Focus: Resident prefers to eat meals in bed, has risk of aspiration while eating in bed, has history of poor appetite, will drink supplements;
-Goals: Resident will get out of bed for meals and be free of aspiration through next review;
-Interventions: Diet changed to puree, encourage resident to get out of bed for meals, Ensure (a liquid calorie and protein supplement) twice per day, nectar thickened liquids, monitor for meal intake, Supercereal (a porridge-like substance with extra calories and protein) at breakfast, 90ml (milliliters) ReadyCare 2.0 (nutritional supplement) three times per day, house shake with all meals.
Review of the resident's medical record, showed:
-A weight loss of 15.19% over the last 6 months;
-A weight loss of 5.34% over the last month;
-A progress note on 12/20/21 from the RD stated the resident should receive supercereal with each breakfast meal, Ensure shakes, a daily multivitamin, and double portions at all meals.
Review of the January 2022 physician order sheet, showed the following nutritional orders:
-An order from 2/19/21 and revised on 10/24/21 for a regular diet, pureed texture, and nectar consistency liquids;
-An order from 2/19/21 and revised on 10/24/21 for supercereal to be served at breakfast meals;
-An order from 6/27/21 for ReadyCare 2.0 (high calorie, high protein nutritional drink) to be given three times per day;
-Staff failed to obtain orders for the RD's receommendation of Ensure shakes, a daily multivitamin, and double portions at all meals.
Review of the resident's medication administration (MAR), showed:
-ReadyCare 2.0 not administered 93 out of 93 possible opportunities in November, 2021;
-ReadyCare 2.0 not administered 93 out of 93 possible opportunities in December 2021;
-ReadyCare 2.0 not administered 75 out of 75 possible opportunities up to the last date of the on-site survey in January, 2022.
Observation of the lunch meal on 1/20/22 at 12:56 P.M., showed the resident lay in bed being fed by nursing staff. The resident's meal was pureed, but did not include double portions. No supercereal was observed on the resident's meal tray. No meal supplements were given to the resident during this meal time and less than half of the meal was consumed.
Observation of the breakfast meal on 1/24/22 at 8:23 A.M., showed the resident lay in bed being fed by nursing staff. The resident's meal consisted of pureed eggs, pureed sausage, and thickened juice. No supercereal or meal supplements were given to the resident during this meal time.
During an interview on 1/25/22 at 1:29 P.M. the Director of Nursing (DON) and administrator stated they would expect residents to receive ordered supplements as prescribed. MARs should accurately reflect medications and supplements given to residents, and staff should complete the MAR once a medication or supplement is given to a resident.
During an interview on 1/28/22 at 10:54 A.M the facility's RD said she visits the facility once or twice a month. During those visits she sees residents who are on tube feedings (therapy where a feeding tube supplies nutrients to people who cannot get enough nutrition through eating), have significant weight loss, or are new admissions. Dietician recommendations are communicated through a standard health technologies report sent to the administrator, and dietary manager. Currently the dietician is unable to view resident meal tickets, so she is unable to verify what residents in her care are receiving for each meal daily. The RD stated she would expect her recommendations to staff to be followed in order to promote the nutritional health of residents. If recommendations are not followed, residents could experience further weight loss and malnutrition. At her last visit, she recommended double portions at meals, Supercereal with breakfast, a daily multivitamin, Ensure shakes, and ReadyCare 2.0 three times daily. The Registered Dietician stated she did not know her recommendations were not being followed and reported it was very disheartening to hear that.
CONCERN
(D)
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 ensure one resident of 24 sampled residents (Resident #55), diagnosed as having dementia with behavioral disturbance and exhibiting symptom...
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Based on interview and record review, the facility failed to ensure one resident of 24 sampled residents (Resident #55), diagnosed as having dementia with behavioral disturbance and exhibiting symptoms/behaviors which contributed to a pattern of falls with injury, received the appropriate treatment and services to attain or maintain his/her highest practicable physical, mental and psychosocial well-being by failing to fully inform his/her psychiatric nurse practitioner (NP) of behaviors which included the following: standing unassisted from his/her wheelchair and bed, wandering throughout the secured unit at night with an unsteady gait, screaming and attempting to enter other residents' rooms. The facility failed to obtain a urine specimen as ordered in a timely manner, failed to ascertain urinalysis results and report them to the NP. Additionally, the facility failed to update the Interdisciplinary team (IDT) of the resident's behaviors, develop and implement a plan of care to address his/her needs. The census was 121.
Review of the facility's policy titled, Fall Evaluation and Prevention, revised 8/2020, showed direction for the facility to evaluate residents for fall risk and develop interventions for prevention. The goal was to prevent falls if possible and avoid injury related to falls. A fall was defined as a sudden, uncontrolled, unintentional downward displacement of the body to the ground or other object, excluding falls resulting from violent blows or other purposeful actions. The policy defined an unwitnessed fall as having occurred when a resident was found on the floor and neither the resident nor anyone else knew how he/she got there. Intrinsic risk factors for falls included changes which were part of normal aging as well as certain acute or chronic conditions and certain classes of medications. Examples of common intrinsic risk factors included confusion, depression, gait and balance disorders, vision and hearing impairments, muscular weakness (particularly of the lower extremities).
Review of Resident #55's undated clinical physician's orders, showed the following:
-4/1/21, Seroquel (antipsychotic which treats schizophrenia, bipolar disorder and depression) 25 milligrams (mg) daily;
-6/4/21, Melatonin (used for short-term treatment of insomnia) tablet 3 mg at bedtime;
-6/27/21 Seroquel, 50 mg daily.
Review of the resident's social service note, dated 9/24/21 at 2:30 P.M., showed the resident enjoyed talking with his/her peers in the locked unit as well as playing bingo, making art, listening to music and watching movies.
Review of the resident's progress notes, showed the following:
-10/20/21 at 12:20 A.M. (late entry for 11:45 P.M.) the resident slipped onto his/her buttocks from the couch. The resident was unable to describe what happened. Range of motion (ROM) performed to upper and lower extremities with no complaint of pain. The resident was in his/her bare feet. Staff applied non-skid socks. Staff educated the resident that he/she must wear socks or shoes, when getting up. The resident said, you're not going to be talking to me like a dog. Staff assisted him/her to the bathroom and to bed;
-10/21/21 at 9:45 A.M., staff noted the resident guarding his/her right arm. The resident verbalized having experienced pain to that limb, since the fall on the previous day. Staff notified the resident's NP and received an order for an x-ray to rule out a fracture. At 11:39 A.M., the charge nurse noted the resident's radiology report showed a right humerus (the bone of the upper arm/forelimb, forming joints at the shoulder and elbow) fracture. The NP was in-house, reviewed the report and issued an order to send the resident to the hospital. At 8:00 P.M., the charge nurse received report on the resident from the hospital nurse. The resident was diagnosed with a displaced fracture (gap formed where the bone was broken) to the right humeral neck (any break in the bone extending from the shoulder to the elbow) and was to wear a sling until it healed;
-10/31/21 at 9:29 P.M., the resident was ambulating with a slightly unsteady gait and had to be redirected/assisted back to his/her chair. The resident did not wear a sling to the arm or keep non-skid socks on for any period of time;
-11/1/21 at 1:57 P.M., the resident was ambulating with a slow, unsteady gait instead of using his/her wheelchair. Staff reseated the resident several times. At 11:10 P.M., staff noted that the resident continued to guard his/her right arm, but also continued to remove the sling. Staff was not able to educate the resident due to his/her cognition.
Review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/3/21, showed the following:
-Severe cognitive impairment;
-Psychosis: delusions;
-Diagnoses including dementia, manic depression, repeated falls, fractures and other multiple trauma, fracture of upper end of right humerus and closed fracture;
-Verbal behavioral symptoms directed at others occurred 1-3 days;
-Wandering occurred four to six days, but less than daily;
-Wheelchair mobility;
-Required set up and supervision of locomotion on unit;
-Required extensive assistance of one with transfers, ambulation, locomotion off unit, dressing, toilet use and personal hygiene.
Further review of the resident's progress notes, showed the following:
-11/4/21 at 10:00 P.M., staff found the resident sitting on the floor in his/her room. When asked how he/she got there, the resident said he/she slipped and fell. Vital signs 126/73 (blood pressure normal range: 90/60 mm/Hg (millimeters of mercury) to 120/80 mm/Hg), 75 (pulse normal range: 60-100 beats per minute), 18 (respiration normal range: 12 - 18 breaths per minute), 98.3 (temperature normal range: 97.8 - 99.1 degrees Fahrenheit), 91% (oxygen saturation normal range: 94% to 99%). Neurochecks within normal limits;
-11/5/21 at 4:24 A.M., staff administered pain medication, due to the resident's non-compliance with wearing the sling to his/her right arm. When staff educated the resident on the importance of the sling, the resident said, I don't need it;
-11/11/21 at 12:06 A.M., the resident was up and down. Staff could not redirect the resident, who became agitated, combative and yelled. He/she refused to keep his/her arm sling in place;
-11/13/21 at 5:22 A.M., the resident's gait was unsteady and he/she refused refusing to wear sling for his/her fractured right arm. The resident needed constant reminders to utilize his/her wheelchair for mobility. He/she was awake all night. Staff assisted the resident to bed several times and he/she would be back up wandering around the unit. The resident became combative, when staff applied skid-free socks;
-11/14/21 at 10:48 P.M., the resident refused to wear his/her sling and needed constant reminders to stay out of other residents' rooms. At 2:52 A.M., the resident's gait was unsteady. He/she refused to wear his/her sling, needed constant reminders to use his/her wheelchair and was non-compliant with care;
-11/15/21 at 3:55 A.M., the resident was awake most of the night, up in his/her room and the hallway. He/she continued to refuse to wear his/her sling. Staff noted increased anxiety and agitation in him/her upon redirection. Staff assisted the resident to bed several times.
Further review of the resident's undated clinical physician's orders, showed an order dated 11/22/21, for Mirtazapine (antidepressant) 7.5 milligrams daily.
Further review of the resident's progress notes, showed the following:
-11/24/21 at 3:40 P.M., the resident continued to transfer him/herself to wheelchair without assistance, remove his/her arm sling and become agitated with education and redirection;
-11/25/21 at 7:47 P.M., staff documented that the resident exhibited agitated behavior, was verbally aggressive and refused his/her meal. The resident said, you force feeding me. At 9:46 P.M., the resident was out of bed sitting on the roommate's bed, telling him/her to go to sleep and disturbing him/her. The roommate said, why don't you just go to bed? Staff assisted the resident back into bed and then eventually out of bed and into a wheelchair, due to the resident continuing to disturb the roommate;
-11/27/21 at 10:45 A.M., staff observed the resident on the floor of the chapel and noted an abrasion to the right forehead and eye. When asked what happened, the resident said, I got up to walk and fell. Then I was crawling. His/her vital signs were as follows: 100/60, pulse 69, respirations 17, oxygen saturation 96%;
-11/28/21 5:49 A.M., the resident was up all night on one-on-one supervision with the nurse. The resident kept trying to ambulate without assistance, was difficult to redirect and became agitated. Staff gave the resident cookies and water. He/she attempted to go down the hallway with a peer of the opposite sex. At 9:56 A.M., staff witnessed the resident slide down out of his/her wheelchair, sit on the floor, lie flat on his/her back, then begin crawling and yelling for help. Staff assisted the resident back to his/her wheelchair and placed him/her in front of the nurse's station. The resident continued yelling help and attempting to get out of the wheelchair;
-No Activities notes for November 2021.
-12/1/21 at 9:31 P.M., the resident required heavy assistance from staff, to keep him/her safe, as the resident was a fall risk and continued to get up from his/her wheelchair and bed without assistance.
Review of the resident's physician patient visit note, dated 12/2/21, showed staff reported a concern about the resident due to poor intake, increased confusion and borderline low blood pressure. The resident had advanced dementia with behavioral disturbance and was no longer on psychiatric medications, except for a low dose of Seroquel per the psychiatric physician.
Further review of the resident's undated clinical physician's orders, showed the following:
-12/2/21, change in primary care physician;
-12/2/21, Urinalysis with culture;
-12/6/21, change in psychiatrist provider.
Further review of the resident's progress notes, showed:
-12/3/21 at 7:57 P.M., the resident had to be redirected throughout the shift. He/she continued to attempt to stand up out of his/her wheelchair or slide down. Staff had to monitor the resident one-on-one during shift;
-12/4/21 at 9:24 P.M., the resident remained on one-on-one monitoring after his/her fall. Redirection was difficult and often unsuccessful;
-12/5/21 at 11:30 P.M., the resident fell in his/her room. Staff completed an assessment and ROM. The resident was non-compliant and confused.
Review of the resident's fall scale, dated 12/9/21, showed a score of 65.0 which indicated a high risk for falling.
Further review of the resident's progress notes, showed the following:
-12/20/21 at 2:05 P.M., the urine sample was collected. FedEx picked it up;
-12/20/21 at 10:19 P.M., showed the resident was on incident follow up (IFU) for a swollen top lip. He/she could not recall how or when the incident occurred;
-12/22/21 at 3:21 P.M., the resident was alert and oriented times two to three. He/she had experienced a decline in both gait and cognition. The resident used a wheelchair due to an unsteady gait. He/she tended to wake at night, wander down the hall and yell for no reason;
-No further notes regarding the urinalysis;
-No Activity notes for December, 2021.
Review of the psychiatric encounter note, dated 12/22/21, showed establishment with his/her new psychiatric provider. Staff reported the resident was falling frequently and more confused recently. Staff reported the resident slept well and had a fair appetite. No agitated or aggressive behavior reported by staff. The clinical opinion of Psychiatric NP S was that the resident was not at baseline, but she was awaiting results of the urinalysis before considering changes to the resident's psychotropic medication.
Further review of the resident's undated clinical physician's orders, showed an order dated 1/5/22, for frequent monitoring every shift for safety.
During an interview on 2/1/22 at 12:03 P.M., Assistant Director of Nursing (ADON) U said the order for frequent monitoring meant exactly what it said; that nursing staff was to frequently check on the resident (there was no specific number of times during a shift), due to the fact that the resident constantly got up and was hard to redirect. The resident was not on one-to-one supervision. So, staff was expected to keep a set of eyes on the resident.
Further review of the resident's progress notes, showed the following:
-1/9/22 at 3:01 A.M., the resident woke up yelling, It's time to eat or I'm busting your head. Staff served the resident two cups of yogurt. The resident continued to fuss, but not speaking of fighting. 11:08 P.M., the resident was sitting in the TV room. The certified nurse aide (CNA) discovered the resident had a hematoma to the forehead. The resident said he/she was not in pain and did not know what happened. The nurse applied ice to the resident's forehead, notified the resident's physician and power of attorney;
-1/10/22 at 7:35 A.M., at 10:45 A.M., staff found the resident in bed resting with a towel around his/her head with some swelling to the left side of the head. No discoloration/bruising noted. The resident responded to verbal and touch stimuli. His/her eyes reacted to light. Passive ROM was tolerated. At 8:28 A.M., staff documented the following vital signs: 97.7, 18, 76, 130/74. The nurse applied a cool compress. At 9:16 A.M., the nurse documented notification via the physician's exchange and ordered a skull series;
-1/11/22 at 3:20 A.M., the resident had some swelling down the left side of his/her forehead;
-1/12/22 at 10:55 P.M., the resident continued to get up out of his/her wheelchair, was constantly having to be redirected and asked to sit in his/her wheelchair. The resident had bruising to the left side of the face and would not stay in bed;
-1/18/22 at 3:56 A.M., the resident was pacing up and down the hallway all night, yelling off and on. The resident continued to have some swelling to the left side of the forehead and both eyes. He/she remained difficult to redirect, pulling at medication carts and other residents' doors;
-No Activity notes through 1/18/22.
Review of the resident's undated care plan, showed the following:
-The resident has a diagnosis of dementia, has a history of resistance to care, as well as a history of agitated, delusional, hyperactive behaviors;
-If the resident resists with activities of daily living (ADLs), reassure the resident, leave and return five to ten minutes later and try again;
-The resident has a diagnosis of insomnia, has a history of being up all night and sleeps during the day;
-Encourage the resident to be out of bed during the day, monitor sleep patterns, inform the physician if melatonin is not effective;
-Redirect negative moods/behaviors;
-The resident is not cognitively stable and is not capable of using a call light for assistance;
-Poor safety awareness and decreased comprehension;
-The resident has dementia and cannot retain education;
-Obtain and monitor lab/diagnostic work as ordered. Report results to physician and follow up as indicated;
-ADL self-care performance deficit related to confusion and dementia;
-Unsteady gait, history of falls and gait disturbance;
-1/22/21, the resident slid out of his/her roommate's bed, hit his/her head on the dresser and incurred a quarter-sized hematoma to the left forehead.
During an interview on 2/1/22 at 2:50 P.M., ADON U said that nursing had collected a sample for the urinalysis and sent it out. However, the lab was saying that they did not have or process the sample. Consequently, the facility never received any results. ADON U discovered this on 2/1/22, when asked about the results. It is the responsibility of the two ADONs to follow up on ordered labs.
During an interview on 1/24/22 at 1:23 P.M., CNA T said he/she worked on the resident's unit from 11:00 P.M. until 7:00 A.M. On 1/18/22, CNA T was still in orientation and it was his/her first night on the floor. When he/she arrived for the night shift, the resident was pacing from one end of the unit to the other all night. He/she was the only resident up and would not go to sleep. Whenever CNA T put non-skid socks on the resident's feet, the resident removed them. The resident understood verbal redirection, but it only seemed to irritate him/her. He/she would say, you don't know what you're talking about. Two minutes later, the resident would be back up ambulating with a gait which was steady, until the resident appeared to grow tired. At that point, the resident's gait looked wobbly; like he/she might fall. CNA T felt compelled to follow the resident, which further irritated him/her. The resident said, you ain't got to follow me. The resident attempted to enter other residents' rooms. That appeared to be due to the resident not knowing his/her room number. The resident did not fall asleep until 6:15 A.M.
During an interview on 1/21/22 at 11:08 A.M., the social services director said the resident was currently on quarantine for COVID. He/she went into quarantine on 12/13/21. The resident could not understand why he/she could not go into certain areas of the COVID unit. However, it was the social services director's understanding that the resident was easily redirected and would be okay for a little while. Having consistent staff often helped with behavioral issues in residents with dementia. With new staff, that was often an issue. No one said anything to the social services director about the resident wandering around the unit all night and requiring constant redirection as well as one-on-one supervision, due to persistent self-transfers and ambulating on bare feet with an unsteady gait.
During an interview on 1/27/22 at 12:07 P.M., the Medical Director said medical problems could cause mental status changes. He/she had gone to see the resident on 12/2/21, upon request of the facility and ordered labs, which included an urinalysis, in addition to prescribing tramadol for pain. However, the psychiatrist also needed to be notified of the resident's increased confusion and behavioral issues such as wandering and agitation. Both underlying problems with the resident's disease process and psychiatric issues could result in behaviors which contributed to falls.
During an interview on 1/24/22 at 2:54 P.M., psychiatric NP S said on 12/22/21, he/she received a report from staff of behaviors and the resident not sleeping well. The resident's symptoms appeared to be related to dementia. Not wanting to be too aggressive with treatment, NP S was waiting on results from a urinalysis ordered by the primary care physician. He/she never got a call from nursing with the results. So, NP S assumed that there had not been a change or worsening in the resident's behavior. Although staff indicated the resident was exhibiting behaviors, they did not go into details. Consequently, NP S was unaware of the resident wandering around the unit all night and periodically yelling for no apparent reason, experiencing increased confusion, increased falls and non-compliance with redirection. If staff had informed NP S of those issues, then he/she would have adjusted the resident's medications. The resident yelling at night and/or attempting to enter other residents' rooms were behaviors which could easily upset other residents in the unit and posed a risk for them reacting with aggression.
During an interview on 1/28/22 at 2:56 P.M., the Director of Nursing (DON) said the resident's behaviors were tied to dementia. His/her psychiatric NP had just looked at the resident's medications and saw that they were ineffective. Consequently, the psychiatric NP would perform a medication review, in order to prescribe doses or medication changes which would treat the resident's symptoms of wandering and insomnia. Due to the resident's dementia disease process, the IDT was going to consider obtaining hospice services, for the resident's decrease in intake and overall decline. Despite the fact that the resident ate snacks, he/she burned a lot of calories with all of his/her wandering. The DON expected staff to keep the psychiatric NP informed of new behavioral issues. The facility used a lot of agency staff, so nursing staff was to document behavioral issues on the 24 hour report (consisting of a note which triggered a 72 hour look back review of progress notes). The report was reviewed and discussed by the IDT during daily clinical meetings. The team would subsequently decide whether or not to update the residents' care plans and what interventions should be implemented. Acute/temporary behavioral issues were not always added to the care plan.
During an interview on 1/25/22 at 8:13 A.M., the administrator said when a resident with a diagnosis of dementia with an unsteady gait persisted with self-transfers, staff should try redirection and stay with him/her. If verbal redirection was unsuccessful, then they should walk with the resident and have him/her sit with them. The CNA should inform the nurse, who should assess the resident, contact the resident's physician and see if he/she wanted a lab like a urinalysis ordered. The nurse should also notify the resident's psychiatrist. Staff should update the resident's care plan, whenever a new pattern of behaviors emerged. Any nurse could update the care plan. The MDS Coordinator was ultimately responsible for ensuring the care plan was updated. The MDS Coordinator was not on duty during the night shift. However, during the IDT meetings, all department heads were notified of new resident concerns. All notifications made by staff should be documented in a resident's progress notes. If it was not written, then it was not performed.
MO00194059
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to provide reasonable accomodations of resident needs and preferences by not serving meals in a timely manner and at the posted times. This defi...
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Based on observation and interview, the facility failed to provide reasonable accomodations of resident needs and preferences by not serving meals in a timely manner and at the posted times. This deficient practice affected all residents who ate at the facility. The census was 121.
During an interview on 1/18/22 at 8:30 A.M., the Dietary Manager said breakfast was served at 8:00 A.M., lunch was served at 12:00 P.M. and dinner was served at 5:00 P.M. There were three cooks and six dietary aides (DA) working in the kitchen. The main dining room was in use and some residents received meals delivered to their room.
Observations of the lunch meal service in the main dining room on 1/18/22, showed:
-At 12:02 P.M., eight residents sat in the dining room;
-At 12:16 P.M., approximately 10 residents sat in the dining room. No drinks or food were served;
-At 12:36 P.M., a DA passed hand sanitizer to residents;
-At 12:45 P.M., the DA brought juice and coffee to the main dining room and began to serve drinks to the residents;
-At 12:46 P.M., the first plate of food was served in the dining room.
During a group interview on 1/20/22 at 2:00 P.M., four out of six residents said meal times in the facility vary from day to day. Breakfast might be served at a certain time one day, then an hour later the next day. Some residents sit in the dining room for hours waiting for dinner to arrive. Residents prefer meals to be served at consistent times each day.
Observation of the lunch meal service on 1/24/22, showed:
-At 11:28 A.M., one cook and three dietary aides were present in the kitchen. The cook prepared food, one DA filled pitchers with ice, another DA stuffed plastic silverware into bags and the third dietary DA was in the dishwash area cleaning the floor;
-At 11:37 A.M., DA E grabbed three rolling unheated carts, where the food would be stored, to deliver to the residents' unit. He/she placed cookies, coffee and plastic silverware on the carts;
-At 11:48 A.M., the cook placed the prepared food in the food warmers for serving;
-At 11:53 A.M., the food sat in the server. Divided Styrofoam plates sat next to the food. DA E placed beverages on the carts for delivery to the units, DA D stuffed plastic silverware in the bags, the cook cleaned his/her dishes and another DA was in the dishwashing area wiping down surfaces;
-At 12:02 P.M., DA E delivered coffee and juice to the main dining room;
-At 12:11 P.M., DA D said he/she would start with the main dining room, and began plating food;
-At 12:18 P.M., DA E took the first six plates of food out to the main dining room;
-At 12:27 P.M., DA E took the remaining plates of food out to the main dining room;
-At 12:28 P.M., DA D began plating food for the first floor, using the divided Styrofoam trays;
-At 12:32 P.M., DA E placed the trays of food on a cart and delivered them to the first floor;
-At 12:35 P.M., DA D began plating food for the second floor main unit;
-At 12:52 P.M., DA E placed the trays of food on the cart and delivered them to the second floor main unit;
-At 12:54 P.M., DA D began plating food for the second floor south unit;
-At 12:59 P.M., DA E placed the trays of food on the cart and delivered them to the second floor south unit. DA D began plating food for the third floor;
-At 1:05 P.M., DA D told the cook he/she needed more rice or potatoes and stopped plating the food;
-At 1:11 P.M., DA D resumed plating after receiving a pan of potatoes;
-At 1:16 P.M., DA D told the cook he/she needed more vegetables and stopped plating;
-At 1:21 P.M., the vegetables were delivered and DA D resumed plating;
-At 1:23 P.M., DA E placed the trays of food on the cart and delivered them to the third floor main unit.
During an interview on 1/25/22 at 7:14 A.M., the Dietary Manager said she was aware of residents complaining of meals being late. The dietary staff were in-serviced on serving meals in a timely manner. They were supposed to plate earlier than noon to ensure meals were delivered on time.
During an interview on 1/25/22 at 1:51 P.M., the administrator and Director of Nursing (DON) said food should be served on time at the stated times.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0567
(Tag F0567)
Could have caused harm · This affected multiple residents
Based on interview, the facility failed to ensure the Business Office Manager (BOM) had access to all resident funds, and to ensure resident requests for less than $100.00 ($50.00 for Medicaid residen...
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Based on interview, the facility failed to ensure the Business Office Manager (BOM) had access to all resident funds, and to ensure resident requests for less than $100.00 ($50.00 for Medicaid residents) are honored within the same day by not assuring residents had access to their trust account on the weekends. This deficient practice affected all the residents who had a resident trust account. The census was 121.
During an interview on 1/25/22 at 10:52 A.M., the BOM said she became employed with the facility in November, 2021. Resident funds are held in the resident trust fund account. In October 2021, the facility changed ownership and opened a new resident trust fund account, Account B. The BOM did not have access to the old account, Account A, until late in December 2021. Funds were held in both accounts until Account A was closed last week. Withdrawals for resident funds are made from a separate account, Account C, through a different bank. BOM does not have access to the account, other than to make withdrawals. She does not know where the money in Account C comes from, or how it is replenished. When residents make requests for less than $100.00, she issues a check and withdraws the money from Account C. If a resident requests money, they usually get it on the same day or at least the next day, depending on when they make the request. If a resident requests money on Friday, the residents know they are not going to get their money on the weekend. The facility has not given residents money on the weekends in the past two months.
During an interview on 1/25/22 at 3:28 P.M., the BOM and administrator said residents should have access to money on the weekends. The administrator said there is a box of money at the front desk for residents who request money on the weekends. The BOM should be aware of all resident funds available. She should have had access to Account A, which was still in use when the facility opened Account B.
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 provide a safe, clean and comfortable, homelike environment. The faci...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide a safe, clean and comfortable, homelike environment. The facility failed to repair pipes leaking outside of the facility's dining room and to address the sound levels of a heating unit in one resident's room (Resident #111). In addition, the facility failed to serve resident meals with appropriate dishware and utensils. The census was 121.
1. Observations on 1/18/22 at 1:08 P.M., 1/19/22 at 8:38 P.M., 1/20/22 at 12:34 P.M., and 1/21/21 at 7:20 A.M., showed two ceiling tiles missing in the hall leading to the dining room. Pipes leaked from the missing ceiling tiles, with mop buckets placed underneath them.
During a group meeting on 1/20/22 at 2:00 P.M., four out of six residents said the plumbing has been an issue in the facility. Two ceiling tiles outside of the dining room are missing because the pipes underneath them leak and staff put buckets underneath them. The pipes outside of the dining room have been leaking for over a year and sometimes the pipes leak so much, the area outside of the dining room floods. The leaking pipes and flooding does not look nice.
During an interview on 1/25/22 at 8:34 A.M., the maintenance director said the pipes had been leaking for a couple of months. He requested bids to have it fixed and was waiting on approval. The leaking pipes were not homelike for the residents.
2. Review of Resident #111's quarterly Minimum Data Set, (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/22/21, showed:
-admitted on [DATE];
-Cognitively intact;
-Exhibited no behaviors.
Observation and interview on 1/18/22 at 1:41 P.M., showed the resident lay in bed, watching television. A loud humming noise came from the heating unit, near the window in the resident's bedroom. The resident said the noise was coming from the heating unit, and was extremely loud. The noise had been coming from the unit since he/she moved in the room in September 2021. Maintenance was aware of the issue. The noise bothered him/her and his/her roommates, but they had gotten used to it.
