ATHENE NURSING AND REHABILITATION
For profit - Limited Liability company
282 Beds
VERTICAL HEALTH SERVICES
Data: November 2025
3 Immediate Jeopardy citations
Trust Grade
0/100
#332 of 479 in MO
Photo by Athene Nursing and Rehabilitation
Photo by Athene Nursing and Rehabilitation
Photo by Athene Nursing and Rehabilitation
1 / 5 photos
Last Inspection: February 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Athene Nursing and Rehabilitation has received a Trust Grade of F, indicating poor performance and significant concerns about care quality. Ranking #332 out of 479 facilities in Missouri places it in the bottom half, and #43 out of 69 in St. Louis County suggests only a few local options are better. While the facility has shown improvement in reducing issues from 37 in 2024 to 8 in 2025, it still has a concerning number of fines totaling $281,231, which is higher than 88% of Missouri facilities. Staffing is also a weakness, with a 1-star rating and less RN coverage than 76% of state facilities, though the turnover rate is reported as 57%, which is slightly better than the state average. Specific incidents raise serious concerns: one staff member physically abused a resident, causing visible injuries, while another resident was able to escape a secured unit, leading to a hospital visit. Additionally, staff were found to be falsifying documentation regarding wound care for another resident, resulting in a severe infection and hospitalization. These findings highlight significant risks and a need for improvement in both staff training and oversight. Families should carefully weigh these strengths and weaknesses when considering this facility for their loved ones.
- Trust Score
- F
- In Missouri
- #332/479
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 57% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $281,231 in fines. Lower than most Missouri facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 14 minutes of Registered Nurse (RN) attention daily — below average for Missouri. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 125 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 31%
Review needed
37 → 8 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 37 issues
2025: 8 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Missouri average (2.5)
Significant quality concerns identified by CMS
Staff Turnover: 57%
11pts above Missouri avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $281,231
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: VERTICAL HEALTH SERVICES
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (57%)
9 points above Missouri average of 48%
The Ugly 125 deficiencies on record
3 life-threatening 2 actual harm
Jul 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 interview and record review, the facility failed to thoroughly assess a resident after a fall with a head injury. Staff...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to thoroughly assess a resident after a fall with a head injury. Staff failed to document neurological (neuro) checks after the head injury. The resident was sent to the hospital via 911 and diagnosed with a subdural hematoma (pool of blood between the brain and the outermost covering) twelve days after the fall (Resident #1). The sample size was three. The census was 152. The Administrator was notified on 7/31/25 of the past non-compliance. The facility had already started in-servicing staff on falls, interventions and documenting prior to the investigation. The facility was in compliance on 7/1/25. Review of the facility's Head Injury policy, dated 9/1/21, showed:-Policy: It is the policy of the facility to report potential head injuries to the physician and implement interventions to prevent further injury;-Policy Explanation and Compliance Guidelines: --Assess resident following a known, suspected or verbalized head injury. The assessment shall include at a minimum: --Vital signs; --General condition and appearance; --Neurological evaluation for changes in: --Physical functioning; --Behavior; --Cognition; --Level of consciousness; --Dizziness; --Nausea; --Irritability; --Slurred speech or slow to answer questions; --Notify physician and follow orders for care; --Provide information from physical assessment; --Describe how injury occurred and how situation has been managed so far; --Report any recent medication changes or use of antiplatelet/anticoagulant medications; --Any recent lab or diagnostic test results; --Perform neuro checks as indicated or as specified by the physician; --Limit activity and/or implement seizure precautions following the injury as specified by the physician; --Continue monitoring for 72 hours following the incident or until the resident is asymptomatic for a period of time specified by the physician; --Notify family and document all assessments, actions and notifications. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/16/25, showed:-Diagnoses of dementia, cognitive communication deficit, aphasia (a language disorder that affects a person's ability to communicate), history of falling and heart failure;-Severe cognitive impairment; -No behaviors or rejection of care;-Dependent on staff (helper does all the effort. Resident does none of the effort to complete the task) for transferring, toileting, bathing and dressing.-History of falls. Review of the resident's progress notes, showed on 6/25/25 at 6:25 P.M., the nurse was called into the dining room to assess the resident related to falling out of his/her wheelchair on to the floor. Upon assessing the resident, a nickel sized knot was noted on the left side of his/her forehead. The resident stated his/her pain is 3 out of 10. The resident is to be monitored, neuro checks and ice applied per the physician's request. Vital signs: Temperature 97.9 Fahrenheit (F -normal body temperature for adults ranges from 97 F to 99 F, pulse 77 (normal pulse for adults ranges from 60 to 100 beats per minute), respiration 20 (normal respiratory rate is between 12 and 20 breaths per minute) and blood pressure 145/70 (normal blood pressure is considered to be less than 120 systolic (top number) and less than 80 diastolic (bottom number). Review of the resident's Neuro Check Flow Sheet, showed:-Neuro Checks Made Simple:--Neuro checks should be done when a resident falls and hits or bumps his/her head or if the fall was unwitnessed with evidence of head injury. Use the Neuro check flowsheet. Neuro checks are completed every shift for 72 hours. The date including year and time are recorded. Neuro checks are an important factor in the early identification of traumatic head injuries;-Neuro checks should be completed for unwitnessed falls or fall in which head was hit. Complete initial then every 15 minutes x 4, every 30 minutes x 2, every hour x 2, every shift for 72 hours;-Date 6/25/25. Times checked: --1:00 P.M.; --1:15 P.M.; --1:30 P.M.; --1:45 P.M.; --2:00 P.M.; --2:30 P.M.; --3:00 P.M.; --4:00 P.M.; --5:00 P.M.; --6:00 P.M.;-No further documentation of any neuro checks done. Review of the resident's medical record under vital signs, showed no vitals recorded for the month of June and none recorded until 7/7/25. During an interview on 7/30/25 at 1:15 P.M., the resident's family member said the facility did not fully assess the resident after his/her fall. The resident continued to complain of pain in his/her head and the staff did not do anything about it. On 7/4/25, the resident complained of head pain to him/her, and he/she had to ask the staff to give the resident something for the pain. On 7/7/25, the staff told the family member the resident vomited over the weekend. He/She demanded the staff send the resident to the hospital. Review of the resident's electronic Medication Administration Record for July 2025, showed on 7/4/25 at 1:00 P.M., staff administered acetaminophen 650 milligrams for pain. Pain level was recorded as a 0. Review of the resident's progress notes on 7/7/25 at 6:38 P.M., showed a communication note regarding the resident's change in condition. The change in condition were falls/nausea/vomiting. No documentation of when the resident vomited, when the physician was notified or when the resident was sent to the hospital. Review of the resident's hospital records, showed:-Resident was admitted on [DATE] from his/her facility for headaches;-Resident's pertinent neurosurgical history includes traumatic brain injury (a serious medical issue that affects how your brain works) at age [AGE] when struck by a motor vehicle;-CT (computerized tomography scan, also called a CT scan, a type of imaging that uses X-ray techniques to create detailed images of the body ) scan in the emergency room showed a subacute left sided subdural hematoma. Review of the resident's progress notes dated 7/8/25 at 7:04 P.M., showed the resident was transported from the hospital via ambulance back to the facility with the diagnosis of subdural hematoma to the left side of the forehead related to a fall. During an interview on 7/31/25 at 10:20 A.M., the Corporate Nurse said the staff performed the neuro checks for 72 hours but did not document them. The therapy team saw the resident several days after he/she fell. They assessed him/her, and he/she did not report any pain to them. The neuro checks should have been documented. During an interview on 7/31/25 at 10:25 A.M., the Director of Nursing said she interviewed all of the staff who worked after the resident's fall, and the documentation was not completed. The resident did not complain of nausea or vomiting. She would have expected staff to document neuro checks for 72 hours after the resident fell and had a head injury. During an interview on 7/31/25 at 3:00 P.M., the Administrator said he would have expected staff to follow policy and document neuro checks for 72 hours after the resident had a fall with a head injury. 2568575
Jun 2025
3 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility staff failed to ensure one of five sampled residents was free fr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility staff failed to ensure one of five sampled residents was free from physical abuse (Resident #1). Resident #1 had diagnoses including dementia, restlessness, agitation, cognitive communication deficit, and other abnormalities of gait and mobility. On 6/6/25 at approximately 5:00 P.M., certified medication technician (CMT) C told the resident he/she was nasty when the resident coughed or pretended to cough on CMT D's neck. CMT C began arguing with the resident, used profanity, and they threatened each other. CMT C pushed the resident and the resident pushed back. CMT C swung at the resident, hitting the resident around the face and neck, and the resident was pushed back against the wall. Staff intervened and pulled the resident away, causing him/her to fall to the ground. The CMT continued to try and strike the resident before staff pulled him/her away. The resident sustained visible injuries to his/her neck and hand. The facility census was 158.
The Administrator was notified on 6/11/25 at 2:00 P.M., of an immediate jeopardy (IJ) which began on 6/6/25. The IJ was removed on 6/10/25 as confirmed by surveyor on-site verification.
Review of the facility's Abuse, Neglect and Exploitation policy revised 8/22/22, showed:
-Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property;
-Definition:
--Abuse: Means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychological well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse including abuse facilitated or enabled through the use of technology;
--Willful: Means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm;
--Verbal abuse: Means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance regardless of their age, ability to comprehend or disability;
--Physical abuse: Includes but is not limited to, slapping, punching, biting and kicking. It also includes controlling behavior through corporal punishment;
--Mistreatment: Means inappropriate treatment or exploitation of a resident;
-Policy Explanation and Compliance Guidelines:
1. The facility will develop and implement written policies and procedures that:
a. Prohibit and prevent abuse, neglect and exploitation of residents and misappropriation of resident property;
b. Establish policies and procedures to investigate any such allegations;
2. The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspect abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law;
3. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written;
-Prevention of Abuse, Neglect and Exploitation: The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property and exploitation that achieves:
--Identifying, correcting and intervening in situations in which abuse, neglect, exploitation and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed and certified staff on each shift in sufficient numbers to meet the needs of the residents and assure that the staff assigned have knowledge of the individual resident's care needs and behavioral symptoms;
--The identification, ongoing assessment, care planning for appropriate interventions and monitoring of residents with needs and behaviors which might lead to conflict or neglect;
--Providing residents, representatives and staff information on how and to whom they may report concerns, incidents and grievances without the fear of retribution and providing feedback regarding the concerns that have been expressed;
--Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors;
-Identification of Abuse, Neglect and Exploitation;
--The facility will have written procedures to assist staff in identifying the different types of abuse - mental/verbal abuse, sexual abuse, physical abuse and the deprivation by an individual of goods and services. This includes staff to resident abuse and certain resident to resident altercations;
--Possible indicators of abuse include, but are not limited to:
--Resident, staff or family report of abuse;
--Physical marks such as bruises or patterned appearances such as a hand print, belt or ring mark on a resident's body;
--Verbal abuse of a resident overheard;
--Physical abuse of a resident observed;
--Psychological abuse of a resident observed;
-Protection of Resident: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to:
--Responding immediately to protect the alleged victim and integrity of the investigation;
--Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed;
--Increased supervision of the alleged victim and residents;
--Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator;
--Protection from retaliation;
--Providing emotional support and counseling to the resident during and after the investigation, as needed;
--Revision of the resident's care plan if the resident's medical, nursing, physical, mental or psychosocial needs or preferences change as a result of an incident of abuse;
--Assuring the reporters are free from retaliation or reprisal;
--Promoting a culture of safety and open communication in the work environment prohibiting retaliation against any employee who reports a suspicion of a crime. This facility will post a conspicuous notice of employee rights, including the right to file a complaint with the state survey agency if the employee believes the facility has retaliated against him/her for reporting a suspected crime and how to file such a complaint;
Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 5/9/25, showed:
-Adequate hearing and vision;
-Sometimes understands others and is sometimes understood;
-Moderately cognitively impaired;
-No behaviors or rejection of care noted;
-Diagnoses included dementia, bladder cancer, generalized anxiety disorder, degenerative disease of the nervous system, restlessness and agitation, lack of coordination, other abnormalities of gait and mobility, elevated blood pressure and muscle weakness.
Review of the resident's care plan dated 6/6/25, showed:
-Focus: Resident rights are guaranteed by the Federal 1987 Nursing Home Reform Law. The law requires Skilled Nursing Facilities to promote and protect the rights of each resident, placing emphasis on individual preferences, dignity, and self-determination;
-Interventions: The resident has the right to be treated with consideration, respect, and dignity, to be free from mental and physical abuse, corporal punishment, involuntary seclusion, and to be free from restraint (physical or chemical);
-Focus: Resident is verbally aggressive related to dementia, ineffective coping skills and mental /emotional illness;
-Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Analyze key times, places, circumstances, triggers, and what de-escalates behavior and document. Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. Assess resident's coping skills and support system. Give the resident as many choices as possible about care and activities;
-Focus: Resident is resistive to care. Resident will sometimes refuse to get blood sugar checked:
-Interventions: Allow the resident to make decisions about treatment regime, to provide sense of control. Educate resident/family/caregivers of the possible outcome(s) of not complying with treatment or care. 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 resident resists with activities of daily living (ADLs), reassure resident, leave and return five to ten minutes later and try again. Praise the resident when behavior is appropriate;
-Focus: Resident will have behaviors when he/she gets agitated;
-Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Anticipate and meet resident's needs. Caregivers to provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by. If reasonable, discuss resident's behavior. 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. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Provide a program of activities that is of interest and accommodates residents status;
-Focus: Resident has dementia;
-Interventions: Ask yes/no questions in order to determine the resident's needs. Communicate with the resident/family/caregivers regarding resident's capabilities and needs. Cue, reorient and supervise as needed;
-Focus: The resident has a communication problem related to dementia;
-Interventions: Anticipate and meet needs. Ensure/provide a safe environment: Call light in reach, Adequate low glare light, bed in lowest position and wheels locked. Avoid isolation.
Monitor/document for physical/nonverbal indicators of discomfort or distress, and follow-up as needed.
Review of the resident's progress notes, showed:
-On 6/6/25 at 5:25 P.M., per staff on duty (CMT C, CMT D, certified nurse aide (CNA) E, CNA F and CNA G), CMT C asked the resident to cover his/her mouth when coughing by CMT D. The resident became irate yelling profanity, increased agitation, and upset. The resident charged CMT C, striking him/her in the face and grabbing him/her. Staff had to get in between the resident and CMT C so the CMT could be allowed to get to safety. The nurse assessed the resident with findings as follows: No visible bruising or open areas. Resident stated he/she hates the sight of the CMT C. At 6:33 P.M., the nurse called the resident's physician and informed him/her of resident aggression towards staff. The physician sent an as needed (PRN) order for Trazodone (used to treat anxiety) 50 milligrams twice a day as needed. At 6:45 P.M., the nurse informed the resident's daughter about new order obtained PRN for agitation/anxiety. The resident's family member returned phone call, and this nurse informed him/her of the resident's aggression towards staff.
Review of the resident's skin assessment dated [DATE], showed no new skin issues.
Review of the resident's care task record dated 5/13/25 through 6/9/25, showed:
-Task: Behavior monitoring and interventions:
-On 6/6/25 at 2:00 P.M., no behaviors observed;
-No other documentation of behaviors for 6/6/25.
Review of the resident's June 2025 physician's order sheet, showed:
-Pain monitoring every shift;
-Aspirin, 81 milligrams (mg) tablet, give one tablet by mouth one time a day for high blood pressure;
-Citalopram Hydrobromide, 20 mg tablet, give one tablet by mouth, one time a day for depression;
-Quetiapine furmate, 25 mg, give one tablet one time a day for generalized anxiety disorder, restlessness and agitation;
-Memantine hydrochloride (HCl), 500 mg, give one tablet by mouth two times a day for depression;
-Trazodone HCl, 50 mg, give 50 mg by mouth two times a day related to anxiety disorder.
Review of the resident's June 2025 electronic Medication Administration Record, showed:
-On 6/6/25:
-Aspirin, 81 mg, at 8:00 A.M., drug refused;
-Citalopram Hydrobromide 20 mg, at 8:00 A.M., drug refused;
-Quetiapine Furmate, 25 mg, at 8:00 A.M., drug refused;
-Memantine HCI, 5 mg, at 8:00 A.M. and at 5:00 P.M., drug refused;
-Trazodone HCI, 50 mg, at 8:00 A.M. and at 5:00 P.M., drug refused;
-On 6/7/25, a 10 recorded for pain monitored on the day shift.
During an interview on 6/9/25 at 11:30 A.M., the resident said he/she got beat a few days ago by the second in command behind the nurse (CMT C). This was the third time the resident had been assaulted by him/her. The staff member was throwing punches at him/her. The staff member continually insulted him/her and told him/her he/she would never get out of the facility. Other staff were there and saw it happen. The staff member beat him/her good. The resident was injured in the incident when the staff member hit him/her in the face and scratched his/her neck. The nurse told the resident he/she would take care of it, but he/she did not do anything. The nurse was never around when things happened. The resident no longer felt safe in the facility and did not trust the staff to help him/her.
Observations of the resident on 6/9/25 between 11:30 A.M. and 5:00 P.M., showed a scratch on the right side of his/her neck, a scratch on the left side of his/her neck and a scratch on his/her right hand.
During an interview on 6/11/25 at 4:30 P.M., the wound nurse said he/she measured the resident's wounds on this date and found the wound on the left side of the neck measured 3 centimeters (cm), the wound on the right side of the neck measured 0.3 cm width on the top and 0.5 cm length at the bottom. The wound on the resident's left wrist measured 0.3 cm in width by 0.5 cm in length.
Review of the resident's trauma informed care form, dated 6/10/25, showed: Physical assault: Happened to me.
During an interview on 6/9/24 at 12:25 P.M., Registered Nurse (RN) J said on 6/6/24, he/she was on his/her way home from working at the facility and CNA G called and told him/her Resident #1 had assaulted CMT C. He/She called the DON and reported the allegation and the DON told RN J he/she needed to return to the facility to get statements from all of the staff who were working. The resident was still agitated when he/she got back to the facility and said he/she wanted a fair fight. He/She never said he/she was assaulted. RN J did not ask him/her if he/she was assaulted, only if he/she was in pain and if he/she felt safe. He/She assessed the resident and did not see any injuries at the time. The staff interviewed who were working (CMT C, CMT D, CNA E, CNA F and CNA G) reported the resident attacked CMT C, and the other staff (CMT D, CNA E, CNA F and CNA G) had to get him/her off him/her. The resident allegedly coughed on CMT D and when CMT C told him/her to cover his/her mouth, the resident ran towards him/her and the staff (CMT D, CNA E, CNA F and CNA G) had to pull the resident off him/her. All of the staff (CMT C, CMT D, CNA E, CNA F and CNA G) who were present wrote statements indicating this is what happened. He/She did not interview the staff individually about what happened, just asked them to write out statements. The resident had never physically assaulted anyone before, but there were certain staff he/she did not like. He/She did not like CMT C, because he/she often had to redirect him/her, and the resident did not like that. The resident told the nurse he/she did not want to be there with CMT C anymore. The RN did not know if the resident received his/her medication on 6/6/25 because CMT C did not tell him/her the resident refused his/her medications and he/she did not administer it that day.
Review of a written statement by CMT C dated 6/6/25, provided by the DON on 6/9/24, showed the resident walked behind him/her and CMT D, and the resident coughed. CMT C told the resident to cover his/her mouth, and the resident turned around and charged him/her, attacking him/her.
During an interview on 6/9/25 at 1:55 P.M., CMT C said he/she and CMT D were at the nurse's station and the resident walked by and coughed on CMT D's neck. CMT C told the resident to cover his/her mouth. The resident does not like CMT C and always has an attitude. CMT C asked the resident why he/she coughed on CMT D, and the resident became enraged, rushed towards CMT C and grabbed his/her arms. The CMT started struggling trying to get free and grabbed at the resident trying to get loose. The other staff (CMT D, CNA E, CNA F and CNA G) pulled the resident back away from him/her, but the resident kept trying to attack him/her. He/She never struck the resident, and he/she did not fall to the ground. CMT C did not know why the resident did not like him/her. The resident would get angry with him/her when he/she found the resident in the wrong. CMT C usually just ignored the resident's behavior when he/she got angry. CMT C did not know who administered the resident's medication on 6/6/25 because he/she often would refuse to take medication from him/her, and he/she would have to get the nurse to administer it.
Review of a written statement by CMT D dated 6/6/25 and provided by the DON on 6/9/25, showed the resident walked behind him/her and coughed on his/her neck. CMT C told him to cover his/her mouth, and then the resident charged at him/her while the staff tried to get him/her off CMT C.
During an interview on 6/6/25 at 1:45 P.M., CMT D said the incident started because the resident walked by and coughed on him/her. CMT C let the resident know not to do that, and the resident got really aggressive, and they had to restrain him/her. The resident got angry so fast. It was out of nowhere. He/She charged at CMT C and the staff had to restrain him/her. CMT C grabbed the resident's arms to try and prevent him/her from hitting him/her. CMT D did not usually work on the memory care floor, so did not know if the resident and CMT C had prior problems with each other.
Review of a written statement by CNA G dated 6/6/25 and provided by the DON on 6/9/25, showed CMT C was talking to CMT D and the resident walked by and coughed on CMT D's neck. CMT C asked the resident why he/she coughed on CMT D's neck. That is when he/she saw the resident walk towards CMT C. CMT C told the resident not to get up in his/her face, and then the resident pushed CMT C and called him/her a bitch.
During interviews on 6/9/25 at 2:20 P.M. and at 3:30 P.M., CNA G said he/she was in the dining room on the day of the incident and heard Resident #1 and CMT C yelling at each other. The resident had coughed on CMT D's neck and CMT C asked the resident why he/she coughed on his/her neck. CMT C told the resident he/she could not believe he/she coughed on his/her neck. CNA G thought they were joking at first, but then the resident got angry and walked towards CMT C. CMT C told the resident not to walk up on him/her, and then the resident charged at CMT C. The resident fell, and CNA E got him/her in a headlock. The resident was on the ground and CNA E had his/her arm around the resident's neck. CNA F grabbed CMT C and attempted to pull him/her away from the resident. CNA G yelled at CNA D to let the resident go and helped him/her up from the ground. The resident was bleeding from his/her neck and hand. CNA G took the resident into the dining room and tried to get him/her to eat dinner. The resident was very upset and asked if CNA G saw what happened. CNA G wrote the statement about the staff member being attacked because he/she was afraid he/she would lose his/her job.
Review of a written statement by CNA E dated 6/6/25 and provided by the DON on 6/9/25, showed he/she heard CMT C ask Resident #1 to cover his/her mouth, and then the resident charged at the CMT. CMT D grabbed CMT C's neck until they could pry the resident's hands from his/her neck.
During interviews on 6/9/25 at 2:10 P.M. and on 6/11/25 at 8:50 A.M., CNA E said he/she was in the dining room on the night of the incident, at the back of the room and did not see what started the problem. He/She heard Resident #1 and CMT C yelling at each other about the resident covering his/her mouth. CNA E had to finish passing out the tray he/she was holding and got there at the end of it. No one was on the floor. CMT D, CNA E, CNA F, and CNA G were standing between the resident and CMT C. The resident was up against the wall. It was chaos and everybody was everywhere. The resident had been upset and agitated all day. He/She did not know if the resident got his/her medication that day. Residents can get agitated if they do not get their medication. The resident did not like to be redirected by CMT C. The resident told CNA E all the staff jumped on him/her except for him/her. He/She did not report it, because he/she believed the resident was restrained to prevent him/her from assaulting CMT C.
Review of a written statement by CNA F dated 6/6/25 and provided by the DON on 6/9/25, showed the resident walked by CMT C and CMT D, and the resident coughed on CMT D's neck. CMT C asked the resident why he/she would do that and to cover his/her mouth. The resident then got mad and charged at CMT C. CNA F, CMT D, CNA E and CNA G had to get the resident off CMT C.
During interviews on 6/9/25 at 2:05 P.M., and on 6/11/25 at 8:15 A.M., CNA F said he/she was in the dining room serving trays on the night of the incident. Resident #1 walked by the nurse's station and he/she playfully coughed on CMT D, and CMT C turned around and started yelling at him/her. CMT C told the resident he/she was nasty. They started arguing back and forth, and then the resident threatened to hit him/her. CMT C said he/she wished the resident would hit him/her. The resident then walked closer to CMT C, and he/she pointed his/her finger in the resident's face and said, You better get the f**k out of my face. The resident stepped closer, and then the CMT pushed him/her back. The resident pushed the CMT and then the CMT started swinging at the resident. CMT C was hitting the resident around the face and neck, and the resident was pushed back against the wall. CNA E got behind the resident and attempted to pull him/her away from the CMT and he/she fell on him/her. CNA F was trying to pull CMT C away from the resident and was telling him/her it was not worth losing his/her job. CMT C continued to yell, I told your ass and tried to swing on the resident again while he/she was on the ground. They were finally able to get CMT C away from the resident and behind the nurse's station. The resident was bleeding from wounds on his/her face and neck. CNA F wrote two statements. The first one was the night of the incident. RN J came in and told all of the staff to write statements about what they witnessed. This was done in front of all of the staff, and CNA F did not feel comfortable writing one. The nurse told him/her the resident attacked the staff, and the staff restrained him/her to protect the CMT and asked if that is what he/she witnessed. The nurse read everyone's statement out loud to ensure they all matched up and then left. CNA F thought about it overnight and then called the DON the next day to tell him/her what really happened, and he/she wanted to change his/her statement. The DON came to the facility on 6/7/25, and CNA F gave him/her a new statement and told him/her CMT C had assaulted the resident. The DON told him/her since they were past the time to report the incident it would look bad if the CNA changed his/her story and he/she would be perceived as a liar. The DON told him/her they were going to go with the original statements and he/she would be back in on 6/11/25 to further investigate the incident. The CNA had a copy of the second statement and had recorded the conversation between him/her and the DON.
Review of the second written statement by CNA F dated 6/7/25, sent to DHSS on 6/11/25 at 8:32 A.M., showed he/she and CNA E were in the dining room the night of the incident, passing trays for dinner. Resident #1 walked by CMT C and CMT D and playfully coughed on CMT D. CMT C told the resident he/she was nasty and why would he/she do that. The resident started getting agitated and they began arguing back and forth. The resident told CMT C he/she would hit him/her, and the CMT told the resident he/she wished he/she would hit him/her. The resident walked up to CMT C, and CMT C said, You better get the f**k out of my face and pushed the resident. The resident pushed the CMT back, and CMT C started swinging on the resident and grabbed him/her down to the floor. CMT D, CNA E and CNA F tried to break up the fight. CNA E got the resident away from the CMT, and CNA F pulled CMT C away. CMT C kept yelling I told your ass! They got the resident to calm down, but he/she would get agitated again every time he/she saw CMT C. RN J called and said he/she was on his/her way back to the building and wanted statements. CNA F felt coerced to write the statement the RN told him/her to write. The resident had visible scratches on both sides of his/her neck.
Review of a recorded interview between the DON and CNA F, provided by CNA F on 6/11/25 at 8:35 A.M., showed:
-The resident was in front of the nurse's station on the night of the incident. He/She was in a playful mood and acted like he/she was going to cough on CMT D;
-CMT C started to yell at the resident, saying he/she saw what he/she did, and it was nasty;
-The resident argued he/she had not done this, but CMT C kept saying he/she did, and the resident started to get agitated;
-The resident and the CMT had words earlier in the day when the resident thought he/she had taken his/her cereal;
-The resident told CMT C he/she would hit him/her, and he/she told the resident he/she wished he/she would hit him/her;
-The resident was on his/her way to the dining room and turned around and came back when the CMT said this to him/her;
-CMT C pointed his/her finger in the resident's face and said, You better get the f**k out of my face;
-The resident took another step closer to the CMT, and CMT C pushed the resident back;
-The resident then pushed the CMT back;
-CMT C then started swinging at the resident and pushed him/her into the wall;
-CMT C was grabbing at the resident's clothes with one hand and swinging with the other;
-CMT C hit the resident on the side of his/her head. The resident was not swinging back;
-The resident fell to the ground;
-CNA F grabbed CMT C by the arms and tried to pull him/her back away from the resident while another staff member was trying to get the resident away. CNA E attempted to pull the resident away and the resident fell on him/her;
-CMT C continued to try and swing on the resident while he/she was on the floor and yelled, I told you not to get in my face;
-The resident was on the ground screaming, This is going to be a lawsuit;
-The staff were finally able to get the CMT to go behind the nurse's station and the resident to the dining room.
During an interview on 6/9/25 at 2:50 P.M., CNA I said he/she was not working the night of the incident but came in the next morning and heard CNA F and CNA H talking about the resident getting jumped on by staff the night before. The resident had visible scratches on both sides of his/her neck, and the resident said they hurt. CNA I did not report this to anyone, because he/she thought they already knew about it.
During an interview on 6/9/25 at 4:30 P.M., CNA H said when he/she came to work on 6/7/25, CNA F told him/her the resident had been jumped on by staff the night before. CNA H told CNA F he/she should do the right thing and report it. Resident #5 told CNA H, he/she saw a staff member put Resident #1 in a choke hold. He/She did not report it, because he/she did not witness it and thought CNA F reported it.
Review of Resident #5's quarterly MDS dated [DATE], showed:
-Moderately cognitively impaired;
-Adequate hearing and vision;
-Usually understands others and makes self understood.
During an interview on 6/9/25 at 4:05 P.M., Resident #5 said he/she was in the dining room the night of the incident and heard Resident #1 and CMT C yelling at each other. Then the yelling stopped, and the staff started running out of the dining room, so he/she went out to see what was happening. Resident #1 was on the floor, and a staff member had a reverse choke hold (a choke hold applied from behind the person, typically with one arm wrapped around the neck) on him/her. The resident had stopped yelling at this time.
During interviews on 6/9/25 at 1:00 P.M. and on 6/11/25 at 11:35 A.M., the DON said she received a call on 6/6/25 around 5:00 P.M. from RN J stating Resident #1 had assaulted CMT C. She directed the RN to return to the facility to take statements from the staff. The staff told the DON the resident became agitated at CMT C after he/she asked the resident not to cough on CMT D and the resident charged at him/her. Staff had to restrain the resident so CMT C could get to safety. The DON removed CMT C as he/she was a trigger for the resident and asked him/her not to return until 6/9/25 so she could investigate the incident further. The DON planned to come back in to the facility on 6/7 and start an investigation. The DON told the staff to keep an eye on the resident. The DON returned to the facility on 6/7/25 after receiving a call from from CNA F regarding the incident. The DON assessed the resident and did not see any injuries. The resident did not allege he/she was abused. The DON did not specifically ask the resident if he/she was assaulted. The first night the resident told CNA E he/she was jumped by six staff members. The DON thought he/she was just confused from being restrained by the staff members. The DON would have expected the staff to document these allegations so they could have been investigated. The DON ensured a referral for a psychiatric evaluation was made for the resident and his/her physician was contacted to get an order for an as needed medication in case he/she got agitated again. The DON knew the resident did not like the CMT but believed it was because the CMT brought in food for the residents who behaved well, and he/she often did not get the food, and it made him/her angry. The DON did not remove the staff member from the unit prior to the incident, because he/she believed the resident just did not like being redirected. No one told the DON, CMT C had expressed he/she did not like the resident. RN J told her the witness statements verified the resident attacked the staff member. The DON suspended CMT C because he/she admitted calling the resident nasty and this was not an appropriate reply, until she could meet with CMT C on 6/9/25 to discuss appropriate behavioral responses. No one told the DON the resident was alleging he/she was abused or they witnessed the resident being abused. If staff had notified her about this, she would have immediately started an investigation and reported the allegations.
During interviews on 6/9/25 at 5:30 P.M. and on 6/11/25 at 3:00 P.M., the Administrator said he is the abuse/neglect coordinator and staff, residents or family can report allegations to him at anytime. He expects staff to report all al[TRUNCATED]
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 observation, interview and record review, the facility failed to thoroughly investigate an altercation between Resident...
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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 thoroughly investigate an altercation between Resident #1 and several staff members which resulted in the resident sustaining scratches on both sides of his/her neck and on his/her left hand. A registered nurse asked for written statements from the staff members involved and then read each others statements in front of each other. The next day, Certified Nurse Aide F reported to the Director of Nursing his/her statement was not correct and provided a new statement of events alleging CMT C had assaulted the resident. The DON did not investigate the incident further, including interviewing the resident and other staff members privately regarding the incident or advise the Administrator of the revised statement. This deficient practice affected one out of five sampled residents. The census was 158.
Review of the facility's Abuse, Neglect and Exploitation policy revised 8/22/22, showed:
-Policy Explanation and Compliance Guidelines:
1. The facility will develop and implement written
policies and procedures that:
a. Prohibit and prevent abuse, neglect and exploitation of residents and misappropriation of resident property;
b. Establish policies and procedures to investigate any such
allegations;
-Investigation of Alleged Abuse, Neglect and Exploitation:
--An immediate investigation is warranted when suspicion of abuse, neglect or exploitation or reports of abuse, neglect or exploitation occur;
--Written procedures for investigations include:
1. Identifying staff responsible for the investigation;
2. Exercising caution in handling evidence that could be used in a criminal investigation;
3. Investigating different types of investigations;
4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses and others who might have knowledge of the allegations;
5. Focusing the investigation on determining if abuse, neglect, exploitation and/or mistreatment has occurred, the extent and cause and;
6. Providing complete and thorough documentation of the
investigation;
-Protection of Resident: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to:
--Responding immediately to protect the alleged victim and integrity of the investigation;
--Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed;
--Increased supervision of the alleged victim and residents;
--Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator;
--Protection from retaliation;
--Providing emotional support and counseling to the resident during and after the investigation, as needed;
--Revision of the resident's care plan if the resident's medical, nursing, physical, mental or psychosocial needs or preferences change as a result of an incident of abuse;
-Reporting/Response: The facility will have written procedures that include:
--Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g. law enforcement when applicable) within specified timeframes:
---Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury or;
---Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury;
--Assuring the reporters are free from retaliation or reprisal;
--Promoting a culture of safety and open communication in the work environment prohibiting retaliation against any employee who reports a suspicion of a crime. This facility will post a conspicuous notice of employee rights, including the right to file a complaint with the state survey agency if the employee believes the facility has retaliated against him/her for reporting a suspected crime and how to file such a complaint;
--Reporting to the state nurse aide registry or licensing authorities any knowledge it has of any actions by a court of law which would indicate an employee is unfit for service;
--Taking all necessary actions as a result of the investigation, which may include, but are not limited to, the following:
---Analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences;
---Defining how care provision will be changed and/or improved to protect residents receiving services;
---Identification of staff responsible for implementation of corrective actions.
Review of Resident #1's progress notes, showed on 6/6/25 at 5:25 P.M., per five staff (Certified Medication Technician (CMT) C, CMT D, Certified Nurse Aide (CNA) E, CNA F and CNA G), the resident was asked by CMT C to cover his/her mouth when coughing. The resident became irate yelling profanity, increased agitation, and upset. The resident charged CMT C , striking him/her in the face and grabbing him/her. CMT D, CNA E, CNA F, and CNA G had to get in between the resident and CMT C so the CMT could be allowed to get to safety. The nurse assessed the resident with findings as follows: No visible bruising or open areas. Resident stated he/she hates the sight of CMT C. At 6:33 P.M., the nurse called the resident's physician and informed him/her of resident aggression towards staff. The physician sent an as needed (PRN) order for Trazodone (used to treat anxiety) 50 milligrams twice a day as needed. At 6:45 P.M., the nurse informed the resident's daughter about the new order obtained PRN for agitation/anxiety. The resident's family member returned the phone call and this nurse informed him/her of the resident's aggression towards staff.
Review of the resident's skin assessment dated [DATE], showed no injuries.
During an interview on 6/9/25 at 11:30 A.M., the resident said he/she got beat a few days ago by the second in command behind the nurse (CMT C). This was the third time the resident had been assaulted by him/her. The staff member was throwing punches at him/her. The staff member continually insulted him/her and told him/her he/she would never get out of the facility. Other staff were there and saw it happen. The staff member beat him/her good. The resident was injured in the incident when the staff member hit him/her in the face and scratched his/her neck. The nurse told the resident he/she would take care of it, but he/she did not do anything. He/She was never around when things happened. The resident no longer felt safe in the facility and did not trust the staff to help him/her.
Observations of the resident on 6/9/25 between 11:30 A.M. and 5:00 P.M., showed a scratch on the right side of his/her neck, a scratch on the left side of his/her neck and a scratch on his/her right hand.
During an interview on 6/11/25 at 4:30 P.M., the wound nurse said he/she measured the resident's wounds on this date and found the wound on the left side of the neck measured 3 centimeters (cm), the wound on the right side of the neck measured 0.3 cm width on the top and 0.5 cm length at the bottom. The wound on the resident's left wrist measured 0.3 cm in width by 0.5 cm in length.
Review of the resident's trauma informed care form, dated 6/10/25, showed: Physical assault: Happened to me.
During an interview on 6/9/24 at 12:25 P.M., Registered Nurse (RN) J said on 6/6/24, he/she was on his/her way home from working at the facility and CNA G called and told him/her Resident #1 had assaulted CMT C. RN J notified the DON about the allegation and she said RN J needed to return to the facility to get statements from all of the staff who were working. The resident was still agitated when he/she got back to the facility and said he/she wanted a fair fight. The resident never said he/she was assaulted. RN J did not ask him/her if he/she was assaulted, only if he/she was in pain and if he/she felt safe. He/She assessed the resident and did not see any injuries at the time. The staff (CMT C, CMT D, CNA E, CNA F and CNA G) reported the resident attacked CMT C, and the other staff (CMT D, CNA E, CNA F and CNA G) had to get him/her off him/her. The resident allegedly coughed on CMT D and when CMT C told him/her to cover his/her mouth, the resident ran towards him/her and the staff had to pull the resident off him/her. All of the staff (CMT C, CMT D, CNA E, CNA F and CNA G) who were present wrote statements indicating this is what happened. He/She did not interview the staff individually about what happened, just asked them to write out statements. He/She placed the statements in the nursing office. He/She was off the next two days and when he/she returned, the statements had been removed from his/her office. The resident had never physically assaulted anyone before, but there were certain staff he/she did not like. He/She did not like CMT C, because he/she often had to redirect him/her, and the resident did not like that. The resident told the nurse he/she did not want to be there with CMT C anymore.
Review of the facility's investigation provided on 6/9/24, showed:
-Five written statements by CMT C, CMT D, CNA E, CNA F and CNA G;
-No documentation of any interviews done with residents.
Review of a written statement by CMT C dated 6/6/25, showed the resident walked behind him/her and CMT D, and the resident coughed. CMT C told the resident to cover his/her mouth, and the resident turned around and charged CMT C, attacking him/her.
During an interview on 6/9/25 at 1:55 P.M., CMT C said he/she and CMT D were at the nurse's station and the resident walked by and coughed on CMT D's neck. CMT C told the resident to cover his/her mouth. The resident does not like CMT C and always has an attitude. CMT C asked him/her why he/she coughed on CMT D, and the resident became enraged, rushed towards CMT C and grabbed his/her arms. CMT C started struggling, trying to get free and grabbed at the resident trying to get loose. CMT D, CNA E, CNA F and CNA G pulled the resident back away from him/her, but the resident kept trying to attack him/her. CMT C never struck the resident, and he/she did not fall to the ground. CMT C usually just ignored the resident's behavior when he/she got angry. CMT C wrote a statement about what happened the night of the incident.
Review of a written statement by CMT D dated 6/6/25, showed the resident walked behind him/her and coughed on his/her neck. CMT C told the resident to cover his/her mouth, and then the resident charged at CMT C while CMT D, CNA E, CNA F and CNA G tried to get him/her off the CMT.
During an interview on 6/6/25 at 1:45 P.M., CMT D said the incident started because the resident walked by and coughed on him/her. CMT C let the resident know not to do that, and the resident got really aggressive and they had to restrain him/her. The resident got angry so fast. It was out of nowhere. The resident charged at CMT C, and CNA E, CNA F, CNA G, and CMT D had to restrain him/her. CMT C grabbed the resident's arms to try and prevent him/her from hitting him/her. CMT D wrote a statement the night it happened.
Review of a written statement by CNA G dated 6/6/25, showed CMT C was talking to CMT D, and the resident walked by and coughed on CMT D's neck. CMT C asked the resident why he/she coughed on CMT D's neck. That is when the resident walked towards CMT C. CMT C told the resident not to get up in his/her face and then the resident pushed CMT C and called him/her a bitch.
During interviews on 6/9/25 at 2:20 P.M. and at 3:30 P.M., CNA G said he/she was in the dining room on the day of the incident and heard Resident #1 and CMT C yelling at each other. The resident had coughed on another staff member's neck, and CMT C asked the resident why he/she coughed on his/her neck. CMT C told the resident he/she could not believe he/she coughed on his/her neck. CNA G thought they were joking at first, but then the resident got angry and walked towards the CMT. CMT C told the resident not to walk up on him/her, and then the resident charged at him/her. The resident fell and CNA E got him/her in a headlock. The resident was on the ground and CNA E had his/her arm around his/her neck. CNA F grabbed CMT C and attempted to pull him/her away from the resident. CNA G yelled at CNA E to let the resident go and helped him/her up from the ground. The resident was bleeding from his/her neck and hand. CNA G took the resident into the dining room and tried to get him/her to eat dinner. The resident was very upset and asked if he/she saw what happened. CNA G wrote the statement about the staff member being attacked because he/she was afraid he/she would lose his/her job.
Review of a written statement by CNA E dated 6/6/25, showed he/she heard CMT C ask Resident #1 to cover his/her mouth, and then the resident charged at the CMT. CMT D grabbed CMT C's neck until they could pry the resident's hands from his/her neck.
During interviews on 6/9/25 at 2:10 P.M. and on 6/11/25 at 8:50 A.M., CNA E said he/she was in the dining room on the night of the incident at the back of the room and did not see what started the problem. He/She heard Resident #1 and CMT C yelling at each other about the resident covering his/her mouth. CNA E was passing out trays and could not run out immediately. He/She got there at the end of the incident, and no one was on the floor. CMT D, CNA E, CNA F and CNA G were standing between the resident and CMT C. The resident was up against the wall. It was chaos and everybody was everywhere. The resident did allege the staff jumped on him after the incident, but CNA E did not report it because he/she believed it was from restraining the resident to prevent him/her from assaulting CMT C.
Review of a written statement by CNA F dated 6/6/25 and provided by the DON on 6/9/25, showed the resident walked by CMT C and CMT D and coughed on CMT D's neck. CMT C asked the resident why he/she would do that and to cover his/her mouth. The resident then got mad and charged at CMT C. CNA F and CMT D, CNA E and CNA G had to get the resident off CMT C.
During interviews on 6/9/25 at 2:05 P.M., and on 6/11/25 at 8:15 A.M., CNA F said he/she was in the dining room serving trays on the night of the incident. Resident #1 walked by the nurse's station and he/she playfully coughed on CMT D, and CMT C turned around and started yelling at him/her. CMT C told the resident he/she was nasty. They started arguing back and forth, and then the resident threatened to hit him/her. CMT C said he/she wished the resident would hit him/her. The resident then walked closer to the CMT and he/she pointed his/her finger in the resident's face and said, You better get the f**k out of my face. The resident stepped closer, and then CMT C pushed the resident back. The resident pushed the CMT, and then CMT C started swinging at the resident. CMT C was hitting the resident around the face and neck, and the resident was pushed back against the wall. CNA E got behind the resident and attempted to pull him/her away from the CMT, and he/she fell on him/her. CNA F was trying to pull CMT C away from the resident and was telling him/her it was not worth losing his/her job. CMT C continued to yell, I told your ass and tried to swing on the resident again while he/she was on the ground. They were finally able to get the CMT away from the resident and behind the nurse's station. The resident was bleeding from wounds on his/her face and neck. CNA F wrote two statements. The first one was the night of the incident. RN J came in and told all of the staff to write statements about what they witnessed. This was done in front of all of the staff, and CNA F did not feel comfortable writing one. The nurse told CNA F the resident attacked the staff, and the staff restrained him/her to protect the CMT and asked if that is what he/she witnessed. CNA told him/her that is not what happened, but the nurse expected him/her to write that. The nurse read everyone's statement out loud to ensure they all matched up and then left. CNA F thought about it overnight and then called the DON the next day to tell her what really happened and he/she wanted to change his/her statement. The DON came to the facility on 6/7/25, and CNA F gave the DON a new statement and told her CMT C had assaulted the resident. The DON told CNA F since they were past the time to report the incident, it would look bad if the CNA changed his/her story, and he/she would be perceived as a liar. The DON told CNA F they were going to go with the original statements, and she would be back in on 6/9/25 to further investigate the incident. CNA F had a copy of the second statement and had recorded the conversation between him/her and the DON.
Review of the second written statement by CNA F dated 6/7/25 sent to DHSS on 6/11/25 at 8:32 A.M., showed he/she and CNA E were in the dining room the night of the incident passing trays for dinner. Resident #1 walked by CMT C and CMT D and playfully coughed on CMT D. CMT C told the resident he/she was nasty and why would he/she do that. The resident started getting agitated and they began arguing back and forth. The resident told CMT C he/she would hit him/her and the CMT told the resident he/she wished he/she would hit him/her. The resident walked up to CMT C, and CMT C said, You better get the f**k out of my face and pushed the resident. The resident pushed the CMT back, and he/she started swinging on the resident and grabbed him/her down to the floor. CMT D, CNA E and CNA F tried to break up the fight. CNA E got the resident away from the CMT, and CNA F pulled CMT C away. CMT C kept yelling I told your ass! They got the resident to calm down, but he/she would get agitated again every time he/she saw CMT C. RN J called and said he/she was on his/her way back to the building and wanted statements. CNA E felt coerced to write the statement the RN told him/her to write. The resident had visible scratches on both sides of his/her neck.
Review of a taped conversation on 6/7/25 between the DON and CNA F, sent to DHSS on 6/11/25 at 8:35 A.M., showed:
-CNA reported the resident was in front of the nurse's station on the night of the incident. He/She was in a playful mood and acted like he/she was going to cough on CMT D;
-CMT C started to yell at the resident saying he/she saw what he/she did, and it was nasty;
-The resident argued he/she had not done this, but CMT C kept saying he/she did, and the resident started to get agitated;
-The resident and the CMT had words earlier in the day when the resident thought he/she had taken his/her cereal;
-The CMT's behavior was nothing new to anyone. He/She has a personal problem with the resident and does not like working with the resident;
-The resident told CMT C he/she would hit him/her, and he/she told the resident he/she wished he/she would hit him/her;
-The resident was on his/her way to the dining room and turned around and came back when the CMT said this to him/her;
-CMT C pointed his/her finger in the resident's face and said, You better get the f**k out of my face'
-The resident took another step closer to CMT C, and CMT C pushed the resident back;
-The resident then pushed CMT C back;
-CMT C then started swinging at the resident and pushed him/her into the wall;
-CMT C was grabbing at the resident's clothes with one hand and swinging with the other;
-CMT C hit the resident on the side of his/her head. The resident was not swinging back;
-The resident fell to the ground;
-CNA F grabbed CMT C by the arms and tried to pull him/her back away from the resident while another staff member was trying to get the resident away. CNA E attempted to pull the resident away and the resident fell on him/her;
-CMT C continued to try and swing on the resident while he/she was on the floor and yelled, I told you not to get in my face;
-The resident was on the ground screaming, This is going to be a lawsuit;
-The staff were finally able to get the CMT to go behind the nurse's station and the resident to the dining room;
-Another staff member told CNA F, the nurse was on his/her way back into the building to take their statements;
-CNA F did not want to get involved because all of the staff are close out there and the nurse asked him/her to write the statement out in front of all the other staff;
-The nurse told him/her it sounded like the resident charged at the CMT and the staff had to pull him/her off and did the CNA agree with that statement. Since this was being said in front of everyone the CNA agreed to write the statement. He/She did tell the nurse that he/she did not agree with what they were writing because they all knew the resident did not charge at the staff member. He/She felt coerced into writing the statement. He/She had written a new statement about what really happened and wanted to turn it in;
-The DON said the problem was everyone turned in statements that got reported to him/her as the resident assaulted the staff member. The regulations said when there was an allegation of abuse, the facility was supposed to report it. If this was not done, the facility would get cited;
-Since CNA F's statement was conflicting with the other statements it would look as if he/she lied when it was investigated. If they found out the other staff wrote out false statements then all of the staff would look like they lied. The DON did not want to turn this into a staff versus staff problem. If the resident told staff six people jumped on him/her, then it looked like they had six liars down there. Since the time had passed to report the abuse allegation, the original statements were going to stand;
-The DON would come in on 6/9/25 and do a more thorough investigation.
During an interview on 6/9/25 at 2:50 P.M., CNA I said he/she was not working the night of the incident, but came in the next morning and heard CNA F and CNA H talking about the resident getting jumped on by staff the night before. The resident had visible scratches on both sides of his/her neck and told CNA I they hurt. He/She did not report this to anyone, because he/she thought they already knew about it.
During an interview on 6/9/25 at 4:30 P.M., CNA H said when he/she came to work on 6/7/25, CNA F told him/her the resident had been jumped on by staff the night before. He/She did not report it, because he/she did not witness it and thought CNA F reported it.
During interviews on 6/9/25 at 1:00 P.M. and on 6/11/25 at 11:35 A.M., the DON said she received a call on 6/6/25 around 5:00 P.M. from RN J stating Resident #1 had assaulted CMT C and she directed RN J to return to the facility to take statements from the staff. The staff told the DON the resident became agitated at CMT C after he/she asked him/her not to cough on another staff member and charged at him/her. Staff had to restrain the resident so the CMT could get to safety. The DON removed the CMT as he/she was a trigger for the resident and asked him/her not to return until 6/9/25 so the DON could investigate the incident further. The DON planned to come back in to the facility on 6/7 and start an investigation. The DON told the staff to keep an eye on the resident. The DON returned to the facility on 6/7/25 after receiving calls from staff who were looking for a particular outcome and were trying to influence the resident. The DON assessed the resident and did not see any injuries. The resident did not allege he/she was abused. The DON did not specifically ask the resident if he/she was assaulted because he/she did not want to put that thought in his/her head. There was a certain employee who was trying to get the resident to claim he/she was assaulted and this was confusing to him/her and he/she did not understand what was happening. The first night the resident told staff he/she was jumped by six staff members. The DON thought the resident was just confused from being restrained by the staff members. The DON would have expected the staff to document these allegations so they could have been investigated. The DON ensured a referral for a psychiatric evaluation was made for the resident and his/her physician was contacted to get an order for an as needed (PRN) medication in case he/she got agitated again. The DON knew the resident did not like the CMT, but believed it was because the CMT brought in food for the residents who behaved well, and he/she often did not get the food, and it made him/her angry. The DON did not remove the staff member from the unit prior to the incident because he/she believed the resident just did not like being redirected. No one told the DON the CMT had expressed he/she did not like the resident. RN J told the DON the witness statements verified the resident attacked the staff member. The DON suspended CMT C because he/she admitted calling the resident nasty and this was not an appropriate reply, until she could meet with him/her on 6/9/25 to discuss appropriate behavioral responses. No one told the DON the resident was alleging he/she was abused or they witnessed the resident being abused. If they had notified her about this, she would have immediately started an investigation and reported the allegations.
During interviews on 6/9/25 at 5:30 P.M. and on 6/11/25 at 3:00 P.M., the Administrator said he is the abuse/neglect coordinator and staff, residents or family can report allegations to him at anytime. He expects staff to report all allegations of abuse immediately. The DON notified him of the incident on the night it happened. He was told the resident attempted to assault the staff member. The incident was witnessed and all of the staff statements showed the resident was the aggressor, and the staff tried to deescalate the situation. If the staff had reported the resident alleged he/she was abused they would have immediately started an investigation and called the police. He expected the staff to report exactly what happened, and anyone who failed to report would be suspended or fired. The DON told him the resident had been assessed and had no injuries. He did not know why the DON did not investigate the allegations and report them the night it happened or when the staff member reported them to her the next day. He did not know the staff member wrote a second statement. The DON should have provided the statement to him. The DON should have immediately notified him of the allegations and started an immediate investigation.
MO00255497
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 F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to provide necessary medications as ordered by the physician for one of seven sampled residents (Resident #5). The facility failed to provide ...
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Based on interview and record review, the facility failed to provide necessary medications as ordered by the physician for one of seven sampled residents (Resident #5). The facility failed to provide twice daily anti-seizure medication to the resident nine out of ten times over a five-day period. Facility staff also failed to notify nursing management and the physician of the medication errors. The facility census was 158.
1. Review of the Facility's Medication Administration Policy, revised 9/1/22, showed:
-Medication carts should be stocked with adequate supplies of medications;
-If expired medications are noted and cannot be administered, the nurse manager should be notified;
-Any adverse side effects or refusals of medications should be documented and reported;
-Discrepancies with orders or supplies of medication should be corrected and reported to the nurse manager.
Review of the Facility's e-kit (Emergency Kit, a standard stock of commonly prescribed life-saving medications to be used in an emergency situation) Inventory on 6/12/25, showed:
-A minimum of four tablets of Levetiracetam (an anticonvulsant medication used to treat seizures and epilepsy, commonly known as Keppra) 250 milligrams (mg) are always kept on hand in the e-kit for emergency situations, and the e-kit will hold a maximum of eight tablets of Levetiracetam 250 mg for emergency situations.
Review of Resident #5's facility medical record, showed:
-An admission date of 6/23/22;
-Medical diagnoses included diabetes, history of stroke, and Moyamoya Disease (a rare disorder causing the blood vessels to the base of the brain to become narrowed and reduce blood flow);
-An active physician order dated 10/14/22 for Levetiracetam 500 mg tablets to be given twice daily;
-Progress notes entered on 6/1/25 at 8:28 A.M. and 9:08 P.M., showed the resident's Levetiracetam was not given as the medication was on order and not available to staff. The note did not indicate the resident's physician or the Director of Nursing (DON) was made aware of the missed medication;
-Progress notes entered on 6/3/25 at 11:46 A.M. and 7:32 P.M., showed the resident's Levetiracetam was not given as the medication was on order and not available to staff. The note did not indicate the resident's physician or the DON was made aware of the missed medication;
-Progress notes entered on 6/4/25 at 9:33 A.M. and 8:19 P.M., showed the resident's Levetiracetam was not given as the medication was on order and not available to staff. The note did not indicate the resident's physician or the DON was made aware of the missed medication;
-Progress notes entered on 6/5/25 at 8:32 A.M. and 8:19 P.M., showed the resident's Levetiracetam was not given as the medication was on order and not available to staff. The note did not indicate the resident's physician or the DON was made aware of the missed medication.
Review of the resident's medication administration record for June 2025, showed only one dose of Levetiracetam administered to the resident between 6/1/25 and 6/5/25, resulting in a total of nine out of 10 doses not administered to the resident as ordered.
During an interview on 6/11/25 at 8:53 A.M., the resident said last week he/she had gone without seizure medication for almost a week, and during that time the resident was fearful that he/she would have another seizure. The resident was newly diagnosed with a seizure disorder that led to a heart attack, and worries often that he/she will have another seizure that he/she won't live through. The resident asked for the medication multiple times from 6/1/25 to 6/5/25 and was given various reasons why it was not available, including pharmacy delivery delays and staff inability to obtain the medication.
During an interview on 6/11/25 at 10:58 A.M., the resident's family member said he/she had been notified of the first missing dose of the resident's seizure medication on 6/1/25 by the resident and called the facility to see what was being done to rectify this. The family member was told by facility staff that they were working on it, but was not given any specifics. The facility did not provide the resident his/her necessary seizure medication until 6/6/25, and the family member was never given a reason why the resident went without the medication for almost ten doses in a row.
During an interview on 6/11/25 at 12:10 P.M., Pharmacist T, a representative of the facility's pharmacy partner, said the last delivery made to the facility was on 5/21/25, when a 30-day supply of the resident's needed seizure medication Levetiracetam was sent to the facility. The facility then sent a request for delivery of the medication on 6/6/25 and reported the medication had been missing. The pharmacy obtained approval for delivery of the missing medication and delivered the medication to the facility the same day, as the medication is high-priority for the resident's condition. It is important for the resident to take this on a routine, consistent basis in order to prevent further seizure-like activity.
During interview on 6/11/25 at 12:21 P.M. Licensed Practical Nurse (LPN) U said he/she had heard the resident had gone without seizure medication for a few days. LPN U said staff are expected to immediately re-order necessary medications like Keppra if noted missing or unable to be found, and the facility's e-kit does have a small supply of Keppra on hand for emergency situations like this. The e-kit is accessible by any member of the nursing staff at the facility.
During interview on 6/11/25 at 3:21 P.M., Regional Nurse Consultants (RNC) V and W said they would expect staff to immediately re-order necessary medications and to notify the Director of Nursing once noted to be missing. Potentially life-saving medications like Keppra are kept in the facility's e-kit and should be used in the event the medication cannot be located or re-ordered in a timely manner. RNC V and RNC W would expect staff to check the e-kit for the medication and to use the e-kit supply until the necessary medication is located or delivered to the facility. All residents in the facility should be administered medications timely and as ordered by the physician to reduce the negative impact of each resident's unique medical condition.
MO00255283
Apr 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were free from significant medication...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were free from significant medication errors. The facility failed to ensure one resident's medication dose for Depakote (divalproex sodium, medication used to treat seizures and mood disorders) was entered correctly from the hospital after admission to the facility (Resident #3). This failure resulted in the resident receiving a lower dose of the medication for six days. The facility also failed to follow manufacturer and pharmacy recommendations and crushed a medication prior to administration for two residents (Resident #5 and Resident #1). One of the residents was hospitalized and found to have a low therapeutic level of the medication (Resident #1). The sample was 6. The census was 158.
Review of the facility's Medication Administration policy, revised 9/1/22, included:
-Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.
-Policy Explanation and Compliance Guidelines:
-Keep medication cart clean, organized, and stocked with adequate supplies;
-Cover and date fluids and food;
-Identify resident by photo in the Medication Administration Record (MAR);
-Wash hands prior to administering medication per facility protocol and product;
-Knock or announce presence;
-Explain purpose of visit;
-Provide privacy;
-Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters;
-Position resident to accommodate administration of medication;
-Review MAR to identify medication to be administered;
-Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time;
-Refer to drug reference material if unfamiliar with the medication, including its mechanism of action or common side effects;
-Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician;
-If other than PO route, administer in accordance with facility policy for the relevant route of administration (i.e., injection, eye, ear, rectal, etc.);
-Identify expiration date. If expired, notify nurse manager;
-Remove medication from source, taking care not to touch medication with bare hand;
-Administer medication as ordered in accordance with manufacturer specifications;
-Provide appropriate amount of food and fluid;
-Shake well to mix suspensions;
-Crush medications as ordered. Do not crush medications with do not crush instructions;
-Observe resident consumption of medication;
-Wash hands using facility protocol and product;
-Sign MAR after administered. For those medications requiring vital signs, record the vital signs onto the MAR;
-If medication is a controlled substance, sign narcotic book;
-Report and document any adverse side effects or refusals;
-Correct any discrepancies and report to nurse manager.
1. Review of Resident #3's medical record showed:
-admission date 4/11/25;
-Diagnoses included Alzheimer's disease, high blood pressure and insomnia.
Review of the resident's hospital discharge medications, dated 4/11/25, showed:
-Divalproex DR (Depakote delayed release) tablet 250 milligram (mg), Oral, three times a day;
-Last received 4/11/25 at 2:02 P.M.
Review of the resident's medical record, showed a progress note, dated 4/11/25 at 11:45 P.M., Resident arrived via family car accompanied by family. Resident ambulated independently to room. Resident alert and oriented to self. Speech is clear but conversation is confused at times. Resident can be redirected easily. Resident taken to room and introduced to staff. Resident offered a meal or snack but refused, stating he/she was not hungry. Skin assessment performed. No open areas noted. Has multiple old healing bruises to bilateral arms and chest. Denies pain. Nurse Practitioner (NP) notified and orders verified with no new orders (NNO) at this time.
Review of the resident's electronic Physician Order Sheet (ePOS), showed:
-An order dated, 4/11/25, Divalproex Sodium Tablet Delayed Release 125 mg. Give 1 tablet by mouth three times a day related to Alzheimer's disease.
Review of the provider progress note, dated 4/14/25, showed Divalproex Sodium Tablet Delayed Release 125 mg. One tablet by mouth three times a day. Give 1 tablet by mouth three times a day related to Alzheimer's disease.
Review of the resident's 4/2025, MAR, on 4/16/25 at 11:30 A.M., showed:
-Divalproex Sodium Tablet Delayed Release 125 mg. Give one tablet by mouth three times a day related to Alzheimer's disease;
-Medication marked as given at 7:30 A.M., 12:00 P.M., and 7:30 P.M. on 4/12/25, 4/13/25, 4/14/25 and 4/15/25;
-Medication marked as given on 4/16/25 at 7:30 A.M.
Observation on 4/16/25 at 9:25 A.M , showed Certified Medication Technician (CMT) A at the medication cart. CMT A popped the resident's morning medication, including Divalproex 125 mg, crushed the medication and proceeded to the dining room. The resident swallowed his/her medications with a sip of water. The resident's Divalproex 125 mg was verified as a delayed release tablet. A sticker was observed on the medication card that showed, do not crush.
During an interview on 4/16/25 at 12:05 P.M., Registered Nurse (RN) B said when a resident is admitted or readmitted to the facility, their discharge orders should be checked and verified with the physician and psychiatrist if necessary. The nurse cannot change what is on the discharge orders versus the verified orders. If the progress notes state orders verified with physician, then nothing should be different from hospital orders. If something is changed, then there should be a note in the medical record. RN B verified that orders for the Depakote dosage entered in the ePOS for the resident did not match the discharge orders for the Depakote dosage from the hospital.
During an interview on 4/16/25 at 12:55 P.M., the Director of Nursing (DON) said if a resident is admitted and the nurse charts NNO then she would expect the orders in the resident's ePOS to match the hospital orders. If the physician did not change the orders when the resident was admitted , then the nurse would document NNO. NNO means exactly how the hospital had it ordered.
2. Review of Resident #1's medical record, showed:
-admission: [DATE]
-discharge: [DATE]
-Diagnoses included transient cerebral ischemic attack (stroke), unspecified, other seizures, dementia, muscle weakness and cognitive communication deficit.
Review of the resident's hospital record prior to facility admission, showed;
-admitted [DATE] for seizure like activity with no history of seizures;
-Discharge to facility 3/21/25.
Review of the resident's medical record, showed:
-An order, dated 3/21/25, Divalproex Sodium Oral Tablet Delayed Release 125 mg (Divalproex Sodium) Give 1 tablet by mouth two times a day for seizures;
-An order, dated 3/21/25, May crush crushable meds, open caps and mix with a palatable substance (like applesauce) unless contraindicated AND may give as a cocktail unless contraindicated.
-An order, dated 4/14/25, May crush divalproex, per resident preference, open caps and mix with a palatable substance (like applesauce) unless contraindicated AND may give as a cocktail unless contraindicated.
Review of the resident's 4/2025 MAR, showed:
-Divalproex Sodium Tablet Delayed Release 125 mg. Give one tablet by mouth two times a day for seizures;
-Medication marked as given at 7:30 A.M. and 7:30 P.M. on 4/1/25, 4/2/25, 4/3/25, 4/4/25, 4/5/25, 4/6/25, 4/7/25 and 4/8/25.
Review of the progress note, dated 4/9/25 at 6:36 A.M., showed resident noted to be lethargic and difficult to arouse. Nonresponsive to verbal and physical stimuli. Oxygen saturation 78%. Resident on 4 liters (L) per nasal cannula applied. EMS called order from primary received to send out to hospital for evaluation.
Review of the hospital assessment and plan, dated 4/9/25, included:
-Breakthrough seizures. No compliance with Depakote (level low);
-Severe late onset Alzheimer with behavioral disturbances.
Review of the hospital progress note, showed resident presents to the emergency room by Emergency Medical Services (EMS) for seizure-like activity. Per the nursing home facility staff, they found the resident sitting up in bed staring off into the ceiling and not speaking. This lasted approximately 5-10 minutes. The resident had no convulsions. There was no injury or fall reported. At baseline the resident is oriented x1. When EMS arrived, the resident's blood pressure was 85/50 (low blood pressure is a reading lower than 90/60). In route, the resident was combative and agitated.
Review of the hospital progress note, showed patient recently hospitalized from 3/3-3/21 after presenting with seizure-like activity without any history of seizures. Reported that the resident was sitting on the floor shaking and yelling out, lasting a few minutes and patient more confused after and slowly back to his/her baseline mental function as per his/her family.
Review of the hospital medical record, showed Valproic Acid level (amount of Depakote in the blood stream ) 6.8 Low (Reference range 50.0-100.0 microgram (mcg)/milliliter (ml)).
Observation on 4/16/25 at 9:00 A.M., showed CMT A with the resident's Depakote medication card. Two tablets were left. Instructions show to take meds whole. A sticker is attached to the card that states do not crush.
During an interview on 4/16/25 at 9:15 A.M., CMT A said they don't have a do not crush list. The CMT checked the diet order and just knows the residents. If they refuse a lot or have a hard time swallowing, then they can crush and put in the pudding. The resident refused a lot so they might have crushed his/her medications. CMT A said they want them to take their medications and believed at one point he/she had to crush the resident's medications. Now all of the resident's medications are supposed to be crushed. The resident will not take any medications without crushing them and putting them in the pudding.
During an interview on 4/16/25 at 10:15 A.M., Registered Nurse (RN) B said the resident was combative/yelling when he/she went to the hospital. RN B was not on the unit when he/she left but was in the facility. The resident never had a seizure. He/She was able to eat food but would refuse medicine. RN B remembers nursing getting an order to crush Depakote. The physician gave the order to crush the resident's medications because he/she would refuse.
3. Review of Resident #5's medical record, showed his/her diagnoses include parkinsonism (a clinical syndrome characterized by the four motor symptoms found in Parkinson's disease: tremor, bradykinesia (slowed movements), rigidity, and postural instability), Alzheimer's Disease, bipolar disorder, schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), anxiety, depression and dementia.
Review of the resident's ePOS, showed:
-An order, dated 7/12/24, Regular texture, Regular/Thin Consistency;
-An order, dated 1/9/25, Divalproex Sodium Tablet Delayed Release 250 mg. Give 1 tablet by mouth three times a day related to schizoaffective disorder, bipolar type;
-An order, dated 4/11/25, Obtain valproic acid level. (Pending confirmation).
Review of the resident's 4/25 MAR, on 4/16/25 at 11:35 A.M., showed:
-Divalproex Sodium Tablet Delayed Release 125 mg. Give one tablet by mouth three times a day related to Alzheimer's Disease;
-Medication marked as given at 7:30 A.M. on 4/1/25, 4/2/25, 4/3/25, 4/4/25, 4/5/25, 4/6/25, 4/7/25, 4/8/25, 4/9/25, 4/10/25, 4/11/25, 4/12/25, 4/13/25, 4/14/25, 4/15/25 and 4/16/25;
-Medication marked as given at 2:00 P.M. on 4/1/25, 4/2/25, 4/3/25, 4/4/25, 4/5/25, 4/6/25, 4/7/25, 4/8/25, 4/9/25, 4/10/25, 4/11/25, 4/12/25, 4/13/25, 4/14/25 and 4/15/25;
-Medication marked as given at 8:00 P.M. on 4/2/25, 4/3/25, 4/4/25, 4/5/25, 4/6/25, 4/7/25, 4/8/25, 4/9/25, 4/10/25, 4/11/25, 4/12/25, 4/13/25, 4/14/25 and 4/15/25;
-The dose for 4/1/25 at 8:00 P.M. is blank.
Observation and interview on 4/16/25 at 9:19 A.M., showed CMT A at the medication cart. The CMT said he/she crushes the resident's medications because of his/her diet. CMT A popped his/her medications and crushed them together, which included Depakote Delayed Release 250 mg. CMT A put the medications in a small medication cup of pudding and administered the medications to the resident.
Review of the Manufacturer instructions, Depakote safety Administration, undated, included:
-Depakote Tablets or Depakote ER Tablets should be swallowed whole and should not be crushed or chewed;
-Depakote Sprinkle Capsules (for seizures only) may be swallowed whole or opened and the contents sprinkled on soft food.
During an interview on 4/16/25 at 12:55 P.M., the DON said the pharmacy provides a rubric for crushed meds and it also tells them when they are passing meds on the Medication Administration Record (MAR) if it can be crushed. The DON said if the medication card says do not crush a medication, she expected staff to not crush unless they have a physician order to crush the medication. The risk of crushing a do not crush medication is inappropriate delivery of that medication. She expected them to get a one time crush order then get another order to change the delivery method or route for future doses. The DON said for Depakote, if the medication card says do not crush, she expected a one time order to crush the medication then should be changed to the released sprinkle capsule. For Resident #1, if the resident would have stayed with the facility, then would have gotten something else. There should be a one-time order and then another order to have the pharmacy change the type that can be crushed or sprinkled, like a capsule.
During an interview on 4/16/25 at 1:40 P.M., the Administrator said he expected staff to follow the policy if it goes with the physician orders and pharmacy recommendations. The Administrator said the reason Resident #1's valproic acid was low was because he/she was only on the medicine a short time and would not have had time to build up a high level. The amount of time the resident was on the medication is the reason the resident did not have a therapeutic level, not because the medication was less effective due to being crushed. The Administrator also said the resident was not sent out for seizures and was not on Depakote for seizures. The resident was on the medication for behaviors and was sent out because they thought he/she was having a stroke. The Administrator said they had a physician order to crush the medication.
During an interview on 4/16/25 at 3:05 P.M., the Pharmacist said it not preferable to crush Depakote in the delayed release form. You can get capsules that are easily pulled apart. The preferred way to do it is as a capsule for the Depakote. There is some time release to it which can be messed up if you crush the tablet. If a resident cannot take a whole pill, the best choice is a capsule or liquid. The physician should switch it to capsule instead of crushing the medication. When a medication that is not recommended to be crushed is crushed, there can be too much of the medication given at once. The other possible concern is the medication not lasting as long as it should in between doses. For example, if the medication is ordered to be given twice a day, it can decrease the effectiveness by an hour or two.
MO00252627
Jan 2025
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were treated with dignity and respect...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were treated with dignity and respect when one employee used profanity while using their personal cell phone and providing feeding assistance to one resident (Resident #1), and four residents reported issues with staff being on their phones while working (Residents #2, #3, #5 and #4). The census was 143.
Review of the facility's Professionalism - Customer Service policy, dated 9/1/21, showed:
-Policy: It is the policy of this facility to provide professional, courteous service to our customers. Every employee is accountable for conducting themselves in a professional manner at all times. This facility strives to create an environment where the resident always comes first;
-The facility is the resident's home and will be regarded as such. Each resident will be treated with compassion and respect at all times.
Review of the facility's Personal Cell Phones policy, undated, showed:
-Policy: It is the policy of this facility to provide quality care to our residents without interruption;
-Policy Explanation and Compliance Guidelines included:
-This facility prohibits employees from using personal cell phone for any reason, on the nursing units or in working areas of the facility;
-This includes calls, texts, social media or any other use of cell phones;
-Cell phones may be used by employees while on a scheduled break or in break areas only.
1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/16/24, showed:
-Severe cognitive impairment;
-Partial to moderate assistance required for eating;
-Diagnoses included dementia, malnutrition, and depression.
Review of the resident's care plan, in use at the time of survey, showed:
-Focus: Resident has an activities of daily living (ADL) self-care performance deficit related to failure to thrive, dementia, other abnormalities of gait and mobility, muscle weakness, and need for assistance with personal care;
-Interventions included partial to moderate with meals and staff assistance to the extended needed to accomplish task.
Observation on 12/27/24 at 9:55 A.M., showed the resident seated near the nurse's station, receiving feeding assistance from Certified Nurse Aide (CNA) A, who was seated next to the resident on his/her right side. Certified Medication Technician (CMT) B stood at a medication cart to the left side of the resident. CNA A had a cell phone in his/her lap. While providing feeding assistance to the resident, CNA A yelled out, The fuck I'm not! The statement could be heard from room [ROOM NUMBER], approximately 30 feet away. CMT B continued to stand at the medication cart and did not respond to CNA A.
During an attempted interview on 12/27/24 at approximately 10:48 A.M., the resident was unable to respond to questions.
During an interview on 12/27/24 at approximately 10:48 A.M., CNA A said he/she has worked with the facility for a year and a half. He/She knows he/she is not supposed to use profanity in front of residents. He/She was just on his/her personal cell phone talking to someone, and cussed in the heat of the moment. He/She knows he/she should not be on his/her cell phone while assisting the resident. It was not appropriate or respectful to be on his/her phone while assisting the resident.
During an interview on 12/27/24 at 10:01 A.M., CMT B said he/she wasn't paying attention when CNA A was providing feeding assistance to the resident, and he/she did not realize CNA A used profanity. It is inappropriate to use profanity in front of residents. It is inappropriate, unprofessional, and disrespectful for staff to be on their cell phones while providing assistance to residents.
2. Review of Resident #2's quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-Diagnoses included anxiety and depression.
During an interview on 12/27/24 at 10:03 A.M., the resident said some of the aides can be disrespectful. There are issues with aides being on their phones when they are supposed to be providing care.
3. Review of Resident #3's quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-Diagnoses included anxiety and depression.
During an interview on 12/27/24 at 10:11 A.M., the resident said some of the staff can be rude and disrespectful. Some of the staff cuss around the resident, but he/she just ignores it. Some of the staff are on their phones when providing care and it is rude.
4. Review of Resident #5's quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-Diagnoses included anxiety and depression.
During an interview on 12/27/24 at 10:22 A.M., the resident said he/she sees staff on their phones all the time and it is rude. Some of the staff get out of hand with it and are just always on their phones when they are working.
5. Review of Resident #4's annual MDS, dated [DATE], showed:
-Cognitively intact;
-Diagnoses included anxiety and depression.
During an interview on 12/27/24 at 10:52 A.M., the resident said he/she sees some aides on their phones all the time. Some of the staff wear earphones and don't even acknowledge residents when they have them in. He/She is tired of staff being on their phones when they are working.
6. During an interview on 12/27/24 at 11:53 A.M., Licensed Practical Nurse (LPN) C said staff should not use their personal cell phones while on the floor. If they need to use their phone, they should step off the floor. It is inappropriate for staff to be on their personal cell phone while providing care. It is inappropriate to curse in front of any resident. If staff witness a coworker using profanity in front of a resident, they should report it to the nurse and the nurse would correct the employee. Using profanity in front of residents is a dignity issue.
7. During an interview on 12/27/24 at 12:40 P.M., the Director of Nurses (DON) said it is inappropriate to use profanity in front of a resident. If an employee witnesses their coworker doing this, they should report it to the nurse. Using profanity in front of residents is a customer service issue. It is inappropriate for staff to be on their personal cell phones while providing care. Some staff use cell phones for charting, but personal cell phone use is not appropriate. In the event that an employee needs to make a personal call, they should notify other staff that they are going to step off the floor. The facility just did an in-service training with staff on personal cell phone use on 12/19/24.
Review of the facility's education sign-in sheet, dated 12/19/24, showed topics included customer service/cell phones. No documentation of CNA A in attendance for the education.
8. During an interview on 12/27/24 at 1:21 P.M., the Administrator said it is inappropriate for staff to be on their cell phones while assisting residents. Employees should not use profanity in front of residents. Customer service and cell phone use are covered during monthly staff meetings. Additional education is needed for the employee who used profanity and their cell phone while providing feeding assistance today. Staff will be in-serviced on cell phone use and customer service.
Review of the facility's list of active employees, provided 12/27/24, showed 170 staff employed by the facility.
Review of the facility's attendance record sign-in sheet, dated 12/27/24, showed subjects included cell phone use and customer service. 16 staff signed as in attendance.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to serve food that was palatable and ensure meal service tray temperatures were maintained to at least 120 degrees Fahrenheit (F)...
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Based on observation, interview and record review, the facility failed to serve food that was palatable and ensure meal service tray temperatures were maintained to at least 120 degrees Fahrenheit (F). Three of six residents complained that hot foods were served cold (Residents #13, #15 and #16). This deficient practice had the potential to affect all residents who ate their meals in their room. The census was 143.
During an interview on 1/9/25 at 10:27 A.M., Resident #13 said he/she eats in his/her room. The food is usually cold by the time he/she gets it. Staff will heat it up in the microwave if you ask.
During an interview on 1/9/25 at 11:19 A.M., Resident #15 and Resident #16 both said the food is improving. As far as food being warm when it is served, sometimes it's warm enough and sometimes it's not.
Observation on 1/13/25 at 12:30 P.M., showed dietary staff brought the tray cart (a warming cart that can be plugged in to keep the trays warm until ready to serve) and left it in the hall. The plates contained roasted chicken, a scoop of mashed potatoes and a scoop of spinach. Certified Nursing Assistant (CNA) H and another CNA pushed the cart down the hall, stopping at rooms to remove lunch trays to serve to residents. The last lunch tray was served at 12:41 P.M. At that time, the following food temperatures were obtained from a test tray on the cart. The mashed potatoes were 108 degrees F and the spinach was 105 degrees F.
Observation on 1/14/25 at 8:40 A.M., showed dietary staff brought the tray cart to the floor and left it sitting near the nurse's station. The Dietary Manager (DM) pushed the cart near the wall and plugged the cart in. A couple of minutes later two CNAs unplugged the cart and began pushing it down the hall, stopping at rooms to remove the trays and serve to the residents. The cart remained unplugged until the last tray was served at 8:53 A.M. At that time, the DM used his thermometer and checked the temperatures from a test tray. The omelet on the tray was 114 degrees F. The DM said the tray cart should be plugged in for the entire duration of serving the trays to keep the food temperatures at a minimum of 120 degrees F.
During an interview on 1/14/25 at 9:14 A.M., CNA H said no one had ever told him/her to keep the tray cart plugged in until all the trays had been served.
During an interview on 1/14/25 at 1:06 P.M., the Administrator said he would expect the heated tray cart to be kept plugged in until the last tray is served to keep the hot foods hot.
MO00243196
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
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to store and serve food in accordance with professional standards for food service safety by failing to date opened packages of food. The facili...
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Based on observation and interview, the facility failed to store and serve food in accordance with professional standards for food service safety by failing to date opened packages of food. The facility also failed to ensure dining room furniture was clean and free of roaches and failed to keep kitchen equipment clean when staff failed to clean the wells of a steam table used to serve resident's food. The sample size was 25. The census was 143.
Review of the facility's Food Safety Requirements, dated 9/1/21, showed:
Policy: Food will be stored, prepared, distributed and served in accordance with professional standards for food service safety;
Definitions:
-Food service: the process involved in actively serving food to the resident;
-Food service safety: refers to handling, preparing, and storing food in ways that prevent foodborne illness;
-Policy Explanation and Compliance Guidelines: Food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with delivery of the food to the resident. Elements of the process include the following:
-Preparation of food, including thawing, cooking, cooling, holding, and reheating;
-Equipment used in handling of food, including dishes, utensils, mixers, grinders, and other equipment that comes in contact with food;
-All equipment used in handling of food shall be cleaned and sanitized, and handled in a manner to prevent contamination;
-Staff shall follow facility procedures for dishwashing and cleaning fixed cooking equipment.
Review of the facility's policy section: Sanitation and Food Safety, titled Sanitation, reviewed 8/1/23, showed:
-Policy: The food service area shall be maintained in a clean and sanitary manner;
-Procedure: All kitchens, kitchen areas, and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies, and other insects.
Review of the facility's weekly cleaning schedule, showed:
-P.M. Cook:
-Clean and sanitize kitchen steamtable and prep area daily. Keep wells filled with clean water;
-Put away all supplies used for meal (seal/label/date);
-Clean outside of steamer;
-A.M. Cook:
-Clean and sanitize kitchen steamtable and prep area daily. Keep wells filled with clean water;
-Put away all supplies used for meal (seal/label/date);
-Clean outside of steamer;
-A.M. Aide:
-Opposite [NAME] Area: Clean and sanitize prep table and lower shelves. Return stock to storage areas, sealed, dated and labeled;
-Clean and sanitize 3rd floor kitchenette counters (interior and outside serving area);
-Clean/organize cabinets and drawers (Mondays);
-Clean/sanitize 3rd floor kitchenette steamtable. All wells and shelving/storage. Fill wells with clean water;
-P.M. Aide:
-Opposite [NAME] Area: Clean and sanitize prep table and lower shelves. Return stock to storage areas, sealed, dated and labeled;
-Clean and sanitize 3rd floor kitchenette counters (interior and outside serving area);
-Clean/sanitize 3rd floor kitchenette steamtable. All wells and shelving/storage. Fill wells with clean water.
1. Observation in the main kitchen on 1/13/25 at 10:15 A.M., showed:
-One opened packet of brown gravy wrapped in plastic wrap, without a date;
-One packet of opened bowtie pasta wrapped in plastic wrap, without a date;
-One packet of opened spaghetti noodles wrapped in plastic wrap, without a date.
2. Observation of the 3rd floor kitchenette and dining room on 1/9/25 at 12:00 P.M., showed a long cabinet with four working drawers and two sets of cabinet doors under the drawers. The following was observed:
-A drawer on the end of the cabinet contained three dead roaches and a box of opened silverware inside the drawer;
-A cabinet door on the end on the left side was opened and revealed approximately five bait traps inside, with more than ten dead roaches and a half a jug of water on the shelving. There were food crumbs on the bottom of the cabinet;
-Two cabinet doors in the middle were opened and revealed three dead roaches along with one brown roach egg sack, two small square black bait traps, various packets of condiments strewn about and dried brown stains of varying sizes on the bottom
During an interview on 1/9/25 at 12:00 P.M. A.M. [NAME] M said he/she didn't know there were dead roaches underneath the cabinets and/or in the drawers in the resident dining room area.
3. Observation of the 3rd floor kitchenette, 1/9/25 at 12:14 P.M. showed:
-Approximately ¼ inch to ½ inch of dirty frothy water with corn and other materials floating in the steam table wells;
-A.M. [NAME] M walked over to the sink and filled a plastic container with water several times and added the clean water to the dirty frothy water in the steam table wells. After which, he/she removed the foil paper from large pans containing the lunch meal and placed the pans inside the steam table wells.
During an interview on 1/9/25 at 12:14 P.M. A.M. [NAME] M said staff should have cleaned the steam table before he/she added the clean water and before the meal.
4. Observation and interview on 1/13/25 at 10:00 A.M., showed Dietary Aide (DA) L cleaning the 3rd floor kitchenette steam table. DA L said it was not his/her normal job but he/she had been asked to clean it. DA L said he/she didn't know there were dead roaches underneath the kitchenette cabinet. Observation showed he/she opened the cabinet doors and removed the condiment boxes to view the dead roaches. He/She began cleaning underneath the cabinet. DA L said staff were supposed to clean underneath the cabinets daily and weekly.
5. During an interview on 1/13/25 at 10:30 A.M., the Dietary Manager said the cooks were supposed to clean the steam tables every day. He told the cooks multiple times to clean the steam tables after every shift. He didn't know there were dead roaches in the kitchenette but said the DAs were supposed to clean it daily. He didn't know there were dead roaches in the dining room drawer but said housekeeping was responsible for cleaning that area. He said nursing staff left resident room trays there after the trays were collected, but they should bring the trays to the kitchen. He said that was probably why roaches were there. He expected the kitchenette steam table and dining area to be clean and free from roaches. He said whom ever opened and used dry goods were responsible to wrap, label, and date the items when it was put back into the storage area. He expected staff to do that.
6. During an interview on 1/13/25 at 11:34 A.M., the Administrator said dietary staff were responsible to clean the steam table, dining room cabinets, and label/date food. He expected staff to follow the facility's food storage, sanitation, and cleaning policy. He expected the facility would be clean.
MO00247072
MO00246491
Aug 2024
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to ensure prepared food items were served at a safe and appetizing temperature when the staff failed to maintain the internal tem...
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Based on observation, interview and record review, the facility failed to ensure prepared food items were served at a safe and appetizing temperature when the staff failed to maintain the internal temperatures of hot food items placed in hot holding at 135 degrees Fahrenheit (F) or higher to prevent the growth of food-borne pathogens and potential food-borne illness. This deficient practice had the potential to affect all residents who ate food from the facility's kitchen. The facility census was 138.
Review of the facility's Food Temperatures Policy, dated 9/1/21, copyright 2021, showed:
-Policy: It is the policy of this facility to record food temperatures daily to ensure food is at the proper serving temperature(s) before trays are assembled;
Definitions:
-Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety (TCS) Food means food that requires time/temperature control for safety to limit the growth of pathogens such as bacterial or viral organisms capable of causing disease;
Policy Explanation and Compliance Guidelines:
-Food temperatures will be checked on all items prepared in the dietary department;
-Hot foods will be held at 135 degrees F or greater;
-Potentially hazardous cold food temperatures will be kept at or below 41 degrees F;
-Measure and record the temperatures for each food product and milk at all meals. Record temperature on temperature log;
-When holding hot foods for service, food temperature should be measured when placing it on the steam table line;
-If the food temperature falls into an unsafe rang, immediately follow procedures for reheating previously cooked food;
-Potentially hazardous food that is cooked and cooled must be reheated so that all parts of the food reach an internal temperature of 165 degrees for at least 15 seconds before holding for hot service;
-No food will be served that does not meet the food code standard temperatures;
-Food temperatures will be verified using a thermometer which is both clean, sanitizes and calibrated to ensure accuracy.
Review of the facility menus dated 8/22/24 (Week 3, Day 8/22/24), showed the menus directed staff to provide the residents on regular diets with fish nuggets, hush puppies and green beans.
Observation on 8/22/24 at 12:30 P.M., showed staff removed trays from the insulated cart of food to serve the residents in the memory care dining room.
Observation on 8/22/24 at 1:11 P.M., of the internal temperature of the sample lunch tray, showed:
-Chocolate pudding: 72.1 degrees F;
-Hush puppy: 88.7 degrees F;
-Breaded/Fried fish: 106.8 degrees F;
-Green beans: 85.2 degrees F.
Review of the Tray Line Food Temperature Log on 8/22/24 at 2:42 P.M., showed no food temperatures were recorded for the lunch meal.
During an interview on 8/22/24 at 2 P.M., Resident #10 said the food was usually cold.
During an interview on 8/22/24 at 1:50 P.M., Resident #11 said the food was good, but it was not hot. It was warm.
During an interview on 8/22/24 at 2:42 P.M., the Dietary Manager said food temperatures were taken between 12:00 P.M. and 12:30 P.M. before going out to be served. Food was served from the steam table and was sent right out to the residents. He wanted more residents to come to the dining room to eat. He expected hot food to be hot and cold food to be cold and he expected staff to take and log the food temperatures.
During an interview on 8/22/24 at 4:15 P.M., the Administrator said he expected staff to take temperatures of the food before every meal. The insulated food carts were old and probably needed to be replaced. Food temperatures should be hot or cold enough to meet regulations.
MO00238158
MO00237880
Aug 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure residents were free from significant medication errors, when staff failed to administer one resident's diabetes medications for seve...
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Based on interview and record review, the facility failed to ensure residents were free from significant medication errors, when staff failed to administer one resident's diabetes medications for several days (Resident #2). The sample was 5. The census was 131.
The Administrator was notified on 8/2/24, of the past non-compliance which began on 7/21/24. The facility began an investigation, audited resident medications, reviewed all new admissions orders, interviewed staff and residents, had a meeting with the pharmacy, and in-serviced staff on following physician orders, the protocols when a medication is not available, and verifying medications for new admissions. The deficiency was corrected on 7/31/24.
Review of the facility's Medical Provider Order Policy, revised 4/7/22, showed:
-This facility shall use uniform guidelines for the ordering and following of medical provider orders;
-Policy Explanation and Compliance Guidelines:
-Medications and/or Treatments should be administered only upon the signed order of a person lawfully authorized to prescribe.
-Verbal orders should be received only by licensed nurses, or pharmacists, and confirmed in writing by the medical provider, on the next visit to the facility.
-Elements of the Medication and/or Treatment Order:
-Date and time the order is written.
-Resident's full name.
-Name of medication and/or treatment
-Dosage-strength of medication is included.
-Time or frequency of administration.
-Route of administration.
-Type/Formulation (if applicable).
-Hour of administration (if applicable).
-Diagnosis or indication for use.
-PRN (as needed) orders should also specify the condition, for which they are being administered, (e.g., as needed for sleep).
-Documentation of Medication and/or Treatment Orders:
-Each medication and/or treatment order should be documented with the date, time, and signature of the person receiving the order.
-If using electronic medication records, input the medication and/or treatment order according to the electronic health record (EHR) instructions and facility policy.
-Call, fax, or electronically transmit the medication and/or treatment order to the provider pharmacy.
-Validate newly prescribed medications and/or treatment is in the electronic Medication Administration Record (MAR)/Treatment Administration Record (TAR).
-When a new order changes the dosage of a previously prescribed medication, discontinue the order as per the electronic software instructions and retype the new order.
-Validate the new order is in the electronic MAR/TAR.
-Notify resident's sponsor/family of new medication order.
-Following of Medication and/or Treatment Orders:
-Medical provider Orders should be reviewed prior to administration of medication and/or treatment to validate the orders contains all required elements.
-Staff should follow all valid medical provider orders timely unless there is an emergency which would temporarily delay the implementation of the order.
Review of the facility's Medication Administration Policy, revised 9/1/22, showed:
-Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.
-Policy Explanation and Compliance Guidelines:
-Keep medication cart clean, organized, and stocked with adequate supplies.
-Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters.
-Review MAR to identify medication to be administered.
-Administer medication as ordered in accordance with manufacturer specifications.
-Sign MAR after administered. For those medications requiring vital signs, record the vital signs onto the MAR.
Review of Resident #2's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/15/24, showed:
-Cognitively intact;
-Diagnoses include diabetes, heart failure, acid reflux, thyroid disorder, asthma, anxiety, and depression.
Review of the resident's electronic Physician Order Sheet (ePOS), showed:
-An order dated 6/11/24-7/17/24, for Farxiga (A medication used to treat type 2 diabetes, it can also be used to treat heart failure and chronic kidney disease) Oral Tablet 10 milligram (mg). Give one tablet by mouth one time a day related to type 2 diabetes mellitus with diabetic chronic kidney disease.
-An order dated 6/12/24, for Trulicity (A medication used to treat type 2 diabetes) 0.75 mg/0.5 milliliter (ml) Solution pen-injector. Inject 0.5 ml subcutaneously one time a day every Saturday related to type 2 diabetes mellitus with diabetic chronic kidney disease.
Review of the resident's June 2024 MAR/TAR, showed:
-Farxiga Oral Tablet 10 mg. Give 1 tablet by mouth one time a day. Marked (9) Other/See progress notes on the following dates: 6/11 through 6/16, 6/18, 6/20, 6/22, and 6/23/24;
-Trulicity 0.75 mg/0.5 ml Solution pen-injector. Inject 0.5 ml subcutaneously one time a day every Saturday. Marked (9) Other/See progress notes on the following dates: 6/15, 6/22, and 6/29/24.
Review of the resident's July 2024 MAR/TAR showed:
-Farxiga Oral Tablet 10 mg. Give 1 tablet by mouth one time a day. Marked (9) Other/See progress notes on the following dates: 7/5/24;
-Trulicity 0.75 mg/0.5 ml Solution pen-injector. Inject 0.5 ml subcutaneously one time a day every Saturday. Marked (9) Other/See progress notes on the following dates: 7/6, 7/13, and 7/20/24.
Review of the progress notes showed:
-6/14/24 12:54 P.M., Spoke with pharmacy regarding resident's order for Farxiga, not administered on shift, cost paper sent via fax and forwarded to management for further evaluation. Physician made aware resident states he/she is not able to consume Metformin the alternative recommendation.
-No other progress note related to the Farxiga not being administered.
-No progress note related to the Trulicity not being administered.
During an interview on 8/1/24 at 12: 15 P.M., the Director of Nursing (DON) said she knows the facility messed up with the resident's Trulicity medication. The resident never got the medication. The DON said the resident was not diabetic though and was on it for weight loss not diabetes. She showed an email from the pharmacy dated 6/10/24. The DON said those emails come with an attachment to be sent back to the pharmacy with approval for the medication. The DON said the Assistant Director of Nursing (ADON) sent the approval but on 6/23/24, they got a second attempt email from the pharmacy. The DON replied for the pharmacy to dispense the medication on 6/25/24. The nurses were marking as unavailable and notified the doctor but were not informing the pharmacy or the DON. The nurse should have put the medication on hold until it was received and followed up on it with the doctor. The DON said she signed off on it so she thought it was here at the facility. She would expect them to notify her. The DON said she immediately started in-services. She also did individual education with all nurses involved. She set up a pharmacy meeting yesterday with the pharmacy liaison and pharmacy to prevent this from happening in the future.
During an interview on 8/2/24 at 4:15 P.M., the DON said the nurse that does the admission would be responsible for verifying orders with the physician. She talked to the admission nurse for the resident and the nurse said he/she verified all the admission orders with the physician. The physician also said the nurse called and verified the orders. The physician said he/she asked for a home medication list from the family but they never brought the list. The ADON is responsible to audit the admissions. The Farxiga is one of the medications she found during her medication audit that the pharmacy had approval for but did not deliver to the facility. The DON said that is why she had the meeting. They did not deliver after the medication was approved and then after they did deliver they were not dispensing correctly. The pharmacy was only sending out 3 day doses instead of the full card, that is why some doses were missed but some were given in June. She would have expected staff to let her know immediately the medication was not there. They should call the pharmacy and then notify the physician. The physician would give orders to hold that medication and/or give order for an alternative medication until the other one arrives. If it does not arrive when the pharmacy states or is not covered, then notify the DON so she can follow up with the pharmacy.