Observation on 1/19/22 at 12:47 P.M., showed the resident in his/her room, reading over paperwork. A loud humming noise came from the heating unit. The resident's roommate asked the resident a question. The resident told the roommate to speak up because he/she could not hear over the heating unit.
Observation on 1/20/22 at 5:55 P.M., showed the resident lay in bed on his/her back asleep. A loud humming noise came from the heating unit.
During an interview on 1/25/22 at 8:34 A.M., the maintenance director said the noise in the resident's room was a motor mount that kept turning on and off. It had been broken for about two weeks. He ordered the part to have it repaired and was waiting for the part to be delivered to the facility.
3. Observations of the meal services on 1/18/22 at 12:46 P.M., 1/20/22 at 12:56 P.M. and 1/24/22 at 12:40 P.M., showed resident meals served in three compartment Styrofoam trays, with a plastic spoon, knife and fork.
During an observation and interview on 1/21/22 at 11:45 A.M., the Dietary Manager said they had tons of silverware. She opened a file cabinet in her office with unopened boxes of knives, forks and spoons.
During a group meeting on 1/20/22 at 2:00 P.M., five out of six residents said they were tired of being served meals in Styrofoam containers with plastic utensils. Sometimes the facility runs out of plastic utensils or residents receive the wrong type of utensils for certain foods. It is hard to cut certain foods, like meat, with plastic utensils. The facility has been out of plastic knives for a day. The other day, residents were served spaghetti with plastic spoons. Last night, there were no plastic forks. The use of plastic utensils is not homelike.
During an interview on 1/25/22 at 7:14 A.M., the Dietary Manager said she was aware of residents complaining about the use of Styrofoam trays and plastic utensils. The facility had enough utensils for all residents, but they were using Styrofoam and plastic silverware because of Covid-19.
4. During an interview on 1/25/22 at 11:51 A.M., the administrator said the leaking pipes on the first floor was not considered home-like and they were in the process of having it repaired. She was not aware of the broken heating unit in Resident #111's room and the noise was not considered comfortable or homelike. The residents were served food in Styrofoam and with plastic silverware because of the Covid outbreak.
MO00195088
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
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 one on one (1:1) activities for six of 23 res...
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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 one on one (1:1) activities for six of 23 residents who were identified as receiving 1:1 activities (Residents #45, #89, #82. #101, #115, #20, and #9). In addition, the facility failed to provide 1:1 activities for one resident identified by staff as having the desire to participate in 1:1 activities. The sample was 24. The census was 121.
1. Review of Resident #45's medical record, showed:
-admission date of 7/16/18;
-Diagnoses included traumatic brain injury, aphasia (impairment of expression and understanding of language), seizures, dementia, and quadriplegia (paralysis affecting all four limbs).
Review of the resident's quarterly activity participation review, dated 9/6/21, showed:
-Resident is on 1:1 with activity staff. Resident will refuse any activity offered, but will socialize with staff;
-Resident likes when staff communicate with him/her and likes to watch television in his/her room, mostly lying in bed. He/she will listen to some music he/she enjoys.
Review of the facility's 1:1 activity visit list, revised 10/15/21, showed the resident listed.
Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/8/21, showed:
-Severe cognitive impairment;
-Staff assessment of daily activities included listening to music, participating in favorite activities, and spending time outdoors;
-Required staff physical assist for transfers and locomotion.
Review of the resident's care plan, in use at the time if survey, showed the following:
-Focus: Resident prefers to watch television in his/her room or in the sun room, he/she interacts with staff;
-Goal: Activity level will remain the same without decline through next review;
-Interventions: 1:1 visits from activities up to three times weekly;
-Prefers to watch television in his/her room or in the sun room;
-Prefers the following TV channels (specify): blank.
Review of the resident's 1:1 activities documentation from 11/1/21 through 1/21/22, showed:
-On 11/12/21 at 1:45 P.M., 1:1 visit conducted. The resident always has a good time when staff comes to see him/her. Listens to music and dances;
-On 12/15/21 at 1:23 P.M., unable to conduct 1:1 visit because resident was asleep;
-No documentation of additional 1:1 visits attempted or completed.
Observation on 1/18/22 at 12:10 P.M., 1/19/22 at 8:11 A.M. and 12:45 P.M., 1/20/22 at 12:42 P.M. and 5:57 P.M., and 1/21/21 at 9:04 A.M., showed the resident seated upright in bed with the television on. Staff did not engage in activities with the resident.
During an interview on 1/18/22 at 12:10 P.M., the resident said he/she stays in his/her room. He/she gets bored sometimes. Staff do not do activities with him/her. He/she would like visits from staff.
2. Review of Resident #89's medical record, showed:
-admission date of 6/2/16;
-Diagnoses included multiple sclerosis (nervous system disease that affects the brain and spinal cord), quadriplegia (paralysis of upper and lower limbs), heart failure, kidney failure, and depression.
Review of the resident's significant change MDS, dated [DATE], showed:
-No cognitive impairment;
-Staff assessment of daily activities included listening to music and participating in favorite activities;
-Upper and lower extremities impaired on both sides.
Review of the facility's 1:1 activity visit list, revised 10/15/21, showed the resident listed.
Review of the resident's quarterly activity participation review, dated 12/10/21, showed:
-Resident refuses any scheduled activity. He/she does talk with activity staff and asks them to assist him/her with getting things for him/her while he/she is in bed in his/her room. Resident is on 1:1 with activity staff;
-Resident prefers to be in his/her room. He/she enjoys watching television.
Review of the resident's care plan, in use at the time if survey, showed the following:
-Focus: Resident mostly stays in his/her room with door closed at all times. He/she has history of getting nails trimmed or to the beauty shop to get hair washed or braided. Resident will accept some snacks from activity staff. He/she enjoys supernatural movies. Resident is at risk for alteration in psychosocial well-being related to restriction on visitation related to COVID-19 and medical status. He/she is withdrawn at times;
-Goal: Resident will participate in more activities, will get out of bed at least twice a week;
-Interventions included: 1:1 visits from activities up to three times weekly. Resident responds positively to music therapy. Play his/her choice of music at his/her request.
Review of the resident's 1:1 activities documentation from 11/1/21 through 1/21/22, showed:
-On 11/2/21, 1:1 visit conducted. Staff watched television with the resident. The resident can't move and feels a bit depressed;
-On 12/8/21, 1:1 visit conducted. The resident was in a better mood today. He/she was watching television;
-On 12/31/21, the resident was busy with a hospice visitor;
-No documentation of additional 1:1 visits attempted or completed.
Observation on 1/18/22 at 12:00 P.M. and 1/19/22 at 8:07 A.M., showed the resident lay on his/her back in bed. The television on. Staff did not attempt to engage with the resident.
During an interview on 1/19/22 at 12:58 P.M., the resident said he/she relies on staff for assistance with all activities of daily living (ADLs) and depends on staff to transfer him/her out of bed. He/she spends all day in bed and watches television. He/she gets bored and is bored with the television. Staff never do activities with him/her and the resident is just left in his/her room. When asked how the resident is doing, he/she stated, Laughing on the outside, crying on the inside.
3. Review of Resident #82's medical record, showed:
-admission date of 6/16/21;
-Diagnoses included stroke, hemiplegia (paralysis of one side of the body), anxiety, and depression.
Review of the resident's admission activity review, dated 6/18/21, showed the resident wishes to have 1:1 with staff.
Review of the resident's admission MDS, dated [DATE], showed:
-Severe cognitive impairment;
-Very important to the resident to listen to music he/she likes, be around animals such as pets, keep up with the news, do his/her favorite activities, and go outside to get fresh air when the weather is good;
-Somewhat important to the resident to do things with groups of people;
-Required staff physical assist for transfers.
Review of the facility's 1:1 activity visit list, revised 10/15/21, showed the resident not listed.
Review of the resident's care plan, in use at the time if survey, showed the following:
-Focus: Resident has little or no activity involvement related to anxiety and depression. He/she prefers to be in bed daily, watching television or asleep;
-Goal: Resident will get out of bed at least two times a week through next review date;
-Interventions: Encourage resident to get out of bed daily;
-The care plan failed to identify the resident's group or individual activity participation level and desire to socialize.
Observation on 1/18/22 at 12:14 P.M., 1/19/22 at 12:45 P.M., 1/20/22 at 12:39 P.M. and 5:56 P.M., and 1/24/21 at 8:57 A.M., showed the resident sat upright in bed with the television on. Staff did not engage in activities with the resident.
During an interview on 1/18/22 at 12:14 P.M., the resident said he/she is paralyzed on his/her left side and requires staff assistance to get him/her out of bed. Staff don't always come help him/her out of bed and he/she spends a lot of time in his/her room. He/she gets bored in his/her room. Staff do not come by his/her room and do activities with him/her.
Observation on 1/20/22 at 12:54 P.M., showed the resident lay on his/her back in bed. Staff did not engage in activities with the resident. During an interview, the resident said he/she had not received 1:1 activities. It would be nice for staff to come by and do activities with him/her. He/she likes to socialize and talk.
4. Review of Resident #101's medical record, showed:
-admission date of 3/26/17;
-Diagnoses included coronary artery disease (CAD), hypertension, diabetes, Alzheimer's disease, stroke, dementia, depression, and schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves).
Review of the resident's annual MDS, dated [DATE], showed:
-Severe cognitive impairment;
-Staff assessment of daily and activity preferences included participating in favorite activities;
-Required staff physical assist for transfers and locomotion.
Review of the facility's 1:1 activity visit list, revised 10/15/21, showed the resident listed.
Review of the resident's quarterly activity participation review, dated 12/16/21, was left blank.
Review of the resident's 1:1 activities documentation from 11/1/21 through 1/21/22, showed:
-On 12/26/21, 1:1 visit not conducted. Resident was asleep.
-No additional documentation of 1:1 visits conducted.
5. Review of Resident #115's medical record, showed:
-admission date of 4/3/19;
-Diagnoses included dementia, hemiplegia, seizure disorder, anxiety, depression, and psychotic disorder.
Review of the resident's significant change MDS, dated [DATE], showed:
-Resident rarely/never understood;
-Staff assessment of daily and activity preferences included listening to music and participating in favorite activities;
-Required staff physical assist for transfers.
Review of the facility's 1:1 activity visit list, revised 10/15/21, showed the resident listed.
Review of the resident's quarterly activity participation review, dated 12/20/21, was left blank.
Review of the resident's 1:1 activities documentation from 11/1/21 through 1/21/22, showed:
-On 11/1/21, 1:1 visit conducted. Resident was up looking at the TV and stated he/she wanted to go home.
-On 12/17/21, 1:1 visit conducted. Staff and resident listened to music.
-No additional documentation of 1:1 visits conducted.
6. Review of Resident #20's medical record showed:
-admission date of 4/26/17;
-Diagnoses included anemia, aphasia, cerebral palsy (a disorder affecting posture and motor function), dementia, quadriplegia, and seizure disorder.
Review of the resident's annual MDS, dated [DATE], showed:
-Resident rarely/never understood;
-Staff assessment of daily and activity preferences included listening to music, being around animals such as pets, doing things with groups of people, participating in favorite activities, spending time outdoors, and participating in religious activities or practices.
Review of the facility's 1:1 activity visit list, revised 10/15/21, showed the resident listed.
Review of the resident's quarterly activity participation review, dated 10/26/21, was left blank.
Review of the resident's 1:1 activities documentation from 11/1/21 through 1/21/22, showed:
-On 11/3/21, 1:1 visit conducted. Staff played music for the resident to listen to.
-On 11/18/21, 1:1 visit conducted. Staff noted the resident likes to watch television.
-On 12/17/21, 1:1 visit conducted. Resident listened to music.
-On 1/20/22, 1:1 visit conducted. Staff played music and the resident watched television.
-No additional documentation of 1:1 visits conducted.
7. Review of Resident #9's medical record, showed:
-An admission date of 3/17/20;
-Diagnoses included anemia, CAD, hyperlipidemia, Alzheimer's disease, stroke, dementia, schizophrenia, bipolar disorder, and psychotic disorder.
Review of the resident's annual MDS, dated [DATE], showed:
-Resident rarely/never understood;
-Staff assessment of daily and activity preferences included listening to music and participating in favorite activities.
Review of the resident's quarterly activity participation review, dated 10/8/21, was left blank.
Review of the facility's 1:1 activity visit list, revised 10/15/21, showed the resident listed.
Review of the resident's 1:1 activities documentation from 11/1/21 through 1/21/22, showed:
-On 1/5/22, 1:1 visit conducted. Staff noted the resident liked looking at the television.
-No additional documentation of 1:1 visits conducted.
8. During an interview on 1/24/22 at 10:08 A.M., certified nurse aide (CNA) G said he/she knows Residents #45, #89, and #82 well. The residents cannot transfer on their own and are totally dependent on staff to assist them out of bed. All three of the residents are social and love to chat and talk with staff. CNAs talk with the residents while providing care, but the residents could benefit from 1:1 visits with activity staff. The CNA has not seen the residents receiving 1:1 activities.
9. During an interview on 1/24/22 at 9:16 A.M., Nurse B said Resident #45 and #89 are totally dependent on staff for transfers and mobility, and they are in bed most of the time. Resident #82 requires staff assistance to get out of bed and uses a wheelchair for mobility. Residents #25, #82, and #89 do not refuse care or assistance from staff. Each of the residents are social and like to interact with staff. The residents would benefit from 1:1 activities. The nurse has not seen the residents involved in 1:1 activities.
10. During an interview on 1/25/22 at 8:29 A.M., activity aide (AA) F said he/she works for the facility full-time. The facility had an Activity Director, but they quit last week. There are residents throughout the facility who receive 1:1 activities. 1:1 activities are also called friendly visits, and they are provided to residents who don't like going to group activities or they can't get out of bed. 1:1 activities are supposed to be provided three times a week. They are not getting done as often as they should because the activity aides get pulled to the floor to assist with other things, like monitoring the hall. If a resident is asleep when activity staff attempt to visit, staff should try to come back later. The activity aides document their 1:1 visits on the 1:1 sheets. Resident #45 enjoys his/her 1:1 activities and likes to sing and play music. Resident #89 also participates in activities and likes to watch television with staff and play music. Resident #82 does not receive 1:1 activities, but the resident is mostly in bed all the time and could benefit from 1:1 visits.
11. During an interview on 1/25/22 at 9:01 A.M., the administrator said the Activity Director just quit last week. The facility currently has two activity aides. The activity aides are responsible for providing 1:1 activities. 1:1 activities should be offered at least three times a week. She was not aware 1:1 activities were not being provided three times a week. If staff attempt to offer 1:1 activities, but a resident is sleeping, the staff should try again another time. 1:1 activities should focus on what a resident likes to do, such as drawing, walking, or listening to music. Residents who might not like crowds or who are bed bound are referred to 1:1 activities. Involvement in activities could help improve a resident's quality of life.
During an interview on 1/25/22 at 1:01 P.M., the administrator said the facility does not have a policy regarding activities.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
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 appropriately store non-expired medications and equipm...
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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 appropriately store non-expired medications and equipment in two of three facility medication storage rooms and in one of five nurse treatment carts. Staff also failed to secure narcotic medication. The facility census was 121.
Review of the facility's Storage of Medications policy, revised April 2007, showed:
-Drugs and biologicals shall be stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers;
-The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner;
-The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed;
-Drugs for external use, as well as poisons, shall be clearly marked as such, and shall be stored separately from other medications;
-Antiseptics, disinfectants, and germicides used in any aspect of resident care must have legible, distinctive labels that identify the contents and the directions for use, and shall be stored separately from regular medications;
-Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others;
-Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents;
-Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medications must be stored separately from food and must be labeled accordingly;
-Only persons authorized to prepare and administer medications shall have access to the medication room, including any keys.
1. Observation of the first floor medication room on 1/19/22 at 12:10 P.M., showed expired medications included:
-Three boxes of [NAME] Real Time Control Solution (a liquid used to calibrate glucose (blood sugar) monitors to produce accurate results) expired as of November 2021.;
-Three bottles of Hormel Thick and Easy cranberry juice expired as of 1/7/21.
-One box of Urinox-10 urinalysis test strips (used to determine the presence of bacteria in urine samples) expired as of 9/30/21.;
-One tube of ConvaTec stomahesive ostomy (an artificial opening in the abdomen) wound appliance expired as of August 2021;
-One box of Nexodyn ointment (antimicrobial wound care solution) expired as of 5/14/20.;
-Two Dynarex suction tubing extensions (used for suctioning the airway) expired as of September 2019;
-One Medikmark non sterile spill clean-up kit (used for cleaning up hazardous substances) expired as of September 2017;
-Two Stradis non sterile spill clean-up kit expired as of 1/31/20.
2. Observation of a second floor nurse's cart on 1/19/22 at 12:44 P.M., showed one bottle of Hormel thickened cranberry juice expired as of 1/7/21 and two tubes of Dermacerin (moisturizing cream) expired as of November, 2021.
3. Observation of the second floor medication room on 1/19/22 at 1:03 P.M., showed expired medications included:
-Two bottles of Ferrous Sulfate (an iron supplement) expired as of 1/7/21;
-Two boxes of [NAME] Real Time glucose control solution expired as of November of 2021.
Further observation of the second floor medication room on 1/19/22 at 1:03 P.M., showed no lock on the medication room refrigerator door that contained stock narcotic medications.
4. Observation of a third floor treatment cart on 1/19/22 at 1:26 P.M., showed one bottle of Nexodyn antimicrobial wound care solution expired as of 5/14/20.
5. During an interview on 1/25/22 at 1:29 P.M. the Director of Nursing and administrator said they would expect nursing staff and certified medication technicians to dispose of expired medications. Medications that are expired should not be used for resident treatments. Night shift nursing staff are responsible for calibrating glucometers (a machine that calculates blood sugar levels) each night, and they would expect staff to verify expiration dates on glucose control solutions before using them to calibrate a glucometer. Narcotics kept in a medication room refrigerator should be kept behind two locks.
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 and interview, the facility failed to ensure meal service tray temperatures were maintained to at least 120 degrees Fahrenheit (F). Five out of six residents attending the Residen...
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Based on observation and interview, the facility failed to ensure meal service tray temperatures were maintained to at least 120 degrees Fahrenheit (F). Five out of six residents attending the Resident Council meeting complained about the food temperatures. The census was 121.
Observation of the lunch meal service on 1/24/22 at 11:53 A.M., showed the prepared food on the warm server in the kitchen. Styrofoam plates sat on top of the server. Three wheeled carts held beverages. Dietary Aide (DA) D began placing food onto the Styrofoam plates. DA E took the plates and placed them onto the wheeled cart, with the beverages, to deliver to the units. The cart did not have any components to keep the meals warm while in transport.
Further observation on 1/24/22, showed:
-At 1:00 P.M., the cart which held the lunch trays was delivered to the second floor. The food was served in divided Styrofoam plates. A resident's tray was taken from the cart. The meal consisted of a beef patty, rice and vegetables. The beef patty reached a temperature of 115.5 degrees, using a digital thermometer;
-At 1:25 P.M., the cart which held lunch was delivered to the third floor. The food was served in divided Styrofoam plates. A resident's tray was taken from the cart. The meal consisted of a beef patty, potatoes and mixed vegetables. The mixed vegetables reached a temperature of 98.4 degrees, using a digital thermometer.
During a group interview on 1/20/22 at 2:00 P.M., five out of six residents said food was not hot enough and was served cold. The residents would prefer their food to be served hot.
During an interview on 1/25/22 at 7:14 A.M., the Dietary Manager said she was aware of residents' complaints of cold food. When she first came to the facility, there were two portable steam tables, but they were no longer operable. She did not want staff to place hot food on a cold steam table because the plugs did not work. She requested a five well steam table. She also requested plate warmers, domes to cover the plates and a covered delivery cart to keep food warm during transport. She also in-serviced dietary staff on serving food at the appropriate temperatures.
During an interview on 1/25/22 at 11:51 A.M., the administrator and Director of Nursing (DON) said food should be served hot.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0909
(Tag F0909)
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 complete an inspection of bed frames, mattresses and b...
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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 complete an inspection of bed frames, mattresses and bed rails as part of a regular maintenance program to identify areas of possible entrapment for four of 24 sampled residents to reduce the risks of accidents (Residents #93, #112, #8, and #45). The facility identified 27 residents who utilized bed rails. Of the 27 residents, four were sampled and problems were identified with all four. The census was 121.
Review of the facility's Bed Rail Policy, dated 7/20/20, showed:
-Preface: It is the policy of this facility to identify and reduce safety risks and hazards commonly associated with bed rail use. A duo-faceted approach will be used to achieve sustainable quality outcomes, including regular bed maintenances and individual bed rail evaluations. In response to the requirement of providing for a safe, clean, comfortable and homelike environment, the facility's regular maintenance program will include regular inspections of all bed systems (e.g. rails, frames, and mattresses and operational components) to ensure they are clean, comfortable and safe;
-The facility will also ensure individual resident bed rail evaluations are performed on a regular basis. The facility's priority is to ensure safe and appropriate bed rail use.
1. Review of Resident #93's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff0, dated 12/13/21, showed:
-admitted on [DATE];
-Exhibited moderate cognitive impairment;
-Required extensive assistance of two staff for bed mobility;
-Required total dependence of two staff for transfers;
-Diagnoses included cancer, high blood pressure and stroke;
-Bed Rails used daily.
Review of the resident's Side Rail Assessment, dated 12/15/21, showed:
-Bilateral quarter side rails used;
-No inspection of bed frames, mattresses and bed rails.
Observation on 1/21/22 at 7:31 A.M., showed the resident lay in bed on his/her back with quarter length bed rails raised on both sides of the bed.
Observation on 1/24/22 at 9:00 A.M., showed the resident lay in bed on his/her back with quarter length bed rails raised on both sides of the bed. The resident grabbed both bed rails and began to shake the rails.
2. Review of Resident #112's Side Rail Assessment, dated 12/13/21, showed:
-Bilateral quarter side rails used;
-No inspection of bed frames, mattresses and bed rails.
Review of the resident's admission MDS, dated [DATE], showed:
-admitted on [DATE];
-Severe cognitive impairment;
-Required total dependence of two staff for bed mobility and transfers;
-Diagnoses included diabetes and seizures;
-Bed rails used daily.
Observation on 1/21/22 at 7:30 A.M. and 1/24/22 at 9:00 A.M., showed the resident lay in bed on his/her back with quarter length bed rails raised on both sides.
3. Review of Resident #8's quarterly MDS, dated [DATE], showed:
-admission date of 5/21/18;
-Moderate cognitive impairment;
-Total dependence of two (+) person physical assist required for bed mobility, transfers, locomotion and toilet use;
-Upper extremity impaired on one side;
-Diagnoses included end stage renal disease (ESRD, kidney disease), high blood pressure, seizures, anxiety, depression, bipolar disorder, schizophrenia, insomnia, restlessness and agitation and repeated falls.
Review of the resident's quarterly side rail assessment, dated 1/12/22, showed the resident determined to benefit from bilateral quarter-length side rails. The assessment did not include an assessment for entrapment zones.
Review of the resident's care plan, in use at the time of survey, showed:
-Focus: Resident is at risk for falls. Resident keeps bed in a high position and needs reminders to call for help;
-Goals: Resident will be free of injury related to falls;
-Interventions included two quarter-length side rails to aide in bed mobility and repositioning.
Observation on 1/18/22 at 1:01 P.M., showed the resident in bed with a quarter-length side rail raised on the left side at the middle of the mattress.
Observation on 1/19/22 at 12:54 P.M., showed the resident in bed with a quarter-length side rail raised on the left side at the middle of the mattress. During an interview, the resident said he/she used the side rail to reposition him/herself in bed.
Observations on 1/21/22 at 7:23 A.M. and 1/24/22 at 9:08 A.M., showed the resident in bed with a quarter-length side rail raised on the left side at the middle of the mattress.
4. Review of Resident 45's annual MDS, dated [DATE], showed:
-admission date of 7/16/18;
-Severe cognitive impairment;
-No behaviors exhibited;
-Total dependence of two (+) person physical assist required for bed mobility, transfers, dressing, toilet use and personal hygiene;
-Upper extremity impaired on one side;
-Lower extremities impaired on both sides;
-Diagnoses included traumatic brain injury, deep venous thrombosis (DVT, blot clot formed in a deep vein), diabetes, aphasia (impairment of expressing and understanding language), seizures, dementia, quadriplegia (paralysis affecting all four limbs) and osteomyelitis (bone infection).
Review of the resident's quarterly side rail assessment, dated 11/10/21, showed the resident assessed for bilateral quarter-length side rails.
Review of the resident's care plan, in use at the time of survey, showed:
-Focus: Resident requires total care with activities of daily living due to diagnosis of quadriplegia, has history of resistance, aggressive behaviors at times;
-Goals: Staff will anticipate resident needs as needed;
-Interventions included two quarter-length side rails for positioning.
Observation on 1/18/22 at 12:10 P.M., showed the resident in bed with quarter-length side rails on both sides of the bed, at the middle of the mattress. During an interview, the resident was unable to say if he/she used the side rails.
5. During an interview on 1/25/22 at 8:44 A.M., the Maintenance Director said he was not aware of the need to do routine inspections of bed rails and had not completed them.
6. During an interview on 1/25/22 at 11:44 A.M., the administrator and Director of Nursing said the Side Rail Assessments were completed, but maintenance had not completed an inspection of bed frames, mattresses and bed rails to reduce the risk of accidents.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0568
(Tag F0568)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to ensure general accounting principles were followed by failing to provide explanations for discrepancies noted during monthly resident trust...
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Based on interview and record review, the facility failed to ensure general accounting principles were followed by failing to provide explanations for discrepancies noted during monthly resident trust fund reconciliations for two accounts, and by failing to complete monthly account reconciliations for a third account in which resident funds were held. In addition, the facility failed to follow up on outstanding checks, and failed to provide quarterly statements to residents and their representatives. This affected 110 residents whose funds were handled by the facility. The census was 121.
Review of the facility's Cash Disbursement Procedure policy, undated, showed no guidance regarding resident trust account reconciliation, outstanding checks, or quarterly statements.
1. Review of the facility's Trust Account Reconciliation from January through December 2021, showed:
-January 2021:
-Bank balance as of 1/31/21: $157,485.53;
-Total of 111 resident accounts as of 1/31/21: $157,723.77;
-The facility showed a difference of $0.00;
-Discrepancy explanation: blank;
-February 2021:
-Bank balance as of 2/28/21: $156,399.65;
-Total of 109 resident accounts as of 2/28/21: $156,393.66;
-The facility showed a difference of $0.00;
-Discrepancy explanation: blank;
-March 2021:
-Bank balance as of 3/31/21: $148,623.83;
-Total of 110 resident accounts as of 3/31/21: $148,617.45;
-The facility showed a difference of $0.00;
-Discrepancy explanation: blank;
-April 2021:
-Bank balance as of 4/30/21: $237,657.51;
-Total of 111 resident accounts as of 4/30/21: $237,648.28;
-The facility showed a difference of $0.00;
-Discrepancy explanation: blank;
-May 2021:
-Bank balance as of 5/31/21: $229,066.66;
-Total of 110 resident accounts as of 5/31/21: $229,056.77;
-The facility showed a difference of $0.00;
-Discrepancy explanation: blank;
-June 2021:
-Bank balance as of 6/30/21: $218,730.98;
-Total of 110 resident accounts as of 6/30/21: $218,960.59;
-The facility showed a difference of -$238.85;
-Discrepancy explanation: blank;
-July 2021:
-Bank balance as of 7/31/21: $183,994.58;
-Total of 108 resident accounts as of 7/31/21: $184,465.10;
-The facility showed a difference of -$479.25;
-Discrepancy explanation: blank;
-August 2021:
-Bank balance as of 8/31/21: $181,660.75;
-Total of 107 resident accounts as of 8/31/21: $181,652.90;
-The facility showed a difference of $0.00;
-Discrepancy explanation: blank.
-September 2021:
-Bank balance as of 9/30/21: $180,421.71;
-Total of 110 resident accounts as of 9/30/21: $180,414.19;
-The facility showed a difference of $0.00;
-Discrepancy explanation: blank.
-October 2021:
-Bank balance as of 10/31/21: $173,758.64;
-Total of 112 resident accounts as of 10/31/21: $173,996.02;
-The facility showed a difference of $0.00;
-Discrepancy explanation: blank.
-November 2021, Account A:
-Bank balance as of 11/30/21: $162,051.33;
-Total of 110 resident accounts as of 11/30/21: $162,293.83;
-The facility showed a difference of $7.10;
-Discrepancy explanation: blank.