MO00239472
Jul 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
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure pre-admission screenings were completed timely and failed to incorporate the recommendations from the Pre-admission screening and re...
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Based on interview and record review, the facility failed to ensure pre-admission screenings were completed timely and failed to incorporate the recommendations from the Pre-admission screening and resident review (PASARR) Level II determination and the PASARR evaluation report for one of six sampled resident's (Resident #1's) plan of care. The census was 92.
Review of the facility's Resident Assessment-Coordination with PASARR Program policy, revised on 9/1/21, showed:
-This facility coordinates assessments with the PASARR program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receive care and services in the most integrated setting appropriate to their needs;
-All applicants to the facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening;
a. PASARR Level 1- initial pre-screening that is completed prior to admission;
-Positive Level I Screen - necessitates a PASARR Level II evaluation prior to admission;
b. PASARR Level II - a comprehensive evaluation by the appropriate state-designated authority (cannot be completed by the facility) that determines whether the individual has mental disorder (MD), intellectual disability (ID), or related condition, determines the appropriate setting for the individual and recommends any specialized services and/or rehabilitation services the individual needs;
-The facility will only admit individuals with a mental disorder or intellectual disability who the State mental health or intellectual disability authority has determined as appropriate for admission;
-The social services director shall be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority;
-Recommendations such as any specialized services from a PASARR Level II determination and/or PASARR evaluation report will be incorporated into the resident's assessment, care planning and transitions of care;
-Any Level II resident who experiences a significant change in status will be referred promptly to the state mental health or intellectual disability authority for additional resident review. Examples include:
*A resident who demonstrates increased behavioral,
psychiatric, or mood related symptoms;
*A resident with behavioral, psychiatric or mood related
symptoms that have not responded to ongoing treatment.
Review of the facility's Comprehensive Care Plan policy revised on 9/1/21, showed:
-It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment:
-Person centered care means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives;
-The comprehensive care plan will describe, at a minimum, the following:
-The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being;
-Any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment;
-Any specialized services or specialized rehabilitation services the nursing facility will provide as a result of PASARR recommendations;
-The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented as needed;
-The facility will document alternate methods for refusal of treatment and services and document such attempts in the clinical record, including discussions with the resident and/or resident representative.
Review of the Missouri Long-Term Care Information Update, dated 2/17/23, showed the following:
-With the recent announcement from the [NAME] House regarding the official end of the Public Health Emergency on May 11, 2023, the waiver that allowed nursing homes to admit new residents who have not received PASARR Level I screenings and Level II evaluations will terminate on May 11, 2023.
-That date is beyond the 60 day notice that Centers for Medicare and Medicaid Services (CMS) has previously said would be given to allow states to unwind any COVID related changes to their PASARR program. As such, CMS will expect states to resume the completion of PASARR activities prior to admission as of May 12, 2023.
-The PASARR process requires that all applicants admitting to Medicaid-certified nursing facilities be screened for possible serious mental disorders or intellectual disabilities and related conditions. This initial pre-screening is referred to as PASARR Level I, and is completed prior to admission to a nursing facility. A negative Level I screen permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. A positive Level 1 screen necessitates an in-depth evaluation of the individual by the state-designated authority, known as PASARR Level II, which must be conducted prior to admission to a nursing facility.
Review of Resident #1's medical record, showed:
-admission date of 5/30/24;
-Diagnoses of chronic kidney disease, diabetes, unspecified mood disorder, schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions), acute kidney failure, unspecified psychosis (mental disorder with symptoms that happen when a person is disconnected from reality and cognitive communication deficit).
Review of the PASARR Level I screening, referral completion date 5/30/24, showed the following:
-Does the individual have any area of impairment due to serious mental illness: Yes;
-Does the individual have a suspected diagnosis or history of an intellectual disability/related condition: Yes;
-admission date to nursing facility 5/30/24.
Review of the resident's PASARR/Level II Evaluation, dated 6/19/24, showed:
-Reason for nursing facility application, admission or continued stay:
-Assistance needed to completed activities of daily living (ADLs; eating, dressing, grooming, bathing, incontinence care);
-Assistance needed for transfers, ambulation, fall prevention;
-Behavioral difficulties and/or mental illness symptoms requiring 24 hr monitoring/management;
-List all documented historical and current psychiatric and intellectual disability/developmental disability diagnoses: Paranoid Schizophrenia;
-List all medical conditions that could exacerbate, mimic to be related to mental illness symptoms or be considered developmental disability related condition: Chronic kidney disease, high blood pressure and diabetes;
-Describe historical symptoms of behavioral symptoms indicating a psychiatric disorder: Hospital discharge summary: 5/29/24: Patient with intermittent tangential speech and reported history of schizophrenia and requested to see psychiatry. During current admission, there has been documentation he/she has been sexually inappropriate to female staff. He/She has been facetiming with people with other residents without their consents. On 6/10/24 he/she called the police after a misunderstanding regarding medication;
-Describe any previous psychiatric treatment: Resident has had multiple inpatient admissions;
-Describe previous medications used to treat mental illness including current or recent use of medications that could mask or mimic mental illness symptoms: Thorazine (antipsychotic - used to treat behavioral disorders)/Cymbalta (antidepressant - used to treat depression) -started while inpatient;
-Mental status examination: Unable or unwilling to participate;
-Affective behavioral observations: Unable to asses;
-Does the individual have a major mental disorder diagnosable under the Diagnostic and Statistical Manual of Mental Disorders including schizophrenic, mood, paranoid, panic or other severe anxiety disorder, other psychotic disorder or another mental disorder that may lead to a chronic disability: Yes: Schizophrenia;
-As a result of the previously indicated major mental disorder, has the individual experienced functional impairment which has substantially affected one or more major life activities (including ADLs or functioning in social, family and academic or vocational contexts) or would have caused functional impairment without the benefit of treatment or other support services? Yes: Adaptation to change: The individual has serious difficulty in adapting to typical changes in circumstances associated with work, school, family or social interactions; agitation, exacerbated signs and symptoms associated with the illness or withdrawal from situations; self-injurious, self-mutilation, suicidal; physical violence or threats, appetite disturbance, delusions, hallucinations, serious loss of interest, tearfulness, irritability or requires intervention by mental health or judicial system;
-Concentration, Persistence and Pace: The individual has serious difficulty in sustaining focused attention for long enough period to permit the completion of tasks commonly found in work settings or in work-like structured activities occurring in school or home settings; difficulties in concentration; inability to complete simple tasks within an established time period; makes frequent errors or requires assistance in the completion of these tasks, or has impairment of ADLs;
-As a result of the previously indicated major mental disorder, has the individual required intensive mental health services (more intensive than routine follow up care) provided by mental health professional to stabilize or maintain a person experiencing a significant disruption of their major mental disorder in the last two years? Yes: Psychiatric consultation of other services by mental health professionals, community mental health services, mental health the primary reason for nursing facility (NF) admission or continued stay;
-Is the level of support for ADLs and other identified needs such that the individual's total care needs could be met in a nursing facility? Yes;
-Could alternatives to nursing facility services be considered at this time: No; The resident was previously living at home and unable to take care of him/herself. He/She was noncompliant with medications and basic daily needs. He/She has a limited support system who is unable to ensure he/she is taking his/her medication and assist with his/her ADLs. He/She requires assistance with ADLs, medications administration and meal preparation. Also, while in the current skilled nursing facility, he/she has had sexually inappropriate behaviors which could put him/her at risk if alone in the community;
-The individual needs or continues to need the following supports and services:
-Provision of specific services to address the individual's mental health and behavioral needs;
-Monitoring of behavioral symptoms;
-Medication therapy and monitoring symptoms;
-Monitoring of therapeutic effects in managing mental health symptoms including labs as indicated;
-Provision of a structured environment:;
-Maintain environment with low stimulation;
-Provide instructions at the individual's level of understanding;
-Assess and plan for the level of supervision required to prevent harm to self or others;
-Provide for sensory supports;
-Provide schedule of daily tasks/activities;
-Implementation of ADL program to increase independence and self-determination:;
-Assess and plan a program for the development and maintenance of necessary living skills including:
-Grooming/dressing;
-Personal hygiene;
-Toileting/bowel/bladder;
-Bathing;
-Maintenance of own living environment;
-Development of personal supports:
-Assess and plan for meaningful socialization and recreational activities to diminish tendencies toward isolation, withdrawal, etc;
-Assess, plan and develop appropriate personal support network through community and social connections;
-Assess and plan for discharge, transition to less restrictive environment. The client will work with the facility to determine if the client is able to transition to a less restrictive environment.
Review of the resident's PASARR determination dated 6/21/24, showed:
-PASARR related disability: Yes;
-Specify: Does have serious mental illness;
-You indicated during the evaluation that you are interested in the possibility of returning to the community;
-The PASARR Level II Evaluation indicated the following supports and services are to be provided by the facility:
-Behavioral support plan;
-Structured environment;
-Personal support network;
-Medication therapy;
-ADL program.
Review of the resident's care plan, dated 6/26/24, showed:
-Focus: Resident wishes to stay here for long-term;
-Focus: Resident has a full code status;
-Focus: Resident requires assist with activities of daily living related to deconditioning;
-Interventions: Encourage resident to participate to the fullest extent possible with each interaction;
-Interventions: Encourage resident to use bell to call for assistance;
-Interventions: Resident requires supervision/set up assistance with self care and functional mobility;
-Interventions: Monitor for changes in status, notify interdisciplinary team as needed;
-Interventions: Requires supervision with walker/wheelchair mobility;
-Focus: Resident is physically and verbally aggressive towards staff and residents;
-Interventions: 6/26/24 - Emergency Medical Services (EMS)/police present; resident refused to be transported to the hospital for psychiatric evaluation;
-Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness;
-Interventions: Anticipate and meet the resident's needs;
-Interventions: Explain all procedures to the resident before starting and allow the resident time to process;
-Interventions: If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident;
-Focus: Resident is at risk for falls;
-Interventions: Anticipate and meet the resident's needs;
-Interventions: Be sure resident's call light is within reach and encourage the resident to use it for assistance when needed. The resident needs prompt response to all requests for assistance;
-Focus: The resident uses psychotropic medications related to schizophrenia;
-Interventions: Administer medications as ordered. Monitor for side effects and effectiveness;
-Interventions: Monitor/document/Report any adverse reactions;
-Focus: Resident has potential for impairment to skin;
-No documentation of a behavioral support plan until 6/26/24 after the resident's behavior escalated;
-No documentation of assessing and planning for meaningful socialization and recreational activities to diminish tendencies toward isolation, withdrawal, etc;
-No documentation of development of personal supports to prevent isolation in the community;
-No documentation of assessing, planning and developing appropriate personal support networks through community and social connections including community based psychiatric treatment and supports, behaviors supports/supervision and individual counseling and psychotherapy.
During an interview on 7/1/24 at 1:30 P.M., Licensed Practical Nurse (LPN) F said the resident was hard to work with because he/she was institutionalized. He/She had been in prison for so many years, he/she still acted like an inmate. He/She was very rigid in his/her thinking and would write everything down. If things did not go the way he/she wanted, he/she would get angry. He/She kept a meticulous room but wanted to drink water from the toilet because this is how he/she used to get water. The nurse had to sit down and educate him/her about infection control and tell him/her it was safe to get water from the pitcher. The resident would continually argue with the staff regarding the medication and wanted to know about each pill. The nurse would have to come to the unit and explain what each pill was before the resident would agree to take it. The resident did have a rapport with some of the staff. He/She was usually fine during the day, but they would start getting phone calls from the staff in the evenings. The resident would use profanity and call the staff out of their names. He/She was not very social and would isolate in the television room.
During an interview on 7/1/24 at 1:45 P.M., LPN K said the resident had different behavior on different shifts. He/She usually did not have a problem with the staff on his/her day shifts, but he/she had heard the resident had a problem on other shifts. Staff had not been given any direction on how to deal with his/her behavior, but he/she needed an understanding approach. The resident liked things a certain way, like his/her food, and if they were not done that way, there was going to be a problem. He/She liked attention and if the staff spent some time talking to him/her, the resident responded well to it.
During an interview on 7/1/24 at 2:10 PM, the Social Services Director said she makes the referral for the PASARR for the resident, and then they have a company who assesses the resident and determines whether he/she meets the qualifications. If he/she does, they list the services the facility will need to provide. It was hard to provide services to the resident because he/she would not talk to them or participate in any activities. She knew the resident had a long history of incarceration and trauma and this setting might be too confining for him/her. The Minimum Data Set (MDS) coordinator was the person who developed and added the information to the care plan. The services listed on the PASARR should have been in the care plan.
During an interview on 7/1/24 at 4:00 P.M., the MDS coordinator said she was responsible for completing the resident's care plan. She would have liked to have seen it be more detailed. She was aware of the resident's history of trauma and incarceration and knew he/she was screened for services on the PASARR II. She thought all of this information had been added to the care plan. It was an oversight on her part. She had only started working at the facility in March and was trying to get caught up on all of the care plans.
During interviews on 7/1/24 at 9:00 A.M. and at 5:15 P.M., the Administrator said the resident was screened for the PASARR services on 6/21/24 and he/she did not start displaying disruptive behaviors until 6/26/24. They added the behavior monitoring on 6/27/24. The resident was having behavioral problems before 6/27/24. He/She had called the sheriff's office and the Governor's office to report various grievances he/she felt were being perpetrated on him/her by staff. The staff would try to reason with him/her, but the resident continued to make baseless claims. These behaviors probably should have been added to the care plan, but everything happened so fast they were just trying to control the situation. The Administrator was aware the resident had been incarcerated for over 30 years, but he/she had not displayed any behaviors during the screening process and they were just trying to do the right thing for him/her.
MO00238156
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 F0740
(Tag F0740)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to provide necessary behavioral health care services for a resident's psychosocial well-being when staff did not address the resident's behavi...
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Based on interview and record review, the facility failed to provide necessary behavioral health care services for a resident's psychosocial well-being when staff did not address the resident's behaviors, which included verbal aggression, for one sampled resident (Resident #1) out of six sampled residents. The facility failed to inform staff how to handle the resident's escalating behaviors. The facility census was 92 residents.
Review of the facility's Comprehensive Care Plan policy revised on 9/1/21, showed:
-It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment:
-Person centered care means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives;
-The comprehensive care plan will describe, at a minimum, the following:
-The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being;
-Any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment;
-Any specialized services or specialized rehabilitation services the nursing facility will provide as a result of pre-admission screening and resident review (PASARR) recommendations;
-The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented as needed;
-The facility will document alternate methods for refusal of treatment and services and document such attempts in the clinical record, including discussions with the resident and/or resident representative.
Review of Resident #1's medical record, showed:
-admission date of 5/30/24;
-Diagnoses of chronic kidney disease, diabetes, unspecified mood disorder, schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions), acute kidney failure, unspecified psychosis (mental disorder with symptoms that happen when a person is disconnected from reality and cognitive communication deficit).
Review of the admission screening, effective 5/30/24, showed:
-admitted from hospital;
-Oriented to person, place, time and situation;
-Cognition: Intact;
-Mood/Behavior: Hallucinations;
Delusions;
Anxiety;
-Musculoskeletal: Wheelchair;
Walker;
-Medication review:
-Were there any of the following Clinically Significant
medication issues identified: No issues identified;
-High Risk Medications:
-Medication reconciliation has been completed with the medical profession in which any clinical significant medication issues have been identified and addressed;
-Psychotropic Medication:
-Focus: The resident uses psychotropic medications: Not checked;
-Goal: The resident will be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date: Not checked.
Review of the resident's psychosocial assessment, effective 5/30/24, showed:
-Adequate hearing and vision;
-Usually understood and understands others;
-Inattention-Behavior not present;
-Disorganized thinking-Behavior not present;
-Altered level of consciousness-Behavior not present;
-Was responsible staff or provider informed that there is a potential for resident self harm? - No;
-Behaviors: None of the above;
-Social service plan: Monitor for social service;
-Progress notes: Social services will follow up with any concerns.
Review of the resident's progress notes, showed:
-On 6/2/24 at 7:22 P.M., no inappropriate behaviors toward staff noted;
-On 6/7/24 at 3:51 P.M., the wound nurse informed social services staff, the resident was talking sexually inappropriately to the female nursing staff and facetiming with other residents without their consent. Staff educated him/her on talking sexually to the female nurses or residents. The staff also educated him/her on not having other residents on his/her facetime when talking to his/her family. The resident said he/she was sorry and would not do it again;
-On 6/10/24 at 5:30 P.M., staff redirected the resident after a misunderstanding over his/her medications. The resident called the police. The resident assured the police he/she was safe and did not feel any harm but wanted the sheriff. Staff notified his/her physician.
-On 6/26/24 at 12:10 A.M., staff notified the nurse the resident displayed agitation towards him/her. He/She jumped out of his/her wheelchair and lunged at him/her after he/she asked him/her to keep the noise level down. The nurse went down to talk to the resident regarding his/her agitation. The resident was upset, cursing and using racial slurs. The nurse attempted to redirect the resident and de-escalate the situation. The resident then became agitated and jumped out of his/her wheelchair and lunged towards the nurse. The nurse called 911. The resident also called 911 numerous times alleging he/she was abused, attacked, beat and spat on by the nurse and certified nurse's aide (CNA). The resident then sat on the floor near the nurse's station and stated, I am going to sit right here. I am not moving. They are gonna have to pick me up and move me. The police were present in the facility and spoke with the resident. The resident stated, I want them arrested. I was abused. I am injured and hurting all over. I want them arrested right now. The resident also called the nurse and CNA, Dogs, crack heads, things, monsters and whores. The police contacted ambulance services per the resident's request. The ambulance arrived at the facility and assessed the resident. He/She stated he/she did not want to go to the emergency room. The police and emergency medical technicians (EMTs) noted no injuries on the resident. The EMTs encouraged the resident to go to the hospital due to his/her elevated blood pressure and increased agitation. The resident continued to refuse to go. The nurse and floor two charge nurse encouraged the resident to stay on floor two for the night but the resident refused. The resident refused to sign a refusal to send to the emergency room (ER) by the EMTs. The police and EMTs left the facility. The resident sat at the nurse's station recording staff on his/her cellular phone. He/She continued to use derogatory names and racial slurs toward staff while recording with his/her phone. At 11:22 A.M., the resident became aggressive with CNAs, accusing them of spitting on them, then took out his/her phone and began to record staff members working with other residents. The resident stated he/she was going to post the video on social media. The nurse asked the resident not to record staff members and other surrounding residents in the hall but the resident continued to yell and curse at staff in a threatening manner. Staff heard a commotion a the desk on the three hall while passing medications to residents and came over to inquire what was going on. The resident was very aggressive, cursing and yelling. He/She was not easily redirected. The staff member asked him/her what was wrong and he/she stated the CNAs were calling him/her names. The staff member did not hear the CNAs respond to the resident at all, other than asking him/her not to record them. The resident continued to record the staff member. He/She asked the resident to please go to his/her room and close the door and after medication pass, he/she would come in and listen to the resident's side of the story. The resident failed to comply with this request and remained in the hallway, yelling and causing a disturbance which upset the residents. Staff asked the resident several times to calm down and go to his/her room, but he/she refused. The CNAs said they were calling the supervisor to inform him/her of the residents behavior. The supervisor came in the building to deal with the situation, which had escalated. At 10:18 P.M., the resident displayed behaviors this shift. The resident noted being verbally aggressive toward other residents. Resident called another resident a derogatory, racial slur. Resident also noted threatening other residents with physical violence. Resident noted verbalizing homicidal ideations towards staff. Resident stated, I got six, and counting. Resident continues to state he/she murdered six people and is looking for number seven. The resident then made physical contact with CNA/Certified Medication Technician (CMT) by using his/her arm to elbow, forcefully pushed him/her in the back as he/she walked past him/her. Staff contacted 911 due to the resident's unpredictable behavior. The resident refused to go to the hospital. The resident stated he/she is willing to sign him/herself out against medical advice (AMA) but will not go to the hospital. Emergency medical services (EMS) made the nurse aware they were unable to transport the resident at the time due to his/her mental status and refusal. EMS departed the building. The resident was now walking through the building with his/her cane attempting to provoke and intimidate staff and other residents. Staff contacted the Director of Nursing (DON) and made her aware;
-On 6/27/24 at 12:50 A.M., staff contacted the resident's physician and made him aware of the resident's behaviors. The physician sent a new order that staff may send the resident to the ER for a Psychiatric hold/evaluation due to physical and verbal aggression towards residents and staff.
During an interview on 7/1/24 at 3:00 P.M., CNA I said he/she came back from break on the morning of 6/26/24, and the resident was on the phone talking really loud. He/She was clapping his/her hands and talking very loudly, and the CNA was worried the resident would wake the other residents. The CNA asked the resident could he/she talk a little quieter, and the resident stood up from his/her wheelchair and started yelling at him/her. It really startled him/her because the resident had never gotten out of the wheelchair and walked for him/her before and they had a pretty good relationship before this. The resident was cursing at him/her and calling him/her a honky. The CNA started to get scared and walked away. Then the resident sat back down in his/her wheelchair and yelled he/she was going to call the police. The CNA walked off the hall and to the nurse's station around the corner to get away from the resident. The resident wheeled down to where he/she was sitting and continued to threaten him/her. He/She was accusing the CNA of hitting and spitting at him/her. When the police got there, the resident told them the CNA beat him/her all over his/her body. The nurse and the police checked out the resident and did not see any marks. He/She refused to go anywhere near him/her the rest of the night. The CNA had heard the resident called the police on other staff when he/she did not like what they did or said, but this is the first time he/she did it to him/her. No one told him/her what to do with the resident or how to handle his/her behavior. It happened so fast and was so scary. He/She could not get the resident to calm down. The next night, the CNA asked the nurse to check on him/her all night so he/she would not have to deal with him/her. The resident was always cursing people and calling them out of their names. No one told him/her how to manage or prevent these behaviors.
During an interview on 7/8/24 at 1:00 P.M., CNA C said he/she was working on the day the resident came onto the other hall to yell at CNA I. The resident was very agitated and he/she sat on the floor and said, Call the police. Try and get me off the floor. I am not going anywhere. The resident wanted the CNA locked up. This was the first time he/she saw the resident like that. Usually he/she was so calm and cool. He/She did not even know he/she could walk. The resident looked threatening and out of control. He/She did not calm down for a long time after the police and EMS staff left. No one gave the CNA any instructions on how to manage or prevent the resident's behaviors.
During an interview on 7/8/24 at 2:30 P.M., CNA J said he/she was working evenings on 6/26/24 and was walking with another CNA when the resident got off the elevator. The resident heard another CNA say something and immediately started yelling the CNA had said something about him/her. The resident pulled out his/her cell phone and started recording the staff at the nurse's station and backed CNA J into a corner. He/She asked the resident to back up so he/she would not be in the corner and he/she stood up from his/her wheelchair. The CNA immediately felt threatened as the resident refused to back up and continued to verbally curse at him/her. This frightened the CNA because he/she had never seen the resident walk before and he/she was so threatening. He/She tried to get past the resident but he/she blocked the way, so he/she called out to the nurse on the other hall. The resident then moved his/her wheelchair to the middle of the hallway and elbowed another CNA as he/she tried to walk past him/her. The CNA had never had a problem with the resident before but he/she heard the resident had problems with the staff the night before and had threatened the staff then too. He/She knew the resident cursed other staff, but the resident had never directed his/her anger at the CNA before. No one told him/her how to manage or prevent the resident's behaviors.
Review of a written statement by Nursing Supervisor G provided by the facility, dated 6/26/24, showed:
-He/She saw the resident calling another resident a derogatory racial slur and threatened he/she would Beat his/her ass;
-When another staff member tried to deescalate the situation, the resident became verbally aggressive towards him/her;
-The resident then began walking around the facility threatening staff and other residents saying, he/she killed six people and was looking for number seven;
-The resident then pushed a staff member forcefully in the back with his/her arm and elbow;
-The nursing supervisor called 911 due to the resident's unpredictable behavior and homicidal ideations;
-After EMS and the police left, the resident continued to ambulate around the facility attempting to provoke and intimidate staff and residents;
-The nursing supervisor was concerned about the safety of the staff and residents.
Review of the resident's care plan, dated 6/27/24, showed:
-Focus: The resident required assistance with Activities of Daily Living (ADL) related to deconditioning;
-Interventions: The resident requires supervision/set up assistance with self care and functional mobility;
-Interventions: Patient requires supervision with walker/wheelchair mobility;
-Focus: The resident is physically and verbally aggressive towards staff and residents;
-Interventions: 6/26 - EMS/Police present; Patient refused to be transported to the hospital for psych evaluation;
-Administer medications as ordered. Monitor/document for side effects and effectiveness;
-Anticipate and meet the resident's needs;
-Explain all procedures to the resident before starting and allow the resident time to process;
-If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident;
-Focus: The resident is on psychotropic medications;
-Interventions: Monitor/document/report any adverse reactions: Behavioral symptoms not usual to the person.
Review of the resident's progress notes, showed on 6/28/24 at 9:45 A.M., the resident reported to staff he/she was leaving the facility and finding somewhere else to go. The nurse approached the resident while he/she was signing out of the facility at the front door and asked if he/she was discharging or going on a leave of absence and returning to the facility today. The resident stated, I am leaving. I do not want to be here. I am going to walk until I find a hospital and check myself in. The resident was alert and oriented times four (person, place, time and situation) and independent with with his/her ADLs and his/her own responsible party. The nurse told the resident he/she was not being discharged by his/her physician at the time, but the resident continued to insist he/she was leaving the facility. The nurse then advised the resident if he/she was leaving and planing on not returning, he/she would be leaving against medical advice (AMA). The resident verbalized understanding at the time. The nurse offered the resident AMA documents to sign, but he/she refused stating he/she had already signed him/herself out. The nurse offered to arrange transportation to the hospital by calling an ambulance, and the resident refused stating he/she would find his/her own way. The resident then stood up behind the facility provided wheelchair with a steady gait and proceeded to ambulate out of the door and out of the driveway towards the road. Staff notified the resident's physician at this time of his/her departure. At 10:17 A.M., the facility received a call from an outside vendor stating they observed the resident ambulating in the street pushing a wheelchair down the road. At this time, the nurse called the police and requested a wellness check on the resident. At 3:19 P.M., the Administrator notified the Social Worker the resident went AMA and would not be returning back to the facility.
Review of the undated typed investigation from the facility, showed:
-A couple of days prior, the resident was in the lobby, banging his/her feet on the door of the business office trying to open it;
-The Receptionist asked the resident to stop and he/she began to curse and use racial slurs towards him/her;
-The Administrator attempted to intervene, but the resident refused to talk to him because he was a European Caucasian and a Cracker;
-The resident later wanted to file a grievance against the Receptionist for verbal abuse;
-The resident wanted to contact the sheriff but the Administrator was able to calm him/her down;
-The next day, the resident came to the Administrator's office with a camera and said he/she was going to record him and tell everyone he was not doing anything;
-The resident called the Governor's office and they hung up on him/her;
-The resident continued to accuse staff of abuse through the evening but would not say who;
-The resident was terrorizing staff threatening physical harm;
-Staff were afraid and called the police;
-The resident immediately calmed down when the police arrived and refused to go to the hospital;
-The next day, the resident told the Director of Nursing (DON) staff spit on him/her;
-Staff were instructed to keep distance to avoid allegations of spitting;
-At 1:00 A.M., the staff called administration crying saying the resident was threatening to murder people and the residents could hear;
-Staff instructed to call police if they felt threatened. Resident could be heard cussing and yelling in the background;
-The resident was calm when the police arrived and said staff were abusing him/her;
-The DON called the nursing supervisor who was crying hysterically after being threatened to be killed. The police were not doing anything, and he/she was having an anxiety attack;
-The Administrator and the DON talked to the police who refused to take the resident because he/she was not being aggressive at that time and was alleging the staff were being aggressive towards him/her;
-The police needed a signed affidavit for the hospital to take the resident against his/her will but the staff did not know about an affidavit and were afraid to sign anything;
-The police left without the resident;
-The DON met with the resident the next day and listened to all of his/her grievances. He/She began talking in circles. He/She has some psychiatric issues that need to be addressed. The DON asked if he/she felt safe. He/She felt like he/she was being evicted;
-Three staff said they are resigning because of the resident;
-As needed staff will not work with the resident;
-Other residents are afraid of the resident;
-The resident called the police three times this week;
-Trying to get psychiatry to do a consult as soon as possible;
-In-servicing staff on interacting with aggressive residents/behaviors;
-The resident's physician said staff can send the resident to the hospital but did not feel comfortable writing a hold because she had not witnessed the behavior;
-Think the behavior is intentional because he/she knows when to do it and when not to do it. Daytime easy to redirect. Nights going above and beyond. Staff are afraid.
Review of an email from the facility to the Department of Health and Senior Services on 6/28/24 at 12:24 P.M., showed:
-This morning at 9:45 A.M., the resident signed him/herself out on the resident sign out sheet and stated to the receptionist and Director of Nursing, he/she was not returning and was going to find a hospital and get checked out. The DON offered to assist him/her with a ride to the hospital and appropriate discharge planning and/or AMA paperwork. All were refused by the resident;
-Staff notified 911 so they can follow up with him/her and make sure he/she is safe;
-Staff notified the local Ombudsman as well;
-Staff observed 911 intervening with the resident on the road;
-The police came to the facility to gather more information and informed them the resident refused to come back to the facility or be taken to the hospital for EMS evaluation.
Review of hospital admission paperwork dated 7/1/24, showed:
-Patient was referred by Police Department and transported via EMS;
-Affidavit from Police Department showed:
-Police department dispatched to nursing home for resident leaving in his/her wheelchair;
-Since at the at the facility, the resident assaulted staff and showed erratic violent behavior;
-The resident told staff he/she was not returning to the facility but refused to sign the necessary forms to discharge him/her as a patient;
-The resident identified him/herself as a sovereign citizen and does not recognize police or EMS as authorities;
-The resident served a long incarceration and is still on parole;
-The resident refused assistance from the police and said he/she was walking to the hospital;
-From 10:00 A.M. - 3:00 P.M., the police received approximately 40 phone calls to check on his/her welfare;
-The resident refused to ride on the sidewalk and walked his/her wheelchair on the right side of the roadway;
-Around 3:00 P.M., he/she began walking down the middle of the roadway and was non-compliant;
-The resident said he/she would not use the sidewalk/trail as it was too close to houses and he/she would get shot;
-When the police attempted to speak with him/her, he/she held his/her hands in the air and said for the officer to shoot him/her;
-The resident was deemed a threat to him/herself because would not stop walking in the roadway causing vehicles to brake and swerve around him/her, so the police called for EMS;
-The resident threw him/herself down in the middle of the roadway and was properly restrained and placed on the EMS stretcher;
-He/She was sweaty and overheated as he/she was wearing a long sleeved shirt and sweat pants in 90 degree weather;
-He/She walked for five hours;
-Based on the resident's psychiatric history and refusing to get out of the roadway, the police sought an involuntary admit for evaluation;
-The resident was admitted to the hospital due to the presence of the following: Imminent danger to self and severe psychiatric or comorbid conditions.
During an interview on 7/1/24 at 1:30 P.M., Licensed Practical Nurse (LPN) F said the resident was hard to work with because he/she was institutionalized. He/She had been in prison for so many years he/she still acted like an inmate. He/She was very rigid in his/her thinking and would write everything down. If things did not go the way he/she wanted, he/she would get angry. He/She kept a meticulous room but wanted to drink water from the toilet because this is how he/she used to get water. The nurse had to sit down and educate him/her about infection control and tell him/her it was safe to get water from the pitcher. The resident would continually argue with the staff regarding the medication and want to know about each pill. The nurse would have to come to the unit and explain what each pill was before the resident would agree to take it. The resident did have a rapport with some of the staff. He/She was usually fine during the day, but they would start getting phone calls from the staff in the evenings. The resident would use profanity and call the staff out of their names. He/She was not very social and would isolate in the television room.
During an interview on 7/1/24 at 1:45 P.M., LPN K said the resident had different behaviors on different shifts. He/She usually did not have a problem with the staff on his/her day shifts, but he/she had heard the resident had a problem on other shifts. They had not been given any direction on how to deal with the resident's behavior, but he/she needed an understanding approach. The resident liked things a certain way, like his/her food, and if they were not done that way, there was going to be a problem. He/She liked attention and if the staff spent some time talking to him/her, the resident responded well to it.
During an interview on 7/1/24 at 2:00 P.M., the Social Services Director said she did not address the resident's behavioral issues because the resident did not have any until his/her last week there. The resident refused to talk to them so it was hard to assess him/her or provide any services or activities. She addressed his/her behaviors when he/she acted out sexually inappropriately with the staff and and he/she agreed not to do it again so she thought it was done. They monitored his/her behavior regularly and made checks on him/her. She knew the resident had been incarcerated for a number of years, and people who have been in jail sometimes have a certain mindset. The resident also had a long history of trauma. She did not know if he would be able to handle the confines of the facility well. This information might have been helpful in the care plan for staff to develop interventions for recognizing and/or preventing behaviors. She thought the resident had seen psychiatric services but was unable to locate the notes or a referral for it.
During an interview on 7/1/24 at 4:00 P.M., the Minimum Data Set coordinator said she was responsible for completing the resident's care plan. She would have liked to have seen it be more detailed. She was aware of the resident's history of trauma and incarceration. The resident had an incident of sexually inappropriate behavior and facetiming other residents without their consent. All of this should have been on the care plan. It was an oversight on her part. She had only started working at the facility in March and was trying to get caught up on all of the care plans.
During interviews on 7/1/24 at 9:00 A.M. and at 5:15 P.M., the Administrator said the resident was screened for the PASARR services on 6/21/24, and he/she did not start displaying disruptive behaviors until 6/26/24. They added the behavior monitoring on 6/27/24. The resident was having behavioral problems before 6/27/24. He/She had called the sheriff's office and the Governor's office to report various grievances he/she felt were being perpetrated on him/her by staff. The staff would try to reason with him/her but the resident continued to make baseless claims. These behaviors probably should have been added to the care plan but everything happened so fast they were just trying to control the situation. The Administrator was aware the resident had been incarcerated for over 30 years, but he/she had not displayed any behaviors during the screening process and they were just trying to do the right thing for him/her.
MO00238156
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 observation, interview and record review, the facility failed to ensure four of six sampled residents were free from ph...
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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 four of six sampled residents were free from physical abuse. The residents' right to be free from physical abuse were violated when during two separate incidents a resident (Resident #2) hit four residents (Resident #5, Resident #6, Resident #3 and #4) in the face and stomach. The census was 92.
On 7/1/24 at 5:00 P.M., the Administrator was notified of the past noncompliance, which occurred on 6/28/24. On 6/28/24, the Administrator was notified by staff of the incident and an investigation was started. The facility immediately took steps to protect the residents and set interventions in place to prevent further abuse. The alleged violation was reported within the required timeframe. Facility staff received education on the facility's Abuse and Neglect Policy. Resident #2 was discharged to the hospital and is not expected to return. Appropriate corrective actions were taken. The deficiency was corrected on 6/30/24.
Review of the facility's Abuse, Neglect and Exploitation policy, revised 8/22/22, showed:
-Definitions:
--Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation of an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology;
--Physical abuse includes but is not limited to hitting, slapping, punching, biting and kicking;
-Policy Explanation and Compliance Guidelines:
--The facility will develop and implement written policies and procedures that:
--- Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property;
---Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, reporting procedures, and dementia management and resident abuse prevention;
--The facility will provide ongoing oversight and supervision of staff to assure that its policies are implemented as written;
-Prevention of Abuse, Neglect, and Exploitation:
--The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that includes:
---Identifying, correcting and intervening in situations in which abuse, neglect, exploitation and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms;
---The identification, ongoing assessment, care planning for appropriate interventions and monitoring of residents with needs and behaviors which might lead to conflict or neglect;
---Addressing features of the physical environment that may make abuse, neglect, exploitation and misappropriation of resident property more likely to occur;
---Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors;
-Identification of Abuse, Neglect and Exploitation:
-The facility will have written procedures to assist staff in identifying the different types of abuse - mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This includes staff to resident abuse and certain resident to resident altercations;
-Possible indicators of abuse include, but are not limited to:
--Physical marks such as bruises or patterned appearances such as a hand print, bell or ring mark on a resident's body;
--Physical abuse of a resident observed;
--Verbal abuse of a resident overheard;
--Psychological abuse of a resident observed;
-Protection of the resident: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to:
--Responding immediately to protect the alleged victim and integrity of the investigation;
--Increased supervision of the alleged victim and residents.
Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/25/24, showed:
-Severely cognitively impaired;
-Diagnoses included dementia, heart failure, Alzheimer's disease, restlessness and agitation, cognitive communication deficit and other abnormalities of gait and mobility.
Review of the resident's progress notes, showed:
-On 3/30/24 at 8:45 P.M., the nurse observed the resident being combative with staff and trying to go into other resident rooms. Staff were able to redirect him/her after 15 minutes;
-On 5/5/24 at 4:43 P.M., the resident was not following directions and was acting inappropriately. He/She blockaded the staff from leaving the station and was moving his/her hands around swinging at staff. He/She was swearing at residents and staff. Staff spoke with the resident's family member and recommended sending him/her to the hospital after consulting with his/her physician for evaluation;
-On 5/17/24 at 9:52 P.M., staff observed the resident being physically abusive toward staff members and attempting to be physically abusive towards residents on the unit. The resident was not easily redirected. The resident had an open area to his/her forearm which reopened and when the nurse tried to clean the area, the resident balled up his/her right fist and hit him/her in the stomach. The resident attempted to swing on staff when they were trying to toilet him/her. He/She propelled down the hall entering other resident rooms. He/She picked up a water pitcher and threw water on staff and residents by the desk. Staff continued to redirect and were not successful. Staff sent the resident to the hospital for evaluation;
-On 6/13/24 at 6:55 P.M., the resident exited his/her room and charged towards a resident and punched him/her in the stomach. The resident then turned towards staff and grabbed their clothing, punching and swinging uncontrollably. The resident then turned towards another resident and punched him/her in the head and slung him/her to the floor. The resident then attacked the Assistant Director of Nursing and another floor nurse who attempted to assist staff. Staff were unable to redirect the resident. The nurse called 911 and sent the resident to the emergency room;
-On 6/13/24 at 8:14 P.M., the resident was up in his/her wheelchair and displayed physical aggression towards a peer. Staff were unable to redirect the resident verbally. The resident became combative with staff. Staff escorted peers in the dining room away from the resident so he/she could not harm them. Staff notified the resident's physician who ordered him/her sent out to the hospital for psych/behaviors due to being harmful to others and him/herself. The resident continued his/her combative behavior by swinging and propelling fast towards staff. Staff stayed with the resident until the police and paramedics arrived. The resident became calm once the police stood next to him/her. The resident had a skin tear on his/her left forearm which was bleeding. He/She allowed the Assistant Director of Nursing to clean and place a bandage on it before leaving with the paramedics.
Review of Resident #5's admission MDS, dated [DATE], showed:
-Mildly cognitively impaired;
-Diagnoses included aphasia (a disorder that affects how you communicate) after stroke, paranoid personality disorder (a mental health condition marked by a pattern of distrust and suspicion of others without adequate reason to be suspicious), dementia, bipolar disorder (a chronic mood disorder that causes intense shifts in mood, energy levels and behavior) and muscle weakness.
Review of Resident #6's quarterly MDS, dated [DATE], showed:
-Severely cognitively impaired;
-Diagnoses included dementia, high blood pressure, major depressive disorder, encephalopathy (damage or disease that affects the brain), unspecified lack of coordination and cognitive communication deficit.
Review of a handwritten statement by Certified Nurse's Aide (CNA) L, dated 6/13/24, showed:
-The staff member witnessed Resident #2 punch Resident # 5 in the stomach and was trying to fight him/her;
-When the staff tried to stop him/her, the resident attacked them;
-The resident then walked up to Resident #6 and pulled him/her by the hair, punched him/her in the head and pulled him/her to the ground;
-The resident was still trying to fight staff as they were pulling the residents apart.
Review of the investigation provided by the facility dated 6/13/24, showed:
-At approximately 7:15 P.M., the resident exited his/her room and propelled his/her wheelchair and charged towards a resident in the hallway and punched him/her in the abdomen;
-He/She then turned towards staff grabbing staff clothing, punching and swinging uncontrollably while staff attempted to redirect him/her and maintain a safe environment for him/her and all the others on the unit;
-While staff were attempting to calm and redirect his/her behaviors, the resident charged towards another resident while he/she was walking in the hallway outside his/her room and punched him/her in the head and pushed him/her to the floor;
-Staff were able to separate the two residents and remove all other residents from the area during the incident preventing any other residents from being struck by the resident;
-The resident continued to display aggressive and combative behaviors with the staff who were attempting to deescalate his/her behaviors and calm him/her down;
-Staff called emergency services due to their inability to calm the resident or redirect his/her behavior and in an effort to maintain the safety of all other residents and staff on the unit;
-On 6/21/24 the resident returned to the facility and the following interventions were put in place:
-Family called and reviewed plan of care for behaviors;
-Care plan meeting scheduled;
-Resident placed on hour rounds for 24 hours to monitor
behaviors and aggression;
-Medication orders received for behavior management from
hospital;
-Resident evaluated by physician upon return from hospital
and orders placed.
Review of the hospital discharge paperwork provided by the facility, showed the following:
-The resident presented from the skilled nursing facility on 6/13/24, for agitation, combative, aggressive behaviors. He/She reportedly injured two staff members;
-The resident was aggressive with emergency department staff and required chemical sedation and restraints overnight;
-The resident's family member said this is the third time in six months the resident was sent to the hospital for aggressive behaviors, and he/she feels helpless to stop the cycle for the resident coming to the hospital and returning to the nursing home without any changes or improvement;
-The hospital staff contacted the facility staff who reported the resident was sent to the hospital because he/she assaulted a resident and one of their staff. He/She knocked down one of the residents who has dementia and punched one of the staff in the face. They had to stop him/her from using a wheelchair. The facility was unlikely to take him/her back and requested a 72 hour hold to make sure his/her behavior was stable before coming there again;
-The treatment options and alternatives, including medications and their side effects were reviewed:
-Close observations for safety;
-The treatment team will develop a comprehensive plan,
including pharmacological and psychological approaches;
-Social work consult to establish outpatient psychiatric and medical follow up care.
Review of the resident's care plan, dated 6/13/24, showed:
-Focus: The resident resides on the memory care unit;
-Interventions: Monitor the resident per protocol to ensure safety;
-Focus: Resident has a behavior problem (date initiated 5/13/24, revision on 5/26/24);
-Interventions: Administer medications as ordered;
-Interventions: Anticipate and meet the resident's needs;
-Interventions: Caregivers to provide opportunity for positive
interaction, attention. Stop and talk to him/her;
-Interventions: Explain all procedures to him/her before starting and allow resident time to process the information (revision on 5/26/24)
-Interventions: 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 alternative location as needed;
-Interventions: Monitor behavior and episodes and attempt to determine underlying cause. Document behavior and potential causes (all interventions initiated on 5/13/24);
-No new documented behavioral interventions after 5/26/24 prior to the 6/28/24 assault.
Review of the resident's progress notes, showed:
-On 6/22/24 at 4:39 A.M., the resident had to be redirected several times during the evening for going in and out of resident rooms and being verbally abusive;
-On 6/28/24 at 11:13 A.M., the staff notified the nurse the resident was in the dining room attempting to take another resident's breakfast tray. When the other resident refused to give up his/her tray, the resident became physically aggressive towards the resident. Staff quickly intervened removing the resident from the dining room, away from other residents. The resident was in the hallway propelling him/herself towards staff with his/her arm in the air and hands balled up into a fist. The staff observed the resident attempting to charge at another staff member. The nurse was unable to redirect the resident. Staff administered an as needed medication. It was ineffective. The resident continued to refuse care and help. Staff notified the resident's physician and sent the resident to the hospital. Staff sent the bed hold policy and a copy of an immediate discharge with the resident to the hospital.
Review of Resident #3's quarterly MDS, dated [DATE], showed:
-Severely cognitively impaired;
-Diagnoses included unspecified dementia, history of falling,
macular degeneration (eye disease), delusional disorders (an unshakable belief in something that's untrue) and cognitive communication deficit.
Review of the facility's investigation, dated 6/27/24, showed:
-On the morning of 6/28/24, on the Memory Care Floor, Resident #2 and Resident #3 were seated in the dining room;
-Resident #2 attempted to take Resident #3's food while he/she was eating and he/she pulled his/her plate back;
-Resident #2 then hit Resident #3 in the face;
-Resident #4 was standing nearby and saw Resident #2 hit Resident #3 and asked why he/she would hit him/her;
-Resident #2 then got aggressive towards Resident #4 and hit him/her in the stomach;
-Staff quickly intervened and separated the residents;
-Staff called for Emergency Medical Services (EMS) to take Resident #2 out for aggressive behavior;
-Staff notified the residents' families and physicians;
-Staff completed skin and pain assessments on the residents.
Observation on 7/1/24 at 1:20 P.M., showed Resident #3 sat at a table in his/her wheelchair in the dining room, on the secured memory care unit. He/She was small in stature and only spoke in garbled speech. He/She had slight reddening to the right side of his/her face.
Observation and interview on 7/1/24 at 1:25 P.M., showed Resident #4 sat at the table in the dining room on the secured memory care hall and said he/she did not know why Resident #2 hit him/her. He/She could not remember the entire incident but did remember being hit. All he/she did was ask the resident, Why did you do that? and the resident hit him/her. He/She was not afraid of the resident but was glad he/she was not at the facility.
During an interview on 7/1/24 at 1:00 P.M., Certified Medication Technician (CMT) M said the resident could be aggressive with members of the opposite sex. He/She had been told to stay close to him/her and watch him/her for triggers, but the problem was you never knew what was going to trigger him/her. The resident could be perfectly fine and then would strike out. It might be okay if there were enough staff to deal with him/her, but if they were short staffed or there were only females working, it might be a problem. He/She did not feel like they could keep the other residents safe from him/her because he/she was so unpredictable.
During an interview on 7/1/24 at 1:15 P.M., Licensed Practical Nurse (LPN) F said he/she was here on 6/28/24 when the resident assaulted the two other residents in the dining room. They immediately removed the other residents from the dining room, but he/she followed them out into the hall. They would think he/she was calm, and then he/she would get agitated again. He/She got more and more combative, and they ended up taking him/her to another floor to calm him/her down. He/She could not assess him/her because he/she was so combative. A male CNA came to the floor to help get him/her off the hall. The resident had been aggressive before and had attacked another resident. It was getting bad. They had been told to remove the parties from the situation and try to redirect the resident, but he/she was hard to redirect. Once his/her trigger was pulled, there was nothing you could do.
During an interview on 7/1/24 at 1:45 P.M., CNA N said the resident and Resident #3 were seated by each other and the resident took his/her plate of food. When Resident #3 went to take it back, the resident hit him/her in the face. You could hear the loud smack where he/she hit him/her. Resident #4 asked Resident #2 why he/she hit Resident #3, and the resident turned around and started attacking Resident #4. The CNA and another staff member pulled Resident #2 away, but he/she kept trying to attack Resident #4. Resident #2 hit Resident #4 in the arm as he/she went by him/her. They were finally able to get some more nurses and a male CNA down to calm the resident down and take him/her off the floor. The resident had been aggressive like that before. He/She had tried to slap CNA N before also, but he/she had been able to redirect him/her. If you did not approach him/her in the right manner, it could be a problem. He/She believed Resident #2 could be a danger to the other residents due to his/her size and unpredictability.
During interviews on 7/1/24 at 9:15 A.M. and at 5:10 P.M., the Administrator said they put interventions in place after the assaults on 6/13/24. The family did not want the resident to be too medicated. They sent the resident out immediately after the assault on 6/28/24. He thought they did everything they could do.
MO00238273
Jun 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0602
(Tag F0602)
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 Resident #2 was free from financial misappropriation resulti...
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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 Resident #2 was free from financial misappropriation resulting in the resident's credit card being taken by two staff members. The census was 134.
The Administrator was notified on 6/4/24 of the past non-compliance, which began on 5/31/24. The facility immediately began an investigation of the incident and removed the staff members who misappropriated the resident's funds pending an investigation. The administrator began in-servicing staff on abuse, neglect, and misappropriation. The noncompliance was corrected on 6/3/24.
Review of the facility's abuse, neglect and exploitation policy, dated 8/22/22, showed:
-Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property;
-Definitions: Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent.
Review of the facility's investigation, started on 6/1/24, showed:
-The Administrator sent the initial self report investigation on 6/1/24 at 6:47 P.M.;
-A photo of the text notification received by Resident #1 from his/her bank detailing that a purchase of $62.20 was made using the resident's credit card on 5/31/24 at 8:35 P.M. from a local area restaurant (Restaurant Z);
-A receipt from the Restaurant Z, dated 5/31/24 at 8:30 P.M., confirmed the total amount of $62.20 was charged to Resident #2's credit card and was ordered by Certified Nursing Assistant (CNA) B;
-A receipt showing that CNA A paid for his/her own food with his/her own money,
-A written statement from Resident #1, dated 6/3/24, showed he/she went to the vending machine using Resident #2's credit card and left the credit card at the vending machine;
-A written statement from Resident #2, dated 6/3/24, showed he/she received an alert from his/her bank that his/her card had been used at Restaurant Z without his/her permission.
Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/28/24, showed:
-Cognitively intact;
-Diagnoses included diabetes and major depressive disorder.
During an interview on 6/4/24 at 7:33 A.M., Resident #1 said Resident #2 is his/her adult child. On 5/31/24 Resident #2 allowed Resident #1 to use his/her card to go to the vending machine for soda. Resident #2 purchased the soda at the vending machine at 7:02 P.M. on 5/31/24. Resident #2 said he/she left Resident #1's card in the vending machine on accident and did not notice until Resident #2 received an alert on his/her phone that his/her credit card was used at Restaurant Z at 8:35 P.M. that evening. Resident #1 said he/she witnessed CNA A, CNA B and CNA C eating from Restaurant Z that evening but did not connect the two together.
Review of Resident #2's quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-Diagnoses included end stage renal disease and muscle weakness.
During an interview on 6/4/24 at 7:45 A.M., Resident #2 said he/she noticed his/her credit card was missing. He/She noticed a text message on his/her cell phone from the bank saying his/her credit card had been used at Restaurant Z. He/She called the restaurant to ask who ordered the food and was told the name of who used the card. Resident #2 called the police and reported his/her credit card as stolen.
During an interview on 6/4/24 at 10:52 A.M., CNA A said he/she was working passing medication on the evening shift of 5/31/24. CNA B and CNA C approached him/her and asked if he/she would like to order anything from Restaurant Z, as they were ordering food to pick up and bring back to the facility to eat. CNA A ordered food using his/her own money, and CNA B picked the food up from the restaurant. CNA A did not see the CNA B or CNA C using Resident #1's credit card.
During an interview on 6/4/24 at 10:11 A.M., the Administrator said that after completing an investigation, he had enough facts and evidence that CNA B and CNA C used Resident #2's credit card at Restaurant Z. He said both CNA B and CNA C were being terminated effective immediately.
MO00237004
Feb 2024
30 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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to respect two of 29 sampled res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to respect two of 29 sampled residents' (Resident (R) 23 and R104) right to be treated with respect and dignity. R23 was brought to the common area and dining area of his unit without trousers on, and R104's urinary catheter drainage bag was left uncovered.
Findings include:
Review of the facility's policy titled, Promoting/Maintaining Resident Dignity, revised 09/01/21, revealed .It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality .Groom and dress residents according to resident preference .Maintain resident privacy .
1. Review of R23's admission Record located in the electronic medical record (EMR) under the Profile tab, revealed R23 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included senile degeneration of the brain, epilepsy, and unspecified intellectual disabilities.
Review of R23's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/14/23 and located under the MDS tab of the EMR, revealed R23 had a Brief Interview for Mental Status (BIMS) score of five out of 15, which indicated R23 was severely cognitively impaired. It was recorded R23 required substantial/maximal assistance with upper body dressing and was dependent on staff for lower body dressing. It was also recorded R23 was dependent on staff for bed to chair transfers.
During an observation on 02/13/24 at 8:30 AM, R23 was observed at the nurses' station, seated in his reclined Broda chair (a positioning wheelchair), with a sheet covering his lower body. At 8:32 AM, R23 was propelled to the dining area by Certified Nurse Aide (CNA) 7 and was placed in front of a table where R81 was seated. R23's Broda chair was placed in an upright position, and CNA7 left the dining area. R23 removed the sheet covering his lower body and placed it on the table. R23 was observed to have only an incontinent brief on his lower body. At 8:36 AM, CNA7 approached the table with breakfast plates for R23 and R81. CNA7 stated, We have to put this (the sheet) on you. R23 responded, No. CNA7 stated, We don't, I'll be right back. CNA7 left the dining area and returned at 8:38 AM with two drinks and napkins and began to prepare the residents' plates. CNA6 approached the table with a drink for R23, removed the sheet from the table and started to put the sheet over R23's legs. CNA7 told CNA6, He will not leave it on. He yanked it off. CNA6 asked CNA7, Where is his stuff to cover him up? CNA7 did not reply and began attempting to feed R23. At 8:43 AM, CNA7 stated, He's in a mood today. CNA7 asked CNA6 to help her put R23 back in bed. CNA6 obtained the sheet, covered R23, and assisted CNA7 in putting R23 back in bed.
During an interview on 02/13/24 at 8:49 AM, CNA7 confirmed R23 had been taken out of his room, placed in the common area in front of the nurses' station, and then taken to breakfast in the dining area without having trousers on. CNA7 made no reply when asked why R23 did not have trousers on.
During an interview on 02/13/24 at 9:10 AM, Registered Nurse (RN) 3 confirmed that all residents should be dressed prior to leaving their rooms. She stated, Oh yes, they should be dressed for dignity. RN3 stated if a resident did not have clothes available in their room, staff should go to the laundry and find their clothes.
During an interview on 02/13/24 at 3:07 PM, the Director of Nursing (DON) stated her expectation was for staff to treat residents with dignity and respect and for all residents to be appropriately dressed before leaving their rooms.
2. Review of R104's admission Record located in the EMR under the Profile tab, revealed R104 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included metabolic encephalopathy, unspecified sequelae of cerebral infarction, diabetes mellitus, acute pyelonephritis, and acute cystitis without hematuria.
Review of R104's five-day MDS with an ARD of 01/28/24 and located under the MDS tab of the EMR, revealed R104 had a BIMS score of 15 out of 15, which indicated R104 was cognitively intact. It was recorded that R104 required substantial/maximal assistance with toileting, hygiene, and bed to chair transfers. It was recorded R104 had an indwelling catheter.
During an observation and interview on 02/12/24 at 4:23 PM, R104 was observed seated in her wheelchair, catheter bag attached uncovered below (no privacy bag), and with urine visible. R104 stated that she was aware her catheter bag was not properly covered with a privacy bag, and that she used to get one. R104 stated that she had asked for a dark bag to cover her catheter bag and had been told by staff that they did not have them anymore. R104 stated she would like to have it covered for her privacy.
During an interview on 02/15/24 at 10:16 AM, the DON stated her expectation was for catheter bags to have privacy covers in place before a resident left their room. DON stated that she often walked around the facility with extra privacy covers to ensure catheter bags were covered.
MO00229664
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy review, the facility failed to ensure the physician was notified of a si...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy review, the facility failed to ensure the physician was notified of a significant weight loss for one of four residents (Resident (R) 98) reviewed for nutrition of 29 sampled residents. (Cross Reference F641, F657, R692, F726, and F777)
Findings include:
Review of a facility's policy titled, Notification of Changes, 09/01/21, indicated .The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, resident's representative when there is a change requiring notification.
Review of R98's electronic medical records (EMR) titled admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE] with a diagnosis of protein-calorie malnutrition.
Review of R98's EMR titled admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/23/24 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which revealed the resident was moderately cognitively impaired. The assessment indicated the resident weighed 123 pounds.
Review of R98's EMR titled quarterly MDS with an ARD of 01/23/24 indicated the resident had a BIMS score of nine out of 15 which revealed the resident was moderately cognitively impaired. The assessment indicated the resident weighed 110 pounds which was a 10.5 percent weight loss since the last comprehensive assessment.
Review of R98's EMR failed to indicate the resident's primary physician was notified of the resident's significant weight loss over the 90-day period.
During an interview with R98's primary care physician, who was also the facility's Medical Director on 02/15/24 at 3:47 PM, the Medical Director stated Why should I be concerned when asked about the resident's significant weight loss. The Director of Nursing (DON) was present during this interview and stated the Medical Director was not notified of the resident's significant weight loss.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to assess a Broda chair (a posit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to assess a Broda chair (a positioning wheelchair) as a restraint and failed to obtain a physician's order, provide a medical symptom, and obtain consent for the use of a restraint for one of one resident (Resident (R) 23) reviewed for restraints of 29 sampled residents.
Findings include:
Review of the facility's policy titled, Restraint Free Environment, revised 09/01/21, revealed .It is the policy of this facility that each resident shall attain and maintain his/her highest practicable wellbeing in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints .'Physical Restraint' refers to 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. Physical restraints may include, but are not limited to .Placing a resident in a chair that prevents the resident from rising independently .'Medical Symptom' refers to an indication or characteristic of a physical or psychological condition . Falls do not constitute self-injurious behavior or a medical symptom that warrants the use of a physical restraints [sic] .Behavioral interventions should be used and exhausted prior to the application of a physical restraint .A physician's order alone is not sufficient to warrant the use of a physical restraint. The facility is responsible for the appropriateness of the determination to use a restraint .Before a resident is restrained, the facility will determine the presence of a specific medical symptom that would require the use of restraints .Medical symptoms warranting the use of restraints should be documented in the resident's medical record .
Review of R23's admission Record located under the Profile tab of the electronic medical record (EMR), revealed R23 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included senile degeneration of the brain, epilepsy, and unspecified intellectual disabilities.
Review of R23's Care Plan located under the Care Plan tab of the EMR and dated 03/30/21, revealed a focus problem related to a high risk for falls due to confusion, deconditioning, gait and balance problems, poor communication/comprehension, and unawareness of safety needs. Interventions included checking on R23 frequently, offering to toilet often, keeping call light within reach, and observing R23 self-propelling in his wheelchair and making sure he was sitting in it correctly.
Review of R23's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/26/23 and located under the MDS tab of the EMR, revealed R23 had a Brief Interview for Mental Status (BIMS) score of five out of 15, which indicated R23 was severely cognitively impaired. It was recorded R23 was dependent on staff for transfers and required supervision for locomotion on and off the unit. It was also recorded R23 had no impairments to the upper and lower extremities and used a wheelchair for mobility. It was recorded R23 had two or more falls with no injury and two or more falls with injury but no major injury. It was recorded that no physical restraints were used with R23.
Review of R23's Care Plan, updated 10/13/23 and located under the Care Plan tab of the EMR, revealed .Hospice consult to eval [evaluate] post deconditioning/frequent falls .
Review of R23's hospice Residential Communication Form, dated 10/16/23 and located in the hospice binder, revealed, .Pleasant, cooperative. [NAME] himself down hall. Assisted him to lunch room .
Review of R23's Nurse's Note, dated 10/19/23 at 6:40 PM and located under the Progress Notes tab of the EMR, revealed .resident was up on wheelchair propelled per self, no acute distress observed .
Review of R23's Nurse's Note, dated 10/23/23 at 8:00 PM and located under the Progress Notes tab of the EMR, revealed .Resident remains on IFU [follow-up] for previous fall on 10/23. Neuro checks remain in place as well as safety precautions .
Review of R23's Care Plan, updated 10/24/23 and located under the Care Plan tab of the EMR, revealed .Hospice provided broda [sic] chair [a positioning wheelchair] to patient use in relation to frequent falls and patient having difficulty maintaining trunk position .
Review of R23's hospice Residential Communication Form, dated 10/30/23 and located in the hospice binder, revealed .Pt [patient] in broda [sic] chair, better for pt than regular wc [wheelchair] .
Review of R23's entire EMR revealed no documentation to show staff assessed R23 to determine if the Broda chair was a restraint for him. There was no signed consent for the use of physical restraints with R23. There was no physician's order for the use of a Broda chair. There were no medical symptoms documented for the use of a physical restraint.
During an observation on 02/12/24 at 10:20 AM, R23 was observed sitting in a Broda chair in front of the nurses' station. The back of the chair was reclined. R23's right leg was hanging off the footrest, and he was leaning to the left side. At 10:24 AM, R23 leaned forward in the Broda chair, bringing his entire body away from the back of the chair, and stretched out his arms. At 11:01 AM, 11:06 AM, and 11:19 AM, R23 leaned forward in the Broda chair, bringing his entire body away from the back of the chair.
During continued observation on 02/12/24 at 11:43 AM, R23 was moved from the nurses' station to the dining area. The back of his chair remained in a reclined position. At 12:45 PM, a noon meal tray was brought to the table and placed in front of R23. R23 raised up, without the back of his chair being repositioned and began to feed himself the noon meal.
During an observation on 02/13/24 at 8:27 AM, R23 was observed in a Broda chair in front of the nurses' station. His feet were drawn up on to the seat, and the back of the chair was reclined. At 8:32 AM, R23 was taken to the dining area, and the back of the chair was placed in the upright position. R23 was able to maintain his position in the Broda chair. At 8:44 AM, R23 was taken to his room and transferred to his bed.
During an interview on 02/13/24 at 8:49 AM, Certified Nurse Aide (CNA) 7 stated R23 was placed in the Broda chair because he's hospice. CNA7 was asked if R23 was at risk of falls, and she stated, In a regular [wheel]chair, definitely. CNA7 was asked why R23 was not at risk for falls with the Broda chair, and she stated, Because he's constricted, he can't sit in a regular [wheel]chair. CNA7 stated she reclined the Broda chair so R23 could sleep while he was seated it in. CNA7 stated R23 got the Broda chair because he kept sliding out of a regular wheelchair. CNA7 stated she thought R23 could plop himself out [of the Broda chair] when he gets really agitated. CNA7 stated R23 could propel his regular wheelchair for very short distances but was unable to propel the Broda chair. CNA7 stated R23 would try to rise from the regular wheelchair even though he should not.
During an interview on 02/13/24 at 9:10 AM, Registered Nurse (RN) 3 stated a Broda chair was used for R23 because when he used a regular wheelchair, he would fall a lot. RN3 stated R23 would lean forward and fall over. RN3 stated she was unaware of the facility attempting any modifications to R23's regular wheelchair to help in the prevention of falls. RN3 stated when R23 was eating, the back of his chair was supposed to be in the upright position, and when he was done eating, staff made him comfortable by reclining the back of the chair. RN3 was asked if the Broda chair was a restraint for R23. She stated, No, because he can come out of it unless it is way back. RN3 was asked if R23 could propel his regular wheelchair. She stated, Yes, some for sure. RN3 confirmed R23 was unable to propel the Broda chair. RN3 stated R23 would try to rise from the regular wheelchair even though he should not.
During an interview on 02/13/24 at 2:30 PM, RN4 stated the facility felt like it would be a good idea to try a Broda chair for R23 for safety issues. RN4 confirmed R23 could propel his wheelchair and could not propel the Broda chair. RN4 stated R23 had started to decline around the end of October 2023 and was falling from the wheelchair from tripping on his feet or slouching too far forward. RN4 confirmed R23 could not rise from the Broda chair.
During an interview on 02/13/24 at 2:45 PM, the Director of Therapy stated R23 had been in a regular wheelchair until the end of October 2023. The Director of Therapy stated R23 had been declining but still attempted to propel his wheelchair. The Director of Therapy provided documentation of R23's therapy visits for October 2023. There was no restraint assessment included in the documentation.
During an interview on 02/13/24 at 3:07 PM, the Director of Nursing (DON) and Corporate Nurse were asked if R23 could propel his regular wheelchair and then was placed in a Broda chair that he could not propel, was the Broda chair a physical restraint for the resident. The Corporate Nurse stated, By definition, yes. The DON and Corporate Nurse confirmed there was no documentation of a medical symptom for the use of a physical restraint.
During an interview on 02/14/24 at 10:30 AM, the DON stated it was the facility's policy to complete restraint assessments before something was used that could be a restraint. The DON stated R23 had received the Broda chair before she came to the facility. She stated staff had reported a restraint assessment had been completed before R23 was given the Broda chair; however, she was not sure when it was done or where it was located. The DON confirmed the assessment was not in R23's clinical record.
During an interview on 02/15/24 at 12:06 PM, the DON stated the facility's policy was for consents to be obtained prior to the use of a physical restraint. The DON confirmed that there was no physical restraint consent for R23.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0605
(Tag F0605)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to ensure one of one resident (R...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to ensure one of one resident (Resident (R) 23) reviewed for chemical restraints did not receive a chemical restraint as a convenience to treat behaviors. R23 was prescribed Haldol and Seroquel, both antipsychotic medications, for behaviors and without a medical symptom for their use.
Findings include:
Review of the facility's policy titled, Restraint Free Environment, revised 09/01/21, revealed, .It is the policy of this facility that each resident shall attain and maintain his/her highest practicable wellbeing in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints .'Chemical Restraint' refers to any medication that is used for discipline or staff convenience, and not required to treat medical symptoms . 'Convenience' refers to any action taken by the facility to control a resident's behavior or manage a resident's behavior with a lesser amount of effort by the facility and not in the resident's best interest. 'Medical Symptom' refers to an indication or characteristic of a physical or psychological condition .Medical symptoms warranting the use of restraints should be documented in the resident's medical record. The resident's record needs to include documentation that less restrictive alternatives were attempted to treat the medical symptom but were ineffective, ongoing re-evaluation of the need for the restraint, and the effectiveness of the restraint in treating the medical symptom. The care plan should be updated accordingly to include the development and implementation of interventions, to address any risks related to the use of the restraint .
Review of R23's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R23 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included senile degeneration of the brain, epilepsy, and unspecified intellectual disabilities.
Review of R23's Care Plan, located under the Care Plan tab of the EMR, revealed a focus, dated 03/10/21, of R23 displaying episodes of agitation and physical aggression to others around him and refusing care due to confusion related to dementia. Interventions included administering medications as ordered, analyzing episodes for date, place, circumstances, triggers, and what de-escalates behaviors and documenting and modifying the environment as necessary. Another focus, dated 08/19/22, was, .may display period of resistive to care r/t [related to] anxiety/impulsiveness, dementia . Interventions included to allow R23 to make decisions about his treatment regime and to leave and return 5-10 minutes later if R23 resists care. Another focus, dated 05/19/23, was that R23 was receiving an antipsychotic medication related to an aggressive behavior problem. It was documented R23 had physically touched another resident, causing that resident mental distress. Interventions included monitoring behavior episodes and attempting to determine any underlying cause and to document behaviors and potential causes.
Review of R23's Physician Orders, located under the Orders tab of the EMR, revealed physician orders for:
-Lorazepam (Ativan, an antianxiety medication), 0.5 milligrams (mg) three times a day (TID) for anxiety, dated 11/21/22; Sertraline (an antidepressant medication), 25 mg once daily, dated 12/17/22; and
-Valproic Acid 250 mg /5 milliliter (ml), give 250 mg three times a day (TID) for anticonvulsants related to unspecified psychosis not due to a substance or known physiological condition . major depressive disorder . The date of this order was 08/12/23.
Review of R23's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/26/23 and located under the MDS tab of the EMR, revealed R23 had a Brief Interview for Mental Status (BIMS) score of five out of 15, which indicated R23 was severely cognitively impaired. It was recorded R23 had no physical behavioral symptoms directed toward others, no verbal behavioral symptoms directed toward others, and no behavioral symptoms directed toward others. It was recorded R23 did not reject care and did not wander. It was recorded R23 received antianxiety and antidepressant medications on seven of the preceding seven days and did not receive antipsychotic medications.
Review of R23's Medication Administration Records (MARs) and Treatment Administration Records (TARs), dated October 2023 and located under the Orders tab of the EMR, revealed no documentation R23 had displayed any behaviors, agitation, or physical aggression towards others.
Review of R23's Progress Notes, dated 10/01/23 through 10/12/23 and located under the Progress Notes tab of the EMR revealed no documentation R23 had displayed any behaviors, agitation, or physical aggression towards others from 10/01/23 through 10/12/23. On 10/13/23 at 4:55 AM, it was documented R23 was waking his new roommate intentionally in an effort to find out who the resident was. On 10/14/23 at 10:02 PM, it was documented R23 was displaying combative behaviors throughout the shift, appeared upset that he had a roommate, and continued to crawl out of bed and go to the roommate's side of the room and pull the roommate's items off of his bedside table. It was documented that the resident was verbally aggressive when staff tried to redirect him. There was no documentation to show what the combative behaviors were. Review of progress notes from 10/15/23 through 10/18/23 revealed no documentation R23 had displayed any behaviors, agitation, or physical aggression towards others.
Review of R23's hospice Residential Communication Form, dated 10/19/23 and located in the hospice binder, revealed, .Combative yesterday, did calm down. Has had a good day so far, according to staff. Slept through VS [vital signs] [and] Assessment. Had just had a bath b/f [before] my arrival .
Review of R23's Progress Notes, dated 10/20/23 through 10/22/23 and located under the Progress Notes tab of the EMR, revealed no documentation R23 had displayed any behaviors, agitation, or physical aggression towards others.
Review of R23's hospice Residential Communication Form, dated 10/23/23 and located in the hospice binder, revealed, .Refused shower. Peri care (assisted aide w/ [with] transfer to toilet [and] back.) .Behavioral, tried to bite this nurse during xfer [transfer] .
Review of R23's Progress Notes, dated 10/24/23 through 10/29/23 and located under the Progress Notes tab of the EMR, revealed no documentation R23 had displayed any behaviors, agitation, or physical aggression towards others.
Review of R23's hospice Residential Communication Form, dated 10/30/23 and located in the hospice binder, recorded, .Cooperative, [no] combativeness noted. Med [Medications] [changed] per [hospice physician name withheld] D/C [discontinue] TID 250 Valproic acid, bid [twice daily] valproic acid 125 [mg] start, start Seroquel [an antipsychotic medication] 25 mg nightly, d/c Ativan tab tid, start Haldol [an antipsychotic medication] 50 mg [transcription error - dose was to be 0.5 mg] BID plus PRN [as needed] q [every] 4 [hour] dosing. Registered Nurse (RN) 4, who was the hospice nurse, signed the form.
Review of R23's Physician Orders, dated 10/30/23 and located under the Orders tab of the EMR, revealed Haldol 0.5 mg twice daily and Seroquel 25 mg every night were ordered for R23 for agitation and behaviors.
In the EMR, under the Orders tab and next to the listing for R23's Haldol order was a black box. When the black box was selected, the following appeared on the screen: Order: Haloperidol [Haldol] Tablet 0.5 MG Black Box Warning: Increased mortality in elderly patients with dementia-related psychosis Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Analyses of 17 placebo-controlled trials (modal duration, 10 weeks), largely in patients taking atypical antipsychotic drugs, revealed a risk of death in drug-treated patients of between 1.6 to 1.7 times the risk of death in placebo-treated patients. Over the course of a typical 10-week controlled trial, the rate of death in drug-treated patients was about 4.5% compared with a rate of about 2.6% in the placebo group. Although the causes of death were varied, most of the deaths appeared to be cardiovascular (eg, heart failure, sudden death) or infectious (eg, pneumonia) in nature. Observational studies suggest that, similar to atypical antipsychotic drugs, treatment with conventional antipsychotic drugs may increase mortality. The extent to which the findings of increased mortality in observational studies may be attributed to the antipsychotic drug as opposed to some characteristic(s) of the patients is not clear. Haloperidol is not approved for the treatment of patients with dementia-related psychosis.
In the EMR, under the Orders tab and next to the listing for R23's Seroquel order was a black box. When the black box was selected, the following appeared on the screen:
Quetiapine Fumarate [Seroquel] 25 MG Tablet Black Box Warning: Increased mortality in elderly patients with dementia-related psychosis Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Quetiapine is not approved for the treatment of patients with dementia-related psychosis. Suicidal thoughts and behavior
Antidepressants increase the risk of suicidal thoughts and behavior in children, adolescents, and young adults in short-term studies. These studies did not show an increase in the risk of suicidal thoughts and behavior with antidepressant use in patients older than 24 years; there was a reduction in risk with antidepressant use in patients 65 years and older. In patients of all ages who are started on antidepressant therapy, monitor closely for clinical worsening and for emergence of suicidal thoughts and behaviors. Advise families and caregivers of the need for close observation and communication with the prescriber. Quetiapine is not approved for use in pediatric patients younger than 10 years.
Review of R23's entire EMR and hospice binder revealed no documentation to show why Haldol and Seroquel were ordered for R23. There was no documentation of a medical symptom for the use of the medications.
During an observation on 02/13/24 at 8:30 AM, R23 was observed at the nurses' station, seated in his reclined Broda chair, with a sheet covering his lower body. At 8:32 AM, R23 was propelled to the dining area by Certified Nurse Aide (CNA) 7 and was placed in front of a table where R81 was seated. R23's Broda chair was placed in an upright position, and CNA7 left the dining area. R23 removed the sheet covering his lower body and placed it on the table. R23 was observed to have only an incontinent brief on his lower body. At 8:36 AM, CNA7 approached the table with breakfast plates for R23 and R81. CNA7 stated, We have to put this (the sheet) on you. R23 responded, No. CNA7 stated, We don't, I'll be right back. CNA7 left the dining area and returned at 8:38 AM with two drinks and napkins, stated, It's time to eat, and began to prepare the residents' plates. CNA6 approached the table with a drink for R23, removed the sheet from the table and started to put the sheet over R23's legs. CNA7 told CNA6, He will not leave it on. He yanked it off. CNA6 asked CNA7, Where is his stuff to cover him up? CNA7 did not reply and began attempting to feed R23. At 8:41 AM, CNA7 gave R23 one bite of food, but R23 pushed it out of his mouth. CNA7 immediately attempted to give him another bite, but R23 pushed it out of his mouth. CNA7 immediately asked R23 if he wanted a drink of chocolate milk, and he stated, No. CNA7 then said, I don't think he wants to eat. I'm going to take him to his room. At 8:43 AM, CNA7 stated, He's in a mood today. CNA7 asked CNA6 to help her put R23 back in bed. CNA6 obtained the sheet, covered R23, and CNA7 pushed R23 to his room.
During continued observation and interview on 02/13/24 at 8:44 AM, CNA7 and CNA6 were asked if they were going to put R23 in his bed. CNA7 stated, Yes. CNA7 stated, He's agitated right now. CNA7 placed a gait belt around R23's waist, and the CNAs placed their arms under R23's arms and lifted him from the chair to his bed. R23's knees were drawn up during the transfer, and his feet did not touch the floor, causing all the resident's weight to be placed on his shoulder joints. At 8:48 AM, CNA7 stated, I will let [RN 3] know he is agitated. CNA7 was asked how she knew R23 was agitated. She stated, The way he was spitting out his food, the way he was grabbing his blankets and throwing them.
During an interview on 02/13/24 at 8:49 AM, CNA 7 stated R23 could be combative at times. She stated, You saw a little of it, agitated. CNA7 was asked what she was supposed to do if R23 had behaviors. She stated, I report it to the nurse and see if she can give him something. CNA7 stated R23 had dementia and mental challenges. CNA7 stated she had received training to try to redirect R23 if he was having behaviors.
During an interview on 02/13/24 at 9:10 AM, RN3 was asked if R23 had behaviors. She stated, Yes, because he is a special needs person. RN3 stated R23 had dementia as well. RN3 stated R23 would kick and punch. RN3 was asked what staff was supposed to do if R23 was exhibiting behaviors. She stated, He is on routine medication which is Haldol. It helps a lot better than the Ativan did. RN3 stated when R23 had behaviors, staff was supposed to remove him from the situation and provide time for R23 to calm down. RN3 confirmed Haldol and Seroquel were ordered for R23's behaviors. RN3 was asked what the facility attempted to do before starting R23 on Haldol and Seroquel. She stated, The only thing we continued doing for him was just to talk to him and check him. RN3 stated staff was supposed to make sure R23 was not hungry or wet and try to meet his basic needs. RN3 confirmed CNA7 had reported that R23 had behaviors this morning. RN3 stated CNA7 did not explain what the behaviors were. RN3 stated, She just said he had behaviors and didn't eat. RN3 was asked if R23 was more sedated since he was receiving Haldol and Seroquel. RN3 stated, I would say it does help because after he takes them, you are going to see a little more cooperation than fighting. RN3 stated she was unsure who had asked for the Haldol and Seroquel and confirmed again that the medications were used for R23's behaviors. RN3 confirmed any behaviors were supposed to be documented in the clinical record and stated she would be documenting that R23 had behaviors this morning.
During an interview with R23's Resident Representative (RR) on 02/13/24 at 12:28 PM, the RR stated she did not remember being informed that R23 had been ordered Haldol and Seroquel and that the risks and benefits of the medications were not discussed with her.
During an interview on 02/13/24 at 2:30 PM, RN4 confirmed she had consulted with the hospice physician related to R23's agitation and aggressive behaviors. RN4 stated R23 had attempted to bite her and had been told he was kicking and hitting facility staff. RN4 stated staff had told her the behaviors had been ongoing. RN4 was asked what staff had told her they had tried to do to help with any behaviors. She stated she did not recall. RN4 was asked what medical symptoms were being treated with the use of Haldol and Seroquel. RN4 stated the hospice physician had made the judgement call. RN4 stated she had talked with the physician and relayed what the facility staff had told her, and the orders came from that. RN4 confirmed the medications were being used to treat behaviors.
During an interview on 02/13/23 at 3:07 PM, the Director of Nursing (DON) and Corporate Nurse were asked what behaviors had been documented for R23 during the month of October 2023. The Corporate Nurse reviewed the clinical record and stated there were no behaviors documented on the MARs and TARs, and only two incidents were documented in the progress notes. The Corporate Nurse stated neither of the incidents were aggressive. The DON and Corporate Nurse were asked what medical symptoms were being treated by the use of Haldol and Seroquel for R23. The Corporate Nurse stated, I don't have a medical reason for it in our records. They were asked what nonpharmacological interventions were in place to treat R23's behaviors. The Corporate Nurse stated, He is very easily redirected. The DON stated, I do know they have talked about him having behaviors. The Corporate Nurse and DON were asked what their expectations were of staff when a resident was exhibiting behaviors. The DON stated, Remove him from the situation and redirect. I would expect them to try to calm him and do other things before trying pharmaceutical. The DON and Corporate Nurse were asked if staff had requested more resources or asked to change assignments because of R23's behaviors. The DON stated, Not to my knowledge. The Corporate Nurse stated, Nothing was ever reported to me. The DON and Corporate Nurse were asked if the Haldol and Seroquel were a chemical restraint for R23. The Corporate Nurse stated, No, because he is still able to function with the medications. They were asked if the medications were used to control R23's behaviors. They stated, Yes.
During an interview on 02/13/24 at 5:03 PM, the Corporate Nurse and Assistant Director of Nursing (ADON) were asked why it was not identified by the facility that R23 had been prescribed antipsychotics to control behaviors. The ADON stated she would not say that nursing administration was unaware R23 was taking Haldol and Seroquel. The ADON stated they just used the wrong diagnosis. The ADON stated she was aware the resident was taking the Haldol and Seroquel but thought it was for agitation. The ADON was asked if it was appropriate to give a resident with dementia Haldol and Seroquel for agitation. The ADON stated, It isn't?
During an interview on 02/14/24 at 12:10 PM, the Consultant Pharmacist confirmed if both the Haldol and Seroquel were ordered for agitation and behaviors, that could be an issue. The Consultant Pharmacist confirmed that Haldol and Seroquel both had black box warnings and were not approved for treatment of patients with dementia related psychosis.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review, the facility failed to ensure one of one resident (Resident (R) 9...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review, the facility failed to ensure one of one resident (Resident (R) 94) and/or responsible party (RP) were given a written bed hold policy at the time the resident was transferred/discharged to the hospital of 29 sampled residents.
Findings include:
Review of a facility's policy provided by the facility titled, Bed Hold Notice Upon Transfer, dated 09/01/21, indicated .At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed.Before a resident is transferred to the hospital or goes on therapeutic leave, the facility shall provide to the resident and/or the resident representative information on the bed hold policy .
Review of R94's electronic medical record (EMR) titled admission Record located under the Profile tab, indicated the resident was admitted to the facility on [DATE] with a diagnosis of chronic respiratory failure.
Review of R94's EMR titled quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/02/23 indicated staff could not complete a Brief Interview for Mental Status (BIMS) score for the resident.
Review of R94's EMR titled nursing Progress Notes located under the Prog [Progress] Notes, dated 02/06/24, indicated the resident had a change in her condition and the clinical staff notified the medical provider who then ordered to transfer the resident to the local hospital for evaluation and treatment. The resident returned back to the facility on [DATE].
Review of R94's EMR failed to contain evidence the resident and/or her representative was provided a bed hold notice.
During an interview on 02/15/24 at 11:31 AM, the Corporate Nurse confirmed the facility did not provide a bed hold notice to R94 and/or her representative.
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 record review, interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure three residents (Resident (R) 98, R94, and R23) out of 29 sampled residents had an accurate Minimum Data Set (MDS) assessment. Failure to code the MDS correctly could potentially lead to inaccurate assessment and care planning of the resident.
Findings include:
Review of the RAI Manual, dated 10/01/19, indicated .It is important to note here that information obtained should cover the same observation period as specified by the Minimum Data Set (MDS) items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT (Interdisciplinary Team) completing the assessment .page 237 showed: Coding Instructions .F0300: Should Interview for Daily and Activity Preferences Be Conducted .Coding Instructions .Code 0, no .This option should be selected for residents who are rarely/never understood .
1. Review of R98's electronic medical record (EMR) titled admission Record located under
the Profile tab indicated the resident was admitted to the facility on [DATE].
Review of R98's EMR titled admission MDS with an Assessment Reference Date (ARD) of 10/23/23 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which revealed the resident was moderately cognitively impaired. The assessment indicated the resident was impaired on one side of her upper and lower extremities. The assessment indicated the resident had no weight loss/gain and weighed 123 pounds.
Review of R98's EMR titled quarterly MDS with an ARD of 01/23/24 indicated the resident had a BIMS score of nine out of 15. The assessment indicated the resident sustained no weight loss in the past 30-day of five percent or more. The assessment indicated the resident had no impairment of one side of her upper and lower body extremities. The assessment indicated the resident had no weight loss of 10 percent or more in the past six months. The assessment indicated the resident weighed 110 which was a 5.77 percent weight loss in the past 30-days and a 10.5 percent weight loss in the past six months. This contradicted the quarterly assessment of no weight loss sustained.
Review of R98's EMR nursing Progress Notes located under the Prog [Progress] Notes failed to indicate the resident had an impairment on one side of the resident's upper and lower body extremities.
2. Review of R94's EMR titled admission Record indicated the resident was admitted to the
facility on 02/18/22.
Review of R94's EMR titled physician Orders, dated 09/10/22, indicated the resident was ordered to receive aripiprazole (an atypical antipsychotic) five milligrams (mg) at bedtime.
Review of R94's EMR quarterly MDS with an ARD of 12/02/23 indicated the resident had a BIMS score of nine out of 15 which revealed the resident was moderately cognitively impaired. The assessment failed to identify the resident was being administered an antipsychotic.
During an interview on 02/14/24 at 9:56 AM, the Director of Nursing (DON) stated the MDS was to be accurate.
During an interview on 02/15/24 at 8:23 AM, the MDS Coordinator (MDSC) stated she had been on her own attempting to complete the MDS for the residents. The MDSC stated her department had turnover and an off-site Registered Nurse (RN) was completing the MDS's for the facility. The MDSC reviewed the EMR during this interview and confirmed the MDS was inaccurate for R98 for the weight loss and the impairment on one side of her body of her upper and lower extremities. The MDSC confirmed the MDS was inaccurate for R94, and the assessment did not identify the resident was on an antipsychotic.
3. Review of R23's admission Record, located under the Profile tab of the EMR, revealed R23 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included senile degeneration of the brain, epilepsy, and unspecified intellectual disabilities.
Review of R23's significant change MDS with an ARD of 10/26/23 and located under the MDS tab of the EMR, revealed R23 was assessed to be severely impaired in cognitive skills for daily decision making, had short-term and long-term memory problems, and was rarely or never understood; however, staff recorded that R23 was able to complete the Interview for Daily and Activity Preferences. It was documented R23 had indicated it was somewhat important to have books, newspapers, and magazines to read; very important to listen to music he liked, very important to be around animals such as pets; somewhat important to keep up with the news; very important to do things with groups of people; very important to do his favorite activities; very important to go outside to get fresh air when the weather was good; and somewhat important to participate in religious services or practices. It was recorded R23 was the primary respondent for the interview.
During an interview on 02/15/24 at 9:10 AM, the MDSC reviewed R23's significant change MDS, dated [DATE]. The MDSC confirmed that based on the cognitive level R23 was assessed to have, the Interview for Daily and Activity Preferences should not have been completed. The MDSC confirmed the assessment was inaccurate.
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, record review, and facility policy review, the facility failed to complete Pre-admission Screening and Resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to complete Pre-admission Screening and Resident Reviews (PASARR) as required for two of four sampled residents (Resident (R) 118 and R6) reviewed for PASARRs. R118 was admitted on [DATE] with a 30-day PASARR exception but was still a resident on 02/12/24. The facility did not perform a Level I PASARR screening after 30 days or refer for a Level II PASARR, if necessary, within 40 days of the resident's admission.
Findings include:
Review of the facility's policy titled, Resident Assessment - Coordination with PASARR Program, revised December 2022, revealed .Exceptions to the preadmission screening program include those individuals who .Are admitted directly from a hospital, require nursing facility services for the condition for which the individual received care in the hospital, and has been certified by the attending physician before admission that the individual is likely to require less than 30 days of nursing facility services .If a resident who was not screened due to an exception above and the resident remains in the facility longer than 30 days .The facility must screen the individual using the State's Level I screening process and refer any resident who has or may have MD [Mental Disorder], ID [Intellectual Disability] or a related condition to the appropriate state-designated authority for Level II PASARR evaluation and determination .The Level II resident review must be completed within 40 calendar days of admission .
1. Review of R118's admission Record located in the electronic medical record (EMR) under the Profile tab, revealed R118 was admitted to the facility on [DATE] with diagnoses that included generalized anxiety disorder, post-traumatic stress disorder (PTSD), major depressive disorder, and insomnia.
Review of R118's Level One Nursing Pre-admission Screening for Mental Illness, Intellectual Disability, or Related Condition, dated 05/22/23 and located under the Misc (Miscellaneous) tab of the EMR, revealed R118 had signs or symptoms of a major mental illness, had areas of impairment due to serious mental illness, had experienced a psychiatric treatment episode that was more intensive than routine care, had experienced at least one episode of significant disruption to his normal living situation, and met the criteria for a special admission to the facility for a stay not more than 30 days. It was recorded R118 would be a short-term resident at the facility for skilled rehabilitation and would return home independently. The form did not record if a Level 2 screening was indicated or if the resident had been referred for a Level 2 screening.
Review of R118's entire EMR revealed no documentation that the resident's stay at the facility had been interrupted for any reason. There was no documentation a PASARR had been completed for the resident after he was at the facility for 30 days.
On 02/12/24 at 9:00 AM, R118 was observed in his room at the facility. R118 stated he had been at the facility since his admission on [DATE].
During an interview on 02/15/24 at 11:43 AM, the Social Services Director (SSD) reviewed the PASARR dated 05/22/23 and confirmed this was the only PASARR for R118. The SSD confirmed the PASARR did not indicate if the Level 1 screening was positive, which would have required a Level II screening. The SSD confirmed the resident had been at the facility since his admission on [DATE]. The SSD confirmed that another screening should have occurred for R118, since his stay had exceeded 30 days.
2. Review of R6's Face Sheet located in the EMR under the admission Record tab, revealed an initial admission date of 08/21/23 from a hospital, and included, but was not limited to diagnoses which included bipolar disorder, major depressive disorder, and generalized anxiety disorder.
During an interview on 02/15/24 at 1:43 PM, the SSD stated that the facility failed to screen R6 for PASARR prior to admission to the facility. She stated that she was responsible for checking the screening and accuracy of PASARR assessments upon admission of a resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, review of the Resident Assessment Instrument (RAI) Manual, and facility policy review the fac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, review of the Resident Assessment Instrument (RAI) Manual, and facility policy review the facility failed to develop and implement a person-centered comprehensive plan of care with measurable goals and plans for three of 29 sampled residents (Resident (R) 130, R68, and R77) reviewed for care plans.
Findings include:
Review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, dated October 2019, indicated .Care Area Assessment (CAA) Process. This process is designed to assist the assessor to systematically interpret the information recorded on the MDS .The CAA process helps the clinician to focus on key issues identified during the assessment process so that decisions as to whether and how to intervene can be explored with the resident .Specific components of the CAA process include: - Care Area Triggers (CATs) are specific resident responses for one or a combination of MDS elements. The triggers identify residents who have or are at risk for developing specific functional problems and require further assessment .The MDS does not constitute a comprehensive assessment. Rather, it is a preliminary assessment to identify potential resident problems, strengths, and preferences. Care Areas are triggered by MDS item responses that indicate the need for additional assessment based on problem identification, known as 'triggered care areas,' which form a critical link between the MDS and decisions about care planning .
Review of a policy provided by the facility titled Comprehensive Care Plans, dated 09/01/21, indicated .The comprehensive care plan will be developed within 7 days after the completion of the comprehensive care plan .
1. Review of R130's electronic medical record (EMR) titled admission Record located under the Profile tab, indicated the resident was admitted to the facility on [DATE].
Review of R130's EMR titled physician Orders located under the Orders tab, dated 01/24/24, indicated the resident was ordered Thorazine 50 milligrams (mg) three times a day.
Review of R130's EMR titled quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/30/24 indicated the resident had a Brief Interview with Mental Status (BIMS) score of 14 out of 15 which revealed the resident was cognitively intact. The assessment indicated the resident was on an antipsychotic. The Care Area Assessment (CAA) triggered under the use of psychotropic medications and directed the clinical staff to develop a care plan.
Review of R130's EMR titled Care Plan located under the Care Plan tab failed to indicate the facility developed a care plan for the use of psychotropic medications.
During an interview on 02/15/24 at 8:23 AM, the MDS Coordinator (MDSC) confirmed R130's CAA directed the clinical staff to develop a care plan for the resident's use of psychotropic medication and the care plan was not developed.
2. Review of R68's admission Record located in the electronic medical record (EMR) under the Profile tab, indicated an admission date of 12/12/22 and a readmission date of 04/28/23 with diagnoses of aphasia, diabetes, and dependency on renal dialysis.
Review of R68's physician orders under the Order tab located in the EMR, dated 04/28/23, revealed Liberal Renal diet Regular texture, Regular/Thin consistency, with diabetic precaution.
Review of R68's Care Plan under the Care Plan tab in the EMR, dated 03/14/23 and revised 12/09/23, revealed there was no care plan for R68's nutrition.
During an interview on 02/14/24 at 10:00 AM, the MDSC was asked if there should be a care plan for nutrition for R68. After reviewing the care plan, the MDSC stated, Yes. There should be a care plan for his nutrition, he has aphasia and end stage renal dialysis and diabetic. The MDSC stated she had been at the facility since July 2023 and was still learning.
3. Review of R77's admission Record located in the EMR under the Profile tab revealed an admission date of 10/18/23 and a readmission date of 12/30/23 with diagnoses of chronic congestive heart failure and shortness of breath.
Review of R77's physician orders under the Order tab located in the EMR, dated 10/18/23, revealed Oxygen via nasal canula 2 liters per minute. Titrate to maintain oxygen at 88% or greater for shortness of breath.
Review of R77's Care Plan under the Care Plan tab in the EMR, dated 10/18/23 and revised 12/30/23, revealed there was no care plan for R77's oxygen.
During an interview on 02/14/24 at 10:00 AM, the MDSC was asked if there should be a care plan for R77's oxygen use. The MDSC stated, yes there should be a care plan for the oxygen. At one point we had people doing the care plans virtually unfortunately not everything was captured.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of facility policy, the facility failed to ensure one of five residents (Resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of facility policy, the facility failed to ensure one of five residents (Resident) (R) 98) and/or their representative was invited to participate in the resident's quarterly care plan meeting and the facility failed to update the activity care plan for one of seven residents (R23) reviewed for activities of 29 sampled residents.
Findings include:
Review of the facility's policy titled, Comprehensive Care Plans, revised 09/01/21, revealed, .The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment . The policy failed to contain information that the resident and/or the resident representative was to be invited on a quarterly basis.
1. Review of R98's electronic medical record (EMR) titled admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease.
Review of R98's EMR titled admission Minimum Data Set (MDS) with Assessment Reference Date of 10/23/23 indicated the resident had a Brief Interview for Mental Status (BIMS) of 10 out of 15 which indicated the resident was moderately cognitively impaired.
A review of R98's EMR failed to indicate the resident, and/or her representative was invited to quarterly care conference meetings which would have been held in 01/24.
During an interview on 02/13/24 at 12:41 PM, family member (FM) 1 for R98 stated she had not been invited to a care plan meeting.
During an interview on 02/14/24 at 3:48 PM, the Social Services Director (SSD) stated she typically invited the resident and/or resident representatives to care conferences on a quarterly basis when there was a change in the resident's status. The SSD stated she could not locate information that R98's representative was invited to the resident's care conference.
During an interview on 02/15/24 at 9:42 AM, the Director of Nursing (DON) stated her expectation was to invite the resident and/or the resident representative to the quarterly care conferences.
2. Review of R23's admission Record, located under the Profile tab of the EMR, revealed R23 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included senile degeneration of the brain, epilepsy, and unspecified intellectual disabilities.
Review of R23's Care Plan, revised 10/10/23 and located under the Care Plan tab of the EMR, revealed a focus problem, .has little or no activity involvement r/t [related to] apparent anxiety in group settings. Interventions included that R23 would participate in activities of his choice three times per week, would express interest in two new individual activity options consistently, and to investigate purpose-driven individual activities.
Review of R23's significant change MDS with an ARD of 10/26/23 and located under the MDS tab of the EMR, revealed R23 was assessed to be severely impaired in cognitive skills for daily decision making, had short-term and long-term memory problems, and was rarely or never understood; however, staff recorded that R23 was able to complete the Interview for Daily and Activity Preferences. It was documented R23 had indicated it was somewhat important to have books, newspapers, and magazines to read; very important to listen to music he liked, very important to be around animals such as pets; somewhat important to keep up with the news; very important to do things with groups of people; very important to do his favorite activities; very important to go outside to get fresh air when the weather was good; and somewhat important to participate in religious services or practices. It was recorded R23 was the primary respondent for the interview.
During an interview on 02/15/24 at 9:10 AM, the MDSC confirmed that R23's significant change MDS dated [DATE] was inaccurate. The MDSC stated R23 should not have been interviewed for his activity preferences due to being severely cognitively impaired. The MDSC stated if the interview had not been recorded as being conducted, activities would have triggered for care planning, and R23's activity care plan would have been reviewed. The MDSC confirmed that R23 did not participate in group activities and that his activity care plan should have addressed the resident's cognitive impairment and the need for staff involvement in one-on-one activities. The MDSC confirmed the activities care plan was not individualized for R23.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to provide timely incontinent ca...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to provide timely incontinent care; assistance with eating, drinking, and dressing; complete transfers in a safe manner; and/or provide showers as scheduled for two of four residents (Resident (R) 23 and R186) reviewed for activities of daily living (ADLs) of 29 sampled residents. R23 and R186 were dependent on staff for meeting their ADL needs. R23 was not provided incontinent care or offered and/or encouraged to have fluids during a three-hour observation, was not assisted with dining during one observation, and was not transferred in a safe manner. R186 was not assisted with showers twice weekly as care planned.
Findings include:
Review of the facility's policy titled, Safe Resident Handling/Transfers, dated 2021, revealed .It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines .
Review of the facility's policy titled, Activities of Daily Living (ADL)s, dated 09/01/21, revealed Policy: The facility will ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable .3. The resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene .
1. Review of R23's admission Record located in the electronic medical record (EMR) under the Profile tab, revealed R23 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included senile degeneration of the brain, epilepsy, and unspecified intellectual disabilities.
Review of R23's Care Plan located in the EMR under the Care Plan tab, revealed R23 had a focus problem, dated 04/05/22, of bladder/bowel incontinence related to dementia with severe cognitive impairment. Interventions included checking routinely and as needed for incontinence. Another focus problem, dated 07/02/23, was the potential for fluid deficit related to poor intake and dementia. Interventions included for staff to offer fluids frequently. Another focus problem, dated 07/02/23, was the ADL self-care performance and mobility deficit. Interventions included using a mechanical lift for transfers related to the resident's decline. Another focus problem, dated 10/13/23, was R23 might display periods of resistance to care related to anxiety, impulsiveness, and dementia. Interventions included reassuring R23 and leaving and returning five to ten minutes later and trying again if R23 was resistant to care.
Review of R23's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/26/24 and located under the MDS tab of the EMR, revealed R23 had a Brief Interview for Mental Status (BIMS) score of five out of 15, which indicated R23 was severely cognitively impaired. It was recorded R23 required supervision or touch assistance with eating, was dependent on staff for toileting and hygiene, was always incontinent of bladder and bowel, and was dependent on staff for transfers.
During a continuous observation on 02/12/24, from 10:20 AM until 11:43 AM, R23 was observed seated in his reclined Broda chair (a positioning wheelchair) in the area in front of the nurses' station on the 500-hall. R23 was not offered fluids or checked for incontinence during this time. At 11:43 AM, R23 was moved to the dining area. R23 remained in the dining room without being offered fluids or being checked for incontinence until 12:45 PM.
During continued observation on 02/12/24 at 12:45 PM, R23 was provided his noon meal, including a beverage. R23 fed himself the meal but did not attempt to drink any of the beverage. Staff did not encourage R23 to drink any fluid.
During continued observation on 02/12/24 at 1:22 PM, Certified Nurse Aide (CNA) 8 took R23 from the dining area to his room. CNA8 shaved R23 and at 1:40 PM, R23 was transferred to his bed. At this time, CNA8 checked R23 for incontinence. A small area of dried feces was noted on R23's sacral area, and CNA8 stated R23's incontinent brief was damp in the back. This was a continuous observation for over three hours, from 10:20 AM until 1:40 PM, where R23 was not checked for incontinence and was not offered or encouraged to have fluid intake.
During an observation on 02/13/24 at 8:30 AM, R23 was observed at the nurses' station, seated in his reclined Broda chair, with a sheet covering his lower body. At 8:32 AM, R23 was propelled to the dining area by Certified Nurse Aide (CNA) 7 and was placed in front of a table where R81 was seated. R23's Broda chair was placed in an upright position, and CNA7 left the dining area. R23 removed the sheet covering his lower body and placed it on the table. R23 was observed to have only an incontinent brief on his lower body. At 8:36 AM, CNA7 approached the table with breakfast plates for R23 and R81. CNA7 stated, We have to put this (the sheet) on you. R23 responded, No. CNA7 stated, We don't, I'll be right back. CNA7 left the dining area and returned at 8:38 AM with two drinks and napkins, stated, It's time to eat, and began to prepare the residents' plates. CNA6 approached the table with a drink for R23, removed the sheet from the table and started to put the sheet over R23's legs. CNA7 told CNA6, He will not leave it on. He yanked it off. CNA6 asked CNA7, Where is his stuff to cover him up? CNA7 did not reply and began attempting to feed R23. At 8:41 AM, CNA7 gave R23 one bite of food, but R23 pushed it out of his mouth. CNA7 immediately attempted to give him another bite, but R23 pushed it out of his mouth. CNA7 immediately asked R23 if he wanted a drink of chocolate milk, and he stated, No. CNA7 then said, I don't think he wants to eat. I'm going to take him to his room. At 8:43 AM, CNA7 stated, He's in a mood today. CNA7 asked CNA6 to help her put R23 back in bed. CNA6 obtained the sheet, covered R23, and CNA7 pushed R23 to his room.
During continued observation and interview on 02/13/24 at 8:44 AM, CNA7 and CNA6 were asked if they were going to put R23 in his bed. CNA7 stated, Yes. CNA7 stated, He's agitated right now. CNA7 placed a gait belt around R23's waist, and the CNAs placed their arms under R23's arms and lifted him from the chair to his bed. R23's knees were drawn up during the transfer, and his feet did not touch the floor, causing all the resident's weight to be placed on his shoulder joints. At 8:48 AM, CNA7 stated, I will let [Registered Nurse (RN) 3] know he is agitated. CNA7 was asked how she knew R23 was agitated. She stated, The way he was spitting out his food, the way he was grabbing his blankets and throwing them.
During an interview on 02/13/24 at 8:49 AM, CNA7 was asked how she knew what transfer method to use with residents. She stated there was a cheat sheet at the nurses' station that detailed which method to use. CNA7 reviewed the cheat sheet and confirmed there was no documentation related to R23 and how he was to be transferred. CNA7 stated, We just know our residents. CNA7 confirmed R23 had been taken out of his room, placed in the common area in front of the nurses' station, and then taken to breakfast in the dining area without having trousers on. CNA7 made no reply when asked why R23 did not have trousers on. CNA7 confirmed she had only attempted to give R23 two bites of food.
During an interview on 02/13/24 at 9:10 AM, RN3 confirmed that R23 could not dress himself and that all residents should have been dressed prior to leaving their rooms. RN3 confirmed that staff should have interacted with residents when attempting to feed them and should have tried different approaches if the resident was not eating. RN3 confirmed residents should have been offered fluids frequently, at least every two hours and with meals. RN3 stated staff could have transferred R23 using a two-person transfer now but that his feet should have touched the ground so that he could bear some of the weight. RN3 stated she was unaware that R23's care plan still called for the use of a mechanical lift for transfers. RN3 confirmed that residents should have been checked for incontinence at least every two hours.
During an interview on 02/13/24 at 3:42 PM, the Director of Nursing (DON) and Corporate Nurse were asked how R23 was supposed to be transferred. The DON reviewed R23's care plan and stated, Hoyer [mechanical] transfer. The DON stated her expectation was for staff to follow the care plan for transfers. The DON confirmed it was not safe practice to transfer a resident using a two-person transfer if the resident did not bear some of the weight on their feet. The DON and Corporate Nurse were asked how often residents should have been provided opportunities for hydration. The Corporate Nurse stated there was no specific hydration policy; however, fluids should be provided frequently. The DON and Corporate Nurse confirmed their expectation was for residents to be appropriately dressed before leaving their room and to be checked every two hours for incontinence. The DON stated her expectation was for staff to attempt to feed residents, and if there were problems, the resident should have been left alone for a few minutes and then staff should have attempted again or staff should have gotten someone else to assist them in trying to feed the resident.
2. Review of R186's admission Record located in the EMR under the Profile tab revealed an admission date of 12/04/23 with diagnosis of polyneuropathy, morbid obesity, pyogenic arthritis, difficulty walking, muscle weakness, and cellulitis of the left lower limb.
Review of the MDS assessment located in the EMR under the MDS tab, dated 12/07/23, revealed a BIMS score of 12 out of 15 indicating moderate cognitive impairment. Review of the functional abilities and goals indicated R186 was dependent on staff for bathing and toileting and R186 was incontinent of bowel and bladder.
During an interview on 02/14/24 at 12:08 PM, a family member (FM) 1 was asked about his concerns. FM1 stated that the staff were asked several times to keep up a bathing schedule for the residents, and the family's request was not followed. FM1 stated they wanted R186 to be showered more than twice a week.
Review of the Shower Sheets/ Skin Condition Report provided by the facility, revealed R186 received a shower or bed bath on 12/14/23, 12/28/23, 01/04/24, 01/11/24, 01/15/24, and 01/18/24. Nine showers were not provided.
During an interview on 02/14/24 at 9:10 AM, CNA2 was asked about what she recalled of R186. CNA2 stated R186 was very alert but sometimes had confusion. She stated during the day R186 could let them know when he needed to use the restroom, but at night was incontinent. CNA2 was asked why R186 did not receive a shower or bed bath for the 10 days after his admission. CNA2 stated she did not know why the resident didn't receive a shower or bed bath. CNA2 was asked how many showers a resident should have and CNA2 replied two showers a week.
During an interview on 02/14/24 at 3:01 PM, the DON was asked about showers. The DON stated residents should get two showers a week. The DON was asked what if a resident wanted more than two a week. The DON stated then they could have as many showers as they wanted. The DON was asked why R186 did not receive two a week and it was 10 days before a shower was documented. The DON stated, there should be more sheets we just have to go through them. I know if it is not documented then it did not happen.
During an interview on 02/15/24 at 8:30 AM, Licensed Practical Nurse (LPN) 1 was asked about showers and how they were assigned. LPN1 stated, When I come in, I look at who is scheduled to get a shower for the day and let the assigned CNA know. They have to fill out the shower sheet and I have to sign off. LPN1 was asked why R186 did not receive a shower for the first 10 days after admission and then did not get two a week. LPN1 stated she did not know why.
MO00230975
MO00231043
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure physician orders were followed for two of 29 sampled reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure physician orders were followed for two of 29 sampled residents (Resident (R)186, and R88). This failed deficiency had the potential to allow residents to go without needs being met or care being provided when physician's orders were not in place.
Findings include:
Review of the facility's policy titled, Blood Glucose Monitoring, dated 09/01/21, indicated It is the policy of this facility to perform blood glucose monitoring to diabetic residents as per physician's orders .The facility will perform blood glucose monitoring as per physician's orders .Report critical test results to physician timely.
Review of the facility's policy titled, Hypoglycemia Management, last revised 10/03/23, indicated It is the policy of this facility to ensure effective management of a resident who experiences a hypoglycemic episode .The facility will identify residents that are at risk for hypoglycemia and observe them for signs and symptoms of low blood glucose .Residents that have a diagnosis of diabetes or on medications that could lower the blood sugar should have orders for glucose monitoring and treatment of hypoglycemia, unless otherwise ordered by the practitioner .If the blood glucose reading is 70 mg/dL [milligrams per deciliter] or below, the nurse will utilize the hypoglycemic protocol as per the practitioner's orders, with follow up blood glucoses as indicated, and notify the practitioner of the results as ordered.
1. Review of R186's admission Record located in the EMR under the Profile tab revealed an admission date of 12/04/23 with diagnoses of polyneuropathy, morbid obesity, pyogenic arthritis, difficulty walking, muscle weakness, and cellulitis of the left lower limb.
Review of the admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 12/07/23 located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicating moderate cognitive impairment. Review of the functional abilities and goals indicated R186 was dependent on staff for bathing and toileting and R186 was incontinent of bowel and bladder.
During an interview on 02/14/24 at 12:08 PM, a family member (FM) 1 was asked about his concerns. FM1 stated that the staff were asked several times to keep up a bathing schedule for the residents, and the family's request was not followed. FM1 stated they wanted R186 to be showered more than twice a week.
Review of R186's Physician Orders located under the Orders tab in the electronic medical record (EMR) revealed on 12/04/23, Weekly Skin Assessment. Perform Skin assessment weekly. Every night shift every Thu [Thursday] if there are any new skin issues, identify on skin assessment.
Review of the Weekly Skin Check located under the Assessment tab in the EMR revealed a weekly skin Check was not performed the first 10 days after admission and during the week of 12/24/23 through 12/30/23.
Review of the All-Inclusive admission & Readmission located under the Assessment tab in the EMR, dated 12/04/23, revealed no issues with the skin.
During an interview on 02/14/24 at 9:26 AM, Certified Nursing Assistant (CNA) 2 was asked about R186 skin. CNA2 stated R186 had a rash in the groin area and abdomen.
During an interview on 02/14/24 at 9:26 AM, the Director of Nursing (DON) was asked about the weekly skin checks. The DON stated, I expect the skin checks to be completed weekly. The DON was asked about the rash in the groin area. The DON stated she was not aware of the rash.
During an interview on 02/15/24 at 8:30 AM, Licensed Practical Nurse (LPN)1 was asked about R186's skin. LPN1 stated she recalled that the resident had a rash in the groin area and up to the abdomen. LPN1 was asked when it was noted. LPN1 stated he was admitted with it. LPN1 was shown the assessment that indicated R186 was not admitted with the rash. LPN1 was asked about the weekly skin checks not being completed per the physician order. LPN1 stated I don't know why the weekly skin checks were not completed on a weekly basis.
2. Review of R88's EMR titled admission Record located under the Profile tab, indicated the resident was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including diabetes mellitus with hyperglycemia, diabetes mellitus with diabetic chronic kidney disease, long-term use of insulin, congestive heart failure, and hypertension.
Review of R88's EMR titled admission MDS with an ARD of 12/17/23 indicated the resident had a BIMS score of 14 out of 15 which revealed the resident was cognitively intact. R88 was documented to have received insulin injections for five of the last seven look-back days.
Review of 88's Care Plan, initiated on 02/13/24 and located in the EMR under the Care Plan tab, documented the resident used insulin. Interventions included to administer insulin as ordered by the physician and to monitor and document for side effects and effectiveness, to provide blood glucose monitoring per physician orders, and to monitor/document/report PRN (as needed) any signs and symptoms of hyperglycemia to give medications as ordered by physician and to monitor/document side effects and effectiveness.
Review of R88's EMR under the Orders tab revealed there was a 12/18/23 physician order for Insulin Lispro Injection Solution, Inject as per sliding scale: if 0-150=0; 151-200=1 unit; 201-250=2 unit; 251-300=3 unit; 301-350=4 unit; 351-400=5 units; 401-450=6 units, Call MD (Medical Doctor)/NP (Nurse Practitioner) if BG (blood sugar)> 450. Subcutaneously before meals for DM2.
Review of R88's EMR under the Orders tab revealed there was a 01/21/24 physician order for Narcan 4 mg, one spray into one nostril, may repeat every two minutes in alternating nostrils until resident is responsive or until EMS (emergency medical service) arrives, every two minutes as needed for overdose. This was ordered originally for R88's pain medication, not for low blood sugar.
Review of R88's EMR under the Orders tab revealed there was a 12/13/23 physician order for Baqsimi One Pack Nasal Powder 3 mg/dose (Glucagon), 3 mg in nostril as needed for low blood ugar (sic). The physician order did not identify the parameters of when to use the medication for low blood sugar. This was not provided per physician order.
Review of R88's EMR under the Orders tab revealed there was a 02/08/24 physician order for Glucagon Emergency Kit 1 mg, inject 1 mg intramuscularly as needed for blood glucose below 70 and if unresponsive. This was not done, prior to emergency service arrival.
Review of R88's EMR under the Orders tab revealed under the February 2024 Treatment Administration Record (TAR) that the resident's blood sugar was documented on 02/08/24 at 12:00 PM at 238 mg/dL and received Insulin per sliding scale as ordered.
Review of R88's EMR titled nursing Progress Notes located under the Prog [Progress] Notes tab, dated 02/08/24, indicated the resident's family was concerned about a change in condition and came to the nurse for assistance with his blood sugar. R88's blood sugar was documented at 44 mg/dL, blood pressure was 144/78, temperature 98.9, respirations 16, and oxygen saturation was 95% on room air. The resident was offered orange juice but was unable to perform swallow motion with mouth. Narcan was given in left nostril per family request. Call place to 911 ambulance EMT x 2 (two emergency medical team members) arrived and began to check vitals. Resident was sent to the hospital. Resident was readmitted to the facility on [DATE].
During an interview on 02/14/24 at 2:00 PM, R88 stated that his blood sugar went high and low a lot. He stated that he was able to keep track of his blood sugar on his phone and displayed that the graph for his blood sugar monitoring indicated it was not well controlled. R88 stated that this was normal for him. R88 confirmed that he was non-compliant with his diabetic diet and supplements and was not worried about high blood sugar levels, only the low levels. He stated that he went out to the hospital recently for low blood sugar levels, and that the facility staff had tried to get him to eat and drink something beforehand.
During an interview on 02/15/24 at 10:22 AM, the DON stated that R88 was displaying signs and symptoms of hypoglycemia and the resident's family was at the bedside. She stated that the resident had received insulin earlier per physician order and had eaten. The family came and told LPN4 that R88 looked different, and when LPN4 checked his blood sugar it was in the 40's. LPN4 tried to get the resident to drink something to get his blood sugar up, and then she called the ambulance. She stated LPN4 tried to give him sugar. The DON stated when she came to see R88 he was awake but not coherent and could tell his blood sugar was low. She stated that the family requested to administer him Narcan because that was what they gave him when he was hypoglycemic. The DON stated she had never heard of that, but she and LPN4 were trying to make sure the family had not given R88 something that would need the administering of Narcan. She stated that per her thought process, maybe the family gave R88 something that would require the Narcan. She stated they told the family they did not normally do that, but the family was insistent. The DON stated that they did not want to take the chance that the family had given him something. She stated she knew the Narcan would have no negative effects for the resident, and it would be quick onset. The DON stated that the physician and the emergency medical team agreed that the Narcan would have no negative affect. The DON stated that normally she would expect LPN4 to give R88 something to raise his blood sugar, and that he did have a physician order for Glucagon. She stated that she believed LPN4 had attempted to get the Glucagon, but the ambulance was already on its way, and by the time they had the Glucagon ready, the emergency medical team was already there. The DON stated that when the Glucagon was being pulled, they did not have the Glucagon powder as it was originally ordered by the physician, so the physician order was changed on 02/08/24 for the Glucagon gel that they did have. She stated that it was not ultimately used because by the time they had the Glucagon gel, the emergency medical team had administered the IV (intravenous) Dex10 (Dextrose). The DON confirmed that she expected the nursing staff to follow the hypoglycemic protocol before anything else, and the low blood sugar parameters should have been identified on the physician orders for clarification.
During an interview on 02/15/24 at 11:57 AM, LPN4 stated that she had checked the blood sugar for R88 that morning and afternoon and it was in normal limits, and she had administered insulin. LPN4 stated that at 1:00 PM on 02/08/24 R88 had been fine, and 45 minutes later the family that was present said he was not looking like himself. LPN4 stated that the resident had a Dexcom Continuous Glucose Monitoring system that let the resident and family check the blood sugar levels on R88's phone, and the resident's blood sugar had now dropped to the 40's. LPN4 stated she took a new blood sugar reading to get an accurate reading and it was in the 40's. She stated the Director of Nursing was present and told her to do whatever she could to get his blood sugar raised. LPN4 said she tried to give him orange juice and mouth swabs to get his blood sugar up, but the resident was non-compliant. LPN4 said that the resident had an order for nasal Glucagon spray, but the family that was present requested the use of Narcan, stating that it was what they administered at home. She stated that was why they administered the Narcan, and when there was no change in his condition, they went to administer the Glucagon. LPN4 stated the emergency medical team arrived and administered the IV (intravenous) Dex10 which boosted his blood sugar dramatically, before they could provide the Glucagon. She said that the regular hypoglycemia process was to give the resident something sweet or peanut butter crackers or something to increase their blood sugar baseline, and then recheck it. LPN4 stated that she would consider following the hypoglycemic protocol when with blood sugar about 80 mg/dL, but she confirmed the resident's had the physician order for nasal Glucagon did not include any parameters.
During an interview on 02/15/24 at 2:59 PM, the Medical Director stated that he would have considered the need for hypoglycemic protocol for a resident if their blood sugar was approximately 30-40 mg/dL. He stated at that point the nurse would be expected to give Glucagon. The Medical Director was not aware of the use of Narcan in a hypoglycemic situation but stated that if the nurse had given that first, and it did not work, he would then expect the nurse to go ahead and give the Glucagon. He could not recall the hypoglycemic event for R88.
MO00230975
MO00231043
MO00231652
CONCERN
(D)
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, record review, staff interviews, and facility policy review, the facility failed to create a care plan, wi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interviews, and facility policy review, the facility failed to create a care plan, with specific approaches, which addressed one of four residents (Resident (R) 98)'s diagnosis of malnutrition upon admission. The facility failed to ensure a dietary intervention was properly implemented as directed by the resident's care plan that addressed potential weight loss. The facility failed to ensure the physician provided a clinical rationale for the resident's significant weight loss. This had the potential to increase the resident's opportunity for unintended weight loss.
Findings include:
Review of the facility's policy titled, Weight Management, dated 09/01/22, indicated .Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise .Developing and consistently implementing pertinent approaches .Monitoring the effectiveness of interventions and revising them as necessary .Information gathered from the nutritional assessment and current dietary standards of practice are used to develop an individualized care plan to address the resident's specific nutritional concerns and preferences .
Review of R98's electronic medical record (EMR) titled admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE] with a diagnosis of protein-calorie malnutrition.
Review of R98's EMR titled Care Plan located under the Care Plan tab, dated 10/12/23, indicated the resident was at risk nutritionally due to history of protein-calorie malnutrition. On the care plan was an intervention to invite the resident to activities that promoted additional intake. There were no other specific interventions identified which would assist the staff to identify problems with a resident who had a diagnosis of malnutrition.
Review of R98's EMR titled admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/23/23 with a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which revealed the resident was moderately cognitively impaired. The assessment indicated the resident weighed 123 pounds and revealed the facility was unaware of any current weight loss. Under the Care Area Assessment revealed nutrition did not trigger and did not indicate the resident should be care planned for being at risk nutritionally.
Review of R98's EMR titled Nutritional Assessment located under the Assmnts (Assessments) tab, dated 11/23/23, indicated the resident was admitted to the facility on a regular diet and had fair intake by mouth. The assessment revealed the resident was on the low end of ideal body range with a Body Mass Index of 19.7.
Review of R98's EMR titled quarterly MDS with an ARD of 01/23/24 indicated the resident had a BIMS score of 9 out of 15 which indicated the resident was moderately cognitively impaired. The assessment indicated the resident was independent with eating. The assessment indicated the resident weighed 110 pounds. This was a 10.5 percent weight loss since her last comprehensive assessment.
Review of R98's EMR titled Registered Dietician (RD) under the Progress Notes tab, dated 01/31/24, indicated the RD recommended health shakes for lunch and dinner. The health shakes were ordered twice a day, 02/01/24.
Review of R98's clinical record failed to indicate if the resident's weight loss was avoidable or unavoidable.
During an observation on 02/13/24 at 9:41 AM, Registered Nurse (RN) 2 sat next to R98 and assisted her with her breakfast meal. During this observation, RN2 stated the resident ate approximately 20 percent of her meal. The resident was served oatmeal and scrambled eggs. At 9:56 AM, the resident refused to eat any more of her meal.
During an interview on 02/13/24 at 11:47 AM, the Activity Assistant (AA) stated the only time food was provided during activities were around the holidays. The AA stated she had on occasion provided residents with an activity that involved [NAME] Crispies, and this was used by the residents to manipulate its form.
During an interview on 02/13/24 at 2:39 PM, the RD stated she came to the facility twice a month and if a resident required supplements, she would write the orders for the supplement. The RD stated the MDS Coordinator developed the care plans for the residents. The RD stated the activity program, would supplement the resident's overall intake, and not replace it. The RD stated she did not develop the R98's care plan.
During an interview on 02/14/24 at 9:56 AM, the Director of Nursing (DON) stated a request was made to identify a physician note which addressed the resident's significant weight loss and if it was avoidable or not.
During an interview on 02/15/24 at 8:23 AM, the MDS Coordinator (MDSC) confirmed she created the residents' care plans. The MDSC confirmed she was the person who created the intervention of providing R98 food-based activities, since in her previous positions at other facilities, activities played a part in the overall roll in the care of the resident by providing consistent snacks. The MDSC stated the facility had a risk management meeting weekly. The MDSC confirmed she had failed to place more appropriate interventions to address the resident's weight loss. During this interview, the MDSC went through the EMR and confirmed there were no physician notes that addressed if the resident's significant weight loss was unavoidable or not.
During an interview on 02/15/24 at 3:47 PM, the physician, who was also the facility's Medical Director, stated R98's weight loss was unavoidable based on her diagnosis of dementia but was unsure if he wrote an assessment which identified this in his progress notes. The Medical Director stated he would need to defer to the DON. The DON was present during this interview and confirmed the Medical Director did not have progress notes which indicated the resident's weight was unavoidable.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, interview, record review and facility policy review, the facility failed to ensure the oxygen concentrator was cleaned, had a filter on the inlet where the air came into the mach...
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Based on observation, interview, record review and facility policy review, the facility failed to ensure the oxygen concentrator was cleaned, had a filter on the inlet where the air came into the machine, and ensured an E cylinder was secured for one of one resident (Resident (R) 77) of 29 sampled residents. This deficient practice had the potential to allow for an increased chance of infection and the improper storage of the cylinder causing severe injury.
Findings include:
Review of the facility's policy titled, Cleaning and Disinfection of Resident- Care Equipment, dated 09/01/21, revealed Policy: Resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC [Centers for Disease Control] recommendations in order to break the chain of infection .
Review of the facility's policy titled, Oxygen Concentrator, dated 09/01/21, revealed Policy: The purpose of this policy is to establish responsibilities for the care and use of oxygen concentrators.5. Care of the Concentrator: a. Follow manufacturer recommendations for frequency of cleaning filters and servicing the device. b. Only trained individuals such as the Maintenance Director or supplier shall service the device. iv. The main body cabinet should be dusted when needed and can be wiped clean with a damp cloth and mild household cleaner if necessary .
Review of the facility's policy titled, Oxygen Safety, dated 09/01/21, revealed Policy: It is the policy for this facility to provide a safe environment for residents, staff, and the public. This policy addresses the use and storage of oxygen and oxygen equipment. Oxygen Storage . c. Cylinders will be properly chained or supported in racks or other fastening (i.e., sturdy portable carts, approved stands) to secure all cylinders from falling whether or connected or unconnected, full, or empty .
Review of R77's admission Record located in the EMR under the Profile tab revealed an admission date of 10/18/23 and a readmission date of 12/30/23 with diagnoses of chronic congestive heart failure and shortness of breath.
Review of R77's physician orders under the Order tab located in the EMR, dated 10/18/23, revealed Oxygen via nasal canula 2 liters per minute. Titrate to maintain oxygen at 88% or greater for shortness of breath.
During an observation on 02/12/24 at 11:07 AM, R77 was sitting up in a wheelchair with a nasal cannula in her nose. The nasal cannula was attached to the concentrator. The concentrator body cabinet was dusty and had debris on the front of the machine. There was no filter on the inlet where the air enters the machine. There was an E-cylinder standing up in the corner freestanding with no security.
During an observation on 02/12/24 at 2:10 PM, R77 was lying in the bed with a nasal cannula in her nose. The nasal cannula was attached to the concentrator. The concentrator body cabinet was dusty and had debris on the front of the machine. There was no filter on the inlet where the air enters the machine. There was an E-cylinder standing up in the corner freestanding with no security.
During an observation on 02/14/24 at 9:45 AM, R77 was lying in bed with a nasal cannula on top of the machine. The nasal cannula was attached to the concentrator. The concentrator body cabinet was dusty and had debris on the front of the machine. There was no filter on the inlet where the air enters the machine. There was an E-cylinder standing up in the corner freestanding with no security.
During an observation and interview on 02/14/24 at 9:50 AM alongside the Licensed Practical Nurse (LPN) 1 and the Director of Nursing (DON), both LPN1 and the DON stated the concentrator machine was dirty. They were both asked about the filter on the back not being there. The DON stated that the filter should be there, and that maintenance should have been checking the filters and cleaning them. The DON then went over to the corner where the unsecured E-Cylinder was located. The DON picked it up and started to take it out of the room. The DON was asked why she picked up the E-cylinder and took it out of the room. The DON stated, The E cylinder was unsecure and should have been placed in a cart.
During an interview on 02/15/24 at 8:15 AM, the Maintenance Director (MD) was asked about cleaning the concentrators and the filters being in place. The MD stated he was not aware of having to check the concentrators for cleanliness and making sure the filters were cleaned and in place.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
Based on record review, document review, interviews, and review of the facility assessment, the facility failed to ensure one Licensed Practical Nurse (LPN) 3 was competently trained to read the resul...
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Based on record review, document review, interviews, and review of the facility assessment, the facility failed to ensure one Licensed Practical Nurse (LPN) 3 was competently trained to read the results of a radiology report for one of one resident (Resident (R) 98) of 29 sampled residents. (Cross Reference F777).
Findings include:
Review of a document provided by the facility titled Facility Assessment Tool, dated 12/06/23, indicated .Staff training, education is conducted by in-services, 1 on l training, and education packets with posttests .
Review of LPN3's employee file indicated the staff member was hired on 12/14/23.
Review of a document provided by the facility titled Position Description for an LPN, dated 11/20/16, indicated .Works under direct supervision in accordance with the state-specific Nurse Practice Act, facility Policies and Procedures, and nursing judgment .Delivers nursing care to patients/residents requiring long-term or rehabilitative care .Collects patient/resident data, makes observations, and reports pertinent information related to the care of the patient/resident .
Review of R98's electronic medical record (EMR) titled nursing Progress Notes, dated 01/26/24, indicated the resident had an unwitnessed fall. On 01/28/24 there was an increase in pain and swelling. The physician was notified and ordered an x-ray.
Review of R98's electronic medical record (EMR) titled Radiology Results Report located under the Misc (Miscellaneous) tab, dated 01/29/24, indicated the resident had negative fracture report. LPN3 signed off on the document and indicated the Nurse Practitioner was notified of the negative results on this same date.
Review of R98's EMR titled nursing Progress Notes located under the Prog (Progress) Notes, dated 02/02/24, indicated Registered Nurse (RN) 2 read the previous 01/29/24 x-ray results and indicated the resident had a positive fracture. RN2 called and notified the medical provider and the medical provider ordered to send the resident to the local emergency room for evaluation and treatment. The resident returned this same day back to the facility.
Review of a document provided by the facility titled Investigative Summary, dated 01/26/24, revealed LPN3 misread the x-ray results from 01/29/24. The investigation revealed LPN3 did not read the second page of the x-ray results which would have identified the positive fracture that the resident sustained. Disciplinary action was given to LPN3.
During an interview conducted on 02/14/24 at 9:56 AM, the Director of Nursing (DON) stated LPN3 did not show up for work on 02/12/24 and had not responded to her calls to be interviewed by the survey team. The DON stated her expectation was for nursing to be competent in their nursing skills.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure medication irregularities were identified and reported by th...
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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 medication irregularities were identified and reported by the Consultant Pharmacist for one of six residents (Resident (R) 23) reviewed for medication regimens of 29 sampled residents. R23 was prescribed Haldol and Seroquel, both antipsychotic medications with Black Box Warnings, without adequate indication for use. (Cross Reference F605)
Findings include:
Review of R23's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R23 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included senile degeneration of the brain, epilepsy, and unspecified intellectual disabilities.
Review of R23's Medication Administration Records (MARs) and Treatment Administration Records (TARs), dated October 2023 and located under the Orders tab of the EMR, revealed no documentation R23 had displayed any behaviors, agitation, or physical aggression towards others.
Review of R23's Progress Notes, dated 10/01/23 through 10/30/23 and located in the EMR under the Progress Notes tab, revealed documentation R23 had two episodes of non-aggressive behaviors. It was documented that the resident's behaviors were addressed through non-pharmacological interventions.
Review of R23's hospice Residential Communication Forms, dated 10/01/23 through 10/29/23 and located in the hospice binder, revealed documentation R23 had two episodes of behaviors. It was documented on 10/19/23 that R23 was combative yesterday, did calm down. There was no documentation to show what the combative behaviors were. It was documented on 10/23/23 that R23 tried to bite this nurse during xfer [transfer]. There was no documentation to show what the circumstances were or what the triggers might have been. There was no documentation to show what de-escalated R23's behaviors or how the environment was modified.
Review of R23's hospice Residential Communication Form, dated 10/30/23 and located in the hospice binder, revealed medication changes were ordered for R23, including the addition of Haldol and Seroquel, both of which were antipsychotic medications.
Review of R23's Physician Orders, dated 10/30/23 and located under the Orders tab of the EMR, revealed Haldol 0.5 milligrams (mg) twice daily and Seroquel 25 mg every night were ordered for R23 for agitation and behaviors.
In the EMR, under the Orders tab and next to the listing for R23's Haldol order was a black box. When the black box was selected, the following appeared on the screen:
Order: Haloperidol [Haldol] Tablet 0.5 MG Black Box Warning: Increased mortality in elderly patients with dementia-related psychosis Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Analyses of 17 placebo-controlled trials (modal duration, 10 weeks), largely in patients taking atypical antipsychotic drugs, revealed a risk of death in drug-treated patients of between 1.6 to 1.7 times the risk of death in placebo-treated patients. Over the course of a typical 10-week controlled trial, the rate of death in drug-treated patients was about 4.5% compared with a rate of about 2.6% in the placebo group. Although the causes of death were varied, most of the deaths appeared to be cardiovascular (eg, heart failure, sudden death) or infectious (eg, pneumonia) in nature. Observational studies suggest that, similar to atypical antipsychotic drugs, treatment with conventional antipsychotic drugs may increase mortality. The extent to which the findings of increased mortality in observational studies may be attributed to the antipsychotic drug as opposed to some characteristic(s) of the patients is not clear. Haloperidol is not approved for the treatment of patients with dementia-related psychosis.
In the EMR, under the Orders tab and next to the listing for R23's Seroquel order was a black box. When the black box was selected, the following appeared on the screen:
Quetiapine Fumarate [Seroquel] 25 MG Tablet Black Box Warning: Increased mortality in elderly patients with dementia-related psychosis Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Quetiapine is not approved for the treatment of patients with dementia-related psychosis. Suicidal thoughts and behavior
Antidepressants increase the risk of suicidal thoughts and behavior in children, adolescents, and young adults in short-term studies. These studies did not show an increase in the risk of suicidal thoughts and behavior with antidepressant use in patients older than 24 years; there was a reduction in risk with antidepressant use in patients 65 years and older. In patients of all ages who are started on antidepressant therapy, monitor closely for clinical worsening and for emergence of suicidal thoughts and behaviors. Advise families and caregivers of the need for close observation and communication with the prescriber. Quetiapine is not approved for use in pediatric patients younger than 10 years.
Review of R23's entire EMR and hospice binder revealed no documentation to show why Haldol and Seroquel were ordered for R23. There was no documentation of a medical symptom for the use of the medications.
During an interview on 02/13/24 at 5:03 PM, the Corporate Nurse was asked to provide Medication Regimen Reviews for R23. The Corporate Nurse provided Resident Monthly Attestation sheets for October 2023 through January 2024. The Corporate Nurse stated if a resident's name was listed on the sheet, it meant their medication regimen had been reviewed and no irregularities were noted.
Review of the Consultant Pharmacist Resident Monthly Attestation sheets, dated 11/18/23, 12/12/23, and 01/16/24, revealed documentation R23's medication regimen had been reviewed and no irregularities were noted.
During an interview on 02/14/24 at 12:10 PM, the Consultant Pharmacist was asked why the use of the Haldol and Seroquel for R23 was not identified as an irregularity and reported on during the reviews dated 11/18/23, 12/12/23, and 01/16/24. The Consultant Pharmacist stated he thought Seroquel was being used for major depression and Haldol was being used for psychosis. The Consultant Pharmacist confirmed he did not substantiate those thoughts with record review. The Consultant Pharmacist confirmed if both of the medications were ordered for agitation and behaviors, that could be an issue. The Consultant Pharmacist confirmed that Haldol and Seroquel both had black box warnings and were not approved for treatment of patients with dementia related psychosis.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, hospital record review, manufacturer guideline review, interview, and facility policy review, the facili...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, hospital record review, manufacturer guideline review, interview, and facility policy review, the facility failed to ensure one of five residents (Resident (R) 130) reviewed for unnecessary medications of 29 sampled residents had appropriate indications for use for an antipsychotic (Thorazine), failed to have proper black box warnings, and failed to ensure behaviors and side effects were monitored associated with this medication.
Findings include:
Review of a facility's policy titled, Use of Psychotropic Drugs, dated 09/01/21, indicated .Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s) .
Review of the National Institute of Health at https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=d43718e5-66d7-44f9-9fc8-80d38d3e41ce&type=display, revised 10/22, revealed .Increased Mortality in Elderly Patients with Dementia-Related Psychosis Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death . Retrieved on 02/15/24.
Review of R130's electronic medical record (EMR) titled located under the Misc [miscellaneous] tab titled Emergency Room, dated 12/21/23, indicated the resident had a psychotic episode and destroyed her room of her family's home. The emergency room records revealed the resident had no prior psychiatric diagnosis but did have a history of dementia. The resident was placed on Thorazine 50 milligrams (mg) three times a day to treat her violence to self and to others.
Review of R130's EMR titled admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, unspecified severity, without behavioral disturbances, psychotic disturbance, mood disturbance, and anxiety.
Review of R130's EMR titled physician Orders located under the Orders tab, dated 01/24/24, indicated the resident was to be administered chlorpromazine (Thorazine) HCI (hydrochloride) three times a day to treat agitation and anxiety.
Review of R130's EMR titled admission Minimum Data Set (MDS) with an Assessment Reference Date of 01/30/24 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 and revealed the resident was cognitively intact. The assessment indicated the resident was on an antipsychotic medication.
Review of R130's EMR titled Care Plan failed to contain information of the resident's antipsychotic medication use, there was no reference to a black box warning for the use of Thorazine, and there was no reference to monitor associated behaviors or side effects from the use of the antipsychotic medication.
Review of R130's EMR titled Medication Administration Record (MAR) located under the Orders tab, dated 01/24 and 02/24, failed to contain information on the monitoring of behaviors and side effects associated with the use of Thorazine.
Review of R130's EMR titled nursing Progress Notes failed to contain information on the resident's behaviors associated with the use of Thorazine and any side effects.
During an interview on 02/14/24 at 12:32 PM, the Consultant Pharmacist stated the medications a resident was sent with while in the hospital was typically not adjusted for four to six months since the resident was in a new environment. The Consultant Pharmacist stated he would look at the progress notes and the physician notes for behaviors that were being monitored. The Consultant Pharmacist stated Thorazine was not recommended for people with dementia since there was an increased risk of death with use.
During an interview on 02/15/24 at 8:23 AM, the MDS Coordinator (MDSC) stated she had not worked at the facility during her time employed with the facility. The MDSC stated she would typically see an order for monitoring behaviors and side effects in the EMR, and black box warnings. The MDSC reviewed the EMR during this interview and verified there were no orders for R130 to monitor behaviors and side effects. The MDSC stated the diagnosis of anxiety was not a proper indication for use of Thorazine and confirmed homicidal ideation was the diagnosis identified while the resident was in the hospital.
During an interview on 02/15/24 at 9:42 AM, the Director of Nursing (DON) stated her expectation was for staff to monitor the side effects of the use of Thorazine with R130 and have proper indications for use.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0777
(Tag F0777)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of facility policy, the facility failed to ensure the radiology report was read c...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of facility policy, the facility failed to ensure the radiology report was read correctly for one of one resident (Resident (R) 98), by one Licensed Practical Nurse (LPN) 3 and as a result there was a delay in care after the resident sustained an acute fracture of the proximal humerus.
Findings include:
Review of the facility's policy titled, Laboratory Services and Reporting, dated 09/01/21, indicated .The facility must provide or obtain laboratory services when ordered by a physician, physician assistance, nurse practitioner, or clinical nurse specialist in accordance with state law.Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside the clinical reference range.
Review of R98's electronic medical record (EMR) titled admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE].
Review of R98's EMR titled admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/23/23 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which revealed the resident was moderately cognitively impaired. The assessment indicated the resident was able to ambulate on her own.
Review of R98's EMR titled nursing Progress Notes located under the Prog (Progress) Note tab, dated 01/26/24, indicated the resident sustained an unwitnessed fall and had no injuries. On 01/28/24 the resident complained of pain to her left arm. The nurse assessed the area and identified swelling. The nurse notified the resident's physician, and the physician ordered an x-ray. The nursing progress notes revealed on 01/29/24, LPN notified the physician and resident representative of the negative x-ray findings. The progress notes revealed there were no new orders received.
Review of R98's electronic medical record (EMR) titled Radiology Results Report located under the Misc (Miscellaneous) tab, dated 01/29/24, indicated the resident had negative fracture report. LPN3 signed off on the document and indicated the Nurse Practitioner was notified of the negative results on this same date. On 02/02/24 the nursing progress notes revealed a nurse had identified the resident did sustain a fracture, the physician was notified, and ordered the resident to be sent to the local hospital for evaluation and treatment. R98 later returned back to the facility on this same day.
Review of a document provided by the facility titled Radiology Reports, dated 01/29/24, indicated R98 sustained an acute fracture of the proximal humerus.
During an interview on 02/14/24 at 9:56 AM, the Director of Nursing (DON) stated her expectation was for the clinical staff to read the entire x-ray results and confirmed LPN 3 read the results from the first page of the radiology report.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to provide influenza vaccines for two of five...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to provide influenza vaccines for two of five residents (Resident (R) 23 and R118) reviewed for immunizations of 29 sampled residents.
Findings include:
Review of the facility's policy titled, Infection Prevention and Control Program, revised 09/01/22, revealed .Influenza .Immunization: a. Residents will be offered the influenza vaccine each year between October 1 and March 31 unless contraindicated or received the vaccine elsewhere during that time .
1. Review of R23's admission Record located under the Profile tab of the electronic medical record (EMR), revealed R23 was admitted to the facility on [DATE] with diagnoses that included senile degeneration of the brain, epilepsy, and unspecified intellectual disabilities.
Review of R23's Physician Orders, dated 06/26/21 and located under the Orders tab of the EMR, revealed a physician's order for R23 to have the influenza vaccination yearly unless contraindicated.
Review of R23's Immunization information, located under the Immun (Immunization) tab of the EMR, revealed documentation of the last influenza vaccine provided to R23 was on 11/08/21.
During an interview on 02/14/24 at 4:17 PM, the Infection Preventionist (IP) was asked when influenza vaccinations were provided to the residents for the 2023-2024 influenza season. The IP stated the vaccines had been provided during November 2023. The IP was asked why R23 did not receive an influenza vaccine during that time. She stated she was waiting on the Power of Attorney (POA) to give consent for it, and she had not heard back from the POA. The IP stated she had called the POA twice.
On 02/13/14 at 11:49 AM, a call was placed to R23's POA, and a message was left. The POA returned the phone call on 02/13/14 at 12:28 PM.
2. Review of R118's admission Record located under the Profile tab of the EMR, revealed R118 was admitted to the facility on [DATE] with diagnoses that included type two diabetes mellitus, generalized anxiety disorder, and major depressive disorder.
Review of R118's Physician Orders located under the Orders tab of the EMR, revealed no documentation of a physician's order for an influenza vaccination.
Review of R118's Immunization information, located under the Immun tab of the EMR, revealed no documentation for an influenza vaccine was provided or offered and declined to R118.
During an interview on 02/14/24 at 4:20 PM, the IP stated she did not know if the resident was at the facility when influenza vaccines were provided. She stated R118 might have been out at the hospital when she completed the vaccinations because she was pretty sure she vaccinated everyone. The IP was asked if R118 had been out at the hospital, why was his vaccination not completed when he returned. The IP reviewed R118's clinical record, stated he had not been out of the facility, and confirmed, I'm not sure how he got missed.
During an interview on 02/15/24 at 10:51 AM, the Director of Nursing (DON) stated it was her expectation for residents to be provided the influenza vaccine per physician orders and policy. The DON stated if a resident did not have an order for an influenza vaccine, she expected staff to obtain an order and administer the vaccine if not contraindicated. The DON confirmed she expected staff to continue to try and obtain consent for an influenza vaccine until it was either obtained or consent was refused.
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 F0565
(Tag F0565)
Could have caused harm · This affected multiple residents
Based on interview, record review, and facility policy review, the facility failed to ensure grievances shared at the monthly meetings by seven of the members of resident council who regularly attend ...
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Based on interview, record review, and facility policy review, the facility failed to ensure grievances shared at the monthly meetings by seven of the members of resident council who regularly attend (Residents (R) 7, R17, R29, R70, R92, R101, and R104) were resolved or a rational provided.
Findings include:
Review of the facility policy titled, Resident and Family Grievances, dated 09/01/21, revealed Policy: It is the policy of this facility to support each resident's and family member's right to voice a grievance without discrimination, reprisal or fear of discrimination or reprisal. Community Administrator has been designated as the Grievance Official. g. In accordance with the resident's right to obtain a written decision regarding his or her grievance, the Grievance Official will issue a written a written decision on the grievance to the resident or representative at the conclusion of the investigation. 12. The facility will make prompt efforts to resolve grievances.
Review of the monthly Resident Council minutes provided by the facility, dated August 2023 through January 2024, revealed reoccurring grievances every month with call lights not being answered timely by nursing staff, food being cold from dietary, missing clothing from laundry,
More activities available on the weekends, and social services being more proactive. The resident council minutes did not include resolution.
During a group interview on 02/13/24 at 10:13 AM, The residents (R7, R17, R29, R70, R92, R101, and R104) were asked about the grievance process. R92 mentioned they knew how to file a grievance and they felt comfortable making a grievance at the meetings. The residents were asked about the repeated grievances that were brought to the monthly meeting and if they felt there was any resolution to those grievances. All the residents laughed. R101 stated, We never get any feedback or resolutions from the meetings. No one comes and talks to us about the issues that are brought up. The issues are given priority and that depends on how quickly they will look into it. We have not had any resolution to the call light issue. Some things might get better for a month or two but then it goes back to the way it was before. All the residents agreed by shaking their heads.
During an interview on 02/14/24 at 9:42 AM, the Director of Nursing (DON) was asked about the grievance process. The DON stated that any concern brought to the attention of staff should be resolved to the residents' satisfaction.
During an interview on 02/14/24 at 10:30 AM, the Administrator was asked about grievances brought up at the Resident Council meetings. The Administrator stated, The Activities Director (AD) will send out an e-mail if anything is brought up. Then the department should be notified and investigate the grievance. Resolution should be given with any grievance.
During an interview on 02/14/24 at 11:33 AM, the AD was asked about the grievances brought up at the Resident Council meetings. The AD stated, The issues are brought to the morning meeting with all departments. If there is a concern with nursing, then it is given to the nursing department, and they do the follow up. I will fill out a grievance form and notify the Administrator. If it is resolved, we will tell the resident council. There is no documentation.
MO00230975
MO00231043
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0572
(Tag F0572)
Could have caused harm · This affected multiple residents
Based on interview, resident council minutes review, and facility policy review, the facility failed to review resident rights with seven of the members of resident council who regularly attend (Resid...
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Based on interview, resident council minutes review, and facility policy review, the facility failed to review resident rights with seven of the members of resident council who regularly attend (Residents (R) 7, R17, R29, R70, R92, R101, and R104) of 29 sampled residents.
Findings include:
Review of the facility policy titled, Resident Rights, dated 09/01/21, revealed Policy: The facility will inform the resident both orally and in writing in a language the resident understands of his or her rights and all rules and regulations goyering [sic] resident conduct and responsibilities during the stay in the facility .
Review of the facility policy titled, Resident Council Meetings, dated 09/01/21, revealed .The policy provides guidance to promoting structure, order, and productivity in these meetings .Example of meeting topics Resident rights .
Review of the monthly Resident Council minutes provided by the facility, dated August 2023 through January 2024, revealed reoccurring grievances every month with call lights not being answered timely by nursing staff, food being cold from dietary, missing clothing from laundry, more activities available on the weekends, and social services being more proactive. There were no other topics in the meeting minutes.
During a group interview on 02/13/24 at 10:13 AM, the residents (R7, R17, R29, R70, R92, R101, and R104) were asked about their rights. The group laughed and R101 said, What are they? We don't know them. We were given a sheet when we first admitted but that paperwork was home with family, and no one has talked to us about them. The rest of the group shook their heads in agreement.
During an interview on 02/14/24 at 10:30 AM, the Administrator was asked about any discussion with residents about resident rights other than on admission. The Administrator stated, I don't think they are discussed any other time.
During an interview on 02/14/24 at 11:33 AM, the Activity Director (AD) was asked if the resident rights were discussed at resident council. The AD stated, We have not discussed resident rights.
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, record review, interviews, and facility policy review, the facility failed to ensure activities were provi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews, and facility policy review, the facility failed to ensure activities were provided to the residents who resided in the secured unit when the Activity Assistant was not assigned to work. In addition, the facility failed to provide individual activities to three out of seven residents (Resident (R) 130, R23 and R25) of 29 sampled residents.
Findings include:
Review of a facility's policy titled, Activities, dated 09/01/21, indicated .It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences of each resident. Facility sponsored group and individual activities and independent activities will be designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, as well as, encourage both independence and interaction within the community .
1. Review of R130's electronic medical record (EMR) titled admission Record located under the Profile tab, indicated the resident was admitted to the facility on [DATE].
Review of R130's EMR titled admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/03/24 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which revealed the resident was cognitively intact. The assessment revealed the resident highly valued the importance for her to read.
Review of R130's EMR titled Care Plan located under the Care Plan tab failed to contain evidence of the resident's preferences for specific activities.
Review of a document provided by the facility, referred to as the activity calendar for 02/24, indicated the residents were to be provided with music therapy at 10:00 AM and then an open activity scheduled at 2:00 PM on 02/12/24. The activity calendar for 02/14/24 indicated the residents were to be provided Bingo at 10:30 AM and jewelry making at 2:30 PM.
During an interview on 02/12/24 at 9:59 AM, R130 stated she had been in the secured unit for the past two weeks and she was bored and there was nothing in place for her to do. The resident stated the television was on and that was it. During an observation at 10:17 AM the resident was observed to wander around on the secured unit. During an observation at 10:29 AM, the resident was observed pulling a chair away from a dining table and began to watch television. The observation concluded at 2:22 PM and there were no activities provided to the residents during this observation.
During an interview on 02/14/24 at 10:55 AM, Registered Nurse (RN) 1 stated the residents on the secured unit were not provided activities this morning.
During an interview on 02/14/24 at 11:33 AM, the Activity Director (AD) stated the Activity Assistant (AA) provided activities to the residents on the secured unit. The AA stated the AA was to provide an activity in the morning and one in the afternoon. The AA stated when the AA was off, the nurse and the Certified Nursing Assistant (CNA)s were to provide activities for the residents on the secured unit.
During an interview on 02/14/24 at 12:52 AM, CNA3 stated she had worked on the secured unit for one day and no one directed her to assist the residents with activities.
During an interview on 02/14/24 at 12:53 PM, RN1 stated she worked a partial day on the secured unit on 02/12/24 and there were no activities provided to the residents. RN1 stated she had never been asked to provide activities for the residents on the secured unit. RN1 stated she had not been asked to direct her CNA staff to provide the residents with activities and the CNAs were busy providing care to the residents.
During an interview on 02/14/24 at 1:17 PM, the AD stated she was unaware the residents did not receive activities when the AA was scheduled to be off.
During an interview on 02/15/24 at 9:42 AM, the Director of Nursing (DON) stated she would expect the CNA staff, on the secured unit, to encourage the residents to participate in activities if the AA was not there.
2. Review of R23's admission Record, located under the Profile tab of the EMR, revealed R23 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included senile degeneration of the brain, epilepsy, and unspecified intellectual disabilities.
Review of R23's Activity Participation Notes, located under the Progress Notes tab of the EMR, revealed the last Activity Participation Note for R23 was on 07/20/21.
Review of R23's Activities Evaluations, located under the Assessments tab of the EMR, revealed the last Activity Evaluation for R23 occurred on 03/17/22. It was documented the evaluation was In Progress.
Review of R23's Care Plan, revised 10/10/23 and located under the Care Plan tab of the EMR, revealed a focus problem .has little or no activity involvement r/t [related to] apparent anxiety in group settings. Interventions included that R23 would participate in activities of his choice three times per week, would express interest in two new individual activity options consistently, and to investigate purpose-driven individual activities.
Review of R23's significant change MDS with an ARD of 10/26/23 and located under the MDS tab of the EMR, revealed R23 was assessed to be severely impaired in cognitive skills for daily decision making, had short-term and long-term memory problems, and was rarely or never understood; however, staff recorded that R23 was able to complete the Interview for Daily and Activity Preferences. It was documented R23 had indicated it was somewhat important to have books, newspapers, and magazines to read; very important to listen to music he liked, very important to be around animals such as pets; somewhat important to keep up with the news; very important to do things with groups of people; very important to do his favorite activities; very important to go outside to get fresh air when the weather was good; and somewhat important to participate in religious services or practices. It was recorded R23 was the primary respondent for the interview.
During an interview on 02/13/24 at 9:10 AM, RN3 was asked how the activities department was involved in identifying and implementing nonpharmacological interventions to help with any behaviors R23 might have. RN3 stated she was unsure how the activities department was involved. She stated they used to go in resident rooms for one-on-one activities. RN3 stated, I've not seen them in a while. RN3 was asked when she had observed the activities department completing room visits last. She stated, I know it's not this month.
During the days of the survey, from 02/12/24 through 02/14/24, no activities were observed occurring in the 500-hall. There were no observations of one-on-one activities being provided to R23.
During an interview on 02/14/24 at 11:33 AM, the AD stated there were no group activities that occurred on the 500-hall. She stated residents were either brought off the unit to group activities or they were able to come to the activities independently. The AD stated R23 did not like to participate in group activities and was provided one on one activities in his room. The AD stated she no longer kept detailed documentation of activities because there would be books and books of it and the state survey agency never looked at it. The AD was asked what activities had been provided to R23 on 02/12/24 and 02/13/24. The AD stated she would provide documentation.
During an interview on 02/14/24 at 2:27 PM, the AD provided eleven One on One/Individual Activity Attendance forms for December 2023 through present. Only one form recorded R23's name. The rest had no resident name recorded. The forms indicated which month and week of the month activities occurred, and only one form recorded 3x week [three times a week]. There were no specific dates recorded, and the resident's involvement in the activities was not indicated. It was indicated the activities provided were looking at pictures, listening to music, listening to poems/stories, and/or looking at magazines for all weeks.
During an interview on 02/14/24 at 3:15 PM, the AD provided an Activities Evaluation, dated 11/15/23. The form contained no information related to R23 and his activities needs.
During an interview on 02/15/24 at 9:30 AM, the AD was asked why the Activities Evaluation, dated 11/15/23, had no information related to R23. She stated when she had looked at R23's assessments in the EMR, she had found the document and printed it. The AD confirmed the document had no information. The AD stated R23 could not hold a conversation and she had reached out to the family with no answer during November 2023. The One on One/Individual Activity Attendance forms were reviewed with the AD, and the AD confirmed the forms did not indicate R23's name, what activities had been provided on what days, or R23's involvement with the activities. The AD confirmed activities were not individualized for R23. The AD was asked how the nurses and the Interdisciplinary Team had involved the activities department in identifying interventions to help R23 and any behaviors. She stated, They haven't. The AD stated she believed the facility's policy called for detailed documentation of activities.
During an interview on 02/15/24 at 11:04 AM, the DON confirmed she would expect the Activities Department to be involved in identifying interventions for R23. The DON stated she had been told that R23 was receiving one-on-one activities. The DON stated she knew hospice came in but did not know what R23's activities were.
3. Review of R25's admission Record located under the Profile tab of the EMR revealed R25 was admitted to the facility on [DATE].
Review of R25's Care plan under the Care Plan tab of the EMR revealed no evidence that a care plan was initiated or implemented for the residents' choices and preferences for activities that supported her needs.
During an interview on 02/15/24 at 4:06 PM, the AD stated that she had not provided an individual activity program for R25 but was aware of the requirements of the activity program policy and the regulations for facility activity programs.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
Based on observations, interviews, and facility policy review, the facility failed to ensure that electrical equipment with exposed cord was not used in a dementia secured unit with the potential to c...
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Based on observations, interviews, and facility policy review, the facility failed to ensure that electrical equipment with exposed cord was not used in a dementia secured unit with the potential to cause accident hazards, such as tripping and/or falling of 26 residents who ambulated and wandered within the unit.
Findings include:
Review of a facility's policy provided by the facility titled Resident Environment Quality, dated 09/01/21, indicated .It is the policy of this facility to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary and comfortable environment for residents and the public .
During an observation on 02/12/24 at 10:39 AM, an exposed (approximately eight feet) extension cord went through the center of a room. The room was open except for an L shaped floor to ceiling column. The column was open to an adjacent room between open areas and had a television in front. The extension cord was medical grade, and the television cord was plugged into the device. The cord had bright orange tape covering it, but the center of the tape was split, and the cord was exposed and loose, potentially causing a tripping hazard. Both areas of the dining rooms had residents wandering. During this observation, no resident walked over the cord. The observation continued until 02/12/24 at 2:22 PM.
During an observation on 02/13/24 at 8:17 AM, the same observation was made of the orange cord. There were residents dining in both areas. There were residents observed wandering in the dining areas.
During an interview on 02/14/24 at 10:54 AM, the Maintenance Director stated he conducted daily rounds at the facility to identify potential accident hazards. The interview took place in the secured unit, and he verified the split orange tape which exposed the electrical cord. The Maintenance Director stated an electrical outlet needed to be placed in the L shaped column to prevent the potential accident hazard.
During an interview on 02/15/24 at 11:54 AM, the Director of Nursing (DON) stated the exposed cord would be a potential accident hazard.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, staff interview, and facility policy review, the facility failed to ensure medications were stored in a locked storage area when left unattended for one of five medication rooms ...
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Based on observation, staff interview, and facility policy review, the facility failed to ensure medications were stored in a locked storage area when left unattended for one of five medication rooms in the facility.
Findings include:
Review of the facility's policy titled, Medication Storage, last revised 09/01/21, revealed .It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security .All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) .Only authorized personnel will have access to the keys to locked compartments.
During an observation on 02/12/24 at 11:10 AM, the Emergency Medication Room was observed to be unlocked on the third floor near the dining room. Inside was noted to have a secured Nexsys system [automated medication dispensing cabinet], unlocked storage containers, and an unlocked medication refrigerator. Four syringes of Heparin flush 5.00 ml (milliliters) were observed on top of the refrigerator. Inside the refrigerator were two vials of tuberculin, 12 boxes of COVID vaccine, ten complete influenza vaccine boxes, and four vials of insulin in an internal locked box. Numerous hypodermic needles, tuberculin safety syringes, laboratory kits, and treatment supplies/kits were observed unsecure throughout the room.
During observations outside the unlocked Emergency Medication Room on 02/12/24 from 11:15 AM until 12:32 PM revealed ten ambulatory residents that either sat near the unlocked room or walked past it, all without the supervision of a staff member being present. No staff members were observed attempting to enter or check the unlocked medication room door.
During an observation and interview on 02/12/24 at 12:30 PM, Certified Medication Technician (CMT) 1 moved the medication cart near the unlocked Emergency Medication Room. CMT1 stated that the medication rooms had to be locked, and only the nurses and Certified Medication Technicians had access. CMT1 confirmed the facility had several ambulatory residents on the third floor. She confirmed that the door was unlocked and stated someone must have forgotten to lock it when they were last in the room. CMT1 relocked the door.
During an observation on 02/13/24 at 4:00 PM, the Emergency Medication Room was observed unlocked. Observed inside were the same medications and supplies. The Director of Nursing (DON) confirmed the door was unlocked and stated that she expected it to always be secured.
During an observation on 02/14/24 at 10:21 AM, the Emergency Medication Room was observed with a sign posted to the front of the door that stated, Keep Locked. The door was again unlocked. The Corporate Nurse confirmed that the door was unlocked and stated that it should have been locked.
During an interview on 02/14/24 at 10:45 AM, the Maintenance Director stated that the door to the Emergency Medication Room was supposed to stay locked at all times, and that a new self-locking door had now been installed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and facility policy review, the facility failed to ensure three residents (Resident (R) 109, R...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and facility policy review, the facility failed to ensure three residents (Resident (R) 109, R24, and R39), out of 31 residents on the secured unit, were provided a timely scheduled lunch meal. As a result, three residents complained of being hungry and were not aware of an unplanned change in the schedule for meal delivery.
Findings include:
Review of the facility's undated policy titled, Accommodation of Needs, indicated .The facility will treat each resident with respect and dignity and will evaluate and make reasonable accommodations for the individual needs and preferences or a resident, except when the health and safety of the individual or other residents would be endangered .
1. Review of R109's electronic medical record (EMR) titled admission Record located under the Profile tab, indicated the resident was admitted to the facility on [DATE] with a diagnosis of unspecified dementia.
Review of R109's EMR titled annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/31/24 indicated the resident had a Brief Interview for Mental Status of three out of 15 which revealed the resident was severely cognitively impaired.
2. Review of R24's EMR titled admission Record located under the Profile tab, indicated the resident was admitted to the facility on [DATE] with a diagnosis of cerebral infarction (stroke).
Review of E24's EMR titled annual MDS with an ARD of 01/09/24 indicated the resident had a BIMS score of eight out of 15 which revealed the resident was moderately cognitively impaired.
3. Review of 39's EMR titled admission Record located under the Profile tab, indicated the resident was admitted to the facility on [DATE] with a diagnosis of unspecified dementia.
Review of R39's EMR titled quarterly MDS with an ARD of 12/06/23 indicated the resident had a BIMS score of five out of 15 which revealed the resident was severely cognitively impaired.
An observation began on 02/12/24 at 10:39 AM on the secured unit. At 12:49 PM, R109 was observed sleeping in a chair which was pushed up against one of the dining room tables. The lunch trays had not been served. At 1:11 PM, R39 stated the lunch meals were delivered by noon and she was very hungry. R39 stated she had breakfast at 8:00 AM. R109 still had his head on a table, sleeping. At 1:16 PM, no lunch trays had been delivered. At 1:19 PM, R24 stated she was hungry, and this was too long to wait,, She stated she ate at 8:00 AM and wanted to eat now. At 1:23 PM, F109 stated he was very hungry and typically would have had lunch by now. The meal trays were delivered at 1:26 PM. At 1:29 PM, R109 asked where the food was. A random staff member pointed to a table and indicated for R109 to sit. R24 was served her food, then stated the food was too hard and began to swear obscenities and slammed her plate on the table and refused to eat. R98 still was not served her lunch meal. At 1:42 PM, R98 finally received her lunch meal. R98 was observed to stare at her lunch meal during this observation. At 1:56 PM, R98 began to be assisted by R18. R18 gave R98 a few bits of pork. Certified Nurse Aide (CNA) 5 was observed passing out drinks to the residents during this observation. It was not until 2:02 PM that CNA5 began to assist R98 with her meal.
During an interview on 02/13/24 at 2:55 PM, the Registered Dietician (RD) stated the secured unit residents were served first. The RD stated the Assistant Administrator changed the schedule for meal delivery. The RD stated the residents in the main dining room were served first on 02/12/24 instead of the residents on the secured unit. The RD stated the secured unit was across from the kitchen and this was convenient for the residents on the secured unit to be served first. The RD stated it was important to provide consistency to residents who had dementia.
During an interview on 02/13/24 at 4:52 PM, the Assistant Administrator (AA) confirmed she was the staff member who changed the delivery times for the lunch meal. The AA stated she attempted to get the residents fed first in the main dining room. The AA stated she had experience working with residents who had dementia and it was important to provide these residents with consistency.
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 F0921)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility policy review, the facility failed to maintain a safe, clean, comfortable, a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility policy review, the facility failed to maintain a safe, clean, comfortable, and homelike environment, including but not limited to ensuring housekeeping and maintenance services were conducted as necessary to maintain a sanitary, orderly, and comfortable interior. This had the potential to affect 127 of 127 residents who resided at the facility.
Findings include:
Review of the facility's policy titled, Safe and Homelike Environment, last revised 09/01/21, revealed In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extend possible .Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment .Minimize odors by disposing of soiled linens promptly and reporting lingering odors and bathrooms needing cleaning to Housekeeping Department .Report any unresolved environmental concerns to the Administrator.
Review of the facility's policy titled, Resident Environmental Quality, last revised 09/01/21, revealed It is the policy of this facility to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary and comfortable environment for residents, staff, and the public .Preventative maintenance schedules, for the maintenance of the building and equipment, should be followed to maintain a safe environment .All facility personnel are responsible for reporting broken, defective or malfunctioning equipment or furnishings immediately upon identification of the issue.
During observations on 02/12/24 at 10:54 AM in the third-floor large common area/dining room revealed two long rows of windows on opposite sides of the room (north and south). The windows were observed with white blinds, and there were long baseboard/registers located along the wall in front of them. Numerous window blinds were observed with heavy dust and debris coating the slates, leaving a dark layer resting on top. Many of the windows were observed with extensive darkened buildup of debris and bugs in the window trims, the windowsills, and in the many unsecured screens. The vents on the baseboard/registers were coated in thick debris, and the metal front covers were missing screws, easily manipulated. Long fluorescent lights were observed throughout the common area/dining room covered in darkened debris and bugs, hanging above dining room tables. The trash can located by the kitchenette, hand sanitizer, and hallway was observed heavily soiled with dried food and liquid on the outside of the container, as well as the wall behind it. This common area/dining room was used extensively by facility residents during meal observations on four of four survey days.
During an observation on 02/12/24 at 10:01 AM, Resident (R) 82's room revealed chip cans behind the bed, a dirty floor, and torn wheelchair arms.
During an observation on 02/12/24 at 11:08 AM, R77's room revealed dirt and debris on the floor under the bed, and a wheelchair arm that was not screwed in.
During an observation on 02/12/24 at 1:48 PM, R93's room had an IV (intravenous) pole for tube feeding, which had dried liquid on the pole and at the base. An additional observation on 02/13/24 at 8:40 AM revealed the pole was still covered in dried liquid on the pole and base.
Observations on 02/13/24 at 8:48 AM revealed soiled briefs disposed of in an unlined trash can in the common shower room across from resident room [ROOM NUMBER]. Windows at the end of the resident hallway, near room [ROOM NUMBER], were observed with extensive black debris in the windowsill and numerous dead insects.
Observations on 02/15/24 at 12:10 PM revealed dark debris build-up in the ceiling vents near resident room [ROOM NUMBER]. The common area near the nurse station on the 300 hallway was observed with dried dirt and liquids on the walls, dark debris on the windows, and ripped wallpaper across the walls. There was extensive dirt buildup in the windowsills in the common area near resident room [ROOM NUMBER]. The trash can in the common area/dining room was noted to have been emptied, but the dried food and liquids were still observed all over the container and the wall behind it. The wall near the 400/500 elevator was noted with ripped wallpaper.
During an interview on 02/15/24 at 10:20 AM, the Director of Nursing (DON) said that the housekeeping staff was expected to keep appropriate schedules for all areas of the facility. The DON confirmed that there had been some housekeeping staffing issues at times, and sometimes the staff had to take on an extra workload. She confirmed that there were areas of the facility that were not kept as clean as they should, including the windows.
During an interview on 02/15/24 at 11:30 AM, the Maintenance Director (MD) confirmed that it was an old building and had cleanliness issues throughout the facility, and with some staffing concerns in the housekeeping department, the ability to get the facility clean had ups and downs.
During an interview on 02/15/24 at 12:54 PM, the Housekeeping Director (HD) stated that the housekeeping department was staffed according to the census, not according to the size of the facility or the number of rooms. HD stated that with the hours available to staff housekeeping, and with five different units to clean, they were unable to go through their full daily room audit checklist, including to clean windows, blinds, dusting of furniture, walls, baseboards, or the air conditioning filters. HD stated the air conditioning filters had not been cleaned out since last summer, and that the only deep cleaning done in resident rooms was when there was a new admission to the facility. HD stated that there was no time to clean the common areas, such as the dining rooms, but the housekeeping staff did the best they could. She stated staff and residents had begun to complain about the cleanliness of the facility. HD stated that she was not aware of who was responsible for cleaning resident care equipment. HD stated that approximately 75% of the facility resident rooms had not received a full cleaning.
During an interview on 02/15/24 at 1:40 PM, the DON stated that anyone who saw an IV pole for tube-feeding should clean it if it was dirty, but believed it was housekeeping's responsibility.
MO00229931
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and the facility policy review, the facility failed to ensure food was labeled and dated properly according to professional standards for food prepared from the facili...
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Based on observation, interview, and the facility policy review, the facility failed to ensure food was labeled and dated properly according to professional standards for food prepared from the facility's kitchen. This failure had the potential to affect 126 of 127 residents consuming food from the kitchen.
Findings include:
Review of the facility's policy titled, Food Storage Sanitation and Food Safety, dated August 2024, revealed that all food stock and products were stored in approved sanitary storage containers, and all contents were covered, with contents labeled and dated.
During an observation, alongside the Assistant Administrator, on 02/12/24 at 9:32 AM, the refrigerator contained food items not labeled or dated. The refrigerator had large containers of cooked and uncooked chicken quarters, cooked chicken patties, a large container of cooked hot dogs, multiple packages of opened lunch meat, multiple packages of opened sliced cheese and shredded cheese, an opened container of sour cream, an opened container of apple sauce, and a large pan of Jello/fruit dessert that was not covered, labeled, or dated. The refrigerator also had a large container of food that could not be identified. The Assistant Administrator verified the food was not labeled or dated.
During an interview on 02/15/24 at 9:46 AM, the Dietary Manager (DM) stated that she was aware of the requirement to label and date all food contained in the refrigerator.
MO00229664
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 F0865
(Tag F0865)
Could have caused harm · This affected most or all residents
Based on interview and review of facility documentation, the facility failed to ensure a Quality Assurance Performance Improvement (QAPI) plan was developed to drive quality assurance (QA) measures wh...
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Based on interview and review of facility documentation, the facility failed to ensure a Quality Assurance Performance Improvement (QAPI) plan was developed to drive quality assurance (QA) measures which addressed resident care and safety, quality of life, and resident choice. This failure had the potential to affect all 127 residents who currently lived in the facility. (Cross Reference F868)
Findings include:
Review of a document provided by the facility titled Quality Assurance and Performance Improvement (QAPI), dated 09/01/21, indicated .It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcome of care and quality of life. The QAPI plan will address the following elements.Design and scope of the facility's QAPI program and QAA Committee responsibilities and actions.Policies and procedures for feedback, data collection systems, and monitoring.Process addressing how the committee will conduct activities necessary to identify and correct quality deficiencies. Key components of this process include, but are not limited to, the following.Tracking and measuring performance.Establishing goals and thresholds for performance improvements.Identifying and prioritizing quality deficiencies.Systematically analyzing underlying causes of systemic quality deficiencies.Developing and implementing corrective action or performance improvement activities. Monitoring and evaluating the effectiveness of corrective action/performance improvement activities and revising as needed .
A document titled QAPI Meeting Agenda and Minutes, dated 11/08/23, failed to include potential quality of care issues. There was no data-driven information, such as tracking and trending, or the measurement of performance made by the facility. There was no evaluation of general nursing issues with corrective action taken, such as pressure ulcers, infections, antibiotic use, antipsychotic medication use, and falls.
During an interview on 02/15/24 at 1:28 PM, the Administrator stated there were no QAPI plans that he could locate, prior to the beginning of his employment. The Administrator stated he began his employment on 11/23.
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 F0868
(Tag F0868)
Could have caused harm · This affected most or all residents
Based on document review, interview, and review of facility policy, the facility failed to ensure that the quality assessment and assurance (QAA) committee met at least quarterly. This had the potenti...
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Based on document review, interview, and review of facility policy, the facility failed to ensure that the quality assessment and assurance (QAA) committee met at least quarterly. This had the potential to affect the care and services for each of the 127 residents in the facility.
Findings include:
Review of a document provided by the facility titled Quality Assurance and Performance Improvement (QAPI), dated 09/01/21, indicated .The QAA Committee shall be interdisciplinary and shall.Consist at a minimum of.The Director of Nursing Services.The Medical Director or his/her designee.Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program.
During an interview on 02/15/24 at 1:28 PM the Administrator stated he had no evidence to present to indicate the attendees conducted prior quarterly QAPI meetings. During this interview he presented the following documents:
A document titled QAPI Meeting Agenda and Minutes, dated 11/08/23, indicated the following mandatory staff members were in attendance: The Administrator, Assistant Director of Nursing, the Infection Control Preventionist, and three other members of the facility staff.
A document titled QAPI Meeting Minutes, dated 12/13/23, which included a sign in sheet which revealed the following mandatory staff members were in attendance: The Director of Nursing (DON), the Medical Director, the Administrator, and at least three other members of the facility staff. The facility failed to include the Infection Control Preventionist in the QAPI meeting.
During an interview on 02/15/24 at 4:34 PM, the Administrator confirmed he began the first official QAPI meeting on 12/13/23. The Administrator stated he had no other documentation which would show past QAPI members in attendance prior to this date. The Administrator stated he searched his office for additional documents and could not locate any.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, facility policy review, and review of Centers for Disease Control and Preventi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, facility policy review, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to establish and maintain an infection prevention and control program (IPCP) for recording incidents of infections identified under the facility's IPCP, surveillance, tracking and trending, and the corrective actions taken by the facility for 127 of 127 census residents. In addition, the facility failed to ensure the Certified Nursing Assistant (CNA) 5 performed hand hygiene after doffing (removing) gloves and failed to ensure a serving of applesauce was replaced, after being contaminated, for one of one resident (Resident (R) 83) of 29 sampled residents.
Findings include:
Review of a document titled, Centers for Disease Control (CDC) .National Healthcare Safety Network (NHSN) .Long Term Care Facility Component Tracking Infections in Long-Term Care Facilities ., located at https://www.cdc.gov/nhsn/pdfs/ltc/ltcf-manual-508.pdf, dated 01/20, indicated .Surveillance is defined as the ongoing systematic collection, analysis, interpretation, and dissemination of data. A facility infection prevention and control (IPC) program should use surveillance to identify infections and monitor performance of practices to reduce infection risks among residents, staff and visitors. Information collected during surveillance activities can be used to develop and track prevention priorities for the facility. When conducting surveillance, facilities should use clearly defined surveillance definitions that are collected in a consistent way. This method ensures accurate and comparable data regardless of who is performing surveillance .
Review of facility's policy titled Hand Hygiene, dated 09/01/21, indicated .The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves .
Review of the facility's policy titled, Infection Prevention and Control Program, revised 09/01/22, revealed .This facility has established and maintains an infection prevention and control program designed to provide a safe. sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections .A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards .
1. Review of the Infection Preventionist's (IP) certificates of completion of the Nursing Home Infection Preventionist Training Course revealed the IP became certified as an IP on 10/26/23.
During an interview on 02/14/24 at 3:55 PM, the IP stated she started her position as IP near the beginning of November 2023 and confirmed she completed the certification process on 10/26/23. The IP was asked to provide the facility's documentation of infection surveillance, process surveillance, antibiotic stewardship program activities, and documentation of the implementation of control measures and precautions. The IP provided documentation dated 11/01/23 through 02/13/24. The IP confirmed that when she began as the IP, she was provided the facility's Infection Control Log and confirmed the log did not contain any information previous to 11/01/23. The IP stated the purpose of the log was to be knowledgeable of where infections were located within the facility, to keep track of who was on antibiotics in the facility, and to notify the state survey agency of any infectious disease outbreaks.
On 02/14/24 at 4:40 PM, the Corporate Nurse was requested provide all of the facility's IPCP documentation prior to November 2023, including the names and IP certifications for the IPs.
During an interview on 02/15/24 at 8:20 AM, the Corporate Nurse reported she had been unable to locate any of the facility's IPCP documentation from August 2021 through October 2023. The Corporate Nurse stated she thought the former Director of Nursing (DON) had been the IP during their employment, but no certifications were provided.
During an interview on 02/15/24 at 10:44 AM, the DON stated she had talked with the Assistant Director of Nursing (ADON) who stated there were books and books of IPCP documentation in her office. The DON reported she had observed binders in the ADON's office but had not looked inside them.
During an interview on 02/15/24 at 1:31 PM, the Administrator confirmed he was the head of the facility's Quality Assurance Performance Improvement (QAPI) committee and confirmed the IP reported to the DON. The Administrator was asked if he was aware the facility had not been able to provide the IPCP's documentation from August 2021 through October 2023. The Administrator stated that he was unaware of any documentation for that time period as he had only been at the facility for a short period of time. The Administrator confirmed the IP provided information to the facility's QAPI program.
During an interview on 02/15/24 at 1:41 PM, the DON brought binders with IPCP documentation for the years 2021 and 2022. The DON reported the ADON had informed her that the IPCP documentation for 2023 was in the binder provided to the current IP. The DON was informed the current IP had stated there was no IPCP documentation provided to her when she assumed the role.
During an interview on 02/15/24 at 2:27 PM, the DON confirmed she could not find any information related to the facility's IPCP documentation from 01/01/23 through 10/31/23.
2. A lunch service was observed in the third-floor dining room on 02/12/24 at 12:18 PM. Meals were served from the kitchenette by facility staff, all who wore gloves. At 12:18 PM, a male staff member who wore gloves, was observed carrying a plate of food in each hand, the thumbs rested on the inside of each plate. The staff member served the meals and returned to the kitchenette. The staff member was then observed taking another plate to a resident with the same gloves on, also resting the thumb on the inside of the plate. The staff member then rubbed his chin, scratched his head, and then returned to the kitchenette. Without changing gloves, the male staff member then picked up two more resident meals and proceeded to serve the plates with his thumbs resting on the inside of the plates.
During an interview on 02/15/24 at 10:18 AM, the DON stated that she expected staff to serve food in the dining rooms restaurant style. She confirmed that she would not want to see staff using gloves to serve residents' meals because it could limit how often the staff washed their hands.
Review of R98's electronic medical record (EMR) titled admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE].
During an observation on 02/12/24 at 2:02 PM, CNA5 began to assist R98 with her lunch meal. CNA5 had a pair of gloves on and then doffed the gloves, failed to perform hand hygiene, and began to assist the resident with her lunch meal.
3. Review of R39's EMR titled admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE].
Review of R39's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/06/23, revealed a Brief Interview for Mental Status (BIMS) score of five out of 15 which indicated the resident had severe cognitive impairment.
Review of R83's EMR titled admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE].
Review of R83's annual MDS with an ARD of 01/26/24 revealed the resident had a BIMS of seven out of 15 which indicated the resident had severe cognitive impairment.
During an observation on the secured unit on 02/12/24 at 1:38 PM, R39 requested a bowl of applesauce from CNA5. CNA5 asked the resident to wait a few minutes. R83 was the tablemate of R39. At 1:51 PM, R39 grabbed the bowl of applesauce from R83 and took a scoop of applesauce from the container and then placed the applesauce on her plate, next to her serving of pork. CNA5 observed this interaction and CNA5 informed R39 the applesauce was R83's and not hers since R83 was on a special diet. CNA5 was observed not to remove the contaminated applesauce from R83, and she was observed to eat the applesauce.
During an interview on 02/15/24 at 9:42 AM, the DON stated her expectation was for staff to perform hand hygiene after doffing. The DON stated the applesauce should have been removed from R83 after it had been contaminated by R39.
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, record review, and policy review, the facility failed to implement their system to monitor the use of antibiotics for 127 of 127 census residents. Specifically, the facility failed...
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Based on interview, record review, and policy review, the facility failed to implement their system to monitor the use of antibiotics for 127 of 127 census residents. Specifically, the facility failed to monitor and evaluate antibiotic use and track measures of antibiotic usage in the facility.
Findings include:
Review of the facility's policy titled, Infection Prevention and Control Program [IPCP], revised 09/01/22, revealed .Antibiotic Stewardship: a. An antibiotic stewardship program will be implemented as part of the overall infection prevention and control program. b. Antibiotic use protocols and a system to monitor antibiotic use will be implemented as part of the antibiotic stewardship program .
During an interview on 02/14/24 at 3:55 PM, the Infection Preventionist (IP) stated she started her position as IP near the beginning of November 2023 and confirmed she completed the certification process on 10/26/23. The IP was asked to provide the facility's documentation of the antibiotic stewardship program from 01/01/23 through 02/01/24. The IP provided documentation dated 11/01/23 through 02/13/24. The IP confirmed that when she began as the IP, she was provided the facility's Infection Control Log and confirmed the log did not contain any information previous to 11/01/23. The IP confirmed antibiotic usage should be tracked with use and outcome criteria applied.
On 02/14/24 at 4:40 PM, the Corporate Nurse was requested to provide all of the facility's IPCP documentation, including antibiotic stewardship, from August 2021 through October 2023.
During an interview on 02/15/24 at 8:20 AM, the Corporate Nurse reported she had been unable to locate any of the facility's IPCP documentation, including antibiotic stewardship, from August 2021 through October 2023.
During an interview on 02/15/24 at 10:44 AM, the Director of Nursing (DON) stated she had talked with the Assistant Director of Nursing (ADON) who stated there were books and books of IPCP documentation in her office. The DON reported she had observed binders in the ADON's office but had not looked inside them.
During an interview on 02/15/24 at 1:31 PM, the Administrator confirmed he was the head of the facility's Quality Assurance Performance Improvement (QAPI) committee and confirmed the IP reported to the DON. The Administrator was asked if he was aware the facility had not been able to provide the IPCP's antibiotic stewardship documentation from August 2021 through October 2023. The Administrator stated that he was unaware of any documentation for that time period as he had only been at the facility for a short period of time. The Administrator confirmed the IP provided information to the facility's QAPI program.
On 02/15/24 at 1:41 PM, the DON brought binders with IPCP documentation, including antibiotic stewardship, for the years 2021 and 2022. The DON reported the ADON had informed her that the IPCP documentation for 2023 was in the binder provided to the current IP. The DON was informed the current IP had stated there was no IPCP documentation provided to her when she assumed the role.
During an interview on 02/15/24 at 2:27 PM, the DON confirmed she could not find any documentation related to the facility's antibiotic stewardship program from 01/01/23 through 10/31/23.
Feb 2024
1 deficiency
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
Based on observation, interview and record review, the facility failed to provide supervision to ensure the safety of one of three sampled residents (Resident #1) diagnosed with vascular dementia (pro...
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Based on observation, interview and record review, the facility failed to provide supervision to ensure the safety of one of three sampled residents (Resident #1) diagnosed with vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain) and encephalopathy (alteration in consciousness caused by diffuse/global brain dysfunction due to a chemical imbalance). On the morning of 1/9/24, the resident became agitated and physically aggressive towards staff. He/She forced his/her way off the locked unit on which he/she resided, was redirected back onto the unit by staff and then shattered a first-floor window in the secured unit and climbed through it. He/She was assessed and treated at the hospital. The resident returned to the facility and became agitated, tearing pictures from the walls in his/her room, sweeping belongings into the hallway and attempting to leave the secured unit. In response, the facility moved the resident to an third-floor unit. Staff, who were unaware of his/her attempt to climb out of a first floor window, failed to provide an appropriate level of supervision when he/she began wandering around the third floor. The resident jumped from a 3rd floor window and incurred fatal injuries. The census was 131.
The administrator was notified on 2/2/24, of the Immediate Jeopardy (IJ) past non-compliance, which occurred on 1/9/24. The facility provided training and in-servicing for all staff regarding the facility's elopement policy as well as monitoring new onset of behaviors and the administration of as needed (PRN) psychotropic medications for behavioral management. The facility also completed elopement assessments on all residents, audited the elopement binder to ensure it was up to date, interviewed all residents for trauma informed care, completed elopement and wandering prevention audits and an environmental audit. The IJ was corrected on 1/12/24.
Review of the facility's policy titled Elopements and Wandering Residents, reviewed/revised, 9/1/22, showed the facility ensured residents who exhibited wandering behavior and/or were at risk for elopement received adequate supervision to prevent accidents and received care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Wandering was defined as random or repetitive locomotion that may be goal-directed (e.g., the person appears to be searching for something such as an exit) or non-goal directed/aimless. Elopement was defined as occurring when a resident left 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. The facility was to establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Residents were to be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. The interdisciplinary team (IDT) was to evaluate the unique factors contributing to risk, in order to develop a person-centered care plan. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to the appropriate staff. Adequate supervision was to be provided to help prevent accidents or elopements. Charge Nurses and Unit Managers were to monitor the implementation of interventions, response to interventions, and document accordingly. The effectiveness of interventions was to be evaluated and changes made PRN. Any changes or new interventions were to be communicated to relevant staff.
Review of the facility policy titled, Incidents and Accidents, reviewed/revised 9/1/22, showed it was the policy of the facility for staff to report, investigate, and review any accidents or incidents that occurred or allegedly occurred on facility property and might involve or allegedly involved a resident. An accident referred to any unexpected or unintentional incident, which resulted or may result in injury or illness to a resident. An incident was defined as an occurrence or situation that was not consistent with the routine care of a resident or with the routine operation of the organization. That could involve a visitor, vendor or staff member. The purpose of incident reporting could include assuring that appropriate and immediate interventions were implemented and corrective actions were taken to prevent recurrences and improve the management of resident care. In the event of an incident or accident, immediate assistance was to be provided or securement of the area was to be initiated, unless it placed one at risk for harm. Any injuries would be assessed by a licensed nurse or practitioner and the affected individual would not be moved, until safe to do so. First aid would be provided for minor injuries such as cuts or abrasions.
Review of Resident #1's undated face sheet, showed an admission date of 1/4/24.
Review of the resident's undated physician's orders, showed the following:
-1/4/24, Levetiracetam tablet 500 mg (milligrams), give 1 tablet two times daily for encephalopathy;
-1/4/24, Quetiapine Fumarate tablet 25 mg, give 1 tablet in the morning for agitation;
-1/4/24, Quetiapine Fumarate tablet 25 mg, give 75 mg at bedtime for agitation;
-1/4/24, Hydroxyzine HCL (hydrochloride) tablet 10 mg, give 10 mg every 8 hours PRN for agitation;
-1/4/24, Divalproex Sodium delayed release tablet 125 mg, give 1 tablet three times daily for vascular dementia.
Review of the resident's all-inclusive admission and readmission assessment, dated 1/5/24, showed the following:
-Orientation: oriented to person (knows his/her name and can recognize significant others);
-Cognition: confused, short-term memory problem;
-Psychotropic medication intervention: administer psychotropic medications as ordered by the physician. Monitor for side effects and effectiveness every shift;
-Reason for admission according to resident/power of attorney (POA): dementia;
-Wandering risk score: 4, wandering risk: at risk for wandering;
-Elopement risk/wanderer intervention: avoid events that lead to wandering behaviors/triggers whenever possible. Identify and avoid the trigger;
-Fall risk score: 28.0, fall risk category: high risk;
Review of the resident's brief interview for mental status evaluation (BIMS), dated 1/5/24, showed a score of 0.0 (indicating severe cognitive impairment).
Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/8/24, showed the following:
-Short-term memory OK;
-Other behavioral symptoms not directed towards others (e.g. pacing, screaming, disruptive sounds, etc.) occurred four to six days but less than daily;
-Rejection of care occurred one to three days;
-Wandering occurred daily;
-Diagnoses including essential (primary) high blood pressure, cerebral infarction (stroke) due to embolism of right anterior cerebral artery (occurs when a blood clot forms in one part of the body and then travels through the blood to the brain, where it blocks adequate oxygen and blood flow in one of the three major arteries that supply blood to the largest part of the brain), aphasia (language disorder caused by damage in the area of the brain that controls language expression and comprehension) following cerebral infarction, muscle weakness (generalized), other abnormalities of gait and mobility, diabetes mellitus;
-Required supervision or touching assistance with eating, oral hygiene, sit to lying/lying to sitting, sit to stand, chair/bed-to-chair transfers, ambulating 10 feet, ambulating 50 feet with two turns;
-Required partial/moderate assistance with lower body dressing, putting on/removing footwear and toilet transfers;
-Required substantial/maximal assistance with toileting hygiene, shower/bathing, upper body dressing.
Review of the resident's undated care plan, showed the following:
-The resident is an elopement risk related to poor safety awareness, diminished cognition related to vascular dementia, acute on chronic (when a chronic condition develops an acute condition) metabolic encephalopathy;
-Distract him/her from wandering by offering pleasant diversions, structured activities, food, conversation, television or a book;
-Monitor for exit-seeking behaviors and document;
-The resident has potential to be physically aggressive and refuse care related to diminished orientation and communication deficits related to vascular dementia, history of cerebral infarction due to embolism of left middle cerebral artery, acute on chronic metabolic encephalopathy and aphasia following cerebral infarction;
-Administer medications as ordered. Monitor/document for side effects and effectiveness;
-Communication: provide physical and verbal cues to alleviate anxiety: give positive feedback, assist in verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff members when agitated;
-Monitor/document/report PRN any signs or symptoms of resident posing a danger to self and others;
-Psychiatric/psychogeriatric consult PRN;
-When the resident becomes agitated, intervene before agitation escalates: guide away from source of distress, engage calmly in conversation. If response is aggressive, staff to walk calmly away and approach later;
-He/She has a communication problem related to vascular dementia, acute on chronic metabolic encephalopathy, mood disorder, history of cerebral infarction, history of hemiplegia (a severe or complete loss of strength or paralysis on one side of the body) and hemiparesis (a mild or partial weakness or loss of strength on one side of the body) post cerebral infarction affecting right dominant side and aphasia;
-Speak on an adult level, speaking clearly and slower than normal;
-Administer psychotropic medications as ordered by his/her physician. Monitor for side effects and effectiveness every shift.
Review of the resident's progress note, showed on 1/9/24 at 7:35 A.M., LATE ENTRY: at approximately 6:30 A.M. on 1/9/24 the resident started becoming agitated and was becoming violent with staff. Central supply staff (Central Supply Coordinator Q) entered the locked unit and was able to redirect the resident. Central supply staff walked the resident to the nurse's station and the resident appeared calm at that time. Central supply staff exited the locked unit, and the resident then went to the window in the hallway, started hitting it and broke the window sustaining small lacerations to both hands. The Physician and Director of Nursing (DON) were notified, and RN received new orders to send the resident out 911 for an evaluation.
Review of the resident's Medication Administration Record (MAR), dated 1/1/24 through 1/31/24, showed no doses of Hydroxyzine HCL 10 mg, prescribed to be given every 8 hours for agitation were administered.
Review of the resident's incident report, dated 1/9/24 at 6:50 A.M., showed the resident was having aggressive behaviors, pushed through the door, trying to get away from staff while staff attempted to redirect the resident. The resident punched out a window and climbed out the window. Central Supply Coordinator Q was with the resident at all times and redirected the resident back into the facility. He/She exhibited aggressive behaviors of charging at staff, swinging at them and breaking items in his/her room. They got the resident into the bathroom, where he/she calmed down. Nurse Supervisor J called 911. His/Her injuries included abrasions to the backs of his/her hands. Predisposing physiological factors were confusion and impaired memory. Nurse Supervisor J notified his/her physician and family member.
Review of the resident's undated police report, showed the following:
-Call received on 1/9/24 at 6:48 A.M.;
-Time of arrival: 6:57 A.M.;
-Police were dispatched to the facility for a resident who had busted out a window, was currently outside and reportedly being violent with staff. Upon arrival of the police, it was determined the window was on the ground floor. The window was in the memory care unit of the facility (Loop Unit). Staff members notified the officer the resident had been awake all night and started to pound his/her fists against the window and when it broke, he/she climbed out. The resident had a minor laceration to his/her left hand from the window and kept repeating his/her last name as the police officers escorted him/her to the exit and out to EMS (Emergency Medical Services). As paramedics secured the resident in the ambulance, the resident kept saying his/her family member's name.