-November 2021, Account B:
-Bank balance as of 11/30/21: $27,679.62;
-Total of 110 resident accounts as of 11/30/21: $27,679.04;
-The facility showed a difference of $0.00;
-Discrepancy explanation: blank.
-December 2021, Account A:
-Bank balance as of 12/31/21: $157,911.22;
-Total of 105 resident accounts as of 12/31/21: $158,143.80
-The facility showed a difference of $4.92;
-Discrepancy explanation: blank.
-December 2021, Account B:
-Bank balance as of 12/31/21: $29,840.04;
-Total of 110 resident accounts as of 12/31/21: $29,839.06;
-The facility showed a difference of $0.00;
-Discrepancy explanation: blank.
During an interview on 1/25/22 at 10:52 A.M., the Business Office Manager (BOM) said she has been in her current position with the facility since November 2021. Resident funds are held in the resident trust fund account. Prior to October 2021, all resident funds were held in Account A. In October 2021, the facility changed ownership and a new resident trust fund account, Account B, was opened. In November and December 2021, the facility held resident funds in two separate accounts, Account A and Account B. The BOM reconciled both Account A and Account B in November and December 2021. Account B was closed last week. The facility should have been using one account for resident funds because two separate accounts will not ensure accurate balances. The resident trust fund, including petty cash, should be reconciled with the bank statements each month. Every month, there should be a $0 balance after the reconciliation is done and the amounts should balance out. She thinks the reconciliation between each month does not match due to checks that had not cleared.
2. During an interview on 1/25/22 at 10:52 A.M., the BOM said when a resident requests a small amount of cash, such as $5.00, the facility can give the resident money from the box. Social Services (SS) gives the BOM the resident's request for money and the money is taken from the box and given to SS to give to the resident. The resident signs off on receiving the money. There is no set amount of money maintained in the box and she does not know where the money in the box came from, but money in the box is considered resident funds. The BOM counted the money contained in the box, which totaled $186.00. She did not reconcile the box money in November or December 2021. When residents request additional funds, the BOM issues a check and withdraws the money from Account C, which is through a different bank than the resident trust accounts. The only access she has to Account C is for withdrawals. She does not know where the money in Account C comes from or how it is replenished. Since Account C is used for resident funds, it should be reconciled monthly.
Review of the facility's resident trust account documentation, showed no bank statements, trial balance reports, or trust account reconciliation regarding Account C.
3. Review of the facility's Disbursement Checking Account Reconciliation, effective 11/30/21, showed:
-Check, dated 3/5/15, for $50.00;
-Check, dated 4/16/15, for $50.00;
-Check, dated 7/21/15, for $11.86;
-Check, dated 9/28/16, for $0.89;
-Check, dated 10/4/16, for $30.00;
-Check, dated 11/21/16, for $0.04;
-Check, dated 1/26/17, for $773.80;
-Check, dated 9/6/17, for $1,214.90;
-Check, dated 11/8/17, for $8.43;
-Check, dated 7/13/18, for $50.00;
-Check, dated 9/14/18, for $50.00;
-Check, dated 11/7/18, for $835.76;
-Check, dated 11/9/18, for $30.00;
-Check, dated 12/17/18, for $13.00;
-Check, dated 2/14/19, for $50.00;
-Check, dated 10/23/19, for $426.71;
-Check, dated 12/12/19, for $989.00;
-Check, dated 1/27/20, for $30.28;
-Check, dated 3/1/21, for $1,760.49;
-Check, dated 4/2/21, for $41.00;
-Check, dated 6/14/21, for $50.00;
-Check, dated 7/15/21, for $696.24;
-Check, dated 11/16/21, for $2,249.16;
-Check, dated 11/18/21, for $569.94;
-A total of $9,981.50 in outstanding checks.
Review of the facility's Disbursement Checking Account Reconciliation, effective 12/31/21, showed:
-Check, dated 3/5/15, for $50.00;
-Check, dated 4/16/15, for $50.00;
-Check, dated 7/21/15, for $11.86;
-Check, dated 9/28/16, for $0.89;
-Check, dated 10/4/16, for $30.00;
-Check, dated 11/21/16, for $0.04;
-Check, dated 1/26/17, for $773.80;
-Check, dated 9/6/17, for $1,214.90;
-Check, dated 11/8/17, for $8.43;
-Check, dated 7/13/18, for $50.00;
-Check, dated 9/14/18, for $50.00;
-Check, dated 11/7/18, for $835.76;
-Check, dated 11/9/18, for $30.00;
-Check, dated 12/17/18, for $13.00;
-Check, dated 2/14/19, for $50.00;
-Check, dated 10/23/19, for $426.71;
-Check, dated 12/12/19, for $989.00;
-Check, dated 1/27/20, for $30.28;
-Check, dated 3/1/21, for $1,760.49;
-Check, dated 4/2/21, for $41.00;
-Check, dated 6/14/21, for $50.00;
-Check, dated 7/15/21, for $696.24;
-Check, dated 11/16/21, for $2,249.16;
-Check, dated 11/18/21, for $569.94;
-Check, dated 12/21/21, for $3,336.00;
-Check, dated 12/21/21, for $1,940.00;
-Check, dated 12/30/21, for $90.90;
-Check, dated 12/30/21, for $50.80;
-Check, dated 12/30/21 for $181.81;
-A total of $15,581.11 in outstanding checks.
During an interview on 1/25/22 at 10:25 A.M., the BOM said old outstanding checks should be voided. As of right now, there is resident money floating around that is not accounted for. The BOM should follow up on old checks issued to account for resident money.
4. Review of resident trust fund documentation from 1/2021 through 12/2021, showed no quarterly statements provided to residents from 1/1/21 through 9/30/21.
During an interview on 1/25/22 at 10:52 A.M., the BOM said residents and their representatives should receive quarterly statements showing the resident's current balance and list of transactions during the previous three months. She was unable to locate documentation to show quarterly statements were provided from 1/1/21 through 9/30/21. On 1/24/22, she received the quarterly statements for October through December 2021, which had not yet been provided to residents and their representatives.
5. During an interview on 1/25/22 at 3:28 P.M., the administrator said the facility did not have any polices regarding funds, other than the Cash Disbursement Procedure policy. She would expect all resident money to be accounted for. The facility should follow up on outstanding checks. When reconciling the resident trust account, there should be a $0 difference. Accounts holding resident money should be reconciled monthly, including Account C. She would expect residents and their responsible parties to receive quarterly statements.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0569
(Tag F0569)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure third party liability (TPL) forms were completed for the fin...
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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 third party liability (TPL) forms were completed for the final accounting for residents who expired, within 30 days. This affected five residents who expired and had money in their account (Residents #323, #322, #350, #321 and #320). The census was 121.
1. Review of Resident #323's resident fund account, showed the following:
-He/she expired on [DATE];
-He/she had a balance of $866.38;
-No documentation of TPL completed.
2. Review of Resident #322's resident fund account, showed the following:
-He/she expired on [DATE];
-He/she had a balance of $2,441.22;
-No documentation of TPL completed.
3. Review of Resident #350's resident fund account, showed the following:
-His/her account closed on [DATE];
-He/she had a balance of $90.00;
-No documentation of TPL completed.
4. Review of Resident #321's resident fund account, showed the following:
-He/she expired on [DATE];
-He/she had a balance of $5,499.72;
-No documentation of TPL completed.
5. Review of Resident #320's resident fund account, showed the following:
-He/she expired on [DATE];
-He/she had a balance of $90.90;
-No documentation of TPL completed.
6. During an interview on [DATE] at 2:41 P.M., the Business Office Manager (BOM) said Resident #350 was found unresponsive and was sent to the hospital on [DATE], where he/she expired. His/her account was closed on [DATE] and the facility issued a check for his/her funds to the resident. Resident #320 expired on [DATE] and the facility issued a check for his/her funds to go to the resident. Checks for expired residents should not be issued to the resident who expired. When a resident has funds held by the facility and the resident expires, the BOM should fill out a TPL form and submit it to the State of Missouri, Department of Social Services (DSS), within 30 days. DSS determines where the resident's remaining funds should be distributed. The BOM could not locate TPL forms or receipts for funeral expenses for the expired residents sampled.
7. During an interview on [DATE] at 3:28 P.M., the administrator said when a resident has funds held by the facility and the resident has a balance when they expire or transfer, she expected the State of Missouri to be notified of funds remaining in the resident's account.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0570
(Tag F0570)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to ensure they maintained an adequate surety bond for the resident trust fund account in the amount of one and one half times the average mont...
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Based on interview and record review, the facility failed to ensure they maintained an adequate surety bond for the resident trust fund account in the amount of one and one half times the average monthly balance for the past 12 months. The census was 121.
Review of the facility's Cash Disbursement policy, undated, showed no instructions on how to monitor the facility's surety bond to ensure it was sufficient.
Review of the resident trust account for the past 12 months, from January 2021 to December 2021, showed an average monthly balance of $187,000. (This would yield a required bond in the amount of $280,500 (one and one half times the average monthly balance)).
Review of the bond report for approved facility bonds by Department of Health and Senior Services (DHSS), showed an approved bond of $270,000, dated 12/17/21.
Review of the ending balance for December 2021, showed an amount of $187,982.86.
During an interview on 1/25/22 at 3:28 P.M., the business office manager (BOM) and administrator said the facility does not have any additional policies regarding funds. The corporate office oversees the bond amount to make sure it is sufficient.
MINOR
(C)
Minor Issue - procedural, no safety impact
Transfer Notice
(Tag F0623)
Minor procedural issue · This affected most or all residents
Based on interview and record review, the facility failed to notify a representative of the State Long-Term Care Ombudsman of resident transfers/discharges for three of three residents sampled for eme...
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Based on interview and record review, the facility failed to notify a representative of the State Long-Term Care Ombudsman of resident transfers/discharges for three of three residents sampled for emergency transfers (Residents #45, #2 and #78). The sample was 24. The census was 121.
1. Review of Resident #45's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, admission and discharge assessments, showed:
-admission date of 7/16/18;
-discharged to the hospital 10/18/21;
-readmission to the facility 10/25/21.
2. Review of Resident #2's MDS admission and discharge assessments, showed:
-admission date of 9/27/21;
-discharged to the hospital 11/3/21;
-readmission to the facility 11/5/21.
3. Review of Resident #78's MDS admission and discharge assessments, showed:
-admission date of 1/23/17;
-discharged to the hospital 12/15/21;
-readmission to the facility 12/18/21.
4. During an interview on 1/11/22 at 2:09 P.M., the director of the regional Ombudsman's office said the facility does not send monthly transfer notices. The Ombudman's office has not received monthly transfer notices from the facility since prior to June 2021.
5. During an interview on 1/25/22 at 2:39 P.M., the Social Services Director (SSD) said she started working with the facility on 12/13/21. Until this week, she was not aware she was responsible for notifying the Ombudsman's office of resident transfers from the facility. The Ombudsman's office should be notified of all resident transfers by the 15th of each month. She did not notify the Ombudsman's office of resident transfers in December 2021 because she was unaware she should.
6. During an interview on 1/24/22 at 7:20 A.M., the administrator said the SSD is responsible for notifying the Ombudsman's office of resident transfers from the facility. The Ombudsman's office should be notified on a monthly basis of all resident transfers. A discharge notification policy was requested.
7. Review of an email on 1/28/22 at 8:06 A.M., showed the administrator documented the facility does not have a policy regarding notice of discharge/transfer.
Dec 2019
27 deficiencies
1 IJ (1 facility-wide)
CRITICAL
(L)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0678
(Tag F0678)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff were able to provide emergency basic life...
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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 staff were able to provide emergency basic life support immediately when needed, including cardiopulmonary resuscitation (CPR), to any resident requiring such care in accordance with physician's orders and the resident's advance directives by failing to have a system in place to ensure resident's code status was documented and that staff were able to quickly identify a resident's code status when needed. The facility failed to obtain an ordered code status for 13 residents (Residents #13, #77, #103, #67, #75, #26, #54, #104, #126, #87, #88, #97 and #32), failed to ensure residents'/resident representatives wishes for code status matched the physician ordered code status for two residents (Residents #107 and #114), failed to ensure one resident's code status was ordered timely after admission (Resident #40) and failed to ensure a process for staff to know a resident's code status in the event of electrical or electronic medical record outage. This had the potential to affect all residents who resided in the facility. The sample was 29. The census was 146.
The administrator was notified on [DATE] at 1:43 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification.
Review of the facility's untitled policy, dated [DATE], provided as the facility's policy and procedure for resident code status and advanced directives, showed:
-While awaiting a physician's order to withhold cardiopulmonary resuscitation (CPR, the manual application of chest compressions and ventilations to patients in cardiac arrest), facility staff should immediately document discussions with the resident or resident representative, including, as appropriate, a resident's wishes to refuse CPR (DNR, do not resuscitate). At minimum, a verbal declination of CPR by a resident, or if applicable a resident's representative, should be witnessed by two staff members. While the physician's order is pending, staff should honor the documented verbal wishes of the resident or the resident's representative, regarding CPR;
-Advance directives: The right to formulate an advance directive applies to each and every resident and facilities must inform residents of their option to formulate advance directives. If a resident has a valid advance directive, the facility's care must reflect the resident's wishes as expressed in their directive;
-Facility Policies: Facility policies should address the provision of basic life support and CPR, including:
-Directing staff to initiate CPR when cardiac or respiratory arrest occurs for residents who do not show obvious clinical signs of irreversible death and who have requested CPR in their advanced directives or who have not formulated an advanced directive or who do not have a valid DNR order;
-The policy failed to identify the process to document code status and to assure the code status is congruent and available during electronic medical record down time.
1. Review of Resident #13's electronic physician order sheet (ePOS), reviewed on [DATE], showed no ordered code status.
Review of the resident's electronic medical record, showed the resident admitted to the facility on [DATE].
Review of the social service signed code status binder, located in the social service office, showed no signed code status.
During an interview on [DATE] at 7:41 P.M., the Social Service Director (SSD) said he/she obtained verbal wishes for a full code on [DATE].
2. Review of Resident #77's ePOS, reviewed on [DATE], showed no ordered code status.
Review of the resident's electronic medical record, showed the resident admitted to the facility on [DATE].
Review of the social service signed code status binder, located in the social service office, showed full code, signed [DATE].
During an interview on [DATE] at 7:41 P.M., the SSD confirmed the resident's code status form was signed on [DATE] as a full code. There was no order for the full code in the ePOS.
3. Review of Resident #103's ePOS, reviewed on [DATE], showed no ordered code status.
Review of the resident's electronic medical record, showed the resident admitted to the facility on [DATE].
4. Review of Resident #67's ePOS, reviewed on [DATE], showed no ordered code status.
Review of the resident's electronic medical record, showed the resident admitted to the facility on [DATE].
5. Review of Resident #75's ePOS, reviewed on [DATE], showed no ordered code status.
Review of the resident's electronic medical record, showed the resident admitted to the facility on [DATE].
Review of the social service signed code status binder, located in the social service office, showed no signed code status.
6. Review of Resident #26's ePOS, reviewed on [DATE], showed no ordered code status.
Review of the resident's electronic medical record, showed the resident admitted to the facility on [DATE].
7. Review of Resident #54's ePOS, reviewed on [DATE], showed no ordered code status.
Review of the resident's electronic medical record, showed the resident admitted to the facility on [DATE].
8. Review of Resident #104's ePOS, reviewed on [DATE], showed no ordered code status.
Review of the resident's electronic medical record, showed the resident admitted to the facility on [DATE].
9. Review of Resident #126's ePOS, reviewed on [DATE], showed no ordered code status.
Review of the resident's electronic medical record, showed the resident admitted to the facility on [DATE].
10. Review of Resident #87's ePOS, reviewed on [DATE], showed no ordered code status.
Review of the resident's electronic medical record, showed the resident admitted to the facility on [DATE].
Review of the social service signed code status binder, located in the social service office, showed no signed code status.
11. Review of Resident #88's ePOS, reviewed on [DATE], showed no ordered code status.
Review of the resident's electronic medical record, showed the resident admitted to the facility on [DATE].
12. Review of Resident #97's ePOS, reviewed on [DATE], showed no ordered code status.
Review of the resident's electronic medical record, showed the resident admitted to the facility on [DATE].
13. Review of Resident #32's ePOS, reviewed on [DATE], showed no ordered code status.
Review of the resident's electronic medical record, showed the resident admitted to the facility on [DATE].
14. During an interview on [DATE] at 8:56 A.M., the SSD said she is responsible to obtain a resident's code status wishes upon admission. If she is off work, the charge nurse is responsible.
15. During an interview on [DATE] at 10:07 A.M., the Director of Nursing (DON) said resident code statuses are reviewed during the quarterly care plan meetings. A resident without a code status should have been identified as not having a code status at the quarterly meeting.
16. Review of Resident #107's ePOS, showed an order dated [DATE], for full code.
Observation on [DATE] at approximately 9:15 A.M., showed Licensed Practical Nurse (LPN) I passed medications to residents on the hall. A staff person came out of the resident's room and asked LPN I to call Assistant Director of Nursing (ADON) A. ADON A came to the floor, then two staff members came out of the resident's room and told LPN I the resident expired and time of death was 9:21 A.M. No CPR was performed. LPN I continued to pass medications to residents on the hall.
During an interview on [DATE] at 10:08 A.M., LPN I said he/she needed to look in the computer to know the resident's code status. LPN I looked in the computer and said he/she was having trouble finding the code status, but I know the resident is a DNR, otherwise staff would have done CPR. At 10:15 A.M., LPN I said Nurse Practitioner (NP) W was the person who came to him/her to call ADON A. The resident was on hospice and was a DNR. The ePOS said full code, but the resident is on hospice. During an interview with ADON A at this time, he/she said he/she was called to the floor. NP W was in to see the resident and he/she did not hear heart or lung sounds. He/she also checked and did not hear anything. The resident was a DNR and the death was expected.
During an interview on [DATE] at 10:20 A.M., the administrator said she would check into the resident's code status. She was pretty sure the code status was changed in the hospital to a DNR. Code status should be updated and accurate. The nurse who admitted the resident should make sure the code status is updated. The administrator went to the second floor and talked with staff about the resident's code status. ADON A got the hospice binder out of the office and said the resident came back from the hospital as a full code. NP W talked with the guardian and the code status was changed to DNR. The administrator said she would expect the code status on the form and the electronic chart to match. It would be the nurse who admits a resident who is responsible to enter the code status into the electronic medical record. If a residents code status is changed after a resident is admitted , it would be the nurse who was on duty at the time the code status was changed to enter the information into the computer.
Review of the signed code status form, located inside the hospice binder, showed a DNR form signed [DATE] by the guardian.
During an interview on [DATE] at approximately 12:00 P.M., Hospice Case Manager S said the resident went on hospice on [DATE] and he/she believed the resident was already a DNR. If hospice obtained the DNR order, they would take the order to the hospice medical director and have the order signed. Hospice would set up a binder and the information would be in the binder at the facility. If they believed the facility already had the resident as a DNR, they would not do this. If the resident was already a DNR at the facility, the facility would be responsible to maintain the order for DNR.
During an interview on [DATE] at 1:32 P.M., NP W, the NP for the Medical Director, said the resident was a DNR. When the resident admitted last week, he/she saw him/her the day after. He/she discussed hospice with Guardian Y. Guardian Y then changed the resident to a DNR. Usually he/she would give a verbal order or he/she will put the order for the DNR into the system. Then staff send the code status sheet to the Medical Director for signature. He/she was not sure if that was done for the resident. He/she gave the verbal order for the DNR. Once the order was given, the order should be entered into the computer and faxed over to the Medical Director's office. He/she talked with ADON A, LPN N and Staff X last week about the DNR order.
During an interview on [DATE] at 2:27 P.M., Guardian Y said he/she prepares the DNR form and the form is based on a questionnaire he/she receives from the physician. He/she has a signed questionnaire for the resident signed by the physician from the hospital.
Review of the signed questionnaire, faxed on [DATE] at 2:38 P.M., showed it contained questions about the resident's condition and no order for code status.
17. Review of Resident #114's medical record, showed an order dated [DATE], for full code.
Review of the social service signed code status binder, located in the social service office, showed a signed code status sheet dated [DATE], for DNR.
During an interview on [DATE] at 11:31 A.M., LPN H said he/she is the nurse for the resident. Everything is in the computer. Staff know a code status by looking in the computer.
18. Review of Resident #40's ePOS, showed an order dated [DATE], for DNR.
Review of the social service signed code status binder, located in the social service office, showed a signed code status sheet dated [DATE], for full code.
Further review of the social service signed code status binder, showed a signed code status for a DNR not obtained until [DATE].
19. During an interview on [DATE] at 8:56 A.M., the SSD said she is responsible to obtain the signed code status sheets. After it is signed, she used to make a copy and place it in the paper chart, but the facility no longer has paper charts. She now keeps them in a binder in her office. Some care coordinators will ask for a copy of them as well. If a copy is not given to the care coordinator, then the copy in her office is the only copy. When she is not at work, her office is locked. If staff needed to access the code status binder when she is not at the facility, the maintenance staff and administrator have a key to the office and would have to come down and unlock it. She is just now learning how to scan the signed code status sheets into the electronic medical record. She would expect the physician order match the signed code status sheet.
20. During an interview on [DATE] at 10:07 A.M., the DON said resident code statuses are reviewed during the quarterly care plan meetings. A resident with an incongruent code status should have had this identified during the quarterly care plan meeting.
21. During an interview on [DATE] at 10:34 A.M., LPN E said the facility has no paper charts. When asked where advanced directives were located, he/she said good question, he/she would have to get back to the surveyor on that.
During an interview on [DATE] at 11:31 A.M., LPN H said everything is in the computer. Staff know a resident's code status by looking in the computer.
During an interview on [DATE] at 11:36 A.M., LPN Q said the residents' code status is in the electronic medical record. That is the only place it is located, since the facility went electronic.
During an interview on [DATE] at 3:17 P.M., Care Coordinator B and LPN C said if a resident ceased to have signs of life, they would check them to verify no vital signs. They then come to the electronic medical chart to see if the resident was a full code. If they were a full code, they would start CPR. If the computers were down, they were not sure where they would look. If a resident is a new admission, upon admission the step of obtaining a code status order is part of the admission process. If a code status changes, staff document in progress notes, but they have to contact social services. Staff need to have the conversation with the resident or representative witnessed. Social services usually changes the documentation of code status.
During an interview on [DATE] at 3:18 P.M., LPN J said if a resident ceased to have signs of life, he/she would call a code over the intercom and at the same time have someone check the resident's code status. Code status is checked in the computer.
During an interview on [DATE] at 3:19 P.M., Certified Nursing Assistant (CNA) D said if a resident were to cease having signs of life, he/she would get the nurse. He/she is new and is not sure how to know a resident's code status.
During an interview on [DATE] at 3:26 P.M., CNA BB said if he/she found a resident unresponsive or expired, he/she would check to see if they had a pulse, then run and tell the charge nurse.
During an interview on [DATE] at 3:28 P.M., CNA CC said if he/she found a resident unresponsive or maybe expired, he/she would run out and check the code status in the electronic chart. If the resident was a full code, he/she would page overhead and run back to start CPR. If the resident was a DNR, he/she would just tell the charge nurse the resident expired.
During an interview on [DATE] at 3:28 P.M., LPN E said if he/she found a resident with no signs of life, he/she would try some lifesaving measures initially and yell code. If it is found the resident was a DNR on the computer, he/she would stop life saving measures. He/she has been at the facility for 4 years. If the computers go down, he/she would not be able to check the code status. The computers have gone down in the past on several occasions. They are down for an hour or so at a time. If he/she does not know the code status, he/she is doing CPR.
22. During an interview on [DATE] at 4:20 P.M., with the administrator and DON, the DON said upon admission, if a resident did not come with an order for a code status, staff ask the physician for one. The physician usually talks to the family and gives staff an order. When asked who was responsible for making sure a resident has a code status, the DON said she was not sure she knew how to answer that. She knew the SSD plays a role in it. Code status is on the electronic physician order sheet and on the care card at the nurse's station. Each nurse's station has a binder with a care card for each resident and that is where code status is documented. They heard some staff did not know where to find the code status, so the care coordinators are in-servicing staff right now. If the computers go down, staff are to refer to the care card. She would expect the advanced directives policy be followed. If the policy requires two witnesses to a DNR request from the resident or family, this would be documented in the nurse's notes. She would expect the facility policy to address how code status will be documented. Staff should be aware of the care cards.
Observation and interview on 1 south and 1 Main on [DATE] at 4:46 P.M., showed a CNA binder at the nurses stations. LPN J said the CNA care card binders have been at the nurse's station, he/she would have never thought to look there for a resident's code status.
Observation and interview on 2 south on [DATE] at 4:35 P.M., showed Care Coordinator B walked down the hall with a binder in his/her hand and said it was the CNA care card binder that will be kept in the cabinet on 2 south. The care coordinators are in-servicing staff now on the location of the CNA care card binders. He/she will also be doing an audit.
Observation and interview on 2 Main on [DATE] at 4:35 P.M., showed the care card binder at the nurses station. LPN E said he/she did not know how often the CNA care card binders are updated and he/she had never looked in the binder. Review of the binder at this time, showed 13 residents documented in the binder without a code status identified.
Observation and interview on 3 south on [DATE] at 4:30 P.M., showed LPN F pulled up a resident's care card in the computer and said there is no care card on paper.
During observation and interview on 3 main on [DATE] at 4:35 P.M., LPN G said he/she knew there was a book on the left side of the wall, in the cubby, but he/she was unsure which book was the CNA care card book. LPN G asked another staff member to get the book down for him/her because he/she could not reach the book. Staff got the book down and it was not the CNA care card binder. The staff person got down a second book and it was the CNA care card binder. The book showed some of the residents who resided on the floor missing from the book, Residents #95, #70, #5, #393 and #50.
23. During an interview on [DATE] at 5:41 P.M., the administrator said the Quality Assurance and Performance Improvement team had not identified code status as an issue. The facility switched over from paper charting to the electronic records and they had not identified the location of resident code statuses as an issue.
NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level L. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements.
At the time of exit, the severity of the deficiency was lowered to the F level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents with pressure ulcers received necessa...
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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 with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection and prevent new ulcers from developing for two residents (Resident #40 and #118). This resulted in tissue decline and larger measurements of a pressure ulcer for one resident when he/she readmitted from the hospital and the facility failed to obtain treatment orders and assess the wound for two days. The facility identified four residents as having pressure ulcers, two were included in the sample of 29 and issues were found with both. The census was 146.
Review of the facility's Skin Ulcer-Wound policy, dated 8/15/18, showed:
-All caregivers are responsible for preventing, caring for and providing treatment for skin ulcerations;
-Licenses staff will, upon admission, perform a head to toe body audit within 2 hours of admission. The findings will be documented in the resident's clinical record;
-Licensed staff members will, upon admission, complete a risk scale weekly for the first four weeks and after admission for each resident at risk, then quarterly, or whenever there is a change in condition;
-Licensed staff will complete a head to toe skin assessment weekly and as needed;
-Staff will institute a plan for any resident who has potential for skin breakdown or whose condition is deteriorating, this may include: Turn and reposition every two hours as appropriate, pressure reduction surfaces for beds and wheelchairs, promotion of clean/dry/well moisturized skin.
1. Review of Resident #40's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/15/19, showed:
-Severe cognitive impairment;
-Diagnosis included cancer, diabetes, and non-Alzheimer's Dementia;
-Extensive assistance with bed mobility, transfers, dressing, eating, toileting and hygiene;
-At risk for pressure ulcers (injury to the skin and/or underlying tissue, as a result of pressure or friction);
-No pressure ulcers at time of admission.
Review of the resident's Braden assessments (assessment used to determine risk for pressure ulcers), dated 9/8/19 and 12/16/19, showed the following:
-On 9/18/19, a score of 17, at risk;
-On 12/16/19, a score of 8, very high risk.
Review of the resident's electronic physician order sheet (ePOS), showed an order dated 12/7/19, for Duoderm (occlusive dressing) dressing. Apply to coccyx (tail bone) topically one time a day every three days.
Review of the resident's care plan, dated 10/10/19 and in use during the survey, showed no documentation of the resident's pressure ulcer, interventions, goals, or stage of the pressure ulcer.
Review of the resident's progress notes, dated 12/1/19 through 12/12/19, showed no documentation of the resident's pressure ulcer.
Review of the facility's weekly wound report, dated 12/6/19 through 12/12/19, showed the following:
-Onset date: 12/9/19;
-Stage: Stage II (a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough (dead tissue), may also present as an intact or open/ruptured blister);
-New Measurements:
-Length: 0.4 centimeter (cm);
-Width: 0.5 cm;
-Depth: 0.1 cm;
-Cite: coccyx;
-Acquired: In-house;
-Treatment: Duoderm, change every three days and as needed.