Review of the resident's ambulance record, dated 1/9/24, showed the following:
-Call received: 6:51 A.M.;
-On scene: 7:04 A.M.;
-Primary impression: behavioral/psychiatric episode;
-Secondary impression: laceration/abrasion/hematoma (minor surface trauma);
-Injury: sharp glass contact;
-Thumb laceration;
-Chief complaint: behavioral episode;
-EMS arrived on the scene at the nursing home and was greeted by police officers walking out with the patient. The patient stated that he/she did not want to hurt him/herself, but that he/she wanted to get out of there.
Review of the resident's hospital Emergency Department notes, dated 1/9/24, showed the following:
-The hospital graduate nurse (GN) received a call from the facility and a staff member (DON) said they needed an intervention for the resident's behavior, in order to be able to take him/her back. The caller explained the resident had become agitated that morning, broke a window, and tried to leave the facility. The GN said the resident had been calm, cooperative and verbally redirectable since his/her arrival at the hospital. The GN was told the facility still needed to know what actions to take, if the resident was to have that behavior again, in order to take him/her back. Otherwise, the resident was going to wind up back at the emergency room (ER) and she did not want the resident to hurt him/herself. The GN explained the interventions which were provided during the resident's stay at the hospital along with the appropriate referrals per the resident's discharge paperwork. The GN notified the resident's hospital Case Manager A of the situation;
-The resident's nurse requested that Case Manager A contact facility staff. The resident was assessed by a Behavioral Health Intake Specialist (BHIS) and did not meet inpatient behavior health criteria. He/She was cleared to return to the facility. Case Manager A phoned the facility DON and discussed the resident's discharge orders to return to the facility. Case Manager A explained the resident had been seen by the ER physician and BHIS, was medically cleared and determined not to qualify for inpatient behavioral health treatment. The DON inquired about discharge plans. Case Manager A encouraged the DON to contact their facility physician. The DON verbalized understanding and agreed the resident could return to the facility;
-The DON received a Registered Nurse (RN) to RN report via telephone. The DON verbally agreed to the resident's transfer back to the facility. All questions were answered by the hospital RN, including the care that was provided to the resident during his/her visit and resources provided in the discharge paperwork. The DON verbalized no further questions at that time.
Review of the resident's hospital after visit summary, dated 1/9/24, showed:
-Reason for visit: laceration;
-Diagnoses: open wound, dementia caused by blood vessel disease, Type II diabetes mellitus with diabetic neuropathy (a common complication of diabetes; damage to the nerves that enable one to feel sensations such as pain), unspecified whether long term insulin use;
-The patient was seen in the ED (emergency department) by an intake clinician. Per the consulting provider, it has been determined the patient is safe for discharge to the facility at this time. He/She lacks evidence of intent, plan and means to do harm and appears to be at baseline functioning;
-The patient has received the following recommendations: psychiatrist: see referrals below, therapist: see referrals below, other: see referrals below (community resources specifically to help with dementia related concerns, suicide prevention and crisis hotlines);
-You should follow up with your primary care and specialty physicians as directed for ongoing medication management;
-The treatment you received today was not a substitute for, nor an effort to provide, complete and ongoing medical care.
Review of the written statement of the DON, signed 1/10/24, showed on 1/9/24 at 12:53 P.M., she received a call from the hospital GN and hospital RN (Nurse B). The DON requested information on the resident's current status and aggressive behaviors. They told her the resident was stable and had not displayed any behaviors at all. The nurse (Nurse B) reported the resident had been pleasant and cooperative and took all medications as prescribed. The DON requested that a new intervention be put in place for behaviors, before the resident returned to the facility. The hospital nurse said that no psychiatrist had been assigned to the resident, because he/she displayed no behaviors and no new interventions had been put in place at that time. The nurse stated the resident was not a threat to him/herself or others at that time and had no wandering behaviors. At 2:13 P.M., the DON received a call from the hospital. She spoke with a Charge Nurse (Nurse B) related to her concerns about the resident's aggressive behaviors and treatment in behavioral health and the lack of interventions provided to keep the resident safe. The Charge Nurse said they had evaluated the resident and determined that he/she was safe for return and required no further intervention. The Charge Nurse also stated the psychiatrist recommended sending the resident back to the facility.
Review of the written statements of the Administrator, dated 1/9/24, showed he spoke with a staff person from the hospital's behavioral health floor who asked if they could send the resident back to the facility. The Administrator questioned this, as the resident had just had a behavioral episode earlier in the morning. He asked if the resident could undergo a psychiatric consult, was told the hospital was not admitting the resident and they deemed it was safe for the resident to return to the facility. Again, the Administrator questioned this, then asked if there would be a nurse to provide report on the resident and was told the ER nurse would call to make report. When the Administrator last saw the resident (after the resident returned from the hospital), the resident was sitting in the DON's office at around 3:15 P.M. The resident was very pleasant, showed no signs of behaviors or exit seeking.
Review of the resident's progress notes, dated 1/9/24 at 2:40 P.M., showed staff documented opening the door to the Loop unit for Emergency Medical Technicians (EMTs) escorting the resident in, standing on both sides of him/her holding him/her by the arms, leading him/her through the door. An EMT stated the resident did not want to stay on the stretcher, was saying he/she had to leave and had to go. The resident retrieved a broom and began making sweeping motions with it, knocking pictures, books, and clothing into the hallway. The RN (Nurse M) immediately called the DON, informing her the resident had returned to the facility and was showing signs of agitation. The DON came to the unit and informed the RN (Nurse M) that she was removing the resident from the unit for safety reasons.
Review of the resident's care plan, showed no interventions added to increase staff awareness of the high risk behaviors which led to the resident's hospitalization on 1/9/24, modify his/her agitated, aggressive and violent behaviors, or to minimize risks associated with the hazards which occurred with him/her breaking a first floor window and jumping through it in an attempt to leave were added to the resident's care plan.
Review of the facility investigation, dated 1/12/24, showed on 1/9/24 at approximately 2:41 P.M., RN (Nurse M) called the DON and notified her the resident had returned and was becoming aggressive again. At approximately 2:43 P.M., the DON arrived on the locked unit and observed the resident striking the door with an object, kicking the walls, and tearing up pictures. Other residents were ambulating on the locked unit, while the resident was having the observed behaviors. The DON removed the resident from the locked unit, in an attempt to de-escalate his/her current behaviors as this was identified as a potential trigger, and to maintain the safety of the other residents on the memory care unit. At approximately 2:46 P.M., the DON escorted the resident to his/her office and attempted to notify his/her Responsible Representative (RR) of the behaviors and have the RR assist with calming the resident. The DON was unsuccessful in contacting the RR. The DON offered verbal de-escalation which was noted to be successful.
Review of the written statement of the Assistant Director of Nursing (ADON), dated 1/9/24, showed the Infection Control Nurse called, stating that paramedics were having a difficult time bringing the resident into the building. Once the ADON got down to the Loop unit with the DON, the resident was sweeping items up with a broom. The ADON and DON escorted the resident up to the DON's office. The resident was calm and pleasant. Several times they phoned the resident's family members, who were listed in his/her chart with no answer. The resident sat in a chair humming and answering simple questions. The ADON then left the DON's office.
Review of the facility investigation, dated 1/12/24, showed the resident remained in the DON's office with the Administrator, the DON and ADON from approximately 3:08 P.M. until 3:35 P.M. They were attempting to contact the RR, to provide an update on the resident's behaviors and notification that he/she was being assigned to a new room on the third floor. The resident remained calm and cooperative with no displays of aggressive, exit seeking or self-harm behaviors while sitting in the DON's office. The IDT (interdisciplinary team) determined that he/she was de-escalated from his/her previous behaviors and the intervention of bringing him/her off the locked unit was effective. At approximately 3:35 P.M., staff notified the DON the resident's room was prepared, and his/her belongings had been transferred to the room. The DON then escorted the resident to his/her room and introduced the resident to his/her roommate. The DON escorted the resident around the unit, to orient him/her to the floor. At approximately 3:35 P.M., the DON took the resident to the nurses' station to introduce him/her to Nurse C, Certified Medication Technician (CMT) D and CNA E. Afterwards, she sat the resident in a chair across from the nurses' station and went into another office next to the nurses' station to speak with a staff member. According to staff who were present, the resident showed no signs of physical or verbal aggression, exit seeking or self-harm behaviors. At approximately 3:45 P.M. CNA E witnessed the resident ambulating on the hall. There were no signs of exit seeking, aggressive or self-harm behaviors noted.
Review of the written statement of CMT D, dated 1/9/24, showed the period of time documented on was from 4:15 P.M.- 4:39 P.M. CMT D first saw the resident, when the DON was showing the resident the room in which the resident would be sleeping. Then she walked the resident back up to the front, where the resident sat in a chair by the desk (nurses' station). CMT D moved away from the desk while working. The resident got up and walked to the T3 Hall and sat in the sitting area. CMT D tried to get the resident to come with him/her, but the resident just sat there. Another worker came and helped CMT D get the resident back onto 3 Long Hall. The resident sat back down in the chair by the nurses' station. CMT D returned to his/her medication cart and was looking at his/her computer. He/She and did not see the resident get up and walk down 3 Long Hall. When CMT D noticed the resident was no longer sitting by the nurses' station, CMT D looked down the hall, saw the resident and called out for the resident to return to his/her seat. As the resident turned around and started walking back up the hall escorted by CNA F, Nurse M gave CMT D the resident's medications to put into the medication cart. Another co-worker then came up to the third floor, with the resident's TV and asked CMT D to hook it up. CMT D proceeded to go and do that. As CMT D walked towards the resident's room, he/she passed the DON who said the resident was in her office. CMT D went to the resident's room and hooked up the TV. While CMT D was doing that, he/she got a call from Nurse C at 4:39 P.M. asking where CMT D was and saying that something happened.
Review of the facility investigation, dated 1/12/24, showed at approximately 4:15 P.M., CNA F observed the resident ambulating along the rear of 3 Long Hall and redirected him/her. The resident turned around and started walking towards his/her room. The resident was not showing any signs of exit seeking, aggressive or self-harm behaviors. Sometime between 4:20 P.M. and 4:25 P.M., CMT D observed the resident walking down 3 Long Hall and called the resident back toward his/her room. The resident was not exhibiting aggressive, exit seeking or self-harm behaviors. At 4:25 P.M., the DON entered her office and observed the resident sitting in her office again. She spoke with the resident, who responded appropriately showing no signs of physical or verbal aggression, exit seeking or self-harm behavior. CMT D was standing in the hallway at the DON's office door. The DON let CMT D know it was ok for the resident to sit in her office. The DON returned to her meeting in the office next door. At approximately 4:30 P.M., Nurse C observed the resident sitting in a chair in the DON's office appearing calm with no signs of aggression, exit seeking or self-harm behavior noted. At around 4:31 P.M., Housekeeper G was taking trash out to the dumpster, when he/she heard a noise and saw a window screen fall to the ground. Housekeeper G looked up and saw the resident hanging headfirst from a (third floor) window out to his/her waist. Housekeeper G yelled for the resident to go back inside. After a few times instructing the resident to go back inside the building, the resident complied and backed into the facility. At that moment, Housekeeper G ran inside and up the stairs to the 3 Hall nurses' station and yelled asking where was the resident. Housekeeper G, along with other staff members, began looking for the resident.
Review of the undated written statement of Nurse C, showed on 1/9/24, he/she saw the resident standing in the DON's office between 4:28 P.M. and 4:30 P.M. At approximately 4:31 P.M., Nurse C was going down 3 Long Hall and noticed Housekeeper G running towards the hall asking where was the resident. At approximately 4:33 P.M., while Nurse C was helping staff look for the resident, Nurse C heard a scream from CNA H in the therapy room on 3 Short Hall. When Nurse C went into the room, he/she saw that the window was open. When Nurse C looked out the window, he/she saw the resident lying face down on the ground.
Observation of the facility grounds, on 1/23/24, showed the therapy/recreation window located on the East side of the building, three floors up with slightly sloped asphalt below.
Review of the facility investigation, dated 1/12/24, showed at approximately 4:31 P.M., the DON was still in a meeting in the office next door (to her office), when she saw staff running and heard a male voice yell, asking where is he/she? Staff immediately searched the third floor for the resident from approximately 4:31 P.M. to 4:33 P.M. At around 4:35 P.M., staff heard a yell from CNA H in the therapy/recreation room. The DON entered the room, observed an open window, looked out the window and saw the resident lying on the ground under the window. The DON instructed staff to call 911 and bring a crash cart downstairs. The DON with assistance from Physician I, who was at the facility at the time of the incident, immediately went to assess the resident. Physician I instructed staff not to move the resident. The resident's vital signs at the time were: blood pressure 169/119, (BP normal range: 90/60 mm/Hg (millimeters of mercury) to 120/80 mm/Hg), heart rate 107, (normal range: 60 - 100 beats per minute), temperature, 97.8 degrees Fahrenheit (normal range: 97.8 - 99.1 degrees Fahrenheit), respirations 12, (rate of breathing, normal range: 12-18 breaths per minute), and oxygen saturation, 98% (normal range: 94% to 99%). Staff applied oxygen but did not move the resident who was lying on his/her left side. At 4:40 P.M., the DON placed another call to 911 to report the resident's condition and obtain an estimated time of arrival for EMS. At 4:41 P.M., the police arrived followed by EMS who assumed care of the resident and transported him/her to the hospital.
Review of the resident's incident report, dated 1/9/24 at 4:38 P.M., showed the resident's mental status was disoriented (distracted, unable to think clearly and being confused about time, location, and identity). Predisposing factors were a self-inflicted injury and impaired memory. The predisposing situational factor was the resident's recent room change.
Review of Physician I's written statement, dated 1/11/24, showed on 1/9/24, he/she happened to be on the third floor early in the afternoon hours for rounding and saw staff running and calling out to one another about a resident who just jumped off the third floor out from a window. The Administrator was at the scene and showed Physician I. Once Physician I saw the resident on the ground, they went down to assess the situation. Staff members were coming out with a crash cart. Physician I directed staff not to move the body, due to possible head and neck trauma. The resident was unconscious and not responding to voice. He/she was face down, on his/her side. Someone had already placed a beanie under his/her face. The resident had blood coming out of his/her right ear and possibly mouth. The DON placed a BP cuff on the forearm. The resident had a BP of 130/ and HR 100. Physician I listened to the resident's breathing with a stethoscope, and he/she had breath sounds on both sides. Staff had already called 911. The police arrived first, and Physician I spoke with them. The medics arrived shortly thereafter. The medics asked a few questions and then log rolled the resident onto his/her back and placed a neck collar on him/her. Physician I helped them move the resident onto the stretcher. The medics immediately transported the resident to the hospital.
Review of the resident's undated police report, showed the following:
-Date/time call received: 1/9/24 at 4:39 P.M.;
-Arrival time: 4:41 P.M.;
-Upon arrival, the officers located the resident who was being treated by Physician I. The resident was unconscious, breathing and appeared to have a major internal head injury as there was a lot of blood coming from the interior of his/her right ear canal. Physician I advised the facility did not have a neck brace onsite, and they did not move the resident from his/her current location and position. Physician I was administering oxygen to the resident. Staff members advised the resident had jumped from the third story window. The officer asked them if the resident had made any statements indicating suicidal ideations and they said the resident had not. EMS arrived on scene, treated, and transported the resident to the hospital. The DON advised the resident was to be under o[TRUNCATED]
Nov 2023
4 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 failed to ensure resident funds were placed in an account separate from the facility operating account. The facility did not provide residents with r...
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Based on record review and interview, the facility failed to ensure resident funds were placed in an account separate from the facility operating account. The facility did not provide residents with refunds of their personal funds from the operating account in a timely manner for five residents (Resident #14, #15, #16, #17 and #18). Additionally, the facility failed to allow residents access to petty cash on an ongoing basis. The facility census was 133.
1. Record review of the facility maintained Accounts Receivable Aging Report, dated 11/09/23, showed the following residents with personal funds held in the facility operating account.
Resident Amount Held in Operating Account
#14 $725.04
#15 $246.00
#16 $2,788.00
#17 $2,547.66
#18 $1,230.00
Total $7,536.70
During an interview on 11/09/23 at 2:10 P.M., the Business Office Manager (BOM) #1 said he/she was transferred from a sister facility to this facility on 09/26/23 to clean up the resident trust accounts. The BOM #1 was not sure why the previous Business Office Manager did not refund the money and was starting to work on the credits in the operating account to refund the money.
2. Record review of the facility maintained Resident Statement, for the period 01/01/23 through 11/09/23, showed Resident #6 had a balance of $398.00 as of 11/08/23.
During an interview on 11/09/23 at 4:03 P.M., Resident #6 said he/she was not allowed to withdraw petty cash for two weeks due to the facility switching bank accounts.
During an interview on 11/09/23 at 4:10 P.M., the Regional Director of Business Office Systems said the bank had the incorrect Automated Clearing House (ACH) account and residents may not have received petty cash during that time.
MO00227084
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 F0568
(Tag F0568)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to maintain a system to ensure the resident trust fund account was managed in accordance with proper accounting principles by not maintaining ...
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Based on record review and interview, the facility failed to maintain a system to ensure the resident trust fund account was managed in accordance with proper accounting principles by not maintaining an accurate accounting of all monies held in the resident trust fund account by not reconciling each month. The facility managed funds for 80 residents. The facility census was 133.
1. Record review of the facility maintained bank statements for the months 01/2023 through 08/2023 showed no documentation showing any reconciliations.
Record review of the facility maintained 09/2023 reconciliation forms, dated 10/05/23, showed the attempted reconciliation had a difference of negative $1,136.62.
Record review of the facility maintained 10/2023 reconciliation forms, dated 11/02/23, showed the attempted reconciliation had a difference of negative $403.56.
During an interview on 11/09/23 at 10:22 A.M., the Business Office Manager (BOM) #2 said resident fund reconciliations were not being done prior to him/her coming to the facility in 09/2023. The BOM #2 said he/she did not know why the reconconcilaitons were not being done.
During an interview on 11/09/23 at 4:10 P.M., the Regional Director of Business Office Systems said resident fund reconciliations could not be located.
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 F0570
(Tag F0570)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to maintain a surety bond sufficient to ensure the protection of resident funds. The facility census was 133.
1. Record review of the facility...
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Based on record review and interview, the facility failed to maintain a surety bond sufficient to ensure the protection of resident funds. The facility census was 133.
1. Record review of the facility maintained Resident Trust Bank Statements and Resident Trust Balance Reports for the period 01/2023 through 10/2023, showed an average monthly balance of $214,759.12.
Record review of the facility maintained Accounts Receivable A/R Aging Report, dated 11/09/23, showed the facility held an average balance of resident funds in the amount of $7,536.70 in the facility operating account.
Record review on 11/09/23, of the Department of Health and Senior Services approved bond list showed the facility did not have an approved bond, making the bond insufficient by $324,000.
During an interview on 11/09/23 at 4:10 P.M., the Regional Director of Business Office Systems said the previous owners had a resident trust bond but was not sure if there was a new bond.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure one resident (Resident #13) was free from misappropriation o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure one resident (Resident #13) was free from misappropriation of resident property when the former Social Services Assistant (SSA) A used resident funds for his/her personal use. The facility census was 133.
1. Record review of the facility maintained Resident Trust Statement for the period 05/05/23 through 11/09/23, showed the following withdrawal from Resident #13's account:
Date Amount Description
08/22/23 $3,300.00 Personal Needs Items
Record review of the facility maintained Resident Face Sheet shows Resident #13 is his/her own responsible party.
Record review of the facility maintained paperwork for Resident #13's Resident Trust Statement, showed written authorization for the $3,300.00 withdrawal was not obtained until 10/20/23.
Record review of the Facility Self Report on 11/09/23, showed the Social Services Director (SSD), SSA A, and the admissions staff members had a conversation on 10/19/23 about Resident #13 needing clothing, and money was going to be withdrawn from Resident #13's resident trust account. SSA A did not mention that he/she withdrew $3,300.00 from the resident's trust account on 08/22/23. During the morning meeting on 10/20/23, the Staffing Coordinator (SC) said he/she cashed a check on 08/2023 for $3,300.00 and gave the money to the former Business Office Manager (BOM) B for shopping for Resident #13. BOM B gave the money to SSA A. The SSD called SSA A on 10/20/23 and verified the $3,300.00 was given to him/her. SSA A said he/she bought a tablet, cell phone and earphones for Resident #13. The SSD asked SSA A where the remaining money has been for the past two months and told SSA A to return the money to the facility.
During an interview on 11/09/23 at 3:58 P.M., Resident #13 said money was taken from his/her resident trust account in 08/2023 without his/her knowledge. He/she usually withdraws $40.00 or $50.00 one time per week. Resident #13 said he/she wanted a tablet, cell phone, head phones and name brand clothing, but did not know the money was being withdrawn at that time. Resident #13 said he/she received a tablet, cell phone and ear phones after the money was withdrawn, but did not receive any clothing. Resident #13 said he/she did not sign paperwork for the withdrawal until the previous Administrator asked him/her to sign the withdrawal form in 10/2023.
During an interview on 11/09/23 at 12:35 P.M., the Regional Director of Business Office Systems said BOM B gave SSA A $3,300.00 to shop for Resident #13 in 08/2023.
During an interview on 11/09/23 at 2:15 P.M., the SC said Resident #13 wanted shopping done and was given a check in the amount of $3,300.00 from the previous BOM B. The SC said he/she went to the bank to cash the check and brought the cash back to the facility and showed the previous Administrator the money. The money was then given to BOM B to keep the money in a safe place until SSA A could do the shopping for Resident #13.
During an interview on 11/20/23 at 2:54 P.M., the previous Administrator said he/she was aware that the Resident #13 wanted brand name clothing, not clothing from Walmart. He/she also said SSA A did not bring any remaining resident money to the facility as of 11/09/23.
During an interview on 11/20/23 at 3:05 P.M., the SSD said he/she had a conversation with SSA A and admissions staff on 10/19/23 regarding Resident #13 in need of new clothing. SSA A did not say anything about receiving $3,300.00 to shop for Resident #13 in 08/2023. The SSD said SSA A did not come to work on 10/20/23, so the SSD called SSA A and said he/she verified on Walmart.com the cost of the items that SSA A purchased for Resident #13 in 08/2023:
- Cell phone in the amount of $89.00;
- Galaxy Tablet in amount of $205.00;
- Earphones in the amount of $39.99.
The SSD asked SSA A where the remaining money was (approximately $2,900.00) and the SSA A said there was only $700-$800 left. SSA A could not explain where the rest of the money was. The SSD said the money needed to be returned. SSA A said he/she was out of town and would bring the money to the facility on [DATE]. SSA A was terminated from employment from the facility on 10/20/23. The SSD said as of 11/20/23, SSA A had not returned any of Resident #13's funds.
MO00226217
MO00226360
Sept 2023
2 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Quality of Care
(Tag F0684)
Someone could have died · This affected 1 resident
Based on observation, interview and record review, the facility failed to provide acceptable nursing practice for one resident with bilateral (right and left) leg wounds (Resident #1). The resident ro...
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Based on observation, interview and record review, the facility failed to provide acceptable nursing practice for one resident with bilateral (right and left) leg wounds (Resident #1). The resident routinely refused care and treatment from nursing staff, and he/she had physician orders for treatments to be performed daily by the resident with staff monitoring the treatments. Staff documented the treatments were completed, however during interviews, staff said they falsely documented completion and had not observed the resident perform his/her wound treatments as ordered. On 9/19/23, the resident called Emergency Medical Services (EMS) for assistance after a fall. EMS arrived, noted an overwhelming odor and had concerns of severe infection and necrosis (dead tissue) in the open wounds. The resident was transferred to the hospital, where it was determined he/she had sepsis (presence of bacteria and infectious organisms in the blood stream), Methicillin-resistant Staphylococcus aureus bacteremia (MRSA, a bacteria that is responsible for many hard-to-treat infections) likely secondary to left extremity (left leg) infection, likely osteomyelitis (infection of the bone), and chronic lymphedema (swelling caused by fluid buildup) of the bilateral lower legs and feet with chronic skin change and wounds. Bilateral amputation was recommended. Additionally, the facility failed to document administration of an opioid medication administered to Resident #2. The facility failed to notify Resident #2's primary care physician when the resident transferred to the hospital after becoming unconscious and unresponsive, requiring Naloxone (Narcan, used to reverse the effects of an opioid overdose) administration by Emergency Medical Services (EMS). The facility failed to investigate the incident, and implement necessary nursing services related to potential medication contraindications when Resident #2 was prescribed medications with potential for drug interactions and was found to have used cannabis purchased off-market. The facility failed to follow-up with the hospital upon discharge of the resident after the overdose, requiring emergency intervention, to determine any changes in treatment or recommendations made to the resident. Nursing staff failed to take immediate action to protect the resident from further health risks, by ensuring the physician, administration, and police were aware and intervene when staff became aware of the resident having possession of the potentially opioid-contaminated product. The facility failed to follow physicians orders and obtain a urine sample for a drug screen in a timely manner. Additionally, the facility failed to notify Resident #4's physician of the resident using marijuana and failed to include the use in the resident's care plan. The sample size was three. The census was 131.
1. The administrator was informed on 9/22/23 of an Immediate Jeopardy (IJ), which began on 9/19/23. The IJ was removed on 9/26/23 as confirmed by surveyor on-site verification.
Review of Resident #1's care plan, undated, showed the following:
-Focus: the resident's desired personal care routine to complete his/her own wound care; Interventions included the resident was educated on wound care, nursing to monitor for changes in the wound, nurses to observe when the resident performed wound care to his/her right lower extremity (RLE, right lower leg);
-Focus: the resident was non-adherent to treatment plan, does not allow nursing staff to clean, treat or evaluate bilateral lower extremities (BLE, right and left lower legs), the resident often stated he/she had performed his/her own wound treatments;
-Goal: the resident will not experience a negative outcome related to non-adherence; Interventions included documentation of the resident's response to education, notify the provider of non-adherence, provide the resident education related to non-adherence to facility or provider treatment plan, and refer to Social Services for potential interventions;
-Focus: The resident has actual impairment to skin integrity of the BLE and will not allow the staff to measure, assess, or treat the area;
-Interventions included: Document refusals, the wound doctor may consult or oversee the resident's wound care with interventions to manage and treat the wounds, frequently monitor and inquire with the resident about self-performed wound care with any potential complications and/or recommendations.
Review of the resident's physician order sheets (POS), showed the following:
-An order, dated 5/9/23, perform weekly skin assessments every night shift on Tuesdays;
-An order, dated 5/17/23, the resident may have wound care products at bedside for dressing changes;
-An order, dated 5/17/23, wound cleanser or normal saline, collagen pad (absorbs wound drainage), calcium alginate (absorbs wound drainage), kerlix (gauze bandage roll) and tape. The resident to change dressing daily and as needed (PRN);
-An order, dated 5/18/23, the resident may perform self-care for wound on left lower leg. Nursing must observe application by the resident, monitor for wound changes and call the doctor with any changes.
Review of the resident's Treatment Administration Record (TAR), dated July 2023, showed the following:
-The nurses documented the wound nurse monitored the resident's RLE wound daily, as ordered on every day except 7/17, 7/20, 7/28 and 7/29, when the resident refused;
-The nurses documented they observed the resident's application of treatments to his/her BLE, monitored the wounds for changes and called the physician with any wound changes, every day as ordered, except for 7/28 and 7/29, when the resident refused;
-The nurses documented the resident used wound cleanser or normal saline, collagen pad, calcium alginate, kerlix, and tape to change his/her dressing daily, as ordered, except for 7/28 and 7/29, when the resident refused;
-The nurses documented they completed weekly skin assessments every Tuesday, as ordered, except on 7/4 and 7/25, when the resident refused;
-The nurses documented they checked the resident's right leg for redness every shift, marked areas of redness and notified the physician if the area increased, every shift as ordered, except for night shift on 7/1, day shift on 7/6, day shift on 7/20 and day shift on 7/30, when the resident refused.
Review of the resident's TAR, dated August 2023, showed the following:
-The nurses documented the wound nurse monitored the resident's RLE wound daily, as ordered;
-The nurses documented they observed the resident's application of treatments to his/her BLE, monitored the wounds for changes and called the physician with any wound changes, every day as ordered;
-The nurses documented the resident used wound cleanser or normal saline, collagen pad, calcium alginate, kerlix, and tape to change his/her dressing daily, as ordered;
-The nurses documented they completed weekly skin assessments every Tuesday, as ordered;
-The nurses documented they checked the resident's right leg for redness every shift, marked areas of redness and notified the physician if the area increased, every shift as ordered.
Review of the resident's medical record, showed the following:
-The facility log, dated 9/5/23, showed the resident had the following: left leg lateral, lymphedema, arterial wound, measuring 9.0 cm by 6.0 cm by 0.2 cm; left leg medial, lymphatic wound, measuring 12.0 cm by 11.0 cm by 0.2 cm; right left medial, lymphatic wound, measuring 3.0 cm by 3.0 cm by 0.2 cm. The resident declined assessment;
-On 9/6/23 at 5:37 A.M., a weekly skin assessment, showed the resident's right lower leg (front), left lower leg (front), right lower leg (rear), left lower leg (rear), left ankle (inner), right ankle (outer), right heel and left heel were all identified; none of the sites had any descriptions or assessments noted. Existing skin issues to BLE with no new skin issues were noted. Nurse Supervisor F signed the document;
-The facility log, dated 9/12/23, showed the resident had the following: left leg lateral, lymphedema, arterial wound, measuring 9.0 cm by 6.0 cm by 0.2 cm; left leg medial, lymphatic wound, measuring 12.0 cm by 11.0 cm by 0.2 cm; right left medial, lymphatic wound, measuring 3.0 cm by 3.0 cm by 0.2 cm. The resident declined assessment;
-On 9/13/23 at 4:25 A.M., a weekly skin assessment, showed no areas were identified. Existing skin issues on BLE with treatments were in place and no new skin issues were noted. Nurse Supervisor F signed the document;
-On 9/15/23 at 3:30 A.M., a weekly skin assessment, showed no areas were identified. Existing skin issues to BLE with no new wounds identified. Nurse Supervisor D signed the document;
-On 9/19/23 at 9:26 P.M., a weekly skin assessment, showed no areas were identified. Areas noted to the BLE and treated with no new open areas. Nurse E started the assessment on 9/19/23 and Nurse Supervisor F signed the document on 9/20/23;
-On 9/19/23 at 9:51 P.M., EMS came to the floor, stating someone had called to say they were on the floor. The nurse and EMS entered the resident's room and found him/her on the floor, at bedside, with urine soaked linen. The resident denied pain and did not want to go to the hospital. EMS told the resident he/she would lose his/her legs if he/she did not let a doctor see his/her legs. The resident agreed to go to the hospital;
-On 9/19/23 at 10:03 P.M., EMS took the resident to the hospital.
Review of the resident's TAR, dated 9/1/23 through 9/19/23, showed the following:
-The nurses documented the wound nurse monitored the resident's RLE wound daily, as ordered;
-The nurses documented they observed the resident's application of treatments to his/her BLE, monitored the wounds for changes and called the physician with any wound changes, every day as ordered;
-The nurses documented the resident used wound cleanser or normal saline, collagen pad, calcium alginate, kerlix, and tape to change his/her dressing daily, as ordered;
-The nurses documented they completed weekly skin assessments every Tuesday, as ordered;
-The nurses documented they checked the resident's right leg for redness every shift, marked areas of redness and notified the physician if the area increased, every shift as ordered.
During an interview on 9/21/22 at 2:43 P.M., Certified Nursing Assistant (CNA) C said the following:
-On 9/19/23, he/she did smell the resident's wound. It was so strong and foul the EMS staff, who were standing outside of the resident's room and wearing surgical masks, tucked their noses into their shirts;
-He/She had smelled the same foul odor emitting from the resident's room since as early as July;
-He/She had alerted Nurse B the resident's wounds smelled like they were infected for months;
-He/She expected the nurse to address the situation and when nothing changed, he/she continued to report to Nurse B. He/She did not report up the chain of command.
During an interview on 9/22/23 at 10:49 A.M., Nurse E said the following:
-He/She was working on the resident's floor on 9/19/23;
-He/She was at the nurses' station when the EMS staff came onto the floor;
-He/She last saw the resident's BLE months ago, and can only remember they looked red;
-He/She did not start or complete a weekly skin check on the resident on 9/19/23, and said if his/her name was on the assessment it must have been in error.
Review of the EMS patient care report, dated 9/19/23, showed the following:
-The resident called 911 on 9/19/23 at 9:32 P.M., to report he/she had slid out of bed a few hours ago and staff would not help him/her back into bed. The resident complained of bilateral leg pain and requested help back into his/her bed. The resident said he/she saw someone about his/her legs one week ago and was told there was an infection. He/She was not currently taking antibiotics;
-The staff on the scene at the facility knew nothing about the resident;
-The resident was found in his/her room seated on the floor. The resident was alert and oriented times four (to self, place, time and situation). The resident's BLE were swollen, reddened, edematous (swollen) and necrotic with white, flakey skin and foul odor. The resident's right leg had an open wound that appeared severely infected. Both legs smelled of necrosis;
-Assessment of the resident's BLE described necrosis in both lower legs with pain and swelling. There was an open wound and what appeared to be severe, limb threatening infection in the right lower leg;
-EMS left the facility at 10:02 P.M. and arrived at the hospital with the resident at 10:11 P.M.
Review of the resident's hospital record, showed the following:
-On 9/19/23 at 10:15 P.M., emergency room physician notes, the resident presented with a wound infection. History was difficult to obtain from the resident due to the acuity of his/her condition. Per EMS, the resident was found with chronic wound to the distal aspect (lower part) of his/her BLE. The resident stated his/her legs were like that for a long time.
-On 9/20/23 at 12:54 A.M., the medical decision making note, the resident presented with fever, sepsis, extensive lower extremity wounds worse to the left side. Extensive skin changes over the feet bilaterally, unclear when the resident's wound dressings were last changed but findings suggesting significant ulcerations with sepsis, no clear evidence of necrotizing infection at this time but plan of broad-spectrum antibiotics and admission to the hospital for podiatry and wound debridement. Significant osteomyelitis on x-ray is most likely;
-On 9/20/23 at 12:37 P.M., the physician progress note, Diagnoses included severe sepsis, suspected osteomyelitis vs. cellulitis, venous stasis dermatitis (condition of the skin which becomes swollen or inflamed caused by poor blood circulation in the veins), charcot's joint BLE, acute metabolic encephalopathy (brain dysfunction caused by a deficiency of vitamins, oxygen or glucose (sugar)) in setting of sepsis. The resident was alert and oriented to place only;
-On 9/21/23 at 12:55 P.M., a physician progress note, the assessment and plan included MRSA bacteremia likely related to left lower extremity infection, related to endocarditis (infection of the heart's inner lining) and osteomyelitis; left lower leg and foot wound infection highly suspect underlining osteomyelitis; chronic bilateral lower leg and feet lymphedema with chronic skin change and wounds; The resident's family member was present with the resident and physician. They discussed the resident's diagnosis and recommendation for leg amputation.
-On 9/21/23 at 1:19 P.M., a physician progress note, the resident was followed by the vascular team who recommended bilateral above the knee amputation for source control and due to unsalvageable nature of bilateral lower limbs. The resident was not agreeable to amputation.
During an interview on 9/20/23 at 11:15 A.M., the resident's nurse at the hospital said the following:
-The resident was admitted with wound infection, the wound was from his/her shin down, not really deep, not really describable, both legs are swollen and weeping;
-The resident's white blood cell count was low at 20.6, showing possible infection;
-The resident seemed fearful or in pain, whenever you touched him/her, he/she said Ow;
- The resident was cleaned up and while getting a bath, he/she was crying in pain.
During an interview on 9/20/23 at 11:21 A.M., the resident's doctor at the hospital said the following:
-The resident has cellulitis (bacterial skin infection);
-The resident had a wound on his/her calf and one on his/her shin;
-The wounds are very difficult to determine condition due to the build up on his/her legs. He/She had a lot of fungus growth on his/her legs. The fungal infection appeared to have traveled up his/her legs from a toenail fungus that went untreated;
-There was a yellow and black film on the wound and testing had to be done to see if there was bone involvement but it appeared necrosis was present in the wound.
During an interview on 9/21/23 at 12:32 P.M., Wound Nurse A said the following:
-She became the facility's wound nurse on 9/4/23;
-She was responsible for collecting shower sheets, auditing weekly skin assessments, completing wound rounds with the Wound Medical Doctor (WMD), collecting the WMD progress notes after his visit and updating the resident's medical record and facility wound logs with the information;
-She was also responsible for all wound treatments in the facility, Monday through Friday;
-Nurses were responsible for wound care when she was not at the facility, on the weekends and when she alerted nurses she was not able to complete treatments;
-She had not seen the resident since she was hired for the position;
-On 9/19/23, the resident had denied a visit from the WMD during wound rounds;
-She expected nurses to administer treatments as ordered;
-She was told by the previous wound nurse, the resident completed his/her own wound treatments and the nurse had to watch the dressing changes to monitor the wound and for infection control;
-She expected the nurses to document in progress notes any changes to a wound, if and when a resident refused orders or the plan of care;
-She was not aware the resident refused to let nurses watch him/her complete his/her wound treatments, refused skin assessments and showers;
-She would have alerted the WMD if she had known the resident had refused the plan of care;
-She expected nurses to completely fill out weekly skin assessments identifying the location, appearance, if there was exudate, if it look infected of any skin condition found on the resident's skin;
-It was important for nurses to give details on the weekly skin assessment or in their corresponding progress note so she knew what action to take when she audited residents' medical records.
During an interview on 9/21/23 at 1:33 P.M., Nurse B said the following:
-He/She worked on the resident's hall on a regular basis on the 7:00 A.M. through 7:00 P.M. shifts;
-He/She was responsible for completing all and any orders on the TAR that were assigned to his/her shift;
-Nurses were responsible for weekly skin assessments;
-Nurses were expected to complete an assessment if there was a new skin condition, document in a progress note the location, appearance of the skin condition, how it was treated, who was notified and when, and put new orders in place if needed;
-He/She would alert the Wound Nurse, Director of Nursing, (DON), nursing supervisors, the Administrator and the Primary Care Physician (PCP) if there was a new skin condition or if an existing wound had changed;
-The resident refused all care and completed his/her own wound care;
-He/She did not document the resident refused wound care since the resident did his/her own wound care;
-He/She did not watch the resident complete his/her own wound care;
-He/She had never seen the resident's BLE or feet;
-He/She knew the resident had an order for the nurse to watch him/her complete wound care;
-He/She documented he/she watched the resident complete wound care even though it was not true;
-He/She documented he/she checked the resident's right leg for redness daily even though it was not true;
-He/She trusted the resident to complete his/her wound care without a nurse supervising;
-The resident did not have the cognitive abilities or knowledge to accurately assess his/her own wounds and report any deterioration to nursing staff;
-He/She said the resident's room always had a strong odor. It was not an odor of urine or bowel movement. The odor was from the resident's wounds;
-If a wound had a foul or strong odor, it meant the wounds were infected or needed medical attention;
-He/She did not document that the resident's wounds were malodorous, did not notify the PCP or wound nurse;
-He/She should have documented and notified the PCP, wound nurse, and nursing supervisors of the resident's continued refusal to allow nurses to watch wound changes and of the foul odor in the resident's room;
-He/She should have documented every time he/she was not able to complete the order as written as it could have alerted physicians and nursing supervisors that the condition of the resident's wounds were unknown and it could have changed the plan of care;
-The resident's medical record was not accurate as he/she documented orders were completed when they were not.
During an interview on 9/21/23 at 3:12 P.M., Nurse Supervisor D said the following:
-He/She was the Nurse Supervisor for the resident's floor;
-He/She was not aware the resident was out to the hospital until the morning of 9/20/23;
-He/She had not seen the resident's BLE since at least a month ago. He/She could not provide a description;
-The resident was noncompliant to care, refusing showers, housekeeping services and wouldn't allow nurses to oversee wound treatments;
-The nurses were responsible to oversee the resident's wound treatments;
-The resident's room had a strong odor due to not letting anyone in to clean the room;
-The resident's room also had a foul odor from his/her wounds;
-He/She believed due to the odor of the wounds, they needed attention as it was likely the wounds had a change in condition;
-Staff had reported for months the resident's room had a foul odor;
-He/She did not know why he/she did not alert PCP or administrative staff to the foul odor;
-He/She expected nurses to chart truthfully and accurately, only documenting what they did during their shift;
-If the nurses were not able to supervise the resident's wound care, they needed to document in the TAR and write a progress note;
-He/She was not aware Nurse B was not able to supervise the resident's wound care;
-He/She was not aware the Wound Nurse had not seen the resident since she was hired on 9/4/23;
-He/She was aware the resident refused treatment and evaluation from the WMD;
-If wounds did not receive the appropriate treatment they could deteriorate, get infected, possible gangrene, cause sepsis and result in the loss of a body part or death;
-He/She expected nurses to document when the resident refused care or did not follow physicians orders, especially if the refusal of care was ongoing as it could affect the plan of care;
-He/She expected nurses to document when they educated the resident on risks of refusal of plan of care, notification of the physicians, wound nurse and administrative staff;
-He/She was responsible for making sure staff followed orders and provided care to the residents as within their professional scope of practice;
-He/She expected nurses to chart truthfully as it was important to know when a task or order was not followed as it could cause a resident to decline.
During an interview on 9/22/23, at 12:01 P.M., Nurse Supervisor F said the following:
-He/She did not see the resident's BLE. The resident always covered them up and refused to let him/her watch when the resident completed wound care;
-He/She falsely documented supervision of the resident's wound care. He/She did not witness the resident treat his/her wounds;
-He/She falsely documented monitoring the resident's RLE for redness. He/She did not assess the resident's RLE;
-He/She falsely documented completed weekly skin assessments. He/She did not assess the resident's skin;
-The purpose of the weekly skin assessments was to assess all areas of the resident's body to see if there were any new conditions or changes to existing skin conditions. They were used to determine plan of care;
-The purpose of supervising the resident's wound care was to ensure the resident was following the treatment orders correctly and to assess the wounds condition, to determine if there was a change of condition;
-It was important to document the resident's refusal of care as it could affect the plan of care by the physicians;
-There was an odor emitting from the resident's room, but he/she could not determine the source. In retrospect, he/she should have found the source or documented the foul odor so that others would be aware.
During an interview on 9/22/23 at 10:48 A.M., the Social Worker (SW) said the following:
-He/She had not seen or heard from the resident since August;
-The resident called him/her when he/she needed something or had any questions;
-The resident called the SW in August to inquire about billing;
-He/She was aware there was an odor emitting from the resident's room and assumed it was from old food;
-He/She was not aware the resident was refusing the plan of care;
-He/She would have tried to intervene if he/she was aware of the resident's non-compliance.
During an interview on 9/22/23 at 1:17 P.M., the DON said the following:
-She expected staff to follow physician orders as written;
-She expected staff to document accurately and truthfully;
-She expected staff to alert the PCP and Nursing Supervisors when the resident continued to reject care;
-She expected staff to follow care plans and apply interventions as written;
-She expected staff to document the resident's refusals each time it occurred;
-She expected staff to document when and what education they gave the resident;
-She expected staff to complete weekly skin assessments and to alert the PCP and Nursing Supervisors when the resident refused;
-Weekly skin checks are performed to assess whether or not a resident had new skin conditions and/or if existing skin conditions had a change;
-Wounds can change overnight, that is why it was so important for a nurse to witness the resident tending to his/her wounds. The nurses needed to see the wounds on a daily basis to ensure there was not a change of condition. Their observations were important as the resident would not have the knowledge to assess the wounds him/herself;
-If the PCP, WMD or Nursing Supervisors knew the resident was not letting staff complete weekly skin assessments, showers, and not letting nurses watch dressing changes, it would have changed the plan of care. They may have insisted the resident go out to the hospital for a higher level of care as the resident was in danger of further skin breakdown or infection;
-She was not aware the resident's room had a strong odor;
-She saw the resident about a week ago while doing rounds. There was no odor in his/her room and the resident was wearing a long dress that covered his/her legs and feet;
-She had no knowledge of the resident refusing evaluation from the WMD, refused to let nurses watch him/her change his/her dressings, and refused skin assessments.
During an interview on 9/22/23 at 3:25 P.M., the Administrator said the following:
-She expected staff to follow the facility policies;
-She expected staff to follow the resident's plan of care;
-She expected staff to follow physician orders as written and to alert their supervisors if a resident continued non-compliance to the plan of care or physician orders;
-She expected staff to complete weekly skin assessments by looking at the resident's entire body, preferably when they were laying down, and document their finding with details;
-She expected staff to alert supervisors to strong odors and to try to locate the source as well as document all details in the resident's medical record;
-She expected staff to document the care they gave or didn't give to residents accurately and truthfully;
-Failure to document accurately could negatively impact the resident's plan of care.
During an interview on 10/2/23 at 10:19 A.M., the facility WMD said the following:
-He discovered the resident had a skin condition on his/her right lower leg on 8/22/23. Before then, the resident kept his/her right leg bandaged with a kerlix but would not allow the WMD to assess the leg;
-The last time he saw the resident's bilateral lower legs was on 8/29/23. The resident only allowed him to measure his/her right leg anterior (front);
-The resident had a history of refusing care from staff, including watching him/her apply wound treatments, showers and assessments;
-He expected nursing staff to educate the resident each time the resident refused care;
-There was not a smell from the resident's room or wounds on 8/22/23 or on 8/29/23. A strong odor would have alerted him to a possible infection in the resident's lower legs;
-The resident was a higher risk of infection at his/her lower legs due to his/her lymphedema, poor blood circulation and denial of care;
-Staff did not report a strong odor was emitting from the resident's room;
-He expected staff to report strong odors associated with the resident. He would have changed the plan of care, attempted to get wound cultures or blood cultures or tried to send the resident out to the hospital for a higher level of care;
-He sent the Wound Nurse his detailed progress notes after each visit so they could use the information to update the resident's medical record;
-He expected nurses to document when the resident refused care from him. The progress notes from the nurse should accurately reflect his wound progress note;
-He was not aware the nurses were not documenting truthfully in the resident's medical record, the TAR or the weekly skin assessments. He wasn't sure what was done for the resident if the medical record was not accurate or truthful;
-He expected the nurse to document truthfully and accurately in the resident's medical record as it affected the plan of care;
-He would have asked for a psychiatric consult to see if there was a change of condition or tried to send the resident out to the hospital for higher level of care if he had known the extent of the resident's refusal of care from staff;
-The resident was responsible for self and could refuse to go to the hospital for higher level care. At that point, the facility and/or Administrator would have the responsibility to make a decision to send the resident out on an emergency or 30 day discharge due to non-compliance to plan of care, which put him/her at greater risk of complications related to his/her medical condition.
2. Review of the facility's Notification of Change policy, dated 9/1/21, showed:
-The purpose of this policy was to ensure the facility promptly informed the resident, consulted the resident's physician and notified the resident's representative when there was a change requiring notification;
-Circumstances requiring notification included significant change in the resident's physical, mental or psychosocial status, which may include life threatening conditions or clinical complications; a transfer or discharge of the resident from the facility.
Review of the facility's Incident/Accident policy, undated, showed the following:
-All accidents or incidents involving residents, employees, visitor, vendors, etc, occurring on our premises shall be investigated and reported to the Administrator;
-The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident;
-The following data, as applicable, shall be included on the Report of Incident/Accident form:
a. The date and time the accident or incident took place;
b. The nature of the injury/illness (e.g., bruise, fall, nausea, etc.);
c. The circumstances surrounding the accident or incident;
d. Where the accident or incident took place;
e. The name(s) of witnesses and their accounts of the accident or incident;
f. The injured person's account of the accident or incident;
g. The time the injured person's Attending Physician was notified, as well as the time the physician responded and his or her instructions;
h. The date/time
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 F0572
(Tag F0572)
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 notify Resident #4 of all rules and regulations govern...
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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 notify Resident #4 of all rules and regulations governing resident conduct and responsibilities during his/her stay at the facility. The facility failed to disclose information to the resident regarding a prohibition of cannabis products in the facility and failed to establish a written policy for residents to review and understand prior to or upon admission, as appropriate during the resident's stay, and when the facility's rules change. The census was 131.
1. Review of the Resident #4's quarterly MDS, dated [DATE], showed the following:
-admitted on [DATE];
-Cognitively intact;
-No behaviors noted;
-Diagnoses included depression, osteoarthritis (inflammation of the bone) of hips, and pain in unspecified joint;
-Received antidepressants and opioids every day for seven days.
Review of the resident's medical record, showed the following:
-The resident was his/her own responsible party;
-On 7/7/23 at 2:10 P.M., a social services note showed the resident was found with a vaporizer which contained marijuana in it. It was in the social worker's (SW) possession in his/her office. The Administrator was informed and said they could give the resident a 30 day notice of discharge for the use of marijuana in a federally funded facility. The SW would send out referral to other facilities for placement;
-On 7/11/23 at 2:08 P.M., a behavioral note said the resident asked for his/her vaporizer over the weekend. The nurse told the resident that he/she turned the vaporizer in to the SW on 7/6/23. The resident said the SW said he/she could have the vaporizer back. The nurse spoke with the SW who said the resident could not have his/her vaporizer as marijuana was not allowed in the building. The nurse went back and relayed the message to the resident.
During an interview on 9/19/23 at 10:52 P.M., the director of nursing (DON) said the following:
-She did not know the resident had a vaporizer with marijuana in it while at the facility;
-She expected staff to notify her if they found a resident had marijuana on the premises because it was not allowed;
-She expected staff to notify the primary care physician (PCP) and administrative staff if there was knowledge a resident was using marijuana as it could affect their plan of care, interact with their medications and/or change the way a resident behaved.
During an interview on 9/19/23 at 1:15 P.M., the SW said the following:
-A nurse informed her that he/she found the resident with a vaporizer with marijuana in it;
-The nurse gave her the vaporizer and she locked it in her desk. It was still locked in her desk in her office;
-She told the resident it would be returned to him/her upon discharge;
-She told the Administrator who said to give the resident a 30 day notice, but the SW still could not find placement for the resident;
-She should have told the DON and nursing supervisors about the vaporizer with marijuana so they could follow up and make sure measures were in place to keep the resident safe.
During an interview on 9/22/23 at 4:28 P.M., the resident said the following:
-He/She was afraid the facility was going to give him/her a 30 day notice of discharge because he/she had a vaporizer with marijuana;
-He/She used the marijuana for pain relief and relaxation;
-He/She would not disclose from where he/she obtained the marijuana;
-He/She did not know the facility did not allow marijuana use in the facility, he/she thought it was okay since it was legal for use in the state;
-He/She did not disclose to the PCP that he/she had used marijuana in the past.
Jul 2023
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** See the deficiency cited at Event ID EIF412.
Based on observation, interview and record review, the facility failed to ensure re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** See the deficiency cited at Event ID EIF412.
Based on observation, interview and record review, the facility failed to ensure residents who required assistance with activities of daily living (ADL) received necessary services to maintain adequate personal hygiene for three residents (Resident #8, Resident #7 and Resident #1). The sample was 13. The census was 142.
Review of the facility's Activities of Daily Living policy, revised 5/4/22, showed:
-The facility shall strive to maintain a resident's ability to perform ADLs, with no deterioration in performance, unless deterioration is unavoidable;
-A resident who is unable to carry out ADLs will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene;
-The facility will maintain individual objectives of the care plan and periodic review and evaluation.
1. Review of Resident # 8's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/12/23, showed:
-Cognitively intact;
-No rejection of care;
-Required limited, one person physical assistance with bed mobility, dressing and personal hygiene;
-Always continent of bowel and bladder.
Review of the resident's face sheet, showed the resident's diagnoses included: Lack of coordination, benign prostatic hypertrophy ((BPH), an enlarged prostate (a small gland in men) that obstructs the flow of urine), urgency of urination, depression and anxiety.
Review of the resident's care plan, undated, showed:
-Focus:
-The resident has occasional bladder incontinence related to urinary urgency and BPH;
-Interventions and tasks:
-The resident should be cleaned after each incontinent episode.
Observations on 7/25/23 at 6:28 AM., 6:39 A.M., 7:02 A.M., and 8:30 A.M., showed the resident's door to his/her room was open and the resident was visible from the hallway. The resident lay uncovered in his/her bed on his/her left side with his/her back facing the doorway. Multiple nursing staff members looked into the resident's room and did not enter the resident's room to check on the resident. The resident's room had a strong odor of urine. The resident wore a brown t-shirt and a urine soaked blue brief.
During observation and interview on 7/25/23 at 9:04 A.M., the resident sat uncovered, upright in bed, eating his/her breakfast. A strong odor of urine was present and the resident's brief remained saturated with urine. The resident said he/she had not been changed since the night before. He/She could smell the urine and it Made (him/her) sick and Disgusted, especially while he/she was eating breakfast. He/She always requires assistance from staff with his/her brief and is incontinent of his/her bowel and bladder.
During an interview on 7/25/23 at 9:10 A.M., Certified Nurse Aide (CNA) G said the resident was well known to him/her, and the resident is always incontinent of bowel and bladder and requires assistance from staff. He/She did not know when the resident was last checked.
2. Review of Resident #7's, quarterly MDS, dated [DATE], showed:
-Cognition not addressed;
-No rejection with care;
-Required total assistance of two staff members for personal hygiene;
-Required extensive assistance of one staff member with bed mobility, dressing and toilet use;
-Always incontinent of bowel and bladder.
Review of the resident's face sheet, showed the resident's diagnoses included: Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), restlessness and agitation, diabetes, assistance with personal care, cognitive communication deficit and chronic (long term) kidney disease.
Review of the resident's care plan, undated, showed:
-Focus:
-The resident has occasional bladder incontinence related to Alzheimer's disease, confusion and impaired mobility;
-Interventions and tasks:
-Check the resident every two hours and as required for incontinence;
-Change the resident's clothing as needed and offer toileting when clean and dry;
-Focus:
-The resident has ADL self-performance deficit related to Alzheimer's disease, confusion and impaired mobility;
-Interventions and tasks:
-The resident requires extensive assist of one person with personal hygiene and oral care.
Observation on 7/24/23 at 7:50 A.M., showed the resident crying and yelling loudly Help me, help me and could be heard from the hallway with the resident's door closed. The resident was on his/her bed with his/her upper body lying flat on the bed and his/her legs off the bed and his/her feet touching the floor. The resident was unable to sit upright in the bed and asked the surveyor to help him/her. A strong odor of urine was present. The resident was wearing tan colored pants, which had a large wet area between the resident's legs and upper thighs. The resident's bed pad and fitted sheet, located under the resident on his/her bed, had a large ring of yellow urine.
During observation and interview on 7/24/23 at 8:15 A.M., CNA C assisted the resident out of the bed and into his/her wheelchair. CNA C removed the resident's pants and brief and the resident's entire brief was saturated with yellow urine. CNA C removed the sheets and bed pad off the bed, and the navy colored mattress cover had a large dark area. CNA C said there must have been someone new working the overnight shift who didn't check the resident. All incontinent residents should be checked every two hours or more as needed.
3. Review of Resident #1's, quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-No rejection of care;
-Total dependence of two person physical assistance with bed mobility, dressing, toilet use and personal hygiene;
-Always incontinent of bowel and bladder.
Review of the resident's face sheet, showed the resident's diagnoses included: cerebral palsy (a neurological condition that affects muscle tone and body movements), muscle weakness, lack of coordination and contractures of the left and right hand.
Review of the resident's care plan, undated, showed:
-Focus:
-The resident has an ADL performance deficit;
-Interventions and tasks:
-The resident requires extensive assistance of one person with personal hygiene and oral care.
During observations on 7/25/23 at 6:28 AM., 6:39 A.M., 7:02 A.M., and 8:20 A.M., the resident's door to his/her room was open and the resident was visible from the door way. The resident lay in bed and his/her bedside table had a urinal one-third full of dark colored urine. Multiple nursing staff members looked into the resident's room and did not enter the resident's room to check on the resident or empty his/her urinal.
During an interview on 7/25/23 at 9:05 A.M., the resident said his/her urinal wasn't emptied all night. He/She didn't like that it wasn't emptied and that he/she had to keep looking at it all night.
4. During an interview on 7/25/23 at 6:39 A.M., CNA E said the residents are checked every two hours to determine if they are clean and dry, to meet any needs they may have, or to be turned.
5. During an interview on 7/25/23 at 10:25 A.M., Licensed Practical Nurse (LPN) F said all residents should be checked every two hours. This includes making sure they are clean and dry. The residents should always be cleaned prior to eating breakfast, when they have an incontinent episode or a urine odor is noted. Urinals should be emptied when they are used.
6. During an interview on 7/25/23 at 1:25 P.M., the Director of Nurses (DON) said that staff are expected to check residents for incontinence episodes every two hours. Urinals are expected to be emptied each time they are used.
MO00220521
MO00220956
MO00221739
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 the deficiency cited at Event ID EIF412.
Based on observation, interview and record review, the facility failed to ensure one resident (Resident #3) received care consistent with professional stan...
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See the deficiency cited at Event ID EIF412.
Based on observation, interview and record review, the facility failed to ensure one resident (Resident #3) received care consistent with professional standards by not following physician orders for lab tests. The lab work was ordered on 6/29/23 and the resident was transferred to the hospital on 7/4/23 with an admitting diagnosis of severe sepsis (develops when the infection causes organ damage) and a urinary tract infection (UTI). The sample was 13. The census was 142.
Review of the facility's Medical Provider Orders, revised 4/7/22, showed:
-Documentation of medication and/or treatment orders:
-Each medication and/or treatment order should be documented with the date, time and signature of the person receiving the order;
-If using electronic medication record, input the medication and/or treatment order according to the electronic health record (EHR) instructions and facility policy;
-Validate the new order is in the electronic Medication Administration Record (MAR)/Treatment Administration Record (TAR);
-Following of medication and/or treatment orders:
-Medical provider orders should be reviewed prior to administration of medication and/or treatment to validate the orders contains all required elements;
-Staff should follow all valid medical provider orders timely unless there is an emergency that would temporarily delay the implementation of the orders;
-If an order does not contain all the required elements, staff should contact the ordering provider for clarification of the order prior to implementation of the order.
Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 7/1/23, showed:
-Cognitively intact;
-No rejection of care;
-Required extensive assistance from staff with bed mobility, dressing, toilet use and personal hygiene;
-Always incontinent of bowel and bladder.
Review of the resident's face sheet, showed his/her diagnoses included schizoaffective disorder (a mental disorder), hypothyroid disease (low levels of thyroid hormone), hyperlipidemia (high cholesterol), UTI, atrial fibrillation (a-fib, irregular heartbeat), long term use of anticoagulants (blood thinner), chronic obstructive pulmonary disease (COPD, a lung condition that restricts breathing), hypokalemia (low potassium levels) and high blood pressure.
Review of the resident's care plan, undated, showed it did not address the resident's lab requirements related to his/her disease processes.
Review of the resident's Physician Order Sheets (POS), dated 6/1/23 through 7/4/23, showed an order: start date: blank; order revised on 6/29/23; check Complete Blood Count with a differential (CBC, a blood test to check levels of red blood cells, blood cells that contain iron and oxygen, (RBC); white blood cells, blood cells that fight infection, (WBC); platelets (blood cells that helps clot the blood); and different types of WBCs); Comprehensive Metabolic Panel (CMP, a blood test that checks electrolytes and fluid balance), lipid panel (a blood test to check cholesterol and fats in the blood), a Thyroid Stimulating Hormone level (TSH, a hormone excreted by the pituitary gland located in the brain), Vitamin D level, Vitamin B12 level, urinalysis (a urine test to detect a UTI) with a reflex microscopy, gram stain and culture sensitivity.
Review of the resident's order entry, showed an order dated 6/29/23 at 4:42 P.M.; Check CBC with differential, CMP, lipid panel, TSH, Vitamin D level, Vitamin B12 level, UA with a reflex microscopy, gram stain and culture sensitivity.
Review of the resident's order audit report, dated 7/24/23, showed an order dated, 6/29/23 at 4:42 P.M., and a confirm date 6/30/23 at 9:21 A.M.; Check CBC with differential; CMP; lipid panel; TSH; Vitamin D level; Vitamin B12 level; UA with a reflex microscopy; gram stain and culture sensitivity.
Review of the resident's MAR and TAR, dated 6/1/23 through 6/30/23 showed no order for the labs.
Review of the resident's MAR and TAR, dated 7/1/23 through 7/31/23 showed no order for the labs.
Review of the progress notes, dated 6/1/23 through 7/4/23 showed:
-On 7/4/23 at 10:50 A.M., the resident was observed not responding and had a decreased level of consciousness (LOC). The physician was notified and a new order was obtained to send the resident to the hospital; The resident was sent 911 and the paramedics came and the resident was sent to the hospital;
-No documentation related to the resident's lab orders was noted.
Review of the resident's hospital records, dated 7/4/23, showed the resident was admitted with a diagnosis of severe sepsis and UTI.
During an interview on 7/25/23 at 11:25 A.M., Registered Nurse (RN) M said he/ she sent the resident out to the hospital on 7/4/23. The resident looked very ill and had a cough. The resident was usually much more alert and knows RN M by name. RN M said he/she called 911 rather than a non-emergent ambulance because the resident looked bad. Lab work that is ordered by the physician to be completed shows up on the MAR or TAR. The nurses will also communicate during report or on the report sheet if the resident has lab orders. RN M said he/she was not aware the resident had lab work ordered.
During an interview on 7/24/23 at 12:10 P.M., Licensed Practical Nurse (LPN)/Unit Manager L said he/she was responsible for the whole building's labs. He/She makes sure that lab orders are accurately placed in the medical record and in the lab portal, and that the labs results are communicated to the physician. The nurses can place orders in the lab portal if they have a password. If they do not have a password, the nurse can order the labs on a paper requisition. The lab technician checks for any paper requisitions when they arrive to the building. LPN/Unit Manager L reviewed the order in the resident's medical record. He/She said there was a physician order placed for lab work on 6/29/23 in the resident's medical record. He/She checked the lab book he/she keeps the lab orders and lab results in and he/she checked the lab portal. He/She could not locate the resident's lab results. LPN/Nurse Manager L said the resident's labs were not completed as ordered. It is expected for staff to document in the progress notes as to why the labs were ordered, such as a change in condition and if the resident refused to have the labs drawn.
During an interview on 7/25/23 at 1:25 P.M., the Director of Nursing (DON) said the orders are placed in the computer by the physician or Nurse Practitioner (NP). Nursing staff will confirm the orders and the orders are to show up on the MAR or TAR as a task to be completed. Any explanation of why the lab was not drawn is expected to be documented in the progress notes. Staff are expected to follow physician orders.
During an interview on 7/25/23 at approximately 1:25 P.M., the Director of Regional Operations said there were no labs completed on the resident.
MO00220956
MO00221195
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 deficiency cited at Event ID EIF412.
This deficiency is uncorrected. For previous examples, see the statement of deficie...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** See the deficiency cited at Event ID EIF412.
This deficiency is uncorrected. For previous examples, see the statement of deficiencies dated 6/8/23.
Based on observation, interview and record review, the facility failed to provide a clean, comfortable, and homelike environment for all residents when staff failed to ensure shower rooms were clean, accessible and well maintained. Two shower rooms on one hall were unavailable for resident use due to water flooding, resulting in 53 residents using one shower room on an adjacent hall. The water flooding caused leaks and damage to the first floor shower rooms, used by 29 residents. The facility failed to ensure carpeted floors were clean and well maintained, and failed to provide a sufficient amount of towels to meet the needs of the residents (Residents #2, #6, #8, #5, #12, #10 and #13). The sample was 13. The census was 142.
1. Review of the facility's daily census, provided 7/24/23, showed:
-First floor Loop, total residents: 29;
-Third floor 3 Short, total residents: 20;
-Third floor Long, total residents: 33;
-Second Terrace 2, total residents: 20;
-Third floor Terrace 3, total residents: 40.
Observations of the first floor Loop shower room A, across from the nurse's station, on 7/24/23 at 8:20 A.M., 7/25/23 at 6:12 A.M. and 9:15 A.M., showed:
-A musty, sour odor combined with the strong odor of urine permeated the shower room;
-An area, approximately 12 inches (in.) by (x) 12 in. of wall missing above the sink, leaving the gap in between walls exposed;
-An area, approximately 4 feet (ft.) x 2 ft. of ceiling material above the sink and toilet was stained and peeling, hanging down approximately 6 to 8 in. in various areas and exposing the ceiling seam;
-Black spotted circles of various sizes on the white ceiling above the toilet and in the shower area;
-A stack of visibly soiled linens on top of a toilet chair in the shower area;
-Soiled linens draped over a cart in the back stall;
-Black and gray grime smeared along the tiled floor.
Observations of the first floor Loop shower room B, at the end of the hall, on 7/24/23 at 8:25 A.M. and 7/25/23 at 9:19 A.M., showed:
-The shower room unlocked;
-A bright green substance covered the interior of the toilet bowl;
-Black spotted circles of various sizes on the white ceiling above the toilet, in the shower area, and in the back stall;
-Chunks of ceiling material along the floor in the shower area, exposing a bowed area along the ceiling seam;
-Three carts in the back stall on which clothing and personal items were stacked;
-Trash, including food wrappers and gloves, along the floor;
-Black and dark gray grime smeared the tiled floor.
Observations of the third floor 3 Short shower room A, next to the TV area, on 7/24/23 at 8:33 A.M. and 10:55 A.M., and 7/25/23 at 8:12 A.M., showed:
-Small chunks of a black substance splattered throughout the inside of the toilet bowl;
-Wallpaper peeling along the doorframe;
-Multiple clumps of hair on the floor underneath the sink and throughout the shower area;
-Dark gray streaks, black spots, and pink stains along the bottom of the beige tiled walls in the shower area;
-No privacy curtain in the shower area;
-No light coming from the fixture above the toilet or in the back stall when the switch was activated;
-A toilet chair inside of a bathtub, which was obstructed by toilet chairs, shower chairs, a supply cart, and a linen cart in the back stall.
Observation of the third floor 3 Short shower room B, at the end of the hall, on 7/24/23 at 8:36 A.M. and 10:55 A.M., showed the shower room locked.
Observations of the third floor 3 Long women's shower room, on 7/24/23 at 9:40 A.M., 11:08 A.M. and 2:08 P.M., and 7/25/23 at 8:16 A.M., showed:
-Rust covering the air vent above the toilet;
-A clump of gray hair and white paper on top of the shower drain;
-Streaks of yellow and pink grime along the bottom of the beige tiled walls of the shower area;
-No showerhead nozzle in the shower area.
Observations of the third floor 3 Long men's shower room, on 7/24/23 at 9:43 A.M., 11:08 A.M. and 2:08 P.M., and 7/25/23 at 8:16 A.M., showed:
-Dust covered the air vent above the toilet;
-Spots of rust on the floor underneath the radiators lining the right wall and back wall;
-Streaks of dark gray and yellow grime along the bottom of the beige tiled walls in the shower area;
-No showerhead nozzle in the shower area;
-Water across the floor in the shower area and back stall.
Observations of the second floor Terrace 2 men's shower room on 7/24/23 at 10:46 A.M., and 7/25/23 at 8:25 A.M.
-A strong odor of urine permeated the shower room;
-A brown substance smeared on the back of the toilet seat and dried urine on the back and bottom of the toilet, as well as the floor next to the toilet;
-A linen cart with folded linens, uncovered, in front of the doorway, across from the toilet;
-A blood pressure machine, utility cart, yellow disposal bin, and unlined trash can containing trash across from the shower area;
-Two piles of wet linens in the shower area;
-A medication cart and three wheelchairs in the back stall.
Observations of the second floor Terrace 2 women's shower room, on 7/24/23 at 10:48 A.M. and 2:12 P.M., and 7/25/23 at 8:24 A.M.
-Bowel movement smeared across the entire toilet seat;
-Wallpaper peeling from the ceiling above the toilet and in the shower area;
-A pile of wet towels in the shower area.
During an interview on 7/25/23 at 6:30 A.M., Certified Nurse Aide (CNA) J said there are leaks from upstairs coming down into the Loop shower rooms. The Loop shower rooms are not safe because the ceilings could fall on someone. Staff try to keep one of the shower rooms locked. If the shower rooms are unlocked, staff watch the residents and sees who goes in there. Housekeeping is supposed to clean the shower rooms.
During an interview on 7/25/23 at 8:18 A.M., CNA H and Certified Medication Technician (CMT) K said the shower rooms on 3 Long cannot be used because they flood and leak down to the Loop. All residents on 3 Long and 3 Short use the same shower room on 3 Short. Housekeeping is responsible for cleaning the shower rooms.
2. Observations of the Loop, showed:
-On 7/24/23 at 8:22 A.M. and 1:40 P.M., a pile of white sheets covered in yellow stains, on the floor under the radiator positioned underneath the window at the end of the hall, next to the shower rooms;
-On 7/25/23 at 9:18 A.M., water pooled on the floor under the radiator positioned underneath the window at the end of the hall, next to the shower rooms.
3. Observations of the third floor Terrace 3 hall on 7/24/23 at 8:38 A.M. and 10:51 A.M., and 7/25/23 at 7:58 A.M., showed teal carpeted floor from the nurse's station down to the end of the hall, with stained dark gray areas, concentrated in the middle of the hall and in front of the shower rooms. The carpets were grimy and sticky.
Observations of the third floor 3 Short hall on 7/24/23 8:49 A.M. and 10:54 A.M., and 7/25/23 at 8:10 A.M., showed teal and multi-colored carpeted floor from the hall entrance down to the end of the hall with stained dark gray areas. The carpets were grimy and sticky.
Observations of the third floor 3 Long hall 7/24/23 at 9:23 A.M. and 10:57 A.M., and 7/25/23 at 8:14 A.M., showed teal and multi-colored carpeted floor from the hall entrance down to the end of the hall with stained dark gray areas. The carpets were grimy and sticky.
4. Observations on 7/24/23, showed:
-At 8:49 A.M., and 10:54 A.M., the 3 Short linen room with no towels or washcloths;
-At 11:18 A.M., the 3 Long linen cart with nine towels and no washcloths;
-At 11:23 A.M., the Terrace 3 linen cart with no towels or washcloths;
-At 11:34 A.M., the Terrace 3 linen room with 12 towels and no washcloths.
Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/12/23, showed:
-Moderate cognitive impairment;
-Total dependence of one person physical assist required for bathing;
-Upper and lower extremity impairment on one side;
-Diagnoses included dementia without behavioral disturbance, Alzheimer's disease, functional quadriplegia (immobility due to severe disability) and need for assistance with personal care.
Observation on 7/24/23 at 11:53 A.M., showed CNA G pulled the resident down the hall from 3 Short to 3 Long in a shower chair. The resident wrapped in two sheets and one towel.
During an interview on 7/24/23 at 2:05 P.M., the resident said he/she received a shower and was not sure why he/she was wrapped in sheets instead of towels.
Observations on 7/25/23, showed:
-At 7:58 A.M., the Terrace 3 linen cart outside of room [ROOM NUMBER] with no towels or washcloths;
-At 7:58 A.M., the Terrace 3 linen cart outside of room [ROOM NUMBER] with one towel;
-At 8:01 A.M. the Terrace 3 linen room with seven towels and no washcloths.
-At 8:10 A.M., the 3 Short linen room with no towels or washcloths;
-At 8:14 A.M., the 3 Long linen cart with three washcloths and no towels.
Observation of the laundry room on 7/25/23 at 8:38 A.M., showed a bin, approximately 4 ft. x 3 ft., filled with linens, including towels. During an interview, Housekeeping Aide (HA) A said he/she works in laundry. The facility has a lot of residents and there are not enough towels or washcloths for all of them. Towels go out to the floor, but never come back to laundry. He/She tries to locate towels throughout the facility, but cannot find them. The facility has been short on towels and washcloths for months.
During an interview on 7/24/23 at 11:19 A.M., CNA H said the facility never has enough towels. He/She wasn't sure if they didn't have enough or if they weren't coming back from laundry. Sometimes aides have to rip up large towels to make small towels. He/She isn't able to start showers for the day because there aren't any towels.
During an interview on 7/24/23 at 11:20 A.M., CNA G said there are not enough towels. When he/she can't find any on the cart, he/she tries to find them in the linen room and in laundry. Nursing staff use whatever linens they can find to make sure the residents receive showers and personal care.
5. Review of Resident #6's quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-Required physical help of one person physical assist in part of bathing activity;
-Lower extremity impairment on both sides;
-Diagnoses included multiple sclerosis (nervous system disease affecting brain and spinal cord) and absence of left and right legs below the knee.
During an interview on 7/24/23 at 8:58 A.M., the resident said the facility does not have enough washcloths or towels. He/She tries to find them in the linen closet and if there aren't any, he/she asks staff. Even the staff have a hard time finding towels. There is only one shower room for all the residents on 3 Short and 3 Long to use. The shower room is disgusting and dirty. There is no shower curtain for privacy. The shower room needs to be cleaned. The carpeted floors need to be washed.
6. Review of Resident #8's quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-Supervision required for bathing;
-Diagnoses included encephalopathy (brain disorder), seizures, anxiety, depression and bipolar disorder (mood disorder that can cause intense mood swings).
During an interview on 7/24/23 at 9:15 A.M., the resident said the facility looks dirty. The residents on 3 Long use the shower room on 3 Short. The shower room is dirty. There are not enough towels for staff use when cleaning the residents.
7. Review of Resident #5's admission MDS, dated [DATE], showed:
-Cognitively intact;
-Required supervision for bathing;
-Diagnoses included anxiety, depression and mild cognitive impairment.
During an interview on 7/24/23 at 9:52 A.M., the resident said the floors in the facility look bad, dirty. All residents on 3 Short are using one shower room at the end of the hall. The shower room is never cleaned and it's nasty. He/She took a shower to get clean in a nasty room. There are never enough towels or washcloths in the facility.
8. Review of Resident #12's quarterly MDS, dated [DATE], showed:
-Moderate cognitive impairment;
-Required physical help of one person physical assist for part of bathing;
-Diagnoses included high blood pressure, anxiety, depression, schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves), schizoaffective disorder (mental health condition that includes features of schizophrenia and a mood disorder) and need for assistance with personal care.
During an interview on 7/25/23 at 8:03 A.M., the resident said the facility never has enough towels. He/She was waiting on laundry to bring towels so he/she can take a shower. There is one shower room for residents to use on 3 Short. The shower room is dirty. There is hair all over the floor and caught in the shower drain.
9. Review of Resident #10's quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-Required supervision for bathing;
-Diagnoses included high blood pressure, dementia, and unspecified mood disorder,
During an interview on 7/25/23 at 8:04 A.M., the resident said there is not enough towels. All residents on 3 Short use the same shower room. The shower room is dark and does not have a privacy curtain. The shower room is dirty and the drain is clogged.
10. Review of Resident #13's quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-Required supervision for bathing;
-Diagnoses included high blood pressure, anxiety, depression, bipolar disorder, and absence of left leg below the knee.
During an interview on 7/25/23 at 8:08 A.M., the resident said the shower rooms are dirty. Staff do not pick up after themselves like they are supposed to. Nursing staff waits on housekeeping to clean the shower rooms, but it's everyone's job. The carpets in the halls look dirty.
11. During an interview on 7/24/23 at 1:45 P.M., HA C said housekeeping's daily cleaning duties include cleaning the shower rooms. The nurse aides are supposed to clean the shower rooms, too. One of the shower rooms on the Loop is locked and the other one has mold on the ceiling. The pipes upstairs leak into the hall and shower rooms on the Loop. Staff put sheets underneath the window at the end of the hall to catch the water and he/she comes by to mop the floor.
12. During an interview on 7/24/23 at 1:51 P.M., CNA I said the carpeted floors are dirty and sticky. The shower room on 3 Short does not look clean. Nursing staff clean the shower room in between resident showers, but it also needs to be fully cleaned just like someone would do at home.
13. During an interview on 7/24/23 at 2:13 P.M., HA B said nursing staff leave towels in the shower room. Housekeeping staff clean the shower rooms every morning. Residents and visitors use the toilet in the shower room on Terrace 2 because it is close to the lobby. The carpeted floors are supposed to be shampooed by floor techs on the evening shift. The carpeted floors are not clean and his/her shoes stick to them. When housekeeping staff observe issues such as mold, leaks, broken lightbulbs, or other issues requiring repair, they are supposed to tell the Maintenance Director. Issues are reported to maintenance verbally. The Maintenance Director is the only employee in maintenance at this time.
14. During an interview on 7/25/23 at 8:38 A.M., HA A said the carpeted floors are dirty, sticky, and should be cleaner. A leak from the third floor shower rooms is going downstairs to the Loop. The ceiling in the Loop shower rooms are coming down and have mold. The shower rooms on the Loop are not safe and they are not clean. Shower rooms should have privacy curtains in the shower area. Housekeeping should clean shower rooms daily and nursing staff should help keep them clean, too. Repairs noted by staff should be reported to the Maintenance Director. There is only person in maintenance at this time.
15. During an interview on 7/25/23 at 8:53 A.M., the Maintenance Director said lights that have gone out are an immediate issue and should be reported to him. He was not aware of lights not working in one of the shower rooms. Two weeks ago, the shower room on 3 Long, on the 3rd floor, was leaking. Staff left water on and caused the shower rooms to flood. The water leaked down to the Loop, on the 1st floor. A plumber came out last week and confirmed the water came through 3 Long shower room floor, not the pipes. The 3 Long shower rooms are not in use, until the floors can be replaced. Residents on 3 Long have to use the shower room on 3 Short. One of the shower rooms on the Loop can be used and the other should be locked. There is a gap in the wall above the sink in one of the shower rooms on the Loop from a mirror that has gone missing. There is mold on the ceilings in the Loop shower rooms due to the humidity and keeping the doors shut. He can't address the repairs needed in the Loop shower rooms until the issues are resolved in the 3 Long shower room. He recently lost staff from his department and he has been the only person working in maintenance for the past two weeks.
16. During an interview on 7/25/23 at 10:10 A.M., the Housekeeping Director said there is one housekeeper assigned to each hall in the facility during the day, Monday through Friday. Weekends are challenging and at most, there are three housekeepers working on Saturdays and Sundays. Part of the daily cleaning schedule includes cleaning the shower room on the housekeeper's assigned hall. She expected housekeeping staff to pick up linens, clean the toilets, and wipe down the walls in the shower rooms. Trash cans should be emptied and sprayed with a deodorizer. The facility does not provide housekeeping staff with the appropriate cleaners to use on soap scum and grime. The facility does not have spray bottles to fill with the bulk cleaning chemicals housekeeping staff are supposed to use. She has tried to get rid of mold in the shower rooms, but some of the mold is underneath the caulking and the only way to address it would be to replace the caulking. The shower room on the third floor floods and causes leaks in the Loop shower rooms. The Loop shower rooms should not be used and she would not take a resident in there because the shower rooms are nasty, unsanitary, and unsafe. When housekeeping notices repairs are needed, such as a light being out in the shower room, they should report it to the Maintenance Director. There is only one person in maintenance to work on all repairs throughout the building. Rain has been causing leaks on the Loop at the end of the hall, so staff have been putting a sheet underneath the radiator at the end of the hall to catch the water. She expected housekeeping staff to swap out the sheets when they are soiled. She does not know what is going on with towels going missing. She puts towels out on the floor and thinks they are thrown down the trash chute by staff on night shift. When nursing staff cannot find towels, she expected them to tell her so she can pull them from the stock room or order them. She has noticed her shoes stick to the carpeted floors. The carpeted floors get soiled with food, drinks, urine, and feces, which makes them unsanitary. The carpeted floors should be shampooed every two to three weeks by the floor tech who works on evenings. At this time, the facility only has enough carpet shampoo to clean one hall, not all of them. The facility needs to replace the carpet or use an extractor to pull dirt from the carpets, but the facility does not have one.
17. During an interview on 7/25/23 at 1:24 P.M., the Administrator said residents on 3 Long have been using the shower room on 3 Short because of leaks. The leaks have caused issues to the shower rooms on the Loop. The 3 Long shower room has to dry out for two weeks before sealer can be applied or the floor can be replaced. She expected nursing staff to clean shower rooms in between residents, and housekeeping staff to deep clean shower rooms daily. The Assistant Director of Nurses (ADON) said one shower room on the Loop should not be in use and should be locked. The other shower room on the Loop should be available for resident use. The Administrator said carpeted floors should be shampooed by the evening housekeeping staff, maybe on a weekly basis. The carpeted floors are sticky. Yesterday, she found out the evening housekeeping staff had been using the wrong cleaner on the carpets. The Director of Nurses (DON) and Administrator said the facility has an adequate supply of towels. Laundry should stock the floors with towels every morning and evening. If there are no towels on the floor, they expected nursing staff to go to laundry. They expected the facility to have a sufficient amount of towels for resident use.
MO00219682
MO00220521
MO00220525
MO00221628
Jun 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
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, the facility failed to implement appropriate interventions and increased monitoring for th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement appropriate interventions and increased monitoring for the protection of residents following a third incident of physical aggression by one resident (Resident #23). Eight days after the third incident of physical aggression, Resident #23 hit another resident (Resident #42) in the face with his/her hands and a wash basin, resulting in injury. The census was 158.
Review of the facility's Abuse, Neglect, and Exploitation policy, revised 9/22/22, showed:
-Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property;
-Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations;
-Prevention of Abuse, Neglect and Exploitation:
--The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves:
---Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms;
---The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect.
Review of Resident #23's medical record, showed:
-admission date 4/3/23;
-Diagnoses included dementia, anxiety, and depression;
-A progress note, dated 4/24/23 at 5:14 P.M., showed staff documented the resident attempted to pull the TV off the wall and employee attempted to stop the resident. Resident grabbed a metal bar from his/her purse and attempted to hit the employee. Employee took the metal bar from the resident and as the employee turned back, the resident hit the employee in the face.
Review of the resident's hospital record from 4/25/23 through 4/28/23, showed:
-Medical progress note, dated 4/28/23, showed diagnoses of major neurocognitive disorder, Alzheimer's type, severe, with psychotic disturbance, and paranoid schizophrenia (a serious mental disorder that affects the way a person thinks, feels and behaves);
-Psychiatric discharge summary, created 4/28/23, showed prognosis: guarded.
Review of the resident's progress notes, showed:
-On 5/1/23 at 2:30 P.M., staff documented the resident observed in the hallway shaking a hanger in another resident's face, accusing him/her of stealing. Staff member intervened, resident stated, I'm going to kill you if you don't stay outta my stuff;
-On 5/1/23 at 4:30 P.M., staff documented the resident accused another resident of stealing. This resident was found in the hallway yelling over the accused resident, who was on the floor. Staff intervened and this resident continued to state the other resident had stolen his/her belongings.
Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/19/23, showed:
-readmitted from hospital on 5/15/23;
-No cognitive impairment;
-Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) occurred 1 to 3 days;
-Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) occurred 1 to 3 days.
Review of the resident's progress note, dated 5/18/23 at 5:43 P.M., showed staff documented the resident was sitting at the dining table amongst peers. Another resident reached over for his/her food tray and this resident slapped the other resident's hand. The resident's physician was contacted and gave new orders to send the resident to the hospital for evaluation.
Review of the resident's care plan, in use at the time of survey, showed:
-Focus, initiated 5/19/23, behavior: Resident had an incident on 5/18/23 with another resident where he/she was sitting at the dining room table amongst peers. Another resident reached over for his/her food tray and the resident slapped the other resident's hand;
-Interventions, initiated 5/19/23, included: Resident will be intensely monitored.
Review of the resident's medical record, showed no documentation of increased or intense monitoring.
Review of the resident's progress notes, dated 5/26/23 at 10:15 A.M., showed Licensed Practical Nurse (LPN) K documented as he/she walked by the entrance to the memory care unit, he/she saw the resident displaying physical aggression toward another resident. Residents were immediately separated. The resident stated the other resident was coming into his/her room, then told the other resident, If you come into this room again, I'm gonna kill you b*tch.
Observation on 5/31/23 at 12:14 P.M., showed the resident watching television in his/her room. The resident had a small area of broken skin near the cuticle on his/her right thumb. During an interview, the resident said he/she recently moved to a different floor of the facility because it was too much in the other place. Two people were coming into his/her apartment at all hours and he/she was not going to have that, so he/she grabbed something and hit the person with it. The other person bit his/her thumb. If someone comes into his/her home, his/her apartment, he/she will try to kill them. He/She won't be dealing with any of that and it won't end well for the other person.
Review of Resident #42's quarterly MDS, dated [DATE], showed:
-Severe cognitive impairment;
-Physical and verbal behavioral symptoms not exhibited;
-Diagnoses included vascular dementia and other amnesia.
Review of the resident's progress note, dated 5/26/23 at 10:15 A.M., showed LPN K documented he/she walked past the entrance to the memory care unit. Upon looking into the memory care unit door window, resident noted displaying physical aggression toward another resident. The other resident stated Resident #42 was coming into his/her room. Resident #42 stated he/she bit the other resident because he/she wouldn't stop hitting me. Head to toe assessment completed. Multiple scratches and abrasions noted to resident's face and hands.
Observation on 5/31/23 at 11:34 A.M., showed the resident with a scratch, approximately 0.5 inches, underneath his/her left eye, and a small, scab surrounded by a reddened area underneath his/her left eyebrow. During an interview, the resident said another person hurt him/her. The person grabbed something from the wall and hit him/her in the face with it. He/She never did anything to this person, but for some reason, the person didn't like him/her.
During an interview on 5/31/23 at 11:19 A.M., Registered Nurse (RN) H said Resident #23 has had ongoing aggression and several physical altercations since admission to the facility. Following each incident, he/she was sent to the hospital for evaluation and returned to the memory care unit with no increased supervision. Following his/her altercation with another resident on 5/18/23, the resident was not placed on one-on-one supervision or increased monitoring and RN H does not know why. A week later, Resident #23 had a physical altercation with Resident #42.
During an interview on 5/31/23 at 11:44 A.M., Certified Nurse Aide (CNA) C said Resident #23 was physically and verbally aggressive. He/She had three separate incidents of becoming physical toward other people. He/She was sent to the hospital following each incident and came back to the memory care unit with no increased monitoring.
During an interview on 5/31/23 at 12:02 P.M., LPN I said Resident #23 was on the memory care unit for behaviors, not because he/she had memory issues. Resident #23 is very alert and knows what he/she is doing. First, Resident #23 used a metal shoe horn to hit an employee in the face. The physician was notified and a medication adjustment was made. Next, the resident had two separate incidents of hitting different residents, for which he/she was sent to the hospital, had his/her medication adjusted, then returned to the memory care unit with no increased supervision. Following the most recent incident, the resident was moved to another floor in the facility and is not on increased supervision.
During an interview on 5/31/23 at 2:08 P.M., LPN J said Resident #23 has confusion about some things, but is alert and knows what he/she is doing. He/She had a history of prior incidents of aggression. Resident #42 is very confused and wanders into other resident rooms. The night before 5/26/23, Resident #42 was in and out of Resident #23's room. On 5/26/23, LPN J worked on the memory care unit and stepped off the hall for a few minutes. During that time, LPN K saw Resident #23 get physical with Resident #42. Resident #23 was not on one-on-one supervision or intensive monitoring prior to the incident. Intensive monitoring requires one-on-one supervision to ensure a resident is not hurting themselves or others.
During an interview on 5/31/23 at 2:20 P.M., LPN K said while passing by the memory care unit, he/she looked through the window of the unit entrance and saw Resident #42 seated in a wheelchair, up against the wall with his/her hands up, defending him/herself, while Resident #23 was hitting him/her in the face with his/her hands and a wash basin. LPN K entered the unit and tried to separate the residents. Resident #23 hit Resident #42 a few more times and Resident #42 bit Resident #23's thumb. LPN K yelled for help and two aides came down the hall. Resident #23 threatened to kill Resident #42 and was taken to his/her room, while Resident #42 was brought to the nurse's station. The residents were assessed for injury and Resident #42 was noted to have scratches on his/her face, including his/her eye, and on the back of his/her hand. Resident #23 had a bite mark on his/her thumb. Resident #42 was very upset, angry, and tearful after the incident. He/She is very confused and could only say he/she had been in a fight. Resident #23 said he/she got physical with Resident #42 because Resident #42 came into his/her room. Resident #23 is very aware, more behavioral. LPN does not think Resident #23 was on one-on-one prior to the incident on 5/26/23.
During an interview on 5/31/23 at 10:05 A.M., the Director of Nurses (DON) said Resident #23 was admitted to the facility in April 2023 and placed on the memory care unit, per his/her family's request. The resident had a diagnosis of dementia and no known prior behaviors. Since admission, the resident hit an employee in the face and pushed and hit a resident. He/She was evaluated by psychiatry and was diagnosed with schizophrenia. On 5/18/23, the resident hit another resident, was sent out to the hospital for evaluation, and returned to the facility. The resident returned to his/her room on the memory care unit and staff monitored him/her more closely. Staff normally complete rounds every two hours. When asked what it meant to monitor the resident more closely, the DON said staff monitored the resident more intensely. There was no formal monitoring in place and the resident mostly stayed in his/her room.
During an interview on 5/31/23 at 2:46 P.M., the Administrator said he/she began working with the facility on 5/24/23 and Resident #23's previous incidents of physical aggression occurred prior to this date. Following each incident of physical aggression, she would expect staff to look at the resident's medications and see if adjustments have been made. If so, the resident should be placed on one-on-one supervision or staff should at least know where he/she is at all times, until the medication adjustments have taken effect. She would expect the interdisciplinary team to identify interventions following each incident. After the third incident of physical aggression, intensive monitoring was added to the resident's care plan, but the Administrator does not know what this means. She would expect intensive monitoring to include specifics for staff to follow, including frequency and whether that means supervision at certain times or all time, in an effort to keep residents safe.
MO00219206
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents who required assistance with activiti...
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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 who required assistance with activities of daily living (ADL) received necessary services to maintain adequate personal hygiene for three residents (Resident #8, Resident #7 and Resident #1). The sample was 13. The census was 142.
Review of the facility's Activities of Daily Living policy, revised 5/4/22, showed:
-The facility shall strive to maintain a resident's ability to perform ADLs, with no deterioration in performance, unless deterioration is unavoidable;
-A resident who is unable to carry out ADLs will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene;
-The facility will maintain individual objectives of the care plan and periodic review and evaluation.
1. Review of Resident # 8's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/12/23, showed:
-Cognitively intact;
-No rejection of care;
-Required limited, one person physical assistance with bed mobility, dressing and personal hygiene;
-Always continent of bowel and bladder.
Review of the resident's face sheet, showed the resident's diagnoses included: Lack of coordination, benign prostatic hypertrophy ((BPH), an enlarged prostate (a small gland in men) that obstructs the flow of urine), urgency of urination, depression and anxiety.
Review of the resident's care plan, undated, showed:
-Focus:
-The resident has occasional bladder incontinence related to urinary urgency and BPH;
-Interventions and tasks:
-The resident should be cleaned after each incontinent episode.
Observations on 7/25/23 at 6:28 AM., 6:39 A.M., 7:02 A.M., and 8:30 A.M., showed the resident's door to his/her room was open and the resident was visible from the hallway. The resident lay uncovered in his/her bed on his/her left side with his/her back facing the doorway. Multiple nursing staff members looked into the resident's room and did not enter the resident's room to check on the resident. The resident's room had a strong odor of urine. The resident wore a brown t-shirt and a urine soaked blue brief.
During observation and interview on 7/25/23 at 9:04 A.M., the resident sat uncovered, upright in bed, eating his/her breakfast. A strong odor of urine was present and the resident's brief remained saturated with urine. The resident said he/she had not been changed since the night before. He/She could smell the urine and it Made (him/her) sick and Disgusted, especially while he/she was eating breakfast. He/She always requires assistance from staff with his/her brief and is incontinent of his/her bowel and bladder.
During an interview on 7/25/23 at 9:10 A.M., Certified Nurse Aide (CNA) G said the resident was well known to him/her, and the resident is always incontinent of bowel and bladder and requires assistance from staff. He/She did not know when the resident was last checked.
2. Review of Resident #7's, quarterly MDS, dated [DATE], showed:
-Cognition not addressed;
-No rejection with care;
-Required total assistance of two staff members for personal hygiene;
-Required extensive assistance of one staff member with bed mobility, dressing and toilet use;
-Always incontinent of bowel and bladder.
Review of the resident's face sheet, showed the resident's diagnoses included: Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), restlessness and agitation, diabetes, assistance with personal care, cognitive communication deficit and chronic (long term) kidney disease.
Review of the resident's care plan, undated, showed:
-Focus:
-The resident has occasional bladder incontinence related to Alzheimer's disease, confusion and impaired mobility;
-Interventions and tasks:
-Check the resident every two hours and as required for incontinence;
-Change the resident's clothing as needed and offer toileting when clean and dry;
-Focus:
-The resident has ADL self-performance deficit related to Alzheimer's disease, confusion and impaired mobility;
-Interventions and tasks:
-The resident requires extensive assist of one person with personal hygiene and oral care.
Observation on 7/24/23 at 7:50 A.M., showed the resident crying and yelling loudly Help me, help me and could be heard from the hallway with the resident's door closed. The resident was on his/her bed with his/her upper body lying flat on the bed and his/her legs off the bed and his/her feet touching the floor. The resident was unable to sit upright in the bed and asked the surveyor to help him/her. A strong odor of urine was present. The resident was wearing tan colored pants, which had a large wet area between the resident's legs and upper thighs. The resident's bed pad and fitted sheet, located under the resident on his/her bed, had a large ring of yellow urine.
During observation and interview on 7/24/23 at 8:15 A.M., CNA C assisted the resident out of the bed and into his/her wheelchair. CNA C removed the resident's pants and brief and the resident's entire brief was saturated with yellow urine. CNA C removed the sheets and bed pad off the bed, and the navy colored mattress cover had a large dark area. CNA C said there must have been someone new working the overnight shift who didn't check the resident. All incontinent residents should be checked every two hours or more as needed.
3. Review of Resident #1's, quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-No rejection of care;
-Total dependence of two person physical assistance with bed mobility, dressing, toilet use and personal hygiene;
-Always incontinent of bowel and bladder.
Review of the resident's face sheet, showed the resident's diagnoses included: cerebral palsy (a neurological condition that affects muscle tone and body movements), muscle weakness, lack of coordination and contractures of the left and right hand.
Review of the resident's care plan, undated, showed:
-Focus:
-The resident has an ADL performance deficit;
-Interventions and tasks:
-The resident requires extensive assistance of one person with personal hygiene and oral care.
During observations on 7/25/23 at 6:28 AM., 6:39 A.M., 7:02 A.M., and 8:20 A.M., the resident's door to his/her room was open and the resident was visible from the door way. The resident lay in bed and his/her bedside table had a urinal one-third full of dark colored urine. Multiple nursing staff members looked into the resident's room and did not enter the resident's room to check on the resident or empty his/her urinal.
During an interview on 7/25/23 at 9:05 A.M., the resident said his/her urinal wasn't emptied all night. He/She didn't like that it wasn't emptied and that he/she had to keep looking at it all night.
4. During an interview on 7/25/23 at 6:39 A.M., CNA E said the residents are checked every two hours to determine if they are clean and dry, to meet any needs they may have, or to be turned.
5. During an interview on 7/25/23 at 10:25 A.M., Licensed Practical Nurse (LPN) F said all residents should be checked every two hours. This includes making sure they are clean and dry. The residents should always be cleaned prior to eating breakfast, when they have an incontinent episode or a urine odor is noted. Urinals should be emptied when they are used.
6. During an interview on 7/25/23 at 1:25 P.M., the Director of Nurses (DON) said that staff are expected to check residents for incontinence episodes every two hours. Urinals are expected to be emptied each time they are used.
MO00220521
MO00220956
MO00221739
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 ensure one resident (Resident #3) received care consistent with professional standards by not following physician orders for l...
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Based on observation, interview and record review, the facility failed to ensure one resident (Resident #3) received care consistent with professional standards by not following physician orders for lab tests. The lab work was ordered on 6/29/23 and the resident was transferred to the hospital on 7/4/23 with an admitting diagnosis of severe sepsis (develops when the infection causes organ damage) and a urinary tract infection (UTI). The sample was 13. The census was 142.
Review of the facility's Medical Provider Orders, revised 4/7/22, showed:
-Documentation of medication and/or treatment orders:
-Each medication and/or treatment order should be documented with the date, time and signature of the person receiving the order;
-If using electronic medication record, input the medication and/or treatment order according to the electronic health record (EHR) instructions and facility policy;
-Validate the new order is in the electronic Medication Administration Record (MAR)/Treatment Administration Record (TAR);
-Following of medication and/or treatment orders:
-Medical provider orders should be reviewed prior to administration of medication and/or treatment to validate the orders contains all required elements;
-Staff should follow all valid medical provider orders timely unless there is an emergency that would temporarily delay the implementation of the orders;
-If an order does not contain all the required elements, staff should contact the ordering provider for clarification of the order prior to implementation of the order.
Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 7/1/23, showed:
-Cognitively intact;
-No rejection of care;
-Required extensive assistance from staff with bed mobility, dressing, toilet use and personal hygiene;
-Always incontinent of bowel and bladder.
Review of the resident's face sheet, showed his/her diagnoses included schizoaffective disorder (a mental disorder), hypothyroid disease (low levels of thyroid hormone), hyperlipidemia (high cholesterol), UTI, atrial fibrillation (a-fib, irregular heartbeat), long term use of anticoagulants (blood thinner), chronic obstructive pulmonary disease (COPD, a lung condition that restricts breathing), hypokalemia (low potassium levels) and high blood pressure.
Review of the resident's care plan, undated, showed it did not address the resident's lab requirements related to his/her disease processes.
Review of the resident's Physician Order Sheets (POS), dated 6/1/23 through 7/4/23, showed an order: start date: blank; order revised on 6/29/23; check Complete Blood Count with a differential (CBC, a blood test to check levels of red blood cells, blood cells that contain iron and oxygen, (RBC); white blood cells, blood cells that fight infection, (WBC); platelets (blood cells that helps clot the blood); and different types of WBCs); Comprehensive Metabolic Panel (CMP, a blood test that checks electrolytes and fluid balance), lipid panel (a blood test to check cholesterol and fats in the blood), a Thyroid Stimulating Hormone level (TSH, a hormone excreted by the pituitary gland located in the brain), Vitamin D level, Vitamin B12 level, urinalysis (a urine test to detect a UTI) with a reflex microscopy, gram stain and culture sensitivity.
Review of the resident's order entry, showed an order dated 6/29/23 at 4:42 P.M.; Check CBC with differential, CMP, lipid panel, TSH, Vitamin D level, Vitamin B12 level, UA with a reflex microscopy, gram stain and culture sensitivity.
Review of the resident's order audit report, dated 7/24/23, showed an order dated, 6/29/23 at 4:42 P.M., and a confirm date 6/30/23 at 9:21 A.M.; Check CBC with differential; CMP; lipid panel; TSH; Vitamin D level; Vitamin B12 level; UA with a reflex microscopy; gram stain and culture sensitivity.
Review of the resident's MAR and TAR, dated 6/1/23 through 6/30/23 showed no order for the labs.
Review of the resident's MAR and TAR, dated 7/1/23 through 7/31/23 showed no order for the labs.
Review of the progress notes, dated 6/1/23 through 7/4/23 showed:
-On 7/4/23 at 10:50 A.M., the resident was observed not responding and had a decreased level of consciousness (LOC). The physician was notified and a new order was obtained to send the resident to the hospital; The resident was sent 911 and the paramedics came and the resident was sent to the hospital;
-No documentation related to the resident's lab orders was noted.
Review of the resident's hospital records, dated 7/4/23, showed the resident was admitted with a diagnosis of severe sepsis and UTI.
During an interview on 7/25/23 at 11:25 A.M., Registered Nurse (RN) M said he/ she sent the resident out to the hospital on 7/4/23. The resident looked very ill and had a cough. The resident was usually much more alert and knows RN M by name. RN M said he/she called 911 rather than a non-emergent ambulance because the resident looked bad. Lab work that is ordered by the physician to be completed shows up on the MAR or TAR. The nurses will also communicate during report or on the report sheet if the resident has lab orders. RN M said he/she was not aware the resident had lab work ordered.
During an interview on 7/24/23 at 12:10 P.M., Licensed Practical Nurse (LPN)/Unit Manager L said he/she was responsible for the whole building's labs. He/She makes sure that lab orders are accurately placed in the medical record and in the lab portal, and that the labs results are communicated to the physician. The nurses can place orders in the lab portal if they have a password. If they do not have a password, the nurse can order the labs on a paper requisition. The lab technician checks for any paper requisitions when they arrive to the building. LPN/Unit Manager L reviewed the order in the resident's medical record. He/She said there was a physician order placed for lab work on 6/29/23 in the resident's medical record. He/She checked the lab book he/she keeps the lab orders and lab results in and he/she checked the lab portal. He/She could not locate the resident's lab results. LPN/Nurse Manager L said the resident's labs were not completed as ordered. It is expected for staff to document in the progress notes as to why the labs were ordered, such as a change in condition and if the resident refused to have the labs drawn.
During an interview on 7/25/23 at 1:25 P.M., the Director of Nursing (DON) said the orders are placed in the computer by the physician or Nurse Practitioner (NP). Nursing staff will confirm the orders and the orders are to show up on the MAR or TAR as a task to be completed. Any explanation of why the lab was not drawn is expected to be documented in the progress notes. Staff are expected to follow physician orders.
During an interview on 7/25/23 at approximately 1:25 P.M., the Director of Regional Operations said there were no labs completed on the resident.
MO00220956
MO00221195
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 sufficient amount of toilet paper and paper...
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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 sufficient amount of toilet paper and paper towels on the memory care unit to meet the needs of residents. The facility failed to provide a homelike environment when they served residents meals on Styrofoam dishes and provided plastic utensils (Residents #27, #33, #30, and #32). The census was 158.
1. Observation of the memory care unit on 5/24/23 at 8:50 A.M., showed:
-room [ROOM NUMBER], shared by two residents, had no paper towels;
-room [ROOM NUMBER], shared by two residents, had no paper towels;
-room [ROOM NUMBER], shared by two residents, had no paper towels;
-room [ROOM NUMBER], occupied by one resident, had no toilet paper;
-room [ROOM NUMBER], shared by two residents, had no paper towels or toilet paper.
Observation of the memory care unit on 5/24/23 at 1:53 P.M., showed:
-room [ROOM NUMBER], shared by two residents, had no paper towels or toilet paper;
-room [ROOM NUMBER], shared by two residents, had no paper towels or toilet paper;
-room [ROOM NUMBER], shared by two residents, had no paper towels;
-room [ROOM NUMBER], shared by two residents, had no paper towels.
Observation of the memory care unit on 5/25/23 at 7:40 A.M., 9:52 A.M., and 11:47 A.M., showed:
-room [ROOM NUMBER], shared by two residents, had no paper towels or toilet paper;
-room [ROOM NUMBER], shared by two residents, had no paper towels or toilet paper;
-room [ROOM NUMBER], shared by two residents, had no paper towels.
Observation of the memory care unit on 5/31/23 at 1:41 P.M., showed:
-room [ROOM NUMBER], shared by two residents, had no paper towels or toilet paper;
-room [ROOM NUMBER], shared by two residents, had no paper towels or toilet paper.
During an interview on 5/24/23 at 8:58 A.M., Housekeeping Aide B said he/she works on the memory care unit several days a week. The facility is short on paper towels and he/she does not have enough of them. Resident rooms are cleaned daily. Each room is supposed to get two rolls of toilet paper but there is not enough toilet paper, so each room should at least get one roll.
During an interview on 5/24/23 at 9:24 A.M., Certified Nurse Aide (CNA) A said the facility is short on paper towels and toilet paper. Housekeeping should be giving each room two rolls of toilet paper, but they don't provide enough.
During an interview on 5/25/23 at 9:52 A.M., CNA C said toilet paper and paper towels are restocked by housekeeping. Housekeeping does not work on the memory care unit every day and when they do work, they do not provide enough toilet paper or paper towels.
During an interview on 5/31/23 at 1:41 P.M., CNA C said the residents in rooms [ROOM NUMBERS] do not get toilet paper or paper towels because they are always flushing too much down the toilets, clogging them. The aides have to clean it up and it's not nice.
During an interview on 5/31/23 at 1:51 P.M., the Housekeeping Director said Housekeeper O works on the memory care unit Monday, Wednesday, Friday, and every other weekend. There is not enough staff in the housekeeping department and the facility is hiring. She would expect housekeeping staff to clean all rooms daily and restock each bathroom's toilet paper and paper towels. Each bathroom should be provided with two rolls of toilet paper. Today, nursing staff told her not to bring paper towels for rooms on the memory care unit because the residents were clogging the toilets. She was not aware of housekeeping staff being told this and she would expect all residents to have access to toilet paper and paper towels to meet their needs.
2. Review of Resident #27's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/11/23, showed:
-Cognitively intact;
-Exhibited no behaviors.
Observation of the Terrace 2 hall on 5/24/23, showed:
-At 1:05 P.M., staff passed trays to resident rooms from a cart containing 19 trays. Trays contained a mixture of regular and Styrofoam plates. Each tray contained a Styrofoam bowl of food, and a plastic cup of fruit;
-At 1:15 P.M., Resident #27 sat upright in bed with a tray of food on his/her bedside table. The tray contained a regular plate of Brussel sprouts and cornbread, a Styrofoam bowl of ravioli and a plastic cup of fruit. During an interview, the resident said he/she was not provided utensils. Why a skilled nursing facility would serve residents on Styrofoam is the million dollar question. It's not exactly professional and he/she would prefer real dishes and silverware.
Review of Resident #33's quarterly MDS, dated [DATE], showed:
-Moderate cognitive impairment;
-Exhibited no behaviors.
Review of Resident #30's quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-Exhibited no behaviors.
Review of Resident #32's quarterly MDS, dated [DATE], showed:
-Moderate cognitive impairment;
-Exhibited no behaviors.
Observation of the Terrace 3 hall on 5/24/23, showed:
-At 1:26 P.M., staff passed trays to resident rooms from a cart of trays containing Styrofoam plates and bowls of food, plastic cups of fruit, and plastic utensils;
-At 1:28 P.M., Resident #33 sat in front of a bedside table, containing a Styrofoam plate of Brussel sprouts, a Styrofoam bowl of ravioli, a plastic cup of fruit, and a plastic spoon. He/She attempted to scoop a Brussel sprout onto the plastic spoon and the sprout rolled off the utensil. During an interview, the resident said plastic utensils were not homelike;
-At 1:30 P.M., Resident #30 sat upright in bed with a Styrofoam plate of Brussel sprouts and bread, a Styrofoam bowl of ravioli, a plastic cup of fruit, and a plastic spoon on the table in front of him/her. During an interview, the resident said serving meals on Styrofoam with plastic utensils was cheap. The facility can't even give residents the right utensils for their meals;
-At 1:31 P.M., Resident #32 sat in front of a bedside table containing a Styrofoam plate of Brussel sprouts and bread, a Styrofoam bowl of ravioli, a plastic cup of fruit, and a plastic spoon. During an interview, the resident said it didn't make any sense to him/her why the facility would serve meals on Styrofoam with plastic spoons instead of forks.
Observation of the Terrace 3 hall on 5/25/23, showed:
-At 9:21 A.M., a cart of 15 trays on the hall. Each tray contained Styrofoam bowls filled with oatmeal. One tray contained regular utensils and the other 14 trays contained two plastic spoons;
-CNA G began passing trays and shook his/her head when he/she observed each tray contained two plastic spoons.
Observation on 5/25/23 at 9:27 A.M., showed Resident #32 sat in front of a bedside table containing a Styrofoam plate with an omelet, a Styrofoam bowl of oatmeal, and two plastic spoons. During an interview, the resident said it was ridiculous to be provided with plastic spoons to eat an omelet and he/she wanted a fork.
During an interview on 5/24/23 at 1:40 P.M., CNA D said residents are served meals on Styrofoam with plastic utensils every day. He/She would not want his/her meals served like this. He/She questioned how residents could eat Brussel sprouts with a plastic spoon.
During an interview on 5/25/23 at 9:45 A.M., Dietary Aide F said the kitchen does not have enough plates, bowls, coffee mugs, or silverware to serve the residents in the facility. This morning, they had to give residents two plastic spoons at breakfast because they didn't even have plastic forks. The facility should be supplied with enough of these items to serve residents at each meal and he/she does not know why the facility does not have enough.
During an interview on 5/25/23 at 9:48 A.M., [NAME] E said the kitchen does not have enough plates, bowls, coffee mugs, or silverware. The facility should have all of these things, but there just is not enough. Residents are given plastic or Styrofoam cups for coffee and he/she doesn't think this is very safe.
During an interview on 5/31/23 at 1:32 P.M., the Dietary Supervisor said meals are served on Styrofoam with plastic utensils because the facility does not have enough dishes or utensils. The facility does not have a sufficient supply of coffee cups, plates, bowls, plate warmers, or utensils. She would expect the facility to have a sufficient supply of these items to serve all residents of the facility at each meal.
3. During an interview on 5/31/23 at 2:46 P.M., the Administrator said she was aware the facility is in short supply of dishware and utensils. Styrofoam dishware has been used at meals and does not hold heat to keep food warm. She plans on ordering new plates, bowls, utensils, and coffee cups. She would expect residents to receive all meals on regular dishes with regular utensils. She was not aware residents on the memory care unit were not being provided with a sufficient supply of toilet paper or paper towels. All residents in the facility should be provided with a sufficient amount of paper products to meet their needs. If a resident had a behavior of flushing excessive amounts of paper down the toilet, she would expect staff to assist with monitoring and for the resident to be provided with a cloth towel.
MO00218889
MO00219391
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
Administration
(Tag F0835)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility management company failed to ensure payments were issued or issued in a timely manner to necessary vendors utilized to provide services for the needs...
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Based on interview and record review, the facility management company failed to ensure payments were issued or issued in a timely manner to necessary vendors utilized to provide services for the needs of residents, including electric utility, gas utility, generator, staffing, and other ancillary vendors. The census was 158.
1. Review of Vendor A, an electric utility provider, invoices for Account #1 and facility payment information, requested 5/24/23, showed:
-Letter dated 5/16/23, Final Notice - Subject to Disconnect After 5/26/23. Amount due: $4,709.79. This notice is based on the past due balance and does not reflect the total account balance. The utility service for the facility will be interrupted after 5/26/23 unless required payment is made for the reason below: past due balance;
-On 5/25/23, after the DHSS onsite visit began, the facility issued an electronic funds transfer (EFT) payment to the vendor for $4,738.75.
Review of Vendor A's invoices for Account #2 and facility payment information, requested 5/24/23, showed:
-Letter dated 5/16/23, Final Notice - Subject to Disconnect After 5/26/23. Amount due: $4,419.79. This notice is based on the past due balance and does not reflect the total account balance. The utility service for the facility will be interrupted after 5/26/23 unless required payment is made for the reason below: past due balance;
-On 5/25/23, after the DHSS onsite visit began, the facility issued an EFT payment to the vendor for $4,448.75.
Review of Vendor A's invoices for Account #3 and facility payment information, requested 5/24/23, showed:
-Letter dated 5/16/23, Final Notice - Subject to Disconnect After 5/26/23. Amount due: $357.83. This notice is based on the past due balance and does not reflect the total account balance. The utility service for the facility will be interrupted after 5/26/23 unless required payment is made for the reason below: past due balance;
-On 5/30/23, after the DHSS onsite visit began, the facility issued an EFT payment to the vendor for $357.83.
2. Review of Vendor B, a gas utility provider, invoices and facility payment information, requested 5/24/23, showed:
-Letter dated 5/15/23, Final Notice. Unfortunately, your most recent gas bill hasn't been paid. And this means if we don't receive a payment for at least the disconnection amount by 5/22/23, we will have to turn off your natural gas service, on or after that date. Amount due: $10,174.69. Disconnection amount: $6,935.67. Disconnect date on or after: 5/22/23;
-On 5/25/23, after the DHSS onsite visit began, the facility issued a payment to the vendor for $6,925.67.
3. Review of Vendor E, a fire protection service company, invoices and facility payment information, requested 5/24/23, showed:
-Invoice date 3/20/23, total due: $5,364.17. Payment terms: net 10 (full payment due 10 days after the invoice date).
During an interview on 5/26/23 at 11:45 A.M., a representative from Vendor E said there have been ongoing issues receiving payments from the facility for services provided by the vendor. The last payment the facility made was in March 2023 for an invoice from January 2023. Currently, the facility has a balance of $5,000 past due.
During an interview on 6/6/23 at 10:21 A.M., a representative from Vendor E said the facility was now $21,000 behind in payments, and they were on a service hold due to the lack of payment.
4. Review of Vendor D, a waste management company, invoices and facility payment information, requested 5/24/23, showed:
-Invoice date 4/15/23, current due: $667.50. 30 days past due: $1,335.00. Please pay $2,002.50. Due date: 5/15/23;
-No payments to vendor for invoice.
During an interview on 5/24/23 at 2:50 P.M., the Maintenance Director said toward the end of April 2023, there was an issue with the vendor's bill not getting paid. Trash piled up for a couple of days and when the bill was paid, the trash was picked up again.
During an interview on 5/26/23 at 12:54 P.M., a representative from Vendor D said the vendor provides waste pickup services. The facility is currently two months in arrears for payment.
5. Review of Vendor C, a generator company, invoices and facility payment information, requested 5/24/23, showed:
-Invoice date 3/7/23, total of $3,098.53 due 4/3/23. This invoice due on 4/3/23 for service according to one month prepayment plan. Any delinquency in payment can result in immediate removal of equipment;
-Invoice date 4/4/23, total of $3,098.53 due 5/3/23. This invoice due on 5/3/23 for service according to one month prepayment plan. Any delinquency in payment can result in immediate removal of equipment.
During an interview on 5/26/23 at 12:31 P.M., a representative from Vendor C said the facility rents generators from the vendor. Invoices are submitted to the facility monthly, in the amount of approximately $3,100.00. There is a recurrent issue with receiving payments from the facility. When checks are received, sometimes they bounce. The March 2023 invoice should have been paid 4/3/23, but the check was not received until 4/26/23. The April invoice should have been paid on 4/26/23, but the facility did not make a payment. The vendor informed the facility that if a payment was not received, the generator would have to be pulled. The payment for the April 2023 invoice was made on 5/16/23.
6. Review of Vendor H, a wound care and wound vacuum-assistive closure device rental company, invoices and facility payment information, requested 5/24/23, showed:
-Statement date 2/2/23, balance due: $980.00;
-Invoice ending 1381, dated 2/6/23, total: $200.00;
-Invoice ending 8481, dated 2/6/23, total: $700.00;
-Invoices ending 6720 and 8230, dated 2/6/23, total: $770.00;
-Invoice ending 8482, dated 2/6/23, total: $805.00;
-Invoices ending 1040 and 6235, dated 2/6/23, total: $1,260.00;
-Invoices ending 1138 and 4684, dated 2/6/23, total $1,260.00;
-Invoices ending 1033 and 6228, dated 2/6/23, total $1,715.00;
-Invoices ending 1032 and 6227, dated 2/6/23, total: $1,715.00;
-No payments to vendor for invoices.
During an interview on 5/26/23 at 9:10 A.M., a representative from Vendor H said the vendor and facility had a payment agreement for outstanding balances. The first payment of $7,445.00 was issued by check and the check bounced. A new check was submitted and went through. The facility has not made a payment since then, since early February 2023. The vendor has reached out to the facility's accounts payable company numerous times, and they say they are processing payments, but the vendor has not received any of these payments.
7. Review of Vendor J, a transportation company, invoices and facility payment information, requested 5/24/23, showed:
-Invoice date 3/17/23, $2,065.08 due 4/17/23;
-Invoice date 4/1/23, outstanding balance: $2,065.00, current balance: $2,656.63, total balance: $4,721.63 due 4/16/23;
-Invoice date 4/17/23, outstanding balance: $2,065.00, current balance: $3,562.50, total balance: $5,627.50 due 5/2/23;
-No payments to vendor for invoices.
During an interview on 5/26/23 at 2:31 P.M., a representative from Vendor J said a payment agreement was made between the vendor and the facility's management company to address balances for the facility and another facility owned by same management company. The facility has not followed through on making payments for services received. The last check issued by the facility's management company bounced. Currently, the facility's management company owes approximately $16,000.00 in past due balances for services provided to both facilities.
8. Review of Vendor G, a cleaning supply company, invoices and facility payment information, requested 5/24/23, showed:
-Invoice date 2/1/23, total of $1,119.17;
-Invoice date 2/23/23, total of $1,266.05;
-No payments to vendor for invoices.
During an interview on 6/8/23 at 3:51 P.M., a representative from Vendor G said his/her company has not received payment from the facility for services provided. The facility said the vendor would get an overnight check, but it was never received.
9. Review of Vendor F, a staffing agency, invoices and facility payment information, requested 5/24/23, showed:
-Invoice date 1/1/23, total of $972.50 due 1/31/23;
-Invoice date 1/7/23, total of $822.50 due 2/6/23;
-Invoice date 1/15/23, total of $5,700.25 due 2/14/23;
-Invoice date 1/23/23, total of $5,388.75, due 2/22/23;
-Invoice date 1/30/23, total of $11,997.35 due 3/1/23;
-Invoice date 2/6/23, total of $13,335.00 due 3/8/23;
-Invoice date 2/13/23, total of $10,095.00 due 3/15/23;
-Invoice date 2/20/23, total of $12,415.00, due 3/19/23;
-Invoice date 2/27/23, total of $15,533.75 due 3/29/23;
-Invoice date 3/6/23, total of $16,161.25 due 4/5/23;
-Invoice date 3/13/23, total of $11,551.25 due 4/12/23;
-Invoice date 3/20/23, total of $5,518.75 due 4/19/23;
-Invoice date 3/27/23, total of $16,266.25 due 4/26/23;
-Invoice date 4/4/23, total of $21,018.75 due 5/4/23;
-Invoice date 4/11/23, total of $1,085.00 due 4/28/23;
-No payments to vendor for invoices.
During an interview on 5/24/23 at 12:41 P.M., the Staffing Coordinator said the facility's nursing staff coverage is approximately 70% agency staff and 30% facility staff. During the past six months, the facility was using Vendor F for staffing, but changed to a different vendor due to Vendor F's bills not being paid. Invoices for Vendor F were sent to the facility's Business Office Manager (BOM) and Regional BOM with the facility's management company.
During an interview on 5/31/23 at 9:00 A.M., a representative from Vendor F said his/her company provided staffing to the facility from late December 2022 to April 2023. After the first month of services, the facility stopped paying the vendor. The facility promised to send payment and the vendor continued to send staffing, but the facility never sent payment. In April 2023, the representative went to the facility to discuss the payment issues, but the facility never got back to the vendor. The facility owes the vendor approximately $152,000.00.
10. Review of Vendor I, a water utility provider, invoices and facility payment information, requested 5/24/23, showed:
-Statement date 4/28/23, balance forward - past due: $5,432.08, fees and adjustments: $81.48, service related charges: $2,576.77, pass through charges: $1.75, taxes: $425.55, total amount due: $8,517.63. Payment due by 5/22/23. The due date on the bill applies to current charges only. However, $5,432.08 is past due and is due immediately;
-No payment to vendor for invoice.
11. Review of Vendor K, a wastewater utility provider, invoices and facility payment information, requested 5/24/23, showed:
-Bill date 4/13/23, previous balance: $4,205.28, outstanding balance: $4,221.02, current charges: $62,333.47, total amount due: $6,554.49, due 5/4/23;
-No payment to vendor for invoice.
12. During an interview on 5/25/23 at 8:05 A.M., the Assistant Business Office Manager said vendor invoices come to the facility and she scans and emails them to someone employed by the facility's management company. The facility recently received disconnection notices from Vendors A and B due to non-payment. Vendor payments are made by the facility's management company. She would expect payments to be made to vendors when payments are due.
13. During an interview on 5/25/23 at 10:55 A.M., the Administrator said she began working with the facility yesterday. The facility's bills are paid by an accounts payable company contracted by the facility's management company. She requested the invoices and facility payment information from the accounts payable company, but they are off today.
During an interview on 5/25/23 at 12:43 P.M., the Administrator said she saw a disconnection notice on the most recent invoice for Vendor A, and that the invoice was not paid until today, a day after the information was requested. She would expect all of the facility's bills to be paid timely by the accounts payable company.
As of the exit date on 6/8/23, additional facility payment information has not been received.
MO00218889
May 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected 1 resident
See the deficiency cited at Event ID O1J312.
Based on interview and record review, the facility failed to provide and document efforts to meet the needs of one resident admitted to the facility with a...
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See the deficiency cited at Event ID O1J312.
Based on interview and record review, the facility failed to provide and document efforts to meet the needs of one resident admitted to the facility with a known history of behaviors, and when the behaviors were exhibited, the resident was issued an immediate discharge from the facility (Resident #20). The census was 158.
Review of the facility's Transfer and Discharge policy, revised 9/1/21, showed:
-Policy: It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility except in limited situations when the health and safety of the individual or other residents are endangered;
-Policy Explanation and Compliance Guidelines:
-1. The facility will evaluate and determine the level of care needed for the resident prior to admission to ensure the facility's ability to meet the resident's needs;
-2. The facility permits each resident to remain in the facility, and not transfer or discharge the resident from the facility except in limited situations when the health and safety of the individual or other residents are endangered;
-3. The facility may initiate transfers or discharges in the following limited circumstances:
-The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility;
-The safety of the individuals in the facility is endangered due to the clinical or behavioral status of the resident;
-The health of the individuals in the facility would otherwise be endangered;
-The policy did not provide guidance on documenting the specific resident needs the facility could not meet in the event of a facility-initiated discharge.
Review of the resident's Referral Documents, a 26-page hospital record, uploaded to the resident's facility medical record on 5/8/23, showed:
-A psychiatry history and physical note, dated 2/25/23, showed:
-Patient has shown evidence of violence to others within the past six months;
-Diagnoses included schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves), and dementia with behavioral disturbance.
Review of the resident's facility medical record, showed:
-admission date of 5/9/23;
-Diagnoses included dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.
Review of the resident's progress notes, showed:
-On 5/9/23 at 5:43 P.M., Registered Nurse (RN) A documented the resident arrived via ambulance on a stretcher. Admitting diagnosis of schizophrenia. Resident alert and oriented times one (oriented to person). Nurse giving report, reported that resident has chronic tooth pain and can be very combative, where resident randomly punches staff and other patients;
-On 5/10/23 at 6:46 A.M., staff documented the resident walking the hallways upon arrival. Resident easily redirected to room. Resident in a cooperative and calm mood;
-On 5/10/23 at 8:05 A.M., the Assistant Director of Nurses (ADON) documented the resident displayed physical aggression toward staff;
-On 5/10/23 at 8:46 A.M., the ADON documented the physician notified of physical aggression being displayed, order for immediate discharge from facility due to being aggressive and causing bodily harm to staff and is a threat to him/herself, staff, and peers.
Review of the resident's discharge notice, dated 5/10/23, showed:
-Involuntary transfer/discharge;
-The discharge or transfer is necessary for the resident's welfare and the facility cannot meet the resident's needs;
-The resident's clinical or behavioral status endangers the health of individuals in the facility and the facility cannot meet the resident's needs;
-Specific details in support of the above reason(s) are: Resident is physically aggressive, charged at and punched a staff worker.
During an interview on 5/19/23 at 10:03 A.M., RN A said he/she received report from the hospital upon the resident's admission and was told the resident was aggressive while at the hospital. The day after he/she was admitted , the resident hit an employee in the mouth and was discharged from the facility, unable to return. RN A was not sure why the resident was not allowed to return to the facility if the facility knew he/she had behaviors and accepted the admission.
During an interview on 5/19/23 at 11:28 A.M., the Admissions Director said admission referrals are reviewed by the Director of Nursing (DON), Administrator, and Corporate Liaison. If an admission referral is accepted, the Corporate Liaison notifies her (Admissions Director) and provides her with a copy of the admission referral. When she saw the resident's referral and his/her history of being in facilities that handle behaviors, she called the Corporate Liaison and asked if she was sure the resident should be admitted to the facility. The Corporate Liaison said the resident could be admitted to the facility because he/she had not had any behaviors in the past 120 days. The facility has a memory care unit, but there is not a unit for residents with behaviors. The resident was not an appropriate candidate for admission to the facility because the facility is not equipped for his/her type of behaviors.
During an interview on 5/19/23 at 1:55 P.M., the ADON and DON said the resident was issued an immediate discharge after he/she punched an employee in the mouth. The resident was not an appropriate placement for the facility and they were not aware of his/her history of behaviors until after he/she punched the employee. The resident was categorized as a green referral, immediately approved for admission, by the Corporate Liaison. The DON and Administrator were not consulted on the resident's admission. If they had been consulted, they would have denied the admission due to the resident's history of behaviors. The facility has a memory care unit but they do not have a behavior unit, which is what the resident would have needed.
During an interview on 5/20/23 at 1:28 P.M., the Administrator said the Corporate Liaison reviews admission referrals and categorizes them as red, yellow, or green. [NAME] referrals are pushed through without being sent to the DON or Administrator, and the resident was categorized as a green referral. The resident was not an appropriate admission to the facility. If the DON or Administrator had been consulted, they would not have accepted the resident due to his/her history of behaviors. When the facility accepts an admission, they are accepting the responsibility to accommodate a resident's needs, including behaviors. When a resident with known behaviors is admitted to the facility, she would expect staff to document the resident's behaviors, interventions, and involvement of the care plan team. This documentation is required before issuing an immediate discharge from the facility.
MO002182778
Mar 2023
9 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
Based on interview and record review, the facility failed to ensure one resident (Resident #2) was free from abuse when an employee, Nurse A, used profanity and derogatory language toward the resident...
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Based on interview and record review, the facility failed to ensure one resident (Resident #2) was free from abuse when an employee, Nurse A, used profanity and derogatory language toward the resident and said he/she hoped the resident would lose his/her limbs and die. The resident stated it hurt his/her feelings as he/she already had one amputation. The sample was 29. The census was 141.
Review of the facility's Abuse, Neglect and Exploitation policy, revised 9/22/22, showed:
-Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of property;
-Definitions:
--Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation of an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology;
--Verbal abuse means the use of oral, written or gestured communication or sounds, that willfully includes disparaging or derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability;
-Policy Explanation and Compliance Guidelines:
--The facility will develop and implement written policies and procedures that:
--- Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property;
---Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriate of resident property, reporting procedures, and dementia management and resident abuse prevention;
--The facility will provide ongoing oversight and supervision of staff to assure that its policies are implemented as written;
-Employee Training:
--New employees will be educated on abuse, neglect, exploitation and misappropriation of resident property during initial orientation;
--Existing staff will receive annual education through planned in-services and as needed;
--Training topics will include;
---Prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property, and exploitation;
---Identifying what constitutes abuse, neglect, exploitation, and misappropriation of resident property;
---Reporting process for abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources;
---Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect such as:
----Aggressive and/or catastrophic reactions of residents;
----Outbursts or yelling;
-Prevention of Abuse, Neglect, and Exploitation:
--The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves
---Identifying, correcting and intervening in situations in which abuse, neglect, exploitation and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms;
---Assigning responsibility for the supervision of staff on all shifts for identifying in appropriate staff behaviors;
-Identification of Abuse, Neglect and Exploitation:
-The facility will have written procedures to assist staff in identifying the different types of abuse - mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This includes staff to resident abuse and certain resident to resident altercations;
-Possible indicators of abuse include, but are not limited to:
--Verbal abuse of a resident overheard;
--Psychological abuse of a resident observed.
Review of Resident #2's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/30/22, showed:
-Brief Interview for Mental Status (BIMS) of 15 out of a possible 15, showed the resident cognitively intact;
-Mood interview showed resident feels down, depressed, or hopeless 12-14 days (nearly every day);
-Behavioral symptoms and rejection of care not exhibited;
-Lower extremity impairment on both sides;
-Diagnoses included paraplegia (paralysis of lower portion of the body), anxiety, and depression;
-One or more unhealed pressure ulcers (injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or friction).
Review of the resident's progress note, dated 3/8/2023 at 8:48 A.M., showed Nurse A documented while in the resident's room, the resident was asked by Certified Nurse Aide (CNA) if he/she wanted his/her breakfast tray, he/she refused to answer, then responded by mumbling something. When asked again, he/she began to cuss and yell at CNA, saying, I know damn well (he/she) heard me. Nurse informed the resident neither the CNA nor the Nurse heard what was said due to resident mumbling, he/she then began to yell and cuss at Nurse A. Nurse informed resident not to talk to him/her or staff in that manner. Resident continued to cuss and yell. Nurse then informed charge nurse that he/she would need to do wound treatments. Nurse also made the Administrator aware of behavior.
Review of the resident's care plan, in use at the time of survey, showed:
-Focus: The resident has an activities of daily living (ADL) self-care performance deficit;
-Intervention: Staff assistance to the extent needed;
-Focus: The resident has actual impairment to skin integrity, left hip, right hip, lower back, right outer ankle, left buttock, right heel;
-Interventions/tasks included follow facility protocols for treatment;
-The care plan did not identify the resident as having behaviors of refusing care or being aggressive toward staff.
During an interview on 3/15/23 at 10:40 A.M., the resident said around breakfast on 3/8/23, Nurse A came into the resident's room to do his/her wound treatments. As Nurse A was getting ready to do the resident's treatment, the CNA came to the doorway and asked if the resident wanted his/her breakfast tray. The resident repeated him/herself twice and said, Damn, I guess motherfuckers can't hear me nowadays. Nurse A said, Ain't nobody owe you shit nigga. The resident and Nurse A started arguing, and the resident told Nurse A to shut up and get out of his/her room. Nurse A said, Fuck this, exited the room, and told Nurse C to do the resident's wound treatment. While Nurse A was in the hall outside of the resident's room, the resident heard Nurse A say, Fuck that nigga, I hope (his/her) limbs fall off. I hope (he/she) dies. This hurt the resident's feelings. He/She has already had one amputation. He/She had a love/hate relationship with Nurse A prior to that. They argued back and forth like siblings, but that day, Nurse A took it too far, to a level the resident never expected.
During an interview on 3/15/23 at 11:10 A.M., Certified Medication Technician (CMT) D said right before or during breakfast on 3/8/23, he/she was in the hall when he/she heard CNA B ask the resident if he/she wanted his/her breakfast tray. CMT D heard the resident say yes, and the CNA asked again two more times, with the resident saying yes each time. The resident said he/she was not going to keep repeating him/herself. CMT D left the area for a few minutes and when he/she returned, he/she observed Nurse A in the hall saying, Don't nobody owe this nigga nothing. Nurse A was yelling this in the hall outside of the resident's room. As Nurse A walked down the hall to the nurse's station, he/she yelled things like, Fuck that nigga. I hope that nigga die. I hope the rest of (his/her) limbs fall off. CMT D saw the resident in his/her room with his/her mouth open. The resident heard what Nurse A said, and the resident said it hurt his/her feelings. The resident is completely alert. Nurse A sat at the nurse's station and continued to yell about the resident. CMT D has worked with the resident and Nurse A for quite some time. Nurse A's words were not shocking because this is how the nurse is; this is his/her attitude. Nurse A talks to people like that all the time and people get used to it. The resident can have a foul mouth with his/her language at times, but he/she wasn't being like that on that day. CMT D considers what Nurse A said to be verbal abuse. About 30-45 minutes after the incident, Medical Records (MR) staff came to the hall to meet with the resident on an unrelated issue and the resident told MR what happened. When an incident of abuse occurs, staff should immediately notify the Administrator or supervisor. CMT D reported the incident to MR when she came to the hall 30-45 minutes after the incident.
During an interview on 3/15/23 at 11:24 A.M., CNA B said on 3/8/23 at around 8:00 A.M., he/she stopped at the resident's room and Nurse A was in the resident's room at that time. When the CNA asked if the resident wanted a breakfast tray, the resident did not respond and Nurse A told the resident the CNA could not hear him/her because he/she was mumbling. The resident used profanity and told Nurse A told leave him/her alone. Nurse A said, Fuck this, I'm not gonna deal with this, and exited the resident's room. In the hall, Nurse A told Nurse C that he/she had to do the resident's treatment because Nurse A was not going to do it, and he/she was not going to let the resident talk to him/her that way. Nurse A went up to the nurse's station and the CNA went the opposite way down the hall and did not see or hear anything else. CNA B knows the resident and has worked with Nurse A for the past year. The resident is alert and can be antagonistic, call staff names and go off on people. If a resident yells at or cusses at staff, staff should leave the room and report it to the charge nurse or Administrator. If an employee cusses at a resident or calls them a derogatory name, it is considered verbal abuse. If an employee witnesses their coworker being verbally abusive, or if they are made aware of an allegation of abuse, the employee should report it to the Administrator right away.
During an interview on 3/16/23 at 7:56 A.M., Housekeeper E said he/she was cleaning on the resident's hall around breakfast time on 3/8/23. He/She heard an aide ask the resident if he/she wanted breakfast, then the aide kept walking. The resident said yes, he/she did want breakfast. Nurse A came flying out of the resident's room, arguing with the resident and yelling at him/her. Housekeeper E is not sure exactly what was said, but Nurse A was yelling at the resident. Housekeeper E entered a different resident's room and did not hear anything else. If a resident yells at an employee, the employee should give the resident space and time to cool down, then report to their supervisor and come back to the resident later. Staff cannot yell at residents. Staff yelling at a resident or telling them off is considered abuse. If an employee witnesses their coworker being abusive, they should tell their supervisor. Housekeeper E told MR about the incident when she came to the hall later that morning.
During an interview on 3/16/23 at 9:03 A.M., MR said she attended the morning meeting on 3/8/23, around 9:00 A.M. During the meeting, it was discussed that the resident said something mean to staff that day, but not much more was described than that. After the meeting, around 9:45 A.M., she started her rounds. She went to the resident's hall and the resident was at the nurse's station with CMT D. MR was talking to the resident when the CMT stopped the resident and told him/her to tell MR what happened. CMT D said Nurse A told the resident, Don't nobody owe this nigga shit. I hope you die, and something about the resident losing the rest of his/her limbs. The resident went to the front office with MR and made a statement. The resident said a CNA came to his/her room and asked if he/she wanted breakfast. The CNA did not hear the resident's response and asked again several times. Nurse A came into the resident's room and hollered at the resident. The resident did not specify what Nurse A said, but said it upset him/her enough to tell Nurse A to shut the fuck up. The resident felt very disrespected and said he/she knew people had bad days, but Nurse A went too far. The resident said the CMT and Housekeeper were in the area and overheard it. MR believed the incident was verbal abuse and reported it to the Social Services Assistant (SSA) and the Director of Nurses (DON), around 10:00 A.M. The resident has no confusion and MR has never seen or known the resident to be mean. If staff witnessed Nurse A being verbally abusive to the resident, they should have immediately reported it up the chain of command.
During an interview on 3/16/23 at 11:01 A.M., SSA said she became aware of the incident involving the resident and Nurse A after the morning meeting was over, around 9:30 A.M. or 10:00 A.M. on 3/8/23. The resident came to her office and said he/she needed to talk. SSA and MR met with the resident, who said he/she was very offended by what Nurse A said. According to the resident, Nurse A said, Nobody owes this nigga, and told the resident he/she hoped the resident dies and his/her limbs fall off. This was a terrible thing to say, especially because the resident was just told by the doctor they might have to take off the resident's other leg. The resident was hurt and disappointed because he/she had a rapport with Nurse A, but he/she took it too far. Nurse A has an aggressive personality and it was not surprising these statements came from him/her. Nurse A's statements would definitely be considered verbal abuse. The resident is very alert and had not had any other known incidents with other residents or staff. He/She might get an attitude if woken up early, but isn't known to cuss at staff. If a resident does cuss at an employee or yell at them, the employee should walk away from the situation, then report and document the incident. After the resident gave his/her statement, SSA and MR reported it to the DON and Administrator.
During an interview on 3/17/23 at 2:36 P.M., Nurse C said on 3/8/23 at around 8:00 A.M., he/she was at the top of the resident's hall while Nurse A was doing wound treatment rounds. Nurse A came out of the resident's room into the hall, yelling and going back and forth with the resident. Nurse A came down the hall, mad, and said he/she was not going to do the resident's wound treatments. While passing by Nurse C in the hallway, Nurse A made a comment about hoping the resident's limbs fell off. Nurse C went to check on the resident. The resident was upset and said he/she couldn't deal with Nurse A and was tired of the nurse's mouth. The resident said CNA B asked if he/she wanted a breakfast tray. The resident said yes, but CNA B did not hear him/her from the hallway and asked multiple times. The resident was frustrated and said he/she was not going to keep repeating him/herself. Nurse A told the resident to stop mumbling, but the CMT and Housekeeper both heard him/her say he wanted a breakfast tray, so clearly, he/she was not mumbling. Nurse A told the resident he/she hoped the rest of his/her limbs fall off. The resident is alert and cognitively intact. This is not the first time there was a disagreement between the resident and Nurse A, but this was the first time it got to this extent. Previous disagreements were more centered around the resident not taking care of him/herself and his/her wounds. Nurse C completed the resident's wound treatments and then notified the DON about what happened. All signs of abuse need to be reported immediately. The department heads went to their morning meeting around 9:00 A.M. After the incident with the resident, Nurse A remained in the building for a while and continued to work with a different resident. Later, the DON came to the hall and started interviewing people and Nurse C wrote a statement about what happened.
During an interview on 3/20/23 at 11:40 A.M., Nurse A said on 3/8/23, at around 8:00 A.M. or 8:30 A.M., he/she was in the resident's room, getting ready to do his/her wound treatments. CNA B stopped at the resident's doorway and asked if the resident wanted a tray. Nurse A was seated at the resident's bedside and heard the resident mumble, but couldn't understand him/her. CNA B asked again and the resident said he/she wasn't going to keep repeating him/herself. The resident used profanity toward the Nurse and told him/her to get out of the room and leave the resident alone. Nurse A said, No problem, I don't have to deal with this shit, and left the resident's room. In the hallway, Nurse A told Nurse C he/she was not going to do the resident's wound treatments. Prior to this incident, Nurse A had a decent rapport with the resident and they would sometimes bump heads, but not like what happened on 3/8/23. The resident is very alert and oriented, but is hard-headed and resistant to taking care of him/herself. Nurse A would talk to the resident on a personal level and was one of the few staff to whom the resident would listen. The resident was over the top that day. After the exchange, Nurse A told the Administrator what happened and that the resident was not going to talk to him/her like that. He/She finished doing what he/she needed to do for the day and clocked out around 10:00 A.M. Nurse A denied using other profanity toward the resident, using derogatory terms when speaking about the resident, or making comments about wishing the resident would die or lose his/her limbs. These actions and statements would be considered abuse. If an employee witnessed their co-worker being abusive toward a resident, the employee should tell their co-worker to stop and then immediately report it to Administration.
Review of Nurse A's time punches, dated 3/8/23, showed the employee clocked in at 6:41 A.M. and clocked out at 10:50 A.M.
During an interview on 3/16/23 at 1:11 P.M., the DON said on 3/8/23, MR notified her of the incident between the resident and Nurse A, sometime after morning meeting and before noon. Morning meeting usually ends around 10:00 A.M. When the DON found out about the incident, Nurse A was already gone for the day. The DON interviewed the resident, who said Nurse A came into his/her room to do his/her wound treatment that morning, around breakfast. The CNA came to the doorway and asked if the resident wanted breakfast several times and the resident said he/she was not going to keep repeating him/herself. Nurse A jumped in and said something about how the resident is not special and staff don't owe him/her a fucking thing. The resident told Nurse A to shut the fuck up, and Nurse A said he/she was not going to do his/her wound treatment. Nurse A walked out of the room and told Nurse C to do the wound treatment, then told the resident, I hope your other limbs fall off. This statement hurt the resident's feelings. The resident has already had one amputation and said he/she is fighting every day to keep his/her other limbs. Nurse A's statements are considered verbal abuse. If an employee witnesses their coworker being verbally abusive, the employee should leave immediately to go tell someone, a supervisor. The facility uses a lot of agency staff so maybe the staff who were in the area at the time of the incident did not know the facility's abuse policies. She would have expected staff who witnessed the incident to have reported it to the Administrator immediately. If the Administrator is not available, staff should report it to the DON. If the DON or Administrator had been notified of the abuse allegation sooner, they would have told Nurse A to leave the building and would have suspended him/her pending investigation. It is the policy of the facility to remove the alleged perpetrator in order to keep residents safe.
During an interview on 3/20/23 at 10:35 A.M., the Administrator said during the morning meeting on 3/8/23, it might have been discussed that Nurse A was not getting along with the resident, but nothing that rose to the level of abuse. After the meeting, around 10:00 A.M., MR notified her of an incident involving the resident and Nurse A. The Administrator spoke to the resident, who reported between 8:00 A.M. and 8:30 A.M., Nurse A was in his/her room while breakfast was going out. According to the resident, an employee asked the resident if he/she wanted something and Nurse A told the resident they could not hear him/her. There was banter back and forth between the resident and Nurse A. As Nurse A was leaving the room, he/she made a comment that he/she hoped the resident's limbs fall off and he/she dies. The resident was just in the hospital and said usually, he/she has thick skin, but Nurse A's comments bothered him/her. The Administrator considers the statements made by Nurse A to be verbal abuse. When the Administrator was notified of the incident, Nurse A had already clocked out for the day. She spoke with Nurse A over the phone, who denied using any abusive language. Nurse A was nonchalant about the situation and said he/she jokes and plays around with the resident. Statements were obtained from staff and at least one employee overheard the exchange between the resident and Nurse A. The resident is cognitively intact and has a history of being verbally aggressive and refusing treatment. Other staff have reported this behavior, but there have not been any current issues. If these behaviors are ongoing, she would expect the behaviors to be documented in the resident's medical record, and care planned with interventions to address the behavior. If a resident becomes verbally aggressive toward an employee, she would expect the employee to step away, document the incident, and notify their supervisor. If staff overhear or witness abuse, they need to make sure the resident is safe, then immediately report the incident to the Administrator or supervisor so they can take action. Immediate action would include immediately suspending the employee who was allegedly being abusive, in order to prevent potential further abuse. If the incident occurred around 8:30 A.M., she would have expected to have been notified right away, more promptly than when it was reported. The Administrator concluded that the resident was treated inappropriately by Nurse A and he/she was terminated.
MO00215173
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
Based on interview and record review, facility staff failed to follow the facility's policy to immediately notify facility administration of an abuse allegation by an employee, Nurse A, toward a resid...
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Based on interview and record review, facility staff failed to follow the facility's policy to immediately notify facility administration of an abuse allegation by an employee, Nurse A, toward a resident (Resident #2), which also resulted in a failure to report the abuse allegation to the Department of Health and Senior Services (DHSS) as required within a two-hour timeframe. The sample was 29. The census was 141.
Review of the facility's Abuse, Neglect and Exploitation policy, revised 9/22/22, showed:
-Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of property;
-Definitions:
--Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation of an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology;
--Verbal abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging or derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability;
-Policy Explanation and Compliance Guidelines:
--The facility will develop and implement written policies and procedures that:
--- Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property;
---Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriate of resident property, reporting procedures, and dementia management and resident abuse prevention;
--The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law;
-Employee Training:
-- New employees will be educated on abuse, neglect, exploitation and misappropriation of resident property during initial orientation;
--Existing staff will receive annual education through planned in-services and as needed;
--Training topics will include;
--- Prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property, and exploitation;
---Identifying what constitutes abuse, neglect, exploitation, and misappropriation of resident property;
--- Reporting process for abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources;
-Protection of Resident:
--The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to:
---Responding immediately to protect the alleged victim and integrity of the investigation;
-Reporting/Response:
--The facility will have written procedures that include:
---Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes:
----Immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.
Review of Resident #2's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/30/22, showed:
-Brief Interview for Mental Status (BIMS) of 15 out of a possible 15, showed the resident cognitively intact;
-Mood interview showed resident feels down, depressed, or hopeless 12-14 days (nearly every day);
-Behavioral symptoms and rejection of care not exhibited;
-Lower extremity impairment on both sides;
-Diagnoses included paraplegia (paralysis of lower portion of the body), anxiety, and depression;
-One or more unhealed pressure ulcers (injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or friction).
Review of the resident's progress note, dated 3/8/2023 at 8:48 A.M., showed Nurse A documented that while in the resident's room, the resident was asked by Certified Nurse Aide (CNA) if he/she wanted his/her breakfast tray, he/she refused to answer, then responded by mumbling something. When asked again, he/she began to cuss and yell at the CNA, saying, I know damn well (he/she) heard me. Nurse informed the resident neither the CNA nor the Nurse heard what was said due to resident mumbling; he/she then began to yell and cuss at Nurse A. The Nurse informed resident not to talk to him/her or staff in that manner. Resident continued to cuss and yell. Nurse A then informed charge nurse that he/she would need to do wound treatments. Nurse A also made the Administrator aware of the behavior.
During an interview on 3/15/23 at 10:40 A.M., the resident said around breakfast on 3/8/23, Nurse A came into the resident's room do his/her wound treatments. As Nurse A was getting ready to do the resident's treatment, the CNA came to the doorway and asked if the resident wanted his/her breakfast tray. The resident repeated him/herself twice and said, Damn, I guess motherfuckers can't hear me nowadays. Nurse A said, Ain't nobody owe you shit nigga. The resident and Nurse A started arguing. Nurse A said, Fuck this, exited the room, and told the Nurse C to do the resident's wound treatment. While Nurse A was in the hall outside of the resident's room, the resident heard Nurse A say, Fuck that nigga, I hope (his/her) limbs fall off. I hope (he/she) dies.
During an interview on 3/15/23 at 11:10 A.M., Certified Medication Technician (CMT) D said right before or during breakfast on 3/8/23, he/she was in the hall when he/she heard CNA B ask the resident if he/she wanted his/her breakfast tray. The resident repeated him/herself twice and said he/she was not going to keep repeating him/herself. CMT D left the area for a few minutes and when he/she returned, he/she observed Nurse A in the hall saying, Don't nobody owe this nigga nothing. Nurse A was yelling this in the hall outside of the resident's room. As Nurse A walked down the hall to the nurse's station, he/she yelled things like, Fuck that nigga. I hope that nigga die. I hope the rest of (his/her) limbs fall off. Nurse A sat at the nurse's station and continued to yell about the resident. CMT D considers what Nurse A said to be verbal abuse. About 30-45 minutes after the incident, Medical Records (MR) staff came to the hall to meet with the resident on an unrelated issue and the resident told MR what happened. When an incident of abuse occurs, staff should immediately notify the Administrator or supervisor. CMT D reported the incident to MR when she came to the hall 30-45 minutes after the incident.
During an interview on 3/15/23 at 11:24 A.M., CNA B said on 3/8/23 at around 8:00 A.M., he/she stopped at the resident's room and Nurse A was in the resident's room at that time. When the CNA asked if the resident wanted a breakfast tray, the resident did not respond and Nurse A told the resident the CNA could not hear him/her because he/she was mumbling. The resident used profanity and told Nurse A to leave him/her alone. Nurse A said, Fuck this, I'm not gonna deal with this, and exited the resident's room. In the hall, Nurse A told Nurse C that he/she had to do the resident's treatment because Nurse A was not going to do it, and he/she was not going to let the resident talk to him/her that way. Nurse A went up to the nurse's station and CNA B went the opposite way down the hall and did not see or hear anything else. If an employee cusses at a resident or calls them a derogatory name, it is considered verbal abuse. If an employee witnesses their coworker being verbally abusive, or if they are made aware of an allegation of abuse, the employee should report it to the Administrator right away.
During an interview on 3/16/23 at 7:56 A.M., Housekeeper E said he/she was cleaning on the resident's hall around breakfast time on 3/8/22. He/She heard an aide ask the resident if he/she wanted breakfast, then the aide kept walking. The resident said yes, he/she did want breakfast. Nurse A came flying out of the resident's room, arguing with the resident and yelling at him/her. Housekeeper E is not sure exactly what was said, but Nurse A was yelling at the resident. Staff cannot yell at residents. Staff yelling at a resident or telling them off is considered abuse. If an employee witnesses their coworker being abusive, they should tell their supervisor. Housekeeper E told MR about the incident when she came to the hall later that morning.
During an interview on 3/16/23 at 9:03 A.M., MR said after the morning meeting on 3/8/23, around 9:45 A.M., she started her rounds. She went to the resident's hall and the resident was at the nurse's station with CMT D. CMT D said Nurse A told the resident, Don't nobody owe this nigga shit. I hope you die, and something about the resident losing the rest of his/her limbs. The resident went to the front office with MR and made a statement. The resident said Nurse A came into the resident's room and hollered at the resident. MR believed the incident was verbal abuse and reported it to the Social Services Assistant (SSA) and the Director of Nurses (DON), around 10:00 A.M. If staff witnessed Nurse A being verbally abusive to the resident, they should have immediately reported it up the chain of command.
During an interview on 3/16/23 at 11:01 A.M., SSA said she became aware of the incident involving the resident and Nurse A after the morning meeting was over, around 9:30 A.M. or 10:00 A.M. on 3/8/23. SSA and MR met with the resident, who reported Nurse A said, Nobody owes this nigga, and told the resident he/she hoped the resident dies and his/her limbs fall off. Nurse A's statements would definitely be considered verbal abuse. After the resident gave his/her statement, SSA and MR reported it to the DON and Administrator.
During an interview on 3/17/23 at 2:36 P.M., Nurse C said on 3/8/23 at around 8:00 A.M., he/she was at the top of the resident's hall while Nurse A was doing wound treatment rounds. Nurse A came out of the resident's room into the hall, yelling and going back and forth with the resident. Nurse A came down the hall, mad, and said he/she was not going to do the resident's wound treatments. While passing by Nurse C in the hallway, Nurse A made a comment about hoping the resident's limbs fell off. Nurse C went to check on the resident. The resident was upset and said he/she couldn't deal with Nurse A and was tired of the nurse's mouth. Nurse A told the resident he/she hoped the rest of his/her limbs fall off. Nurse C completed the resident's wound treatments and then notified the DON about what happened. All signs of abuse need to be reported immediately. The department heads went to their morning meeting around 9:00 A.M. After the incident with the resident, Nurse A remained in the building for a while and continued to work with a different resident. Later, the DON came to the hall and started interviewing people and Nurse C wrote a statement about what happened.
During an interview on 3/20/23 at 11:40 A.M., Nurse A said on 3/8/23, he/she clocked out around 10:00 A.M. He/She denied using other profanity toward the resident, using derogatory terms when speaking about the resident, or making comments about wishing the resident would die or lose his/her limbs. These actions and statements would be considered abuse. If an employee witnessed their co-worker being abusive toward a resident, the employee should tell their co-worker to stop and then immediately report it to Administration.
Review of Nurse A's time punches, dated 3/8/23, showed the employee clocked in at 6:41 A.M. and clocked out at 10:50 A.M.
During an interview on 3/16/23 at 1:11 P.M., the DON said on 3/8/23, MR notified her of the incident between the resident and Nurse A, sometime after morning meeting and before noon. Morning meeting usually ends around 10:00 A.M. When the DON found out about the incident, Nurse A was already gone for the day. The DON interviewed the resident, who said Nurse A came into his/her room to do his/her wound treatment that morning, around breakfast. A CNA asked if the resident wanted breakfast several times, and the resident said he/she was not going to keep repeating him/herself. Nurse A jumped in and said something about how the resident is not special and staff don't owe him/her a fucking thing. The resident told Nurse A to shut the fuck up, and Nurse A said he/she was not going to do his/her wound treatment. Nurse A walked out of the room and told Nurse C to do the wound treatment, then told the resident, I hope your other limbs fall off. Nurse A's statements are considered verbal abuse. If an employee witnesses their coworker being verbally abusive, the employee should leave immediately to go tell someone, a supervisor. The facility uses a lot of agency staff so maybe the staff who were in the area at the time of the incident did not know the facility's abuse policies. She would have expected staff who witnessed the incident to have reported it to the Administrator immediately. If the Administrator is not available, staff should report it to the DON. If the DON or Administrator had been notified of the abuse allegation sooner, they would have told Nurse A to leave the building and would have suspended him/her pending investigation. It is the policy of the facility to remove the alleged perpetrator in order to keep residents safe. The Administrator is the abuse coordinator and she reports abuse allegations to DHSS within two hours.
Review of the facility's self-report to DHSS, showed the facility reported the incident on 3/8/23 at 1:37 P.M.
During an interview on 3/20/23 at 10:35 A.M., the Administrator said after the meeting on 3/8/23, MR notified her of an incident involving the resident and Nurse A. The Administrator spoke to the resident, who reported between 8:00 A.M. and 8:30 A.M., Nurse A was in his/her room while breakfast was going out. There was banter back and forth between the resident and Nurse A. As Nurse A was leaving the room, he/she made a comment that he/she hoped the resident's limbs fall off and he/she dies. The Administrator considers the statements made by Nurse A to be verbal abuse. When the Administrator was notified of the incident, Nurse A had already clocked out for the day. If staff overhear or witness abuse, they need to make sure the resident is safe, then immediately report the incident to the Administrator or supervisor so they can take action. Immediate action would include immediately suspending the employee who was allegedly being abusive, in order to prevent potential further abuse. If the incident involving the resident and Nurse A occurred around 8:30 A.M., she would have expected to have been notified right away, more promptly than when it was reported. Allegations of abuse should be reported to DHSS immediately, within two hours. She made the report to DHSS within two hours of being made aware of the allegation by 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
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to provide and document efforts to meet the needs of one resident admitted to the facility with a known history of behaviors, and when the beh...
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Based on interview and record review, the facility failed to provide and document efforts to meet the needs of one resident admitted to the facility with a known history of behaviors, and when the behaviors were exhibited, the resident was issued an immediate discharge from the facility (Resident #20). The census was 158.
Review of the facility's Transfer and Discharge policy, revised 9/1/21, showed:
-Policy: It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility except in limited situations when the health and safety of the individual or other residents are endangered;
-Policy Explanation and Compliance Guidelines:
-1. The facility will evaluate and determine the level of care needed for the resident prior to admission to ensure the facility's ability to meet the resident's needs;
-2. The facility permits each resident to remain in the facility, and not transfer or discharge the resident from the facility except in limited situations when the health and safety of the individual or other residents are endangered;
-3. The facility may initiate transfers or discharges in the following limited circumstances:
-The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility;
-The safety of the individuals in the facility is endangered due to the clinical or behavioral status of the resident;
-The health of the individuals in the facility would otherwise be endangered;
-The policy did not provide guidance on documenting the specific resident needs the facility could not meet in the event of a facility-initiated discharge.
Review of the resident's Referral Documents, a 26-page hospital record, uploaded to the resident's facility medical record on 5/8/23, showed:
-A psychiatry history and physical note, dated 2/25/23, showed:
-Patient has shown evidence of violence to others within the past six months;
-Diagnoses included schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves), and dementia with behavioral disturbance.
Review of the resident's facility medical record, showed:
-admission date of 5/9/23;
-Diagnoses included dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.
Review of the resident's progress notes, showed:
-On 5/9/23 at 5:43 P.M., Registered Nurse (RN) A documented the resident arrived via ambulance on a stretcher. Admitting diagnosis of schizophrenia. Resident alert and oriented times one (oriented to person). Nurse giving report, reported that resident has chronic tooth pain and can be very combative, where resident randomly punches staff and other patients;
-On 5/10/23 at 6:46 A.M., staff documented the resident walking the hallways upon arrival. Resident easily redirected to room. Resident in a cooperative and calm mood;
-On 5/10/23 at 8:05 A.M., the Assistant Director of Nurses (ADON) documented the resident displayed physical aggression toward staff;
-On 5/10/23 at 8:46 A.M., the ADON documented the physician notified of physical aggression being displayed, order for immediate discharge from facility due to being aggressive and causing bodily harm to staff and is a threat to him/herself, staff, and peers.
Review of the resident's discharge notice, dated 5/10/23, showed:
-Involuntary transfer/discharge;
-The discharge or transfer is necessary for the resident's welfare and the facility cannot meet the resident's needs;
-The resident's clinical or behavioral status endangers the health of individuals in the facility and the facility cannot meet the resident's needs;
-Specific details in support of the above reason(s) are: Resident is physically aggressive, charged at and punched a staff worker.
During an interview on 5/19/23 at 10:03 A.M., RN A said he/she received report from the hospital upon the resident's admission and was told the resident was aggressive while at the hospital. The day after he/she was admitted , the resident hit an employee in the mouth and was discharged from the facility, unable to return. RN A was not sure why the resident was not allowed to return to the facility if the facility knew he/she had behaviors and accepted the admission.
During an interview on 5/19/23 at 11:28 A.M., the Admissions Director said admission referrals are reviewed by the Director of Nursing (DON), Administrator, and Corporate Liaison. If an admission referral is accepted, the Corporate Liaison notifies her (Admissions Director) and provides her with a copy of the admission referral. When she saw the resident's referral and his/her history of being in facilities that handle behaviors, she called the Corporate Liaison and asked if she was sure the resident should be admitted to the facility. The Corporate Liaison said the resident could be admitted to the facility because he/she had not had any behaviors in the past 120 days. The facility has a memory care unit, but there is not a unit for residents with behaviors. The resident was not an appropriate candidate for admission to the facility because the facility is not equipped for his/her type of behaviors.
During an interview on 5/19/23 at 1:55 P.M., the ADON and DON said the resident was issued an immediate discharge after he/she punched an employee in the mouth. The resident was not an appropriate placement for the facility and they were not aware of his/her history of behaviors until after he/she punched the employee. The resident was categorized as a green referral, immediately approved for admission, by the Corporate Liaison. The DON and Administrator were not consulted on the resident's admission. If they had been consulted, they would have denied the admission due to the resident's history of behaviors. The facility has a memory care unit but they do not have a behavior unit, which is what the resident would have needed.
During an interview on 5/20/23 at 1:28 P.M., the Administrator said the Corporate Liaison reviews admission referrals and categorizes them as red, yellow, or green. [NAME] referrals are pushed through without being sent to the DON or Administrator, and the resident was categorized as a green referral. The resident was not an appropriate admission to the facility. If the DON or Administrator had been consulted, they would not have accepted the resident due to his/her history of behaviors. When the facility accepts an admission, they are accepting the responsibility to accommodate a resident's needs, including behaviors. When a resident with known behaviors is admitted to the facility, she would expect staff to document the resident's behaviors, interventions, and involvement of the care plan team. This documentation is required before issuing an immediate discharge from the facility.
MO002182778
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 observation, interview and record review, the facility failed to follow physician orders for wound care for two residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow physician orders for wound care for two residents (Residents #4 and #6). The sample was 29. The census was 141.
Review of the facility's Medical Provider Orders policy, revised 4/7/22, showed:
-Policy: This facility shall use uniform guidelines for the ordering and following of medical provider orders;
-Policy Explanation and Compliance Guidelines:
-1. Medications and/or Treatments should be administered only upon the signed order of a person lawfully authorized to prescribe;
-2. Verbal orders should be received only by licensed nurses, or pharmacists, and confirmed in writing by the medical provider, on the next visit to the facility;
-3. Elements of the Medication and/or Treatment Order:
-a. Date and time the order is written;
-b. Resident's full name;
-c. Name of medication and/or treatment;
-d. Dosage-strength of medication is included;
-e. Time or frequency of administration;
-f. Route of administration;
-g. Type/Formulation (if applicable);
-h. Hour of administration (if applicable);
-1. Diagnosis or indication for use;
-J. As needed (PRN) orders should also specify the condition, for which they are being administered, (e.g., as needed for sleep);
-4. Documentation of Medication and/or Treatment Orders:
-a. Each medication and/or treatment order should be documented with the date, time, and signature of the person receiving the order;
-b. lf using electronic medication records, input the medication and/or treatment order according to the electronic health record (EHR) instructions and facility policy;
-c. Call, fax, or electronically transmit the medication and/or treatment order to the provider pharmacy;
-d. Validate newly prescribed medications and/or treatment is in the electronic medication administration record (eMAR)/treatment administration record (eTAR);
-e. When a new order changes the dosage of a previously prescribed medication, discontinue the order as per the electronic software instructions and retype the new order;
-f. Validate the new order is in the eMAR/eTAR;
-g. Notify resident's sponsor/family of new medication order;
-5. Following of Medication and/or Treatment Orders:
-a. Medical provider orders should be reviewed prior to administration of medication and/or treatment to validate the orders contains all required elements;
-b. Staff should follow all valid medical provider orders timely unless there is an emergency which would temporarily delay the implementation of the order;
-c. If an order does not contain all the required elements, staff should contact the ordering provider for clarification of the order prior to implementation of the order;
-6. Specific Procedures for Medication Orders:
-a. Handwritten order signed by the medical provider - The charge nurse on duty at the time the order is received should note the order and enter it on the medical provider order sheet or electronic order format, if not written by the medical provider. If necessary, the order should be clarified before the medical provider leaves the nursing station, whenever possible;
-b. Verbal Orders - The nurse should document an order by telephone or in person on the medical provider's order sheet or input into electronic record as per facility policy, transmit the appropriate copy to the pharmacy for dispensing, and place the signed copy on the designated page in the resident's medical records. Medical provider orders should be signed per state specific guidelines;
-c. Written Transfer Orders (sent with a resident by a hospital or other health care facility) - Implement a transfer order without further validation, if it is signed and dated by the resident's current attending medical provider, unless the order is unclear or incomplete, or the date signed is different from the date of admission. If the order is unsigned, or signed by another medical provider, or the date is other than the date of admission, the receiving nurse should verify the order with the current attending medical provider before medications are administered. The nurse should document verification on the admission order record, by entering the time, date, and signature. Example: Order verified by the phone with Dr. [NAME]/M. [NAME], R.N.
1. Review of Resident #4's quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-No rejection of care;
-Required extensive assistance of staff for bed mobility and bathing;
-Required total assistance of staff for dressing, eating, toilet use and personal hygiene;
-Functional limitation in ROM for both upper and lower extremities;
-Diagnoses included: quadriplegia (paralysis of all four limbs) and other neurological conditions;
-Number of Stage III pressure ulcers (full thickness tissue loss, subcutaneous fat may be visible but the bone, tendon or muscle is not exposed) Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) was two.
Review of the care plan, in use at the time of the survey, dated 9/2/22, showed:
-Focus: the resident was at risk for developing a pressure ulcer related to immobility. Resident had pressure ulcers, the right ischial started on 6/29/21, and the left ischial started on 6/3/22;
-Goal: the pressure ulcers will show signs of healing and remain free from infection by/through review date;
-Interventions included: administer treatments as ordered and monitor for effectiveness; assess/record/monitor wound healing daily. Report improvements and declines to the medical doctor.
Review of the census, showed the resident readmitted to the facility on [DATE].
Review of the Order Summary Report, dated 3/16/23, showed:
-An order for house barrier cream after incontinent episodes and as needed. The start date was 3/2/23;
-An order to cleanse wound to left ischial with normal saline (NS), apply Santyl (Collagenase, sterile enzymatic debriding ointment) nickel thick, apply calcium alginate/fibercol (highly absorbent dressing that promotes healing), cover with border gauze every day shift for wound care. The order date was 3/2/23 and the start date was 3/13/23;
-An order to cleanse wound to right ischial with NS, apply santyl-nickel thick, apply calcium alginate, and cover with bordered gauze every day shift for wound care. The order date was 3/2/23 and start date was 3/13/23;
-An order for wound vacuum (wound vac, vacuum assisted closure used to conduct negative pressure wound therapy to promote healing) suction set at 125 millimeters of mercury (mmgh) continuous. Change the dressing every Monday, Wednesday and Friday (M-W-F). The order date was 3/2/23 and there was no end date;
-An order for wound vac to left ischial at 125 mmhg continuous, change the dressing M-W-F, if the wound vac fails, remove the wound vac, cleanse wound with NS, lightly pack the wound with gauze, change daily/as needed (PRN) until the wound vac can be resumed, for left ischial wound healing, order date was 3/8/23. The start date was 3/9/23 and there was no end date;
-An order for Collagenase ointment 250 unit/gram (GM), apply to left ischial topically every day shift for wound care. The order date was 3/2/23, the start date was 3/13/23, and there was no end date;
-An order for Collagenase ointment 250 unit/GM, apply to right ischial topically every day shift for wound care. The order date was 3/2/23, the start date was 3/13/23, and there was no end date;
Review of the progress notes dated 2/22/23 through 3/14/23, showed:
-On 3/2/23 at 11:48 A.M., wound vac applied per wound nurse;
-On 3/3/23 at 5:21 P.M., has wound vac, noted seen by treatment nurse, no changes noted;
-On 3/5/23 at 9:40 P.M., wound vac in place with suction working well;
-On 3/6/23 at 4:26 A.M., wound vac functioning within normal limits to sacrum;
-On 3/7/23 at 1:29 P.M., wound vac in place and operating as ordered;
-On 3/8/23 at 4:21 P.M., wound vac changed, wound tissue appears to be beefy red, moderate sanguineous (bloody) drainage noted;
-On 3/9/23 at 1:34 P.M., wound vac noted to be in place and operating as ordered this shift, treatment completed as ordered and tolerated well;
-3/10/23 at 5:31 A.M., wound vac to sacrum dressing occlusive, intact, dressing changes from hip to hip completed as ordered;
-On 3/13/23 at 8:00 P.M., wound care provided per wound nurse;
-On 3/14/23 at 1:48 A.M., wound care done daily as ordered to bottom.
Observation and interview on 3/15/23 at 12:06 P.M., showed the resident lay in bed on his/her back with no wound vacuum in use. The resident said the wound vac has been off for about a week. The wound nurse has been on vacation for two weeks. If the wound nurse was off or pulled to the floor, his/her dressing doesn't always get changed and sometimes he/she had gone days without getting his/her dressings changed.
Observation on 3/15/23 at 2:15 P.M., showed the resident lay in bed positioned on his/her side. Nurse L:
-Cleaned the left hip/ischium with wound cleanser, applied Santyl, Calcium Alginate, and applied an Abdomen (ABD) pad and a super absorbent pad and taped the dressing into place. The dressing was dated 3/15 and initialed; the nurse said the area used to be two separate wounds but now it has combined into one wound, Nurse L described the wound as a stage IV wound pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling), but he/she did not know the size, the resident said the size of the wound was 16 centimeters (cm) X 9 cm;
-Cleaned the coccyx area with wound cleanser and applied a super absorbent pad. The dressing was dated 3/15 and initialed; the nurse described the area as healed; Observation showed the coccyx was red and blanchable with a gray/white center, the area was closed. The wound was approximately the size of a silver dollar;
-Cleaned the right buttocks with wound cleanser and applied calmoseptine (barrier). No dressing was applied. Observation showed there was some red excoriation on the right buttocks, approximate size was silver dollar. The center of the redness was a dark red area, approximate size was 1 cm x 1 cm.
Review of the TAR, dated 3/15/23, showed:
-An order for: Collagenase ointment 250 unit/GM, apply to right ischial topically every day shift for wound care. The start date was 3/13/23;
-Documentation showed: On 3/15, it was documented as administrated;
-An order for: cleanse wound to right ischial with NS, apply Santyl nickel thick, apply calcium alginate/fibracol (soft, absorbent wound dressing), cover with border gauze (gauze dressing with tape) every day shift for wound, start date was 3/13/23;
-Documentation showed: On 3/15, it was documented as administered.
Review of the progress notes, dated 3/15/23 through 3/16/23, showed:
-On 3/15/23 at 2:11 A.M., treatments orders are in place for left and right hip/bottom open wound;
-On 3/15/23 at 3:15 P.M. wound vac was discontinued;
-On 3/16/23 at 4:40 A.M., dressing to left and right hip/bottom wound dry and intact.
Observation on 3/16/23 at 10:40 A.M. showed the resident lay in bed, positioned on his/her side. The dressings to the left hip/ischial and coccyx remained in place. The dressings were dated 3/15 and had the same initials as yesterday. There was no dressing on the right side of the buttocks/ischial area. The right buttocks had a scant amount of bright red blood. Nurse M, said the area on the resident's right buttocks was a stage II, an approximate size 1.5 cm X 0.8 cm. The area was blanchable and the peri-wound (area around the wound) was a darker red color and the approximate size was 3 cm X 3 cm. Nurse M described the location as between the rectum and ischium.
During an interview on 3/16/23 at 12:45 P.M., Nurse M said he/she called the physician to obtain a new order for the resident's new open area on the right buttocks. Nurse M verified the resident only had two dressings on, one on the coccyx and one on the left hip, and technically the right buttocks should have a dressing, but that was tricky because he/she did not know if this new wound was the same wound for the previous treatment order. Nurse M said the wound looked new to him/her. Nurse M checked the resident's progress notes and said he/she did not see the wound notes, so it would be hard to say if the new area should have had a treatment completed or not, but Nurse M did not see another wound on the right buttocks/ischium that the treatment should have been applied to.
2. Review of Resident #6's admission MDS, dated [DATE], showed:
-Cognitively intact;
-No rejection of care;
-Required supervision and set up for bed mobility and dressing;
-Required set up for toilet use, personal hygiene and bathing and required supervision for transfers and eating;
-Diagnoses included: heart failure, diabetes, and wound infection;
-Infection of the foot;
-Applications of nonsurgical dressing (with or without topical medications) other than feet;
-Applications of ointments/medications other than feet;
-Application of dressing to feet (with or without topical medications).
Observation and interview on 3/15/23 at 12:35 P.M., showed the resident sat on the side of the bed, with both legs hanging down. Both legs were edematous (swollen) and both legs had a dressing on from mid-calf to toes. There was white gauze sticking out of the top of the dressing. The gauze was wrapped with tan colored coban (compression wrap). There was no date was on the dressing. The resident said his/her dressings were last changed on Monday (3/13/23) and they should be changed today. Last week, the bandages were changed on Wednesday but they were not changed on Friday and on Monday his/her legs were sore.
During an interview on 3/16/23 at 11:04 A.M., the resident said the nurse came in yesterday (3/15/23) between 1:30 and 2:00 P.M. to do his/her treatment but he/she was taking a nap and told the nurse to come back after 3:00 P.M. The nurse never came back. Both legs were wrapped from the mid-calf to the toes. [NAME] gauze was sticking out the top of the dressing, and the edges of the gauze look worn. The gauze was wrapped with tan colored coban with no date on the dressing. On the left heel, there was an ABD pad hanging out of the bottom of the dressing. The resident said his/her dressings felt wet from the drainage and the coban felt tighter than when it was first put on. It was making a dent in his/her leg so he/she pulled the coban down.
Observation on 3/16/23 at 4:21 P.M., showed the dressing on both lower legs remained unchanged.
Review of the TAR, dated 3/1/23 through 3/16/23, showed:
-An order to assist resident in applying lymphedema boots to both lower extremities, then assist in showering, following treatment, every M-W-F for wound care, start date was 12/28/22;
-Friday, 3/10/23 treatment was not documented as provided;
-Wednesday, 3/15/23 the treatment was documented as administered, contrary to the residents statement;
-An order for Dakin's (antiseptic) ¼ strength solution, apply to both lower extremities topically every M-W-F for wound care. The start date was 12/28/22;
-Friday, 3/10/23 treatment was not documented as provided;
-Monday, 3/13/23 treatment was not documented as provided;
-Wednesday, 3/15/23 the treatment was documented as administered, contrary to the residents statement;
-An order for following shower, dry legs, apply zinc covered ABD pads secure with kerlix (gauze roll) and six inch coban, M-W-F for wound care. The start date was 12/28/22;
-Friday, 3/10/23 treatment was not documented as provided;
-Monday, 3/13/23 treatment was not documented as provided;
-Wednesday, 3/15/23 the treatment was documented as administered, contrary to the residents statement;
-An order for: Gentamicin sulfate (antibiotic) cream 0.1%, apply to both lower extremities topically every M-W-F for wound care. The start date was 1/4/23;
-Friday, 3/10/23 treatment was not documented as provided;
-Monday, 3/13/23 treatment was not documented as provided;
-Wednesday, 3/15/23 the treatment was documented as administered, contrary to the residents statement;
-An order for hibiclens (antimicrobial and antiseptic soap) liquid, cleanse right lower leg with hibiclens antiseptic soap while in shower, pat dry, apply zinc, unna boot (compression dressing) , ABD, kerlix and coban on M-W-F. The start date was 1/4/23;
--Friday, 3/10/23 treatment was not documented as provided;
-Monday, 3/13/23 treatment was not documented as provided;
-Wednesday, 3/15/23 the treatment was documented as administered, contrary to the residents statement.
During an interview on 3/17/23 at 2:00 P.M., Certified Medication Technician (CMT) Q said just the other day, he/she believed it was either 3/15/23 or 3/12/23, he/she clicked on a resident's TAR and he/she did not realize it. Someone showed him/her the difference between the MAR and the TAR. CMT Q said he/she asked a CNA if the resident got his/her shower and the CNA said yes, so he/she assumed the treatment was done because the resident gets their treatment done after their shower. CMT Q did not provide the treatment, and he/she did not know if there was a way to unclick or remove something after it was documented. CMT Q said he/she should have removed it or reported it but he/she was running late and had to move on to another hall.
During an interview on 3/16/23 at 11:22 A.M., Nurse R said when the wound nurse is off or is working the floor, the charge nurse on the floor is responsible for doing the wound care that day.
During an interview on 3/16/23 at 12:45 P.M., Nurse M said treatments should be documented when completed. If an error was made with documenting a treatment, he/she would have to ask another nurse what to do, but he/she believes you can strike out the documentation.
During an interview on 3/22/23 at 11:20 A.M., the DON said when the wound nurse is in the house, he/she will do the more complex wound treatments. The floor nurses are responsible for doing the treatments when the wound nurse was off or working the floor. The wound nurse has access to the wound NP notes and he/she is made aware of changes in the treatments during wound rounds. The plan on the wound NP notes should match the treatment on the TAR. If a resident had an order for a wound vac to a site, the resident would not have a treatment order for the same site such as Santyl. If a resident had a treatment order and a wound vac order to the same site, the DON expected staff to call the physician to clarify the orders and document it in the progress notes. Treatments should be administered as ordered. If an error is made in documentation, the DON expected the staff member to make a progress note about it, and report to the next shift and document it on the 24 hour report sheet. The DON did not know why a CMT would document on a TAR, as CMTs do not provide wound care. A blank on the TAR meant the staff member did not document. The DON expected staff to document treatments when administered and if the treatment was not administered, staff should enter no, then enter the correct code and make a progress note. If the code entered means see progress note, the DON expected to see a progress note. The DON expected the medical record to be accurate and for staff to follow the physician orders. Staff should follow the facility policies and procedures.
MO00215488
MO00215324
MO00215294
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a system was in place to ensure resident's orde...
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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 system was in place to ensure resident's orders and treatments were coordinated between hospice and the facility and were reflected in the facility's physician orders and care plan. Resident #1 required supplemental oxygen for comfort and shortness of breath. The facility did not ensure the resident's physician orders or a care plan included the amount of liters of oxygen to be administered, directions for when to change oxygen tubing, or the use of a humidifier bottle. The facility failed to ensure physician orders for a treatment to Resident #1's coccyx were obtained and consistent with hospice orders. The facility failed to ensure Resident #1's catheter use was included on the resident's physician orders including catheter type/size/balloon (the balloon portion of the catheter is inflated with saline solution to keep the catheter in the bladder) milliliter (ml), catheter anchor checks and change weekly, and catheter care. The facility failed to ensure Resident #1's physician orders and care plan included the use of a hand stretcher to the left hand for contracture (involuntary shortening of the muscle). The facility also failed to ensure two residents received care consistent with professional standards when facility staff failed to monitor and document one resident's urine output after their indwelling urinary catheter (a sterile tube inserted into the bladder through the urinary tract to drain urine) was removed (Resident #19) and when staff failed to obtain a physician order for a wound vacuum (wound vac, vacuum assisted closure used to conduct negative pressure wound therapy to promote healing) for one resident (Resident #18). The sample was 29. The census was 141.
1. Review of Resident #1's all-inclusive admission with baseline care plans for the facility, dated 3/3/23 at 2:33 P.M., showed:
-admission details: Reason for admission as per resident or family/caregiver-hospice.
-Most recent oxygen saturations: Oxygen saturations 96% (normal range, 95-100%) on room air on 3/3/23 at 3:38 P.M.
Review of the resident's admission point click care (PCC) checklist, used by nursing management at the facility to audit admissions, not dated, showed the following care area not checked for the resident:
-Orders:
-If on oxygen, order to change oxygen tubing and humidifier bottle weekly.
Review of the resident's physician orders showed no physician order obtained to change oxygen tubing and humidifier bottle weekly.
Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/9/23, showed the following:
-admission date of 3/3/23;
-Cognitively intact;
-Oxygen therapy, while not a resident and while a resident.
Review of the resident's comprehensive assessment for hospice admission, dated 3/4/23 at 12:00 P.M., showed:
-Primary diagnosis of cerebral infarction (stroke);
-Education provided on comfort measures including dyspnea (SOB, shortness of breath), management and skin care with family;
-Order dated 3/4/23, oxygen via oxygen concentrator 2-4 liters (L) per nasal cannula, PRN for comfort, dyspnea, and air hunger.
Review of the resident's physician orders showed no physician order obtained to change oxygen tubing and humidifier bottle weekly.
Review of the resident's facility progress notes, showed:
-3/14/23 at 2:13 A.M., respirations unlabored and 2 L oxygen per nasal cannula in place, frequently checked due to resident takes it off often.
Review of the resident's care plan, date initiated 3/4/23, and in use during the survey, showed the care plan did not include oxygen use as a focus area, including the resident's tendency to take the oxygen off.
Review of the hospice nursing visit note, dated 3/7/23 at 10:07 A.M., showed:
-Resident's SPO2 (pulse oximeter that shows the percentage of oxygen in someone's blood, oxygen saturation) 82% on room air, oxygen administered per nasal cannula at 2 L and saturations increased to 97%.
Review of the resident's facility progress notes, showed:
-3/8/23 at 2:28 A.M., respirations unlabored, 2 L oxygen per nasal cannula in place.
-3/9/23 at 2:51 A.M., respirations unlabored, oxygen per 2 L nasal cannula in place and frequently checked on because it slips from resident nostrils, humidity attached to concentrator.
-3/10/23 at 5:23 A.M., resident resting quietly, respirations unlabored, 2 L oxygen per nasal cannula in place.
-3/11/23 at 4:28 A.M., respirations unlabored, 2 L oxygen per nasal cannula in place, no coughing or SOB.
-3/12/23 at 6:30 P.M., respirations even and unlabored, no SOB noted, oxygen per nasal cannula intact;
-3/13/23 at 7:30 A.M., oxygen in place per orders.
Review of the hospice nursing visit note, dated 3/14/23 at 12:15 P.M., showed:
-Oxygen use per nasal cannula 2 L continuous;
-SPO2 92%;
Review of the resident's facility progress notes, showed:
-3/14/23 at 2:13 A.M., respirations unlabored and 2 L oxygen per nasal cannula in place, frequently checked due to resident takes it off often;
-3/15/23 at 2:30 A.M., respirations non-labored, oxygen per nasal cannula in place at 2 L.
Observation on 3/15/23 at 10:13 A.M., showed the resident lay in bed, and his/her eyes were closed with the HOB elevated to approximately 30 degrees. The oxygen concentrator was on the left side of the bed, turned on 2 L with a humidifier bottle attached. The resident had a nasal cannula on but the prongs were shifted to the right of the resident's nostrils. CNA G entered room and adjusted the resident's nasal cannula prongs into the resident's nostrils.
Observation on 3/15/23 at 12:45 P.M., showed the resident lay in bed, eyes closed with the HOB elevated to approximately 30 degrees. The oxygen concentrator was on the left side of the bed turned on 2 L with humidifier bottle attached. The resident had a nasal cannula on but the prongs were shifted to the right of the resident's nostrils.
Observation on 3/15/23 at 12:52 P.M., showed the resident lay in bed with eyes closed with the HOB elevated to approximately 30 degrees. The oxygen concentrator on the left side of the bed turned on 2 L with humidifier bottle attached. Nasal cannula prongs resting in the resident's nostrils.
Observation 3/15/23 at 1:39 P.M., showed the resident lay in bed with his/her eyes closed with the HOB elevated to approximately 30 degrees. The oxygen concentrator on the left side of the bed turned on 2 L with humidifier bottle attached.
Review of the resident's hospice Discharge summary, dated [DATE], showed:
-discharged for cause;
-Date of discharge 3/15/23;
-Significant health history: 20 year history with stroke and left sided hemiparesis (paralysis affecting one side of the body);
-Current Care plans: dyspnea (difficult or labored breathing)
-Current physician orders: oxygen 2-4 L as needed for comfort.
Review of the resident's facility progress notes, showed:
-3/16/23 at 5:18 A.M., respirations unlabored, 2 L oxygen per nasal cannula in place and frequently checked because resident does rub/take it off rather often;
-3/16/23 at 8:56 A.M., Spoke with family over the phone and informed him/her that the resident is resting comfortably with oxygen on and in place with HOB elevated, as this nurse was just in the room to see resident. Attempted to check resident SP02 and resident said, No, cover me up. Although resident was already covered with 2 blankets, raised blanket to cover shoulders and told resident we can check SP02 another time today;
-3/16/23 at 9:58 A.M., hospice came to take back concentrator. New oxygen concentrator provided. HOB elevated with oxygen on and in place.
Observation 3/16/23 at 9:50 A.M., showed the resident lay in bed with his/her eyes closed with the HOB elevated to approximately 30 degrees. The hospice oxygen concentrator was no longer at resident's bedside. The resident had a facility oxygen concentrator on the left side of the bed turned on 2 L with no humidifier bottle attached. Nasal cannula prongs resting in the resident nostrils.
Review of the resident's electronic order summary report for the facility, dated 3/16/23 at 10:44 A.M., showed:
-No active orders for oxygen, although hospice ordered it on 3/4/23.
Review of the resident's facility progress notes, showed:
-3/16/23 at 12:29 P.M., Resident resting in broda chair (reclining wheeled chair), snoring, respirations even and unlabored. Nurse asked resident if he/she wanted oxygen due to previously having it from hospice for comfort measures. Resident verbalized, Yes, please help me, I can't breathe. Nurse applied oxygen on 2 L, notified physician via telephone that hospice is no longer caring for resident and explained that oxygen was applied because resident voiced she could not breathe. Physician gave order for 2 L of oxygen as needed via nasal cannula for respiratory distress, comfort measures, and shortness of breath. Notified charge nurse of new order;
-3/16/23 at 12:30 P.M., in to assess resident per supervisors, resident complains of not being able to breath. Upon assessment resident respirations 14, SP02 at 99% on 2 L oxygen per nasal cannula.
Observation 3/16/23 at 11:10 A.M., showed the resident lay in bed with his/her eyes closed with the HOB elevated to approximately 30 degrees. The oxygen concentrator sat on the left side of the bed, set at 2 L with no humidifier bottle attached. Nasal cannula prongs rested in the resident's nostrils.
Observation 3/16/23 at 12:23 P.M., showed the resident sat in a reclining chair and leaned to the right side of the chair with eyes closed. The reclining chair was between both beds in the room. The oxygen concentrator was at the foot of the reclining chair on at 2 L. A nasal cannula was on resident's nose, with the prongs resting in the residents nostrils. Nurse M entered the resident's room and checked the resident's SPO2. It was at 99% on 2 L and respirations were 14.
Review of the resident's electronic order listing for the facility, dated 3/22/23 at 12:24 P.M., showed:
-Active order started on 3/16/23 at 12:27 P.M., oxygen at 2 L per minute per nasal cannula as needed for shortness of breath, respiratory distress if saturations below 92% or resident feels in distress.
During an interview on 3/21/23 at 1:54 P.M., Hospice Nurse (HN) N said he/she visited the resident on 3/7/23 and noticed while doing the resident's vitals, the resident's SPO2 was decreased at 82% on room air. HN N said the resident was asleep during the assessment. HN N said oxygen was placed on the resident at 2 L and the SPO2 raised to 97%. If hospice has any new orders for the resident, a verbal order can be given to the nurse who is taking care of the resident at that time. HN N said the facility nurse was made aware of oxygen being placed on the resident during the visit. He/she said residents placed on hospice normally have standing orders for PRN oxygen that are placed by the hospice admission nurse. HN N would expect the hospice orders and the facility orders to be the same. HN N said he/she does not check the facility orders against the hospice orders on every visit. If he/she notices something not being done, he/she will ask to have the resident's orders printed and will check the hospice orders against the facility orders.
During an interview on 3/22/23 at 7:05 A.M., Nurse H said hospice orders and facility orders should match. If a resident is on oxygen, they should have orders that include the amount of oxygen liters per minute to be administered, and for the oxygen tubing to be changed weekly.
During an interview on 3/22/23 at 7:34 A.M., Nurse I said a resident needs a physician's order to receive oxygen. The order should include the amount of liters of oxygen to be administered, and to change the oxygen tubing weekly. Nurse I said hospice nurses are responsible for checking the hospice orders against the facility orders on admission and once hospice is in place, the facility calls them for instructions. He/She expected hospice orders and facility orders to be the same. Hospice gives the facility orders and the nurse is responsible for entering the orders. If the facility nurse had questions, they can call and clarify the order with hospice and the physician.
During an interview on 3/22/23 at 8:40 A.M., the DON said she did the admission assessment on the resident. When hospice admits a resident, the charge nurse is responsible for entering any new orders hospice has. Hospice orders supercede orders that the facility has. If hospice has new orders, they should be written and placed into the hospice binder and the hospice nurse should communicate there are new orders to the charge nurse. Hospice orders and the facility orders should match. Nursing management does an admission audit on new admissions to the facility to make sure everything is in place. The DON was unsure if audits were completed on hospice admissions. If residents are on oxygen, there should be a physician's order that includes the oxygen rate, to check SPO2, and to change tubing once a week.
During an interview on 3/22/23 at 12:42 P.M., the Assistant Director of Nursing (ADON) said audits on new admissions to the facility are completed the next day or within 48-72 hours, depending on what's going on in the building. Audits are not completed on admissions to hospice. Hospice gives the charge nurse new orders verbally, some write it down, and verbally over the phone. The charge nurse is responsible for entering orders into PCC. The ADON expected the facility orders and the hospice orders to match. The ADON expected a resident on oxygen to have orders. The orders should include the rate, the reason or diagnosis, monitoring SPO2, the type of device the resident uses for the oxygen (such as a mask or nasal cannula), and the tubing to be changed weekly.
During an interview on 3/22/23 at 1:48 P.M., the Administrator said she expected the facility to have orders in place for a resident that has oxygen. The Administrator expected the facility orders and hospice orders to match.
During an interview on 3/23/23 at 9:58 A.M., HN O said he/she completed a visit on 3/5/23 to follow up on the hospice admission from 3/4/23. HN O said he/she did not compare the facility orders to the orders hospice had on the visit. If hospice has orders, they are written and verbally are given to the facility nurse to enter. HN O expected the facility orders and hospice orders to match. HN O said he/she is not sure if a list of hospice medications and treatments are kept in the hospice binder.