Review of the resident's treatment administration record (TAR), dated 12/1/19 through 12/12/19, showed:
-On 12/9/19, the order for Duoderm dressing, apply to the coccyx one time a day every three days: Blank;
-On 12/12/19, the order for Duoderm dressing, apply to the coccyx one time a day every three days, documented as administered as ordered.
Review of the resident's hospital record, dated 12/12/19, showed:
-admitted to the hospital on [DATE];
-Active pressure ulcer sacrum (tail bone area): Assessment date 12/12/19;
-Present on admission: Yes;
-Wound measurement to sacrum on 12/12/19:
-Length: 4.5 cm;
-Width: 5 cm;
-Depth: 0.2 cm;
-discharged from the hospital on [DATE].
Review of the resident's medical record, showed the resident re-admitted to the facility on [DATE].
Further review of the resident's ePOS, showed:
-An order dated 12/18/19, for Venelex Ointment (Balsam Peru Castor Oil). Apply to sacrum topically every day shift, every two days for pressure ulcer. Clean with normal saline or wound cleaner, skin prep (protective barrier wipe) to periwound (intact skin around wound edges), apply Venelex ointment to wound bed and cover with foam dressing and apply to sacrum topically as needed for pressure ulcer;
-An order dated 12/18/19, for foam Dressing Bordered Pad (wound dressings). Apply to sacrum topically every day shift, every two days for pressure ulcer after skin prepping and applying Venelex and apply to sacrum topically as needed for pressure ulcer.
Review of the resident's progress notes, dated 12/18/19 at 12:12 P.M., showed staff and hospice nurse at bedside for evaluation and treatment of sacral wound. Area measured approximately 5.8 cm by 6.0 cm by 0.2 cm. Periwound macerated (the softening and breaking down of skin resulting from prolonged exposure to moisture) and denuded skin (loss of the epidermis (top layer of skin), caused by exposure to urine, feces, body fluids) noted. Hospice nurse and nurse practitioner (NP) agreed on treatment plan change due to decline to tissue and larger measurement. Venelex and foam dressing, change every two days and as needed, noted and implemented.
Further review of the resident's medical record, showed physician orders and assessments of the pressure ulcer were not obtained until 12/18/19.
Further review of the resident's TAR, dated 12/16/19 through 12/31/19, showed:
-On 12/18/19 and 12/20/19, foam Dressing Bordered Pad, apply to sacrum topically every day shift, every two days: blank. Not documented as applied until 12/22/19;
-On 12/18/19 and 12/20/19, Venelex Ointment, apply to sacrum topically every day shift, every two days: blank. Not documented as applied until 12/22/19;
-No documentation of any wound treatment applied to the sacrum/coccyx area after readmission on [DATE] until 12/22/19.
During an interview on 12/19/19 at 2:40 P.M., Licensed Practical Nurse (LPN) N said the pressure ulcer was found somewhere between 12/7/19 through 12/20/19. It was before he/she went to the hospital and the treatment order came soon after it was discovered.
During an interview on 12/20/19 at 5:26 P.M., the DON said she would expect there to be documentation of the resident's pressure ulcer. She would expect staff to follow physician's orders. The resident's care plan is expected to be updated to include the pressure ulcer, measurements, and treatments.
2. Review of Resident 118's quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-Two staff person assist for activities of daily living;
-Upper/lower extremity impairment of both sides;
-Wheelchair for mobility;
-One Stage III pressure ulcer;
-One unstageable pressure ulcer (depth of the wound is unable to be determined);
-Diagnoses included quadriplegia (paralysis of all four limbs), multiple sclerosis, (MS, disease in which the immune system eats away at the protective covering of nerves), heart failure, high blood pressure, kidney failure and diabetes.
Further review of the resident's MDS records, showed:
-discharge date of 11/25/19;
-Entry date of 11/30/19.
Review of the resident's Braden assessments, showed the following:
-On 5/20/19, a score of 14, moderate risk;
-On 11/11/19, a score of 15, at risk;
-On 11/30/19, a score of 13, moderate risk.
Review of the resident's ePOS, showed:
-An order dated 6/14/17, for a low air loss mattress for pressure prevention;
-An order dated 12/2/19 for Santyl ointment (a debriding ointment, the medical removal of dead, damaged, or infected tissue), 250 unit/gram. Apply to right ischium (area of the skin where the leg connects to the buttocks) topically every night shift for wound care. Clean with normal saline or wound cleaner. Apply Santyl ointment, nickel thick, pack lightly with calcium alginate (absorbent product) and cover with dry dressing;
-An order dated 12/11/19, for Santyl ointment (a debriding ointment, the medical removal of dead, damaged, or infected tissue), 250 unit/gram. Apply to left ischium topically every night shift for wound care. Clean with normal saline or wound cleaner. Apply Santyl ointment, nickel thick, pack lightly with calcium alginate and cover with dry dressing.
Review of the resident's care plan, in use during the survey, showed:
-Problem: Resident has a history of having a healed unstageable pressure ulcer to the right ischium. He/she is at risk for developing other pressure related areas due to refusing to offload the area, incontinent of bowel and requiring assistance with turning and repositioning while in bed. He/she refuses to return to bed once he/she gets up into the motorized wheelchair and stays up for prolonged periods of time. On 10/15/19, stage II ulcer to right ischium;
-Approach: Skin will remain intact through review date. Inform resident/family/caregivers and physician of any new area of skin breakdown. Instruct/assist him/her with shifting his/her weight in wheelchair on a frequent basis. Needs monitoring/reminding/assistance to turn/reposition at least every 2 hours, more often as needed or requested. Monitor/document/report as needed any changes in skin status. Treatment to right ischium as ordered, inform physician if treatment plan is unsuccessful;
-Further review of the care plan, showed the care plan not updated with a pressure area to left ischium.
Review of the resident's wound analysis report, right ischial, showed:
-On 12/4/19, (length, width, depth) 1.3 cm, 1 cm, 1.1 cm, stage III pressure injury;
-On 12/11/19, 1 cm, 1 cm, 0.7 cm, stage III pressure injury;
-On 12/18/19, 0.8 cm, 1 cm, 0.5 cm, stage III pressure injury.
Review of the resident's wound analysis report, left ischial, showed:
-On 12/4/19, 2.5 cm, 2.5 cm, 0.4, unstageable due to non-removable dressing/device;
-On 12/11/19, 3 cm, 2.5 cm, 0.6 cm, unstageable due to non-removable dressing/device;
-On 12/18/19, 3.5 cm, 2.7 cm, 0.8 cm, stage III pressure Injury.
During an interview on 12/18/19 at 11:45 A.M., Nurse Practitioner W said the resident was hospitalized on [DATE] and returned with a worsened wound from the hospital. He/she went from a stage II to a stage III. The area on his/her left side worsened.
Observation on 12/19/19 at 7:57 A.M., showed LPN N complete a dressing change for Resident #118. LPN N said he/she was the treatment nurse for the building. The resident's air mattress alarmed, turned off and then immediately kicked back on. The resident said this happens, there is a short. Staff have to come back in to fix it when it turns off. Observation of the front control panel of the air mattress, showed three buttons cracked through the plastic cover and exposed the inner workings of the machine. Certified Nurse Assistant (CNA) K assisted LPN N to reposition the resident to the left side. A brown substance visible on the outside of the dressing on the resident's left ischium and bowel movement visible on the resident's buttocks. LPN N removed the soiled dressing. He/she removed his/her gloves, washed his/her hands and went to the treatment cart. He/she mixed Santyl and collagen together in a medication cup and obtained a boarder dressing, gauze and wound cleanser. LPN N washed his/her hands and applied gloves. Wound bed yellow and pink in color. LPN N cleansed the wound with wound cleanser. Bowel movement continued to be visible on the resident's buttocks. LPN N applied the collagen and Santyl mix to the wound bed with an applicator. He/she removed his/her gloves, washed his/her hands, dated the border dressing, applied gloves and placed the dressing on the wound to the resident's left ischium. Bowel movement continued to be on the resident's buttocks. The air mattress turned off again. The resident said LPN N must have hit the cord, so the air mattress turned off. The resident's air mattress had gone flat. LPN N adjusted the electrical cord and the air mattress turned back on. The resident said the bed does this at times, ever since he/she got it. CNA K said the dysfunction of the air mattress might happen at night and no one would know. As staff assisted the resident to reposition in bed, the bowel movement fell out of the resident's rectum and fell onto the bed. Staff cleansed the resident's buttocks, assisted the resident to get positioned in bed and prepared to get the resident up for breakfast.
During an interview on 12/20/19 at 4:02 P.M., the resident said if you bump the bed, it will deflate. The bed stayed deflated as long as thirty minutes at a time, and it is very uncomfortable when the bed deflated.
During an interview on 12/20/19 at 4:07 P.M., LPN UU said he/she was aware the bed deflates when the plug is bumped.
During an interview on 12/20/19 at 3:11 P.M., the Maintenance Director said any staff person can report an environment concern to maintenance. Maintenance staff complete room audit check sheets periodically. The sheets were part of the Quality Assurance and Performance Improvement (QAPI) plan. He would expect staff to report issues with an air mattress. Maintenance was not aware of the issue. No staff reported this issue as of this time.
During an interview on 12/19/19 at 4:10 P.M., the DON said when the resident's bed gets pushed against the wall and the bed hits the plug, it deflates, LPN N is part of the wound team, is aware of the settings on the air mattress and if the bed is functioning as it should. On 12/20/19 at 2:36 P.M., the DON said if a resident had bowel movement on his/her buttocks during a treatment, she would expect it be cleaned prior to applying the new treatment.
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 assess a resident's ability to safely self-administer their own medications for one resident when staff left medications at th...
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Based on observation, interview and record review, the facility failed to assess a resident's ability to safely self-administer their own medications for one resident when staff left medications at the bedside (Resident #43). The sample was 29. The census was 146.
Review of the facility's Self-Administration policy, dated 3/1/02, showed:
-Residents who express no desire to participate will have all medication administration functions handled by the facility;
-If the resident desires to participate, the facility's Interdisciplinary Team (IDT) will evaluate the resident's cognitive, physical, and visual ability to self-medicate using the self-medication evaluation tool;
-All self-medication assessments will be kept in the clinical record under assessments tab;
-The program will be included in the resident's care plan;
-Monthly documentation of the resident's response to this program will be completed by a licensed nursing personnel in conjunction with monthly summaries or separately as assigned.
Review of Resident #43's medical record, showed the following:
-A quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/18/19, showed diagnoses of anemia, high blood pressure, dementia, seizure, and kidney disease;
-No order to self-administer medications;
-No assessment for the ability to self-administer medications.
Review of the resident's care plan, in use at the time of the survey, showed no documentation for the ability to self-administer medication.
Observation and interview on 12/20/19 at 8:50 A.M., showed the resident lay in bed with his/her arms over his/her face. A medication cup was located on the bedside table with approximately seven pills inside. The resident was asked if he/she just received his/her medication. He/she removed his/her arms from over his/her face, looked at the medication cup and said, I guess so and placed his/her arms over his/her face. Licensed Practical Nurse (LPN) E stood at the medication cart on the hall. LPN E confirmed that he/she administered the medications and the resident said he/she would take them. LPN E did not see the resident take his/her medications. LPN E said the resident was assessed to show that he/she could safely take medications without staff present.
During an interview on 12/20/19 at 4:41 P.M., the Director of Nursing (DON) said the resident was not able to self-administer his/her medications. In order for a resident to self- administer, they would have to show a desire and staff would complete an assessment. She would expect the nurse to stay in the room with the resident to ensure all medications were taken.
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 that each resident receives an accurate assessm...
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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 that each resident receives an accurate assessment, reflective of the resident's status at the time of the assessment for two of 29 sampled residents (Residents #60 and #43). The census was 146.
1. Review of Resident #60's medical record, showed an active order dated 4/26/19, for intermittent straight catheterization (temporary insertion of a urinary catheter into the bladder to drain urine) three times a day. Resident may straight catheterize self.
Review of the resident's quarterly Minimum Data Sets (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/1/19 and 10/1/19, showed intermittent catheterization not indicated.
2. Review of Resident #43's medical record, showed an active order dated 6/4/19, to check and record vitals before and after dialysis (the process of filtering toxins from the blood in individuals with kidney failure) two times a day every Tuesday, Thursday and Saturday.
Review of the resident's quarterly MDS, dated [DATE], showed dialysis not indicated.
3. During an interview on 12/20/19 at 3:36 P.M., MDS coordinator JJ said the MDS should be accurate.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
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 residents with a mental disorder and individuals with intell...
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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 residents with a mental disorder and individuals with intellectual disability as determined by the DA-124c level I screen (used to evaluate for the presence of psychiatric conditions), indicating the required preadmission screening/resident review (PASARR, level II screen), had one completed for one of 29 sampled residents (Resident #8). The census was 146.
Review of Resident #8's face sheet, showed:
-admitted to the facility on [DATE];
-Diagnoses included schizoaffective disorder (a psychiatric disorder in which either a major depressive or a manic episode develops concurrently, displaying the symptoms of schizophrenia), psychotic disorder (delusions, hallucinations, talking incoherently, and agitation) and anxiety disorder.
Review of the resident's medical record, showed:
-DA-124c level I screen, dated 3/16/16, indicated a PASARR level II was required;
-No PASARR level II screen found.
During an interview on 12/20/19 at 5:19 P.M., the Director of Nursing said she was unable to locate the resident's PASARR.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0661
(Tag F0661)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure a resident discharged to the community had a recapitulation of stay, final summary of status, reconciliation of all pre-discharge an...
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Based on interview and record review, the facility failed to ensure a resident discharged to the community had a recapitulation of stay, final summary of status, reconciliation of all pre-discharge and post-discharge medications and post-discharge plan of care completed for one of two residents investigated for discharge to the community (Resident #83). The census was 146.
Review of Resident #83's medical record, showed:
-On 12/9/19 at 12:33 P.M., the social worker spoke with a friend to inquire about placement for the resident. The friend stated he/she made plans to pick the resident up today (12/9/19). Social worker will continue to assist the resident with discharge plans;
-On 12/9/19 at 4:27 P.M., discharged home with medications and narcotics. Ambulatory to car with friend;
-No documentation of a recapitulation of stay, final summary of the resident's status, reconciliation of all pre-discharge and post-discharge medications and post-discharge plan of care.
During an interview on 12/20/19 at 4:25 P.M., the Director of Nursing said the Social Service Director has a note dated 12/9/19 where she talked with the resident about discharge. They have no further information and no documentation of a discharge summary.
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 ensure that residents receive treatment and care in ac...
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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 that residents receive treatment and care in accordance with professional standards of practice for one resident who had a diagnostic procedure canceled due to the resident not having a next of kin who was able to be contacted. The facility failed to take steps to assist the resident to find an individual to make medical decisions for the resident. This resulted in the resident having a delay in the diagnosing of symptoms. The resident had a change of condition, went to the hospital and was diagnosed with intussusception (condition in which one segment of intestine telescopes inside of another, causing an intestinal obstruction), requiring surgery (Resident #124). One resident had a change in condition documented and no further documented assessments for approximately 12 hours, when the resident expired (Resident #144). In addition, staff failed to communicate blood sugar levels that were out of range to the physician for one resident (Resident #68). The sample was 29. The census was 146.
Review of the facility's Change in Condition policy, dated 10/2017, showed:
-It is the responsibility of licensed staff to contact the physician and the resident's responsible party whenever there is a change in the resident's physical, mental or psychosocial status;
-Acute change in condition is sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral or functional status that, without intervention, may result in complications or death;
-Non-urgent change in condition is a deviation from a patient's baseline in physical, cognitive, behavioral or functional status that is not reasonably expected to result in complications or death or may be a persistent or intermittent result of the patient's diagnosed disease state;
-Upon identification of any change in condition, licensed nursing personnel will contact the resident's attending physician/on-call physician/practitioner to notify him/her of the change. Acute changes in condition should occur immediately upon recognition while non-urgent changes should occur no later than 72 hours from the noted change;
-All notifications should be preceded by an appropriate physical, mental or psychosocial assessment to enable the physician to make adequate and appropriate treatment and/or transfer decision;
-Following notification of the physician, licensed nursing personnel will contact the resident's responsible party to inform him/her of the change. For acute changes in condition, this should occur immediately when practicable and after addressing the resident's immediate needs and for non-urgent changes in condition, the notification should occur within 72 hours of the noted change;
-All notification should be documented to include: Date and time, name of the individual contacted, specific reasons for the notification, any specific responses that were given by the person contacted;
-The policy did not address documentation and follow up of the resident's condition after the initial identification.
1. Review of Resident #124's annual Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 2/6/19, showed:
-Rarely understood;
-Diagnoses included anemia (low red blood cell count), high blood pressure, gastroesophageal reflux disease (GERD, acid reflux), colitis (inflammation of the colon), diabetes, non-Alzheimer's dementia, schizophrenia (severe mental disorder that affects thinking), restlessness and agitation;
-Signs and symptoms of delirium present;
-Wandering exhibited in the last 1-3 days;
-Independent with bed mobility and transfers;
-Supervision with dressing, eating, and hygiene.
Review of the resident's care plan, updated 12/17/19 and in use during the survey, showed:
-Focus: Resident has impaired cognition function related to dementia:
-Goal: Resident will maintain current level of cognitive function through the review date. Resident will be able to communicate basic needs on a daily basis through the review date;
-Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness;
-Focus: Resident has communication problem:
-Goal: Resident will be able to make basic needs known;
-Interventions: Encourage him/her to continue stating thoughts even if he/she is having difficulty. Focus on a word or phrase that makes sense, or responds to the feeling he/she is trying to express.
Review of the resident's labs, showed:
-On 6/14/19, a hemoglobin (red blood cell count) result of 7.8;
-Hemoglobin reference range, 14-18.
Review of the resident's electronic physician orders sheet (ePOS), showed:
-An order dated 6/15/19, for STAT (immediately) stool guaiac (lab test used to determine if there is blood in the stool), diagnosis of anemia;
-An order dated 7/18/19, for clear liquids, no food the entire day, for pre-procedure order for colonoscopy (diagnostic procedure used to diagnose conditions of the intestines) scheduled 8/22/19, related to anemia;
-An order dated 7/18/19, for nothing by mouth (NPO) after midnight for procedure;
-An order dated 7/18/19, for gastrointestinal appointment for colonoscopy related to anemia;
-An order dated 7/18/19, for pre-procedure orders for colonoscopy 8/22/19. On 8/15/19 start low fiber diet. On 8/15/19, hold iron complex. On 8/17/19, hold blood thinner (Plavix). On 8/21/19, start clear liquid diet. Give Golytely (liquid medication used to evacuate the colon and intestine of all stool) 1 liter (L) at 5:00 P.M., 8 ounces (oz) every 15 minutes. On 8/22/19 nothing by mouth (NPO) except: give another liter of Golytely at 4:00 A.M., 8 oz every 15 minutes. May take medications with sips of water;
-An order dated 7/18/19, for Golytely solution reconstituted 236 gram (gm). Give 1 L by mouth one time only related to anemia for three days. Give 8 oz every 15 min minutes until first liter is completed. Give another liter the following at morning at 4:00 A.M.;
-An order dated 10/21/19, to discharge to hospital for evaluation and treatment.
Review of the resident's progress notes, showed:
-No documentation staff attempted to contact the next of kin to inform of the change in condition or needed STAT laboratory test. No documentation staff notified social services if contact could not be made;
-On 6/17/19 at 3:02 P.M., resident up and about on unit. Assisted with activities of daily living (ADLs). Respiration even and non-labored. Lung sounds clear. Abdomen soft and round with active bowel sounds times four quadrants. Resident informed that a stool collection is needed today. Specimen placed inside of toilet to obtain stool sample;
-On 7/8/19 at 8:56 A.M., (23 days after the order to obtain the stool sample, ordered on 6/15/19 STAT) call placed to lab pending guaiac stool. He/she did not see specimen results, but will contact supervisor to see where is specimen is waiting;
-On 7/15/19 at 2:43 P.M., called placed to hospital regarding instructions to prep related to colonoscopy scheduled for 8/22/19. No answer received at this time. Left message. Will await call. No documentation staff attempted to contact the next of kin for consent of the diagnostic procedure or notified social services if contact could not be made;
-On 8/22/19 at 8:55 A.M., resident is up and about on unit. Remains NPO related to colonoscopy scheduled today at 11:00 A.M. Completed Golytely as ordered. Tolerated well. Remains alert and oriented times two. Respirations even and non-labored. Lung sounds clear times two. Abdomen soft and round with active bowel sounds times four quadrants. Gait and balance steady;
-On 8/27/19 at 10:56 A.M., spoke to hospital staff. He/she informed writer that the resident's colonoscopy scheduled for 8/22/19 was not performed due to his/her cognitive deficits. He/she was unable to tell them if he/she had drank the prep prior to coming for the procedure, he/she could not verbalize understanding of the procedure or why it needed to be performed. He/she stated the resident was alert and oriented to person only. He/she also stated that he/she attempted to reach his/her emergency contacts and no one answered either number. Staff informed them that they would make Nurse Practitioner W aware of the conversation;
-On 8/27/19 at 11:09 A.M., notified Nurse Practitioner W of the conversation from hospital staff. He/she stated that he/she was aware and has been unsuccessful in locating a family member to give consent for the procedure. No documentation staff notified social services that contact with the next of kin for consent could not be made;
-On 9/29/19 at 6:59 P.M., resident holding on to railing walking down the hall, holding onto railing to assist with balance, at times was given a wheelchair to use and after sitting in the wheelchair for short periods of time, would get up to continue to walk;
-On 9/30/19 at 11:14 P.M., resident holding on to railing walking down the hall, gait extremely unsteady and requires more assistance than usual. Nurse Practitioner W notified about change in condition. No documentation staff attempted to contact the next of kin regarding the change in condition or notified social services if contact could not be made;
-On 10/6/19 at 11:31 P.M., resident was noted lowering him/herself to the floor in the hallway during dinner. Resident has required frequent help transferring with unsteady gait. No injury noted at this time. Nurse Practitioner W contacted with no new orders;
-On 10/8/19 at 3:17 P.M., resident was observed sitting down on the floor x 2 today. Resident assisted off of the floor onto a wheelchair as his/her gait is unsteady and bilateral lower extremities weakness noted as his/her legs buckled under him/her when staff assisted him/her off of the floor. Resident encouraged to use the wheelchair to propel him/herself so he/she does not fall. Resident re-directed back to his/her wheelchair a couple of times as he/she was observed getting out of the wheelchair trying to walk. Resident sits back in the wheelchair when re-directed;
-On 10/15/19 at 9:33 P.M., resident is noted in bed watching TV. He/she is able to make needs known and required frequent help with transfer and ambulation this shift. Resident does not pick feet up off the ground at times. He/she is sliding feet and shuffling feet quite often. No complaints of pain voiced at this time;
-On 10/15/19 at 10:59 P.M., while walking down the hall, resident holds furniture and the railings. Wheelchair offered to resident, however he/she does not sit in the chair;
-On 10/16/19 at 2:58 P.M., resident is alert/responsive to person, up ambulating slowly on the unit. Resident encouraged to sit down on the hallway bench from time to time and he/she has been compliant with that request. Resident's gait is slow, unsteady;
-On 10/17/19 at 2:27 P.M., resident continues to sit on the floor throughout shift which is care planned for resident. Resident also continues to hold on to railing walking down the hallway and does not walk upright;
-On 10/20/19 at 10:59 P.M., resident was noted with large bowel sitting at anal opening while lying on his/her side during Certified Nurse Aide (CNA) round. The bowel was the size of a baseball. No distress was noted from resident. No signs/symptoms of pain nor discomfort noted. Resident did refuse CNA assistance. This writer showered resident, provided fresh linen and encouraged fluids since bowel was noted hard and formed. Vital signs are within normal limits for this resident at this time;
-On 10/21/19 at 11:00 A.M., resident received orders from Nurse Practitioner W to be discharged to the hospital for evaluation and treatment. Follow up with Hepatitis C management and overall decline. No documentation staff attempted to contact the next of kin regarding the resident being sent to the hospital or notified social services if contact could not be made;
-On 10/22/19 at 2:22 P.M., received call from nurse at hospital; the resident is being admitted to the hospital with a diagnosis of intussusception (obstruction) of the intestines.
Review of the resident's medical record, showed no social services notes regarding an attempt to locate next of kin or someone with decision making capabilities for the resident.
Further review of the resident's labs, showed:
-On 7/10/19, hemoglobin 7.9;
-On 7/15/19, hemoglobin 8.3;
-On 7/25/19, hemoglobin 7.4;
-On 9/5/19, hemoglobin 7.9;
-On 10/2/19, hemoglobin 8.0;
-Reference range of 14-18.
Review of the resident's fecal occult blood immunochemical (a test that detects hidden blood in the stool and screens for colon cancer) lab result, showed:
-Collection date of 7/5/19 (20 days after the STAT order was obtained);
-Reported date of 7/9/19;
-Result: negative.
Review of the resident's physician's progress notes, showed:
-On 10/1/19: History of Present Illness: Resident with continued weight loss and poor appetite. Often refusing to eat meals even when he/she is brought to the dining room. He/she recently went for a colonoscopy, but was unable to get consent for procedure, family was unable to be contacted, so they sent him/her back to the facility. He/she denies any pain at this time;
-On 10/10/19: History of Present Illness: Resident with continued weight loss over the last few months. His/her appetite has been poor and he/she often refuses to go to meals. He/she is noted to have some weight loss of ten pounds over the last month;
-On 10/17/19: History of Present Illness: Per nursing discussion: vital signs, weight loss has been at a steady decline, no hospitalizations in the last month. Decline cognitive and physical status. Resident is noted to still not be eating regularly. He/she also has been noted to be laying on the floor, which has been a regular behavior for him/her lately;
-On 10/21/19: History of Present Illness: Resident had some weight loss with generalized allover decline over the last few months. His/her dementia has been worsening and he/she has been experiencing failure to thrive. Lately he/she has not been able to get up. He/she has been noted to lay on the couch and urinate on him/herself. He/she has increased incontinence of fecal and urine. His/her Hepatitis C markers have come back elevated;
-Plan: Sent to hospital for evaluation due to weight loss and generalized decline;
-On 11/5/19: History of Present Illness: Resident recently re-admitted to the facility following hospitalization for fecal mass, intussusception of the intestine and severe malnutrition. He/she was sent out due to further decline with mobility and mentation, for cancer work-up. Computed tomography (CT, scan makes use of computer-processed combinations of many X-ray measurements taken from different angles). He/she received laparoscopic right colectomy (a surgical procedure to remove all or part of your colon). Since he/she has been back at the facility, he/she has been improving as far as his/her mentation and eating habits.
Review of the resident's hospital records, dated 10/21/19 through 11/4/19, showed:
-admitted on [DATE];
-Primary discharge diagnosis: Intussusception;
-Secondary discharge diagnosis: Cecum mass (a lump of volume of tissue in the beginning of the large intestine), intussusception intestine, and severe malnutrition;
-History of present illness: Resident with untreated hepatitis C, dementia, schizoaffective disorder, and high blood pressure, who lives in a nursing home and had weight loss and worsening mental status. Nursing home sent him/her to hospital for possible cancer work up. His/her liver enzymes were normal. Vital signs are within normal range. Urinalysis (test to detect urinary tract infections) was negative. CCT scan showed long segment intussusception extending from the distal ileum (the end of the small intestine before it transitions into the large intestine) to the ileocecal valve (sphincter muscle valve that separates the small intestine from the large intestine). He/she was admitted for evaluation and possible surgical treatment. Patient was admitted with intussusception and he/she underwent Golytely prep with multiple enemas in preparation for colonoscopy prior to surgical intervention;
-By 10/28/19, patient had not been adequately prepped despite persistent bowel prep/enemas, so the decision was made to precede with operating room for laparoscopic right colectomy.
During an interview on 12/19/19 at 2:53 P.M., Licensed Practical Nurse (LPN) N said the resident did not receive a colonoscopy, because the resident was not able to give consent for the procedure. He/she was his/her own responsible party. He/she had a family member, but they could not be reached. His/her information was also sent to the hospital and they were unsuccessful in getting information. The resident had a steady decline before October 2019 and it was hard to get to the bottom of what was going on, because he/she did not have anyone to sign for him/her. It was hard to send him/her to the hospital. He/she is a poor historian and does not have anyone to talk for him/her. Obtaining a public administrator was not that simple; however, LPN N did not know how that worked. LPN N remembered Nurse Practitioner W asked someone at the hospital regarding how they could obtain consent for the resident.