During an interview on 3/23/23 at 11:54 A.M., HN P said he/she completed a visit on 3/14/23 with the resident. HN P said during the visit, the family had questions about medications and he/she compared the facility medication list to the hospice list and they matched. HN P said there should never be a discrepancy between the hospice and facility orders. If an order is given to the facility nurse, it is usually verbally if the facility's system is computerized. If the facility uses paper, then hospice will write the new order on the resident's paper chart. HN P said if he/she gives an order, he/she writes it down on a piece of paper and has the facility nurse sign it and takes a picture of it to keep in the hospice records, and he/she also talks to the facility nurse about the order. HN P said a current list of hospice orders, medications and treatments should be in the hospice binder. HN P said there was a possibility the resident didn't have a binder because the resident's services started on 3/4/23 and ended on 3/15/23.
During an interview on 3/23/23 at 2:35 P.M., the Administrator said she spoke with the hospice company and they said the resident did not have a hospice binder because the resident was not on services long enough.
2. Review of Resident #1's all-inclusive admission with baseline care plans for the facility, dated 3/3/23 at 2:33 P.M., showed:
-admission details: Reason for admission as per resident or family/caregiver-hospice.
-Skin observation: head to toe skin evaluation
-Skin integrity, skin intact;
-Groin, reddened-no open areas;
-left arm-bruising and discoloration noted;
-right arm-bruising and discoloration noted;
-Additional skin comments: has podus boots (helps prevent and manage heel pressure) on, legs and heels intact;
-At risk for alteration in skin integrity:
-Focus: the resident has potential for impairment to skin integrity;
-Goal: the resident will maintain or develop clean and intact skin by the review date;
-Intervention: monitor and report to physician and signs or symptoms of skin breakdown;
-Intervention: provide pressure relieving devices if indicated;
-Intervention: provide preventive skin care;
Braden scale (assessment used to determine pressure ulcer risk):
-Mobility: Completely immobile. Does not make even slight changes in body or extremity position without assistance;
-Friction & Shear: Problem: Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures or agitation leads to almost constant friction.
Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/9/23, showed the following:
-Required extensive assistance with bed mobility, transfer and dressing;
-Total dependence toilet use;
-At risk for pressure ulcer (injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or friction);
-Pressure reducing device for bed;
-No unhealed pressure ulcers;
-No skin problems listed.
Review of the resident's comprehensive assessment for hospice admission, dated 3/4/23 at 12:00 P.M., showed:
-New skin impairments during past 60/90/180 days:
-Location: coccyx (tail bone);
-Wound type: skin tear;
-Wound 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);
-Length: 0.5 centimeters (cm);
-Width: 0.2 cm;
-Drainage amount: none;
-Wound bed appearance: pink, red, granulation (healing new growth);
-Surrounding tissue appearance: pink or normal for ethnic group;
-Treatment orders: 3/4/23 - treatment orders - coccyx skin tear, cleanse with wound cleanser, leave open to air, perform daily;
-Care provided: yes;
-Response to care: effective;
-Order dated 3/4/23, coccyx skin tear: cleanse with wound cleanser, leave open to air, perform daily.
Review of the resident's care plan, date initiated 3/4/23, and in use during the survey, showed:
Focus: The resident has potential for impairment to skin integrity;
-Goal: The resident will maintain or develop clean and intact skin by the review date;
-Interventions/tasks included:
-Monitor for and report to physician any signs or symptoms of skin breakdown;
-Provide pressure relieving devices if indicated;
-Provide preventive skin care;
*The care plan did not include information related to the coccyx skin tear, including to cleanse with wound cleanser and leave open to air.
Review of the hospice nursing visit note, dated 3/5/23 at 1:20 P.M., showed:
-No skin issues.
Review of the resident's facility progress notes, showed:
-3/6/23 at 4:55 A.M., respirations even and unlabored, moister barrier cream (a product applied directly to the skin surface to help maintain the skin's physical barrier, providing protection from irritants and preventing the skin from drying out) applied to bottom.
Review of the resident's facility progress notes, showed:
-3/8/23 at 2:28 A.M., Moisture barrier cream applied to buttocks.
-3/10/23 at 5:23 A.M., Repositioned for skin care, comfort and heels floated (heel positioned to remove all contact between the heel and the bed to prevent wounds on the heel).
-3/11/23 at 4:28 A.M., Heels floated for skin care and comfort.
Review of the resident's facility progress notes, showed:
-3/14/23 at 10:49 A.M., upon my assessment with hospice nurse, resident is noted to have excoriation (a scratch or abrasion (a wound caused by rubbing or scraping the skin ) of the skin) to buttocks, applied border gauze (an absorptive dressing consisting of three layers with a non-woven adhesive tape that holds the dressing in place) for protection, new order calmoseptine (a barrier on the skin to protect it from irritants/moisture) to buttocks with every incontinent episode and PRN, will continue to monitor.
Review of the hospice nursing visit note, dated 3/14/23 at 12:15 P.M., showed:
-Skin:
-Other: shearing (occurs when one layer of tissue slides horizontally over another, deforming fat and muscle tissue, and disrupting blood flow) like area to buttock, skilled nursing home staff applied collagen (aids in wound healing, stimulates new blood vessel formation) dressing;
-Offload pressure by repositioning to aid in comfort of back pain.
Review of the resident's facility progress notes, showed:
-3/15/23 at 2:30 A.M., head of bed (HOB) elevated approximately 30 degrees, resident gently repositioned for skin care and comfort and heels floated.
Observation on 3/15/23 at 10:13 A.M., showed the resident lay in bed, and his/her eyes were closed with the HOB elevated to approximately 30 degrees.
During an interview on 3/15/23 at 12:33 P.M., Nurse L said the resident has a treatment. It is barrier cream and a border gauze dressing. The family requested the border gauze dressing because the family did not believe the barrier cream was working.
Observation 3/15/23 at 1:39 P.M., showed the resident lay in bed with his/her eyes closed with the HOB elevated to approximately 30 degrees. Nurse L entered to perform wound treatment and CNA F entered to assist. Nurse L removed old dressing dated 3/14/23 with initials on the dressing. Nurse L cleaned the area with wound cleanser and described the area as a formed callused area that is surrounding an area approximately 0.4 cm to 0.5 cm that is round with a darker red area in the middle that was scabbed and closed. Nurse L cleaned area with wound cleanser then applied protective ointment and 4X4 border gauze dressing dated and initialed it.
Review of the resident's hospice Discharge summary, dated [DATE], showed:
-Date of discharge 3/15/23;
-Significant health history: 20 year history with stroke and left sided hemiparesis (paralysis affecting one side of the body);
-Current Care plans: skin breakdown;
-Current physician orders: coccyx treatment cleanse with wound cleanser and leave open to air,
Review of the resident's facility progress notes, showed:
-3/16/23 at 5:18 A.M resident gently repositioned for skin care and comfort and heels floated;
-3/16/23 at 9:58 A.M., resident repositioned, hospice came to take back low air loss mattress. New mattress provided and HOB elevated.
Review of the resident's electronic order summary report for the facility, dated 3/16/23 at 10:44 A.M., showed:
-No active order for treatment to coccyx skin tear.
Review of the resident's facility progress notes, showed:
-3/16/23 at 12:29 P.M., Resident resting in broda chair (reclining wheeled chair), snoring, respirations even and unlabored.
-3/16/23 at 3:14 P.M., This writer went to answer call light and family in room stating the resident needs to lay down now he/she has been left in this chair and his/her call light is on the wrong side of his/her body and he/she is not comfortable. Resident transferred to bed without difficulty, bilateral heels floating, HOB elevated;
-3/16/23 at 5:22 P.M., dry dressing removed from sheared area on buttock, applied protective ointment and repositioned;.
-3/17/23 at 10:27 A.M., at 8:30 A.M., skin assessment completed by Director of Nursing (DON) assisted by Certified Nursing Assistant (CNA). Resident was wearing a brief, superficial area 2 cm x 1.5 cm noted to left buttock and redness noted to inner buttocks. There was no dressing on this area. Area is from incontinence and is non-pressure. Barrier cream applied to area.
During an interview on 3/16/23 at 10:09 A.M., Nurse M said if a treatment is not listed on the eMAR, it may be listed on the 24 hour report sheet or may be verbally informed during shift report. Nurse M said he/she has only worked with the resident one other time and cannot recall if the resident has a treatment or a wound. Nurse M said the resident may have some shearing. Nurse M said a scabbed area would not require a treatment and would not require the physician to be notified. Nurse M said if a resident has a scabbed area, the preventative care would be protective ointment. A 4X4 border gauze dressing could be added for extra protection. Nurse M said he/she does not believe a physician's order is needed for a 4X4 border gauze dressing to be placed for extra protection- that would be nursing judgement. Nurse M said if a protective border gauze dressing was applied to a resident, it would normally be documented in a nurse's note, put on the 24 hour report sheet, and verbally inform the next nurse during shift report.
Review of facility's 24 hour Report Sheet, dated 3/7/23 through 3/17/23, showed no treatments or wounds listed for the resident.
Review of the facility's electronic order listing for Resident #1, dated 3/22/23 at 12:24 P.M., showed:
-No active order for coccyx skin tear.
During an interview on 3/20/23 at 1:13 P.M., the Wound Nurse said if a treatment is not listed on the eTAR, it could be listed on the 24 hour report sheet. The Wound Nurse said preventative care treatments should have orders and be listed on the eTAR and a progress note should be entered about the preventative treatment. The Wound Nurse said a physician's order is needed to place a 4X4 border gauze dressing. The Wound Nurse said if there was a preventative treatment that was on a resident and there was no ordered treatment and no documentation that a preventative treatment was placed on the resident, it could cause further skin breakdown because nobody would know that it was on the resident and nobody would know to change the dressing. The Wound Nurse said the last time she worked with the resident was on 3/14/23 and the resident's coccyx was excoriated (a place where your skin is scraped or abraded (a superficial rub or wearing off of the skin)) but the skin was intact. The hospice nurse was at the facility on 3/14/23 and it was decided to cover the area with border gauze and place protective ointment after every incontinent episode and PRN. The Wound Nurse forgot to put the order in PCC. The Wound Nurse was not aware of an order to cleanse with wound cleanser and leave open to air daily. When hospice gives new orders, they normally write them down and give them verbally to the nurse working the floor that day. The charge nurse is responsible for entering the new orders into PCC. The Wound Nurse is responsible for completing the treatment unless unavailable and then the floor nurse is responsible for completing the treatment. The hospice nurse may also complete the treatment if they come before the treatment had been completed for the day hospice is visiting. When hospice comes to see residents, they normally ask for a list of the resident's current orders and will come back and inform the nurse if the physician wants to discontinue or add any orders for the resident. Hospice nurses communicate any new orders or orders that need to be discontinued to the charge nurse on the floor.
During an interview on 3/20/23 at 2:15 P.M., Nurse L said the treatment that he/she performed on the resident on 3/15/23 was never an ordered treatment. The resident had an order for protective barrier cream PRN, which is standard to help prevent skin breakdown. The nurse said he/she used the border gauze to help pad the skin from the point of pressure. The nurse said the resident had the scabbed area since admission. Nurse L said he/she would not contact the physician for a scabbed area. He/She would only contact the physician if an area was open with any type of drainage. Nurse L said an order is not needed for the 4X4 dressing to be placed because there was nothing there but a scab. Nurse L thought he/she documented the dressing under progress notes. Nurse L said the next shift would know about the dressing through verbal shift report. Nurse L did not believe the border gauze would cause any skin breakdown, that it provides protection.
During an interview on 3/21/23 at 1:54 P.M., Hospice Nurse (HN) N said he/she visited the resident on 3/7/23. HN N said he/she did look at the resident's skin and there was an unopened scab on the resident's coccyx, the area was dry and there were no open areas. HN N said the scabbed area did not look like pressure and all surrounding tissue looked good. HN N said the resident's family was upset that it was not covered. HN N called the family after the visit and educated the family that the area was to be cleaned and left open to air and the family voiced understanding and did not voice any other concerns. HN N said the facility nurse is responsible for providing any scheduled treatments on the days the hospice is not there to see the resident. If hospice has any new orders for the resident, a verbal order can be given to the nurse who is taking care of the resident at that time. HN N would expect the hospice orders and the facility orders to be the same. HN N said he/she does not check the facility orders against the hospice orders on every visit. If he/she notices something not being done, he/she will ask to have the resident's orders printed and will check the hospice orders against the facility orders.
During an interview on 3/22/23 at 7:05 A.M., Nurse H said hospice orders and facility orders should match.
During an interview on 3/22/23 at 7:34 A.M., Nurse I said hospice nurses are responsible for checking the hospice orders against the facility orders on admission and once hospice is in place, the facility calls them for instructions. He/She expected hospice orders and facility orders to be the same, including any treatment orders. Hospice gives the facility orders and the nurse is responsible for entering the orders. If the facility nurse had questions, they can call and clarify the order with hospice and the physician. If a treatment is not listed on the eTAR, staff would clarify the treatment with hospice or the physician and enter the treatment on the eTAR. Treatments should be documented in the eTAR. When clarifying an order, it should be documented in the progress notes. If at night and unable to get clarification, h[TRUNCATED]
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 document when one resident was lowered to the floor/fell and failed...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document when one resident was lowered to the floor/fell and failed to obtain the x-ray timely for the resident (Resident #5). Staff also failed to complete neuro checks (neurological assessment) for one resident who fell and hit his/her head (Resident #29). The sample was 29. The census was 141.
Review of the facility's Fall Prevention Program, revised 3/30/22, showed:
-Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls;
-A fall is an event in which an individual unintentionally comes to rest on the ground, floor, or other level, but not as a result of an overwhelming external force. The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere;
-A near miss which is also considered a fall, is when a resident would have fallen if someone else had not caught the resident from doing so;
-Procedure: When any resident experiences a fall, the facility will:
-Assess the resident;
-Complete a post-fall assessment;
-Complete an incident report;
-Notify medical provider and family;
-Review the resident's care plan and update as indicated;
-Document all assessments and actions;
-Obtain witness statements in the case of injury.
1. Review of the Resident #5's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/6/23, showed:
-Moderately impaired cognition;
-Required extensive assistance of staff for bed mobility, transfers, locomotion, dressing and personal hygiene;
-Required total assistance of staff for toilet use;
-Mobility devices: wheelchair;
-Always incontinent of bladder and frequently incontinent of bowel;
-Diagnoses included: diabetes and other neurological conditions.
Review of the care plan in use at the time of survey, revised on 11/8/22, showed:
-Focus: The resident is at risk for falls;
-Goal: Will be free of minor injury through next review date and the resident will not sustain major injury through next review date;
-Interventions: Anticipate and meet the resident's needs; be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance; follow facility fall protocol;
-Focus: the resident has limited physical mobility;
-Goals: Will demonstrate the appropriate use of adaptive device(s) to increase mobility through review date; will maintain current level of mobility through review date; will increase level of mobility by through next review date;
-Interventions: Ambulation: the resident uses walker for walking; locomotion: the resident requires maximum by two staff for locomotion using walker;
Review of daily skilled therapy note, dated 2/21/23, showed: the resident participated in wheelchair-commode transfer requiring contact guard assist/ minimum assistance for balance support. The resident completed toileting and toilet hygiene requiring supervision and stand by assistance. The resident performed multiple sit-stand transfers requiring minimum assistance for support. (The resident's care plan was not updated to include the change in assistance needed for ambulation.)
During an interview on 3/15/23 at 11:43 A.M., the resident said he/she had not gotten out of bed for 11 days because of foot pain and swelling. On 2/25/23 between 1:00 P.M. and 2:00 P.M., he/she had to go to the bathroom real bad and there wasn't a lift (mechanical lift, a mechanical device used to transfer someone who is unable to stand on their own or whose weight or other circumstance makes it unsafe to move or lift them manually, from one place to another) in sight. So, he/she thought he/she could transfer onto the bedside commode (BSC). Certified Nurse Aide (CNA) F, assisted the resident onto the BSC. When it was time to get off the BSC, the resident tried to get up three or four times but his/her knees buckled and he/she fell to the floor. The resident said, My foot got caught and I hurt my leg. Three CNA's and a nurse rolled the resident from his/her belly onto his/back and helped him/her sit up. Then they picked the resident up and put him/her back into the wheelchair. The nurse did not look at the resident's foot and the nurse did not check the resident's blood pressure. The Nurse Practitioner (NP) came to the facility on 2/27/23 and she did not know anything about the fall until the resident's representative notified her. The NP ordered an x-ray and it was never done.
Review of progress notes, written by the NP, dated 2/25/23 through 3/15/23 showed:
-On 2/25/23-No fall documented;
-Late entry on 2/27/27 at 5:30 A.M., He/She states on Saturday he/she hurt the top of his/her foot; Assessment/Plan: Recent fall on Saturday with left foot pain. Will obtain left foot x-ray and continue pain control;
-On 3/1/23 at 5:29 A.M., He/She still has pain in left foot. Patient's pain is controlled. Assessment/Plan: Recent fall on Saturday with left foot pain. Will obtain left foot x-ray and continue pain control. We are still waiting on the left foot x-ray to be completed. I discussed this with the nurse;
-On 3/6/23 at 5:46 A.M., He/She is still having a lot of pain in his/her left foot. We are waiting for x-rays to be done. I ordered these a couple of weeks ago, so I re-ordered them today. Assessment/Plan: Recent fall on Saturday with left foot pain. Will obtain left foot x-ray and continue pain control. We are still waiting on the left foot x-ray to be completed. I discussed this with the nurse;
-On 3/13/23 at 5:20 A.M., He/She denies any issues at this time; Plan/Assessment: We are still waiting on the left foot x-ray to be completed. I discussed this with the nurse.
Review of the physician orders, dated 2/27/23 through 3/15/23, showed:
-An order for left foot x-ray, two views from fall on Saturday, one time for pain. Start date 2/27/23 and end date 2/28/23;
-An order for left foot x-ray two views, one time for pain. Start date 3/3/23, end date 3/4/23;
-An order for left foot x-ray two views, one time for pain. Start date 3/6/23, end date 3/7/23.
Review of the radiology results tab, showed no x-ray results for the left foot.
During an interview on 3/16/23 and 3/23/23 at 3:50 P.M., CNA F said, the resident was alert and oriented times four (person, place, time and situation). About a month ago, the resident was transitioning off the lift, the resident had been using the stand up lift for transfers and the resident had been working with therapy. CNA F said, he/she was doing what the resident wanted. The resident told CNA F he/she could stand and transfer now, and someone had put a commode in the room. The resident had to go to the bathroom urgently. CNA F helped the resident stand up and pivot to the BSC without any issues. When it was time for the resident to get off the BSC, the resident stood up but he/she could not turn. The resident's legs gave out, and CNA F lowered the resident to the floor. Once the resident's legs stretched out on the floor, the resident laid back on the floor. CNA F went out of the room to get the nurse. When the nurse and CNA F entered the room, the resident was lying on the floor face down. CNA F did not recall how the resident got in that position. After the nurse assessed the resident, they used four staff members and assisted the resident up and into his/her wheelchair. The resident did not complain of pain or discomfort. After the resident was in his/her wheelchair, everyone left the room.
Observation on 3/16/23 at 12:45 P.M., showed the resident was lying in bed on his/her back. Observation of the left foot and ankle showed the skin over the left lateral ankle was slightly discolored at the distal end of an old incision. There was a yellowish discoloration at the base of the left great toe.
During an interview on 3/16/23 at 12:45 P.M., Nurse M said if a resident had a witnessed fall, he/she would click on progress notes, then click on incident note and that is where he/she would document a fall. If a resident was lowered to the floor it would not be considered a fall. Nurse M checked the resident's chart and said he/she did not see the type of note he/she would write if a resident had a fall. Nurse M said the NP ordered an x-ray of the left ankle on 2/27/23 and he/she did not see any results for the x-ray. He/She did not know if the x-ray had been completed.
During an interview on 3/16/23 at 3:55 P.M., Nurse S said if a resident had a witnessed fall, he/she would assess the resident, call the physician and write a report and document it in the progress notes. If a resident was lowered to the floor, he/she did not know if it would be considered a fall or not. He/She would have to check with a supervisor.
During an interview on 3/16/23 at 4:35 P.M., the resident said an x-ray of his/her left leg had just been taken.
During an interview on 3/20/23 at 12:16 P.M., CNA G said a couple of weeks ago, around noon, CNA F asked if he/she could help get the resident up. When CNA G went into the room, the resident was on the floor on his/her belly. The resident complained of pain in his/her right side and left foot. CNA F said the resident slipped off the BSC, but the resident said he/she fell. It took about four to five staff to roll the resident over and get the resident up and into his/her wheelchair. Once the resident was in his/her wheelchair, CNA G left the room. CNA G did not believe any vital signs or assessment were completed.
During an interview on 3/20/23 at 2:55 P.M. Nurse T said the resident did not fall last month; he/she was lowered to the floor. The incident occurred the last part of February. It happened before lunch. Nurse T did not recall which CNA it was, but thought the CNA said the resident was lowered to the floor. Nurse T was walking by the resident's room and was asked to help get the resident up. When Nurse T entered the room, the resident was sitting on his/her buttocks. They used a gait belt and assisted the resident up to his/her feet then onto the bed. The resident was not hurt. The charge nurse was notified and went into the room. The charge nurse would be the one responsible for assessing the resident, checking the vital signs, notifying the physician and family and documenting the incident. Nurse T did not report the incident to anyone.
During an interview on 3/20/23 at 4:20 P.M., the NP said a couple of weeks ago, the Saturday before her note was written, the resident slid down and fell on his/her foot. The resident was complaining of pain when he/she attempted to bear weight on his/her foot and there was some swelling in the foot. An x-ray was ordered but it was never completed. The facility had to call the x-ray company and order the x-ray. The nurse said he/she was going to order the x-ray but it was never done. The NP would expect for staff to follow her orders and obtain the x-ray as ordered.
During an interview on 3/21/23 at 12:41 P.M., the Assistant Director of Nursing (ADON) said if a resident was lowered to the floor, that would be considered a fall. If a resident had a witnessed fall, the staff member should report it to the nurse, the nurse should assess the resident and vital signs should be done every shift for 72 hours. The physician, responsible party and the chain of command should be notified. Falls are documented in the electronic medical record under Risk Management and it should pull over into a progress note. The ADON said she was not aware the resident fell until the surveyor started asking questions about it and asked for the NP's phone number. The Primary Care Physician (PCP) was not aware of the incident. The ADON called the NP and was told she ordered an x-ray for the resident because the resident told the NP he/she fell and had some swelling in his/her foot; the x-ray had not been completed. The ADON said she reported this to the Administrator and the Director of Nursing (DON). The ADON would expect the nurse on duty at the time of an incident to complete documentation and notify the physician and responsible party. The ADON would also expect x-rays to be completed timely as ordered.
During an interview on 3/22/23 at 3:06 P.M., The DON said she was not aware the resident was lowered to the floor/fall prior to today. If the resident was lowered to the floor and was found face down by the nurse, she would expect for the nurse to assess the resident and to do neuro checks. The DON would expect for staff to notify her, the physician and the responsible party when a resident is lowered to the floor. She would expect for the nurse to document the incident and complete post fall x-rays immediately.
2. Review of the Neuro Check schedule listed on the top of the facility's Neuro Check Assessment Form, showed:
-Neuro Checks:
-Every 15 minutes X one hour;
-Every 30 minutes X one hour;
-Every one hour X four hours;
-Every four hours X 24 hours;
-Every shift until 72 hours.
Review of Resident #29's admission MDS, dated [DATE], showed:
-Moderately impaired cognition;
-Required extensive assistance of staff for bed mobility, dressing, eating, personal hygiene and bathing;
-Required total assistance of staff for transfers and toilet use;
-Diagnoses included heart failure, cancer, diabetes and high blood pressure.
Review of the care plan in use at the time of the survey, dated 3/9/23, showed the resident had no history of falls or was a fall risk.
Review of the progress notes dated 3/24/23 through 3/27/23, showed:
-On 3/24/23 at 10:46 P.M., patient found on the floor, physical assessment performed. Abrasion to top of right eyebrow noted. Skin tear to right knee and abrasion to left shin noted. Area cleaned with normal saline (NS) and covered. Vital Signs (VS): Blood Pressure (B/P, normal is 90/60 through 120/80) 128/73, Respirations (normal is 12 through 18) 18, Temperature (normal is 97.8 through 99.1) 97.2. Family and physician notified. Neuro checks performed. Alert and oriented X 4; (No further progress notes showed neuro checks completed every 15 minutes for one hour or every 30 minutes for one hour.)
-On 3/25/23 at 12:30 A.M., continue observation for fall. Resting in bed at this time, denies pain or discomfort. Bandage to right forehead dry and intact. Neuro checks within normal limits. No distress noted. B/P 122/82. Pulse (normal is 60 through 100) 60, respiration 18. Oxygen saturation (O2 sat, normal is 95 to 100%) 96% on room air; (No further progress notes showed neuro checks completed every 30 minutes for one hour or every one hour for four hours, or every four hours for 24 hours)
-On 3/26/23 at 5:17 A.M., resident remains on incident follow up (IFU) for fall with no further falls or injuries noted. No complaints or signs and symptoms of pain or acute distress noted. Will continue to monitor;
-Staff did not document vital signs;
-On 3/27/23 at 6:06 A.M., resident remains on IFU for a fall with no further falls or injuries noted. Neuro checks within normal limits for this resident. No complaints or signs and symptoms of pain or acute distress noted. Will continue to monitor;
-Staff did not document vital signs;
-On 3/28/23 at 5:31 A.M., resident remains on IFU for a fall with no further falls or injuries noted. Neuro checks within normal limits for this resident. No complaints or signs and symptoms of pain or acute distress noted. Will continue to monitor;
-Staff did not document vital signs.
Review of the Temperature Summary, dated 3/24/23 through 3/27/23, showed:
-On 3/24/23 at 6:20 A.M., the temperature was 97.8;
-On 3/25/23 no temperature documented;
-On 3/26/23 at 5:14 P.M., the temperature was 98.1;
-On 3/27/23 no temperature documented.
Review of the Pulse Summary, dated 3/24/23 through 3/27/23, showed:
-On 3/24/23 no pulse documented;
-On 3/25/23 at 12:21 P.M., pulse was 71;
-On 3/26/23 at 12:07 P.M., pulse was 72,
-On 3/27/23 at 1:22 P.M., pulse was 78.
Review of the Respiration Summary, dated 3/24/23 through 3/27/23, showed:
-On 3/24/23 at 6:20 A.M., respiration was 18,
-On 3/25/23 no respirations documented;
-On 3/26/23 at 5:14 P.M., respiration was 18,
-On 3/27/23 no respirations documented.
Review of the B/P Summary, dated 3/24/23 through 3/27/23, showed:
-On 3/24/23: no B/P documented;
-On 3/25/23 at 12:21 P.M., B/P was 123/71;
-On 3/26/23 at 12:07 P.M., B/P was 126/76;
-On 3/27/23 at 1:22 P.M., B/P was 134/78.
During interviews on 3/27/23 at 12:00 P.M. and 3/28/23 at 11:00 A.M., Nurse U said the floor was so busy he/she assessed the resident, made the notifications and documented the falls in the progress notes but he/she did not have time to complete the fall documentation.
During an interview on 3/21/23 at 12:41 P.M., the ADON said, if a resident had a witnessed fall, the staff member should report it to the nurse, the nurse should assess the resident and vital signs should be done every shift for 72 hours. The physician, responsible party and the chain of command should be notified. Falls are documented in the electronic medical record under Risk Management and it should pull over into a progress note. If a resident had an unwitnessed fall or hit their head, the nurse should do the same thing with the addition of neuro checks. Neuro checks are completed per schedule and are documented on paper.
During an interview on 3/22/23 at 3:06 P.M., The DON said, she would expect for staff to follow physician orders and the facility policy and procedures.
A copy of the paper neuro checks was requested. As of 5:00 P.M. on 3/30/23 no neuro checks had been received.
MO00215320
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 F0760
(Tag F0760)
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 two residents (Residents #27 and #18) were free from signifi...
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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 two residents (Residents #27 and #18) were free from significant medication errors when facility staff failed to initiate their medications timely after being admitted to the facility. Resident #27 did not receive any medications during the first two days after admission, and Resident #18 did not receive his/her intravenous (IV) antibiotic during the first two days of admission to the facility. The sample was 29. The census was 141.
Review of the facility's Medication Administration Policy, reviewed and revised date of 4/7/22, showed:
-Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the medical provider and in accordance with professional standards of practice, in a manner to prevent contamination or infection;
-Report and document any adverse side effects or refusals. Notify medical provider after three doses of a medication refusal or per Medical Provider parameters;
-The policy did not address what staff should do if medication was unavailable.
1. Review of Resident #27's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/31/23, showed:
-Cognitively intact;
-No rejection of care;
-Required extensive assistance of staff for bed mobility and transfers;
-Required total assistance of staff for locomotion, dressing, toilet use and personal hygiene;
-Diagnoses included: atrial fibrillation (a-fib, irregular heart rhythm), high blood pressure and diabetes.
Review of the electronic medical record, showed the resident was admitted to the facility on [DATE].
Review of the Discharge Summary and Inpatient Acute Therapy orders at transition of care, dated: date of discharge: [DATE], showed:
-Discharge orders: Medication list, Continue taking these medications:
-Apixaban (blood thinner) 5 milligrams (mg), take by mouth two times daily;
-Clopidogrel (used to helps prevent blood clots) 75 mg, take 75 mg by mouth;
-Diltiazem (used to treat a-fib) 180 mg, take 180 mg by mouth daily;
-Fluticasone propion salmeterol 230-21 micrograms (mcg)-21 mcg/actuation HFA aerosol inhaler, (used to treat asthma and chronic obstructive lung disease), take two puffs by inhalation every 12 hours;
-Metformin (used to treat diabetes) 1000 mg, take 1000 mg by mouth two times a day with meals;
-Metoprolol tartrate (used to treat high blood pressure) 50 mg, take 50 mg by mouth two times daily.
Review of the Medication Administration Record (MAR), dated 3/1/23 through 3/31/23, showed:
-An order, dated 3/26/23, for Clopidogrel bisulfate tablet 75 mg, give one tablet by mouth one time a day;
-Medication started on 3/26/23;
-An order, dated 3/26/23, for Diltiazem HCL extended release capsule 24 hour, 180 mg, give one capsule by mouth one time;
-Medication started on 3/26/23;
-An order, dated 3/26/23, for Apixaban oral tablet 5 mg, give 5 mg by mouth two times a day;
-Medication started on 3/26/23;
-An order, dated 3/26/23, for Fluticasone-Salmeterol Aerosol 45-21 mcg/actuation, two inhalations, inhale orally two times a day related to Covid-19;
-Medication started on 3/26/23;
-An order, dated 3/26/23, for Metformin HCL oral tablet 1000 mg, give 1000 mg by mouth two times a day;
-Medication started on 3/26/23;
-An order, dated 3/26/23, for Metoprolol tartrate 50 mg, give 50 mg by mouth two times a day;
-Medication started on 3/26/23.
Review of the facility's Inventory on Hand for the Pyxis machine (storage system for emergency supplies of medications), dated 10/11/22, showed the following items were available:
-Clopidogrel 75 mg tablet;
-Tamsulosin HCL 0.4 mg;
-Apixaban 2.5 mg tablet;
-Metformin 500 mg tablet;
-Metoprolol tartrate 25 mg.
Review of the shipping manifest for pharmaceuticals, dated 3/26/23, showed Resident #27's medications were delivered on 3/26/23.
Review of the progress notes, dated 3/24/23 through 3/26/23, showed no documentation the medical doctor was notified the medications were not started until 3/26/23.
During an interview on 3/30/23 at 12:15 P.M., Nurse X said he/she did not know why resident #27 medications were not started until 3/26/23.
2. Review of Resident #18's electronic medical record, showed the resident was admitted to the facility on [DATE].
Review of the After Visit Summary dated 3/14/23 through 3/23/23, showed:
-Start taking these medications:
-Ceftriaxone (antibiotic) 2 gram (gm) (2000 mg) in 0.9% Sodium Chloride (NaCl) 50 milliliter (ml), give 2000 mg by IV every 24 hours for 36 days, last dose given was 3/22/23 at 5:42 P.M.
Review of the MAR, dated 3/1/23 through 3/31/23, showed:
-An order for: Ceftriaxone, 2 gm IV every 24 hours for infection related to arthritis;
-On 3/23/23, a 5 (other, see progress notes) was documented and on 3/24/23, the entry was blank.
Review of the progress notes dated 3/23/23 through 3/24/23, showed:
-On 3/23/23 at 7:23 P.M., resident arrived to facility. Medication list sent to pharmacy;
-On 3/23/23 at 9:34 P.M., electronic (e)MAR administration note, Ceftriaxone sodium solution reconstituted 2 gm, use 2 gm IV every 24 hours for infection; the note failed to show why it was not administered;
-There was no documentation showing the medical doctor was notified the IV medication was not given.
During an interview on 3/28/23 at 11:50 A.M., Nurse V said, on 3/23/23, the resident had an IV and he/she flushed the line, but he/she did not give any IV medications.
During an interview on 3/28/23 at 11:00 A.M. Nurse U said, on 3/24/23, the resident had an IV, but he/she did not give the resident any IV medication.
During an interview on 3/29/23 at 3:35 P.M., the Pharmacist said on 3/23/23, the pharmacy delivered an IV pump, IV tubing, flush solution, heparin (used to prevent blood clots from forming) and Ceftriaxone, enough for five days for Resident #18. The delivery arrived at the facility between 7:30 P.M. and 7:50 P.M. and no items had been returned.
3. During an interview on 3/30/23 at 12:15 P.M. Nurse X said if he/she did not have the resident's medication, he/she would call the pharmacy to check on the medication and tell the nurse supervisor. He/She did not have access to the Pyxis.
4. During an interview on 3/30/23 at 12:33 P.M., Certified Medication Technician (CMT) Y said if a resident's medication was unavailable, he/she would check the Pyxis to see if the medication was in there and give it if it was available. He/She had access to the Pyxis.
5. During an interview on 3/30/23 at 1:00 P.M., the Administrator and the Assistant Director of Nursing (ADON) said if a staff member documents a 5 on the MAR, which meant see progress note, they would expect to see a progress note related to that medication. If a medication was unavailable, they would expect for the CMT to notify the nurse. The nurse should notify the ADON/Director of Nursing (DON), call the pharmacy and check the Pyxis to see if the medication was available. If the medication was unavailable, the nurse should notify the medical doctor and document it in the progress notes. On the MAR, staff should document the correct code for why the medication was not administered. The nurses and CMTs have access to the Pyxis. If the nurse is new or an agency nurse, he/she may not have access to the Pyxis, but there is always someone in the building who has access to the Pyxis. The ADON did not know why Resident #27's medications were not started until 3/26/23. Resident #18 did not arrive at the facility until around 6-6:30 P.M. on 3/23/23. When it was time for his/her IV antibiotic, the medication was probably not at the facility yet. The facility does have some IV supplies and IV medications in the Pyxis, but the facility does not have an IV pump. The ADON would expect for staff to administer the IV antibiotic once the medication was received from the pharmacy.
MO00215989
MO00215966
MO00215957
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 F0919
(Tag F0919)
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 residents' call lights were in reach for tw...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the residents' call lights were in reach for two residents (Residents #1 and #5) and failed to answer one resident's call light timely (Resident #23). The sample was 29. The census was 141.
Review of the facility's Call Lights: Accessibility and Timely Response Policy, dated reviewed/revised 7/14/22, showed:
-Policy: The purpose of this policy is to provide guidance to the facility to be adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response;
-Policy Explanation and Compliance Guidelines:
-Staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light;
-Residents will be evaluated as needed for unique needs and preferences to determine any special accommodations that may be needed in order for the resident to utilize the call system;
-Staff should check and place the call light within reach of resident and secured, as needed;
-Staff members who see or hear an activated call light are responsible for responding;
-If the staff member cannot provide what the resident desires, the appropriate personnel should be notified.
1. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/9/23, showed the following:
-Cognitively intact;
-Required extensive assistance with bed mobility, transfers and dressing;
-Total dependence with eating and toilet use;
-Required limited assistance with personal hygiene;
-No impairment with functional limitation in range of motion to upper and lower extremity;
-Diagnosis included cancer, coronary artery disease (CAD, a narrowing or blockage of the arteries and vessels that provide oxygen and nutrients to the heart), heart failure and hypertension (HTN, high blood pressure).
Review of the resident's comprehensive assessment for hospice admission, dated 3/4/23, showed:
-Primary diagnosis of cerebral infarction (stroke);
-The resident's cerebral infarction has contributed to 6/6 dependent (total dependence) for activities of daily living (ADL);
-Left sided contractures (involuntary shortening of the muscle) and bilateral (affecting both sides) lower extremity contractures.
Review of the resident's care plan, revised 3/8/23, and in use during the survey, showed:
-Focus: The resident has an ADL self-care performance deficit;
-Goal: The resident will maintain/improve level of functioning through next review;
-Interventions/tasks included: Encourage the resident to use bell to call for assistance;
-The care plan did not document the resident's left upper extremity impairment.
Observation on 3/16/23 at 12:09 P.M., showed the resident sat in a reclining chair to the right of his/her bed, in between both beds in the room. The resident's touch call light was hooked on the right side rail of the resident's bed and not in reach.
Observation on 3/16/23 at 2:34 P.M., showed the resident sat in a reclining chair to the right of his/her bed, in between both beds in the room. The resident's touch call light was on the left side of the resident in the reclining chair, next to his/her hips.
During an interview on 3/22/23 at 8:40 A.M., the Director of Nursing (DON) said the resident had a touch call light and it was really sensitive. The DON assisted with the resident's admission assessment and discharge assessment and the light was going off when it was barely touched. She said if a resident is impaired on the left side, the call light should be placed on the right side. She expected call lights to be in reach for residents.
2. Review of Resident #5's quarterly MDS, dated [DATE], showed:
-Moderately impaired cognition;
-Required extensive assistance with bed mobility, transfers, locomotion once in the chair, dressing and personal hygiene;
-Required total assistance of staff for toileting;
-Required set up for eating,
-Always incontinent of bladder and frequently incontinent of bowel;
-Diagnoses included diabetes and neurological conditions.
Review of the care plan in use at the time of the survey, dated revision on 11/8/22, showed:
-Focus: resident is at risk for falls;
-Goal: will be free of minor injury through next review date; will not sustain serious injury through the review date;
-Interventions included: be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.
During an interview on 3/15/23 at 11:43 A.M., the resident said staff do not answer his/her call light timely and sometimes he/she had to wait a long time to get on/off the bed pan.
During an interview on 3/20/23 at 9:18 A.M., the resident said he/she dropped his/her call light on the floor Friday (3/17/23) night and he/she did not have the call light all night long.
3. Review of Resident #23's admission MDS, dated [DATE], showed:
-Cognitively intact;
-Required extensive assistance of staff for bed mobility, transfers, dressing, toilet use and personal hygiene;
-Always continent of bowel and bladder;
-Diagnoses included stroke.
Review of the care plan in use at the time of survey, dated revision on 3/16/23, showed:
-Focus: resident has an ADL self-care performance deficit;
-Goal: the resident will maintain/improve level of functioning;
-Interventions: staff assistance to the extent resident to accomplish task.
During an interview on 3/28/23 at approximately 2:00 P.M., the resident said on Saturday (3/25/23), he/she put his/her call light on and waited for 30 minutes. The staff did not respond, so he/she rolled him/herself out of bed onto the floor. It took the staff another 30 minutes before they came into the room. On Sunday (3/26/23), he/she put the call light on and had to wait for two hours for staff to answer the light. By the time staff answered the light, he/she was incontinent. Normally he/she is not incontinent.
Review of the resident's progress notes, dated 3/25/23 at 1:45 P.M., showed the resident stated he/she rolled onto the floor, bed in lowest position. Removed from floor using a Hoyer (mechanical lift) lift by nurse and certified nurse aide (CNA).
4. During an interview on 3/15/23 at 11:56 A.M., CNA G said rounds are made on residents every two hours and as needed. Before leaving the room, staff make sure the call light is in reach.
5. During an interview on 3/16/23 at 10:09 A.M., CNA F said the facility has two types of call lights: a soft touch and a regular push button. Resident call lights should be within reach of the resident. During rounds, residents are checked to ensure the lights are within reach. Anyone can answer a call light. If they cannot take care of what the resident needs, they would tell that resident's CNA or nurse. Call lights should be answered as quickly as possible.
6. During an interview on 3/22/23 at 7:05 A.M., Nurse H said staff round on residents every two hours. Rounds consist of checking to see if call lights are in reach. When placing call lights, he/she will hook the call light onto the pillow. Nurse H does not see call lights that are not in reach. If a resident dropped a call light on the floor, the resident would have to yell out for assistance. If a resident was impaired on the left side, the proper place for the call light to be placed is on the right side, the side that is not impaired.
7. During an interview on 3/22/23 at 7:34 A.M., Nurse I said if a resident were to drop their call light, staff would pick it up and place within reach of the resident. If a resident were to not have access to their call light, they would need to yell out if they didn't have their call light. Rounds are done to try and prevent the call light from being out of reach.
8. During an interview on 3/22/23 at 8:40 A.M., the DON said she expected call lights to be in reach for residents.
9. During an interview on 3/22/23 at 12:42 P.M., the Assistant Director of Nursing (ADON) said call lights are expected to be within reach for the residents. If a call light was not in reach, a resident could yell for assistance, or their roommate could turn on their light for them. If the resident had a phone, he/she could call the facility or family to notify them the call light was not in reach. If a resident had an impairment on their left side, the appropriate place for the call light would be on the resident's right side. The ADON said if she gets complaints about call lights not being answered, she will investigate it and reeducate the staff on answering call lights. The ADON also said if she sees staff not responding to call lights, she will talk to the staff member about it.
10. During an interview on 3/22/23 at 1:48 P.M., the Administrator said she expected call lights to be in reach for the residents at all times. She said she has gone into rooms and attached the call light with a clip to the resident's clothing to make sure it is in reach. The Administrator said if a resident was impaired on the left side, she expected the call light to be placed on the resident's right side and for the resident to have a touch call light if the resident cannot push the button.
MO00215488
MO00215294
MO00215320
MO00215957
MO00215938
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure there was a sufficient number of staff to meet the needs of ...
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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 there was a sufficient number of staff to meet the needs of the residents. Staff were unable to complete resident admissions timely per the facility's policy for four out of six residents sampled (Residents #20, #27, #25 and #26). Staff also failed to follow the facility's transfer/discharge policy for two residents (Residents #20 and #18) when the resident's representative called an ambulance to have the resident transferred out of the facility while several staff members voiced concerns with not having enough staff. The census was 141.
Review of the Facility Assessment, most recently assessed on 3/30/23, showed the following:
-Number of residents licensed to care for: 282;
-Average daily census: 140
-Average number of admissions for weekday and weekend: 1-3;
-Decisions regarding caring for residents with conditions not listed in the Common Diagnoses category identified by the facility: New admissions begin with the referral process. The Director of Nursing (DON) will review the referral upon receipt and look for any diagnoses, conditions or symptoms. If any issue is identified, the DON will discuss with the Administrator and any other discipline that may be involved to determine the facility's ability to meet the needs of the patient. During this evaluation, the following is reviewed as necessary:
-Medications;
-Treatments;
-Equipment needs;
-Capability and capacity of staff as required;
-If these resources are readily available through established vendors and can be procured at rates that are fiscally responsible for the operation, the patient could be admitted ;
-New admission clinical needs are evaluated using the clinical admission grid;
-Staffing plan, total number needed or average or range:
-Licensed nurses providing direct care: 3-5;
-Nurse's aides: 10-15;
-Certified Medication Technicians (CMT): 3-5;
-Individual staff assignment: Nurse Management makes frequent rounds to evaluate resident needs and review in weekly clinical meeting to determine staffing needs.
Review of the facility's admission of a Resident Policy, reviewed/revised 4/6/23, showed:
-Policy: The admission process is intended to obtain all information possible about the resident for the development of the comprehensive plan of care, and to assist the resident in becoming comfortable in the facility. Residents are admitted to the facility under orders of the attending physician;
-Nursing: Resident will be made comfortable; resident will be oriented to the new environment/room; nurse will complete physical assessment and documentation; call medical professional to verify orders received from the referring facility/hospital; order medications from pharmacy; obtain weight and vital signs.
Review of the Admission/readmission Point Click Care (PCC) Checklist, undated, located in the admission and Discharge binder at the nurses station, showed:
-Orders tab/batch orders:
-Orders entered and completed;
-Diet order;
-Code status;
-Weights/Vitals:
-Height entered;
-Weight entered;
-Initial set of vital signs (VS, Blood Pressure (B/P), Pulse (p), Respirations (r), Temperature (t) entered;
-Assessments:
-admission assessment completed;
-Fall assessment completed;
-Elopement assessment completed;
-Pain assessment completed;
-Baseline care plan completed;
-Braden completed;
-Weekly skin check completed;
-Wound assessment (if applicable/wound present upon admission);
-Covid respiratory assessment;
-Progress note upon arrival. Note should include notification of Medical Doctor (MD) and orders verified by MD. Notification to family that MD orders were verified;
-Progress note each shift for the next 72 hours to include how resident is doing post admission;
-Tasks: Edit Activities of Daily Living to set up the specific day shifts for showers.
Review of the facility's Transfer and Discharge (including Against Medical Advice (AMA)) policy, reviewed/revised: 9/1/21, showed:
-It is the policy of this facility to permit each resident to remain in the facility and not to transfer or discharge the resident from the facility except in limited situations when the health and safety of the individual or other residents are endangered;
-Non-emergency transfer or discharges: document the reason for the transfer or discharge in the resident's medical record;
-Emergency transfer/discharges: document assessment finding and other relevant information regarding the transfer in the medical record.
Review of the facility's Admission/Discharge To/From Report, dated 3/1/23 through 3/28/23, showed:
-On 3/23/23 on the 400 hall, the rehabilitation (rehab, health care services that help a person get back or improve skills and functioning for daily living that have been lost or impaired because of illness, injury or disabled) hall: received four admissions;
-On 3/24/23 on the 400 hall: received two admissions and one resident was transferred to the hospital from the rehab hall.
1. Review of Resident #20's medical record, showed:
-The resident was admitted on [DATE] to the 400 hall;
-discharged on 3/24/23;
-Diagnoses included: back pain, lumbosacral (lower part of the spine), cervical (neck) stenosis (narrowing) of spinal canal, surgical wound infection, diarrhea, stage I skin ulcer (intact skin with localized area of non-blanchable erythema (superficial redden area)) of sacral (tail bone) region;
-No admission assessment documentation;
-No fall assessment documentation;
-No elopement assessment documentation;
-No pain assessment documentation;
-No baseline care plan documentation;
-No weekly skin assessment documentation;
-No wound assessment documentation;
-No covid respiratory assessments documentation;
-No height and weight documentation;
-No orders were entered;
-No progress notes, showing when the resident arrived to the facility, the orders were verified with the physician or when the resident went to the emergency room.
Review of the ambulance run sheet dated 3/24/23 on scene at 6:14 P.M., showed:
-Primary impression: pain, non-traumatic;
-Chief complaint: pain from bed sores;
-Duration: six hours;
-Patients level of distress: mild;
-Signs and symptoms: pain;
-Skin: bed sores along back side;
-Call notes state, problem description: resident has not been attended to and laying in own urine.
-The ambulance (EMS) arrived to scene to find resident supine (on back) in bed. The resident's representative explained the resident was there for rehab for a neck injury. They arrived at 2 P.M. after being discharged from the hospital. The resident did not have a call light and hasn't been seen or helped by staff. They haven't feed him/her lunch or dinner, given any medications, turned him/her in bed or given him/her a call light. He/She has urinated on him/herself multiple times now and needs to be cleaned and changed;
-The resident complained of pain associated with bed sores. And said, I need to be rotated in bed to combat the bed sores but no one has helped me. He/She stated No staff has been in my room since I got here. I've not eaten lunch or dinner. I'm covered in my urine. I need to be moved off my bed sores;
-The resident was alert and oriented times (x) four (person, place, time and situation). The resident's gown was saturated with what smelled like urine. The resident had bed-sore booties on feet and legs. The resident was not ambulatory;
-The resident was treated and transported to the hospital.
Review of the discharge nurses note, supplied by the facility, dated 3/24/23 at 9:21 P.M., showed:
-Date and time of discharge was 3/24/23 at 8:00 P.M.;
-discharged to: other-hospital;
-Mode of transportation: ambulance;
-Physician order for discharge: no;
-Description transferred location, specific items or other: refused to stay at facility, refused to sign Against Medical Advice (AMA) paperwork, refused to discuss reason of not staying at facility besides that he/she doesn't like it per previous nurse.
2. Review of Resident 27's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/31/23, showed:
-Cognitively intact;
-Diagnoses included: covid, atrial fibrillation (a-fib, irregular heart rhythm) generalized weakness, diabetes and dementia.
Review of the medical record, showed:
-The resident was admitted on [DATE] to a room on the 400 hall;
-No admission assessment documentation;
-No fall assessment documentation;
-No elopement assessment documentation;
-No pain assessment documentation;
-No baseline care plan documentation;
-No weekly skin assessment documentation;
-No covid respiratory assessments documentation;
-No height and weight documentation.
Review of the progress notes dated 3/24/23 through 3/26/23, showed:
-On 3/25/23 at 12:04 A.M., per report, resident admitted around 3:00 P.M. today;
-No documentation showing the MD was notified and the orders were verified.
3. Review of Resident #25's medical record, showed:
-The resident was admitted on [DATE] to the 400 hall;
-Alert and oriented;
-Diagnoses included: congestive heart failure (CHF, impaired heart function), spinal stenosis (happens when the spaces in the spine narrow and create pressure on the spinal cord and nerve roots);
-No admission assessment documentation;
-No fall assessment documentation;
-No elopement assessment documentation;
-No pain assessment documentation;
-No baseline care plan documentation;
-No weekly skin assessment documentation;
-No wound assessment documentation;
-No covid respiratory assessments documentation;
-No height and weight documentation.
Review of the progress notes dated 3/23/23 through 3/27/23, showed on 3/23/23, staff failed to document the resident's admission and if the hospital discharge orders had been verified by the MD.
During an interview on 3/28/23 at 8:10 A.M. and 3:49 P.M., the resident, said he/she arrived at the facility at approximately 8:00 P.M. by ambulance. It took staff a while before anyone came into his/her room. I thought they took me to the wrong floor. Staff did not do an assessment nor did they check his/her vital signs when he/she was admitted .
4. Review of Resident #26's medical record, showed:
-The resident admitted on [DATE] to the 400 hall;
-Diagnoses included: CHF, confusion, a-fib, benign prostatic hyperplasia (BPH, enlarged prostate) and volume overload (the body has too much fluid)
-No admission assessment documentation;
-No fall assessment documentation;
-No elopement assessment documentation;
-No pain assessment documentation;
-No baseline care plan documentation;
-No weekly skin assessment documentation;
-No covid respiratory assessments documentation;
-No height and weight documentation.
Review of the Order Recap Summary, dated 3/28/23, showed, an order for:
-Daily weight;
-Notify MD of weight gain of weight greater than three pounds in 24 hours or greater than five pounds within seven days;
-Start date 3/24/23.
Observation and interview on 3/30/23 at 11:25 A.M. showed the resident sat up in his/her wheelchair in his/her room. The resident's representative was present in the resident's room. The resident's representative said the resident had been at the facility since 3/23/23 and they had not weighed him/her yet and the resident had a diagnoses of CHF.
During an interview on 3/30/23 at 12:15 P.M., Nurse X, said he/she did not have a weight for the resident.
5. Review of Resident #18's medical record, showed:
-The resident was admitted on [DATE] to the 400 hall.
-Alert and oriented x two to three (person, place and time) with confusion;
-Diagnoses included: septic arthritis (painful infection in a joint that came from germs that travel through the bloodstream from another part of the body) and altered mental status.
Review of the Ambulance Run Sheet dated 3/24/23 at 6:44 P.M., showed:
-Primary impression: generalized weakness;
-Chief compliant: weakness;
-Duration: 5 hours;
-Patient's level of distress: mild;
-Left leg: whole leg swelling;
-EMS arrived on the scene and met with the resident representative, who stated the resident was admitted to the facility yesterday for rehab and when he/she arrived at the facility (report did not say when resident representative arrived at facility), the resident was covered in urine and had not been cared for. The resident's representative stated the resident needed his/her leg cared for and has not been getting the care needed. The staff made contact with EMS and stated they were unsure why 911 was called. Staff stated there were only two employees for the hall and that it was tough for them to keep up with the patients. EMS proceeded to the resident's room and found the resident lying supine in bed. The resident complained of a little pain in his/her leg but nothing bad for him/her. The resident stated the last time he/she had seen the nurse was this morning. The resident wanted to be transported to the hospital to be evaluated. The resident stated the puddle of fluid near the bed was his/her urine. The resident was transferred onto the stretcher and transported to the hospital.
Review of the progress notes dated 3/24/23 through 3/27/23, showed:
-On 3/25/23 at 12:22 A.M., per report from evening shift nurse, resident representative came and picked the resident up and took him/her home this evening, room was empty;
-On 3/27/23 at 10:14 A.M., resident went to the hospital last weekend;
-The progress notes failed to show the MD was notified the resident was transferred to the hospital.
Review of the discharge nurses' notes, dated 3/27/23 at 6:37 P.M., showed:
-Date and time of discharge: [DATE] at 12:00 A.M.;
-discharged to the hospital;
-Mode of transportation was ambulance;
-Physician order for discharge: no;
-Describe transferred location, specific items or other: Previous shift reported, resident representative took resident without paperwork, notified MD and management, resident representative not satisfied with facility.
6. Review of the requested shower sheets (a form staff use to document if a resident received a shower or bed bath) for the 400 hall for 3/23/23 through 3/24/23, showed the facility could only provide documentation that two residents received a shower or bed bath within the requested timeframe.
7. During an interview on 3/27/23 at 12:00 P.M. and 3/28/23 at 11:00 A.M., Nurse U said, he/she worked 3/24/23 from approximately 7:00 A.M. to 11:45 P.M. on the 400/rehab hall. This was his/her second day at the facility and his/her first day on that hall. There was no night nurse on the hall when he/she arrived and Nurse U did not get a report at the beginning of the shift. He/she used the electronic chart and went room to room trying to read a history about each resident. There were some rooms that had residents in them but no chart for that resident. He/she had to look for that resident's history. Nurse U sent one resident to the hospital for their abdomen being distended, two residents just showed up from the hospital without him/her receiving a report on them. Two family members came and took their family members out of there. Staff found one resident on the floor around 7:00 P.M. or 8:00 P.M. The resident was assessed and was not hurt. The notifications were made and a note was made in the chart for each resident, but there was no time to complete a report. There was a lot of commotion going on, the lights were going off and staff were trying to care for just the critically ill residents. The floor was too busy to leave to go look if there was another nurse in the building to help. The supervisor showed up around 5:00 P.M. when the alarm was sounding and the police showed up, because a family member could not get inside the building. When no one is at the receptionist's desk, all the calls get routed to the rehab hall. So, when a family member showed up at the facility, they call the facility to have someone let them in. Staff were too busy to answer the phones, plus when they were down the hall, they could cannot hear the phone ring. Staff did not answer the door and the family member called the police. Staff really tried their best to get things done but could not get everything done. It was not possible to get all the residents changed and showered. Staffing was a big issues on this hall. This is a rehab hall and the residents on this hall need more care as compared to some of the other halls. One nurse to 25 residents makes it impossible to catch a change of condition. Nurse U said he/she has talked to the Assistant Director of Nursing (ADON) about this issue.
8. During an interview on 3/27/23 at 2:46 P.M., Family Member (FM) C said the facility was short staffed on the weekend of 3/24/23 through 3/26/23. On the evening of 3/24/23, FM C received a call stating his/her family member had fallen out of bed. On Saturday, 3/25/23, there was one nurse and one aide working on the hall, They were walking around like they did not know what they were doing or where anything was. FM C helped staff provide care for his/her family member and offered to help care for the other residents but was told he/she could not help.
9. During an interview on 3/28/23 at 6:00 A.M., Nurse Y said new admissions/re-admissions usually arrive late in the afternoon/evening. The nurse on the floor is responsible for doing admissions, including entering the orders into the medical record and doing the assessments. The assessments are all included in one assessment called the All-inclusive Assessment. The nurse should document in the progress notes the resident was admitted to the facility and the orders were verified with the doctor. Nurse Y tried to follow up to be sure the admission had been completed. Sometimes the admission documentation didn't always get completed on the day shift. They should write the resident's name on the report sheet and communicate what was done or what needed to be done so the next shift can complete the admission. When he/she has made rounds, he/she has seen a resident in a room and looked in their chart and the resident may not have had their medications entered. There are a lot of agency staff here. He/she did not recall any inconsistency from the weekend. If a resident goes to the hospital or if a resident/resident representative called an ambulance, he/she would notify the MD, family if needed, DON/ADON or supervisor and make a progress note. If the facility was short staffed, he/she would call management and usually they can get an agency staff there within a couple of hours.
10. During an interview on 3/28/23 at 9:00 A.M., the Staffing Coordinator said the facility had a lot of call ins and no-call no-shows from 3/23/23 through 3/26/23. It is never ideal to not have staff scheduled. If it is manageable, it would depend on the staff who were working and what was going on the floor at the time.
A legible copy of the schedule for 3/23/23 through 3/26/23 was requested, as of 3/30/23 at 5:00 P.M., a copy of the schedule had not been provided.
11. During an interview on 3/28/23 at 11:50 A.M., Nurse V said when a resident was admitted to the facility, the nurse on the floor was responsible for completing the admission. The nurse was responsible for entering the orders into the chart, notifying and verifying the orders with the MD, send the orders to the pharmacy, complete the All- in-one Assessment and make a progress note. On Thursday 3/23/23, he/she had four admissions. The ADON helped by entering the residents' orders into their charts. Nurse V completed two of the admissions and passed two of the admissions to the next shift. However he/she did not know if there was a nurse working on the hall that night because the nurse who usually worked upstairs called in, and he/she did not know what time the next nurse came in. If a resident or resident representative called an ambulance, he/she would call the physician and let them know what happened and document it in the progress notes. If a family member took a resident home, the resident or resident representative would sign the AMA paperwork, the ADON, Administrator and physician would be notified and it would be documented in the progress notes. If the hall was short staffed he/she would report to the Staffing Coordinator, ADON or whomever was on call. Then they would try to pull someone to the floor or call someone in.
12. During an interview on 3/28/23 at 1:48 P.M. the ADON said she assisted with the admissions on Thursday, 3/23/23, by entering 2 or 3 residents' orders into the computer. The nurse on the floor completed the assessments and the documentation. If something was not completed that shift, it should have been passed on to the next shift. If there was not a nurse working on that hall, the night supervisor should have completed it. All nurses are made aware of the admission and discharge process through the binder labeled admission and Discharges located at the nurses' station. Even agency nurses can pick up the binder and look inside and see everything they need to know to complete an admission or discharge. If staff needed help with the admission/discharge process they could ask another nurse. The ADON did not know a timeframe when an admission should be completed, but staff should be able to prioritize their time.
13. During an interview on 3/29/23 at 8:15 A.M., Nurse T said, he/she was the nurse on call the weekend of 3/25/23 through 3/26/23 and he/she was aware of the staffing issues. He/She worked all weekend. On Saturday 3/25/23, he/she worked the 400 hall with one CNA. He/she had to pass the medications, pass out hall trays and do all the nursing tasks. One resident's representative wanted the staff to get their family member up by 3:00 P.M., but Nurse T told the resident representative it was impossible to get the resident up because there was not enough staff. The resident's representative was upset and Nurse T reported it to the ADON. Therapy helped get some residents up, but most of the residents stayed in bed. There is not enough staff to provide the care the residents needed. He/She was not sure if the admissions from 3/23/23 and 3/24/23 had been completed or not.
14. During an interview on 3/29/23 at 3:01 P.M., CNA F said he/she worked the evening shifts on 3/24/23 and on 3/25/23. On both shifts CNA F was the only only CNA on the 400 hall with the one nurse. CNA F said he/she was not able to take care of all the residents' needs. The 400 floor normally runs with two CNAs, a CMT and a nurse. This is because the majority of the residents are two person assist or require a mechanical lift that require two people. CNA F felt like he/she did not provide adequate care because he/she was only one person.
15. During an interview on 3/30/23 at 10:11 A.M., CMT Z said, he/she worked Friday, 3/24/23, on the 400 hall from approximately 7:30 A.M. to 4:30 P.M. It was a challenging day, and they could not get a report on the new residents. The nurse was an agency nurse and there was a lack of help. When CMT Z saw the ADON on the hall, he/she asked her for a report and the ADON said she would give him/her a report, but CMT Z never saw the ADON again.
16. During an interview on 3/30/23 at 11:20 A.M., FM D, said the facility didn't have enough staff. He/she was not asking the staff to do anything extra for his/her family member. He/she just wanted the resident to get up into his/her wheelchair so his/her family member could receive therapy. On Saturday, 3/25/23, the resident had been in bed for over 36 hours. FM D, asked staff to get the resident up. He/She was told by staff they could either give the resident his/her medications or they could get the resident up, but they could not do both. They were short staffed. FM D tried to ask another staff member and was told that was above that staff person's pay grade.
17. During an interview on 3/30/23 at 4:00 P.M., the Unit Manager said if the facility was short staffed, the Staffing Coordinator will send out a message if the on-call person was already working and more staff was needed. The Staffing Coordinator will also specify in the message if the need was critical or not. If she is able to come in, she will come in. She received a message on 3/25/23 and 3/26/23. The Unit Manager felt the message would be considered critical because the message did not specify what hours were needed, just if she could, to come in. If management can't cover the shift, the facility will call agency.
18. During an interview on 3/30/23 at approximately 4:30 P.M., the Administrator said the 400 hall was the rehab hall. The residents on that hall required more care as compared to the other halls because they are just coming from the hospital. In a way they are also more independent as compared to some of the other residents. The Administrator did not feel the hall was short staffed on Thursday (3/23/23) or Friday (3/24/23) day shift and it was unusual for the hall to receive four admissions in one day. The on-call nurse worked all weekend. The Administrator was at the facility on 3/25/23 and the ADON worked on 3/26/23. The hall may have been short staffed on 3/25/23 and 3/26/23.
MO00215965
MO00215989
MO00215966
MO00215945
MO00215957
Nov 2022
1 deficiency
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
Administration
(Tag F0835)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility management company failed to ensure payments were issued or issued in a timely manner, to the facility's medical director, dietician, and other neces...
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Based on interview and record review, the facility management company failed to ensure payments were issued or issued in a timely manner, to the facility's medical director, dietician, and other necessary vendors utilized to provide services for the needs of residents. The census was 97.
1. During an interview on 10/18/22 at 11:36 A.M., a management representative for Vendor B, a mobile x-ray and ultrasound provider, said there is an active contract with the facility but services are currently on suspension due to lack of payment. When a facility's services are suspended, the company will not provide services to any resident for which the facility is financially responsible, based on their insurance coverage and per diem rates. The facility has an outstanding balance of approximately $4,200.00.
Review of Vendor B's invoices and facility payment information, provided 10/21/22, showed:
-Invoice, dated 11/30/21, current amount: $288.00;
-Invoice, dated 12/31/21, current amount: $252.00;
-Invoice, dated 1/31/22, current amount: $288.00;
-Invoice, dated 2/28/22, current amount: $792.00;
-Invoice, dated 4/30/22, current amount: $72.00;
-Invoice, dated 6/30/22, current amount: $648.00;
-Invoice, dated 7/31/22, current amount: $284.00;
-Invoice, dated 9/30/22, current amount: $72.00, previous balance due: $4,093.00. Balances dated back to 2/28/21;
-No payments issued to vendor for invoices submitted November 2021 through September 2022.
2. During an interview on 10/18/22 at 1:33 P.M., a corporate representative for Vendor F, a pharmacy service provider, said the facility's management company did not pay his/her company for their services for one and a half years. He/she offered the facility's management company various options, such as payment plans, but the management company did not issue any payments.
Review of Vendor F's invoices and facility payment information, provided 10/21/22, showed:
-Invoice, dated 10/31/21, amount: $5,044.84;
-Invoice, dated 11/30/21, amount: $12,898.20;
-Invoice, dated 12/31/21, amount: $12,648.40;
-Invoice, dated 1/31/22, amount: $21,254.22;
-Invoice, dated 2/28/22, amount: $17,685.73;
-Invoice, dated 3/31/22, amount: $9,444.81;
-Invoice, dated 4/30/22, amount: $3,963.91;
-Invoice, dated 5/31/22, amount: $2,242.70;
-Invoice, dated 6/30/22, amount: $2,680.12;
-No payments to vendor for invoices submitted October 2021 through June 2022.
3. During an interview on 10/20/22 at 11:13 A.M., a billing representative for Vendor H, a laboratory service provider, said the facility has an outstanding balance of $12,941.45. The vendor has not received a payment from the facility since 1/27/22.
Review of Vendor H's invoices and facility payment information, provided 10/21/22, showed:
-Statement date 10/1/21, current amount due: $948.75;
-Statement date 11/8/21, current amount due: $467.13;
-Statement date 12/2/21, current amount due: $293.49
-Statement date 1/4/22, current amount due: $434.45;
-Statement date 2/23/22, current amount due: $157.65;
-Statement date 4/7/22, current amount due: $913.94;
-Statement date 5/4/22, current amount due: $597.61;
-Statement date 6/2/22, current amount due: $352.69;
-Statement date 7/7/22, current amount due: $853.24;
-Statement date 8/2/22, current amount due: $771.25;
-Statement date, 9/26/22, current amount due: $1,156.87. Past due: $8,794.86. Total due: $9,951.73;
-No payments made to vendor for invoices submitted October 2021 through September 2022.
4. During an interview on 10/20/22 at 11:28 A.M., a registered dietician for Vendor E said his/her company provided dietician services to the facility for over a year, until October 2022. The facility owes his/her company thousands of dollars, but he/she has not received payment from the facility since November 2021. He/she reached out to the facility's administrator and they sent emails to the facility's management company, but he/she never received a response. He/she reached out to the accounting company who issues payments, but still hasn't received payments for the past year.
Review of Vendor E's invoices and facility payment information, provided 10/21/22, showed:
-Invoice, dated 12/31/21, amount: $716.30, due 1/12/22;
-Invoice, dated 1/15/22, amount: $786.30, due 2/14/22;
-Invoice, dated 2/11/22, amount: $806.30, due 3/13/22;
-Invoice, dated 3/10/22, amount: $856.30, due 4/9/22;
-Invoice, dated 4/10/22, amount: $872.60, due 5/10/22;
-Invoice, dated 5/13/22, amount: $896.30, due 6/12/22;
-Invoice, dated 6/10/22, amount: $902.60, due 7/10/22;
-Invoice, dated 7/11/22, amount: $792.60, due 8/10/22;
-Invoice, dated 8/11/22, amount: $862.60, due 9/10/22;
-Invoice, dated 9/9/22, amount: $752.60, due 10/9/22;
-No payments made to vendor for invoices submitted December 2021 through September 2022.
5. During an interview on 10/24/22 at 8:15 A.M., the administrator said the facility changed over to a new food service vendor in August 2022. Prior to August, the food service distributer was Vendor G.
During an interview on 11/3/22 at 10:28 A.M., a controller with Vendor G, a food service distributor, said the facility has an outstanding balance due to non-payment. The facility's management company owes the vendor thousands of dollars for services provided.
Review of Vendor G's invoices and facility payment information, provided 10/21/22, showed:
-Invoices submitted by the vendor 7/5/22 through 8/22/22;
-Invoices on 60 day payment plan;
-No payments to vendor for invoices dated 7/5/22 through 8/22/22.
6. During an interview on 11/3/22 at 8:17 A.M., an accounts receivable representative from Vendor I said the vendor is a medical supply company that provides anything needed in a hospital setting, from linens to wheelchairs. The facility has an outstanding balance of $97,713.42. He/she would expect facilities to pay the vendor according to the payment plan indicated on their invoices.
Review of Vendor I's invoices and facility payment information, provided 10/21/22, showed:
-Invoices submitted by the vendor from October 2021 through May 2022;
-Invoices on a 120 day payment plan;
-No payments issued to the vendor for invoices submitted October 2021 through May 2022.
7. Review of Vendor C, a wastewater company, invoices and facility payment information, provided 11/2/22, showed:
-Invoice, dated 11/12/21, current charges: $2,149.04, due 12/6/21;
-Invoice, dated 12/15/21, current charges: $2,068.84, due 1/5/22;
-Invoice, dated 1/12/22, current charges: $12,921.17, due 2/2/22;
-Invoice, dated 2/14/22, current charges: $2,068.84, due 3/7/22;
-Invoice, dated 3/14/22, current charges: $1,805.17, due 4/4/22;
-Invoice, dated 4/14/22, current charges: $2,001.63, due 5/5/22;
-Invoice, dated 5/13/22, current charges: $1,856.87, due 6/6/22;
-Invoice, dated 6/15/22, current charges: $1,851.70, due 7/6/22;
-Invoice, dated 7/14/22, current charges: $1,789.66, due 8/4/22;
-Invoice, dated 8/15/22, current charges: $2,082.02, due 9/6/22;
-Invoice, dated 9/15/22, current charges: $2,285.32. Previous balance: $27,243.80. Total due: $29,709.52, due 10/6/22;
-No payments to vendor for invoices submitted November 2021 through September 2022.
8. Review of Vendor A, an electric power provider, invoices for Account #1 (electric usage for five meters) and facility payment information, showed:
-Statement date 7/19/22: current charges of $10,075.89, prior balance of $11,562.56, total amount of $21,638.45 due 8/9/22;
-Statement date 8/17/22: current charges of $9,657.81, prior balance of $10,075.89, payment of $11,562.56 received (full payment not received), total amount of $19,733.70 due 9/8/22;
-No payments to vendor for invoices submitted 7/19/22 and 8/17/22.
Review of Vendor A's invoices for Account #2 (electric usage for two meters) and facility payment information, showed:
-Statement date 7/19/22: current charge of $8,256.72, prior balance of $8,031.73, total amount of $16,288.45 due 8/9/22;
-Statement date 8/17/22: current charge of $6,830.17, prior balance of $8,256.72, total amount of $15,086.89 due 9/8/22;
-No payments to vendor for invoices submitted 7/19/22 and 8/17/22.
9. Review of Vendor J, a gas company, invoices and facility payment information, provided 10/21/22, showed:
-Statement date 7/22/22, current charges: $1,392.57, due 8/1/22;
-Statement date 8/26/22, current charges: $1,514.02, total balance: $2,906.59, due 9/6/22;
-No payments made to vendor for invoices submitted 7/22/22 and 8/26/22.
10. Review of invoices for Vendor D, the facility's medical director from May 2021 through August 2022, showed:
-Invoice, undated, medical director fees in July 2022: $2,500.00, due 7/31/22;
-Invoice, undated, medical director fees in August 2022: $2,500.00, due 8/31/22;
-No payments to vendor for invoices for medical director fees in July and August 2022.
11. During an interview on 10/24/22 at 12:25 P.M., the administrator said she was aware of an ongoing issue with non-payment to vendors providing services to the facility. Two to three weeks ago, Vendor E reported his/her payments were behind. Last week, Vendor A said they had not received payment and would consider disconnecting services. The administrator contacted the facility's management company and they said they issued payment to the vendor within three hours of being notified. Vendor payments are issued by an accounting company contracted by the facility's management company. If the administrator receives an invoice directly or receives a report from a vendor about issues with their payment, she submits a direct check request through the facility's management company and the accounting company will issue an electronic check for the administrator to print out and give to the vendor. She would expect all vendors to receive payment for services provided to the facility, and for the payments to be issued in a timely manner.
12. During an interview on 10/31/22 at 1:59 P.M., the Chief Executive Officer (CEO) and Regional Director of Operations (RDO) of the facility's management company said they became largely aware of the issue with vendor payments a month ago, at which time they both became more involved with bill pay. Issues with vendor payments has affected all facilities overseen by the management company in Missouri. Vendor invoices for each facility gets uploaded into an accounts payable software. Once uploaded, the invoice should be approved by the facility administrator. The approved invoices go to an accounts payable company contracted by the facility's management company. The accounts payable company issues the check to the vendor. This is the same process used to issue payments for medical directors. The facility's management company has a Chief Financial Officer (CFO). The CFO's involvement has more so been auditing invoices, not necessarily on a daily basis. Up until this point, the accounts payable company has not had a whole lot of oversight by the management company. Each facility administrator is responsible for doing their own audits and making sure invoices are uploaded correctly and submitted to the accounts payable software timely. The facility's management company has Regional staff available as resources to support each facility and ensure quality care. The administrator should report issues with vendor payments to the management company immediately, via phone call or email. The CEO and RDO would expect the accounts payable company to issue vendor in a timely manner, per the timeframe indicated in the vendor's contract. The management company has started working on putting measures in place to address the issue with vendor payment. The CEO started her position with the management company a month and a half ago and met with the accounts payable company last month to discuss how things can go more smoothly.
MO00208526
Aug 2021
26 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN-form CMS-10055) or a denial letter at the initiation, reduction, or t...
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Based on interview and record review, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN-form CMS-10055) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for two of two sampled residents who remained in the facility upon discharge from Medicare Part A services (Residents #47 and #93). The sample was 20. The census was 96.
Review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C-09-20), dated 1/9/09, showed the following:
-If the skilled nursing facility (SNF) believes on admission or during a resident's stay that Medicare will not pay for skilled nursing or specialized rehabilitative services and the provider believes that an otherwise covered item or service may be denied as not reasonable or necessary, the facility must inform the resident or his/her legal representative in writing why these specific services may not be covered and the beneficiary's potential liability for payment for the non-covered services. The SNF's responsibility to provide notice to the resident can be fulfilled by the use of either the SNFABN (form CMS-10055) or one of the five uniform denial letters;
-The SNFABN provides an estimated cost of items or services in case the beneficiary had to pay for them him/herself or through other insurance they may have; and
-If the SNF provides the beneficiary with either the SNFABN or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits, the provider has met its obligation to inform the beneficiary of his/her potential liability for payment and related standard claim appeal rights.
1. Review of Resident #47's medical record, showed:
-Medicare Part A skilled services start date of 1/28/21 and end date of 2/18/21;
-There was no SNFABN form issued.
2. Review of Resident #93's medical record, showed:
-Medicare Part A skilled services start date of 2/10/21 and end date of 2/25/21;
-There was no SNFABN form issued.
3. During an interview on 8/25/21 at 7:21 A.M., the social worker said he started working with the facility in late February 2021. If a resident is discharged from Med A and they remain in the facility, he is responsible for providing the resident with a SNFABN form. During an interview on 8/25/21 at 1:11 P.M., the social worker said any time a resident is discharged from Medicare Part A skilled services and remains in the facility, they must be provided with the SNFABN form. The facility did not issue the SNFABN forms for Residents #47 and #93, but should have.
4. During an interview on 8/27/21 at 10:10 A.M., the administrator said when a resident is discharged from Medicare Part A skilled services and they remain in the facility, facility staff should provide the resident with a SNFABN form. She did not know these forms had not been provided until the survey.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to report allegations of abuse to the Department of Healt...
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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 report allegations of abuse to the Department of Health and Senior Services (DHSS) as required, within a two-hour time frame, for three residents (Residents #304, #7, and #73). The sample was 20. The census was 96.
Review of the facility's Abuse Investigation and Reporting policy, revised July 2017, showed:
-All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state, and federal agencies and thoroughly investigated by facility management. Findings of abuse investigations will also be reported;
-Role of the 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: The individual conducting the investigation will, as a minimum:
-Review the completed documentation forms;
-Review the resident's medical record to determine events leading up to the incident;
-Interview the person(s) reporting the incident;
-Interview any witnesses to the incident;
-Interview the resident (as medically appropriate);
-Interview the resident's attending physician as needed to determine the resident's current level of cognitive function and medical conditions;
-Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident;
-Review all events leading up to the alleged incident;
-The following guidelines will be used when conducting interviews, included witness reports will be obtained in writing. Either the witness will write his/her statement and sign and date it, or the investigator may obtain a statement, read it back to the member and have him/her sign and date it;
-Reporting:
-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 State licensing/certification agency responsible for surveying/licensing the facility;
-An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriate of resident property) will be reported immediately, but not later than:
-Two (2) hours if the alleged violation involves suspicion of a crime, abuse or has resulted in serious bodily injury, or;
-24 hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury;
-The administrator, or his/her designee will provide the appropriate agencies of individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident.
1. Review of Resident #304's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, showed diagnoses included Alzheimer's disease, dementia, anxiety, depression, bipolar disorder, mild cognitive impairment, restlessness and agitation.
Review of the resident's progress note, dated 7/15/21 at 5:03 P.M., showed Licensed Practical Nurse (LPN) H documented while walking up the hall, LPN noted this resident and another resident facing each other with resident yelling, You fucking bitch, you're not going to hit me while the other resident was waving his/her arms around. LPN and an aide began to approach the residents when this resident struck the other resident to the left side of the face with open palm. Residents separated and redirected. Resident was removed from floor temporarily to help calm other resident. Resident was unable to communicate what had transpired. Physician notified and new orders received for medication. Message left for responsible party;
Review of Resident #7's quarterly MDS, dated [DATE], showed diagnoses included Alzheimer's disease, anxiety, depression, psychotic disorder, and schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves).
Review of the resident's progress note, dated 7/15/21 at 5:10 P.M., showed LPN H documented while walking up the hall, staff noted this resident face to face with another resident, yelling, You are not going to hit me you fucking bitch, while waving his/her arms. LPN and an aide began approaching residents and noted the other resident struck this resident on the left side of the face with open palm. Residents separated. Resident was very upset. No injuries noted. Physician notified with no new orders. Message left for responsible party.
Review of DHSS' system for reporting alleged violations, showed no report from the facility regarding the 7/15/21 incident.
During an interview on 8/27/21 at 11:47 A.M., LPN H confirmed he/she wrote the progress notes on 7/15/21, regarding the incident in which Resident #304 slapped Resident #7 in the face. Every times there is a resident to resident altercation, staff should report it to the Director of Nurses (DON). LPN recalled he/she did report the incident to the DON on 7/15/21.
During an interview on 8/30/21 at 11:06 A.M., the DON said if staff witnesses resident to resident abuse, they must separate the residents and have the nurse assess the residents for injury. Staff must report the incident to their supervisor, the DON, or administrator, and the physician and family should be notified. All allegations of abuse should be reported to DHSS within 2 hours. The administrator determines who will investigate the allegation, which is typically the Assistant Director of Nurses (ADON), DON, or administrator. During an abuse investigation, they review if there have been any prior incidents involving the resident or staff. Residents and staff should be interviewed and staff should provide written statements. Everything pertaining to the abuse investigation should be documented. A staff member did tell her about an incident on 7/15/21, in which Resident #304 called another resident a fucking bitch and threw up his/her hand like he/she was going to slap the other resident, but contact was not made. If the resident made contact and slapped the other resident in the face, this should have been reported to the DON.
During an interview on 8/31/21 at 8:44 A.M., the administrator said if a resident has a physical altercation with another resident, which is considered abuse, the facility conducts an investigation. The administrator might investigate the situation or appoint someone else. Whoever conducts the investigation should interview the residents involved, other residents, staff involved, and other staff who worked with the residents around the time of the incident. The physician and family must be notified of the incident. She remembers notifying DHSS of an incident regarding Resident #304 on 7/18/21, but she was not aware of a prior incident involving Resident #304 on 7/15/21. The staff who witnessed this incident should have reported it to the administrator. This information would have been helpful to know when the next incident occurred on 7/18/21. The facility should report allegations of abuse to DHSS within two hours.
2. Review of Resident #73's quarterly MDS, dated [DATE], showed:
-Rarely understood;
-Exhibited no behaviors;
-Diagnoses included dementia;
Review of the facility's self-report summary, dated 3/2/20, showed:
-Date of alleged incident: 2/21/20
-Allegation: Bruising of unknown origin;
-Summary: On 2/21/20, the aide providing care for the resident noted some redness around the resident's eye, and asked for the nurse to evaluate it. The nurse and the certified nurse aide (CNA) both described the area as a scratch, or a small reddened area. There was no indication of any bruising at the time of the initial evaluation. No other abnormalities were noted during skin assessments during the resident's shower. As the day progressed, some bruising became apparent around the resident's eye. The resident denied pain and stated he/she fell in the bathroom. The resident did not verbalize fear, nor did his/her nonverbal communication indicate that he/she was fearful. No other staff member noted anything unusual that happened while the resident was sitting in the dining room, although they were busy providing care and did not have eyes on the resident the entire time. The resident is oriented to self and not able to express what happened to him/her. Other residents were not able to state if they had noticed anything unusual, although when asked, all denied being afraid;
-Interventions: The nurse assessed the resident from head to toe, and notified both the attending physician and the family of the scratch. DON was not initially notified due to the bruising not immediately appearing. Staff educated on reporting injuries of unknown origins. DON began investigation;
-Conclusion: There is no evidence to suggest any abuse occurred in this situation. The resident may have inadvertently scratched or hit him/herself, or he/she may have hit him/herself on the table.
Review of DHSS' system for reporting alleged violations, showed no report from the facility regarding the incident on 2/21/20.
Further review of the facility's Summary of Injury of Unknown Origin, showed:
-Information on this incident was reported to DON on 2/24/20 at approximately 1:15 P.M. Investigation into bruising has begun, and staff is being in-serviced on proper reporting and documentation of injuries of unknown origin.
Further review of DHSS' system for reporting alleged violations, showed the facility reported the incident on 2/24/20 at 2:25 P.M.
During an interview on 8/31/21 at 8:44 A.M., the administrator said all allegations of injuries of unknown origin should be reported to DHSS within two hours.
CONCERN
(D)
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 appropriate discharge procedures and complete discharge and/...
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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 appropriate discharge procedures and complete discharge and/or transfer documentation for two residents discharged from the facility (Residents #550 and #303). The census was 96.
1. Review of Resident #550's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/7/20, showed the following:
-admitted to the facility on [DATE];
-No cognitive impairment;
-Extensive assistance required for ambulation, transfers, bed mobility and personal hygiene;
-Impairment to bilateral legs;
-Received physical therapy (PT) four days a week and occupational therapy (OT) five days a week.
-Diagnoses included progressive neurological conditions, high blood pressure and diabetes.
Review of the medical record, showed a notice of Medicare non-coverage issued on 4/6/21 with the effective date on non-coverage as 4/8/21. The resident signed the form on 4/6/21 to verify he/she received the notice.
Review of the progress notes, showed the following:
-A note written by administration, dated 4/6/21 at 5:32 P.M., that the resident will receive notice of Medicare non coverage due to being at baseline and ambulating 250 feet.
-A note written by the social worker (SW), dated 4/6/21 at 5:32 P.M., he spoke to the resident regarding the letter and non-coverage of Medicare effective 4/8/21. He explained the appeal process and if the appeal was denied the resident would be responsible for payment.
Review of the physician's order sheet (POS), showed an order, dated 4/8/21 at 10:54 A.M., to discharge home with medications, narcotics and PT/OT evaluations.
Further review of the progress notes, showed the following:
-An entry by the SW on 4/8/21 at 1:10 P.M., the resident had filed an appeal.
-Resident discharged on 4/9/21 at 1:15 P.M.
During an interview on 4/19/20 at 1:30 P.M., the SW said he could not remember if the resident chose to leave before the results of the appeal process were complete or if the nursing staff told him/her to go ahead and leave. He should have made that information clear in the resident's chart and the resident should have been allowed to stay until the results of the appeal were complete.
During an interview on 8/20/21 at 10:00 A.M., the Director of Rehab C said the resident would have been discharged from therapy because he/she had met rehab goals. He/she made significant progress with walking and transferring.
Review of the discharge MDS, dated [DATE], showed the following:
-Supervision required for ambulation;
-Extensive assistance required for dressing;
-Limited assistance required for personal hygiene.
2. Review of Resident #303's quarterly MDS, dated [DATE], showed:
-admission date of 1/21/20;
-Resident rarely/never understood;
-Physical behavioral symptoms directed toward others (example, hitting, kicking, pushing, scratching, grabbing, abusing other sexually) not exhibited;
-Verbal behavioral symptoms directed toward others (example, threatening others, screaming at others, cursing at others) not exhibited.
Review of the resident's medical record, showed:
-Spouse listed as resident's responsible party and legal guardian;
-Diagnoses included dementia with behavioral disturbance and schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves).
Review of the resident's progress notes, dated 12/22/20, showed:
-On 12/22/20 at 6:36 P.M., staff documented the resident sent out to the hospital for behaviors, physician aware, call to family went to voicemail;
-On 12/22/20 at 10:18 P.M., staff documented the resident made sexual remarks toward staff, stated that one staff member really turned him/her on. Very agitated, continued to pace the hall, wandering in and out of resident rooms. Staff not able to redirect at this time. Order to send to hospital for psychiatric evaluation and possible admission.
-On 12/23/20 at 9:07 A.M., social services documented they mailed an emergency transfer notice to the resident's spouse.
Review of the resident's medical record, showed no discharge summary from the resident's hospitalization from 12/23/20 through 1/12/21.
Review of the resident's progress notes, showed:
-On 1/12/21 at 8:15 P.M., staff documented the resident arrived to facility by emergency medical transport (EMT). Resident alert and oriented, he/she is able to state staff by name and that he/she was in the hospital. Family (spouse) notified of arrival. Resident is in room with a sitter. Will continue to monitor;
-On 1/13/21, social services documented they will reevaluate the resident in one month;
-On 1/18/21 at 2:29 P.M., staff documented the resident was discharged to another facility;
-No further notes or documentation of incidents between 1/12/21 and 1/18/21.
Review of the resident's emergency transfer letter, dated 1/18/21, showed:
-Provided to resident via hand delivery;
-Notice is being provided as formal notification that resident is being transferred and/or discharged from facility due to resident's clinical or behavioral status endangers the safety of individuals in the facility;
-The reason for discharge: Inappropriate sexual comments and suggestions to female resident making them feel unsafe in their home. Resident has acknowledged that the comments and suggestions are inappropriate however continue to speak to the female residents in a matter that they have verbal ask to stop. Last incident was on 1/17/21 when resident entered a female resident's room and stated he/she wanted to touch their breast, resident was escorted out of the room and placed on 1:1 until they could find safe placement for resident;
-Effective date of discharge: [DATE];
-No documentation of notification provided to resident's legal guardian.
Further review of the resident's medical record, showed:
-A physician order, dated 1/12/21, for skilled services, discontinued 1/18/21 due to discharge;
-No physician documentation regarding how the safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident.
Review of the resident's discharge MDS, dated [DATE], showed:
-Physical behavioral symptoms not exhibited;
-Verbal behavioral symptoms occurred daily.
During an interview on 8/23/21 at 8:20 A.M., the resident's spouse confirmed he/she is the resident's legal guardian. He/she found out the resident was being discharged from the facility on the day he/she was transferred. On the day of the transfer, the resident called him/her and the facility called him/her. He/she never received anything from the facility in writing and felt like he/she had no choice about where the resident was being transferred.
During an interview on 8/30/21 at 8:17 A.M., certified nurse aide (CNA) F said he/she has been employed with the facility for several years and was familiar with the resident. The resident used to be on the memory care unit. Residents on the memory care unit require a secured unit due to wandering, attempts to elope or behaviors. The resident had sexual behavior toward staff, such as grabbing at them or verbally stating he/she wanted to have sex with them. He/she never exhibited behaviors toward other residents. He/she was placed on 1:1 supervision and eventually transferred to another facility due to increased aggression toward staff.
During an interview on 8/30/21, the Assistant Direct of Nurses (ADON) said the resident used to be on the memory care unit. He/she walked a lot, never sat down, and had some behaviors, but the ADON does not recall the behaviors being sexual in nature. The administrator said if the facility felt like an emergency discharge is needed for any resident, staff should discuss with the physician and document this in the resident's medical record, in the progress notes. If a resident has a legal guardian, the guardian should be involved in the transfer process. If Resident #303 told another resident he/she wanted to touch their breast, it should be documented in his/her medical record.
MOOO183967
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered plan of care for one of 20 sampled residents (Resident #310). The resident's care pla...
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Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered plan of care for one of 20 sampled residents (Resident #310). The resident's care plan did not address his/her wounds, pressure ulcers, potential for pain, refusal of care and did not specify the amount of staff assistance needed with his/her activities of daily living (ADLs). The census was 96.
Review of Resident #310's progress notes, dated 9/1/20 at 11:17 P.M., showed he/she was admitted around 6:30 P.M. The resident's admitting diagnoses were respiratory failure and septic shock (a life-threatening condition that happens when blood pressure drops to a dangerously low level after an infection). The resident had a large wound to his/her lower right abdomen fold stretching to his/her groin area along with a quarter sized open area to his/her coccyx (a small triangular bone at the base of the spinal column) and another one right below it. The resident had generalized weakness, flaccid (hanging loosely or limply) right arm and edema to his/her bilateral lower extremities.
Review of the resident's medication administration record, dated 9/1/20 through 9/30/20, showed:
-An order dated 9/2/20, for Lantus U-100 insulin solution 30 units once daily;
-An order dated 9/11/20, for Lantus U-100 insulin solution 40 units once daily;
-An order dated 9/11/20, for sliding scale insulin three times daily;
-An order dated 9/2/20, for Oxycodone (medication that treats moderate to severe pain), 5 milligrams every four hours as needed (PRN). Administered 20 times;
-An order dated 9/3/20, to cleanse entire abdominal incision site with normal saline, apply wound gel and cover with ABD (a highly absorbent sterile dressing) daily;
-An order dated 9/3/20 through 9/10/20, to cleanse right buttocks with wound cleanser, cover Stage II pressure ulcers (partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed) with duoderms (a hydrocolloid dressing indicated for the management of lightly exuding wounds) every three days and PRN;
-An order dated 9/10/20 through 9/24/20, to cleanse right buttocks with normal saline, apply santyl (removes dead tissue from wounds so they can start to heal), cover with moist gauze and ABD (extra absorbent thick padded dressing) daily;
-An order dated 9/24/20, to irrigate abscess (tailbone area) with normal saline, lightly pack abscess with moist 4 X 4 gauze (amount 4), cover with AG (a sterile post-operative dressing) and ABD every shift.
Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/8/20, showed:
-Cognitively intact;
-No rejection of care;
-Total dependence on one person for bed mobility and bathing;
-Required assistance of 2+ for transfers and dressing, and activity only occurred once or twice;
-Required extensive assistance of 2+ for toilet use;
-Required extensive assistance of one for personal hygiene;
-No walking or locomotion occurred;
-Always incontinent of bowel and bladder;
-On a pain medication regimen and received as needed (PRN) medications;
-Six Stage I pressure ulcers (intact skin with non-blanchable of a localized area, usually over a bony prominence), 2 venous and arterial wounds and a surgical wound;
-Diagnoses of anemia (a condition in which the blood does not have enough healthy red blood cells), atrial fibrillation (an irregular and often rapid heart rate), hypertension (high blood pressure), gastroesophageal reflux disease (a digestive disease in which stomach acid or bile irritates the food pipe lining), renal insufficiency/renal failure/end stage renal disease, diabetes mellitus, malnutrition, anxiety and depression.
Review of the resident's care plan, dated 9/2/20, showed the following:
-ADLs: Limited ability to perform self-care;
-Approach: Assist with bath, shower as needed once a day 7:00 A.M. to 7:00 P.M.; assist with oral hygiene as needed once a day 7:00 A.M. to 7:00 P.M.; assist with toileting needed once a day 7:00 A.M. to 7:00 P.M.; assist with transfers, bed mobility needed once a day 7:00 A.M. to 7:00 P.M.; restorative program as outlined once a day 7:00 A.M. to 7:00 P.M.;
-The care plan did not address the resident's wounds, pressure ulcers, potential for pain and refusal of care;
-The care plan did not address the amount of assistance required for bed mobility, bathing, transfers, dressing, toilet use and personal hygiene.
Further review of the resident's progress notes, dated 9/9/20 at 3:40 P.M., showed the nurse practitioner met with the resident, and noted he/she had a lot of pain, had a wider mattress, and was rather anxious. The resident refused to wear continuous positive airway pressure (C-PAP, a common treatment for obstructive sleep apnea (OSA, intermittent airflow blockage during sleep.) A C-PAP machine uses a hose and mask or nosepiece to deliver constant and steady air pressure). The resident complained of pain following a transfer by the Hoyer lift (mechanical lift). On night shift, aide positioned him/herself outside of the resident's room because the resident called out for attention and in pain.
During an interview on 9/10/21 at 12:52 P.M., the Director of Nurses said she expected wounds, pressure ulcers, pain, refusal of care and the amount of assistance a resident needed with his/her ADLs addressed on residents' care plans. The current care plan nurse is new and did not coordinate the resident's care plan.
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 ensure residents received showers as scheduled/desired...
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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 showers as scheduled/desired. Twenty residents were sampled and problems were identified with three (Residents #19, #94 and #99). In addition, one resident selected as an expanded sample complained of not receiving showers (Resident #39). The census was 96.
1. Review of Resident #19's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/16/21, showed:
-Adequate hearing and vision;
-Clear speech - distinct intelligible words;
-Ability to express ideas and wants: Understood;
-Ability to understand others: Understands - clear comprehension;
-Brief Interview for Mental Status (BIMS, a cognitive assessment) score of 15 of 15, which indicates intact cognition;
-Rejection of care: Behavior not exhibited;
-Total dependence of two (+) persons required for bed mobility, transfers, dressing and toilet use;
-Total dependence of one person required for personal hygiene and bathing;
-Diagnoses of quadriplegia (paralysis of both arms, legs and trunk), seizure disorder, anxiety and depression.
During an observation and interview on 8/19/21 at 9:19 A.M., the resident sat in an electric wheelchair in his/her room. The resident said he/she is not getting showered. He/she could not recall the last time he/she received a shower, but he/she would like to have showers on a regular basis and needs to be showered. He/she has told staff he/she wants a shower, they say ok, then never come back to give him/her the shower. He/she said he/she felt better after a shower rather than a bed bath.
Review of the facility shower schedule, showed the resident was scheduled to receive a shower every Tuesday and Friday on the night sift (7:00 P.M. - 7:00 A.M.).
Review of the shower sheets on 8/31/21 at 2:00 P.M., showed the facility could provide no shower sheets for the resident for July or August 2021.
2. Review of Resident #94's significant change in status MDS, dated [DATE], showed:
-Adequate hearing and vision;
-Clear speech - distinct intelligible words;
-Ability to express ideas and wants: Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time;
-Ability to understand others: Usually understands - misses some part/intent of message but comprehends most conversation;
-Rejection of care: Behavior not exhibited;
-Extensive assistance of one person required for bed mobility, dressing, and personal hygiene;
-Extensive assistance of two (+) persons required for transfers and toilet use;
-Total dependence of one person required for bathing;
-Moving from seated to standing position: Not steady, only able to stabilize with human assistance;
-Moving on/off toilet: Not steady, only able to stabilize with human assistance;
-Surface to surface transfer: Not steady, only able to stabilize with human assistance;
-Always incontinent of bowel and bladder;
-Mobility device: Wheelchair;
-Diagnoses of dementia and seizure disorder;
-Any falls since prior assessment?: No.
Observations of the resident, showed:
-On 8/20/21 at 7:11 A.M., he/she lay in bed;
-On 8/23/21 at 6:44 A.M., he/she sat in his/her wheelchair in his/her room. At 8:43 A.M., he/she remained in his/her room and ate breakfast. At 11:57 A.M., he/she lay in bed in his/her room;
-On 8/24/21 at 6:28 A.M., he/she sat in his/her wheelchair in his/her room. At 8:28 A.M., the resident remained in his/her room;
-On 8/27/21 at 8:26 A.M., he/she sat in his/her wheelchair in his/her room.
Review of the facility shower schedule, showed the resident was scheduled to receive a shower every Tuesday and Friday on day shift (7:00 A.M. - 7:00 P.M.).
Review of the shower sheets on 8/31/21 at 2:00 P.M., showed the facility provided two shower sheets, for the resident, dated 8/21/21 and 8/25/21.
3. Review of Resident #99's annual MDS, dated [DATE], showed:
-Adequate hearing and vision;
-Clear speech - distinct intelligible words;
-Ability to express ideas and wants: Understood;
-Ability to understand others: Understands - clear comprehension;
-BIMS score of 15;
-Rejection of care: Behavior not exhibited;
-Total dependence of one person required for bed mobility, toilet use and personal hygiene;
-Total dependence of two (+) persons required for transfers;
-Urinary Continence: Not rated, resident had an indwelling catheter;
-Diagnoses of neurogenic bladder (refers to bladder problems due to disease or injury of the central nervous system or peripheral (outer boundary or outer edges) nerves involved in the control of urination), obstructive uropathy (disorder of the urinary tract that occurs due to obstructed urinary flow), diabetes mellitus, quadriplegia, multiple sclerosis (disease of the central nervous system), anxiety and depression.
During an observation and interview on 8/19/21 at 8:49 A.M., showed the resident lay in bed wearing a gown. He/she said he/she is supposed to receive two showers a week, but usually gets one. He/she mostly gets bed baths, but would prefer a shower.
Review of the facility shower schedule, showed the resident was scheduled to receive a shower every Tuesday and Friday on day shift.
Review of the shower sheets on 8/31/21 at 2:00 P.M., showed the facility provided five shower sheets, for the resident, dated 7/2/21, 7/6/21, 7/9/21, 7/31/21 and 8/24/21.
4. Review of Resident #39's annual MDS, dated [DATE], showed:
-Adequate hearing and vision;
-Clear speech - distinct intelligible words;
-Ability to express ideas and wants: Understood;
-Ability to understand others: Understands - clear comprehension;
-BIMS score of 15;
-Rejection of care: Behavior not exhibited;
-Independent for bed mobility and toilet use;
-Supervision of one person required for transfers, personal hygiene and bathing;
-Diagnoses of diabetes mellitus, arthritis, anxiety and depression.
During an observation and interview on 8/19/21 at 9:19 A.M., showed the resident lay in bed. He/she said he/she could not recall when his/her last shower was and said a shower gets you much cleaner than a bed bath. He/she wants to be showered.
Review of the facility shower schedule, showed the resident was scheduled to receive a shower every Wednesday and Saturday on the night shift.
Review of the shower sheets on 8/31/21 at 2:00 P.M., showed the facility provided one shower sheet, for the resident, dated 8/25/21.
5. During an interview on 8/30/21 at 1:05 P.M., Certified Nurse Aide (CNA) S said he/she had worked at the facility for over five years. The showers are assigned to the CNAs working the floor. At one time they had shower aides. Residents are supposed to receive two showers a week, but there are a lot of days the showers can't be done because there is not enough help or time.
6. During an interview on 8/31/21 at 2:00 P.M., the administrator said she thought the CNAs documented their showers in their electronic chart in addition to completing a shower sheet. Staff present at that time searched the electronic records and could not find any more documentation. The administrator said she was unaware residents were not receiving their showers. She did not know residents had not been getting their showers and no one had reported to her there was a problem. Had she known, they would have made arrangements to ensure residents received their showers as scheduled.
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 receive treatment and care in accordance with professional standards of practice by failing to monitor the e...
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Based on observation, interview, and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice by failing to monitor the effectiveness of medication, and to notify the physician to address the abnormal medication level, for a one resident (Resident #84). The resident had a seizure disorder and required the use of anti-seizure medications. The facility failed to ensure the medication was administered in sufficient amount to ensure a therapeutic level. This resulted in the lab test, used to determine if the medication was at a therapeutic level, showing the levels as below therapeutic range. The facility failed to notify the physician that the levels were below therapeutic range. This resulted in the resident having seizure activity resulting an abrasion to the head. The facility census was 96.
Review of Resident #84's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/2/21, showed neurological issues with aphasia (inability to understand or express speech) and seizure disorder.
Review of the resident's care plan, in use at the time of the survey, showed;
-Is at risk for convulsions (seizures) and injury related to diagnosis Tuberous Sclerosis (a genetic disease that causes tumors or growths in the brain, which can result in epilepsy (seizure disorder) which causes seizures) with seizures;
-Give seizure medication as ordered by doctor;
-Monitor and document side effects and effectiveness of the medication.
Review of the resident's electronic physician order sheet (ePOS), showed:
-An order dated 12/4/20, for Levetiracetam (medication that can treat seizures) 3,500 milligrams (mg) tablet a day, for seizures. To be administered 1,500 mg in the morning, and 2,000 mg in the evening;
-An order dated 6/29/21, for Levetiracetam level.
Review of the resident's July and August 2021, electronic medication administration record (eMAR), showed Levetiracetam documented as administered as ordered.
Review of the resident's progress notes, showed:
-On 6/7/21 at 2:50 P.M., resident had a seizure activity while up in his/her wheelchair;
-On 7/14/21 at 10:47 P.M., resident had four seizure activities;
-On 7/17/21 at 2:57 P.M., resident had three seizure activities;
-On 7/26/21 at 9:23 A.M. (late entry), resident had a seizure activity, slid off the wheelchair, resulted a small abrasion to right side of his/her head;
-On 8/5/21 at 7:06 P.M., resident had a seizure activity;
-On 8/21/21 at 3:36 P.M., resident had a seizure activity while up in a wheelchair by the nurse's station.
Review of the resident's electronic medical record (EMR), showed:
-Diagnoses include, Tuberous Sclerosis;
-A scanned laboratory result, located under the documents tab, labeled xray abdomen, dated 7/27/21. The laboratory Levetiracetam results were attached to the x-ray result.
Review of the resident's laboratory test results, showed blood drawn on 7/2/21, Levetiracetam level results below 2 micrograms per milliliter (ug/mL), with a normal range of 6-46 ug/mL.
Further review of the resident's progress notes, showed:
-On 6/30/21 at 9:43 A.M., laboratory technician was unable to draw blood due to resident's behavior;
-No documentation of follow-up or notification to ordering physician regarding the delay in obtaining Levetiracetam level;
-No documentation the physician was notified of the low Levetiracetam level.
During an observation on 8/20/21 at 11:49 A.M., the resident's parent fed the resident with total assistance. He/she occasionally talked and provided verbal cues to the resident, with minimal response. The resident showed no attempts of feeding him/herself.
During an interview on 8/20/21 at 11:50 A.M., the resident's parent said he/she comes to the facility at times to administer the resident's medication when he/she gets notified of the resident refusing medications.
Further review of the resident's medical record, showed no documentation of the resident's refusals to take medications.
During an interview on 8/30/21 at 12:38 P.M., the Assistant Director of Nursing (ADON), said he/she expected the staff to notify the physician of abnormal test results in a timely manner. He/she also expected the staff to document properly, and records are to be labeled appropriately in the EMR.
During an interview on 8/31/21 at 10:16 A.M., the prescribing physician said he/she could not recall being notified by the facility staff about the abnormal laboratory test results. The physician asked if the resident's eMAR showed if the Levetiracetam had been administered by staff and was informed that the record indicated the medication was administered as ordered. The physician said that he/she was made aware of the resident's refusal to take medicines at times, but does not expect to be notified every time. He/she added that with the test results being too low, it's not just refusing, it's not given. The physician confirmed that he/she believes that the anti-seizure medicine has not been administered as ordered or as documented.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interviews, and record reviews the facility failed to ensure the resident environment remains as free of ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interviews, and record reviews the facility failed to ensure the resident environment remains as free of accident hazards as is possible and to ensure each resident received adequate supervision and assistance devices to prevent accidents for 19 residents who resided on the secured unit when the facility failed to ensure water temperatures were maintained at a safe level below 120 degrees (°) Fahrenheit (F). In addition, staff failed to implement a care planned intervention to encourage the resident to use a walker for ambulation, and left one resident on the toilet unattended who required supervision (Resident's #41, and #94). The census was 96.
1. Review of facility's Safety of Water Temperatures policy, undated and reviewed on 8/23/21 at 8:03 A.M., showed water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 120°F or the maximum allowable temperature per state regulation.
Observation of the third floor secured unit on 8/19/21 at 1:44 P.M., showed:
-Hot water from a sink in resident room [ROOM NUMBER] that measured 124.1° F with a calibrated digital thermometer. Hot water from the same sink in resident room [ROOM NUMBER] measured 124.1° F a second time on 8/19/21 at 1:52 P.M.;
-Hot water from a sink in resident room [ROOM NUMBER] that measured 122.3° F with a calibrated digital thermometer.
During an interview on 8/19/21 at 3:02 P.M., Maintenance Employee P said acceptable hot water temperatures in any resident area should be under 120 degrees as higher temperatures can cause potential injury to residents. Water temperatures in resident care areas are supposed to be checked weekly on Wednesdays, and random rooms on each hall are used to log temperatures, but not every resident room is checked. Shower rooms on each hall are not checked during these regular maintenance checks.
During an interview on 8/19/21 at 3:10 P.M., the administrator said she would expect water temperature checks to occur weekly, as that is the maintenance department's policy.
Review of facility's maintenance logs dating back to March of 2021, reviewed on 8/19/21 at 2:28 P.M., showed the most recent temperature check was done on 6/8/21. Review of these logs showed additional temperature checks conducted on 3/26, 4/1, 4/14, 4/23, and 5/13/21.
Review of the facility's temperature checks done on 8/19/21, showed temperatures at or above 120° F in 10 of 72 resident rooms.
4. Review of Resident #41's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/27/21, showed:
-Mental status memory problem;
-Long term and short term memory problem;
-Limited assistance in transfer, and locomotion on the unit;
-Diagnoses include Alzheimer's disease, dementia, anxiety and depression;
-Medications include antidepressant, and antibiotic medications used.
Review of the resident's electronic medical record (EMR), showed:
-admission date of 2/20/21;
-Medical diagnoses include Alzheimer's disease, history of falling, lumbar fracture, spinal stenosis (a narrowing of the spinal canal), and major depressive disorder.
Review of the resident's electronic physician order sheet (ePOS), showed the following orders:
-On 2/20/21, assistive device to use (walker);
-On 2/22/21, monitor antidepressant medication side effects, such as anxiety;
-On 3/24/21, Venlafaxine (antidepressant medicine) tablet 75 milligrams (mg) a day.
Review of the resident's care plan, dated 6/10/21, showed:
-Has actual/potential for fall, related to dementia, spinal stenosis, history of fracture;
-Check on resident frequently;
-Make sure resident's assistive device is close by;
-Review medications that increase the risk for falls;
-Needs assistance or escort to activity functions;
-Needs limited assistance from 1 staff to move between surfaces.
Review of the resident's progress notes, showed:
-On 7/21/21 at 4:13 P.M., the resident fell in the dining area, stated the resident was in dining room ambulating without a walker then tripped and fell;
-On 8/9/21 at 2:08 P.M., urinalysis (UA, lab test to check for a urinary tract infection) results reported to physician, an antibiotic ordered for 7 days;
-On 8/20/21 at 11:21 A.M., the resident complained of pain to the right wrist, swelling noted, x-ray showed fracture to the right wrist;
-On 8/21/21 at 8:39 P.M., the resident fell, witnessed by another resident who said that resident tried to reach for the walker, then stumbled and fell.
During an observation on 8/24/21 at 9:51 A.M., in the hall 3-short dining area, showed it lacked space for the residents and staff to move around freely. Residents were in either wheelchairs or dining chairs, and had to move a chair for residents in wheelchairs to pass. Some residents who are confused but can mobilized independently, had to turn to the side and squeeze through due to tight space. Resident #41 observed to stand without his/her walker. He/she sat in a dining chair against the wall, his/her walker placed next to him/her. He/she then attempted to reach for the walker, but it was trapped behind a chair.
During an interview on 8/27/21 at 10:16 A.M., the Certified Nurse Assistant (CNA) E, said that the dining area in hall 3-short is cluttered. He/she added that there is not enough space for residents to move around if needed, and believes this increases risks for residents' falls.
During an interview on 8/31/21 at 9:04 A.M., the administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) O, expected residents' care plan interventions to be followed.
5. Review of Resident #94's significant change in status MDS, dated [DATE], showed:
-admission date of 5/27/21;
-Ability to express ideas and wants: Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time;
-Ability to understand others: Usually understands - misses some part/intent of message but comprehends most conversation;
-Extensive assistance of one person required for bed mobility, dressing, and personal hygiene;
-Extensive assistance of two (+) persons required for transfers and toilet use;
-Moving from seated to standing position: Not steady, only able to stabilize with human assistance;
-Moving on/off toilet: Not steady, only able to stabilize with human assistance;
-Surface to surface transfer: Not steady, only able to stabilize with human assistance;
-Always incontinent of bowel and bladder;
-Mobility device: Wheelchair;
-Diagnoses of dementia and seizure disorder;
-Any falls since prior assessment: No.
Review of the resident's care plan, dated 7/8/21, showed:
-The resident is high risk for additional falls related to confusion, gait/balance problems, poor communication/comprehension and unaware of safety needs;
-Anticipate and meet the resident's needs;
-Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed;
-The resident has bladder/bowel incontinence related to dementia and severe cognitive impairment.
Review of the facility incident/accident tracking, showed the following for the resident:
-Unwitnessed Falls:
-On 8/9/21 at 4:00 P.M.;
-On 8/11/21 at 6:27 P.M.;
-Witnessed Fall:
-On 8/12/21 at 2:58 P.M.
Review of the resident's progress note, dated 8/11/21 at 6:44 P.M., showed:
-Writer was summoned to resident room by his/her caregiver and noted resident in front of his/her toilet, sitting on his/her buttocks with knees flexed, pants still upright and sitting in a puddle of urine. Resident could not explain how he/she had fell, but said he/she wanted to use the toilet. This writer, with assistance from caregiver, assisted the resident to his/her wheelchair. The resident remained at his/her toilet stating he/she needed to use the toilet. After five to seven minutes, the resident was noted lying across his/her bed with his/her pants around his/her ankles and his/her brief on. His/her wheelchair was adjacent to the bed.
Observation on 8/19/21 at 9:57 A.M., showed the resident's room door was open. The resident sat on the toilet and leaned against the wall next to the toilet. One staff member pushed a medication cart in the hall and stopped, asking the resident are you ok? The resident's response could not be heard. The staff member then said, ok, stay right there. He/she pushed his/her medication cart past the resident's room approximately 10 to 15 feet, and close to the nurse's station, locked the cart, and returned to and entered the resident's room and closed the door.
During an interview on 8/31/21 at 2:00 P.M., the DON said the resident has a history of falls and should not be left unattended on the toilet.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure staff positioned two residents' urinary catheter drainage bags off the floor. The facility identified seven residents w...
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Based on observation, interview and record review, the facility failed to ensure staff positioned two residents' urinary catheter drainage bags off the floor. The facility identified seven residents with indwelling urinary catheters (a tube inserted into the bladder to drain the bladder of urine. Urine is collected in a drainage bag until emptying). Of those seven, five were sampled and problems were identified with two. (Residents #99 and #57). The census was 96.
Review of the facility Catheter Care, Urinary policy, dated 2001 and revised on 2014, showed:
Purpose:
-The purpose of this procedure is to prevent catheter-associated urinary tract infection;;
Infection Control:
-Use standard precautions when handling or manipulating the drainage system;
-Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag;
-Be sure the catheter tubing and drainage bag are kept off the floor;
-Empty the drainage bag at least every eight hours.
1. Review of Resident #99's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/19/21, showed:
-Total dependence of one person required for bed mobility, toilet use and personal hygiene;
-Total dependence of two (+) persons required for transfers;
-Urinary Continence: Not rated, resident had an indwelling catheter;
-Diagnoses of neurogenic bladder (refers to bladder problems due to disease or injury of the central nervous system or peripheral (outer boundary or outer edges) nerves involved in the control of urination), obstructive uropathy (disorder of the urinary tract that occurs due to obstructed urinary flow), diabetes mellitus, quadriplegia (paralysis of both arms, legs and trunk), multiple sclerosis (disease of the central nervous system), anxiety and depression.
Observations of the resident, showed:
-On 8/23/21 at 6:27 A.M., he/she lay in bed sleeping. His/her urine drainage bag lay on the floor, uncovered and contained yellow urine;
-On 8/24/21 at 5:28 A.M., he/she lay in bed sleeping. His/her urine drainage bag lay on the floor, uncovered and contained yellow urine. The urine drainage bag remained uncovered and on the floor at 5:54 A.M., 7:30 A.M., and 10:20 A.M.;
-On 8/25/21 at 6:23 A.M., he/she lay in bed sleeping. His/her urine drainage bag lay on the floor, uncovered and contained yellow urine.
During an interview on 8/31/21 at 2:00 P.M., the Director of Nurses said she expects staff to follow the Catheter Care, Urinary policy. The catheter bag should not be on the floor. It should be attached to the bed frame off the floor and in a privacy bag to prevent infection.
2. Review of Resident #57's medical record, showed diagnoses included muscle weakness, unspecified lack of coordination, limitation of activities due to disability, encounter for fitting and adjustment of urinary device and retention of urine, unspecified.
Review of the resident's physician's order sheet, showed:
-An order, dated 8/19/21, for suprapubic/condom/indwelling catheter care. Keep tubing free of kinks and positioned below level of bladder every shift and as needed;
-An order, dated 8/19/21, to change catheter and/or drainage bag when clinically indicated such as infection, obstruction or when closed system is compromised, as needed.
Observations of the resident, showed:
-On 8/23/21 at 7:57 A.M. and 8:58 A.M., he/she lay on his/her back in bed. The catheter bag sat on the floor, uncovered on top of a white towel next to the resident's bed;
-On 8/25/21 at 7:08 A.M. and 9:10 A.M., he/she lay on his/her back in bed. The catheter bag sat, uncovered on the floor next to the resident's bed;
-On 8/26/21 at 8:21 A.M., he/she lay on his/her back in bed. The catheter tubing lay underneath the resident's bottom. The catheter bag sat on the floor next to the resident, uncovered and full of yellow urine.
During an interview on 8/26/21 at approximately 8:25 A.M., Certified Medication Technician (CMT) Q said the resident was not supposed to lay on his/her tubing. The tubing should fall below the bladder level and under the bed. It should not be on the resident. The catheter bag and tubing should be emptied to prevent urinary tract infections. The bag should be covered to maintain the resident's privacy.
During an interview on 8/26/21 at approximately 8:30 A.M., Nurse H said the tubing should be over the resident's legs. He/she was not supposed to be laying on the tubing. The bag and the tube was full and should be emptied. Not emptying the catheter bag and laying on the tubing could cause a urinary tract infection. The bag should be covered and not laying on the floor.
During an interview on 8/31/21 at 9:04 A.M., the administrator said the catheter bags should be covered and off the floor.
CONCERN
(D)
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, interviews, and record review, the facility failed to provide care and services to maintain acceptable par...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to provide care and services to maintain acceptable parameters of nutritional status for two of five residents investigated for nutrition (Resident #68 and #86). This resulted in both residents experiencing a significant weight loss. The sample was 20. The census was 96.
1. Review of Resident #68's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/2/21, showed:
-Severely impaired cognition;
-Extensive assistance with eating;
-Diagnoses included progressive neurological conditions including aphasia (difficulty forming and expressing spoken words) and Multiple Sclerosis (a progressive decline in neuromuscular function);
-Recorded weight of 131 pounds (lbs);
-Care Area Assessment Summary (CAAS): Cognitive loss/dementia and nutritional status triggered.
Review of the resident's quarterly MDS, dated [DATE], showed:
-Moderately impaired cognition;
-Extensive assistance with eating;
-Diagnoses included progressive neurological conditions including aphasia and Multiple Sclerosis;
-Recorded weight of 128 lbs.
Review of the resident's care plan, in use at the time of the survey, showed:
-Problem: The resident has a swallowing problem related to dysphagia (difficulty swallowing) associated with a diagnosis of Bulbar Palsy (a neurologic condition affecting muscles in the face and jaw) and requires mechanically altered diet. Recent history of weight loss and receives a dietary supplement;
-Goal: The resident will have no choking episodes when eating through the review date;
-Interventions: Resident to eat only with supervision and assistance from staff to avoid wasting. Resident drops food when trying to feed him/herself;
Review of the resident's progress notes, showed:
-An occupational therapy note dated 5/28/21: Interventions included an entry dated 5/28/21, patient to have divided plate, built-up spoon and 2-handled cups with lids for meals.
Review of the resident's weights, showed a recorded weight of 127.6 pounds on 6/1/21 and a recorded weight of 116 pounds on 8/14/21, a calculated weight loss of 9.09% in two months.
Review of the resident's electronic physician order sheet (ePOS), showed:
-An order for discharge skilled occupational Therapy (OT), patient met goals and may have Restorative Nursing Program (RNP) or Functional Maintenance Program (FNP). Recommend for patient to use divided plate, built-up spoon and 2-handled cup(s) with lid(s) during meals;
-An order dated 7/30/21, for meal supplement Ready Care/Med Pass 2.0 (nutritional supplements) three times daily;
-Regular, pureed diet;
-An order for monthly weights.
During observations on 8/20/21 at 1:25 P.M., 8/23/21 at 9:21 A.M., 8/24/21 at 10:01 A.M., and 8/30/21 at 1:20 P.M., showed the resident struggled to eat his/her pureed meals with no assistance. The resident attempted to use regular, plastic utensils to eat his/her meal but appeared to have poor coordination and poor motor skills and was unable to feed him/herself. The majority of his/her food fell onto his/her lap or onto the table, as well as on his/her face. He/she ate quickly, but periodically rested his/her head in his/her hands and appeared fatigued while eating.
During observations on 8/23/21 and 8/30/21, showed during the breakfast and lunch meal services, the facility served the resident meals with no assistive utensils and regular cups. The resident struggled to drink from the regular, styrofoam cups that staff provided and had difficulty eating with the standard, plastic utensils.
During an observation on 8/25/21 at 9:37 A.M., showed the resident sat in the unit dining room at a table with other residents and reached for the other residents' food. He/she appeared to still be hungry despite eating all of his/her meal. Staff did not offer him/her extra portions, substitutes, or ask if he/she was still hungry.
Observation of the resident's meal ticket, on 8/26/21 at 1:16 P.M., showed the resident should be served a regular, pureed diet, but mentioned no need for special utensils.
During an interview on 8/26/21 at 9:34 A.M., Certified Nursing Assistant (CNA) E said he/she was aware the resident needed built-up utensils, a divided plate, and a two-handled cup for meals. The OT department put orders in for the resident to have these special utensils, but he/she believes the utensils are kept in OT rather than on the unit.
During an interview on 8/26/21 at 11:55 P.M., the Dietary Manager said special utensils are kept in the kitchen and are sent up to the floor with resident trays. The nursing staff or therapy department will put orders in for the use of special utensils during meals, and those orders will be reflected on each resident's meal ticket so the kitchen is aware of what each resident needs sent up with their tray.
During an interview on 8/30/21 at 10:01 A.M., OT N said each day the department heads hold a morning meeting where they can discuss residents who have care or therapy concerns. He/she is familiar with the resident and reports the resident's deficits revolve around self-feeding and coordination with his/her hands, but that no issues have been brought up during the daily meetings in regards to this resident. They recommended the resident have built-up utensils at each meal, including a divided plate and a lidded cup with two handles. The resident should be using these utensils during every meal and would benefit immensely from doing so. At this time OT N does not believe the resident is using these utensils during meals on the floor, although the recommendation is to do so. The kitchen provides special utensils to residents on the floor for each meal, and he/she met with the dietary manager to confirm that these utensils are available for residents. When the recommendation was first made for the resident to use special utensils with meals, he/she delivered a built-up spoon, lidded cup, and divided plate to the floor. He/she labeled the utensils with the resident's information and advised staff to keep these utensils on the floor and to wash them between each meal in order to ensure they are available for the resident.
During an interview with the administrator, director of nursing, and ADON (Assistant Director of Nursing) O on 8/31/21 at 9:04 A.M. the administration stated they would expect care plans to be followed as entered and physician orders to be followed as written for reach resident.
2. Review of Resident #86's quarterly MDS, dated [DATE], showed:
-Severely impaired vision, no vision or sees only light;
-Moderately impaired cognition with poor decision making;
-Requires supervision and setup help only for eating;
-Diagnoses included active progressive neurological conditions including Alzheimer's disease and dementia;
-Marked for cataracts, glaucoma, or macular degeneration;
-Recorded weight of 144 lbs;
-CAAS: cognitive loss/dementia, visual function, and nutritional status triggered.
Review of the resident's quarterly MDS, dated [DATE], showed:
-Severely impaired vision, no vision or sees only light;
-Moderately impaired cognition with poor decision making;
-Requires supervision and setup help only for eating;
-Diagnoses included active progressive neurological conditions including Alzheimer's disease and dementia;
-Recorded weight of 138 lbs.
Review of the resident's care plan, in use at the time of the survey, showed:
-Problem: The resident has a potential nutritional problem;
-Goal: The resident will maintain adequate nutritional status as evidenced by no signs and symptoms of malnutrition through review date;
-Interventions included: Monitor/record/report to medical doctor (MD) as needed (PRN) signs and symptoms of malnutrition: Emaciation (progressive weakness and fatigue caused by significant weight loss), muscle wasting, significant weight loss: 3 lbs in 1 week, greater than 5% in 1 month, 7.5% in 3 months, greater than 10% in 6 months;
-The care plan made no mention of the resident needing assistance during mealtimes.
Further review of the resident's care plan, in use at the time of the survey, showed:
-Problem: He/she has impaired cognitive function/dementia or impaired thought processes related to Alzheimer's disease, Dementia, Developmentally delayed (Down's Syndrome, a congenital condition characterized by some degree of limitation of intellectual ability and social and practical skills);
-Goals included: He/she will be able to communicate basic needs on a daily basis through the review date. He/she will maintain current level of cognitive function through the review date;
-Interventions included: Provide a program of activities that accommodates his/her abilities keeping in mind that he/she is legally blind.
Review of the resident's medical record, reviewed on 8/24/21 at 11:52 A.M., showed the following recorded weights:
-On 2/6/21 a recorded weight of 146.9;
-On 5/4/21 a recorded weight of 142.9;
-On 8/3/21 a recorded weight of 131.5;
-On 8/24/21 a recorded weight of 132.0;
-A significant weight loss of 10.14% in six months.
Review of the resident's ePOS, reviewed on 8/26/21 at 7:37 A.M., showed a regular diet with ground meat. No active order for any feeding assistance.
During observations on 8/19/21 at 9:31 A.M., 8/20/21 at 12:52 P.M., and 8/23/21 at 12:46 P.M., showed the resident stood at a table in the dining room, called out loudly that he/she wanted his/her plate and after a moment became tearful. On 8/26/21 at 9:31 A.M., the resident complained loudly to staff that the food is nasty and that he/she did not want to eat it. Staff attempted to reorient the resident but offered no substitutes for the meal.
During an interview on 8/27/21 at 11:30 A.M., the Registered Dietician said dietary staff did not follow any recipes for special dietary meals, such as pureed/mechanically altered foods.
3. During an interview with the administrator, director of nursing, and ADON O on 8/31/21 at 9:04 A.M., the administrator stated they would expect care plans to be followed as entered and physician orders to be followed as written for reach resident. The administrator stated a recipe should be followed for all pureed meals.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
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 residents using bed/side rails, had adequate a...
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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 using bed/side rails, had adequate assessments to determine the side rails were appropriate and safe to be used and/or had physician's orders. The facility identified 22 residents with side rails in use. Two of 20 sampled residents (Residents #16 and #63) and one expanded resident (Resident #13) had side rails but were not identified by the facility as having them. The census was 96.
Review of the facility's Proper Use of Side Rails policy, revised December 2016, showed:
-The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms;
-Physical restraints are defined by the Centers for Medicare and Medicaid Services (CMS) 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 (Note: The definition of restraints is based on the functional status of the resident and not on the device, therefore any device that has the effect on the resident of restricting freedom of movement or normal access to one's body could be considered a restraint);
-General Guidelines:
-Side rails are considered a restraint when they are used to limit the resident's freedom of movement (prevent the resident from leaving his/her bed);
-Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents;
-An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfers, an assessment will include a review of the resident's:
-Bed mobility;
-Ability to change positions, transfers to and from bed or chair, and to stand and toilet;
-Risk of entrapment from the use of side rails;
-That the bed's dimensions are appropriate for the resident's size and weight;
-The use of side rails as an assistive device will be addressed in the resident care plan;
-Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks;
-The resident will be checked periodically for safety relative to side rail use;
-When side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk of entrapment.
1. Review of Resident #16's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/14/21, showed:
-admission date of 5/6/21;
-Resident rarely/never understood;
-Total dependence of two (+) person physical assist required for bed mobility;
-Upper and lower extremities impaired on both sides;
-Diagnoses included cerebral palsy (group of disorders that affect a person's ability to move and maintain balance and posture), quadriplegia (paralysis of all four limbs), anxiety, depression, left knee contracture (stiffness or constriction in connective tissues), right knee contracture and muscle spasms;
-Bed rails not used.
Review of the resident's medical record, showed no physician orders for side rails or assessments for the use of side rails.
Review of the binder of side rail assessments, located at the nurse's station, showed no assessments for the resident's use of side rails.
Review of the resident's care plan, undated, showed no documentation regarding the use of side rails.
Observation on 8/19/21 at 9:52 A.M. and 6:03 P.M., 8/20/21 at 7:41 A.M. and 12:12 P.M., 8/23/21 at 6:33 A.M. and 8:59 A.M., 8/24/21 at 5:58 A.M., 8/25/21 at 9:01 A.M., 8/26/21 at 9:25 A.M., and 8/27/21 at 11:29 A.M., showed the resident lay on his/her back in bed, on a low air loss (LAL) mattress. Half-length side rails were raised on both sides of the bed, at the head of the bed on both sides. At that time, the resident was unable to be interviewed. He/she was unable to respond to questions.
2. Review of Resident #63's admission MDS, dated [DATE], showed the following:
-admission date 6/16/21;
-No cognitive impairment;
-No behaviors or mood concerns;
-Extensive assistance with bed mobility;
-Diagnoses of medical complex conditions, high blood pressure, high cholesterol and quadriplegia;
-No bed rails used.
Review of the resident's care plan, dated 6/16/21, showed the following:
-Focus: The resident has side rails in place to increase independence with bed mobility;
-Goal: The resident will use side rail(s) to maintain bed mobility and assist with positioning;
-Interventions: Evaluation for use of side rails will be completed prior to side rail placement and will be reviewed quarterly. The resident will sign consent prior to side rail placement and will renew consent yearly. The resident will demonstrate the ability safely use side rails for positioning, transfer and bed mobility.
Review of the resident medical record, showed a bed rail data collection tool/consent, dated 6/16/21, for 1/8 side rails for left and right.
Observation on 8/20/21 at 7:05 A.M., 8/23/21 at 8:23 A.M. and 8/25/21 at 8:45 A.M., showed the resident lay in bed with his/her feet approximately 1 inch from the foot board. The resident had 1/8 U shaped side rails on each side. The resident said he/she uses the side rails to adjust him/herself while in bed. The resident said he/she has never been caught in the side rails.
Review of the resident's Order Recap Report, dated 6/1/21 through 8/30/21, showed no documentation for an order for side rails.
3. Review of Resident #13's admission MDS, dated [DATE], showed:
-admission date of 5/7/21;
-Cognitively intact;
-Extensive assistance of one person physical assist required for bed mobility;
-Diagnoses included arthritis, anxiety, bipolar disorder, schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves), insomnia, severe obesity and generalized muscle weakness;
-Bed rails not used.
Review of the resident's electronic physician orders, showed an order, dated 8/30/21, for half-length side rails for positioning and bed mobility.
Review of the resident's medical record, showed no assessments for the use of side rails.
Review of the binder of side rail assessments, located at the nurse's station, showed no assessments for the resident's use of side rails.
Review of the resident's care plan, undated, showed no documentation regarding the use of side rails.
Observation on 8/23/21 at 9:13 A.M., 8/24/21 at 6:19 A.M., 8/26/21 at 8:22 A.M., and 8/30/21 at 12:59 P.M., showed the resident on his/her back in bed, on a LAL mattress. Half rails were raised at the head of the bed on both sides.
During an interview on 8/24/21 at 6:19 A.M., the resident said he/she likes his/her side rails and uses one to keep his/her call light in place and within his/her reach.
4. During an interview on 8/26/21 at 12:06 P.M., licensed practical nurse (LPN) W said the charge nurse completes side rail assessments upon admission, a change in condition, and on a monthly basis. The assessments are documented in the electronic medical record (EMR). There is also a binder at the nurse's station with some assessments. Therapy might make the recommendation for the use of a side rail and then the nurse completes the side rail assessment. Physician orders for the use of a side rail must be obtained.
5. During an interview on 8/30/21 at 11:06 A.M., the Director of Nurses (DON) said the nurse assesses residents for the use of side rails upon admission. If any resident has side rails, they should be assessed for them. Side rail assessments are completed on paper and are kept in a binder at the nurse's station. Physician orders must be obtained for the use of side rails, and side rails should be documented on the resident's care plan.
6. During an interview on 8/31/21 at 9:03 A.M., the Assistant Director of Nurses (ADON) and administrator said residents with side rails must be assessed for entrapment risk. Side rails should be ordered by the physician and documented on the resident's care plan. Orders for the use of side rails were just obtained for Resident #13.
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 on residents that are complete and readily accessible in accordance with accepted professional standa...
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Based on observation, interview and record review, the facility failed to maintain medical records on residents that are complete and readily accessible in accordance with accepted professional standards and practices for two of 20 sampled residents (Residents #251 and #250). The census was 96.
1. Review of Resident #251's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/30/20, showed:
-admission date: 10/26/20;
-Severe cognitive impairment;
-No moods or behaviors;
-Total dependence with activities of daily living;
-Diagnoses of medically complex conditions, high blood pressure, diabetes, Alzheimer's disease, Parkinson's disease and asthma;
-Feeding tube;
-Tracheostomy Care (an opening in the front of the neck so a tube may be inserted so the person can breathe).
Review of the resident's hospital record, dated 1/16/21, showed:
-Chief complaint: Dislodged trachea;
-History of Present Illness: The resident was unable to give any history. The resident's family member provided history over the phone. It is unclear how long or when the trachea was dislodged. The resident's family member did not think the resident pulled it out. The facility attempted to replace the trachea without success. The resident's tracheostomy was replaced in the emergency room department. The inner cannula was fully hardened with pus. The resident has thick yellow secretions from the tracheostomy site. The tracheostomy was replaced uneventfully in the emergency room department.
Review of the resident's medical record, showed no documentation as the why the resident was sent to the hospital for treatment of his/her tracheostomy.
During an interview on 8/26/21 at 10:52 A.M. the Assistant Director of Nursing (ADON) said she could not find any documentation as to why the resident was sent to the hospital. The ADON said she would have expected documentation of the event regarding the tracheostomy, who was notified and when the resident was sent. The ADON said she did not know why there was no documentation.
During an interview on 8/31/21 at 12:40 P.M., the Director of Nursing said the charge nurse should have documented the event regarding the resident's tracheostomy in his/her medical record. She did not know why it was not documented.
2. Review of Resident #250's facesheet, showed:
-admission date: 8/28/20;
-discharged date: 8/30/20;
-Diagnoses of acute respiratory disease, major depression, stroke and high blood pressure.
Review of the resident physician's order history, dated 8/27/20 through 8/31/20, with orders dated 8/28/20, showed:
-Amlodipine (treats high blood pressure) 5 milligrams (mg), one tablet, once per day;
-Atorvastatin (treats high cholesterol) 80 mg, one tablet at bedtime;
-Cyanocobalamin (Vitamin B-12 treat anemia) 1000 microgram (mcg), one tablet, once every other day;
-Dexamethasone (treats inflammation) 6 mg, one tablet, once a day;
-Eliquis (treat blood clots) 5 mg, one tablet, twice a day;
-Escitalopram oxalate (treats bipolar disorder) 10 mg tablet, one tablet at bedtime.
Review of the resident's medical record, showed no documentation of the medications being administered.
During an interview on 8/26/21 at 7:35 A.M., the administrator said they were unable to locate the medication administration records (MAR) to show the medication had been administered. The administrator said she did not know why they could not be found. The MARs should be apart of the resident's medical record.
MO00174841
MO00180656
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to provide resident council members with verbal and written responses, actions and rationale taken regarding their concerns. In addition, the ...
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Based on interview and record review, the facility failed to provide resident council members with verbal and written responses, actions and rationale taken regarding their concerns. In addition, the facility failed to provide a timely written response to a grievance regarding missing personal items for one of 20 sampled residents (Resident #11), in accordance with the facility's grievance policy. The census was 96.
Review of the facility's Grievance/Complaints, Filing, revised April 2017, showed the following:
-Policy Statement: Resident 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 (e.g., the state Ombudsman).
-Policy Interpretation and Implementation:
-Any resident, family member, or appointed resident representative may file a grievance or complaint concerning 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;
-Residents, family and resident representatives have the right to voice of file grievances without discrimination or reprisal in any form and without fear of discrimination or reprisal;
-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;
-Grievances and/or complaints may be submitted orally or in writing, and may be filed anonymously;
-The administrator has delegated herself as the Grievance Officer and the responsibility of grievance and/or complaint investigation;
-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 within five working days of receiving the grievance and/or complaint.
During an interview on 8/25/21 at 10:08 A.M., seven of seven residents who attended the meeting said when grievances are filed, staff do not get back with them on their grievances. They say they will get to but they never do.
1. Review of the Resident Council Meeting Minutes, dated April 2021 through June 2021, showed the following:
-April, 2021:
-Nursing: Request of head nurses on halls, too many cell phones being used and not enough of answering call lights. The nurses should help the Certified Nurse Aides (CNAs) with the call lights. Often call lights will be on down the halls and the staff will be on their phones;
-Dietary: The food is icky and some have stopped eating it. The food is always cold. The kitchen is not serving fresh fruit. The residents would like to use the dining room again;
-Activities: There is no stimulation on the weekends. The residents would like an activity every day.
-No documentation addressing any of these concerns.
May, 2021;
-Old Business: Cell phones. No documentation of any responses regarding this concern;
-Nursing: Cell phones are being answered by nurses and CNAs;
-Dietary: The food stinks and some residents do not eat it.
-No documentation addressing any of these concerns.
June, 2021;
-Nursing: Residents do not like the agency staff, because they just don't do care correctly;
-Dietary: The food sucks. The residents would like better food. The food is not appealing to the palette of the nose.
-No documentation addressing any of these concerns.
During an interview on 8/25/21 at 1:06 P.M., the activity director said regarding the grievance policy and what to do when residents voice grievances during the resident council, she was not sure if there is anything written on the process to address the concerns. When holding the resident council meetings, she takes the complaints to the appropriate department head and then they provide her with notes on how they plan to address it. Those are supposed to go in the resident council meeting minutes, but it is currently not being done. She does not necessary document the response from residents when concerns are addressed at the following meeting.
During an interview on 8/25/21 at 1:38 P.M., the administrator said the grievances are taken to the department heads to be addressed, then the resolutions are taken to the next meeting. If it is something that needs to be addressed immediately, it is addressed. The previous Activity director probably took the resolutions for the previous months.
2. Review of Resident #11's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/11/21, showed;
-admission date of 12/5/20;
-Resident rarely/never understood;
-Required extensive assistance of one person for dressing;
-Diagnoses included dementia.
Review of the resident's medical record, showed no personal inventory sheets.
Review of the resident's Service Recovery form, dated 7/23/21, showed:
-Reported by: blank;
-Phone number: blank;
-Department involved: maintenance, social services (SS), and laundry;
-Explanation of concern and your resolution thus far: Family was allowed in resident's room. Family stated resident is missing all of his/her nice clothes, socks, and a large TV. Family is very upset. Family also said resident's nice clothes were dropped off in June. Family will provide a list;
-Department head/manager resolution: Administrator, laundry, and SS are looking for missing items. Maintenance found resident's television. Resident had clothes in his/her closet found by SS assistant. Although family was provided with the list of belongings found in resident's room, they still felt that things were missing. Our facility will continue to work with resident and his/her family;
-Date resolved: blank;
-Signed by Social Worker.
Review of the resident's progress note, dated 8/18/21, showed SS documented an inventory list was provided to the resident's family. Family said they would look over the list and let the facility know what else is missing.
During an interview on 8/25/21 at 7:21 A.M., the social worker said nursing staff is responsible for completing inventory sheets for all residents upon admission to the facility. When family brings in additional items, the inventory sheet should be updated by whichever staff is available at that time. He is responsible for handling grievance or complaints regarding lost or stolen items. The resident's family reported he/she was missing $250 worth of clothing. The facility did investigate and completed an inventory of what items the resident had in his/her closet and compared it to the list provided by the family.
During an interview on 9/2/21 at 10:34 A.M., the social worker said he could not recall who filed the grievance in July 2021 regarding the resident's missing items. He has not closed out the resident's grievance yet because he wanted to make sure the missing items could not be located, or the family gave approval to close out the grievance. When a grievance is resolved, a written response should be provided to the person who filed the grievance.
MO00188546
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0570
(Tag F0570)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to maintain a surety bond for the resident trust fund account in the amount of one and one half times the average monthly balance for the past...
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Based on interview and record review, the facility failed to maintain a 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 sample size was 20. The census was 96.
Review of the resident trust account for the past 8 months, from December 2020 through July 2021, showed an average monthly balance of $118,000.00. This would yield a required bond in the amount of $177,000.00 (one and one half times the average monthly balance).
Review of the bond report for approved facility bonds by the Department of Health and Senior Services (DHSS), dated 2/26/21, showed an approved bond of $175,000.00.
During an interview on 8/23/21 at 8:00 A.M., the administrator said it was possibly due to the residents receiving their stimulus checks, which is why the current surety bond is short.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure the residents' right to request, refuse, and/or discontinue treatment was followed, in the event the resident was foun...
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Based on observation, interview, and record review, the facility failed to ensure the residents' right to request, refuse, and/or discontinue treatment was followed, in the event the resident was found without signs of life, when the facility failed to maintain accurate, congruent, and easily accessible documentation of advance directives for five residents investigated for accuracy of code status (Residents #15, #11, #71, #100, and #32). The sample was 20. The census was 96.
1. Review of the facility's census and room roster, showed Residents #15 and #11 identified as residing in the locked memory care unit.
Observation of the code status book, located at the nurse's station on the locked unit, reviewed on 8/30/21 at 7:45 A.M., showed (Residents #15 and #11) did not have hard copies of advance directive information in it.
Review of Resident #15's electronic medical record (EMR), showed the code status listed as do not resuscitate (DNR, no life saving measures performed if the resident were to be found with no signs of life). Review of the documents tab, showed no signed code status sheet scanned into the EMR.
Review of Resident #11's EMR, showed code status listed DNR. Review of the documents tab, showed no signed code status sheet scanned into the EMR.
During an interview on 8/30/21 at 9:20 A.M., Certified Nursing Assistant (CNA) F said during the power outage at the facility on 8/26/21, the computer system was down and the staff worked off of a paper process. Code statuses are kept in a book at the nurse's station on each unit. If he/she needed to verify a resident's code status during computer system downtime, he/she would consult this book.
During an interview on 8/30/21 at 9:30 A.M., Registered Nurse (RN) I said during the facility power outage on 8/26/21, the computer system went down briefly, and staff documented care and interventions on paper during this time. There is a code status book where staff can locate accurate code statuses for each resident on the unit. It is kept at the nurse's station. He/she would use this book to verify code status for a resident if the electronic medical record was down.
2. Review of Resident #71's EMR, reviewed on 8/30/21 at 10:36 A.M., showed:
-An order for DNR code status;
-The care plan, in use at the time of the survey, dated 7/6/21, listed the resident as full code (all life-saving measures to be performed);
-The documents tab in the record, showed a scanned copy of the resident's advanced directives, for DNR.
3. Review of Resident #100's EMR, reviewed on 8/30/21 at 11:24 A.M., showed:
-No order for a code status;
-The care plan, in use at the time of the survey, listed the resident as full code;
-A scanned and signed DNR form dated 7/16/21.
4. Review of Resident #32's EMR, reviewed on 8/30/21 at 12:26 P.M., showed:
-No order for a code status;
-The care plan, in use at the time of the survey, listed the resident as full code;
-A scanned and signed DNR form dated 7/4/21.
5. During an interview on 8/31/21 at 2:04 P.M., the administrator stated she would expect all electronic resident medical records to be accurate. All code status books housed at the nurse's station on each unit should be accurate and include code statuses for every resident on that unit. She would expect all care plans to be accurate and reflect the resident's current code status.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a sufficient amount of supplies to meet the ...
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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 a sufficient amount of supplies to meet the care needs of residents in a dignified manner. This deficient practice had the potential to affect all residents receiving bathing services in the facility. The census was 96.
Review of the Resident's Handbook, revised in 2018, provided upon admission, showed:
-admission Agreement;
-Our responsibilities: We will provide you with room and board, nursing services, personal and housekeeping services, and routine supplies required by your condition;
-Appendix 5, Items and Services Included in the Daily Rate:
-Private pay: Items and services included in the daily rate, include nursing services, bathing services, and linen, housekeeping and maintenance services;
-Medicare Part A: If you are eligible to receive benefits under the Medicare Part A program, the following services will be covered by the daily rate paid to us, include nursing services, bathing services, and linen, housekeeping, and maintenance services;
-Medicaid: If you are eligible to receive benefits under the Missouri Medicaid program, the following services will be covered by the daily rate paid to us by Medicaid, including nursing services, bathing services, and linen, housekeeping, and maintenance services.
1. Review of Resident #47's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/3/21, showed:
-admission date of 4/14/20;
-Total dependence of two (+) person physical assist required for transfers;
-Limited assistance of one person physical assist required for personal hygiene and bathing;
-Upper and lower extremities impaired on one side;
-Diagnoses included stroke, seizures, paralysis following stroke affecting right dominant side, severe obesity, dementia and depression;
-Weight: 374 pounds (lbs).
Observation on 8/23/21 at 8:51 A.M., showed the resident sat in an electric wheelchair with his/her right arm wrapped and resting on the wheelchair arm rest. During an interview, the resident said he/she cannot use his/her right arm. He/she requires staff assistance with showers, which are supposed to be twice a week.
During an interview on 8/25/21 at 8:50 A.M., the resident said he/she received a shower this morning and the aide had to dry him/her off with a bed sheet. There are no towels for staff to use when it's time for a shower and that is a problem for him/her.
During an interview on 8/25/21 at 8:53 A.M., certified nurse aide (CNA) Z said he/she gets towels from laundry in the morning and stocks the supply room on his/her assigned hall. If staff stock the supply room and supply carts on their hall, there are not enough for the residents on the other halls. CNAs are supposed to use three towels for each shower. This morning, there were no small towels available so he/she had to use one large towel to wash Resident #47, and one large towel to dry him/her off. That was not enough towels for this resident. CNAs use towels when providing personal care to residents, too. During personal care, he/she uses three small towels and three large towels to make sure the resident is cleaned properly. There are not enough towels in the facility.
2. Review of Resident #26's quarterly MDS, dated [DATE], showed:
-admission date of 2/6/19;
-Supervision required for locomotion;
-One person physical assist required in part of bathing activity;
-Diagnoses included legal blindness.
Observation on 8/31/21 at 11:31 A.M., showed the resident ambulated down the hall, escorted by CNA AA. When they arrived at the shower room, CNA said he/she just remembered there are no towels for the resident to take a shower. The resident said the problem with not having towels is that he/she can't even take care of him/herself. CNA AA apologized and escorted the resident back to his/her room.
During an interview on 8/31/21 at 11:37 A.M., CNA AA said the facility has been short on towels for the past couple of months.
3. Observation on 8/23/21 at 8:50 A.M., showed one large towel in the linen supply room on the T3 hall.
During an interview on 8/23/21 at 8:50 A.M., CNA U said it is usually like this at the facility; they never have enough towels or wash cloths. Staff use wash cloths and towels for personal care, showers and bed baths. Everyone is aware of this issue, but nothing has changed and more towels have not come in.
4. Observations on 8/24/21 at approximately 6:11 A.M., showed:
-On the T3 hall, the linen cart contained six large towels. The linen supply room contained no towels;
-On the 3 Long hall, no towels on the linen cart or in the linen supply room.
5. Observation on 8/26/21 at 8:53 A.M., showed no towels in the linen room on the T3 hall. A white linen cart on the hall contained one small towel.
During an interview on 8/26/21 at 8:53 A.M., laundry aide (LA) X said staff have been requesting large and small towels, or washcloths, for months. The facility needs about 10 boxes of each sized towel. Administration is aware of the towel shortage and they keep saying more towels are coming, but they never do. He/she does not know what to do anymore and it makes him/her sad and want to cry. Towels are used by residents for showers, washing their faces, and personal care. The residents keep asking him/her for towels just so they can take a shower and then they have to use bed linens to dry off because there are not enough towels for them.
6. Observation on 8/26/21 at 9:21 A.M., showed two linen carts on the T3 hall. The blue linen cart contained one small towel and two large towels and the white linen cart contained no towels.
7. Observation on 8/26/21 at 12:31 P.M., showed LA Y brought a cart of linens to the linen supply room on T3. The cart contained approximately 40 small towels and 60 large towels. LA stocked the linen supply room with approximately 20 small towels and 30 large towels.
During an interview on 8/26/21 at 12:31 P.M., LA Y said the towels on his/her cart are all the facility has. He/she will put half in the linen room on T3, and the other half will go to the other side of the building. The amount of towels they have is not enough for all the residents in the facility. Staff have been asking for more towels for three months, but nothing has changed and more towels have not been received.
8. Observations on 8/30/21, at approximately 8:44 A.M., showed:
-On the memory care unit, the linen cart contained 10 large towels and five small towels. The linen supply room contained no towels.
-On the T3 hall, the linen supply room contained no towels.
9. During an interview on 8/26/21 at 9:41 A.M., CNA U said the facility is so short on towels and washcloths. Staff need towels for personal care and showers. The aides are trying to improvise by using bath sheets and blankets for showers, and clothing protectors to wipe residents during personal care. The aides were told that clothing protectors have the same texture as towels, but this isn't right. He/she questioned how staff were supposed to wipe a resident with a clothing protector, then wash it, and have the resident use that same clothing protector during a meal. There just is not enough towels in the facility.
10. During an interview on 8/26/21 at 11:33 A.M., CNA V said the facility has been short on towels for past couple months. If his/her assigned hall is out of towels, he/she has to check with laundry or other halls to see if they have any. Staff need to provide personal care or bathing assistance, but the facility is in short supply.
11. During an interview on 8/26/21 at 12:06 P.M., licensed practical nurse (LPN) W said the facility needs more supplies, particularly towels. Staff use towels to clean residents for personal care, and to give residents showers. He/she has seen and heard of staff using clothing protectors for personal care when they are out of towels, or using blankets and sheets for showers or bathing.
12. During an interview on 8/30/21 at 8:17 A.M., CNA F said there are not enough towels in the facility and it has been that way for a while now. CNA F questioned how staff can provide proper care when they don't have enough towels. Staff can use wipes for personal care, but they need at least three washcloths and four large towels for showers.
13. During an interview on 8/30/21 at 9:06 A.M., the administrator said staff has reported a towel shortage in the facility, but staff are also throwing towels away. She just ordered more towels on 8/23/21 and was promised they would be here the next day, but they never arrived. At this time, the facility is in a critical towel shortage and she will follow up with the facility's corporate office and will purchase more towels.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate r...
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Based on observation, interview, and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation when four out of four controlled substance shift change count sheets, for August 2021, were observed to lack consistent documentation of the count of controlled substances at shift change. The census was 96.
Review of the facility's Controlled Substances policy, revised 12/2012, showed:
-Policy statement included: The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances;
-Controlled substances must be counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together;
-Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services (DON);
-The DON shall investigate any discrepancies in narcotics reconciliation to determine the cause and identify any responsible parties, and shall give the Administrator a written report of such findings.
1. Observation on 8/26/21 at 12:00 P.M., of the Controlled Substance Shift Change Count sheet from the H3 Long Narcotic Binder, showed:
-The form used to count narcotics not the same form used on other floors;
-Every date with two lines for documentation. Each line included a slot to enter the time, number of packages, and a slot for both the nurse on and nurse off initials;
-The first time slot designated for each day filled in with 7:00 A.M. on all days but two, including pre filled out through the end of the month. The two days without 7:00 A.M. entered, blank;
-The second time slot designated for each day filled in with 7:00 P.M. on all days but one, including pre filled out through the end of the month. The one day without 7:00 P.M. entered, blank;
-For 13 of 51 opportunities, only one staff signed for count of narcotics;
-For two of 51 opportunities, no staff signed for count of narcotics;
-For seven of 51 opportunities, the number of packages of controlled substances not recorded.
2. Observation on 8/26/21 at 12:00 P.M., of the Controlled Substance Shift Change Count-Check sheet from the Terrace 2 (T2) Narcotic Binder, showed:
-The form used to count narcotics not the same form used on other floors;
-Every date with two lines for documentation. Each line included a slot to enter the time, number of packages, and a slot for both the nurse on and nurse off initials;
-The first time slot designated for each day filled in with 7:00 A.M. on all days but three. The three days without 7:00 A.M. entered, blank;
-The second time slot designated for each day filled in with 7:00 P.M. on all days but two. The two day without 7:00 P.M. entered, blank;
-For eight of 51 opportunities, only one staff signed for count of narcotics;
-For four of 51 opportunities, the number of packages of controlled substances not recorded.
3. Observation on 8/26/21 at 12:00 P.M., of the Controlled Substance Shift Change Count sheet from the Terrace 3 (T3) Front Narcotic Binder, showed:
-The form used to count narcotics not the same form used on other floors;
-Every date with three lines for documentation. Each line included a pre-filled out time, with the times of 6:00 A.M., 2:00 P.M., and 10:00 P.M. Each line included a slot to enter the number of packages, and a slot for both the nurse on and nurse off initials;
-Random 6:00 A.M. time slots crossed off and 7 hand written in;
-For 39 of 76 opportunities, only one staff signed for count of narcotics;
-For two of 76 opportunities, no staff signed for count of narcotics;
-For 22 of 76 opportunities, the number of packages of controlled substances not recorded;
-For five of 76 opportunities, no documentation of narcotic count.
4. Observation on 8/26/21 at 12:00 P.M., of the Controlled Substance Shift Change Count sheet from the T3 Back Narcotic Binder, showed:
-The form used to count narcotics not the same form used on other floors;
-Every date with three lines for documentation. Each line included a pre-filled out time, with the times of 6:00 A.M., 2:00 P.M., and 10:00 P.M. Each line included a slot to enter the number of packages, and a slot for both the nurse on and nurse off initials;
-Random 6:00 A.M. time slots crossed off and 7 hand written in;
-For 31 of 76 opportunities, only one staff signed for count of narcotics;
-For 22 of 76 opportunities, the number of packages of controlled substances not recorded;
-For eight of 76 opportunities, no documentation of narcotic count.
5. During an interview on 8/26/21 at 12:40 P.M., Certified Medication Technician (CMT) DD said facility staff worked 7:00 A.M. through 7:00 P.M. or 7:00 P.M. through 7:00 A.M., whereas CMTs from agencies could work 6:00 A.M. through 2:00 P.M., 7:00 A.M. through 7:00 P.M., 2:00 P.M. through 10:00 P.M., or 10:00 P.M. through 7:00 A.M., because the facility ensured there was a CMT to work each medication pass. The CMT working Terrace 3 was responsible for passing medications from two medication carts i.e. the Terrace 3 Front and back carts.
6. During an interview on 8/26/21 at 1:35 P.M., Staffing Coordinator EE said the facility aimed to have 16-hour CMT coverage on the Terrace 3 unit, from 6:30 A.M. to 10:00 P.M. Facility-staffed CMTs were scheduled to work 12-hour shifts on Terrace 3 i.e. 7:00 A.M. through 7:00 P.M. or 7:00 P.M. through 7:00 A.M. Agency or facility-staffed CMTs were scheduled to work four hours on Terrace 3 from 6:30 A.M. through 10:00 A.M. or 6:30 P.M. through 10:30 P.M. An exception included two facility-staffed CMTs who worked eight hour shifts due to them having worked at the facility for years prior and were permitted to continue to do so. Said staffs' eight hour shifts were grandfathered-in (grandfather clause, when an outdated rule continues to apply to individuals allowed to be exempted from the updated rule due to well established history of being governed under the old rule). Another exception included when staff called off.
7. During an interview on 8/26/21 at 9:47 A.M., the DON said that she expected Controlled Substance Shift Count sheets to show accurate and complete documentation of the count of controlled substances at shift change. At approximately 1:35 P.M., she confirmed that the T3 Front Controlled Substance Shift Change Count sheet, dated 08/2021 and the T3 Back Controlled Substance Shift Change Count sheet, dated 08/2021 did not accurately account for all shifts CMTs worked on the Terrace 3 unit. A controlled substance shift change count could have occurred more often than the Controlled Substance Shift Change Count sheets in use for this unit could account for; she had not previously considered this. This was not a good system to account for the count of controlled substances at shift change.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure the proper storage of medications in three of three treatment carts, and three of four medication carts observed. The ...
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Based on observation, interview, and record review, the facility failed to ensure the proper storage of medications in three of three treatment carts, and three of four medication carts observed. The treatment carts had medications not labeled properly. The medication carts contained spills over supplement containers, opened food, and improperly labeled medications. The facility had five medication carts and three treatment carts. The census was 96.
Review of the facility's Storage of Medications policy, revised 4/2007, showed:
-The facility shall store all drugs and biologicals in a safe, secure, and orderly manner;
-Drugs shall be stored in the packaging, containers, or other dispensing systems in which they are received;
-The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner;
-Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing;
-The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals;
-Drugs for external use shall be clearly marked as such, and shall be stored separately from other medications;
-Compartments containing drugs shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or potentially available to others;
-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 must be stored separately from food and must be labelled accordingly.
1. Observation on 8/19/21 at 10:43 A.M., of the Terrace 2 treatment cart, showed an undated and opened container of Solosite Wound Gel (applied to wound to create a moist wound environment) and a tube of Nystatin/Triamcinolone (a combination medication that treats fungal or yeast infections) without a resident's name on it.
2. Observation on 8/19/21 at 10:43 A.M., of the Terrace 2 medication cart, showed an opened, undated bottle of Proheal Liquid Protein supplement that was sticky to the touch, with a manufacturer expiration date of 2022 noted on it. License Practical Nurse (LPN) HH denied knowing if ProHeal Liquid Protein supplement should be dated when opened. He/she said residents were not actively receiving it.
3. Observation on 8/19/21 at 11:45 A.M., of the 3 Long treatment cart, showed two opened tubes of Santyl (medication used to treat wounds) and an opened container of anti-itch cream, undated. LPN H said he/she did not expect to see topical medications opened and undated in the 3 Long treatment cart.
4. Observation on 8/19/21 at 11:53 A.M., of the 3 Long Medication cart, showed a box of opened cheese crackers sat in the upper drawer adjacent to the locked compartment designated for controlled substance storage. An opened and undated bottle of ProHeal Protein supplement in another drawer. On the bottle were manufacturer instructions that read to discard two months after the opening. During an interview with Certified Medication Technician (CMT) Q at this time, he/she denied that it was normal to store cheese crackers in the medication cart and admitted storing the cheese crackers for another staff person. The ProHeal Protein supplement should have been dated when it was opened.
5. Observation on 8/20/21 at 7:10 A.M., of the Terrace 3 treatment cart, showed an opened tube of Zinc Oxide (used to aid in wound healing) without an open date, in the 3rd drawer down from the top of cart.
6. Observation on 8/20/21 at 7:25 A.M., of the Back Terrace 3 medication cart, showed an opened package of bulk-wrapped Ipratropium/Albuterol (medications used to treat asthma) vials that were not labeled with a resident's name. CMT II denied knowing who the package of Ipratropium/Albuterol belonged to and removed it from the cart.
7. During an interview on 8/26/21 at 9:47 A.M., the Director of Nursing (DON) said she expected stock topical medications to be dated when they are opened. The facility purchased a supply of Santyl topical medication because it is no longer covered under Medicaid and it should be dated, when it is opened. Anti-itch cream and Solosite Wound gel are stock medications that should be labeled with the date opened. Nystatin/Triamcinolone is a prescription medication that she would expect to be labeled with a resident's name and date. ProHeal Liquid Protein supplement should be dated when opened because one would not know how long it has been there. She denies knowing if giving ProHeal Liquid Protein, that has been opened longer than manufacturer recommendation, would cause adverse effects to residents. She states it would likely not be as potent. She did not expect employee food to be stored on a medication cart. Foods and medication should be stored separately. She would not expect a package of Ipratropium/albuterol vials to be stored on the medication cart without a resident's name labeled on it because how would you know who they belonged to.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to provide for requests of additional food at meal times and failed to offer nourishing snacks at bedtime. This had the potential...
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Based on observation, interview and record review, the facility failed to provide for requests of additional food at meal times and failed to offer nourishing snacks at bedtime. This had the potential to affect all residents. The census was 96.
1. Review of the resident council meeting minutes, dated April 28, 2021, showed the following for dietary:
-Food is icky, I stopped eating it;
-No documentation which resident in attendance voiced this concern;
-He/she got sick the same day I did. Saturday and Sunday. I know it was off the food;
-No documentation which resident in attendance voiced this concern;
-Food is always cold;
-Lots of unintended weight loss;
-The kitchen has not been serving fresh fruit. There used to be fruit available anytime. Maybe COVID is an issue. Would bananas and oranges be safer due to their skins?;
-We want to use the dining room again.
2. Review of the resident council meeting minutes, dated May 26, 2021, showed the following for dietary:
-Dietary food stinks;
-What would make it better;
-Starting June 21, new dietary manger;
-One resident said: I don't eat it;
-One resident said: Some's good, some not so good;
-No documented follow-up for the April, 2021 dietary concerns with responses from the dietary department head.
3. Review of the resident council meeting minutes, dated June 30, 2021, showed the following for dietary:
-One resident said: it sucks;
-One resident said: need better food;
-One resident said: I don't eat it;
-One resident said: No corn on the ticket, they still put corn on my plate;
-One resident said: I eat it if I want it, if I don't, I leave it there. If you don't want it, you can call down and get something else;
-One resident said: They are not cooking it, they are short staffed down there;
-One resident said: No cooks down there in the evening;
-One resident said: Not appealing for the palette or the nose;
-One resident said: He/she understands it's a budget issue. The kitchen is not coming up with the menus;
-I assured them we are working to address the issues because it's not fair and not healthy when they feel they can't eat;
-Two residents said: Meals get to rooms considerably later, sometimes lunch is at 2:00, any day, weekends are worse;
-One resident said: the dream of eating in the dining room;
-Response: We are short staffed, so when we fix our concerns, then we can get back to the dining room.
4. Review of the resident council meeting minutes, dated July 28, 2021, showed the following for dietary:
-The administrator attended the meeting;
-Doing a lot better;
-A work in progress.
5. Review of the menus for Weeks 1 through 4, showed no snacks listed.
6. Observation on 8/23/21 at 8:55 A.M., on the locked unit, three short hall, showed the refrigerator had four frozen meals, four peanut butter and jelly sandwiches dated 8/22, a quarter rind of watermelon, leftover Chinese takeout, and three milk cartons. It was unknown if these items were for the residents.
7. During an interview on 8/23/21 at 12:43 P.M., Certified Medication Technician T said the facility does not provide snacks for the residents. Certified Nurse's Aide (CNA) F will go out and purchase snacks for the residents on his/her unit.
8. Observation on 8/24/21 at 9:59 A.M. showed CNA E called to the kitchen for another portion of biscuits and gravy for two residents, but was told they didn't have anymore. CNA F offered cold cereal as a substitute.
9. During an interview on 8/20/21 at 1:00 P.M., CNA F said he/she worked at the facility for five years. Since the new management took over, residents have not received snacks from the facility. He/she will go to the grocery store and purchase snacks for the residents with his/her own money.
10. During an interview on 8/25/21 at 9:46 A.M., CNA F said he/she can't always get residents extra portions and cannot always get substitutes. The kitchen staff always have an attitude when he/she calls for extra portions or substitutes. CNA F has to make due with what he/she has, and he/she buys food to keep on the unit so the residents can have snacks and substitutes. CNA F is planning to buy lunch for the locked unit tomorrow so that they can have some real food.
11. During an interview on 8/25/21 at 1:53 P.M., the dietary manager said up until about a week or so ago, they were not giving out snacks to the residents. The residents will receive sandwiches at night.
12. During an interview on 8/25/21 at 1:24 P.M., the administrator said they are aware of concerns regarding dietary, it is a work in progress. There are things that must be put into place. Food is getting better, but they still need to progress more. As far as snacks, the facility addressed that. No residents ever told the administrator and Director of Nurses they are going hungry. Sometimes they don't like the food and want a sandwich. On 8/27/21 at 7:52 P.M., the administrator said she started at the facility on July 5th of this year.
MO00171135
MO00183658
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure the quality assurance and performance improvement (QAPI) program committee developed and implemented appropriate plans of action to ...
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Based on interview and record review, the facility failed to ensure the quality assurance and performance improvement (QAPI) program committee developed and implemented appropriate plans of action to correct identified quality of life deficiencies related to dietary and activity concerns. This had the potential to affect all residents in the facility. The census was 96.
Review of the facility Quality Assurance and Performance Improvement (QAPI) Program policy, dated 2001 and revised on 2/2020, showed:
Policy Statement:
-This facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents;
Policy Interpretation and Implementation:
The objective of the QAPI program are to:
-Provide a means to measure current and potential indicators for outcomes of care and quality of life;
-Provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators;
-Reinforce and build upon effective systems and processes related to the delivery of quality care and services;
-Establish systems through which to monitor and evaluate corrective actions;
Authority:
-The owner and/or governing board (body) of our facility is ultimately responsible for the QAPI program;
-The governing board/owner evaluates the effectiveness of its QAPI program at least annually and presents findings to the QAPI committee;
-The administrator is responsible for assuring that this facility's QAPI program complies with federal, state and local regulatory requirements;
-The QAPI committee reports directly to the administrator;
Implementation:
-The QAPI committee oversees implementation of our QAPI plan, which is the written component describing the specifics of the QAPI program, how the facility will conduct is QAPI functions, and the activities of the QAPI committee;
-The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include:
a. Tracking and measuring performance;
b. Establishing goals and thresholds for performance measurement;
c. Identifying and prioritizing quality deficiencies;
d. Systematically analyzing underlying causes of systemic quality deficiencies;
e. Developing and implementing corrective action or performance improvement activities;
f. Monitoring or evaluating the effectiveness of corrective action/performance improvement activities, and revising as needed;
-The committee meets monthly to review reports, evaluate data, and monitor QAPI-related activities and make adjustments to the plan;
Coordination:
-The QAPI coordinator manages QAPI committee activities and changes to the QAPI plan;
-The QAPI coordinator assists other committees, individuals, departments, and/or services in developing quality indicators, monitoring tools, assessment methodologies and documentation, and in making adjustments to the plan;
-The QAPI coordinator serves as a liaison between the QAPI committee and individual, services, and/or departments regarding QAPI activities.
1. Review of the resident council meeting minutes, dated April 28, 2021, showed:
Dietary:
-Food is icky, I stopped eating it;
-No documentation which resident in attendance voiced this concern;
-He/she got sick the same day I did. Saturday and Sunday. I know it was off the food;
-No documentation which resident in attendance voiced this concern;
-Food is always cold;
-Lots of unintended weight loss;
-The kitchen has not been serving fresh fruit. There used to be fruit available anytime. Maybe COVID is an issue. Would bananas and oranges be safer due to their skins?;
-Miscellaneous: Please bring back the snack cart. For people that miss the snack cart/meals, it would be helpful to have more food available to them at all hours (on the halls).
Wellness/Activity's:
-No stimulation on the weekends;
-We ought to have an activity every day;
-Need more people to work;
-Want more outside of rooms as a group such as outdoors, when we did the snow cones;
-Snow cones would have been improved with better notice. A resident said he/she just happened to notice it was going on when it happened on 4/27;
-We want to do more walks:
-Response: Walks might be a safety issue, we need more staff or a different approach;
-No further responses to the resident's concerns.
Review of the resident council meeting minutes, dated May 26, 2021, showed:
Dietary:
-Dietary food stinks;
-What would make it better;
-Starting June 21, new dietary manger;
-One resident said: I don't eat it;
-One resident said: Some's good, some not so good;
-No documented follow-up for the April 2021 dietary concerns with responses from the dietary department head;
Wellness/Activities:
-No resident concerns documented.
Review of the resident council meeting minutes, dated June 30, 2021, showed:
-Dietary:
-One resident said: it sucks;
-One resident said: need better food;
-One resident said: I don't eat it;
-One resident said: I eat it if I want it, if I don't, I leave it there. If you don't want it, you can call down and get something else;
-One resident said: Not appealing for the palette or the nose;
Wellness/Activities:
-Suggestions:
-Ice cream, more ice cream, drumsticks;
-Toss across;
-Bean bag tic tack toe;
-Improvement on basket games;
-Snow cones;
-More outside activities;
-Corn hole was always a fun game. It would be a great idea;
-Wii bowling;
-More crafts;
-Cooking club;
-Painting;
-Entertainers, probably budget and COVID;
-Old administration took the slot machines.
Review of the resident council meeting minutes, dated July 28, 2021, showed:
Dietary:
-The administrator attended the meeting;
-Doing a lot better;
-A work in progress;
Wellness/Activities:
-The administrator and other department heads attended the meeting;
-Hopefully soon we'll get somebody else to join our team;
-Maybe BINGO on Monday and Wednesday if we get someone, since we don't have Sunday BINGO?;
On 8/27/21 at 11:10 A.M., the administrator reviewed the monthly QAPI records, and identified the following:
April 2021:
-Activities: Problem - Residents are not ready when activities starting. Intervention: Inservice staff;
-Dietary: No problems identified;
May 2021:
-Activities: Problems - Getting residents ready for activities, but improved since last month;
-Dietary: Problem - Sanitation, food storage needs reorganizing, leftovers labeled. Food quality, handwashing, temperature control and weight loss. Food temperatures per the Registered Dietician, but no examples as to what if anything was identified regarding food temperatures. Cooks are conscientious. Food quality and temperature control during food production handling;
June 2021:
-Activities: No issues discussed;
-Dietary: No issues discussed. No problems identified regarding resident complaints during the May or June resident council;
July:
-Activities: No issues discussed. No information regarding a lack of staff to carry out activity programs;
-Dietary: No issues discussed. No information regarding a lack of staffing to meet resident needs.
During an interview on 8/25/21 at 10:00 A.M., seven of seven residents who attended the resident council meeting said the food is cold at all meals. They don't get choice of what they can have. The staff will get really rude about it. The residents said they would like to have menus to be able to choose from. The facility has BINGO and movies for activities, but there are not any other activities. They believe that it is due to activity staff being short. Activities are put on the calendar every month, but these activities might not be done. Often, movies are repeated multiple times through the week, and staff report they don't have any other movies.
During an interview on 8/25/21 at 1:06 P.M., the activity director they are looking to hire more activity staff. She is currently the only activity staff person at this time. They would like to hire a full and part time person. She has been employed at the facility for 2 1/2 years in the activity department but has only been the activity director for 2 weeks when the prior director left. Being the only activity staff is not sufficient to provide a full activities program to the residents. There are times when activities are not able to be provided as scheduled due to staffing. There are also currently not enough staff to provide evening or weekend activities. The facility has been short staffed for a while. She works Monday through Friday from 8:30 A.M. to 5:00 P.M. There are currently no activities occurring in the evening.
During an interview on 8/27/21 at 8:20 A.M., the administrator said until the 3rd week of July there were 2 activity staff, that is when the former activity director's employment ended. The facility is looking for two full and one part time activity staff to help the activity director. The current activity director has been employed for a while, but has not enrolled into the activity directors training yet. She has 90 days to get the training done. The prior activity director had a degree.
During an interview on 8/27/21 at 11:10 A.M., the administrator said for the May 2021 QAPI meeting, activities was discussed. It was not identified that there was a concern with a lack of activities. The concern was that staff were not assisting the residents to be up and ready for activities. Staffing concerns regarding activities was not identified. Activities has not been documented in the QAPI notes as an area of concern since May.
During a telephone interview on 9/7/21 at 1:20 P.M., the Director of Nurses (DON) said she had been at the facility for about a month and had attended the only QAPI meeting since her arrival. She has been a DON for several years prior to working for this facility. The purpose of the QAPI meeting is to address problems identified by staff or residents. The facility has a monthly QAPI meeting attended by all department managers and the medical director. The problems identified with activities and the dietary department during the survey process have been on-going and should be addressed in the QAPI meetings.
During an interview on 8/31/21 at 9:04 A.M., the administrator said dietary was short staffed in the kitchen. The facility is working to hire more kitchen staff.
During a telephone interview on 9/9/21 at 11:57 A.M., the administrator said after she reviewed the QAPI records from April 2021 through July 2021, from what she could tell, the facility had not identified the systemic problems with dietary or activities. She had just started about a month ago and had only attended one of those QAPI meetings. The QAPI Program policy is the policy the facility should have followed to identify those problems, implement interventions and monitor outcomes.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program 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 maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure staff received the required tuberculosis (TB) screening as required per their policy, perform proper hand hygiene when providing personal care for two residents (Residents #16 and #84), ensure a shared electric razor was disinfected between uses (Resident #9), and ensure staff appropriately wore masks to cover both their nose and mouth when around residents or other staff. The census was 96.
1. Review of the facility's Tuberculosis Infection Control Program Policy, revised January 2012, showed:
-Policy Statement: The facility recognizes that TB transmission has been identified as a risk in healthcare settings. To try to prevent nosocomial (acquired in house) transmission of TB, our facility has instituted a Tuberculosis Infection Control Program;
-Upon hire, employee shall receive first step during orientation, read in two days and employee may then start work. Fourteen days later, the employee shall receive second step, read in two days and annually thereafter.
Review of Therapy A's employee file showed:
-Date of Hire (DOH): 12/3/20;
-First TB administered: 2/9/21; No documentation of read date;
-No documentation of second TB test administered.
Review of Nurse B's employee file showed:
-DOH: 2/5/21;
-No documentation of first or second TB test administered or read.
Review of Therapy C's employee file showed:
-DOH: 2/22/21;
-First TB administered: 2/22/21; No documentation of a read date;
-No documentation of second TB test administered.
Review of [NAME] D's employee file showed:
-DOH: 5/12/21;
-No documentation of the first or second TB test administered or read.
During an interview on 8/23/21 at 7:27 A.M., the administrator said she would expect the first TB test to be administered during employee orientation and read two days later and the second step to be completed 14 days later. The administrator said she did not know why the TB screenings were not completed.
2. Review of the facility Perineal (genitalia area) Care policy, dated 2001 and revised in 2018, showed:
Purpose:
-The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition;
Steps in the Procedure:
-Place the equipment on the bedside stand. Arrange the supplies so they can be easily reached;
-Wash and dry your hands thoroughly;
-Put on gloves;
-Wash perineal area, wiping from front to back;
-Gently dry the perineum;
-Ask the resident to turn on his/her side with legs slightly bent;
-Wash buttocks and rectal area thoroughly;
-Rinse and dry thoroughly;
-Discard disposable items into designated containers;
-Remove gloves and discard into designated containers;
-Wash and dry your hands thoroughly.
3. Review of the facility Infection Control Guidelines for All Nursing Procedures policy, dated 2005 and revised in 2012, showed:
Purpose:
-To provide guidelines for general infection control while caring for residents;
General Guidelines:
Employees must wash their hands for 10 to 15 seconds using antimicrobial or non-antimicrobial soap and water under the following conditions;
-Before and after direct contact with residents;
-When hands are visibly dirty or soiled with blood or other body fluids;
-After contact with blood, body fluids, secretions, mucous membranes, or non-intact skin;
-After removing gloves;
-After handling items potentially contaminated with blood, body fluids, or secretions.
4. Review of the facility Handwashing/Hand Hygiene policy, dated 2001 and revised in 2015, showed:
Policy Statement:
-This facility considers hand hygiene the primary means to prevent the spread of infection;
Policy Interpretation and Implementation;
-All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections;
-All personnel shall follow the handwashing/hand hygiene procedures to help prevent spread of infections to other personnel, residents, and visitors;
-The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.
5. Review of Resident #16's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/14/21, showed:
-Rarely/never understood or understands;
-Total dependence of two (+) persons for bed mobility, transfers and toilet use;
-Total dependence of one person for personal hygiene;
-Always incontinent of bowel and bladder;
-Diagnoses of cerebral palsy (impaired muscle coordination), quadriplegia (paralysis of both arms, legs and trunk), anxiety and depression.
Observation on 8/24/21 at 5:31 A.M., showed the resident lay in bed Certified Nursing Assistant (CNA) J and Nurse K washed their hands and donned (applied) gloves. The nurse cleaned bowel movement from the resident's buttocks. The resident was positioned onto his/her other side and the CNA cleaned bowel movement from the resident's buttocks. Without changing or removing his/her soiled gloves, the nurse touched the resident's new incontinence brief, pillow case, incontinence pad, a multi-use tube of barrier cream and the resident's tube feeding pump before he/she removed his/her gloves, washed his/her hands and left the resident's room. The CNA, without removing his/her soiled gloves, touched the bed controls and the room door handle. The CNA exited and entered the room twice before he/she removed his/her soiled gloves and washed his/her hands. During an interview at 6:10 A.M., the nurse said he/she should have removed his/her soiled gloves and washed his/her hands prior to touching any clean objects.
During an interview on 8/31/21 at 2:00 P.M., the Director of Nurses (DON) said she expected staff to follow the facility infection control policies. Staff should wash hands before and after providing personal care. Gloves are considered soiled after providing care and should be removed and hands should be washed prior to touching anything clean.
6. Review of Resident #84's significant change MDS, dated [DATE], showed:
-Severely impaired cognition;
-Extensive assistance with bed mobility, dressing and personal hygiene;
-Active diagnoses included arthritis, aphasia (inability to understand or express speech) and seizure disorder.
Review of the resident's electronic medical record (EMR), showed diagnoses included Tuberous Sclerosis (a genetic disease that causes tumors or growths in the brain, which can result in epilepsy (seizure disorder)) and generalized muscle weakness.
Review of the resident's care plan, in use at the time of survey, showed:
-Activities of Daily Living (ADL) self-care performance deficit;
-Extensive to dependent assist with one assist in dressing and personal hygiene care.
Observation on 8/20/21 at 12:14 P.M., showed Certified Medical Technician (CMT) R applied gloves and removed the resident's dirty incontinence brief, while CNA F gathered supplies. CMT R disposed of the dirty brief, wiped the resident's perineal area, and applied a clean brief without removing his/her dirty gloves. He/she then removed the soiled gloves, but did not perform hand hygiene after removing his/her dirty gloves. He/she then used the bed remote to lower the bed, replaced the fall mat next to the resident's bed, covered the resident with sheets, and left the room without performing hand hygiene.
During an interview on 8/20/21 at 12:22 P.M., CMT R said he/she was not aware of the policy for perineal care procedures, but gloves should be changed after wiping the resident's incontinence soiled areas. Hands should be washed and new gloves should be put on before applying clean briefs on the residents. The facility had not provided a perineal care policy since the start of his/her employment about three weeks ago.
7. Review of the facility's Blood Borne Pathogen Control Plan, dated 6/2003, showed:
-Mask technique included letting the mask cover nose and mouth;
-Equipment which may become contaminated with blood or other infectious material shall be decontaminated prior to reuse;
-Any equipment used mutually on patients must be cleaned with an FDA (Food and Drug Administration)-approved germicide after contact with body fluids.
Review of Resident #9's quarterly MDS, dated [DATE], showed:
-Mental status memory problem;
-Long term and short term memory problems;
-Modified independence cognitively;
-Physical help in part of bathing activity;
-Active diagnoses included dementia and Alzheimer's disease;
-Antipsychotic medications used.
Observation on 8/25/21 at 8:06 A.M., showed CNA F obtained an electric razor from the clean linen cart and used it to shave the resident. He/she did not sanitize the razor before and after use. CNA F said he/she does not like the disposable razors, so he/she bought an electric razor for the residents. He/she said, Oh, I rinse it, when asked if he/she used the same razor on other residents. CNA F rinsed the razor with running tap water after shaving the resident. CNA F then returned the razor to the linen cart.
During an interview on 8/30/21 at 7:19 A.M., the DON said it is appropriate for staff to use shared razors, as long as they are properly cleaned. Staff are expected to disinfect the razors with an approved cleaning agent. A copy of the policy to address shared personal hygiene equipment was requested at this time.
8. Review of the Centers for Disease Control and Prevention (CDC), Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, updated March 29, 2021, showed:
-Older adults living in congregate settings are at high risk of being affected by respiratory and other pathogens, such as SARS-CoV-2;
-A strong infection prevention and control (IPC) program is critical to protect both residents and healthcare personnel (HCP);
-Personal Protective Equipment (PPE):
-Facilities should have supplies of facemasks, N95 or higher-level respirators, gowns, gloves, and eye protection (i.e., face shield or goggles);
-Implement Universal Use of Personal Protective Equipment:
-One of the following should be worn by HCP while in the facility and for protection during resident care encounters:
-An approved N95 respirator;
-A well-fitting facemask.
Observation on 8/19/21 at 2:45 P.M., showed Laundry Aide X stood in front of his/her housekeeping cart in the hall and donned a surgical mask that did not cover his/her nose. He/she touched the front of his/her surgical mask to pull it up over his/her nose. He/she did not wash his/her hands or use hand sanitizer. He/she touched the handles of the housekeeping cart with both hands.
Observation on 8/20/21 at 7:02 A.M., Laundry Aide X stood near the Terrace 3 nursing station without his/her surgical mask covering his/her nose. During an additional observation at approximately 7:45 A.M., he/she hugged Resident #93, who was not wearing a mask, Laundry Aide X's, mask did not cover his/her nose.
Observation on 8/20/21 at 11:55 A.M., showed Staff Person JJ stood in front of the elevator adjacent to the Terrace 3 nursing station and not wearing a mask. Other staff and residents were located near the Terrace 3 nursing station at the time. The elevator approximately 10 feet from the nurses station. He/she boarded and rode the elevator down to floor one, where he/she exited, then walked down the hallway and entered the employee breakroom. He/she exited the employee breakroom, then walked up the hallway back toward the elevator and continued to wear no mask.
Observation on 8/25/21 at 6:40 A.M., Staff Person JJ did not wear a mask as he/she stood near the time-clock adjacent to the coronavirus disease 2019 (COVID-19) screening station, near the front entrance.
Observation on 8/26/21 at 12:30 P.M., showed Lead Housekeeper BB wore his/her mask on his/her chin and not covering his/her nose and mouth as he/she stood on the elevator with Laundry Aide X. During an interview at that time, he/she said his/her surgical mask should have covered his/her nose and mouth while he/she was in the elevator with the other staff person.
During an additional interview on 8/27/21 at 10:40 A.M., Lead Housekeeper BB said he/she would get hot and feel as if he/she could not breathe when wearing a mask while working. He/she just needed to pull the mask down for a moment to get air.
During an interview on 8/25/21 at 7:54 A.M., the administrator and the DON said staff should wear masks at all times, while in the facility. The administrator denied any exceptions for mask wearing, aside from when an employee was eating while on break.
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 ensure staff completed routine inspections of bed fram...
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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 completed routine inspections of bed frames, mattresses and bed/side rails as part of a regular maintenance program to identify areas of possible entrapment for six residents (Residents #16, #13, #49, #47, #19 and #39) with side rails to reduce the risks of accidents. The facility identified 22 residents with side rails in use. Residents #16 and #13 were not identified by the facility as having side rails. The sample was 20. The census was 96.
Review of the FDA (Federal Drug Administration) documents, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated 3/10/06, showed bed rails, also called side rails, may be used as a restraint, reminder, or assistive device. Evaluating the gaps in hospital beds is one component of a mitigation strategy to reduce entrapment. Hospital beds have seven potential entrapment zones. The neck, head, and chest are the key body parts at risk for life-threatening entrapment. Elderly residents are among the most vulnerable for entrapment, particularly those who are frail, confused, restless, or who have uncontrolled body movement.
Review of the facility's Proper Use of Side Rails policy, revised December 2016, showed:
-The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms;
-Physical restraints are defined by the Centers for Medicare and Medicaid Services (CMS) 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 (Note: The definition of restraints is based on the functional status of the resident and not on the device, therefore any device that has the effect on the resident of restricting freedom of movement or normal access to one's body could be considered a restraint);
-General Guidelines:
-Side rails are considered a restraint when they are used to limit the resident's freedom of movement (prevent the resident from leaving his/her bed);
-Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents;
-An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfers, an assessment will include a review of the resident's:
-Bed mobility;
-Ability to change positions, transfers to and from bed or chair, and to stand and toilet;
-Risk of entrapment from the use of side rails;
-That the bed's dimensions are appropriate for the resident's size and weight;
-The use of side rails as an assistive device will be addressed in the resident care plan;
-Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks;
-The resident will be checked periodically for safety relative to side rail use;
-When side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk of entrapment;
-The policy failed to provide guidance regarding routine inspections of side rails.
1. Review of Resident #16's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/14/21, showed:
-Resident rarely/never understood;
-Total dependence of two (+) person physical assist required for bed mobility;
-Upper and lower extremities impaired on both sides;
-Diagnoses included cerebral palsy (group of disorders that affect a person's ability to move and maintain balance and posture), quadriplegia (paralysis of all four limbs), anxiety, depression, left knee contracture (stiffness or constriction in connective tissues), right knee contracture and muscle spasms;
-Bed rails not used.
Review of the resident's medical record, showed no physician's orders for side rails, no bed rail assessments, no documentation of a maintenance inspection of side rails and no documentation regarding the assessment of spaces/gaps between the resident's mattress and side rails.
Review of the resident's care plan, undated and use at the time of survey, showed no documentation regarding use of side rails.
Observation on 8/19/21 at 9:52 A.M. and 6:03 P.M., 8/20/21 at 7:41 A.M. and 12:12 P.M., 8/23/21 at 6:33 A.M. and 8:59 A.M., 8/24/21 at 5:58 A.M., 8/25/21 at 9:01 A.M., 8/26/21 at 9:25 A.M. and 8/27/21 at 11:29 A.M., showed the resident lay in bed on his/her back, on a low air loss (LAL) mattress. Half-length side rails were raised on both sides of the bed, at at the head of the bed on both sides. The resident was unable to be interviewed.
2. Review of Resident #13's admission MDS, dated [DATE], showed:
-Cognitively intact;
-Extensive assistance of one person physical assist required for bed mobility;
-Diagnoses included arthritis, anxiety, bipolar disorder, schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves), insomnia, severe obesity and generalized muscle weakness;
-Bed rails not used.
Review of the resident's electronic physician's orders, showed an order, dated 8/30/21, for half-length side rails for positioning and bed mobility.
Review of the resident's medical record, showed no bed rail assessments, no documentation of a maintenance inspection of side rails and no documentation regarding the assessment of spaces/gaps between the resident's mattress and side rails.
Review of the resident's care plan, undated and use at the time of survey, showed no documentation regarding use of side rails.
Observation on 8/23/21 at 9:13 A.M., 8/24/21 at 6:19 A.M., 8/26/21 at 8:22 A.M. and 8/30/21 at 12:59 P.M., showed the resident lay in bed on his/her back, on a LAL mattress. Half-length side rails were raised at the head of the bed on both sides.
During an interview on 8/24/21 at 6:19 A.M., the resident said he/she likes his/her side rails and uses one to keep his/her call light in places and within reach.
3. Review of Resident #49's quarterly MDS, dated [DATE], showed:
-Resident rarely/never understood;
-Extensive assistance of one person physical assist required for bed mobility;
-Upper extremity impaired on one side, and lower extremities impaired on both sides;
-Diagnoses included unspecified fracture of lower end of left femur, aphasia (disorder caused by damage to the parts of the brain that control language), stroke, weakness or paralysis to one side, dementia, depression, lack of coordination, contracture unspecified joint, muscle weakness and history of falling;
-Bed rails not used.
Review of the resident's electronic physician's orders, showed an order, dated 3/29/21, for quarter-length side rails for positioning and bed mobility.
Review of the resident's bed rail assessment, dated 3/10/21, showed:
-Bed rails recommended due to resident request;
-Quarter-length rails on upper left and right side of bed;
-No documentation regarding the assessment of space/gaps between the resident's mattress and side rails.
Review of the resident's medical record, showed no documentation of a maintenance inspection of side rails.
Review of the resident's care plan, undated and in use at the time of survey, showed:
-Focus: Resident has quarter-length side rails in place for positioning and improved bed mobility;
-Tasks included: Evaluation for use of side rails will be completed prior to side rail placement and will be reviewed quarterly. Gap measurements will be performed on resident beds where side rails are in use. The 7 entrapment zones will be measured and recorded to ensure they are within FDA recommendations.
Observation on 8/19/21 at 9:59 A.M., showed the resident sat in bed, using his/her right hand to eat breakfast. His/her left hand bent at the wrist, approximately 60 degrees, and his/her legs bent at a 90 degree angle and leaning to the left side of the bed. U-shaped positioning rails were raised at the head of the bed on both sides. The resident was unable to speak and could not be interviewed.
4. Review of Resident #47's quarterly MDS, dated [DATE], showed:
-Moderate cognitive impairment;
-Extensive assistance of two (+) person physical assist required for bed mobility;
-Upper and lower extremities impaired on one side;
-Diagnoses included stroke, seizure disorder, paralysis to right dominant side following stroke, severe obesity, dementia and depression;
-Bed rails not used.
Review of the resident's electronic physician's orders, showed an order, dated 3/11/21, for use of half-length side rails for bed mobility.
Review of the resident's bed rail assessment, dated 3/11/21, showed:
-Bed rails recommended due to resident request;
-Half-length rails on upper left and right side of bed;
-No documentation regarding the assessment of spaces/gaps between the resident's mattress and side rails.
Review of the resident's medical record, no documentation of a maintenance inspection of side rails.
Review of the resident's care plan, undated and in use at the time of survey, showed:
-Focus: The resident has an activities of daily living (ADL) self-care performance deficit related to paralysis to one side with right hand contracture;
-Tasks included: The resident requires assist by two staff to turn and reposition in bed. Bilateral assist rails to enhance self bed mobility.
Observation on 8/19/21 at 9:33 A.M., showed the resident sat in a wheelchair in his/her room. A trapeze bar hung over the resident's bed and half-length side rails were raised at the head of the bed on each side. During an interview, the resident said he/she does not have use of his/her right hand. The bars on his/her bed help him/her move and make him/her feel safe.
5. Review of Resident#19's quarterly MDS, dated [DATE], showed:
-Intact cognition;
-Total dependence of two (+) persons required for bed mobility, transfers, dressing and toilet use;
-Total dependence of one person required for personal hygiene and bathing;
-Diagnoses of quadriplegia, seizure disorder, anxiety and depression;
-Side rails not used.
Review of the resident's electronic physician's orders, showed an order, dated 4/16/21, for quarter-length side rails for positioning and bed mobility.