During an interview on 12/19/19 at 4:00 P.M., the Director of Social Services said she might have heard about the resident in need of someone to consent for him/her. She was not aware that due to the resident not having anyone to consent for him/her, he/she was not able to proceed with the colonoscopy appointment. If a resident was able to make decisions at the time of admission and later declined and they could no longer make medical decisions, they would call the next of kin. The Director of Social Services was not aware of what the next step would be if there was a resident without a next of kin. She did not know if there was a facility policy that addressed guardianship. She had never contacted a public administrator at any point since she had been employed with the facility, nor assisted anyone with guardianship at any point in her career as a social worker, and did not know the process.
During an interview on 12/20/19 at 9:18 A.M., Nurse Practitioner W confirmed that the resident needed the colonoscopy; however, he/she could not consent. He/she needed an acute reason to go to the hospital. The hospital was not going to keep him/her at first. He/she had a cousin that was listed, but there was no answer. That also happened at the doctor's office and at the hospital. He/she could not consent.
During an interview on 12/20/19 at 5:26 P.M., the Director of Nursing (DON) said if the physician said to reach out to the family and get a guardian, or get the social worker and the Ombudsman involved to see what the options were, the facility would have done that. There was no sense of urgency, but there was a conversation about the issue. The nurse practitioner attended the clinical meetings and spoke with the physician about the resident. The nurse practitioner had a lot to do with the resident receiving the surgery. The DON was not aware of the colonoscopy appointment in January 2020 and if there would be an issue with the resident giving consent. That would be the physician's determination. If they had a resident that could no longer make decisions, they would go through the Ombudsman. There is a lot of legal ramifications to make decisions for a resident. The DON was not aware of the process of how to obtain guardianship if a resident could not make decisions and did not have family. She was not aware that the Social Services Director did not know the process. The DON said she would have to follow up with the social services director and the administrator to get more information.
2. Review of Resident #144's significant change MDS, dated [DATE], showed:
-Severe cognitive impairment;
-Poor appetite for 2-6 days;
-No behaviors;
-Total staff dependence for hygiene, toileting and eating;
-Diagnoses: high blood pressure, diabetes, Alzheimer's disease, anxiety and depression.
Review of the resident's progress notes, showed:
-A nursing note, dated 11/1/19 at 8:37 P.M., audible crackles heard from the resident's bedside. Nurse Practitioner (NP) called and new orders received for a STAT complete blood count (CBC, determines general health status and screens for and monitors for a variety of disorders including anemia) and complete metabolic panel (CMP, measurement of blood sugar, electrolytes, fluid balance, kidney and liver function). Vital signs are temperature of 100.3 (normal 97.8 through 99.1), pulse 132 (normal 60 through 100), respirations 20 (normal) and blood pressure 116/70 (normal 90/60 through 120/80);
-No further nursing progress notes located to show further assessment after the resident's change in condition or further contact with the medical providers;
-A nursing progress note, dated 11/2/19 at 8:50 A.M., the resident noted to be in his/her bed unresponsive. Upon further assessment, he/she observed to be pulseless (no pulse) and no respirations. An emergency code called per facility policy and 911 notified. Cardiopulmonary resuscitation initiated. Emergency medical services (EMS) arrived approximately 20 minutes later. Electrocardiography (ECG, monitors and records the heart rate and rhythm) attached to the resident by EMS staff. The resident noted to have no heart rhythm and had an asystole (full cardiac flat line, no heart contraction) heart pattern. The paramedic onsite called EMS dispatch and had been notified to call the resident's time of death at 8:55 A.M. The resident's guardian called and his/her family notified. The Coroner notified;
-The resident's remains released to funeral home at 12:00 P.M.
During an interview on 12/20/19 at 11:19 A.M., LPN Q said he/she had arrived at the facility to work day shift at 7:00 A.M., on the morning of 11/2/19. He/she received report from the night shift nurse and the resident had been alive at that time, appeared to be normal color and had not appeared to be in distress. He/she and the night shift nurse walked the unit during report. The night shift nurse reported the resident had been ordered to receive a hospice evaluation and had received oxygen. He/she completed shift change report and began his/her medication pass at the resident's room. When he/she administered medication to the resident's roommate, he/she looked at the resident and observed the resident was not breathing. The resident had been a full code and CPR was started. The resident had expired within an hour of his/her shift starting. The resident did not have hospice evaluation orders and did not receive a hospice evaluation. There had been a chest X-ray completed and blood work, LPN Q had not been notified of any results. He/she had not notified the resident's physician of any STAT results.
During an interview on 12/20/19 on 1:25 PM Certified Nursing Assistant (CNA) O said he/she had cared for the resident on Friday 11/1/19. He/she had assisted the resident with his/her breakfast and lunch. The resident ate in the dining room and sat in his/her Geri-chair (medical reclining chair). The resident did not have any issues with swallowing or coughing. No abnormal behaviors.
During an interview on 12/20/19 at 4:28 P.M., the DON said the resident had been a full code. If the staff note a change in condition, she expected the nurses to provide frequent assessments and document assessments in the resident's medical record at least every two hours. The nurses should have notified the physician of additional changes and the ordered laboratory values. The facility received the ordered blood work late and the resident had expired before the staff could notify the physician. The facility provided in-servicing to all the nurses regarding when a resident experienced a change in condition. There should have been more nursing notes regarding assessments from the time of discovery to the time of the resident's death.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to follow the facility policy and the resident's care plan to prevent one resident (Resident #21) from falling during a staff assisted transfe...
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Based on interview and record review, the facility failed to follow the facility policy and the resident's care plan to prevent one resident (Resident #21) from falling during a staff assisted transfer. The sample was 29. The census was 146.
Review of the facility accidents and incidents policy, dated May 15, 2019, showed:
-All incidents and accidents occurring at the facility reported, investigated and tracked in accordance with the guidelines contained herein. Reports of findings will be forwarded to the Director of Nursing (DON) and/or Administrator;
-Care plan revision: The safety committee will review the incident report and preliminary investigation and implement new interventions. If a fall event continues despite new interventions, analysis will be performed to determine the appropriateness of current interventions. Ensure any new interventions have been entered on the resident's care plan.
Review of Resident #21's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/9/19, showed:
-Cognitively intact;
-Assistance of one staff for bed mobility and dressing;
-Assistance of two staff for transfers and toileting;
-Upper/lower extremity impairment on one side;
-Wheelchair for mobility;
-Diagnoses included stroke, seizure disorder, high blood pressure, diabetes and anemia.
Review of the resident's nurse's note, dated 11/17/2019 at 10:30 P.M., showed a nurse assistant put resident to bed at 9:00 P.M. He/she slid from the end of the bed, and the nurse assistant held resident as he/she slid down with him/her to keep him/her from hurting him/herself. Resident stated he/she was not hurt, just slid to the floor. Resident was uninjured during this time. Resident alert and orientated.
Review of the resident's care plan, in use during the survey, showed:
-Problem: At risk for falls due to seizure, spastic movements, non-ambulatory, and decreased cognitive skills. History of left sided weakness. Fall on 9/13/19, noted on floor in shower room, attempted to transfer self from toilet. On 9/29/19, fell during transfer of one staff, no injuries;
-Approaches: The resident will not sustain serious injury through the review date. The resident will be free of injury due to falls. Continue to educate/re-educate staff on proper transfers of two person assist. Continuous staff education on safe transfers. Educate on importance of waiting for assistance with transfers. Educate staff to use two persons to transfer resident. Educate staff to lock wheelchair prior to transfer. Educate staff on transfer with gait belt and resident requires two person transfer;
-The care plan not updated with current fall, 11/17/19.
During an interview on 12/19/19 at 10:08 A.M., the DON said she did not have an investigation into the resident's fall. The incident happened on the evening shift, around 9:00 P.M., the certified nursing assistant (CNA) was a new employee. The CNA was educated that the resident is a two person assist. The DON said she was unsure if the CNA used a gait belt during the transfer. She would expect new employees to ask and/or reference the resident's care card if not familiar with the resident's transfer status.
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 maintain proper placement of a urinary catheter (a tube inserted into the bladder for purpose of urine drainage) and position ...
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Based on observation, interview and record review, the facility failed to maintain proper placement of a urinary catheter (a tube inserted into the bladder for purpose of urine drainage) and position of the catheter tubing. In addition, the facility failed to obtain orders for the catheter size. The facility identified three residents as having urinary catheters, two were included in the sample of 29 and issues were identified with one (Resident #40). The census was 146.
Review of Resident #40's admission Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 9/15/19, showed:
-A Brief Interview for Mental Status (BIMS) score of 3 out of 15, shows severe cognitive impairment;
-Diagnoses included cancer, neurogenic bladder (the bladder does not empty urine properly due to a neurological condition), diabetes, and non-Alzheimer's Dementia;
-Extensive assistance required for bed mobility, transfers, dressing, eating, toileting and hygiene;
-Has a catheter.
Review of the resident's electronic physician order sheet, showed:
-An order dated 9/26/19, to cleanse the suprapubic catheter (urinary catheter inserted through the abdominal wall) site daily with normal saline or wound cleanser. Place drain sponge around area and secure daily;
-An order dated 10/10/19, to flush the suprapubic catheter daily with sterile water, 30 milliliter (ml) every day shift for irrigation;
-An order dated 10/17/19, to change the suprapubic catheter every three weeks;
-No orders for the French (size) and balloon size (portion of the catheter inflated to keep the catheter in the bladder).
Review of the resident's care plan, dated 10/10/19, and in use during the survey, showed no documentation of the resident's catheter, interventions, and goals.
Review of the resident's treatment administration record, dated 12/1/19 through 12/23/19, showed:
-Staff documented a treatment to cleanse suprapubic catheter site daily with normal saline or wound cleanser every night shift on the following dates and times: On 12/2, 12/5, 12/6, 12/10, 12/16, 12/18, 12/19, and 12/20/19;
-Staff documented the changing of the suprapubic catheter on 12/19/19;
-The order to flush the suprapubic catheter daily with sterile water, 30 ml every day shift, not documented.
Observation and interview, showed:
-On 12/19/19 at 6:41 A.M., the resident in bed with eyes closed and the catheter on the left side of the bed with the drainage bag inside a privacy bag. At 2:34 P.M., the catheter tubing lay on the floor with approximately 24 inches of dark yellow inside the tube that did not drain. Certified Nurse Aide (CNA) DD entered the resident's room, but did not assess the catheter tubing on the floor;
-On 12/20/19 at 7:30 A.M., CNA DD assisted the resident with his/her meal. The resident lay in bed with the head of bed up. The catheter tubing lay on the floor with approximately 24 inches of amber colored urine in the tube that did not drain. At 11:49 A.M., the resident lay in bed with his/her eyes closed. The catheter tubing lay on the floor with approximately 24 inches of urine in the tube.
During an interview on 12/18/19 at 11:36 A.M., the resident's family member said there was an infection in the catheter. There was an odor and the resident was on antibiotics for it.
During an interview on 12/19/19 at 2:40 P.M., Licensed Practical Nurse (LPN) N said the resident's catheter would get clogged with sediment and the urine was always on the darker side. He/she had one urinary tract infection (UTI) since he/she was admitted . He/she was sent out to the hospital. LPN N was unsure when the resident was sent to the hospital.
During an interview on 12/20/19 at 5:26 P.M., the Director of Nursing said she would expect the resident to have complete orders for the catheter, including the French and balloon size. She would expect staff to ensure the resident's catheter tubing and drainage bag is below the bladder, and the tubing is straight so the urine can completely drain, and not on the floor due to infection control.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0745
(Tag F0745)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial wel...
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Based on observation, interview and record review, the facility failed to provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by not providing advocacy for one resident without the capacity to consent (Resident #124). The census was 146.
1. Review of Resident #124's annual Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 2/6/19, showed:
-Rarely understood;
-Diagnoses included anemia, high blood pressure, gastroesophageal reflux disease (GERD, acid reflux), colitis (inflammation of the colon), diabetes, non-Alzheimer's dementia, schizophrenia (severe mental disorder that affects thinking), schizoaffective disorder, restlessness and agitation;
-Signs and symptoms of delirium present;
-Wandering exhibited in the last 1-3 days;
-Independent with bed mobility and transfers;
-Supervision with dressing, eating and hygiene.
Review of the resident's care plan, updated 12/17/19 and in use during the survey, showed:
-Focus: Resident has impaired cognition function related to dementia:
-Goal: Resident will maintain current level of cognitive function through the review date. Resident will be able to communicate basic needs on a daily basis through the review date;
-Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness;
-Focus: Resident has communication problem:
-Goal: Resident will be able to make basic needs known;
-Interventions: Encourage him/her to continue stating thoughts even if he/she is having difficulty. Focus on a word or phrase that makes sense, or respond to the feeling he/she is trying to express.
Review of the resident's social service progress notes, dated 8/13/19, showed:
-Resident is a full code. There are no plans for discharge at this time. Resident has no complaints or concerns at this time.
Review of the resident's progress notes, showed:
-On 8/13/19 at 3:07 P.M., care plan meeting held with Interdisciplinary Team (IDT). Resident in attendance, and is his/her own responsible party;
-On 8/27/19 at 10:56 A.M., spoke to hospital staff. He/she informed facility that the resident's colonoscopy (an exam used to detect changes or abnormalities in the large intestine and rectum) scheduled for 8/22/19 was not performed due to his/her cognitive deficits. He/she was unable to tell them if he/she had drank the prep, prior to coming for the procedure, he/she could not verbalize understanding of the procedure or why it needed to be performed. Stated the resident was alert and oriented to person only. He/she also stated that he/she attempted to reach his/her emergency contacts and no one answered either number. Staff informed them that they would make Nurse Practitioner W aware of the conversation;
-On 8/27/19 at 11:09 A.M., notified Nurse Practitioner W of the conversation from hospital staff. He/she stated that he/she was aware and has been unsuccessful in locating a family member to give consent for the procedure;
-On 10/20/19 at 10:59 P.M., resident was noted with large bowel sitting at anal opening while lying on his/her side during Certified Nurse Aide (CNA) rounds. The bowel was the size of a baseball. No distress was noted from resident. No signs/symptoms of pain nor discomfort noted. Resident did refuse CNA assistance. This writer showered resident, provided fresh linen and encouraged fluids since bowel was noted hard and formed. Vital signs are within normal limits for this resident at this time;
-On 10/21/19 at 11:00 A.M., resident received orders from Nurse Practitioner W to be discharged to the hospital for evaluation and treatment. Follow up with Hepatitis C management and overall decline;
-On 10/22/19 at 2:22 P.M., received call from nurse at the hospital, making facility aware that the resident is being admitted to the hospital with a diagnosis of intussusception (obstruction resulting from the intestines telescoping on themselves) of the intestines;
-No documentation social services attempted to contact the next of kin, locate an alternate family member or advocated for a representative to assist the resident with medical decision making.
During an interview on 12/19/19 at 2:53 P.M., Licensed Practical Nurse (LPN) N said the resident did not receive a colonoscopy because he/she was not able to give consent to the procedure. He/she was his/her own responsible party. He/she had a family member, but they could not be reached. His/her information was also sent to the hospital and they were unsuccessful in getting information. The resident had a steady decline before October 2019 and it was hard to get to the bottom of what was going on, because he/she did not have anyone to sign for him/her. It was hard to send him/her to the hospital. He/she is a poor historian and does not have anyone to talk for him/her. Obtaining a public administrator was not that simple; however, LPN N did not know how that worked. LPN N remembered Nurse Practitioner W asked someone at the hospital regarding how they could obtain consent for the resident.
During an interview on 12/19/19 at 4:00 P.M., the Director of Social Services said he/she might have heard about the resident in need of someone to consent for him/her. He/she was not aware that due to the resident not having anyone to consent for him/her, he/she was not able to proceed with the colonoscopy appointment. If a resident was able to make decisions at the time of admission and later declined and they could no longer make medical decisions, they would call the next of kin. The Director of Social Services was not aware of what the next step would be if there was a resident without a next of kin. There was only one time he/she experienced providing a resident with a POA and it was a family member in regards to a code status. He/she did not know if there was a facility policy that addressed this. He/she had never contacted a public administrator at any point since he/she had been employed with the facility, nor assisted anyone with guardianship at any point in his/her career as a social worker and did not know the process.
During an interview on 12/20/19 at 9:18 A.M., Nurse Practitioner W confirmed that the resident needed the colonoscopy; however, he/she could not consent. He/she needed an acute reason to go to the hospital. The hospital was not going to keep him/her at first. He/she had a cousin that was listed, but there was no answer. That also happened at the doctor's office and at the hospital. He/she could not consent.
During an interview on 12/20/19 at 5:26 P.M., the Director of Nursing (DON) said if the physician said to reach out to the family and get a guardian, or get the social worker and the Ombudsman involved to see what the options were, we would have done that. There was no sense of urgency, but there was a conversation about the issue. The nurse practitioner attended the clinical meetings and spoke with the physician about the resident. The DON was not aware of the colonoscopy appointment in January 2020 and if there would be an issue with the resident giving consent. That would be the physician's determination. If they had a resident that could no longer make decisions, they would go through the Ombudsman. There is a lot of legal ramifications to make decisions for a resident. The DON was not aware of the process of how to obtain someone with decision making capabilities if a resident could not make decisions and did not have family. She was not aware that the Social Services Director did not know the process. The DON said she would have to follow up with the social services director and the administrator to get more information.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure a resident had appropriate diagnoses for the use of psychotropic medications, for one of five residents investigated for unnecessary...
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Based on interview and record review, the facility failed to ensure a resident had appropriate diagnoses for the use of psychotropic medications, for one of five residents investigated for unnecessary medication review (Resident #124). The census was 146.
Review of Resident #124's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/9/19, showed:
-Has delusions;
-Diagnoses included anemia, high blood pressure, viral hepatitis, diabetes, non-Alzheimer's dementia, and schizophrenia (brain disorder that causes distorted thinking);
-Antipsychotics and antidepressants were administered 7 of the last 7 days;
-Diagnosis of depression not documented.
Review of the resident's electronic medical record, showed no diagnosis of depression.
Review of the resident's care plan, dated 12/17/19, and in use during the survey, showed no documentation of depression, interventions, or goals.
Review of the resident's electronic physician orders sheet, showed:
-An order dated 11/5/19, for Trazodone HCL (used to treat depression) tablet, 50 milligram (mg). Give 25 mg by mouth at bedtime for antidepressant;
-An order dated 11/5/19, for Lexapro (used to treat depression) tablet 20 mg. Give 20 mg by mouth one time a day for antidepressant.
During an interview on 12/23/19 at 11:39 A.M., the Director of Nursing (DON) said the resident's diagnosis was transcribed incorrectly on the POS. The correct diagnosis should have been coded at mood disorder.
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 are free of any significant medication errors for one resident administered insulin during the medication adm...
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Based on observation, interview and record review, the facility failed to ensure residents are free of any significant medication errors for one resident administered insulin during the medication administration observation (Resident #394). The census was 146.
Review of Resident #394's electronic physician order sheet, showed an order dated 11/26/19, for Novolog (short acting insulin). Inject as per sliding scale: If 151 to 250 = 3 units.
Observation on 12/18/19 at 5:47 A.M., showed Licensed Practical Nurse (LPN) II obtained the residents blood sugar result of 194. He/she withdrew insulin from an insulin vial into an insulin syringe and said he/she was giving 3 units. The plunger was visible at the 3 unit line, but an air bubble of approximately 1 unit visible in the syringe. He/she administered the insulin without clearing the air bubble.
During an interview on 12/20/19 at 2:38 P.M., the Director of Nursing said medications should be administered as ordered. Staff should make sure all air bubbles are out of the syringe when administering insulin from a vial. An air bubble could affect the dose administered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently acceptable professional principles,...
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Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently acceptable professional principles, by failing to ensure all controlled substances were stored under double locks and failed to ensure medications were labeled with residents name, injectable medications were dated when opened, and expired medications were disposed of. This effected two of three medication rooms and two of three medication carts reviewed. The census was 146.
Review of the facility's Controlled Substance policy, dated 8/2/19, showed the following:
-Policy: The facility shall attempt to comply with Federal and State laws, regulations, and other requirements related to handling, storing, disposal, and documentation of controlled substances;
-Securing and storage:
-The controlled substances must be stored in a locked container separate from non-controlled medications;
-The controlled substances must be stored where they can be doubled locked, for example: in a locked container which is stored in a locked medication room, or in a medication cart which houses secured locked box with the medication being locked when not being directly supervised by authorized personnel.
During an interview on 12/19/19 at 6:13 P.M., the administrator said the facility has no policy on medication storage.
1. Observation on 12/19/19 at 6:00 A.M., of the third floor south medication room, showed the following:
-One vial of floor stock tuberculin (medication used in aiding the diagnosis of tuberculosis), opened and not dated (medication is good for 30 days after it is opened);
-One Humalog (insulin) mix 75/25, opened and not dated. The medication label had a dispense date of 10/14/19;
-Inside the medication refrigerator:
-The door to the medication refrigerator unlocked. Inside the refrigerator, located in the door of the refrigerator, one lorazepam (narcotic medication used to treat anxiety) vial 2 milligram (mg)/milliliter (ml) injectable medication, not behind a double lock;
-One carton of two percent milk;
-One container of chocolate pudding;
-One peanut butter and jelly sandwich;
-One block of open cheddar cheese wrapped in a paper towel;
-Inside the freezer portion of the refrigerator, a white Styrofoam cup with an abundance of frost that prevented the cup from being removed from the freezer.
2. Observation on 12/19/19 at 7:00 A.M., of the second floor main medication room, showed one vial of floor stock aplisol injectable (medication used in aiding the diagnosis of tuberculosis), opened and not dated. The label of the medication had a dispense date of 6/21/19.
3. Observation on 12/19/19 at 6:15 A.M., of the third floor main medication cart, showed the following:
-One vial of floor stock tuberculin, open and dated 11/14/19;
-One Basaglar (insulin) pen with no name on the medication and no date;
-Two separate containers, each container contained three vials of Haldol injectable medication (antipsychotic medication used to treat psychotic disorders) opened and not dated. The dispense date labeled 10/14/19 and 10/26/19;
-One loose vial of Haldol located in the sixth drawer of the medication cart with no name on the medication;
-LPN II said he/she did not know who the medications with no name belonged to. LPN II removed the medication from the cart.
4. Observation on 12/19/19 at 7:15 A.M., of the first floor main medication room, showed one bottle of Folic Acid (B vitamin) with an expiration date of 10/19.
5. During an interview on 12/19/19 at 7:25 A.M., Licensed Practical Nurse (LPN) C said:
-Controlled substances should be locked under two locks;
-Medications should be dated when opened;
-Stock medications are checked for expiration dates before they are put on the medication cart.
During an interview on 12/19/19 at 7:30 A.M., the Director of Nursing said:
-Controlled substances are to be kept under two locks;
-Medications are to be dated when the medication is opened;
-If a medication does not have a name or date on them, the medication is discarded;
-Food should not be in the medication refrigerator.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Laboratory Services
(Tag F0770)
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 ordered STAT (immediate) laboratory testing had ...
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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 ordered STAT (immediate) laboratory testing had been obtained and the results received in a timely manner for one closed record resident and one sampled resident (Resident #144 and #124). The sample was 29. The census was 146.
Review of the facility's laboratory service agreement between the facility and the facility's contracted Laboratory Company, dated [DATE], showed:
-Testing: The laboratory shall provide collection of specimens for STAT laboratory services during regular business hours or after business hours, as well as other collections after regular business hours. STAT testing will be ordered only when medically necessary for the care of the resident and must be testing that is included on STAT eligible testing. The laboratory will typically provide STAT results within four hours of laboratory collection or pick-up.
1. Review of Resident #144's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated, [DATE], showed:
-Severe cognitive impairment;
-Poor appetite for 2-6 days;
-No behaviors
-Total staff dependence for hygiene, toileting and eating;
-Diagnoses: high blood pressure, diabetes, Alzheimer's disease, anxiety and depression.
Review of the resident's medical record, showed:
-A progress note, dated [DATE] at 8:37 P.M., audible crackles heard from the resident's bedside. Nurse Practitioner (NP) called and new orders received for a STAT complete blood count (CBC, determines general health status and screens for and monitors for a variety of disorders including anemia) and complete metabolic panel (CMP, measurement of blood sugar, electrolytes, fluid balance, kidney and liver function). Vital signs are temperature of 100.3 (normal 97.8 through 99.1), pulse 132 (normal 60 through 100), respirations 20 (normal) and blood pressure 116/70 (normal 90/60 through 120/80);
-No further progress notes showed communication with the laboratory.
Review of the resident's radiological and laboratory results, showed a STAT CMP and CBC collected on [DATE] at 2:29 A.M. No noted results within the four hour window.
Further review of the progress notes, showed on [DATE] at 8:50 A.M., the resident found in bed unresponsive and pulseless. Emergency services called and cardiopulmonary resuscitation (CPR) preformed. Emergency services on scene and the resident did not respond. Paramedic called the resident's time of death. The resident's guardian and physician notified.
Further review of the laboratory results, showed the STAT CMP and CBC reported on [DATE] at 7:07 P.M. to the facility.
2. Review of Resident #124's annual MDS, dated [DATE], showed:
-Rarely understood;
-Diagnoses included anemia (low red blood cell count), high blood pressure, gastroesophageal reflux disease (GERD, acid reflux), colitis (inflammation of the colon), diabetes, non-Alzheimer's dementia, schizophrenia (severe mental disorder that affects thinking), restlessness and agitation;
-Signs and symptoms of delirium present;
-Supervision with dressing, eating, and hygiene.
Review of the resident's electronic physician orders sheet (ePOS), showed an order dated [DATE], for STAT stool guaiac (lab test used to determine if there is blood in the stool), diagnosis of anemia.
Review of the resident's progress notes, showed:
-On [DATE] at 3:02 P.M., resident up and about on unit. Assisted with activities of daily living (ADLs). Respiration even and non-labored. Lung sounds clear. Abdomen soft and round with active bowel sounds times four quadrants. Resident informed that a stool collection is needed today. Specimen placed inside of toilet to obtain stool sample;
-On [DATE] at 8:56 A.M., (23 days after the order to obtain the stool sample, ordered on [DATE] STAT) call placed to lab pending guaiac stool. He/she did not see specimen results, but will contact supervisor to see where specimen is waiting.
Review of the resident's fecal occult blood immunochem (a test that screens for colon cancer by using antibodies to detect blood in the stool) lab result, showed:
-Collection date of [DATE] (20 days after the STAT order was obtained);
-Reported date of [DATE];
-Result: negative.
3. During an interview on [DATE] at 4:28 PM the Director of Nursing said the facility had to go through the hospital to get the laboratory testing completed for Resident #144. The resident expired before the results came back. The facility had been told that the laboratory was supposed to have a four hour result time for STAT results. Since the hospital drew the blood work, the hospital will only call the facility if the results are at a critical level. Since the resident's results were not critical, the hospital did not report the results to the facility and sent the results back to the laboratory and then the results were faxed over to the facility from the laboratory. By the time the blood work results came through, the resident had expired. The nurses should have been calling the hospital and the laboratory for the STAT results. The staff should have also been documenting attempts to contact the hospital and laboratory. The nursing management had done an in-service with the staff nurses regarding communication and follow up for ordered labs.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a pressure reducing air mattress (a mattresses ...
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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 a pressure reducing air mattress (a mattresses which redistributes a patient's weight so as to relieve pressure points) was maintained in a safe operating condition, for one resident (Resident #118) of 29 sampled residents. The census was 146.
1. Review of Resident #118's quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-Two staff person assist for activities of daily living;
-Upper/lower extremity impairment of both sides;
-Wheelchair for mobility;
-One Stage III pressure ulcer (full thickness tissue loss injury to the skin as a result of pressure or friction, subcutaneous fat may be visible but the bone, tendon or muscle is not exposed);
-One unstageable pressure ulcer (depth of the wound is unable to be determined);
-Diagnoses included quadriplegia (paralysis of all four limbs), multiple sclerosis, (MS, disease in which the immune system eats away at the protective covering of nerves), heart failure, high blood pressure, kidney failure, and diabetes.
Review of the resident's care plan, in use during the survey, showed:
Problem: Resident has a history of having a healed wound. He/she is at risk for developing other pressure related areas due to refusing to offload the area, incontinent of bowel and requiring assistance with turning and repositioning while in bed. He/she refuses to return to bed once he/she gets up into the motorized wheelchair and stays up for prolonged period of times;
-The resident's skin will remain intact through review date. Inform him/her/family/caregivers and physician of any new area of skin breakdown. Instruct/assist him/her with shifting his/her weight in wheelchair on a frequent basis. Needs monitoring/reminding/assistance, to turn/reposition at least every 2 hours, more often as needed or requested.
Review of the resident's electronic physician order sheet, showed an order dated 6/14/17, for a low air loss mattress for pressure prevention.
During an interview on 12/18/19 at 11:45 A.M., the nurse practitioner said the resident was hospitalized on [DATE] and returned with a worsened wound from the hospital.
Observation on 12/19/19 at 7:57 A.M., slowed Licensed Practical Nurse (LPN) N and Certified Nursing Assistant (CNA) K provided care for the resident. The resident lay on his/her right side. The resident's air mattress alarmed, turned off and then immediately kicked back on. The resident said this happens, there is a short. Staff have to come back in to fix it when it turns off. CNA K said he/she will tell maintenance. Observation of the front control panel of the air mattress, showed three buttons cracked through the plastic cover and exposed the inner workings of the machine. Staff assisted the resident to the left side. The air mattress turned off again. The resident said LPN N must have hit the cord, so the air mattress turned off. The resident's air mattress had gone flat. LPN N adjusted the electrical cord and the air mattress turned back on. The resident said the bed does this at times, ever since he/she got it. CNA K said the dysfunction of the air mattress might happen at night and no one would know.
During an interview on 12/20/19 at 4:02 P.M., the resident said if you bump the bed, it will deflate. The bed had stayed deflated as long as thirty minutes at a time, it is very uncomfortable when the bed deflated.
During an interview on 12/20/19 at 4:07 P.M., LPN UU said he/she was aware the bed deflates when the plug is bumped.
During an interview on 12/20/19 at 3:11 P.M., the Maintenance Director said any staff person can report an environment concern to maintenance. Maintenance staff complete room audit check sheets periodically. The sheets were part of the Quality Assurance and Performance Improvement (QAPI) plan. He would expect staff to report issues with an air mattress. Maintenance was not aware of the issue. No staff had reported this issue as of this time.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a clean, comfortable and homelike environment ...
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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 a clean, comfortable and homelike environment in common areas, on the 100 hall, 3 South, 2 Main and 3 Main. In addition, the facility failed to provide a clean, comfortable and homelike environment for one resident with bubbled and peeled paint above his/her bed (Resident #142), one resident with a brown substance on the floor (Resident #60) and nine resident rooms with a variety of environmental concerns (rooms 126, 132, 330, 332, 333, 334, 335, 336 and 338). The census was 146.
1. Observations of the 100 Hall on 12/17/19 at 9:00 A.M., during the environmental tour, showed the following:
-The water fountain, between the nurse's station and the sunroom, inoperable;
-The shower room, across from the South nurse's station, on the left side of the hall:
-A broken shower chair, the seat of the chair lay on the floor. On the chair, a note which read not working properly';
-The kick plate on the back of the shower room entrance/door, covered with black streaks, the perimeter of the doorway, covered with build-up and dirt;
-The shower room, across from the South nurse's station, on the right side of the hall:
-The kick plate on the back of the shower room entrance/door, covered with black streaks, the perimeter of the doorway, covered with build-up and dirt;
-Inside the shower, along the left side, a darkened area extended upward, approximately 12 inches from the base of the shower. The area on the left bottom side of the shower, covered with a blackened area, approximately 3 inches tall by 24 inches wide;
-The plumbing, extending upward from the rear of the toilet, approximately 2 feet, covered in a blueish/green residue.
2. Observation on 12/17/19 at 9:12 A.M., during the environmental tour of 3 South, showed:
-In the hall outside of the elevator near room [ROOM NUMBER]: One area of missing and chipped floor tiles approximately 3 inches by 3 inches. A second area approximately 8 inches by 1 inch with missing and chipped floor tiles;
-In the 3 south dining room, the ceiling in the right far corner with an area that measured approximately 4 feet by 4 feet of missing tiles. The ceiling in the area with the missing tiles with a black discoloration.
3. Observation on 12/18/19 at 6:31 A.M., on 2 Main, showed a dried, red substance on the door handle of the shower room. The substance measured approximately 2 inches long. Certified Nurse Aide (CNA) R entered the shower room. He/she used the door handle to open the door. CNA R exited the shower room with a paper towel to dry his/her hands. CNA R did not clean the dried, red substance off the door handle. At 6:46 A.M., housekeeping staff entered the 2 main unit. He/she saw the dried, red substance on the door handle and put gloves on his/her hand. He/she wiped the door handle before entering the shower room.
4. Observations on 3 Main, on 12/17/19 at 2:30 P.M., 12/19/19 at 5:15 P.M., and 12/20/19 at 8:00 A.M., showed the following:
-Shower room with a crack in the cove base in the shower area;
-The dining room with two ceiling tiles that had a brownish discoloration on them.
5. Review of Resident #142's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/26/19, showed:
-Cognitively intact;
-Diagnoses included anxiety disorder and depression.
During an interview on 12/17/19 at 9:20 A.M., the resident said this place is falling apart, staff do not make repairs when things break. Observation of the resident's room at this time, showed an area approximately 3 feet by 2 feet on the ceiling above the resident's bed, with paint bubbled, peeled and chipped.
During an interview on 12/20/19 at 3:11 P.M., the Maintenance Director said he was not aware of the area above the resident's bed. The bubbling paint is probably from moisture. There had been a water leak in the next room over that had been repaired. It is possible the leak also affected the resident's room. He would expect staff to report the issue.
6. Observation of Resident #60's room on 12/17/19 at 4:44 P.M., 12/18/19 at 6:23 A.M., 12/19/19 at 6:31 A.M., and 12/20/19 at 9:20 A.M., showed several areas of a dried, brown substance on the bathroom floor.
During an interview on 12/20/19 at 3:28 P.M., the Housekeeping Supervisor said the resident bathrooms are cleaned daily. Resident #60 eats brownies all the time, but the housekeeper is expected to clean daily.
7. Observations of the 100 Hall on 12/17/19 at 9:00 A.M., during the environmental tour, showed the following:
-In room [ROOM NUMBER]: Caulk missing around the sink basin;
-In room [ROOM NUMBER]: Caulk missing around the sink basin.
8. Observation of the environment during the initial tour of the facility, on 12/17/19 at 2:30 P.M., 12/19/19 at 5:15 P.M., and 12/20/19 at 8:00 A.M., showed the following:
-Rooms 330, 332, 333, 334, 335, 336 and 338: The metal appliance behind the toilet with a greenish discoloration;
-room [ROOM NUMBER]: The caulk around the toilet cracked;
-room [ROOM NUMBER]: Tiles missing from the bathroom wall, near the floor;
-room [ROOM NUMBER]: Broken titles on the bathroom wall, near the floor.
9. During an interview on 12/20/19 at 3:11 P.M., the Maintenance Director said any staff person can report an environmental concern to maintenance. Maintenance staff complete room audit check sheets periodically. The sheets were part of the Quality Assurance and Performance Improvement (QAPI) plan. The maintenance director said he tours the facility and makes room audits every month, looking for issues that need to be corrected. There had been a leak in the dining room on 3 south and he was aware of the issue. The leak was fixed and the area just needs new ceiling tiles. The greenish discoloration noted in the bathroom on the metal appliance is probably from condensation and caused by lime build-up. The brownish discoloration on the third floor main ceiling tiles is probably caused by steam from the steam tables.
10. During an interview on 12/20/19 at 3:28 P.M., the Housekeeping Supervisor said housekeeping staff complete a check of the walls two times per week. They complete rounds of the building weekly, every Monday and Friday to look for any issues with housekeeping. If housekeeping notices a problem that needs to be repaired, housekeeping will notify maintenance. Housekeeping cleans the resident bathrooms daily.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to issue written transfer notices to residents and/or their representative upon transfer to a hospital when their return to the facility was e...
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Based on interview and record review, the facility failed to issue written transfer notices to residents and/or their representative upon transfer to a hospital when their return to the facility was expected, for seven of eight residents investigated for discharge notices. The sample was 29. The census was 146.
Review of the facility's General Administrative/Discharges and Transfers policy, dated 10/1/19, showed:
-It is the policy of the facility to ensure residents are treated equally regarding transfer, discharges and the provision of services, regardless of their payment source in accordance with state and federal regulations;
-The policy failed to direct staff to provide the resident with a transfer notice upon transfer to a hospital.
1. Review of Resident #40's medical record, showed:
-On 9/18/19, admitted to the facility;
-On 10/9/19, discharge return anticipated;
-On 10/10/19, reentry to the facility;
-On 12/12/19, discharge return anticipated;
-On 12/16/19, reentry to the facility;
-No documentation of transfer notices.
2. Review of Resident #124's medical record, showed:
-On 4/17/09, admitted to the facility;
-On 10/21/19, discharge return anticipated;
-On 11/4/19, reentry to the facility;
-No documentation of a transfer notice.
3. Review of Resident #72's medical record, showed:
-On 3/27/17, admitted to the facility;
-On 10/16/19, discharge return anticipated;
-On 10/25/19, reentry to the facility;
-No documentation of a transfer notice.
4. Review of Resident #74's medical record, showed:
-On 1/29/08, admitted to the facility;
-On 11/19/19, discharge return anticipated;
-On 11/27/19, reentry to the facility;
-No documentation of a transfer notice.
5. Review of Resident #118's medical record, showed:
-On 6/2/16, admitted to the facility;
-On 11/25/19, discharge return anticipated;
-On 11/30/19, reentry to the facility;
-No documentation of a transfer notice.
6. Review of Resident #68's medical record, showed:
-On 4/30/19, admitted to the facility;
-On 8/16/19, discharge return anticipated;
-On 8/20/19, reentry to the facility;
-No documentation of a transfer notice.
7. Review of Resident #120's medical record, showed:
-On 1/30/18, admitted to the facility;
-On 11/25/19, discharge return anticipated;
-On 12/3/19, reentry to the facility;
-No documentation of a transfer notice.
8. During an interview on 12/23/19 at 12:14 P.M., the Director of Nursing said the nurse who transfers the resident to the hospital is responsible to provide the resident or representative with the transfer notice.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to inform the resident, family and/or legal representative of their bed hold policy at the time of transfer to the hospital when their return ...
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Based on interview and record review, the facility failed to inform the resident, family and/or legal representative of their bed hold policy at the time of transfer to the hospital when their return to the facility was expected, for seven of eight residents investigated for bed hold notices. The sample was 29. The census was 146.
Review of the facility's Bed Hold policy, dated 12/18/18, showed:
-It is the policy of this facility to inform and notify a resident and/or their legal representative of their rights and obligations pertaining to the facility's bed hold policies at the time of admission and upon a temporary leave of absence;
-A temporary leave of absence is a situation in which a resident is discharged from the facility as a result of a hospitalization or therapeutic home stay.
1. Review of Resident #40's medical record, showed:
-On 9/18/19, admitted to the facility;
-On 10/9/19, discharge return anticipated;
-On 10/10/19, reentry to the facility;
-On 12/12/19, discharge return anticipated;
-On 12/16/19, reentry to the facility;
-No documentation the resident or representative was issued a bed hold policy upon transfers.
2. Review of Resident #124's medical record, showed:
-On 4/17/09, admitted to the facility;
-On 10/21/19, discharge return anticipated;
-On 11/4/19, reentry to the facility;
-No documentation the resident or representative was issued a bed hold policy upon transfer.
3. Review of Resident #72's medical record, showed:
-On 3/27/17, admitted to the facility;
-On 10/16/19, discharge return anticipated;
-On 10/25/19, reentry to the facility;
-No documentation the resident or representative was issued a bed hold policy upon transfer.
4. Review of Resident #74's medical record, showed:
-On 1/29/08, admitted to the facility;
-On 11/19/19, discharge return anticipated;
-On 11/27/19, reentry to the facility;
-No documentation the resident or representative was issued a bed hold policy upon transfer.
5. Review of Resident #118's medical record, showed:
-On 6/2/16, admitted to the facility;
-On 11/25/19, discharge return anticipated;
-On 11/30/19, reentry to the facility;
-No documentation the resident or representative was issued a bed hold policy upon transfer.
6. Review of Resident #68's medical record, showed:
-On 4/30/19, admitted to the facility;
-On 8/16/19, discharge return anticipated;
-On 8/20/19, reentry to the facility;
-No documentation the resident or representative was issued a bed hold policy upon transfer.
7. Review of Resident #120's medical record, showed:
-On 1/30/18, admitted to the facility;
-On 11/25/19, discharge return anticipated;
-On 12/3/19, reentry to the facility;
-No documentation the resident or representative was issued a bed hold policy upon transfer.
8. During an interview on 12/23/19 at 12:14 P.M., the Director of Nursing said the nurse who transfers the resident to the hospital is responsible to provide the resident or representative with the bed hold notice.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individual...
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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 had complete, accurate and individualized care plans, to address the specific care needs of the residents, for 10 out of 29 sampled residents (Residents #71, #2, #393, #114, #106, #93, #40, #60, #21 and #118). The census was 146.
1. Review of Resident #71's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/8/19, showed:
-Cognitively intact;
-Has the resident wandered: Behavior not exhibited;
-No behaviors;
-Limited assistance required to transfer;
-Limited assistance for locomotion off the unit;
-Diagnoses included anxiety disorder, depression and psychotic disorder;
-No falls.
Review of the facility's resident roster, showed the resident resided on the locked unit.
Review of the facility's policy and procedure for the Secure Horizon Program, provided as the requirements for residents to be placed on the locked units, revised 8/31/12, showed:
-The facility will implement psychiatric rehabilitation services called the Secure Horizon Program which has the primary purpose of providing therapeutic interventions to individuals diagnosed with a serious mental illness;
-Program Goals: To improve or maintain the resident's level of functioning and independence; encourage the engagement of each resident in his/her recovery and rehabilitation; increase acquisition, performance and retention of skills to enhance independence and when possible promote community integration; support the progressive assumption of as much personal responsibility, self-management, and self-determination as each resident can manage; broaden the use of living, coping, and occupational skills to new environments with an ultimate goal of discharge to more independent arrangements as appropriate; decrease psychotic, self-injurious, antisocial and aggressive behaviors; decrease impact of cognitive deficits and impediment to learning new skills; and foster the human dignity, persons worth and quality of life of each resident;
-Program overview: The facility may utilize any combination of therapeutic modalities designed to address the individual's needs of residents with a serious mental illness. This may include assignment to a secure unit, a level system: and skills training group;
-The policy did not identify the requirements for placement on the locked unit or how the facility will assess a resident's appropriateness to be placed on the unit.
Review of the resident's care plan, in use at the time of the survey, showed:
-The resident has a history of aggressive behaviors related to anger, attention seeking behaviors and gets upset. States staff ignores him/her. Diagnoses of anxiety, history of physical aggression. Laughs and cries inappropriately. Unable to say what makes him/her sad. Childlike affect, gets upset and states no one wants to be his/her friend. History of biting his/her wrist, stating he/she is afraid to be here;
-The care plan failed to identify the need to be placed on a locked unit, goals to be achieved with placement on the locked unit, identify goals for less restrictive placement and interventions to meet goals related to placement on the locked unit.
During an interview on 12/17/19 at 11:40 A.M., the resident cried and said he/she wanted to go back to the 1st floor. He/she hates it up here and he/she felt he/she was being punished.
During an interview on 12/19/19 at 8:57 A.M., the Social Service Director (SSD) said, regarding the different floors, on the resident's floor there are less privileges. It is less restrictive and residents gain more privileges when they move down off the locked unit. Sometimes residents are moved to the unit because they do not get along with their roommates.
During an interview on 12/20/19 at 5:27 P.M., the Director of Nursing (DON) said residents are assessed to determine if they are appropriate for the locked unit mainly using their diagnoses and behavior. The resident was placed on the locked unit because he/she lashed out and staff felt the floor was more appropriate. The resident likes the attention he/she gets on the locked unit. The resident's care plan should address the reason for being placed on the unit, goals to be achieved and goal to return to the 1st floor.
2. Review of Resident #2's annual MDS, dated [DATE], showed:
-Cognitively intact;
-How important is it to have books, newspapers and magazines to read: Somewhat important;
-How important is it to listen to music you like: Very important;
-How important is it to keep up with the news: Very important;
-How important is it to do your favorite activities: Very important;
-How important is it to go outside to get fresh air when the weather is good: Somewhat important;
-How important is it to participate in religious services or practices: Very important;
-Diagnoses included depression.
Review of the resident's activities participation documentation, showed:
-An activity participation note, dated 8/27/19, the resident comes to very few activities. He/she sends a list for staff to go shopping for him/her. He/she has been encouraged to come to activities. He/she enjoys reading and watching his/her television programs.
Review of the resident's care plan, in use at the time of the survey, showed activity preferences not addressed. Goals and interventions to increase activity participation not addressed.
During an interview on 12/17/19 at 8:00 A.M., the resident said he/she wished he/she had some books to read.
During an interview on 12/20/19 at 3:45 P.M., the Activity Director said he/she wished he/she knew the resident wanted books, because the library visited earlier in the day and he/she could have gotten a book for him/her.
3. Review of Resident #393's admission MDS, dated [DATE], showed:
-Cognitively intact;
-How important is it to listen to music you like: Very important;
-How important is it to be around animals such as pets: Very important;
-How important is it to keep up with the news: Very important;
-How important is it to do your favorite activities: Very important;
-How important is it to go outside to get fresh air when the weather is good: Very important;
-How important is it to participate in religious services or practices: Very important;
-Diagnoses included anxiety and depression.
Review of the resident's Activity Participation Notes, showed:
-On 10/6/19, the resident is new to the facility. He/she is a nonsmoker who enjoys music and television. He/she is Catholic and wants to come to services on Monday mornings. He/she enjoys bingo and Italian food;
-On 12/20/19, the resident establishes his/her own agenda. He/she stays to him/herself and refuses to do any activities on or off the unit. He/she will socialize with staff in short sentences when asked a question. He/she has come to the beauty shop to get a haircut a couple of times since his/her admission.
Review of the resident's care plan, dated 10/10/19, showed activity preferences not care planned. Goals and interventions to increase activity participation not addressed.
Observation of the resident on 12/17/19, showed the resident walked the halls. He/she said he/she has been at the facility about 2-6 weeks.
4. Review of Resident #114's annual MDS, dated [DATE], showed:
-Cognitively intact;
-How important is it to have books, newspapers and magazines to read: Very important;
-How important is it to listen to music you like: Very important;
-How important is it to keep up with the news: Very important;
-How important is it to do things with groups of people: Very important;
-How important is it to do your favorite activities: Very important;
-How important is it to go outside to get fresh air when the weather is good: Very important;
-How important is it to participate in religious services or practices: very important;
-Diagnoses included schizophrenia.
Review of the resident's care plan, in use at the time of the survey, showed activity preferences not care planned.
Review of the resident's Activity Participation Notes, showed:
-On 8/8/19, spoke to the resident about his/her likes in activities. He/she continues to like money games and anything dealing with food. He/she also enjoys music and movies. The resident will go on trips when he/she has money to shop and enjoys food outings. He/she comes to exercise bingo;
-On 11/14/19, the resident establishes his/her own agenda. He/she enjoys movies and popcorn and happy hours. The resident usually takes out all of his/her spending money very early and spends it, preventing him/her from going on shopping trips. He/she also enjoys ice cream socials and birthday parties.
During an interview on 12/17/19 at 3:38 P.M., the resident said he/she wants more activities on the floor, not just the ground level. Observation of the resident's room showed no activity calendar available. The resident said he/she does not know where it went.
5. During an interview on 12/20/19 at 3:45 P.M., the Activity Director said the facility currently has four activity staff. He/she just got the position of activity director as the position was vacant. Activity preferences are assessed by staff talking to the residents.
6. During an interview on 12/23/19 at 12:14 P.M., the DON said for residents that do not routinely attend activities, they would benefit from routine one on one visits. If a resident's comprehensive MDS indicated an activity as important, she would expect the areas marked be provided to the resident and included in the resident's plan of care.
7. Review of Resident # 106's quarterly MDS, dated [DATE], showed:
-Severe cognitive impairment;
-Signs and symptoms of possible swallowing disorders: None;
-Weight loss of five percent or more in the last month or 10% or more in the last six months: No or unknown;
-Nutritional approach: None;
-Dental section: Blank;
-Eating with set up and supervision only;
-Diagnoses included: high blood pressure, ulcerative colitis (chronic, inflammatory bowel disease), high cholesterol, dementia, Parkinson's disease (a disorder of the brain that leads to tremors, difficulty with walking, movement and coordination), manic depression (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), psychotic disorder (disorder characterized by a disconnection from reality) and schizophrenia (long-term mental disorder, involving a breakdown in the relation between thought, emotion and behavior).
Review of the resident's current electronic physician order sheet (ePOS), showed:
-Ensure Liquid (nutritional supplements), give 240 milliliters (mL) by mouth after meals for weight loss;
-An order dated 11/18/19, for weekly weights, weight every Monday related to mild protein-calorie malnutrition;
-Ready Care 2.0 three times a day related to mild protein-calorie malnutrition;
-Scopolamine base patch (used to treat nausea) 72 Hour 1.5 milligram (mg), apply 1 patch transdermal (on the skin) every 3 days for nausea and vomiting/excessive secretions;
-Diet: regular texture, regular consistency.
Review of the resident's comprehensive care plan, in use at the time of survey showed:
-Problem: The resident consumes a mechanical soft diet;
-Goal: The resident will not have signs and symptoms of aspiration. Weight to remain stable thru next review;
-Interventions: Diet as ordered, dietician to evaluate as needed, monitor weight monthly and as needed, inform the medical doctor of significant weight changes.
During an interview on 12/20/19 at 4:30 P.M., MDS coordinator HH said both the care plan and the ePOS should match. The MDS coordinator is responsible to be ensure the care plan is accurate and reflects diet orders accurately.
8. Review of Resident #93's quarterly MDS, dated [DATE], showed:
-Extensive assistance with two person physical assistance with bed mobility;
-Diagnoses of insomnia.
Review of the resident's ePOS, showed:
-An order dated 3/7/17, for melatonin (natural sleep aide) 5 mg, give one by mouth at bedtime for insomnia;
-An order dated 8/19/18, may have bed rails;
-An order dated 12/6/19, for Trazodone HCI (sedative and antidepressant) 50 mg, give one tablet by mouth at bedtime for insomnia.
Review of the resident's side rail assessment, dated 7/20/18, showed side rails indicated to assist with positioning/support.
Review of the resident's care plan, dated 10/24/19, showed:
-No documentation of side rails, interventions, or diagnosis to support the use of side rails;
-No documentation of the use of insomnia medication, interventions, or goals.
Observation on 12/18/19 at 6:18 A.M., 12/19/19 at 6:37 A.M. and 8:46 A.M. and 12/20/19 at 7:42 A.M., showed the resident in bed with both quarter side rails raised on the bed.
9. Review of Resident #40's ePOS, showed:
-An order dated 9/26/19, to cleanse suprapubic catheter (urinary catheter inserted through the abdominal wall to drain urine) site daily with normal saline or wound cleanser. Place drain sponge around area and secure daily;
-An order dated 10/10/19, to flush suprapubic catheter daily with sterile water, 30 milliliter (ml) every day shift for irrigation;
-An order dated 10/17/19, to change suprapubic catheter every three weeks;
-An order dated 12/7/19, for Duoderm (protective dressing). Apply to coccyx (tail bone area) topically one time a day every three days;
-An order dated 12/18/19, for Venelex Ointment (Balsam Peru Castor Oil). Apply to sacrum (buttocks/tailbone area) topically every day shift, every two days for pressure ulcer (injury to the skin and/or underlying tissue, as a result of pressure or friction). Clean with normal saline or wound cleaner, skin prep (protective barrier wipe) to periwound (intact skin surrounding a wound), apply Venelex ointment to wound bed, cover with foam dressing and apply to sacrum topically as needed for pressure ulcer;
-An order dated 12/18/19, for foam Dressing Bordered Pad (wound dressings). Apply to sacrum topically every day shift, every two days for pressure ulcer after skin prep and Venelex, apply to sacrum topically as needed for pressure ulcer.
Review of the resident's care plan, dated 10/10/19, showed:
-No documentation of the resident's catheter, interventions, goals, and diagnosis to support the use of the catheter;
-No documentation of the resident's pressure ulcer, interventions, goals, and stage of the pressure ulcer.
Observation on 12/18/19 at 6:45 A.M. and 11:36 A.M., 12/19/19 at 6:45 A.M. and 2:34 P.M., and 12/20/19 at 7:30 A.M. and 11:49 A.M., showed the resident in his/her bed. The catheter tubing and drainage bag on the left side of the bed.
10. Review of #60's quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-Rejects care one to three days;
-Diagnoses of benign prostatic hyperplasia (BPH, urinary tract blocked by large prostate) and diabetes;
-Frequently incontinent of bowel and bladder.
Review of the resident's ePOS, showed an order dated 4/26/19, for intermittent straight catheterization (temporary insertion of a urinary catheter to drain urine) three times a day for BPH. The resident may straight catheterize self per physician.
Review of the resident's care plan, in use at the time of the survey, showed:
-Focus: The resident experienced bladder incontinence related to a neurogenic bladder (difficulty with emptying the bladder due to neurological conditions);
-Goal: The resident will remain free from skin breakdown due to incontinence and brief use through the review date;
-Interventions: Staff to check the resident at least every two hours and as needed for incontinence. Provide incontinent care. Staff may catheterize as needed;
-The care plan did not address the resident ability to self-catheterize, education required or supplies needed for the resident.
11. Review of Resident 21's quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-Assistance of one staff person for bed mobility and dressing;
-Assistance of two staff person for transfers and toileting;
-Upper/lower extremity impairment on one side;
-Wheelchair for mobility;
-Diagnoses included stroke, seizure disorder, high blood pressure, diabetes and anemia.
Review of the resident's nurse's note, dated 11/17/19 at 10:30 P.M., showed:
-Nurse assistant putting resident to bed at 9:00 P.M. He/she slid from the end of the bed, nurse assistant held resident as he/she slid down with him/her to keep him/her from hurting him/herself. Resident stated he/she was not hurt, just slid to the floor. Resident was uninjured during this time. Resident alert and orientated;
-Further review of the progress note, showed staff failed to follow the resident's care plan during the transfer, resulting in a fall.
Review of the resident's care plan, in use during the survey, showed:
-Problem: At risk for falls due to seizure, spastic movements, non-ambulatory, and decreased cognitive skills. History of left sided weakness. Fall on 9/13/19, noted on floor in shower room, attempted to transfer self from toilet. On 9/29/19, fell during transfer of one staff no injuries;
-Approaches: The resident will not sustain serious injury through the review date. The resident will be free of injury due to falls. Continue to educate/re-educate staff on proper transfers of two person assist. Continuous staff education on safe transfers. Educate on importance of waiting for assistance with transfers. Educate staff to use 2 persons to transfer resident. Educate staff to lock wheelchair prior to transfer. Educate staff on transfer with gait belt and resident requires two person transfer;
-The care plan was not updated with current fall, 11/17/19.
During an interview on 12/19/19 at 10:08 A.M., the DON said she would expect new employees to ask and/or reference the resident's care card if not familiar with the resident's transfer status.
12. Review of Resident 118's quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-Two staff person assist for activities of daily living;
-Upper/lower extremity impairment of both sides;
-Wheelchair for mobility;
-One Stage III pressure ulcer (full thickness tissue loss injury to the skin as a result of pressure or friction, subcutaneous fat may be visible but the bone, tendon or muscle is not exposed);
-One unstageable pressure ulcer (depth of the wound is unable to be determined);
-Diagnoses included quadriplegia (paralysis of all four limbs), multiple sclerosis, (MS, disease in which the immune system eats away at the protective covering of nerves), heart failure, high blood pressure, kidney failure and diabetes.
Further review of the resident's MDS records, showed:
-discharge date of 11/25/19;
-Entry date of 11/30/19.
Review of the resident's wound assessment, dated 12/18/19, showed:
-Wound #1, Right ischial (area of the skin where the leg connects to the buttocks) is an acute Stage III pressure injury ulcer, measuring 0.8 centimeter (cm) length by 1 cm width by 0.5 cm depth, with an area of 0.8 square cm and a volume of 0.4 cubic cm. Undermining (wound open underneath the border of the wound) has been noted at 9 o'clock (visual location based on the face of a clock) and ends at 3 o'clock with a maximum distance of 1.6 cm. There is a moderate amount of serosanguineous (clear, blood tinged) drainage noted with no odor. The patient reports a wound pain of level 0 out of 10;
-Wound #2, Left Ischial is an acute Stage III pressure injury, measuring 3.5 cm length by 2.7 cm width by 0.8 cm depth, with an area of 9.45 square cm and a volume of 7.56 cubic cm. No drainage noted. Patient reports a pain level of 0 out of 10.
During an interview on 12/18/19 at 11:45 A.M., Nurse Practitioner W said the resident was hospitalized on [DATE] and returned with a worsened wound from the hospital. He/she went from a stage II (a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough, may also present as an intact or open/ruptured blister) to a stage III. The area on his/her left side had worsened.
Review of the resident's care plan, in use during the survey, showed:
Problem: Resident has a history of having a healed unstageable pressure ulcer to the right ischium. He/she is at risk for developing other pressure related areas due to refusing to offload the area, incontinent of bowel and requiring assistance with turning and repositioning while in bed. He/she refuses to return to bed once he/she gets up into the motorized wheelchair and stays up for prolonged period of times. On 10/15/19, stage II ulcers to right ischium;
-Approach: Skin will remain intact through review date. Inform resident/family/caregivers and physician of any new area of skin breakdown. Instruct/assist him/her with shifting his/her weight in wheelchair on a frequent basis. Needs monitoring/reminding/assistance to turn/reposition at least every 2 hours, more often as needed or requested. Monitor/document/report as needed any changes in skin status. Treatment to right ischium as ordered, inform physician if treatment plan is unsuccessful;
-Further review of the care plan, showed the care plan not updated with a pressure area to left ischium.
During an interview on 12/20/19 at 5:38 P.M., the DON said the resident's care plan should have been updated and the pressure area to the left ischium noted on the care plan.
13. During an interview on 12/20/19 at 3:36 P.M., MDS Coordinator JJ said the care plans should be correct and accurate and represent the resident's medical status and needs. The MDS Coordinators and the unit managers will update the care plans when the resident experienced a change. The care plan drives the care of the resident and staff are trained to use the care plan as a reference for care and needs.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
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, based on the comprehensive assessment, care p...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide, based on the comprehensive assessment, care plan and preferences of each resident, an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, for eight of nine residents identified by the facility as residing on a locked floor, not attending routine activities and not provided one on one activities (Residents #2, #22, #393, #48, #113, #139, #78 and #81). One resident identified a desire to have more activities take place on the locked floors (Resident #114). In addition, residents who resided on 2 Main and requires staff with a key card to enter and exit the floor, did not have activities provided to them on the floor. The sample was 29. The census was 146.
1. Review of Resident #2's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/17/19, showed:
-Cognitively intact;
-How important is it to have books, newspapers and magazines to read: Somewhat important;
-How important is it to listen to music you like: Very important;
-How important is it to keep up with the news: Very important;
-How important is it to do your favorite activities: Very important;
-How important is it to go outside to get fresh air when the weather is good: Somewhat important;
-How important is it to participate in religious services or practices: Very important;
-Diagnoses included depression.
Review of the resident's activities participation documentation, showed:
-A quarterly/annual participation review, dated 2/28/18;
-No further quarterly/annual participation review assessments;
-An activity participation note, dated 11/10/17, the resident establishes his/her own agenda. He/she enjoys snack related activities, church, parties, and shopping. The resident likes to go on shopping trips or he/she sends a list for the staff to pick up items. He/she enjoys watching television shows in his/her room and in the dining room;
-An activity participation note, dated 8/27/19, the resident comes to very few activities. He/she sends a list for staff to go shopping for him/her. He/she has been encouraged to come to activities. He/she enjoys reading and watching his/her television programs.
Review of the resident's care plan, in use at the time of the survey, showed activity preferences not addressed.
During an interview on 12/17/19 at 8:00 A.M., the resident said he/she wished he/she had some books to read.
During an interview on 12/20/19 at 3:45 P.M., the Activity Director said he/she wished he/she knew the resident wanted books, because the library visited earlier in the day and he/she could have gotten a book for him/her. They come once a month. On 12/23/19 at 9:29 A.M., the Activity Director identified the resident as a resident who resides on a locked unit and does not routinely attend activities off of the floor. The resident receives friendly visits, but does not receive one on one activities.
2. Review of Resident #22's annual MDS, dated [DATE], showed:
-Cognitively intact;
-Clear speech, distinct intelligible words;
-Makes self understood;
-Understands, clear comprehension;
-Hearing: Adequate, no difficulties;
-Should interview for daily and activity preferences be conducted: No, resident is rarely/never understood;
-Diagnoses included depression.
Review of the resident's activities documentation, showed:
-An admission activities initial review, dated 12/5/17;
-No quarterly/annual participation review assessments;
-An activity note dated 12/20/19 at 5:06 P.M., resident establishes his/her own agenda. He/she gets money whenever he/she has funds available to purchase snacks out of the machine. He/she is on a locked unit and when asked to come to activities for an event, he/she always refuses. The resident is always quiet, but will speak if addressed;
-No further activity assessments or participation documented.
Review of the resident's care plan, dated 12/9/18, showed:
-The resident's preferred activities are staying in his/her room by him/herself;
-Explain to the resident the importance of social interaction, leisure activity time. Encourage his/her participation;
-Offer road trips on days he/she is not scheduled to go to treatments, which occurs every other Wednesday.
During an interview on 12/23/19 at 9:29 A.M., the Activity Director identified the resident as a resident who resides on a locked unit and does not routinely attend activities off of the floor. The resident receives friendly visits, but does not receive one on one activities.
3. Review of Resident #393's admission MDS, dated [DATE], showed:
-Cognitively intact;
-How important is it to listen to music you like: Very important;
-How important is it to be around animals such as pets: Very important;
-How important is it to keep up with the news: Very important;
-How important is it to do your favorite activities: Very important;
-How important is it to go outside to get fresh air when the weather is good: Very important;
-How important is it to participate in religious services or practices: Very important;
-Diagnoses included anxiety and depression.
Review of the resident's Activity Participation Notes, showed:
-On 10/6/19, the resident is new to the facility. He/she is a nonsmoker who enjoys music and television. He/she is Catholic and wants to come to services on Monday mornings. He/she enjoys bingo and Italian food;
-On 12/20/19, the resident establishes his/her own agenda. He/she stays to him/herself and refuses to do any activities, on or off the unit. He/she will socialize with staff in short sentences, when asked a question. He/she has come to the beauty shop to get a haircut a couple of times since his/her admission.
Review of the resident's activities initial review, dated 12/11/19, showed the resident enjoys staying in his/her room. He/she looks at his/her roommate's television in his/her room. The resident will sometimes come out of his/her room on the unit for church in the unit. He/she refuses to attend any activities in or outside the facility. He/she says he/she is a loner. He/she is in a locked unit and requires supervision from staff to leave unit.
Review of the resident's care plan, dated 10/10/19, showed activity preferences not care planned.
Observation of the resident on 12/17/19, showed the resident walked the halls. He/she said he/she has been at the facility about 2-6 weeks.
During an interview on 12/23/19 at 9:29 A.M., the Activity Director identified the resident as a resident who resides on a locked unit and does not routinely attend activities off of the floor. The resident receives friendly visits, but does not receive one on one activities.
4. Review of Resident #48's annual MDS, dated [DATE], showed:
-Cognitively intact;
-How important is it to have books, newspapers and magazines to read: Very important;
-How important is it to listen to music you like: Somewhat important;
-How important is it to keep up with the news: Somewhat important;
-How important is it to do your favorite activities: Somewhat important;
-Diagnoses included psychotic disorder.
Review of the resident's care plan, dated 10/3/17, showed:
-Updated 7/3/19, the resident has little or no activity involvement related to disinterest and wishes not to participate. He/she is an introvert and is content with his/her level of activity participation;
-The resident will express contentment with his/her level of activity participation;
-Allow to watch TV in the common room when prefers;
-Invite/encourage family members to attend activities with resident in order to support participation;
-Modify daily schedule, treatment plan as needed to accommodate activity participation as requested by the resident;
-Monitor/document for impact of medical problems on activity level.
Review of the residents Participation Review assessments, showed:
-On 9/15/17, Activities Initial Review completed;
-On 9/21/18, Activities Quarterly Participation Review completed;
-No further annual or quarterly activity reviews documented.
Review of the resident's Activity Participation Notes, showed:
-On 1/9/19, the resident establishes his/her own agenda. He/she likes to read and meditate. At times he/she will go watch television in the back television room. He/she was offered to move off of the floor, but declined;
-On 10/20/19, the resident continues to establish his/her own agenda. He/she does not like to come off of the unit. He/she likes to read and will sometimes sit in the back room and watch television;
-No further activity participation documented.
During an interview on 12/23/19 at 9:29 A.M., the Activity Director identified the resident as a resident who resides on a locked unit and does not routinely attend activities off of the floor. The resident receives friendly visits, but does not receive one on one activities.
5. Review of Resident #113's annual MDS, dated [DATE], showed:
-Moderately impaired cognition;
-Adequate hearing;
-Clear speech, distinct intelligible words;
-Makes self understood;
-Understands, clear comprehension;
-Should interview for daily and activity preferences be conducted: No, resident is rarely/never understood;
-Diagnoses included Alzheimer's disease.
Review of the resident's Activities Quarterly/Annual Participation Review assessment, showed completed 7/25/17. No further quarterly or annual activity participation review assessments completed.
Review of the resident's Activity Participation Notes, showed:
-On 8/9/18, the resident establishes his/her own agenda. He/she likes to watch television in his/her room. He/she will come get coffee and snacks from activities on occasion. He/she also likes to get vending machine money each day;
-On 11/14/19, the resident establishes his/her own agenda. He/she enjoys watching television in his/her room. He/she enjoys sweet treats and gets out daily money to go to the snack machine. Staff has invited him/her several times off the unit, but he/she refuses;
-No further activity participation documented.
Review of the resident's care plan, dated 11/12/19, showed:
-On 11/15/19 update: The resident prefers to spend most of his/her time in his/her room. He/she is at risk for social isolation;
-The resident will have adequate stimulation. Staff will continue to encourage out of/off unit activities;
-Encourage the resident to attend psychological group meetings;
-Invite and encourage the resident to attend scheduled activities;
-Provide a calendar in the resident's room with upcoming events.
During an interview on 12/23/19 at 9:29 A.M., the Activity Director identified the resident as a resident who resides on a locked unit and does not routinely attend activities off of the floor. The resident receives friendly visits, but does not receive one on one activities.
6. Review of Resident #139's annual MDS, dated [DATE], showed:
-Rarely/never understood;
-How important is it to have books, newspapers and magazines to read: Somewhat important;
-How important is it to listen to music you like: Very important;
-How important is it to do things with groups of people: Somewhat important;
-How important is it to do your favorite activities: Very important;
-How important is it to participate in religious services or practices: Somewhat important;
-Diagnoses included Alzheimer's disease and dementia.
Review of the resident's Activities Quarterly/Annual Participation Review assessment, showed completed 8/30/17. No further quarterly or annual activity participation review assessments completed.
Review of the resident's Activity Participation Notes, showed:
-On 8/20/18, the resident enjoys listening to music on a daily basis. He/she enjoys ice cream and talking about his/her younger days in Mississippi. He/she enjoys watching some movies at times and getting snacks;
-No further activity participation notes documented.
Review of the resident's care plan, dated 12/10/19, showed:
-The resident has participated in the activities that he/she enjoys such as listening to old time blues and he/she prefers to sit in the doorway and monitor his/her room. He/she talks and interacts with others as they walk down the hallway. He/she communicates with staff and other residents in the activities area during movie and music time;
-The resident will participate in activities of choice two times per week;
-The resident prefers watching and talking to staff/other residents while she is sitting outside of her bedroom door;
-Remind him/her that he/she may leave activities at any time, and is not required to stay for entire activity.
During an interview on 12/23/19 at 9:29 A.M., the Activity Director identified the resident as a resident who resides on a locked unit and does not routinely attend activities off of the floor. The resident receives friendly visits, but does not receive one on one activities.
7. Review of Resident #78's annual MDS, dated [DATE], showed:
-Moderately impaired cognition;
-How important is it to have books, newspapers and magazines to read: Somewhat important;
-How important is it to listen to music you like: Somewhat important;
-How important is it to keep up with the news: Very important;
-How important is it to do your favorite activities: Very important;
-How important is it to go outside to get fresh air when the weather is good: Somewhat important;
-How important is it to participate in religious services or practices: Somewhat important;
-Diagnoses included schizophrenia.
Review of the resident's Activities Initial Review assessment, showed:
-Completed on 11/2/16 and 10/17/17;
-No further activities annual or quarterly assessments documented.
Review of the resident's Activity Participation Notes, showed:
-On 7/18/17, the resident participates in snack related activities and goes on outings. He/she remains a supervised smoker on the locked unit;
-On 7/15/19, staff spoke with the resident about his/her likes and dislikes in activities. The resident likes to play bingo at times. He/she still enjoys snack related activities. He/she remains a supervised smoker on the locked unit. The resident prefers to stay on the unit most days, because he/she doesn't like to walk far;
-On 10/20/19, the resident likes to establish his/her own agenda. He/she likes music and bingo sometimes. He/she remains a supervised smoker on the locked unit.
Review of the resident's care plan, dated 10/15/19, showed activity preferences not care planned.
During an interview on 12/23/19 at 9:29 A.M., the Activity Director identified the resident as a resident who resides on a locked unit and does not routinely attend activities off of the floor. The resident receives friendly visits, but does not receive one on one activities.
8. Review of Resident #81's annual MDS, dated [DATE], showed:
-Cognitively intact;
-How important is it to have books, newspapers and magazines to read: Very important;
-How important is it to keep up with the news: Very important;
-How important is it to do things with groups of people: Somewhat important;
-How important is it to do your favorite activities: Somewhat important;
-How important is it to go outside to get fresh air when the weather is good: Very important;
-How important is it to participate in religious services or practices: Very important;
-Diagnoses included depression and anxiety.
Review of the resident's Activity Participation Notes, showed:
-On 7/18/17, the resident remains a supervised smoker on the locked unit. He/she enjoys bingo and snack related activities. He/she also has family that visits and brings him/her food and candy;
-On 7/15/19, the resident spoke to staff about his/her likes and dislikes. He/she enjoys sweet snacks and coffee and news in the morning. He/she likes to play bingo sometimes, but prefers to stay on the unit. He/she has family that come see him/her and brings him/her cigarettes each month. He/she is a supervised smoker on the locked unit;
-On 10/20/19, the resident continues to be a supervised smoker on the locked unit. He/she enjoys playing bingo if it is done on the locked unit. He/she has family that he/she calls and that comes to visit with him/her.
Review of the resident's Activities Quarterly/Annual Participation Review assessment, showed completed 4/12/18. No further quarterly and annual participation review assessments completed.
Review of the resident's care plan, dated 10/22/19, showed:
-The resident has little or no activity involvement related to depression. The resident goes to activities, but does not participate, enjoys sitting at nurse's station waiting to smoke. Also likes to sit in his/her doorway and observe passer-byers;
-The resident will be content with his/her level of participation in activities as evidenced by few emotional outbursts thru next review period;
-Allow the resident to sit in doorway during waking hours;
-The resident's preferred activities are bingo and smoking cigarettes;
-Staff will encourage participation in activities and socialization.
During an interview on 12/23/19 at 9:29 A.M., the Activity Director identified the resident as a resident who resides on a locked unit and does not routinely attend activities off of the floor. The resident receives friendly visits, but does not receive one on one activities.
9. Review of Resident #114's annual MDS, dated [DATE], showed:
-Cognitively intact;
-How important is it to have books, newspapers and magazines to read: Very important;
-How important is it to listen to music you like: Very important;
-How important is it to keep up with the news: Very important;
-How important is it to do things with groups of people: Very important;
-How important is it to do your favorite activities: Very important;
-How important is it to go outside to get fresh air when the weather is good: Very important;
-How important is it to you to participate in religious services or practices: Very important;
-Diagnoses included schizophrenia.
Review of the resident's care plan, in use at the time of the survey, showed activity preferences not care planned.
Review of the resident's Activities Initial Review assessment, showed completed on 10/26/17. No further annual or quarterly Activity Participation Review assessments documented.
Review of the resident's Activity Participation Notes, showed:
-On 8/9/18, the resident participates in activities daily. He/she likes to play exercise bingo and regular bingo. The resident also likes to go on the shopping outings when he/she can;
-On 8/8/19, spoke to the resident about his/her likes in activities. He/she continues to like money games and anything dealing with food. He/she also enjoys music and movies. The resident will go on trips when he/she has money to shop and enjoys food outings. He/she comes to exercise bingo;
-On 11/14/19, the resident establishes his/her own agenda. He/she enjoys movies and popcorn and happy hours. The resident usually takes out all of his/her spending money very early and spends it, preventing him/her from going on shopping trips. He/she also enjoys ice cream socials and birthday parties.
During an interview on 12/17/19 at 3:38 P.M., the resident said he/she wants more activities on the floor, not just the ground level. Observation of the resident's room, showed no activity calendar available. The resident said he/she does not know where it went.
10. During an interview on 12/20/19 at 3:45 P.M., the Activity Director said the facility currently has four activity staff. He/she just got the position of activity director, as the position was vacant. Activity preferences are assessed by staff talking to the residents. The activity department provides activities on the locked units two times a week. Which locked unit the activity is provided on, varies. When activities are provided on a locked unit, residents from the other locked units are invited. Sometimes these activities include staff bringing popcorn and movies upstairs. Activity staff visit the floor every day to bring the residents coffee. Activity wise, if a resident doesn't come down off the units, activity staff will sometimes do friendly visits. These are not documented. Residents who receive one on one activities have documentation to show the one on one activities took place. He/she is not aware of any resident who voiced they want more activities on the units. There is no way to know, based on the activity calendar, where the scheduled activity is going to occur.
11. Observation of the 2 Main hall, showed a key card required to enter the floor. Residents unable to enter or leave the floor without assistance of a staff person with a key card.
During an interview on 12/23/19 at 9:29 A.M., the Activity Director said activities are provided on the main floor activity room and on the third floor locked units two times a week.
Review of 2 Main's activity calendar, located in the dining room, dated 12/17/19, showed:
-At 8:30 A.M., coffee and news;
-At 10:15 A.M., exercise and bingo;
-At 2:15 P.M., popcorn mania.
Observation of the residents on 2 Main on 12/17/19 at 8:30 A.M., 10:15 A.M., and 2:15 P.M., showed:
-At 8:30 A.M., residents seated in the dining room eating a meal. No observation of the coffee and news activity provided by staff;
-At 10:30 A.M., no observations of exercise bingo or other activities;
-At 2:15 P.M., no observations of residents consuming popcorn or involved in other activities.
Review of 2 Main's activity calendar, located in the dining room, dated 12/18/19, showed:
-At 8:30 A.M., coffee and news;
-At 10:15 A.M., crafts;
-At 2:15 P.M., staff game of choice;
Observation of the resident's on 2 Main on 12/18/19 at 8:30 A.M. and 2:15 P.M., showed:
-At 8:30 A.M., residents seated in the dining room eating a meal. No observation of the coffee and news activity provided by staff;
-At 2:15 P.M., no observations of residents playing a game or other activities with staff.
Review of 2 Main's activity calendar, located in the dining room, dated 12/19/19, showed:
-At 8:30 A.M., coffee and news;
-At 10:15 A.M., activity meeting;
-At 2:00 P.M., cake walk.
Observation of the resident's on 2 Main on 12/19/19 at 8:30 A.M. and 2:00 P.M., showed:
-At 8:30 A.M., residents seated in the dining room eating a meal. No observation of the coffee and news activity provided by staff;
-At 2:00 P.M., no observations of activity staff on the unit serving cake to the residents.
Review of 2 Main's activity calendar, located in the dining room, dated 12/20/19, showed:
-At 8:30 A.M., coffee and news;
-At 10:15 A.M., exercise fun;
-At 2:30 P.M., ice cream social.
Observation of the resident's on 2 Main on 12/20/19 at 8:30 A.M., showed:
-At 8:30 A.M., residents seated in the dining room eating a meal. No observation of the coffee and news activity provided by staff.
During an interview on 12/19/19 at 6:52 A.M., Licensed Practical Nurse (LPN) RR said regarding activities provided to the residents on 2 Main, activity staff come up to the unit. He/she did not know how often the residents received activities.
During an interview on 12/20/19 at 3:54 P.M., the Director of Activities said he/she was not sure if there was a calendar posted on 2 Main; however, it is on the television. The activities are the same week by week, but it depends on what the residents like. Every morning they receive coffee and at 9:00 A.M., they are served snacks and cocoa. On Tuesdays after lunch, they are served popcorn and on Wednesdays they are served a snack. After lunch, staff would talk to them and watch TV in the big room. The residents like to look at the cars drive by. The residents enjoy ball toss, ice cream social, pet therapy, and bingo. The Director of Activities confirmed the same calendar located on 2 Main was the same calendar throughout the facility.
12. During an interview on 12/23/19 at 12:14 P.M., the Director of Nursing said for residents on the locked floors that do not routinely attend activities, they would benefit from routine one on one visits. She would expect activity staff to document quarterly on residents. If a resident's comprehensive MDS indicated an activity as important, she would expect the areas marked be provided to the resident. One on one visits should be documented.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
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 communicate weight loss with the registered dietician ...
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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 communicate weight loss with the registered dietician (RD), obtain weights as ordered and ensure residents had physician ordered diets for four residents (Residents #106, #69, #77 and #50). The sample size was 29. The census was 146.
Review of the facility's Nutrition and Unplanned Weight Loss/Gain Policy, dated 6/28/19, showed the following:
-The facility will assess and monitor the nutritional status of the residents to assist in maintaining adequate nutritional status, to the extent possible, giving careful consideration to the following: The resident's choice to make informed decisions, the resident's nutritional and hydration needs, and by considering any physiological or functional impairments which may need to be addresses;
-Guidelines: All residents shall be weighed upon admission, monthly, and as required by their clinical condition, and/or the discretion of weighing residents as often as is required by the resident's clinical condition. Indications that would prompt more frequent weight measurements;
-Weekly weights should occur: with significant weight loss or gain;
-The nutritional committee, Medical Doctor and RD will determine when weekly weights may be discontinued based on individual resident needs or condition;
-Monthly weights should be obtained no later than the 7th day of each month. Weekly weights should be obtained, when possible, on the same day and the same approximate time to prevent drastic changes;
-The director of nursing and his/her designee will review all weights for accuracy and will, when necessary, assign reweights;
-Weights are recorded in the electronic medical record by the 15th of the month;
-The physician and the resident's responsible party will be notified of any significant weight changes and the need for modification of the resident nutritional regimen within 72 hours of the identification of a significant loss or gain;
-The RD is responsible to complete an assessment; estimating calorie, nutrient and fluid needs of all residents upon admission, annually, and as needed. Nursing is responsible to ensure all needed information is submitted to the RD.
1. Review of Resident # 106's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility, dated 10/30/19, showed the following:
-Severe cognitive impairment;
-Signs and symptoms of possible swallowing disorders: None;
-Weight loss of 5% or more in the last month or 10% or more in the last six months: No or unknown;
-Nutritional approach: None;
-Dental section: Blank;
-Eating: set up and supervision only;
-Diagnoses included: high blood pressure, ulcerative colitis (chronic, inflammatory bowel disease that causes inflammation in the digestive tract), high cholesterol, dementia, Parkinson's disease (a disorder of the brain that leads to tremors, difficulty with walking, movement and coordination), manic depression (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), psychotic disorder (disorder characterized by a disconnection from reality) and schizophrenia (long-term mental disorder, involving a breakdown in the relation between thought, emotion and behavior).
Review of the resident's monthly weights from June through December 2019, showed:
-On 6/7/19, weight 191.4 pounds (LBS);
-On 8/8/19, weight 196 LBS;
-On 11/8/19 weight 173.8 LBS;
-On 11/19/19 weight 175.8 LBS;
-On 11/25/19 weight 174.9 LBS;
-On 12/2/19 weight 168 LBS;
-The documentation of the weight of 191.4 LBS in June and the weight of 168 LBS in December showed a significant weight loss of 12.23% in six months.
Review of the resident's dietary notes, dated 8/12/19, showed:
-Residents weight on 8/6/19, documented as 196 LBS;
-Diet is regular;
-Summary: The resident's by mouth intake has been good; weight has been stable over the last year. The resident is alert and able to consume his/her meals independently. May require altered texture diet with disease progression;
-Continue regular diet; monitor chewing and swallowing.
-No other RD notes documented.
Review of the resident's electronic physician order sheet (ePOS), showed:
-Ensure Liquid (Nutritional Supplements) Give 240 milliliters (mL) by mouth after meals for weight loss;
-An order dated 11/18/19, for weekly weights, weight every Monday related to mild protein-calorie malnutrition;
-Ready Care 2.0 (nutritional supplement) three times a day related to mild protein-calorie malnutrition;
-Scopolamine (used to treat nausea) base patch 72 Hour 1.5 mg, apply 1 patch transdermal (on the skin) one time a day every 3 days for nausea and vomiting/excessive secretions;
-Diet: Regular texture, regular consistency.
Review of the resident's weekly weights, showed the weekly weights for the weeks of 12/9/19 and 12/16/19, not documented.
Observation of the resident during the survey, showed:
-On 12/17/19 at 1:00 P.M., the resident sat in his/her wheelchair at the dining room table. The staff served the resident a regular diet. The resident fed him/herself. The resident ate well for lunch;
-On 12/19/19 at 6:00 P.M., the resident sat at the dining room table. The staff served the resident apple sauce, hamburger helper, salad, lemon-aid and coffee. The resident fed him/herself. The resident ate well. After dinner, Licensed Practical Nurse (LPN) N gave the resident one bottle of Ensure. The resident took the Ensure back to his/her room to drink.
Review of the resident's comprehensive care plan, in use at the time of survey, showed:
-Problem: The resident consumes a mechanical soft diet;
-Goal: The resident will not have signs and symptoms of aspiration. Weight to remain stable thru next review;
-Interventions: Diet as ordered. Dietician to evaluate as needed. Monitor weight monthly and as needed. Inform the medical doctor of significant weight changes.
During an interview on 12/19/19 at 1:30 P.M., LPN Q said if a resident's weight goes up or down, the facility would get an order for a dietary consult. If a resident has weight loss, staff usually get an order for a supplement. The dietician visits monthly. If the dietician recommends an intervention for a resident, the dietician would give the recommendations to the Director of Nursing (DON), then the DON would notify the MDS nurse, then the floor manager would be notified, then the charge nurse on the unit would be notified. The MDS nurse usually puts the orders in the computer, but sometimes the nurse on the floor will put the order into the computer. The facility has a daily clinical meeting with licensed staff and discuss what is going on with residents, like weight loss. The clinical meetings are held all three shifts and weekends. All the residents get a monthly weight. Nurse Practitioner W will give an order for weekly weights. Weekly weights are documented on the medication administration record (MAR), and/or under the Vital Signs (VS) tab in the electronic medical record.
During an interview on 12/20/19 at 6:30 P.M., the DON said the RD should have been notified of the significant weight loss and the RD recommendations should have been followed. The DON said the RD would give the DON a report, then the DON gives the report to Assistant Director of Nursing (ADON) A. ADON A would ensure the orders are carried out.
During an interview on 12/23/19 at 11:30 A.M., the DON said she did review the resident's record for weight loss, the resident was on a hunger strike.
Further review of the resident's care plan, showed no documentation of the resident's hunger strike with goals and interventions.
2. Review of Resident #69's quarterly MDS, dated [DATE], showed;
-Cognitively intact;
-One person assist with activities of daily living;
-Wheelchair for mobility;
-Diagnoses included cancer, hepatitis and malnutrition/at risk.
Review of the resident's ePOS, showed an order dated 7/11/19, for regular diet, regular texture, and regular consistency. Mighty Shake (caloric and protein supplement) with meals.
Review of the resident's care plan, in use during the survey, showed:
-Problem: Resident has had significant weight loss diagnosis with severe protein calorie malnutrition, is at risk for further weight loss due to diagnosis of liver cell carcinoma (cancer);
-Approach: Resident will have adequate food/fluid intake thru next review. Monitor for decline in appetite and health. Provide and serve diet as ordered.
Review of the resident's monthly weights for 2019, showed:
-On 7/9/19, 151.7 LBS;
-On 7/16/19, 148 LBS;
-On 9/16/19 140.6 LBS.
Review of the RD note, dated 9/30/19, showed current weight of 140.6 LBS; August weight not available. A 20.7 LBS significant weight loss x 3 months. Recommend Mighty Shake with each meal for additional support.
Further review of the resident's monthly weights for 2019, showed:
-On 10/6/19, 140.8 LBS;
-On 11/8/19, 133.8 LBS;
Review of the RD note, dated 11/15/19, showed weight recorded as 133.8 LBS, another 7# loss x 1 month. Resident continues on a regular diet with reasonably good appetite. He/she remains on Hospice. Recommend Mighty Shake with each meal as decreased appetite anticipated.
Further review of the resident's monthly weights for 2019, showed:
-On 12/8/19, 136.2 LBS;
-The documentation of the weight of 151.7 LBS in July and the weight of 136.2 LBS in December, showed a weight loss of 10.22% for 5 months.
During an interview on 12/20/19 at 9:14 A.M., Certified Nursing Assistant (CNA) SS said the resident ate pretty well, he/she doesn't like eggs, so he/she won't eat them, but he/she ate everything else.
During an interview on 12/20/19 at 9:16 A.M., CNA TT said the resident will eat what he/she likes, he/she does not like health shakes and won't drink them.
During an interview on 12/20/19 at 5:35 P.M., the DON said she would expect staff to relay likes and dislikes to the RD, so he/she could add supplements to the resident's diet that he/she would like.
3. Review of Resident #77's quarterly MDS, dated [DATE], showed:
-Severe cognitive impairment;
-Diagnoses included diabetes, high blood pressure, dementia, depression and asthma;
-Supervision with eating;
-Weight loss of 5% or more in the last month or 10% or more in the last six months: No or unknown;
-Weighs 220 LBS.
Review of the resident's care plan, dated 10/24/19, showed:
-Focus: Resident has actual nutritional risk related diagnoses of diabetes, stroke, depression, the use of psychotropic and impaired cognition;
-Interventions: Provide and serve diet as ordered. RD to evaluate and make diet change recommendations as needed.
Review of the resident's dietician progress note, dated 7/8/19, showed:
-Nutritional plan: Continue Regular diet;
-Nutritional summary: Resident appears well nourished. He/she is alert and independent with his/her meals; has demonstrated a good appetite since admission. Weight indicated obesity. There are no chewing or swallowing concerns; skin is intact. Blood sugar has been in fair control. Goal = stable weight and blood sugar.
Review of the resident's ePOS, showed:
-An order dated 10/12/19, for weights, check and record monthly;
-An order dated 12/20/19, for regular diet, regular texture, and regular consistency.
Review of the resident's monthly weight record, showed:
-On 9/16/19: 230.0 LBS;
-On 10/8/19: 219.8 LBS;
-On 12/4/19: 211.6 LBS;
-Indicated a significant weight loss of 8% in three months.
Review of the resident's medical record, showed no RD documentation regarding the resident's significant weight loss.
Observation of the resident, showed:
-On 12/18/19 at 8:23 A.M., staff served the resident scrambled eggs, cereal, and toast that were regular texture. The resident was able to consume the meal independently;
-On 12/18/19 at 12:40 P.M., the resident sat in the dining room with one table mate. Staff served the resident his/her regular diet;
-On 12/20/19 at 12:48 P.M., staff served the resident his/her meal, shrimp served on a bed of long strands of pasta and broccoli. Resident ate the meal independently.
4. Review of Resident #50's quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-Resident eats independently with no set up;
-Diagnosis included: high blood pressure, low sodium levels, seizures and schizophrenia.
Review of the resident's ePOS, showed:
-No order for a diet as of 12/19/19;
-On 12/20/19,an order for a regular diet had been entered into the electronic medical record.
Review of the resident's dietary note, date 1/17/19, showed:
-Diet: regular;
-Nutritional Summary: Resident is tolerating mechanical soft and intake has been good. Sodium levels tend to run low. Current weight is consistent with weight one year ago. Continue current plan;
-Nutritional Plan: Continue mechanical soft diet.
Observation of the resident during survey, showed the following:
-On 12/17/19 at 1:00 P.M., the resident sat at the dining room table and fed him/herself. The resident ate 100% of a regular diet. The menu was creamy chicken, carrots, bread stick, red velvet cake, lemon-aid and coffee;
-On 12/19/19 at 6:00 P.M., the resident sat in the dining room and fed him/herself. The resident ate well. The resident ate applesauce, hamburger helper and a sandwich. He/she drank lemon-aid and coffee.
Review of the resident's diet card, reviewed on 12/20/19 at 3:00 P.M., showed regular diet with regular liquids.
Review of the resident's care plan, in use during survey, showed:
-Problem: The resident is edentulous (not having teeth);
Goal: Maintain current level of function with eating, and will not show signs and symptoms of malnutrition;
-Interventions: Speech therapy consulted and regular diet approved.
During an interview on 12/20/19 at 1:30 P.M., the dietary manager said the following:
-The resident is on a regular diet and sometimes he/she will eat a pureed diet, when he/she chooses;
-When the doctor or RD give an order for dietary orders, the nurse writes the order on a carbon copy paper and gives the order to dietary department;
-If the RD is in the facility, the RD will tell the dietary manager of any changes or recommendations he/she is making;
-Sometimes the RD will email the dietary manager with new orders.
5. During an interview on 12/20/19 at 5:20 P.M., the Director of Nursing (DON) said if there is an RD recommendation, it is discussed with the DON. The DON gives a written report to the ADON to ensure the orders are carried out. The DON would expect all residents to have dietary orders. Staff are expected to report weight loss to her and the registered dietician.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
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 thorough assessments, on-going monitoring and ...
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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 thorough assessments, on-going monitoring and communication with the dialysis center. In addition, the facility failed to have a policy to address the assessments, monitoring and communication with dialysis centers for their dialysis residents. The facility identified five residents who receive dialysis. Of those five, three were included in the sample of 29 and concerns were identified with two (Residents #64 and #43). The census was 149.
During an interview on 12/23/19 at 12:14 P.M., the Director of Nursing (DON) said the facility does not have a dialysis (process of filtering toxins from the blood in individuals with kidney failure) policy. The pre and post dialysis assessments are scanned into the system. They are still working on scanning the assessments for December.
1. Review of Resident #64's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/3/19, showed:
-The resident received dialysis;
-Diagnoses included kidney failure.
Review of the facility's dialysis schedule for all residents on dialysis, showed the resident attended dialysis on Monday, Wednesday and Friday.
Review of the resident's dialysis assessments for Mondays, Wednesdays and Fridays in November 2019, showed:
-On 11/1/19, no pre or post dialysis assessment completed;
-On 11/4/19, no post dialysis assessment completed;
-On 11/6/19, no post dialysis assessment completed;
-On 11/8/19, no pre or post dialysis assessment completed;
-On 11/11/19, no post dialysis assessment completed.
Review of the resident's progress notes for November 2019, showed no pre or post dialysis assessments documented on 11/1, 11/4, 11/6, 11/8 and 11/11/19.
Review of the resident's care plan, in use at the time of the survey, showed:
-The resident needs dialysis;
-The resident has diagnosis of end stage kidney disease, he/she receives dialysis three times weekly, is at risk for weight variances, fluid electrolyte imbalance, dehydration;
-The resident will not have signs and symptoms of dehydration/fluid overload or of complications to dialysis shunt (dialysis access site);
-Check and change dressing daily at access site. Document;
-Do not draw blood or take blood pressure in arm with shunt;
-Monitor weight monthly/as needed;
-Send or fax dialysis communication form with resident.
Review of the resident's electronic physician order sheet (ePOS), showed:
-An order dated 12/11/18, for regular diet, regular texture, regular consistency, no oranges, no orange juice, no tomatoes or tomato products, no bananas, may have potatoes two times weekly related dialysis, sack lunch provided on dialysis days for diet;
-An order dated 6/2/19, to check fistula (dialysis access site) for thrill and bruit (the sound you hear and vibration you feel at the dialysis access site) to left upper arm every shift for dialysis access;
-An order dated 9/27/19, for the dialysis company, transportation via transport company;
-The order did not identify how many times a week the resident attends dialysis or what days the resident attends dialysis;
-No order for check and change dressing at access site.
During an observation and interview on 12/17/19 at 2:12 P.M., the resident said he/she receives dialysis. Observation of the resident's left outer/upper arm, showed a bandage. The resident said the bandage covers his/her dialysis shunt.
2. Review of Resident #43's quarterly MDS, dated [DATE], showed;
-Moderate cognitive impairment;
-Extensive staff assistance with hygiene, dressing and transfers;
-Diagnoses of anemia, high blood pressure, dementia, seizure and kidney disease.
Review of the resident's care plan, in use at the time of the survey, showed:
-Focus: The resident received dialysis treatment three days a week. The dialysis shunt is located in the left upper arm;
-Goal: The resident will have no signs or symptoms of bleeding or infection to the dialysis shunt site;
-Interventions: No blood draws will be taken from the left arm, monitor the resident for signs and symptoms of bleeding and swelling, staff to monitor and report lab results to the physician.
Review of the resident's ePOS, showed:
-An order dated 6/4/19, to check and record weight before dialysis and check vital signs before and after dialysis every Tuesday, Thursday and Saturday;
-No orders noted to assess the dialysis access site for bleeding, bruit or thrill.
Review of the resident's treatment administration record (TAR), dated 11/1/19 through 11/30/19, showed no dialysis shunt site assessment ordered.
Review of the resident's dialysis communication record, showed:
-On 11/2/19, a pre dialysis weight and vital sign assessment completed by the facility, showed the right chest wall site intact. An assessment was done while at the dialysis center by the dialysis staff;
-No pre dialysis weight, vital sign assessment communication noted for 11/5/19 or 11/7/19;
-On 11/9/19, a pre dialysis weight and vital sign assessment completed by the facility and an assessment completed by the dialysis staff, showed an intact right chest wall access site;
-An incomplete post dialysis communication form, dated 11/12/19;
-A completed pre and post dialysis communication form dated 11/14/19;
-No communication forms noted for 11/16/19 or 11/18/19;
-A communication form dated 11/21/19, completed for pre dialysis included vital signs and the resident's weight. The form contained no onsite dialysis or post dialysis communication to the right chest wall;
-No communication forms noted for 11/23/19, 11/26/19 or 11/30/19.
Review of the progress notes, showed:
-On 12/12/19 at 2:44 P.M., the resident returned from dialysis treatment. Vital signs and weight taken. The left upper arm dialysis shunt is positive for bruit and thrill. The resident is alert/oriented to person, place and reports having no pain or discomfort at this time;
-On 12/13/19 at 3:42 P.M., the resident returned from dialysis, observed a small amount of bleeding to the old shunt site to the left upper arm. The resident cannot recall what caused the bleeding, but denied any pain or discomfort. Applied a dry dressing and compression wrap. Notified the Nurse Practitioner (NP) and no new orders noted. Will continue to monitor. (No further assessments or documentation noted regarding bleeding);
-On 12/14/19 at 2:55 P.M., the resident arrived back from dialysis. No complaints of pain or discomfort. Vital signs stable, no bleeding noted to left shunt, dressing intact. Port dressing intact to the left chest. If the left arm access starts to bleed, send to the emergency room per the dialysis clinic. Resident is currently with his/her spouse. Will return tomorrow, meds sent;
-On 12/17/19 at 11:45 A.M., the resident returned from dialysis. Vital signs stable. Left upper extremity shunt cite clogged. The resident has a right chest wall access site in place. No redness or swelling noted to chest wall site;
-On 12/19/19 at 11:19 A.M., the resident returned from dialysis and his/her vital signs noted to be stable. The left upper extremity shunt site remained clogged and the right chest wall site noted to be intact.
3. During an interview on 12/20/19 at 5:27 P.M., the DON said she would expect staff check the bruit and thrill as ordered. This should be documented. She did not think it was necessary to include the days the residents attend dialysis in the dialysis order. She expected the nurses to complete the post dialysis assessment. In addition, the orders should include orders to assess the bruit and thrill of the dialysis site. The access area should be monitored and assessed, because the residents receive heparin (blood thinner) at the time of dialysis and staff should be monitoring for bleeding.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure each nurse aide had no less than 12 hours of in-service education per year for four of five sampled certified nursing assistants (CN...
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Based on interview and record review, the facility failed to ensure each nurse aide had no less than 12 hours of in-service education per year for four of five sampled certified nursing assistants (CNAs). The census was 146.
Review of the facility's CNA training records, showed:
-CNA FF: Date of hire (DOH) 11/12/01: Hours from 11/12/18 to 11/12/19 = 8.75;
-CNA EE: DOH 8/15/12: Hours from 8/15/18 to 8/15/19 = 4.75;
-CNA GG: DOH 5/31/17: Hours from 5/31/18 to 5/31/19 = 2.75;
-CNA T: DOH 8/12/19: Hours from 8/12/18 to 8/12/19 = 10.75.
During an interview on 12/20/19 at 1:18 P.M., Licensed Practical Nurse (LPN) I said he/she was the staff development coordinator. She would expect CNAs to have the required 12 hours of training per year. He/she started this position in September and has been working on catching up.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 30 opportunities observed, two errors occurred resulting in a 6.6% erro...
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Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 30 opportunities observed, two errors occurred resulting in a 6.6% error rate (Residents #394 and #129). The census was 146.
1. Review of Resident #394's electronic physician order sheet (ePOS), showed an order dated 11/26/19, for Novolog (short acting insulin). Inject as per sliding scale: If 151 to 250 = 3 units.
Observation on 12/18/19 at 5:47 A.M., showed Licensed Practical Nurse (LPN) II obtained the resident's blood sugar result of 194. He/she withdrew insulin from an insulin vial into an insulin syringe and said he/she was giving 3 units. The plunger was visible at the 3 unit line, but an air bubble of approximately 1 unit visible in the syringe. He/she administered the insulin without clearing the air bubble.
2. Review of Resident #129's ePOS, showed an order dated 4/27/17, for ferrous sulfate (iron) tablet, 325 milligrams (mg). Give 1 tablet via gastric tube (tube inserted into the stomach to provide food, fluid and medications) one time a day for supplementation.
Observation on 12/18/19 at 8:08 A.M., showed LPN L administered the resident's medications via gastric tube. He/she obtained a 325 mg iron tablet, crushed the tablet, mixed it with water and administered it to the resident via the gastric tube.
Review of Drugs.com, last updated 4/25/19, showed ferrous sulfate is a type of iron. Swallow iron tablets and capsules whole. Do not crush, open or chew. Available in liquid form.
3. During an interview on 12/20/19 at 2:38 P.M., the Director of Nursing said medications should be administered as ordered. Staff should make sure all air bubbles are out of the syringe when administering insulin from a vial. An air bubble could affect the dose administered. Ferrous sulfate should not be crushed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to follow their policy on employee tuberculosis (TB) testing for seven of 10 sampled employees. The census was 146.
Review of the facility's ...
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Based on interview and record review, the facility failed to follow their policy on employee tuberculosis (TB) testing for seven of 10 sampled employees. The census was 146.
Review of the facility's TB screening for long term care employees policy, updated 3/11/14, showed:
-If no documentation of a prior two step tuberculin skin test (TST): Administer the first step TST prior to employment, can coincide reading the results with employment start date by administering the TST 2-3 days prior to employee start date;
-If there is documentation of a first step TST with negative results within the past year: Administer the second step within 1-3 weeks;
-If documentation of a two-step TST in the past and at least one subsequent annual test within the past year, all negative: Do a first step TST by anniversary date of the last TST and then annually;
-Read results within 48-72 hours of administration.
1. Review of the employee file for Laundry Aide KK, showed:
-Date of Hire (DOH) 6/19/19;
-First step TST administered 6/17/19 and read negative on 6/19/19;
-No second step TST administered or read.
2. Review of the employee file for Certified Nursing Assistant LL, showed:
-DOH 11/13/19;
-First step TST administered 11/12/19 and read negative on 11/14/19;
-No second step TST administered or read.
3. Review of the employee file for Licensed Practical Nurse MM, showed:
-DOH 1/16/19;
-No documentation of first or second step TST administered or read.
4. Review of the employee file for Social Worker NN, showed:
-DOH 4/24/19;
-First step TST administered on 4/22/19 and read negative on 4/24/19;
-No second step TST administered or read.
5. Review of the employee file for Dietary Aide OO, showed:
-DOH 9/18/19;
-No documentation of first or second step TST administered or read.
6. Review of the employee file for Receptionist PP, showed:
-DOH 10/30/19;
-No documentation of first or second step TST administered or read.
7. Review of the employee file for [NAME] QQ, showed:
-DOH 10/30/19;
-No documentation of first or second step TST administered or read.
8. During an interview on 12/20/19 at 4:41 P.M., the Director of Nursing said the staff development coordinator usually does the new hire PPD's. She would have expected the facility policy to be followed. For several months, the facility did not have a staff development coordinator and several new hires may have been missed.
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 serve and store food under sanitary conditions by not dating and covering stored food, thawing frozen food properly, ensuring food was covere...
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Based on observation and interview, the facility failed to serve and store food under sanitary conditions by not dating and covering stored food, thawing frozen food properly, ensuring food was covered during meal service and that staff serving food did not touch food contact surfaces. In addition, two ice machines used for residents had no air-gap. These deficient practices had the potential to affect all residents who ate at the facility. The census was 146.
1. Observation of the kitchen on 12/17/19 at 8:52 A.M., showed:
-On the prep table, a small container of sugar. Inside the container, a measuring spoon;
-An opened box of baking soda, not covered;
-Inside the walk in cooler:
-Approximately 22 individual sized mixed fruit containers, not dated;
-An opened bag of buns, not dated;
-An opened bag of carrots, not dated;
-An opened bag of croutons, not dated;
-A large container of cranberry sauce, opened, not dated;
-A tub of opened salad dressing, not dated;
-Inside a metal tub, approximately five containers of salad dressings, opened to air and not dated;
-Inside the walk in freezer, opened packages of frozen pies, not dated.
2. Observation of the kitchen on 12/17/19 at 12:33 P.M., showed five large blocks of hamburger thawed inside a large sink as water ran into the sink. A white wash rag plugged the drain and water filled the sink. At 12:35 P.M., an unidentified dietary staff person walked past the sink and shut off the water. At 1:06 P.M., the hamburger sat in the sink, thawing, the water not running.
3. Observation of the kitchen on 12/17/19 at 12:35 P.M., showed the ice machine drained directly into the drain, with no air-gap observed to protect ice from possible contamination.
4. Observations of the 100 Hall, main dining room, showed:
-On 12/17/19:
-At 12:40 P.M., six plates of open faced hamburgers, sat on top of a three tiered serving cart, uncovered, as dietary staff wheeled the cart through the dining room, in between the seated residents;
-At 12:44 P.M., five plates of open faced hamburgers, sat on top of a three tiered serving cart, uncovered, as dietary staff wheeled the cart through the dining room, in between the seated residents;
-At 12:55 P.M., dietary staff wheeled a multi-level cart, filled with sliced red velvet cake, uncovered, through the dining room, as staff asked residents if they would like a slice of cake;
-On 12/18/19:
-At 8:20 A.M., dietary staff wheeled a three tiered cart through the dining room, in between residents as they waited for their breakfast. On the top of the cart were four plates of eggs, sausage patties and toast, and two bowls of hot cereal, uncovered;
-At 8:25 A.M., dietary staff wheeled a three tiered cart through the dining room, in between residents as they waited for their breakfast. On the top of the cart, were two plates, both with peeled boiled eggs and toast, uncovered;
-At 12:42 P.M., dietary staff wheeled a three tiered cart through the dining room, in between residents as they sat at their tables. On the cart were 12 plates of country fried steak or ham, mashed potatoes and bread, uncovered, as staff asked which they would prefer;
-At 12:44 P.M., dietary staff wheeled a three tiered cart through the dining room, in between residents as they sat at their tables. On the cart were six plates of country fried steak or ham, mashed potatoes and bread, uncovered, as staff asked which they would prefer;
-At 12:51 P.M., two additional carts wheeled past residents, with twelve plates of country fried steak or ham, mashed potatoes and bread, uncovered, as staff asked which they would prefer.
5. Observation of the 100 Hall meal service on 12/18/19 at 8:32 A.M., showed a serving cart sat on the hallway as staff plated food for individual resident hall trays. All of the individual food items, eggs, sausage, hot cereal, and two cups of poured coffee sat uncovered as dietary staff plated food and additional staff and residents walked behind the cart with no hair nets on. No protective barrier observed on the cart between the residents/staff and food.
6. Observation on 12/19/19 at 6:00 P.M., showed Certified Nursing Assistant (CNA) DD went to the steam table to pick up a plate and deliver the plate to a resident. CNA DD held the plate with four fingers under the plate and his/her thumb inside the plate. CNA DD returned to the steam cart to collect another plate and served the plate in the same manner, until all the residents in the dining room were served. CNA DD did not wear gloves or sanitize his/her hands between plate service.
7. Observation of the 100 Hall kitchenette on 12/20/19 at 4:30 P.M., showed the ice machine drained into a funnel, between the drain and the ice machine drain. The funnel rose above the ice machine drain. No air gap was observed to protect the ice from possible contamination.
8. During an interview on 12/20/19 at 5:03 P.M., the Dietary Manager said food should not be thawed under standing water, the water should be running. All items stored in the freezer/refrigerators should be dated and covered. During meal service, food should be covered and staff should sanitize their hands before handling food. She said the ice machines should have an air gap and the facility does not have a policy on food storage.
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 interview and record review, the facility failed to implement an effective quality assurance (QA)/quality assurance performance improvement (QAPI) program when they did not implement appropri...
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Based on interview and record review, the facility failed to implement an effective quality assurance (QA)/quality assurance performance improvement (QAPI) program when they did not implement appropriate interventions to correct on-going, systemic issues. In addition, the facility's QA/QAPI committee failed to identify a widespread deficiency that caused immediate jeopardy to resident health or safety. This deficient practice had the potential to affect all residents. The sample was 29. The census was 149.
Review of the facility's Quality Assurance Process Improvement and Compliance (QAPIC) policy, last revised on 2/1/13, showed:
-This organization is committed to providing quality services in a safe, ethical and competent fashion. The purpose of this plan is to provide a framework using common principles found in risk management, quality improvement and compliance methodologies for the development of structures and processes that support the mission and values of our organization; that encourage a systems approach to performance assessment and improvement; that promotes high quality resident care; that protects facility assets; and that fosters a culture of compliance with all regulatory and ethical standards;
-QAPIC efforts will be ongoing, comprehensive and will encompass the full range of services performed by the facility and its departments including but not limited to clinical care, quality of life, resident rights, safety, operations, billing, human resources and management practices.
1. Review of the Centers for Medicare and Medicaid services (CMS) form 2567, dated 11/13/18, showed the following deficiencies identified:
-F678: The facility failed to obtain a signed code status sheet or failed to obtain physician orders for code status for four of 29 sampled residents;
-F623: The facility failed to issue written transfer notices to residents and/or their representative upon discharge to a hospital when their return to the facility was expected;
-F625: The facility failed to inform the resident and family or legal representative of their bed hold policy at the time of transfer to the hospital;
-F641: The facility failed to ensure that each resident receives an accurate assessment, reflective of the resident's status at the time of the assessment;
-F656: The facility failed to ensure residents had complete, accurate and individualized care plans, to address the specific needs of the residents;
-F679: The facility failed to implement an ongoing resident centered activity program that incorporates the resident's interests to maintain and/or improve a resident's physical, mental and psychosocial well-being;
-F690: The facility failed to maintain proper insertion of an indwelling urinary catheter (a tube inserted into the bladder for the purpose of continual urine drainage);
-F698: The facility failed to provide thorough assessments, on-going monitoring and communication with the dialysis center;
-F759: The facility failed to ensure a medication error rate of less than 5%;
-F812: The facility failed to date all health shakes and failed to ensure the dish machine sanitized properly.
Review of the CMS form 2567, dated 12/24/19, showed the following deficiencies identified:
-F678: The facility failed to obtain an ordered code status for 13 residents, failed to essure residents/resident representatives wishes for code status matched the physician ordered code status, failed to ensure one resident's code status was ordered timely after admission and failed to ensure a process for staff to know a resident's code status in the event of electrical or electronic medical record outage;
-F623: The facility failed to issue written transfer notices to residents and/or their representative upon transfer to a hospital when their return to the facility was expected;
-F625: The facility failed to inform the resident and family and/or legal representative of their bed hold policy at the time of transfer to the hospital;
-F641: The facility failed to ensure that each resident receives an accurate assessment, reflective of the resident's status at the time of the assessment;
-F656: The facility failed to ensure residents had complete, accurate and individualized care plans, to address the specific needs of the residents;
-F679: The facility failed to provide, based on the comprehensive assessment, care plan and preferences of each resident, an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident;
-F690: The facility failed to maintain proper placement of a urinary catheter and position of the catheter tubing;
-F698: The facility failed to provide thorough assessments, on-going monitoring and communication with the dialysis center;
-F759: The facility failed to ensure a medication error rate of less than 5%;
-F812: The facility failed to serve and store food under sanitary conditions by not dating and covering stored food, thawing frozen food properly, ensuring food was covered during meal service and that staff serving the food did not touch food contact surfaces.
Based on multiple deficiencies cited in resident rights; admission, transfer and discharge; resident assessments; comprehensive resident centered care plan; quality of life; quality of care; pharmacy services; and food and nutrition services, the facility failed have an effective quality assessment and assurance program to ensure staff identify issues and develop and implement appropriate plans of action to correct identified deficiencies that affect the residents' health, safety and quality of life.
During an interview on 12/19/19 at 5:41 P.M., the administrator said the Quality Assurance and Performance Improvement team meets at least quarterly to identify and correct deficient practices.
2. Based on observation, interview and record review, the facility failed to ensure staff were able to provide emergency basic life support immediately when needed, including cardiopulmonary resuscitation (CPR), to any resident requiring such care in accordance with physician's orders and the resident's advance directives by failing to have a system in place to ensure resident's code status was documented and staff were able to quickly identify a resident's code status when needed. The facility failed to obtain an ordered code status for 13 residents, failed to ensure residents/resident representatives wishes for code status matched the physician ordered code status for two residents, failed to ensure one resident's code status was ordered timely after admission and failed to ensure a process for staff to know a resident's code status in the event of electrical or electronic medical record outage.
During an interview on 12/19/19 at 5:41 P.M., the administrator said the Quality Assurance and Performance Improvement team had not identified code status as an issue. The facility had switched over from paper charting to the electronic records and they had not identified the location of resident code statuses as an issue.
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: 5 life-threatening violation(s), Special Focus Facility, 9 harm violation(s), $126,156 in fines, Payment denial on record. Review inspection reports carefully.
- • 121 deficiencies on record, including 5 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $126,156 in fines. Extremely high, among the most fined facilities in Missouri. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility is on CMS's Special Focus list for poor performance. Consider alternatives strongly.
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About This Facility
What is Hillside Rehab And Healthcare Center's CMS Rating?
CMS assigns HILLSIDE REHAB AND HEALTHCARE CENTER 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 Hillside Rehab And Healthcare Center Staffed?
CMS rates HILLSIDE REHAB AND HEALTHCARE CENTER's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 65%, which is 18 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 77%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Hillside Rehab And Healthcare Center?
State health inspectors documented 121 deficiencies at HILLSIDE REHAB AND HEALTHCARE CENTER during 2019 to 2025. These included: 5 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 9 that caused actual resident harm, 105 with potential for harm, and 2 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Hillside Rehab And Healthcare Center?
HILLSIDE REHAB AND HEALTHCARE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by AMA HOLDINGS, a chain that manages multiple nursing homes. With 208 certified beds and approximately 145 residents (about 70% occupancy), it is a large facility located in SAINT LOUIS, Missouri.
How Does Hillside Rehab And Healthcare Center Compare to Other Missouri Nursing Homes?
Compared to the 100 nursing homes in Missouri, HILLSIDE REHAB AND HEALTHCARE CENTER's overall rating (1 stars) is below the state average of 2.5, staff turnover (65%) 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 Hillside Rehab And Healthcare Center?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can 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 Hillside Rehab And Healthcare Center Safe?
Based on CMS inspection data, HILLSIDE REHAB AND HEALTHCARE CENTER has documented safety concerns. Inspectors have issued 5 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility is currently on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes nationwide). The facility has a 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 Hillside Rehab And Healthcare Center Stick Around?
Staff turnover at HILLSIDE REHAB AND HEALTHCARE CENTER is high. At 65%, the facility is 18 percentage points above the Missouri average of 46%. Registered Nurse turnover is particularly concerning at 77%. 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 Hillside Rehab And Healthcare Center Ever Fined?
HILLSIDE REHAB AND HEALTHCARE CENTER has been fined $126,156 across 3 penalty actions. This is 3.7x the Missouri average of $34,340. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Hillside Rehab And Healthcare Center on Any Federal Watch List?
HILLSIDE REHAB AND HEALTHCARE CENTER is currently an SFF Candidate, meaning CMS has identified it as potentially qualifying for the Special Focus Facility watch list. SFF Candidates have a history of serious deficiencies but haven't yet reached the threshold for full SFF designation. The facility is being monitored more closely — if problems continue, it may be added to the official watch list. Families should ask what the facility is doing to address the issues that led to this status.