Review of the resident's medical record, showed no documentation of a maintenance inspection of side rails and no documentation regarding the assessment of spaces/gaps between the resident's mattress and side rails.
Observations on the following dates and times, showed the resident lay in bed with two quarter-length bed rails up at the head of the bed:
-8/20/21 at 7:35 A.M.;
-8/23/21 at 6:17 A.M. and 9:48 A.M.;
-8/24/21 at 5:46 A.M.;
-8/25/21 at 6:17 A.M., 8:32 A.M. and 9:31 A.M.;
-8/26/21 at 6:06 A.M. and 12:07 P.M.;
-8/27/21 at 9:20 A.M.
6. Review of Resident #39's annual MDS, dated [DATE], showed:
-Intact cognition;
-Independent for bed mobility and toilet use;
-Supervision of one person required for transfers, personal hygiene and bathing;
-Diagnoses of diabetes mellitus, arthritis, anxiety and depression;
-Side rails not used.
Review of the resident's electronic physician's order, showed an order, dated 3/12/21, for quarter-length side rails for bed mobility and transfers.
Review of the resident's medical record, showed no documentation of a maintenance inspection of side rails and no documentation regarding the assessment of spaces/gaps between the resident's mattress and side rails.
Observations on the following dates and times, showed the resident lay in bed with two quarter-length bed rails up at the head of the bed:
-8/23/21 at 6:22 A.M.;
-8/24/21 at 5:49 A.M.;
-8/25/21 at 8:36 A.M.;
-8/26/21 at 6:12 A.M.
7. During an interview on 8/26/21 at 8:41 A.M., Licensed Practical Nurse (LPN) H said therapy determines what type of side rail a resident needs. Nursing staff completes a side rail assessment to determine the use of side rails, and the assessments are done on a quarterly basis. Maintenance completes a separate assessment regarding the side rail inspection.
8. During an interview on 8/26/21 at 12:06 P.M., LPN W said the charge nurse completes side rail assessments upon admission, a change in condition, and on a monthly basis. The assessments are documented in the electronic medical record (EMR). There is also a binder at the nurse's station with some assessments. Therapy might make the recommendation for the use of a side rail and then the nurse completes the side rail assessment. Physician's orders for the use of a side rail must be obtained. Maintenance is responsible for installing and inspecting the side rails.
9. During an interview on 8/26/21 at 9:03 A.M., the maintenance director said the Assistant Director of Nurses (ADON) or Director of Nurses (DON) gives him the physician's order for a resident's use of side rails. Maintenance installs the side rails and inspects them for safety at the time of inspection. They write down whether the side rails fail or pass inspection, and this is documented in a book maintained by the ADON or DON. Maintenance staff eyeball the side rails to make sure there are no gaps where a resident might get stuck. They do not take measurements. After the side rail is installed and passes inspection, maintenance does not reassess the side rails at a later date, unless the ADON or DON report issues. There is no system for routine inspections of side rails and he was unaware he should be doing this.
10. During an interview on 8/31/21 at 9:03 A.M., the ADON and administrator said side rails must be assessed at the zones of entrapment. Maintenance is responsible for assessing entrapment zones and their measurements should be documented.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
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 provide an ongoing program to support residents in th...
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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 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 13 of 14 residents investigated for activities (Residents #68, #84, #7, #94, #38, #40, #8, #31, #41, #90, #15, #11, and #86). The facility failed to have activity staff in sufficient numbers to provide a complete activities program, and failed to ensure the facility assessment addressed activity staff under their staffing plan and/or staff training/education. The facility failed to provide one on one activities to residents, failed to ensure evening activities occurred or have activity staff available to assist residents in attending weekend activities. This had the potential to affect all residents who reside in the facility. The sample was 20. The census was 96.
1. Review of the facility's Statement of Resident Rights, provided to residents during the admission process as part of the admission packet, showed:
-Under federal and state laws, you have the following rights and responsibilities;
-Right to a dignified existence: Quality of life is maintained or improved;
-Right to self-determination: Choice of activities, schedules health care and providers;
-Right of access to: Individuals, services, community members and activities inside and outside the facility. Participate in social, religious and community activities.
Review of the June 2021 activity calendar, showed:
-Activities are subject to change to better serve our residents;
-Weekend activities included group activities on both Saturday and Sunday, in addition to church services;
-Several activities included snacks and Wii games;
-No activity scheduled after 3:00 P.M. on any day.
Review of the July 2021 activity calendar, showed:
-Weekend activities included group activities on both Saturday and Sunday, in addition to church services;
-Several activities included snacks and Wii games;
-No activity scheduled after 3:00 P.M. on any day.
Review of the August 2021 activity calendar, showed:
-Activities scheduled as either occurring in the memory care unit, sun room or as a non-group activity;
-Saturdays with Movie Matinee, scheduled as the only activity on every Saturday;
-Sundays with two separate church services scheduled. No group, non-religious, or any other activities scheduled on Sundays;
-Mail listed as an activity a total of 10 out of 22 week days and indicated as a non-group activity;
-Out of state video chats listed as an activity a total of nine out of 22 week days, and listed as a non-group activity;
-Music time in the memory care unit scheduled a total of 17 out of 22 week days;
-The only other activity besides music time scheduled in the memory care unit, scheduled on 8/30/21 at 10:15 A.M., for book club;
-Three week days with no activities scheduled in the memory care unit;
-No weekend activities scheduled on the memory care unit;
-14 of 22 week days with only one group activity scheduled in the sun room;
-Four of 22 week days with no group activities scheduled in the sun room;
-Three of 22 week days with two group activities scheduled in the sun room;
-One week day with three activities scheduled in the sun room;
-No activities scheduled after 3:30 P.M., on any day.
During an interview on 8/25/21 at 1:06 P.M., the activity director said regarding the current activity calendar for August 2021; the activity titled mail consists of her passing out the mail to the residents who received mail. The activity titled out of state video chats consisted of assisting residents who have family that live out of state having a video chat. The activity titled music time takes place in the memory care unit for those residents. It entails a sing along, sometimes dancing, and sometimes instruments. It only occurs on the memory care unit. If there is an activity occurring on the memory care unit, there are not activities being provided for other residents at that time. There are currently no activities occurring in the evening. On 8/27/21 at 12:30 P.M., the activity director said the August activity calendar is color coded. Purple is the memory care, blue is the sun room, green are non-group activities that are resident specific, such as receiving mail or having a video visit with family. Residents who do not reside in the memory care unit do not attend the activities that occur on the unit. Sometimes residents on the memory care unit will come off the unit for activities that occur in the sun room. The activities that take place in the memory care unit are geared towards those residents. There are currently only 3-4 residents who participate in the video chat activities because they have family that live out of state. She was not certain if the mail activity qualifies as a scheduled activity as residents should be receiving their mail regardless, but she does try to talk with the residents when she passes the mail.
2. Review of the resident council meeting minutes, dated April 28, 2021, showed the following for activities:
-No stimulation on the weekends;
-We ought to have an activity every day;
-Need more people to work;
-Want more outside of rooms as a group such as outdoors, when we did the snow cones;
-Snow cones would have been improved with better notice. A resident said he/she just happened to notice it was going on when it happed on 4/27;
-We want to do more walks:
-Response: Walks might be a safety issue, we need more staff or a different approach;
-No further responses to the resident's concerns.
Review of the resident council meeting minutes, dated May 26, 2021, showed the following for activities:
-Activity concerns mentioned in the prior meeting not addressed under old business;
-Church services are coming back;
-Communion on Thursdays;
-The comfort dog Wednesday June 23 at 10:30 A.M., and will come twice, the second and fourth Wednesday of the month;
-The library is coming to visit, you need to return your books.
During an interview on 8/27/21 at 12:30 P.M., the activity director said on the May resident council meeting notes, under the activities section, this documentation was information that was provided to the group about upcoming activities. It was more informative. One resident did mention they had books to return, but the rest of the documentation was information provided to the residents.
Review of the resident council meeting minutes, dated June 30, 2021, showed the following for activities:
-We want coffee at ten o'clock, there were a lot of people coming down for that;
-One resident said they like BINGO twice a week;
-Suggestions:
-Ice cream, more ice cream, drumsticks;
-Toss across;
-Bean bag tic tack toe;
-Improvement on basket games;
-Snow cones;
-More outside activities;
-Corn hole was always a fun game. It would be a great idea;
-Wii bowling;
-More crafts;
-Cooking club;
-Painting;
-Entertainers, probably budget and COVID;
-Old administration took the slot machines.
During an interview on 8/27/21 at 12:30 P.M., the activity director said on the June resident council notes, the residents requested more ice-cream, toss across and bean bag tic tack toe and this is not consistently on the activity calendar. Ice-cream is slowly coming back. There was one last week. That was during the cooking club activity. It ended up turning into more of an ice-cream social. They will get back to doing these activities once the facility hires more activity staff. The facility no longer has the Wii game. The residents used to enjoy Wii bowling.
Review of the resident council meeting minutes, dated July 28, 2021, showed the following for activities:
-The administrator and other department heads attended the meeting;
-Hopefully soon we'll get somebody else to join our team;
-Maybe BINGO on Monday and Wednesday if we get someone, since we don't have Sunday BINGO?;
-The comfort dog is coming on Wednesday;
-Library will come in Monday with totes of books, magazines, music and movies;
-No rosary on Thursdays, but we do have mass on Sundays;
-One resident said they don't get me up three weeks in a row for 9:45 service;
-Response: Update church list and laminated for nurses station;
-Today at BINGO we have popcorn, tomorrow is waffle cones, and Friday is snow cones.
During a group interview on 8/25/21 at 10:00 A.M., conducted with seven residents who represent the resident council, the facility had BINGO and movies for activities, but there are not any other activities. They believe it is due to activity staff being short. Activities are put on the calendar every month, but these activities might not be done. Often, movies are repeated multiple times through the week, and staff report they don't have any other movies.
3. Review of the facility's self-assessment tool, updated 7/26/21, showed:
-Average daily census: 70;
-Staff type: Activities professionals, other activities staff;
-Staffing plan: Activities not addressed;
-Staff training/education and competencies: Requirement for activities professionals not addressed.
4. Review of Resident #68's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/2/21, showed:
-Resident is rarely/never understood;
-Short and long-term memory problems;
-Cognitive skills for daily decision making severely impaired;
-Staff assessment of daily and activity preferences: Resident prefers:
-Snacks between meals;
-Reading books, newspapers, or magazines;
-Listening to music;
-Being around animals such as pets;
-Doing things with groups of people;
-Spending time outdoors;
-Locomotion on unit: Extensive assistance required;
-Locomotion off unit: Activity occurred only once or twice;
-Mobility devices: Wheelchair;
-Diagnoses included progressive neurological conditions, aphasia (inability to speak or communicate), multiple sclerosis (MS, autoimmune disease affecting the nervous system), anxiety disorder, and depression;
Review of the resident's care plan, in use at the time of the survey, showed:
-Focus: Little or no activity involvement related to deficits in cognition and communication;
-Goal: Resident will participate in activities of choice 3-5 times per week;
-Interventions: Resident is able to respond to his/her favorite songs, smile, and turn attention towards person or activity of interest. Needs assistance/escort to activity functions. He/she loves music opportunities and puree friendly snacks the most;
-Focus: Dependent on staff for meeting emotional, intellectual, physical, and social need related to cognitive deficits;
-Goal: Maintain involvement in cognitive stimulation and social activities as desired;
-Interventions: The resident prefers activities which do not involve overly demanding cognitive tasks. Engage in simple, structured activities such as sing along and balloon games.
Review of the resident's medical record, showed:
-No activity preference assessment;
-On 2/5/21 at 4:47 P.M., activity participation note: The resident resides on the memory care unit. Is alert to self. Loves to wear pretty clothes and listening to music. His/her favorite song is Pretty Woman. Also enjoys getting his/her nails painted. The resident does not speak, but will smile if spoken to. Enjoys snacks, especially chocolate pudding. Currently eats a puree diet. Staff will continue to search for ways to engage the resident, including sing along's, and findings sensory, tactile activities he/she may enjoy, like simple crafts with one on one supervision or caring for dolls;
-No further activity documentation as of 8/26/21.
-No documentation of activities the resident participated in.
Observations of the resident, showed the resident in the secured unit:
-On 8/19/21 at 9:08 A.M., the resident sat in a wheelchair as he/she watched television.
-On 8/20/21 at 12:35 P.M., the resident sat in a wheelchair in the dining area with no activity.
-On 8/23/21 at 9:52 A.M., the resident sat in a wheelchair in the dining area with no activity.
-On 8/25/21 at 8:38 A.M., the resident sat in a wheelchair in the dining area with no activity.
-On 8/26/21 at 9:11 A.M., the resident sat in a wheelchair in the dining area. His/her head hung down he/she did not have any activities to do;
-On 8/27/21 at 7:04 A.M., the resident sat in a wheelchair in the dining area, television off, no activity provided. At 10:16 A.M., the resident appeared asleep with his/her head on the table. He/she did not have any activities to do.
During an interview on 8/27/21 at 12:30 P.M., the activity director said the resident mostly enjoys sing along's. He/she does like animals and was part of a conversation about animals held on the unit, instead of the music activity today. He/she never attends activities off the unit. There have been no food related activities on the unit recently. The activity department needs more staff for the cooking club if they would want to bring residents from the unit. The resident's care plan indicates little to no activity involvement due to cognitive and communication deficits, the resident would benefit from a one on one activities program. Music is the one thing he/she does do and he/she was not always there during the activity.
5. Review of Resident #84's significant change MDS, dated [DATE], showed:
-Resident is rarely/never understood;
-Short and long-term memory problem;
-Staff assessment of daily and activity preferences: Resident prefers:
-Snacks between meals;
-Listening to music;
-Being around animals such as pets;
-Doing things with groups of people;
-Participating in favorite activities;
-Spending time outdoors;
-Locomotion on unit: Extensive assistance required;
-Locomotion off unit: Activity occurred only once or twice;
-Mobility device: Wheelchair;
-Diagnoses included medically complex conditions, aphasia, and seizure disorder.
Review of the resident's care plan, in use at the time of the survey, showed:
-Focus: Little to no activity involvement related to cognitive limitations;
-Goal: Attend activities of choice four times per week;
-Interventions: Encourage and assist family visits. The resident needs assistance/escort to activity functions;
-Focus: Dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits;
-Goal: Attend/participate in activities of choice;
-Interventions: Staff to converse while providing care. Help with eating snacks when snacks are available, the resident especially appreciates chocolate milk. Encourage ongoing family involvement. Invite the resident's family to attend special events, activities, and meals.
Review of the resident's medical record, showed:
-No activity preference assessment;
-On 3/9/21 at 3:34 P.M., activity participation note: Resident resides on the memory care unit. Is alert to self. Can walk short distances with assistance, but spends most of the time in a Broda chair (medical reclining chair). Gets restless at times and may try to get out of the chair without assistance. Often seems calm when around the group activity, but is passive. Seems calmest when there is music and when other residents are also calm and quite. Enjoys milk at most any time of day;
-On 6/10/21 at 4:09 P.M., activity participation note: Resides in the memory care unit. Alert to self. Is passive in most activities, unable to communicate verbally, but will yell when something is wrong or unfavorable (e.g., when being guided to sit back in the chair, but has been enjoying a walk). Resident spends much of the time in a Broda chair, but is able to walk with medical staff, therapy, and parent when they visit. It is unclear whether or not the resident enjoys music. The resident may get overstimulated at times being among the people and listening to music, as he/she sometimes yells when this is happening, but it is unclear. His/her parent said he/she may enjoy looking at black and white photographs. Staff will continue to bring the resident out of his/her room and watch for signs that he/she likes or dislikes the group activities or the amount of people around him/her. Staff will offer appropriate snacks when available, including chocolate milk;
-No documentation of activities the resident participated in.
Observations of the resident, showed the resident in the secured unit:
-On 8/19/21 at approximately 9:35 A.M., the resident sat with three other residents in the hall in his/her Broda chair with no activity. At 1:26 P.M., the resident continued to sit in the hallway with no activity;
-On 8/20/21 at 7:30 A.M., the resident lay in bed with no activity;
-On 8/23/21 at 8:15 A.M., the resident sat in a Broda chair in the dining area, positioned in front of a table. The resident appeared restless, stretching, leaning and attempting to push him/herself up. The resident did not have any activities to do;
-On 8/24/21 at 7:13 A.M., the resident sat up in his/her Broda chair. The resident appeared restless, repeatedly pushing him/herself up and rocking back and forth. The resident did not have any activities to do.
During an interview on 8/27/21 at 12:30 P.M., the activity director said she consulted with the resident's parent and the parent does not know what activities the resident enjoys. He/she yells out during sing along's and if people touch him/her. She gives the resident snacks. He/she loves chocolate milk. The care plan indicates he/she has little to no activity involvement due to cognitive deficits. He/she would benefit some from a one on one activities program.
6. Review of Resident #7's admission MDS, dated [DATE], showed:
-Resident is rarely/never understood;
-Short and long-term memory problems;
-Resident mood interview: Feeling down, depressed or hopeless: Yes. Trouble concentration on things such as reading the newspaper or watching television: Yes;
-Interview for activity preferences:
-How important is it to you to have books, newspapers and magazines to read: Somewhat important;
-How important is it to you to listen to music you like: Very important;
-How important is it to you to be around animals such as pets: Very important;
-How important is it to you to keep up with the news: Somewhat important;
-How important is it to you to do things with groups of people: Very important;
-How important is it to you to go outside to get fresh air when the weather is good: Very important;
-Supervision required for locomotion on and off the unit;
-Diagnoses included progressive neurological conditions, Alzheimer's disease, depression and schizophrenia.
Review of the resident's care plan, in use at the time of the survey, showed:
-Focus: Little to no activity involvement related to preoccupation with desire to return to previous facility;
-Goal: Participate in activities of choice 3-5 times per week;
-Interventions: Enjoys listening to the radio, enjoys watching television, preferred activities are sing along's.
Review of the resident's medical record, showed:
-No activity preference assessment;
-On 4/29/21 at 3:44 P.M., activity participation note: Meet and greet. The resident arrived to the facility. Seems to be confused and agitated. Will continue to redirect and revisit to learn more about activity preferences;
-On 5/12/21 at 5:11 P.M., activity participation note: The resident resides on the memory care unit. Is alert and aware with some confusion. Currently having trouble adjusting to the new nursing home and said he/she wanted to go back to his/her last one. He/she was friendly to residents and staff, but gets frustrated when he/she cannot find help to move back to his/her own place. When music is playing, sometimes he/she begins singing along to the music and his/her singing will redirect attention for a time. Will continue to offer ways to be engaged, especially in sing along's and will investigate whether he/she enjoys helping tasks such as folding, crafts, or sorting. Will investigate interest in simple exercise opportunities;
-No documentation of activities the resident participated in.
Observation on 8/26/21 at 10:01 A.M., during a scheduled music time activity in the memory care unit, showed breakfast meal service still in progress and no activities taking place. The television on a non-local news channel and the volume too low to hear. No residents were observed to be watching the television. At 10:36 A.M., the resident, paced the hall and appeared to be upset. The resident said he/she feels like he/she is in a jail house because he/she was locked in. At 10:42 A.M., the activity director arrived to the unit, she brought a basket with instruments. The activity director preceded to assist residents with getting socks on and helping with basic care needs. At 10:49 A.M., the activity director started to prepare to start the activity. The resident came to the activity director and asked what is going on. The activity director discussed the activity that was going to take place. The resident said that would be too loud. The activity director asked if there was anywhere else the resident could go and the resident just said he/she does not want the activity to be done here and said the doors are all locked. The activity director found a room and told the resident, look I found a quiet place. The resident began cursing. The activity director attempted to de-escalate the resident. The activity still had not begun. At 10:57 A.M., the activity director sat down in a chair in the dining/activity room, made a note and then started to pass out instruments. At 11:00 A.M., the activity director put on the radio and began the activity. Residents started to sing and dance. The resident, did not participate. He/she walked up and down the hall cursing and saying that he/she is locked in. After several more minutes of walking up and down the hall, a staff person talked with the resident, who preceded to complain about the noise. The staff person showed the resident a room and called it the quiet room. The resident became more agitated. After several minutes of talking with the resident, the staff person told the other staff on the floor that he/she was taking the resident for a walk off the unit, because he/she does not like the music. The resident seemed very happy about that, stopped cursing, held the staff persons hand and walked calmly down the hall and off of the unit.
During an interview on 8/27/21 at 12:30 P.M., the activity director said the resident is the reason the morning music activity was canceled and replaced with a discussion about animals. He/she does not want to be at the facility. She is not sure why the resident gets upset with the sing along's. He/she is just set on not liking it. The resident does not really attend any activities. The resident would benefit from one on one activities, especially walks off the unit during the sing along. The care plan indicates the resident enjoys sing along's, because when he/she arrived to the facility he/she did. This is a former preference.
7. Review of Resident #94's significant change MDS, dated [DATE], showed:
-Resident is rarely/never understood;
-Short and long-term memory problems;
-Staff assessment of daily and activity preferences: No preferences indicated;
-Locomotion on and off the unit: Activity did not occur;
-Diagnoses included progressive neurological conditions and dementia.
Review of the resident's care plan, in use at the time of the survey, showed:
-Focus: Little or no activity involvement related to apparent anxiety in group settings;
-Goal: Express interest in two new individual activity options consistently, two times weekly. Participate in activities of choice three times per week;
-Interventions: Remind the resident that he/she may leave activities at any time, and is not required to stay for entire activity. Search for activities that the resident can do in quieter, less populated settings. Investigate whether the resident would be comfortable near enough to group sing along to listen, but not be overly close to the group. Find ways to offer music outside of group settings. Investigate purpose-drive individual activities.
Review of the resident's medical record, showed:
-On 1/19/21 at 5:39 P.M., activity participation note: Resident resides in the memory care unit. Is aware with some confusion. Is very independent and often prefers time alone to time with the main group. Does enjoy some music and has favorite songs. Because the resident is out of his/her room less, he/she has also been missing out on snack opportunities. Staff will search for more activities the resident can do independently and encourage him/her to come to snack and singing opportunities;
-On 3/19/21:
-At 4:57 P.M., activity participation note. The resident is anticipated to soon return to the memory care unit. He/she is seldom involved in group activities, though he/she will stop by to appreciate sing along's on occasion. He/she had visited large group gatherings in the past off the memory care unit. When he/she has, he/she has left the activity early. He/she used to play balloon volleyball. Staff will encourage him/her to spend time outside of his/her room and will reinvestigate his/her interests, especially if he/she would care for some materials for individual activities;
-At 5:27 P.M., the resident appreciates napping during the day most days. He/she may be very interested in a dog visit. He/she was very close with his/her pet dog in the past;
-On 7/20/21 at 1:58 P.M., activity participation note: The resident is alert and aware with confusion, previously resided on the memory car unit. He/she slept often during the day. In the past, when the resident would attend group activities, he/she would leave them early and it seemed that group activities, such as parties and sing along's, are overwhelming. While on his/her new unit, he/she has expressed little interest in activities. The resident's past interested included riding a bicycle and his/her pet dog. Staff will investigate activities that may appeal to a former bicyclist and will update the comfort dog volunteers of the resident's possible interest and will explore other ways in which the resident can engaged in an individual or one on one setting;
-No documentation of activities the resident participated in.
Review of the resident's activity evaluation, dated 2/17/21, showed:
-The resident enjoys: Movies/TV and music/talk radio;
-Location of activities: Day/activity room;
-Preferred activity settings: Small group;
-Time of activities: Afternoon;
-Interest in life/activities: Interested;
-Attitude: Cooperative.
Review of the resident's activity participation review, showed:
-On 3/11/21 at 2:35 P.M., (blank);
-On 3/19/21 at 5:14 P.M., resident currently attends some sing along's. In the past, he/she had tried group activities off of the hall, but had a tendency to leave them very early. He/she had favorite songs. He/she once had a beloved dog and used to be a bicyclist. Staff will assess the resident's interests in individual activities and will try to engage in helpful tasks that will increase sense of purpose.
Observations of the resident showed:
-The resident did not reside on the secured memory care unit;
-On 8/20/21 at 7:11 A.M., the resident lay in bed with no activity;
-On 8/23/21 at 6:44 A.M., the resident sat in his/her wheelchair in his/her room with no activity. At 8:43 A.M., the resident remained, TV on. At 11:57 A.M., the resident lay in bed in his/her room with no activity.;
-On 8/24/21 at 6:28 A.M., the resident sat in his/her wheelchair in his/her room with no activity. At 8:28 A.M., the resident remained in his/her room with the TV on;
-On 8/27/21 at 8:26 A.M., the resident sat in his/her wheelchair in his/her room with the TV on.
During an interview on 8/25/21 at 1:06 P.M., the activity director said the activity titled music time takes place in the memory care unit for those residents. It only occurs on the memory care unit. If there is an activity occurring on the memory care unit, there are not activities being provided for other residents.
During an interview on 8/27/21 at 12:30 P.M., the activity director said residents who do not reside in the memory care unit do not attend the activities that occur on the unit.
8. During an interview on 8/25/21 at 1:06 P.M., the activity director said the activity assistant is responsible to provide one on one activities, but the position is currently open. The facility had been short staffed for a while. She will look to see if there is any documentation of one on one activities for the past 3 months.
Review of the facility's undated one on one activities documentation, provide by the activity director as three months of one on one activity documentation, and provided on 8/26/21, showed:
-The documentation hand written, no documentation of the date the activities were provided or how long the activity lasted;
-Resident #68: I sing to him/her. No further one on one documentation;
-Resident #84: No documentation of one on one activities provided;
-Resident #7: No documentation of one on one activities provided;
-Resident #94: No documentation of one on one activities provided.
During an interview on 8/27/21 at 12:30 P.M., the activity director said regarding the documentation provided for the requested three months' worth of one on one documentation, she documented that after the information was requested by the survey team, based on memory. She had examples of how to document one on one activities, but she needs to get back into proper documentation practices for one on one activities. Residents who are more passive, or cannot make their wants and needs known would benefit from one on one activities.
9. Review of Resident #38's admission MDS, dated [DATE], showed:
-Cognitively intact;
-Resident mood interview: Feeling down, depressed or hopeless: Yes;
-Interview for activity preferences:
-How important is it to you to have books, newspapers and magazines to read: Very important;
-How important is it to you to listen to music you like: Very important;
-How important is it to you to be around animals such as pets: Not very important;
-How important is it to you to keep up with the news: Very important;
-How importan
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0802
(Tag F0802)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review, the facility failed to ensure staffing was sufficient to serve meals to residents in a timely manner and meet the needs and preferences of the reside...
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Based on observation, interview and record review, the facility failed to ensure staffing was sufficient to serve meals to residents in a timely manner and meet the needs and preferences of the residents wanting to eat in the dining room. This deficient practice had the potential to affect all residents who ate at the facility. The census was 96.
Review of the resident council meeting minutes, dated 6/30/21, showed the following for dietary:
-One resident said: it sucks;
-One resident said: They're not cooking it, they're short staffed down there;
-One resident said: No cooks down there in the evening;
-Two residents said: Meals get to rooms considerably later, sometimes lunch is at 2:00, any day, weekends are worse;
-One resident said: the dream of eating in the dining room;
-Response: We are short staffed, so when we fix our concerns, then we can get back to the dining room.
During an interview on 8/19/21 at 8:36 A.M., the dietary manager (DM) said breakfast was served at 8:00 A.M., lunch was served at 12:00 P.M. and dinner was served at 4:30 P.M. The residents received meals delivered to their rooms. The dining rooms were not in use.
Observation of the lunch meal service on 8/19/21, showed:
-Six empty meal carts near the food preparation area. The dietary manager, Dietary Aide (DA) L, a porter and dishwasher were present in the kitchen;
-Lunch consisted of breaded chicken patties, mashed potatoes, carrots, bread and dessert. The alternative was hot dogs and hamburgers;
-At 12:07 P.M., the DM began prepping and serving the food into divided Styrofoam plates. There were three assistants in the kitchen during the meal service. DA L loaded the plates onto the carts. The dishwasher sat and waited for the cart to load. The porter wiped down the appliances while the DM and DA L loaded the carts;
-At 12:12 P.M., the first cart was loaded and the dishwasher left the kitchen to deliver the meals to the resident unit;
-At 12:23 P.M., the kitchen staff received a phone call. A resident requested a salad. DA L told the caller the salad would have to be made and they did not have time to make it at the moment;
-At 12:24 P.M., the second cart was loaded and the porter left the kitchen to deliver the meals to the resident unit;
-At 12:36 P.M., the third cart was loaded and the dishwasher left the kitchen to deliver the meals to the resident unit;
-At 12:44 P.M., the fourth cart was loaded and the porter left the kitchen to deliver the meals to the resident unit;
-At 12:59 P.M., the fifth cart was loaded and the dishwasher left the kitchen to deliver the meals to the resident unit;
-At 1:06 P.M., the sixth cart was loaded and the porter left the kitchen to deliver the meals to the resident unit.
Observations of the breakfast meal service on 8/24/21, showed:
-The DM, DA M, the dishwasher and porter were present in the kitchen. Six empty meal carts near the food preparation area;
-Breakfast consisted of hot or cold cereal, sausage and gravy, biscuits, milk and juice. The alternative was boiled eggs and grilled cheese sandwiches. The food was served in divided Styrofoam plates;
-At 8:26 A.M., the first cart was loaded and delivered to the resident unit;
-At 8:36 A.M., the second cart was loaded and delivered to the resident unit;
-At 8:47 A.M., the third cart was loaded and delivered to the resident unit;
-At 8:52 A.M., the forth cart was loaded and delivered to the resident unit;
-At 8:55 A.M., the fifth cart was loaded and delivered to the resident unit;
-At 8:56 A.M., the DM said she ran out of food. She began to prepare more hot cereal, sausage and gravy;
-At 9:14 A.M., the sixth and last cart was loaded and delivered to the resident unit.
During interviews on 8/24/21 at approximately 9:15 A.M. and 8/25/21 at 1:53 P.M., the DM said the kitchen only has two full time cooks working, but the other cook is never at work. They also have a porter and a dishwasher. The residents are eating in their rooms because they do not have the staff to serve in the dining room.
During an interview on 8/25/21 at 1:24 P.M., with the administrator and Director of Nursing (DON), the administrator said they are aware of concerns regarding dietary, it is a work in progress. When she first arrived as administrator at the facility, the facility had just hired a dietary manager, then a cook, then a couple of dietary aides. They just recently hired a dish washer and someone to do deep cleaning. The dietary manager has experience. Currently all meals are served in resident rooms. This started because of COVID-19. It was her understanding that the facilities were not doing communal dining. She thought it was still the expectation due to COVID-19. It may be a misunderstanding on her part. The two main reasons that residents are still using Styrofoam dishes is the kitchen staffing issues and they need more plates, which are ordered.
During an interview on 8/31/21 at 9:04 A.M., the administrator said the DM was short staffed in the kitchen. The facility is working to hire more kitchen staff.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review, the facility failed to serve food that was palatable and ensure meal service tray temperatures were maintained to at least 120 degrees Fahrenheit (F)...
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Based on observation, interview and record review, the facility failed to serve food that was palatable and ensure meal service tray temperatures were maintained to at least 120 degrees Fahrenheit (F). Seven of seven residents attending the resident council meeting complained about the food, the lack of choices, and the food temperatures. In addition, two residents complained about the food during individual interviews (Resident's #47 and #99). Furthermore, the facility failed to follow standardized recipes for preparing pureed foods. These deficient practices had the potential to affect all residents who ate at the facility. The census was 96.
1. Review of the resident council meeting minutes, dated April 28, 2021, showed the following for dietary:
-Food is icky, I stopped eating it;
-No documentation which resident in attendance voiced this concern;
-He/she got sick the same day I did. Saturday and Sunday. I know it was off the food;
-No documentation which resident in attendance voiced this concern;
-Food is always cold;
-Lots of unintended weight loss;
-The kitchen has not been serving fresh fruit. There used to be fruit available anytime. Maybe COVID is an issue. Would bananas and oranges be safer due to their skins?;
-Miscellaneous: Please bring back the snack cart. For people that miss the snack cart/meals, it would be helpful to have more food available to them at all hours (on the halls).
2. Review of the resident council meeting minutes, dated May 26, 2021, showed the following for dietary:
-Dietary food stinks;
-What would make it better;
-Starting June 21, new dietary manger;
-One resident said: I don't eat it;
-One resident said: Some's good, some not so good;
-No documented follow-up for the April 2021 dietary concerns with responses from the dietary department head.
3. Review of the resident council meeting minutes, dated June 30, 2021, showed the following for dietary:
-One resident said: it sucks;
-One resident said: need better food;
-One resident said: I don't eat it;
-One resident said: I eat it if I want it, if I don't, I leave it there. If you don't want it, you can call down and get something else;
-One resident said: Not appealing for the palette or the nose;
4. Review of the resident council meeting minutes, dated July 28, 2021, showed the following for dietary:
-The administrator attended the meeting;
-Doing a lot better;
-A work in progress.
5. During an interview on 8/19/21 at 8:36 A.M., the Dietary Manager (DM) said lunch was served at 12:00 P.M. The residents received meals delivered to their rooms. The dining rooms were not in use.
6. During an interview on 8/19/21 at 8:49 AM, Resident #99 said the food is terrible. Breakfast is pretty much the same everyday, sausage, eggs and toast. You can ask for a substitution, but then it takes a lot longer to get it. The food temperatures are not good by the time it arrives.
7. During an interview on 8/19/21 at 9:33 A.M., Resident #47 said the food is terrible. The person over food is wonderful but the food he/she has to work with is poor quality, not enough variety.
8. During an interview on 8/25/21 at 10:08 A.M., seven of seven residents who attended the resident council meeting said the food is cold at all meals. They don't get a choice of what they have . The staff will get really rude about. The residents said they would like to have menus to be able to choose from.
9. During an interview on 8/25/21 at 1:24 P.M., with the administrator and Director of Nursing (DON), the administrator said they are aware of concerns regarding dietary, it is a work in progress. There are things that must be put into place. The resident's concerns are not unfounded. They have been addressed and are getting better. When she first arrived as administrator at the facility, the facility had just hired a dietary manager (DM), then a cook, then a couple of dietary aides. The dietary manager has experience. Food is getting better, but needs to progress more. Sometimes they don't like the food and want a sandwich. The two main reasons that residents are still using Styrofoam dishes is the kitchen staffing issues and they need more plates, which are ordered. They are due to arrive on September 15th. The administrator said she started at the facility on July 5th of this year.
10. During an interview on 8/26/21 at 6:30 A.M., Nurse FF said he/she works the 7:00 P.M. to 7:00 A.M. shift. There is usually milk and graham crackers, maybe a granola bar, but if a resident wanted anything more, it would not be available to them.
11. During an interview on 8/26/21 at 7:32 A.M., Nurse W said the new company took over late last year. They were told the dietary budget was getting cut. Several food items they once had were eliminated. There have been several times residents have asked for substitutions that are on the menu, but they aren't available when requested. Some residents will not eat the meal sent to them, electing to go to the snack machine. Some residents that don't have the money to go to the snack machines just won't eat. Residents do get upset because of the lack of choices.
12. Observation on 8/26/21 at 1:15 P.M., showed the cart which held lunch was delivered to the resident unit. The food was served on divided Styrofoam trays. The certified nursing assistants (CNAs) began passing trays to residents. A resident's tray was taken from the cart. The meal consisted of mashed potatoes, green beans and meat loaf. The mashed potatoes tasted bland and lacked seasoning. The green beans reached a temperature of 110.8 F, using a digital thermometer. The green beans were cold to the taste. The meatloaf reached a temperature of 95.0 F, using a digital thermometer. The meat loaf was cold and lacked seasoning.
During an interview on 8/31/21 at 9:04 A.M., the administrator said food should be served hot and be palatable.
13. During an interview on 8/27/21 at 9:11 A.M., Laundry Aide X said since the corporate change, he/she had heard several residents complain about not getting a meal substitution or about the food temperatures.
14. During an interview on 8/19/21 at approximately 8:36 A.M., the DM said seven residents received a pureed diet.
Observation on 8/24/21 at approximately 7:15 A.M., showed the DM prepared pureed biscuits for six residents. The DM took six biscuits and placed them into the blender. She added five one half cups of milk into the blender and blended. She poured the mixture into a serving container and placed the food into the oven to keep warm. The DM then prepared pureed sausage and gravy for six residents. She used a total of ¾ cups of a mixture of sausage and gravy, placed it in the blender and blended. She said it was too thin. She then placed two slices of bread into the blended to thicken up the consistency. The surveyor tasted the mixture and it was bland. She poured the mixture into the serving container and placed it into the oven to keep warm.
During an interview on 8/24/21 at approximately 7:45 A.M., the DM said she did not use a recipe for the pureed meals. She knows what to do because she has been a cook for a long time. She had never used a recipe book for the pureed diets since she has been at the facility.
During an interview on 8/27/21 at 11:30 A.M., the dietician said the DM had worked in dietary for a long time and probably knew what to do. No one ever follows a recipe for purees. They do it for you when you are there. If anything, she could follow the manufacturers' recipe. She wanted to know exactly what the DM did to know if she followed the pureed diet recipe. She said, I will not say if she did it incorrectly because I wasn't there. When asked if the DM should follow a recipe for the pureed diets for the nutritive value, the dietician asked if the surveyor followed a recipe at home. She would not say if a recipe should be used by the facility when preparing pureed meals for residents.
During an interview on 8/31/21 at 9:04 A.M., the administrator said the DM had been a cook for a long time and probably knew how to make pureed recipes without a recipe book. However, a pureed recipe should have been followed.
MO00186034
MO00188254
MO00189196
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0577
(Tag F0577)
Minor procedural issue · This affected most or all residents
Based on observation, interview and record review, the facility failed to maintain reports with respect to infection control surveys and complaint investigations made during the preceding three years,...
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Based on observation, interview and record review, the facility failed to maintain reports with respect to infection control surveys and complaint investigations made during the preceding three years, for review by residents, family members and legal representatives of residents. The census was 96.
Observation on all days of the survey, from 8/19/21 through 8/31/21, showed a survey binder displayed across from the receptionist's desk near the front entrance to the facility.
Review of the survey binder, showed the binder contained annual survey results from April 2019, but did not contain the results of any infection control surveys or complaint investigations completed October through December 2019, 2020, or January through June 2021.
During an interview on 8/31/21 at 8:44 A.M., the administrator said she is responsible for updating the survey binder, which has been by the receptionist's desk since July 2021. The binder should contain documentation of all inspections completed within the past three years, including annual surveys, infection control surveys, and complaint investigations. She was not aware the binder was missing documentation of survey reports completed between October 2019 and June 2021.
MINOR
(C)
Minor Issue - procedural, no safety impact
Food Safety
(Tag F0812)
Minor procedural issue · This affected most or all residents
Based on observation, interview and record review, the facility failed to ensure temperatures were taken for the walk-in refrigerator and the walk-in freezer of the main kitchen. This deficient practi...
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Based on observation, interview and record review, the facility failed to ensure temperatures were taken for the walk-in refrigerator and the walk-in freezer of the main kitchen. This deficient practice had the potential to affect all residents who ate at the facility. The census was 96.
Observation on 8/19/21 at 8:36 A.M., of the kitchen, showed no temperature logs for the walk-in refrigerator and freezer.
During an interview on 8/24/21 at 6:07 A.M., Dietary Aide (DA) M said prior to 8/19/21, they were taking the temperatures of the walk-in freezer and refrigerator, but were not documenting the temperatures. They were short-staffed, but began recording the temperatures after 8/19/21.
During an interview on 8/31/21 at 9:04 A.M., the administrator said the kitchen was short-staffed. Temperature logs should be recorded and maintained in the kitchen.
Apr 2019
29 deficiencies
1 Harm
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 receive necessar...
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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 receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This resulted in one resident with a history of pressure ulcers developing a new unstageable (depth unable to be determined) pressure ulcer which required surgical debridement (removal of dead tissue) when the facility failed to monitor the resident's skin, accurately assess and document the wound observations and obtain treatment orders timely after staff identified the development of the pressure ulcer (Resident #43). In addition, issues were identified with two additional residents when the facility failed to follow physician orders, accurately assess and document wound observations, and use proper technique when treating wounds to prevent infection (Residents #122 and #272). The facility identified six residents with pressure ulcers, five were included in the sample of 25 and issues were identified with three. The census was 126.
1. Review of the facility's wound tracking reports, showed no wound tracking completed for residents at the facility the last two weeks in January 2019 and the first week in February 2019.
During an interview on 4/25/19 at 2:31 P.M., the wound nurse said she measures wounds weekly and tracks wounds on the wound reports. She was on maternity leave during the timeframe the wound reports were not completed.
2. Review of the facility's skin integrity manual, skin integrity prevention and management policies and procedures, revised 1/1/06, showed:
-Purpose: To assure that patients admitted without pressure ulcers (injury to the skin and/or underlying tissue, as a result of pressure or friction) do not develop pressure ulcers unless the individual patient's clinical condition demonstrates that the pressure ulcer was unavoidable. To ensure that patients having pressure ulcers receive the necessary treatment and services to promote healing and prevent infection and prevent new pressure ulcers from developing;
-Objectives:
-To provide guidelines for early assessment and intervention geared to preventing the development of pressure ulcers;
-To provide guidelines for immediate and ongoing communication between center staff, physicians, patients and their families regarding those risk factors and interventions;
-To provide guidelines for systems for communicating nursing interventions between shifts and to all nursing staff;
-To provide guidelines for early and ongoing identification of patients with pressure ulcers;
-To define standards for early intervention and treatment of pressure ulcers;
-To provide guidelines for immediate and ongoing communication with physicians, patients and their families regarding wound treatment and wound status;
-To provide guidelines for tracking and comprehensive documentation of all pressure ulcers;
-Assessment guidelines: Admission, readmit and return from transfer assessments initiated promptly;
-Tools: Braden (used for predicting pressure ulcer risk), Resident Assessment Instrument (RAI), admission nursing assessment, history, diagnosis list, medication list, skin assessment record, wound assessment record;
-Wound assessment includes type, stage, location, measurement of site (Length, width, depth). Exudate (drainage) to include type, odor, amount, and color. Wound bed to include necrotic (dead) tissue, slough (moist dead tissue), fibrin (a fibrous protein involved in the clotting of blood), granulation (new tissue growth), epithelization (formation of granulation tissue), tunneling (a narrow opening or passageway underneath the skin that can extend in any direction through soft tissue)/undermining (wound open underneath the border of the wound). Periwound (skin around the wound) and wound edges appearance to include description and measurement. Presence of pain. Presence of signs and symptoms of infection. Peripheral pulses, capillary refill (return of blood to the blood vessels after pressure applied), edema (swelling), color and temperature of skin. At the time of diagnosis, it is important to document the clinical basis (underlying condition contributing to the ulceration, ulcer edges and would bed location shape condition of surrounding tissue) which permit determination of the ulcer type, especially if the ulcers characteristics are consistent with a pressure ulcer but it is determined not to be one;
-Ongoing assessment: Braden within 24 hours of admission and weekly times 4 weeks. Thereafter, it is completed in conjunction with completion of Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) assessment. When the score falls to 14 or below, a new assess is to be done monthly;
-Weekly skin and wound assessments:
-Include type, stage, location, measurement of site, exudate, wound bed, periwound, presence or absence of pain, presence or absence of signs and symptoms of infection. Response to treatment;
-Daily pressure ulcer monitoring:
-When a pressure ulcer is present, daily monitoring will include an evaluation of the ulcer if no dressing is present, and evaluation of the status of the dressing if present, the status of the area surrounding the ulcer, the presence of possible complications such as signs of increasing area of ulceration or soft tissue infections;
-Daily skin inspection monitoring:
-Daily skin inspection is performed by caregivers during baths and/or assistance with activities of daily living (ADLs). Change in skin integrity and/or signs and symptoms of complications are reported to the licensed nurse;
-Prevention guidelines:
-Identification of patients at risk, implementation of interventions/prevention strategies, care process includes efforts to stabilize, reduce or remove underlying risk factors (pressure redistribution, moisture management, nutritional assessment/support, management of underlying psychological deficits that cause increased risks. Includes physician notification of patient's deterioration and/or poor response to interventions. Weekly skin assessments and daily skin inspections.
3. Review of Resident #43's quarterly MDS dated [DATE], showed:
-Cognitively intact;
-Rejection of care: Behavior not exhibited;
-Extensive assistance required for bed mobility, transfers, dressing and toilet use;
-Bathing: Two person physical assist;
-Always incontinent of bowel and bladder;
-Diagnoses included stroke, dementia, hemiplegia/hemiparesis (weakness or paralysis on one side of the body) and seizure disorder;
-At risk for pressure ulcers;
-No current unhealed pressure ulcers.
Review of the resident's medical record, showed no MDS completed in March 2019.
Review of the resident's paper care plan, located in the hard chart, dated 12/20/18, showed:
-The care plan did not address pressure ulcer with goals and interventions;
-The care plan did not identify a behavior of refusing to be repositioned in the bed with goals and interventions.
Review of the resident's electronic care plan, last reviewed/revised 4/16/19, showed:
-Diagnoses included hemiplegia and hemiparesis after stroke. No diagnosis for pressure ulcers;
-Problem: Assistance required in performing, improving and maintaining some ADLs:
-Total Hoyer (mechanical lift) with assist of two;
-Prefers showering during the evening on Wednesday/Saturday;
-Incontinent undergarments;
-Provide perineal care following incontinent episodes. Apply moisture barrier cream as needed. Incontinent of bowel and bladder;
-The care plan did not address pressure ulcers with goals and interventions;
-The care plan did not identify a behavior of refusing to be repositioned in the bed with goals and interventions.
Review of the resident's Braden assessments, dated 6/29/18, 9/21/18 and 4/9/19, showed a score of 17 (12 or less is high risk).
Review of the resident's paper and electronic physician order sheets (POS), showed:
-An order dated 9/19/17, for weekly skin assessments on Mondays;
-An order dated 7/26/18, to apply skin prep (protective barrier wipe) to the coccyx (tailbone area) dermaLevin (water proof adhesive foam dressing) once daily on the 7:00 A.M. through 7:00 P.M. shift.
Review of the resident's progress notes, showed:
-On 10/16/18, skin: No rash or skin breakdown;
-On 1/17/19, skin: No rash or skin breakdown.
During an interview on 4/25/19 at 2:31 P.M., the wound nurse said the resident originally had an order for skin prep and a protective dressing because he/she had a history of having a wound and it had healed. The skin prep was for protection and not treatment of a wound.
Review of the resident's weekly wound assessment record, showed:
-On 2/3/19, no new or concerning skin issues noted. Skin is dry and intact and warm;
-On 2/11/19, no new skin issues noted;
-On 2/15/19, sacral (is at the bottom of the spine at the coccyx) unstageable, wound measured 5 by 3.5 (no unit of measurement specified). No exudate. Wound base moist, no odor or signs and symptoms of infection, no eschar (hard dead tissue) or slough, granulation tissue present periwound redness and maceration (skin deterioration caused by moisture). NOTE: Wound noted with 100% slough mild periwound maceration. Mild odor noted. No redness or warmth noted, air loss mattress replaced. Staff educated to provide 2 hour position changes. Resident noted with non-compliance at times resident noted change position to back after turned on side. Education provided and resident agrees to comply to position changes. Treatment completed.
Further review of the resident's POS, showed:
-No treatment order obtained for the sacral wound on 2/15/19 through 2/21/19;
-An order dated 2/22/19, for sacral area treatment, cleanse with wound cleanser, apply Santyl (sterile enzymatic debriding ointment) apply Mepilex (occlusive absorbent dressing) or Allevyn (adhesive absorbent dressing) daily and as needed;
-An order dated 3/8/19, for Santyl topical daily and as needed (no location specified);
-Verbal order (no date specified) may have wound consult at wound clinic;
-An order dated 3/10/19, please refer to medical center wound clinic as soon as possible (ASAP);
-An order dated 3/14/19, to send to the hospital;
-An order dated 3/19/19, reschedule appointment at wound clinic ASAP;
-An order dated 3/21/19, for Santyl ointment 250 unit/gram topical once a day, 7:00 A.M. through 7:00 P.M. shift. Cleanse wound with wound cleanser, apply Santyl, pack and cover with saline moistened 2 by 2 (gauze) and cover with dry dressing. Order discontinued 3/25/19;
-An order, dated 3/25/19, for Biostep AG (collagen dressing with silver targets and deactivates excess matrix metalloproteinase (MMPs, a group of enzymes that are responsible for the degradation of most extracellular matrix proteins during growth and normal tissue) to optimize wound closure for chronic wounds) bandage 4 by 4 (gauze) topical once a day on the 7:00 A.M. through 7:00 P.M. shift. Cleanse area with normal saline or wound cleanser before applying dressing.
Further review of the resident's progress notes, showed:
-On 2/22/19, wound to coccyx/sacral area noted with 100% slough and foul odor. New order for Santyl noted. Area cleansed and treatment done. Position changed. Resident complained of pain 10/10 (on scale of 0 to 10, 0 indicates no pain 10 is severe pain) new air loss mattress replaced;
-On 3/1/19, skin: Large sacral decubitus (pressure ulcer) unstageable;
-On 3/5/19, resident educated on importance of repositioning while in bed and getting up from bed even if only for meals related wound on coccyx.
Further review of the resident's weekly wound assessment record, showed:
-On 2/22/19, no wound location or stage listed. Wound measured 6.2 x 4.5 (no unit if measurement specified), exudate, wound base moist, eschar, granulation present, periwound redness and maceration present, pain present, no signs and symptoms of infection. NOTE: Wound to sacral noted to increase in size. Continues with 100% slough. Periwound redness. Discoloration noted. Resident complains of pain at all times, scheduled pain medications and as needed given per order as needed. Resident continues with noncompliance of position change at times. Continue with education and importance of alternating pressure relief, will continue to monitor;
-On 2/25/19, has same wound to coccyx but no other skin issues. Treatment order is still in place, dressing dry and intact;
-On 3/4/19, alteration in skin integrity. Resident still has open area to coccyx, treatment in place and no signs and symptoms of any change to wound.
Review of the resident's hospital records, dated 3/7/19, showed:
-The resident admitted to the hospital on [DATE];
-Wound care: Nurse consulted for decubitus. Patient admitted with a deep sacral ulcer. Patient is pleasant and cooperative. He/she arrived to the emergency department by ambulance. Chief complaint is weakness and increasing slow to respond over this week;
-Sacral ulcer: Open through epidermis (top layer of skin), dermis (lower layer of skin) to subcutaneous tissue (hypodermis, under the skin layer). Malodorous (bad odor), moderate serosanguineous (yellowish drainage will small amounts of blood) drainage. Gaping, necrotic white and yellow slough covering base of ulcer. Unable to stage;
-Recommendation: sacral ulcer: daily apply triad paste (helps to maintain optimal wound healing environment) dime thick to sacral ulcer. If incontinent, clean area, leave adhered triad in place. Use sea-cleans wound cleanser to completely clean and then reapply triad. Cover with aquacel (absorbent dressing) 4 by 4. ROHO mattress (pressure releasing mattress) on bed.
Review of the resident's hospital records, dated 3/19/19, showed:
-admitted to the hospital 3/14/19:
-Chief complaint: Wound on bottom, sent by skilled nursing facility for increased lethargy (sleepiness) and hypotension (low blood pressure);
-Recently admitted to the hospital with similar presentation of lethargy and was noted to have a urinary tract infection and an infected decubitus ulcer;
-Sacral decubitus ulcer approximately 4 by 4 centimeters (cm);
-Assessment and plan: metabolic encephalopathy (disorder where medical problems such as blood infections or liver or kidney failure cause brain damage) secondary to dehydration and sepsis (blood infection) presumably from infected decubitus ulcer and urinary tract infection. Sacral decubitus ulcer infected, wound care consulted.
Review of the resident's electronic wound notes, showed on 3/22/19, pressure ulcer, stage III (full thickness tissue loss, subcutaneous fat may be visible but the bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) to sacrum, not present on admit. Measured 4 cm by 3 cm. On 4/19/19, pressure ulcer measured 4 cm by 3.5 cm.
Review of the resident's wound clinic notes, dated 3/25/19, showed:
-Sacrum pressure ulcer measured 4.7 cm length by 4 width by 0.5 depth;
-Undermining: Yes;
-Stage III;
-Large amount of exudate;
-Pre-procedure diagnosis of wound is a pressure ulcer located on the sacrum. There was an excisional skin/subcutaneous tissue debridement (surgical removal of dead tissue) with a total area of 16 square cm. Post debridement measurements: 4.7 cm length by 4 cm width by 0.5 cm depth. Post debridement stage noted as stage III. Requires further debridement.
Review of the shower book, located at the nurse's station, which contained showers sheets completed for April 2019 and reviewed on 4/23/19 at 12:14 P.M., showed the following for the resident:
-On 4/20/19- Refused, stated he/she got a shower from hospice;
-No further documentation of showers provided or refused in April, 2019.
Observation on 4/23/19 at 3:12 P.M., showed Nurse Y provided wound care for the resident. He/she removed the dressing, dated 4/22, saturated with green tinged drainage. Nurse Y measured the wound as 4.7 cm length by 5.3 cm wide. The wound bed pink;
During an interview on 4/24/19 at 8:50 A.M., medical records personal said the information provided is all that could be found on the resident's pressure ulcer.
On 4/24/19 at 12:44 P.M., a call placed to the resident's primary care physician by the surveyor. As of 5/7/19, no return call received.
During an interview on 4/25/19 at 2:31 P.M., the wound nurse said when she first saw the resident's wound, it was unstageable. The resident went to the hospital and it was debrided. When the resident returned, it was identified as a stage III. Seven days is too long between identifying a wound and obtaining a treatment order. The resident originally had an order for skin prep and a protective dressing because he/she had a history of having a wound and it had healed. The skin prep was for protection and not treatment of a wound. When she came back from maternity leave, the resident had an unstageable wound.
4. Review of Resident #122's medical record, showed:
-admit date of 4/12/19;
-Medical diagnoses included:
-Pressure ulcer of the sacrum, stage IV (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining (wound open underneath the border of the wound) or tunneling (channels or tracks that extend from a wound into and through the surrounding tissue or muscle));
-Osteomyelitis (infection of the bone) of vertebra and sacrum region;
-Pseudomonas aeruginosa (a bacterial infection highly resistant to antibiotics);
-Braden Scale dated 4/21/19, showed a score of 12, indicating the resident was at high risk for a pressure ulcer.
Further review of the medical record, showed no MDS completed in April 2019.
Review of the resident's hospital admission paper work, dated 4/12/19, showed:
-BioFlo Peripherally inserted central catheter (PICC, a thin flexible tube inserted in a smaller vein in the upper arm and guided into a large vein above the right side of the heart used to give intravenous (IV) fluids or medications) inserted in the resident on 4/9/19.
Review of BioFlo PICC manufacture' instruction for use, showed flush instructions per manufacture:
-Always aspirate first to confirm blood return;
-Flush each lumen with sterile normal saline per directions for use or per institutional protocol;
-Flush after every use or every 12 hours if not in use;
-Close clamp after flushing. Open clamp before use;
-Flush the catheter with a minimum of 10 milliliter (ml) of sterile normal saline, using pulse or stop start technique;
-Following saline flush, lock with heparinized saline per directions for use or institutionalized protocol.
Review of the resident's electronic POS on 4/22/19 at 3:55 P.M., showed:
-Orders dated 4/12/19, for:
-Mercopenem (antibiotic to treat infections) 1 gram reconstituted with sodium chloride 0.9% 100 ml, give IV every eight hours, 6:30 A.M., 2:30 P.M. and 10:30 P.M.;
-Heparin (used to prevent blood clots) 100 units/ml, 5 ml. Flush port-a-cath (a small chamber or reservoir implanted under the skin with a thin, flexible tube threaded into a large vein above the heart) before and after each use, every eight hours;
-Orders dated 4/15/19, showed:
-Normal saline flush, sodium chloride 0.9%. Flush IV with 3 ml before and after use, every eight hours;
-Change PICC dressing weekly;
-Flush sacral wound with normal saline once a day;
-Dakin's solution (used to cleanse wounds to prevent infection); Special Instructions: Wet Kerlix (absorbent, woven gauze used for wound care) with Dakin's and pack sacral wound once a day;
-Cover sacral wound with dressing once a day;
-Turn every two hours, keep off back.
Review of the resident's care plan, dated 4/15/19, showed:
-Problem: Resident was admitted with an infected stage III pressure ulcer to sacrum;
-Goal: Resident will respond to ulcer treatment as evidenced by improved wound healing with less pain and drainage or positive lab results through the next review;
-Approach: Administer treatment as ordered; Assess condition of surrounding skin; Assist/encourage resident to turn and reposition to alleviate pressure to sacrum; Institute antibiotic therapy as ordered; Record the amount, type, and odor of drainage from the wound;
-Problem: Resident requires IV antibiotics related to wound infection;
-Goal: Resident will not exhibit signs of complications from the IV;
-Approach: Administer IV meds per physician orders.
During an interview on 4/25/19 at 2:35 P.M., the wound nurse said nursing staff should document daily progress notes describing the condition of the wound after providing treatment or changing dressings. Without daily progress notes detailing the condition of the wound, it is difficult to track the healing process of the wound as well as if the current treatment orders are appropriate to promote healing of the wound.
Review of a wound progress note, dated 4/19/19 at 12:33 P.M., showed:
-Wound Type: Pressure Ulcer;
-Wound Location: Sacrum;
-Measurements:
-Length- head to toe direction- 7.5 cm;
-Width - side to side direction - 8.5 cm;
-Depth - measure deepest part of visible wound- 2 cm;
-Exudate:
-Amount: light;
-Color and consistency: serosanguineous (pale red to pink, thin and watery);
-Stage IV with tunneling present;
-Tissue:
-60% of wound covered by granulation tissue;
-40% of wound covered by slough tissue;
-Well defined wound edges;
-Skin surrounding wound: pink, normal.
Review of the resident's medical record on 4/29/19 at 12:22 P.M., showed there were not any progress notes describing the condition of the wound after nursing staff changed the daily dressing.
Observations on 4/22/19 at 7:00 A.M., showed resident asleep in bed with the head of the bed raised approximately 30 degrees, slumped slightly over to the left side with his/her feet pressed up against the foot board. The resident's PICC line was connected to the IV pump which was infusing Mercopenem at a rate of 100 ml/hour.
Observations on 4/23/19, showed:
-At 7:25 A.M., the resident asleep in bed, slumped over to the left side, head of bed raised at approximately 20 degree, legs outstretched in front of him/her and his/her feet pressed flat against the foot board. The resident's PICC line connected to the IV pump which administered Mercopenem at a rate of 100 ml/hour;
-At 12:55 P.M., 1:18 P.M., and 1:43 P.M., the resident awake, sat upright in bed with the head of bed raised to approximately 40 degrees, slumped over slightly to the left side, legs outstretched in front of him/her with knees slightly bent, feet pressed up against the foot board. The resident did not have any pillows underneath him/her to off load pressure from his/her sacrum;
-At 1:45 P.M., Licensed Practical Nurse (LPN) N gathered supplies from the treatment cart and entered the resident's room to change the dressing on the resident's Stage IV pressure ulcer located at his/her sacrum. After setting the treatment supplies on a barrier on top of the resident's bedside table, LPN N washed his/her hands and donned gloves and then removed the bowel movement filled brief from the resident. Bowel movement was visible on the wound dressing and underneath the wound dressing. LPN N removed the dressing from the wound, exposing the wound bed. There was a moderate amount of bowel movement inside of the wound bed and there was no Kerlix packed inside the wound. LPN N took off his/her gloves, cleansed his/her hands and donned new gloves. He/she then took wet, soapy wash cloths and wiped the rectum, buttocks and the wound bed free of bowel movement. LPN N measured the wound and verified the pressure ulcer was approximately 8 cm long and 9 cm wide with a depth of approximately 2 cm. The resident's proximal vertebrae were visible (located at the top of the wound, closest to the head), with slough present at the 12 o'clock to 3 o'clock position that covered approximately 40% of the wound base. Eschar present at the top of the wound that covered approximately 5% of the wound base, and hyper granulated tissue (an overly large amount of reddish connective tissue) located at the sides of the wound base. After cleansing the wound with normal saline, without changing gloves, LPN N took Dakin's soaked Kerlix and began to pack the wound base by unrolling the gauze and using a cotton tipped applicator to push the gauze into the wound bed. LPN N continued packing the gauze into the wound base. He/she pressed it into the wound and caused the gauze to spill out back into LPN N's hand. The skin around the edges of the wound bed bulged out due to the gauze. After removing his/her gloves, cleansing hands and donning new gloves, LPN N placed an absorbent dressing against the wound and pressed it firmly with the palm of his/her hand. LPN N took medical tape and attempted to tape down the dressing to the resident's skin. The tape only adhered to the resident's skin on two sides, and left the proximal and distal sides of the dressing open. The wound base was opened to air and to the resident's rectum. There was a gap of approximately 3 inches between the wound base and the dressing. As LPN N and Certified Nursing Assistant (CNA) O turned the resident back over to his/her back, the wound base was visible as it not covered by the dressing;
-At 2:15 P.M., after the resident received wound care for his/her sacrum, LPN N and CNA O positioned him/her with the head of bed raised approximately 20 degrees, with his/her legs outstretched, without pillows underneath him/her to off load pressure.
Observations on 4/24/19, showed:
-At 7:54 A.M., 8:15 A.M., 8:50 A.M., 10:20 A.M., 11:07 A.M. and 11:35 A.M., the resident lay asleep in his/her bed, slumped to the left side with the head of bed raised approximately 30 degree, legs outstretched in front him/her with knees slightly bent and feet pressed against the foot board. The resident did not have any pillows underneath him/her to off load pressure from his/her sacrum;
-At 8:30 A.M., Nurse A gathered all supplies and prepared to administer Mercopenem to the resident. Nurse A verified approximately 6 ml of medication remained in the Mercopenem vial from the infusion administered on 4/23/19 at 10:30 P.M.
During an interview on 4/24/19 at 8:35 A.M., Nurse A said when there is still medication in the Mercopenem vial after infusion, it means the entire dose of antibiotics was not administered. If it continued to happen, it would have an accumulative effect and the resident would not receive the entire antibiotic treatment as ordered. If there was medication left in the Mercopenem vial, it could be pushed back into the normal saline bag such that entire dose would be infused into the resident.
Observations on 4/24/19, showed:
-At 8:50 A.M., Nurse A started the Medocopenem infusion to the resident;
-At 10:20 A.M., the resident's infusion pump alarm was heard beeping and the infusion stopped. It was audible in the hall outside the resident's room;
-At 10:43 A.M., the resident's infusion pump continued to alarm. The resident pushed his/her call light. CNA Z walked into the resident's room and told the resident he/she is not able to adjust the resident because the electronic control to the bed is unplugged. There was a strong smell of bowel movement in the room. CNA Z left the room without assisting the resident;
-At 10:51 A.M., CNA B walked into the resident's room, removed a bag of clothing from the dresser and left the room. A strong odor of bowel movement in the room. The infusion pump continued to beep and did not infuse the antibiotic. Certified Medication Technician (CMT) Q was in the hall outside the resident's room. The beep of the infusion pump audible in the hall;
-At 11:07 A.M., Nurse A entered the resident's room, turned the infusion pump alarm off, readjusted the IV tubing, and started the infusion again;
-At 11:46 A.M., CNA B removed a brief, heavily soiled with urine and bowel movement from the resident. Bowel movement visible on the resident's sacral pressure ulcer. The dressing not taped down to the resident's skin on all four sides and bowel movement visible in the wound bed. CNA B removed the dressing from the pressure ulcer, took a wet, soapy wash cloth and wiped bowel movement from the resident's rectum towards the wound. CNA B took another wet, soapy washcloth and used it to remove bowel movement from the resident's rectum and buttocks using a continuous sweeping motion down and around the wound base. After disposing of the soiled washcloth, the CNA tucked a clean absorbent incontinent pad underneath the resident and positioned the resident over on to his/her back and placed a pillow under his/her right hip. CNA B failed to cleanse his/her hands or don clean gloves while performing incontinent care and cleansing the wound base.
During an interview on 4/24/19 at 2:24 P.M., Nurse A stated he/she would expect nursing staff to alert him/her to an alarm beeping on an infusion pump. When an infusion pump alarms, it automatically turns off the infusion which delays the antibiotic treatment to the resident.
Observations on 4/25/19, showed:
-At 6:45 A.M., 8:01 A.M. and 8:58 A.M., the resident lay in bed, slumped to the left side, with the head of bed raised approximately 30 degrees, legs outstretched in front of him/her with knees slightly bent and his/her feet pressed against the foot board. The resident did not have any pillows underneath him/her to off load pressure from his/her sacrum;
-At 8:16 A.M., approximately 15 ml of medication visible in the Mercopenem vial from the infusion which was administered previously.
Observations on 4/26/19 at 4:45 A.M. 6:00 A.M. and 10:05 A.M., showed the resident asleep in his/her bed with the head of bed raised to 35 degrees. The resident slumped to the left side, legs straight in front of him/her, slightly bent at the knee, and his/her feet pressed against the footboard. The resident did not have any pillows underneath him/her to off load pressure from his/her sacrum.
During an interview on 4/25/19 at 8:58 A.M., the Medical Director said:
-Repositioning the resident to take pressure (off load) off of the resident's sacrum is very important;
-It is especially important for Resident #122 due to the severity of the pressure ulcer;
-He expects the nurses to follow physician orders.
During an interview on 4/25/19 at 9:03 A.M., LPN P said the resident should be turned or repositioned every 2 hours to relieve pressure off of his/her sacral pressure ulcer stage IV. The facility had longer beds available for residents who need them.
During an interview on 4/26/19 at 6:20 A.M., LPN T said:
-If a resident was positioned flat on a bed with the head of the bed raised, legs out stretched with feet pressed against the foot board, it results in increased pressure located at the resident's sacrum and the pads of the feet;
-Increased pressure localized at the sacrum could cause further breakdown of the resident's tissue, causing harm;
-Extended beds were ordered by placing a request in the maintenance log located at the nurse's station.
During an interview on 4/29/19 at 10:30 A.M., the administrator said:
-Treatment orders f
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to promote a resident's self-determination though support of resident choices when staff failed to provide transfer assistance to...
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Based on observation, interview and record review, the facility failed to promote a resident's self-determination though support of resident choices when staff failed to provide transfer assistance to a resident to ensure he/she was able to attend a meeting he/she wanted to attend (Resident #98). The sample was 25. The facility census was 126.
Review of Resident #98's face sheet, showed the facility admitted the resident on 1/16/14, with diagnoses which included hemiplegia (paralysis of part of the body) following stroke affecting right dominant side, epilepsy (seizure disorder), type 2 diabetes, heart disease, dependence on other enabling machines and devices, urge incontinence, vascular dementia, obesity and muscle weakness.
Review of the resident's care plan, updated 3/19/19, showed the resident required a two person assist with a Hoyer (mechanical lift) for transfers.
During an interview on 4/23/19 at 3:10 P.M., the resident said when he/she turns on the call light, it takes a very long time for staff to respond. He/she requires the use of a mechanical lift and if staff do not respond, he/she wets him/herself. Then the mechanical lift pad is soiled. He/she only has one lift pad, so if it is soiled, he/she either has to be transferred with a soiled pad or he/she has to stay in bed until staff can get it cleaned.
During interviews on 4/24/19 at 8:38 A.M. and at 3:23 P.M., the resident said staff often cannot find the equipment they need to transfer him/her. He/she requires the use of a special pad and they only have one of the kind he/she prefers. He/she often has to wait to get up when he/she wants to because staff do not have the equipment he/she needs. They sometimes give him/her a bed bath when they do not have the right pad to transfer him/her to the shower but he/she did not want to take bed baths and preferred to take showers.
Observation on 4/24/19 at 10:10 A.M., showed the resident lay in his/her bed. The resident said he/she wanted to get up and go to the resident meeting but staff had not gotten him/her up yet.
During an interview on 4/24/19 at 10:15 A.M., the surveyor informed the Director of Nursing (DON) of the resident's request to attend the meeting and the DON said he/she would ask staff to get the resident up and take him/her to the meeting.
Observation on 4/24/19 between 10:30 A.M. and 11:45 A.M., of the resident council meeting, showed the resident not present.
During an interview on 4/24/19 at 12:27 P.M., the resident said staff finally came in and got him/her up around noon. He/she would have liked to have gotten up earlier so he/she could have attended the meeting. The resident asked the surveyor to tell him/her about the meeting and how it went, since he/she was not able to attend like he/she wanted to.
During an interview 4/29/19 at 10:25 A.M., the DON said residents should be allowed to make choices about when they want to get up and do things and staff should accommodate them. Staff told her they were in the resident's room, getting him/her up when she called up to the third floor, before the meeting on 4/24/19. She was not sure why the resident was not taken to the meeting.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy for abuse and neglect by failing to report to t...
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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 abuse and neglect by failing to report to the State Survey Agency, a resident to resident altercation that resulted in an injury (Residents #4 and #46). The census was 126.
Review of the facility's abuse policy, revised 9/14/17, showed:
-Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents irrespective if any mental or physical condition cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology;
-Reporting policy: Any partner having either direct or indirect knowledge or any event that might constitute abuse, neglect, misappropriation of patient property or exploitation must report the event immediately. It is the policy of this facility that abuse allegations (abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported per Federal and State Law, but not later than two hours after the allegation is made. If the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation did not involve abuse and do no result in serious bodily injury, to the administrator of the facility and to other officials (including State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures;
-Further review of the facility's policy, showed no documentation of resident to resident altercations to be addressed as potential abuse.
1. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/31/18, showed:
-Brief Interview for Mental Status (BIMS) score of 12 out of 15, which shows the resident with moderately impaired cognition;
-Diagnoses included hypertension (HTN, high blood pressure), hyperlipidemia (high level of lipids), fracture, multiple sclerosis (MS, neurological disease), seizure disorder, anxiety disorder, depression and asthma;
-No behaviors;
-Independent with bed mobility, transfers, dressing, eating, toileting and hygiene;
-Anti-depressants and anti-anxiety medications administered in the last seven days.
Review of the resident's care plan, dated 3/7/19, showed:
-Problem: Resident is at risk for physically acting out with aggressive behaviors when provoked related to an incident with another resident. He/she struck the resident with an open hand as a result of being struck by the other resident first;
-Approach: Staff will intervene if the resident becomes upset with another resident to facilitate conflict resolution.
Review of the resident's event report, dated 3/7/19, showed:
-Behavior and mood events: Aggressive/Combative behavior;
-Description: Resident was passing another resident in the hallway when their wheelchairs rubbed each other. The resident was hit by the other resident and retaliated. The resident was hit in the high forearm. Patient has a scratch to his/her chest wall on the right side. Patient denies pain at this time.
Review of the resident's progress notes, showed:
-On 3/8/19, resident remains on observation for scratches on right upper chest from another resident. Resident scratches intact, redness noted, no signs and symptoms of infection. No signs and symptoms of pain/discomfort;
-On 3/9/19, resident remains on follow up for being scratched on right upper chest. Scratch has no signs or symptoms of infection. Skin intact. Resident has no signs and symptoms of pain/discomfort.
During an interview on 4/23/19 at 9:12 A.M., the resident said he/she remembered an incident involving another resident on the unit. He/she was scratched by another resident. He/she did not remember the resident's name; however, he/she knew what the resident looked like. He/she tried to stay away from the resident since the altercation.
During an interview on 4/23/19 at 1:45 P.M., Licensed Practical Nurse (LPN) N said he/she was not aware of a resident to resident altercation involving Resident #4.
During an interview on 4/24/19 at 9:51 A.M., Certified Medication Technician (CMT) Q said he/she did not know anything about a resident to resident altercation involving Resident #4.
2. Review of Resident #46's quarterly MDS, dated [DATE], showed:
-A BIMS score of 13 out of 15, which shows the resident is cognitively intact;
-Diagnoses included heart failure, hyperlipidemia, seizure disorder, asthma, muscle weakness, difficulty in walking and discoid lupus erythematosus (autoimmune disease affecting the skin);
-Has physical and verbal behaviors;
-Independent with bed mobility and eating;
-Supervision with transfers, dressing, toileting and hygiene;
-Anti-psychotics and anti-depressants administered in the last seven days;
Review of the resident's care plan, dated 4/11/19, showed:
-Problem: Behaviors:
-At risk for complications due to verbal aggression, yelling out, history of physical aggression and attention seeking;
-Approach: Administer psychotropic medications per order. Observe for effectiveness of the medication and consult physician as needed;
-Approach at later time when patient does not comply;
-Ask what you could do to make patient feel more comfortable;
-Assess behavior and try to determine cause;
-Assess for stressors in their environment;
-Assess if patient's anxiety is in response to fear, helplessness, or disruptions or changes in life style;
-Be direct and prompt when telling patient that a behavior is inappropriate;
-Calmly reassure patient;
-Involve them in activities of their choice such as pet therapy, going outside, sensory stimulation, independent activities, etc. as tolerated;
-Keep patient in calm and quiet environment;
-Notify Social Services of their behavior;
-Observe for changes in patient's mood and behavior;
-Observe for signs of increasing hostility;
-Restrict harmful physical action in a cautious, non-harmful manner;
-Problem: Resident can become socially disruptive and inappropriate with other residents and staff at times:
-Provide and encourage 1:1 conversation in room when he/she is escorted out of activity due to being inappropriate or fighting;
-Redirect the resident with conversation and a snack when she has an outburst of cussing and lashing out at residents;
-Problem: Impaired adjustment related to combative behavior:
-Approach: Determine past effective and ineffective coping mechanisms.
Review of the resident's event report, dated 3/7/19, showed:
-Behavior and mood events: Aggressive/Combative behavior;
-Description: Patient was in hallway when another resident was passing by. The two resident's wheelchairs rubbed against each other and this resident started to hit the other resident in his/her right upper arm. The other resident retaliated and was hitting back. No injury noted to either resident. Both residents were separated.
During an interview on 4/24/19 at 9:52 A.M. and 1:13 P.M., LPN KK said Resident #4 was in an altercation with Resident #46. Both residents remain on the same unit. Their wheelchairs bumped into each other in the hall, and it started from here. Both residents are very impatient. Staff have to do one on one redirection with both residents.
During an interview on 4/24/19 at 1:05 P.M., the administrator said she was not aware of an altercation between Resident #4 and #46. The assistant administrator was not aware of an altercation, but would follow up with other staff for more information.
During an interview on 4/24/19 at 1:11 P.M., Certified Nurse Aide (CNA) LL said Resident #46 is impatient and yells a lot. He/she yells and screams at the other residents and staff, but it is not physical. He/she did not know about the altercation between Resident #4 and 46.
3. During an interview on 4/29/19 at 9:00 A.M., the administrator said the altercation between the residents was not reported to the State Agency. She was not aware it resulted in an injury and she would expect staff to report it to her, so she could report it. She would expect the facility's abuse policy to include resident to resident altercations.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
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 complete a comprehensive assessment of a resident's needs, strength...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by the Centers for Medicare and Medicaid Service (CMS) within 14 calendar days after admission and not less than once every 12 months, for five of 39 residents reviewed for resident assessments (Residents #2, #3, #119, #28 and #9). The census was 126.
1. Review of Resident #2's medical record, showed admitted on [DATE].
Review of the resident's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, records, showed:
-An annual MDS, dated [DATE];
-No annual MDS completed February 2019.
2. Review of Resident #3's medical record, showed readmitted on [DATE].
Review of the resident's MDS records, showed:
-An annual MDS, dated [DATE];
-No annual MDS completed February 2019.
3. Review of Resident #119's medical record, showed admitted on [DATE].
Review of the resident's MDS records, showed:
-An entry MDS, dated [DATE];
-No admission MDS completed.
4. Review of Resident #28's medical record, showed admitted on [DATE].
Review of the resident's MDS records, showed:
-An annual MDS, dated [DATE];
-No annual MDS completed March 2019.
5. Review of Resident #9's medical record, showed admitted on [DATE].
Review of the resident's MDS records, showed:
-An annual MDS, dated [DATE];
-No annual MDS completed February 2019.
6. During an interview on 4/24/19 at 10:40 A.M., the MDS coordinator said she is the only MDS coordinator for the facility. She has been in her position since 12/26/18. The position was open before that. She is responsible for all MDS in the facility and is aware that she is behind on MDS. MDS assessments are completed quarterly, on admission, annually, on discharges and on reentry.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
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 encode and be capable of transmitting the resident assessment instr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to encode and be capable of transmitting the resident assessment instrument (RAI) within 7 days after completing a resident's assessment, to include a subset of items upon a resident's transfer, reentry, discharge, and death, for two of 39 residents reviewed for resident assessments (Residents #40 and #13). In addition, the facility failed to electronically transmit encoded, accurate, and complete Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) data to the Centers for Medicare and Medicaid Services (CMS) system within 14 days after a facility completes a resident's assessment. The census was 126.
1. Review of Resident #40's medical record, showed:
-admitted [DATE];
-discharged [DATE].
Review of the resident's MDS records, showed no discharge MDS completed for the 2/23/19 discharge.
2. Review of Resident #13's medical record, showed:
-admitted [DATE];
-discharged [DATE].
Review of the resident's MDS records, showed no discharge MDS completed for the 2/7/19 discharge.
3. Review of the facility's CMS MDS Submission Reports, showed:
-On 2/7/19, 3 records submitted, 1 submitted late;
-On 2/11/19, 5 records submitted, 1 submitted late;
-On 2/14/19, 7 records submitted, 1 submitted late;
-On 2/27/19, 3 records submitted, 2 submitted late;
-On 3/7/19, 6 records submitted, 1 submitted late;
-On 3/13/19, 4 records submitted, 2 submitted late;
-On 3/14/19, 7 records submitted, 3 submitted late;
-On 4/15/19, 3 records submitted, 3 submitted late.
4. During an interview on 4/24/19 10:40 A.M., the MDS coordinator said she is the only MDS coordinator for the facility. She has been in her position since 12/26/18. The position was open before that. She is responsible for all MDS in the facility and is aware that she is behind on MDS. MDS assessments are completed quarterly, on admission, annually, on discharges and on reentry.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a baseline care plan for each 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 develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care, for one of one newly admitted sampled resident who had not had a comprehensive assessment completed (Resident #222). The sample was 25. The census was 126.
Review of Resident #222's face sheet, showed:
-Originally admitted to the facility on [DATE], and readmitted from a local hospital on 4/19/19;
-Diagnoses included Alzheimer's disease, dementia, aspiration pneumonia, severe protein-calorie malnutrition, gastrostomy tube (G-tube, a tube surgically inserted into the stomach through the abdomen for the purpose of providing liquid nutrition, hydration and medications), cerebral vascular accident (CVA - stroke), dysphagia (difficulty swallowing), bacteremia (blood infection) and dependence on supplemental oxygen.
Review of the resident's electronic and hard copy physician order sheet (POS), dated 4/1/19 through 4/30/19, showed:
-An order dated 4/19/19, to administer oxygen at 2 to 5 liters a minute by nasal cannula continuously as need for shortness of breath;
-An order dated 4/19/19, for staff to administer nothing by mouth (NPO) to the resident;
-An order dated 4/20/19, to administer Teflaro (antibiotic) 400 milligrams (mg) intravenously (IV) every 12 hours for 33 doses;
-An order dated 4/20/19, to flush the left upper peripherally inserted central catheter (PICC line, a thin, soft, flexible tube to provide IV access), with heparin (blood thinner) flush 10 units in every milliliter (ml) every 12 hours;
-An order dated 4/23/19, to administer 2 Cal HN (a high nutritional liquid supplement that provides 2 calories for every cubic centimeter (cc) of formula) at 45 cc an hour through the G-tube for 22 hours out of 24 hours.
Review of the resident's baseline care plan, dated 4/22/19 and in use during the survey, showed:
-Problem: Recreation/wellness. Resident is unable to communicate or get out of bed and cannot make wants and needs know;
-Goal: Placed on one on ones. Will have needs anticipated and met by staff;
-Interventions: Staff will anticipate needs, ask yes/no questions and be alert to nonverbal communications;
-The care plan failed to identify the resident's gastrostomy tube usage, oxygen usage, PICC line, or IV antibiotic usage.
Observations on 4/22/19 at 9:50 A.M., on 4/23/19 at 1:09 P.M., on 4/24/19 at 9:14 A.M., and on 4/25/19 at 8:11 A.M., showed the resident lay in bed with oxygen on at 3 liters by nasal cannula. 2 Cal HN infused at 45 cc an hour by pump into his/her G-tube. A dressing, dated 4/18/19, covered the PICC line in his/her left upper arm.
During an interview on 4/25/19 at 12:45 P.M., the Director of Nurses (DON) said she would expect a resident's care plan to be person center, Resident #222's baseline care plan should have included the use of the gastrostomy tube, oxygen usage, PICC line and antibiotic therapy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure care provided to residents meets professional s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure care provided to residents meets professional standards of quality by failing to ensure residents received the appropriate services when there was a change in condition for one of one resident investigated for change in condition and death (Resident #123). The census was 126.
Review of Resident #123's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed:
-Total dependence on staff for bed mobility, transfers, dressing, eating and hygiene;
-Incontinent of bowel and bladder;
-Diagnoses included anemia, arthritis, dementia, constipation, dysphasia (difficulty swallowing), anxiety and muscle weakness;
-Received hospice services.
Review of the resident's diagnostic problem list, dated [DATE], showed he/she received hospices services from [DATE] to [DATE].
Review of the resident's nurse's notes, showed:
-On [DATE] (no time noted) written by Nurse P, physician ordered Compazine (used to treat nausea) suppository 10 milligram (mg), every 6 hours as needed for nausea and Imodium (used to treat diarrhea) 2 mg every 4 hours as needed for diarrhea. Vital signs every shift for three days. Push fluids and call physician for oxygen levels less than 90%.
Review of the resident's physician's order sheet (POS), dated [DATE] through [DATE], showed:
-Push fluids;
-An order dated [DATE], for Miralax powder (bulk fiber laxative) for constipation twice a day;
-An order dated [DATE], for Senokot 8.6 mg (stool softener) for constipation at bedtime;
-An order dated [DATE], for Imodium 2 mg as needed every four hours for diarrhea;
-An order dated [DATE], for Compazine suppository 10 mg as needed for nausea;
-No order for oxygen;
-An order [DATE], to call the physician if his/her oxygen is less than 90%;
-Do not resuscitate (DNR, no life-saving measures desired) order.
Review of the SBAR communication form (a form used for a resident's change in condition), completed by Nurse P, dated [DATE] at 6:00 P.M., showed the resident had a decreased level of consciousness. Staff notified the physician who ordered Compazine suppository as needed for nausea and Imodium for diarrhea as needed and check vital signs every shift. On [DATE] staff noted on the form no further nausea and vomiting reported.
Review of the vital signs record, showed no documented vitals for the resident after [DATE].
Review of the resident's medication administration record (MAR) and treatment administration record (TAR) for [DATE] through [DATE], showed:
-The only documented vitals recorded were on [DATE] which were his/her temperature, pulse and blood pressure;
-Nothing recorded under push fluids;
-Compazine not administered;
-Imodium not administered;
-Miralax administered twice a day for the month;
-Senokot administered at bedtime for the month.
Review of the resident's nurse's MAR, showed on [DATE], written on the back, the resident was unable to take all medications.
Review of the resident's medical record, showed the resident expired [DATE].
Further review of the resident's nurses notes, showed:
-On [DATE] at 6:15 A.M. (next note after [DATE]), Nurse called to residents room at about 5:10 A.M., resident lying in bed, oxygen at 4 liters with an oxygen saturation (amount of oxygen in the blood) at 87% (normal 95-100%), temperature 99 Fahrenheit (F) (normal 97.9-99.1 F), respirations 44 (normal 12-18), pulse 116 (normal 60-100) and dropping, blood pressure 80/58 (normal 120/80). Resident noted just lying in bed with his/her mouth open, no distress noted, skin warm to touch. Call placed to physician at 5:25 A.M. and received new order for Roxanol (for pain) 20 mg per milliliter (ml), give 10 mg (0.5 ml) every hour for respirations greater than 26 or for pain. Give Lorazepam (antianxiety) intensol 2 mg/ml, given 1 mg/0.5 ml every hour for restlessness. Hospice to treat and evaluate. Call placed to hospice. Call placed to family. Staff gave the resident Roxanol at 5:50 A.M., will continue to monitor and note any changes;
-On [DATE] at 7:10 A.M., staff noted the night supervisor was made aware of change in condition at 5:30 A.M.;
-No further documentation in the residents nurses notes.
Review of the hospice admission note, dated [DATE] at 11:45 A.M., showed the resident had a change of condition and was non-responsive the last 24 hours. Upon exam, imminent death, could not obtain blood pressure or oxygen saturation or radial pulse. Respirations were 48, pulse 120 temperature 102.5 F.
During an interview on [DATE] at 7:45 A.M., Nurse XX said he/she worked with the resident up until [DATE]. He/she did not remember giving the resident the medications on [DATE]. The resident was not eating much and was lethargic (extreme drowsiness). The resident's vitals should have been documented and his/her change in condition should have been addressed in the nurse's notes.
During an interview on [DATE] at 12:25 P.M., the director of nursing (DON) said the resident was declining the last month and had decreased intake with eating. The nurses should have charted his/her condition and documented changes. The DON was not familiar with the paper charting for vitals but the newly implemented computerized charting has a vital sign tab and the order will pop up. The nurse who wrote on [DATE] was an agency nurse. She would expect there to be complete charting on the day the resident expired. She does not know why there was not complete charting.
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 the review, the facility failed to ensure that residents receive treatment and care f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record the review, the facility failed to ensure that residents receive treatment and care for new and existing wounds in accordance with professional standards of practice for two residents (Resident's #122 and #26) out of 25 sampled residents. The census was 126.
1. Review of Resident #122's medical record, showed:
-Medical diagnoses included: Pressure ulcer (PU, pressure injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or friction) of the sacrum (triangular bone located above the coccyx), stage IV (full thickness tissue loss with exposed bone, tendon or muscle. Slough (dead tissue separating from living tissue) or eschar (dead tissue) may be present on some parts of the wound bed. Often includes undermining (wound open underneath the border of the wound) or tunneling (channels or tracks that extend from a wound into and through the surrounding tissue or muscle);
-Osteomyelitis (infection of the bone) of vertebra and sacrum region;
-Pseudomonas aeruginosa (a bacterial infection highly resistant to antibiotics);
-Braden Scale (used for predicting pressure ulcer risk) dated 4/21/19, showed a score of 12, indicating the resident was at high risk for a pressure ulcer.
Review of the resident's hospital records dated 4/12/19, showed medical diagnoses included:
-Lower leg cellulitis (bacterial skin infection);
-Arterial insufficiency with ischemic ulcer (wound caused by poor blood flow to the leg).
Review of the resident's electronic physician order sheet (POS), showed an order dated 4/18/19, for wound care: Ischemic ulcer on left leg: Apply protective dressing daily and as needed.
Review of the resident's care plan, dated 4/15/19, showed:
-Problem: Cognition deficits;
-Goal: Needs related to cognition deficits will be addressed and risks of complications minimized;
-Approach: Alert/cognitively intact, with confusion; able to make needs known;
-Problem: Activities of daily living (ADLs) related to total dependence;
-Goal: ADL needs will be met with staff assistance;
-Approach: Assist with two staff members; Assist with toileting /incontinence care as needed;
-Problem: Skin/Wound (did not specify location or type);
-Goal: Will have risks related to compromised skin integrity addressed and complications minimized; and/or skin condition/wounds will exhibit signs of improvement;
-Approach: Administer medications as ordered; assist with turning and positioning; keep skin clean and dry; Skin/wound care treatments as ordered.
Observations on 4/22/19 at 7:00 A.M. and at 1:50 P.M., showed the resident lay in bed without a dressing to his/her lower left leg. The ischemic ulcer open to air, the wound edges appeared red, and the wound base approximately 7 centimeters (cm) in length and 4 cm wide and appeared yellow in color.
Observations on 4/23/19 at 7:25 A.M., 12:55 P.M., 1:18 P.M., 1:43 P.M and 2:15 P.M., showed the resident lay in bed without a dressing to his/her lower left leg. The ischemic ulcer open air, the wound edges appeared red, and the wound base approximately 7 cm in length and 4 cm wide and appeared yellow in color.
Observations on 4/24/19 at 7:54 A.M., 8:15 A.M., 8:50 A.M., 10:20 A.M., 11:07 A.M., 11:35 A.M and 2:40 P.M., showed the resident lay in bed without a dressing to his/her lower left leg. The ischemic ulcer open air, the wound edges appeared red, and the wound base approximately 7 cm in length and 4 cm wide and appeared yellow in color.
Review of the resident's April medication and treatment administration record (MAR/TAR), reviewed on 4/24/19 at 2:32 P.M., showed:
-An order dated 4/18/19: Ischemic ulcer on left lower leg: apply protective dressing daily and as needed;
-Nurses initialed completion of the treatment for 4/21/19, 4/22/19 and 4/24/19;
-On 4/23/19 at 4:02 P.M., staff documented the resident refused treatment.
Review of the resident's medical record on 4/29/19 at 12:22 P.M., showed no progress notes that referenced the left lower ischemic ulcer or treatments administered. No note on 4/23/19 stating the resident refused treatment to his/her left lower ischemic ulcer or how the nurse educated the resident on the treatment plan to promote healing.
During an interview on 4/25/19 at 2:35 P.M., the wound nurse said nursing staff should document daily progress notes describing the condition of the wound after providing treatment or changing dressings. Without daily progress notes detailing the condition of the wound, it is difficult to track the healing process of the wound as well as determine if the current treatment orders are appropriate to promote healing of the wound.
During an interview on 4/29/19 at 7:25 A.M., the Director of Nurses (DON) said nurses are expected to follow treatments as ordered.
2. Review of Resident #26's admission MDS, dated [DATE], showed:
-Diagnoses included Alzheimer's disease, dementia, high blood pressure, diabetes and urine incontinence;
-Severe cognitive impairment;
-No behaviors;
-Incontinent of bowel and bladder;
-Required maximum assistance from staff for transfers, dressing, hygiene and bathing.
Review of the resident's weekly skin assessments showed:
-On 4/17/19 - Skin tear to left shoulder;
-No further skin assessments found.
Review of the resident's MAR and TAR, dated 4/1/19 through 4/30/19, showed no documentation of any treatment to the left shoulder wound.
Review of the resident's electronic and hard copy POS, dated 4/1/19 through 4/30/19, showed no orders for any type of treatment to the resident's left shoulder wound.
Review of the resident's progress notes, showed:
-On 4/26/19 at 7:09 A.M., open area to left upper back. Area cleansed and dry dressing applied. No complaints of pain or discomfort at this time;
-No documentation found of the skin tear to the left shoulder on 4/17/19, any treatment orders, or of the physician or responsible party notification as late as 4/29/19.
Observation on 4/26/19 at 5:45 A.M., showed the resident lay in bed on his/her right side with his/her back exposed. An approximate 2 cm round, black/brown colored scabbed area surrounded by an approximate ½ cm red area observed on his/her left shoulder blade area. No dressing covered the area, or was found in or around the resident's bed. CNA I and Nurse J provided the resident with care, repositioned the resident onto his/her back using the cloth incontinence pad underneath him/her, turned him/her onto his/her right side and revealed the scab had been peeled off of the area and fresh blood oozed from the wound.
During an interview on 4/29/19 at 7:00 A.M., the DON said she could not find any skin assessment for the resident since 4/17/19, could not find any documentation staff had notified the physician, responsible party, obtained orders for treatment, or treated the wound on the resident's left shoulder and she would have expected staff to document that information in the resident's progress notes. Since staff had not documented, that meant they had not done anything about the wound.
3. Review of the facility's skin integrity manual skin integrity prevention and management policies and procedures, revised 1/1/06, showed:
-Wound assessment includes type, stage, location, measurement of site (Length, width, depth). Exudate (drainage) to include type, odor, amount, and color. Wound bed to include necrotic (dead) tissue, slough (moist dead tissue), fibrin (a fibrous protein involved in the clotting of blood), granulation (new tissue growth), epithelization (formation of granulation tissue), tunneling (a narrow opening or passageway underneath the skin that can extend in any direction through soft tissue)/undermining (wound open underneath the border of the wound). Periwound (skin around the wound) and wound edges appearance to include description and measurement. Presence of pain. Presence of signs and symptoms of infection. Peripheral pulses, capillary refill (return of blood to the blood vessels after pressure applied), edema (swelling), color and temperature of skin. At the time of diagnosis, it is important to document the clinical basis (underlying condition contributing to the ulceration, ulcer edges and would bed location shape condition of surrounding tissue) which permit determination of the ulcer type, especially if the ulcers characteristics are consistent with a pressure ulcer but it is determined not to be one;
-Weekly skin and wound assessments:
-Include type, stage, location, measurement of site, exudate, wound bed, periwound, presence or absence of pain, presence or absence of signs and symptoms of infection. Response to treatment;
-Daily skin inspection monitoring:
-Daily skin inspection is performed by caregivers during baths and/or assistance with ADLs. Change in skin integrity and/or signs and symptoms of complications are reported to the licensed nurse;
-Prevention guidelines:
-Identification of patients at risk, implementation of interventions/prevention strategies, care process includes efforts to stabilize, reduce or remove underlying risk factors (pressure redistribution, moisture management, nutritional assessment/support, management of underlying psychological deficits that cause increased risks. Includes physician notification of patient's deterioration and/or poor response to interventions. Weekly skin assessments and daily skin inspections.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents, who are fed by enteral means, receiv...
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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, who are fed by enteral means, receive the appropriate treatment and services for the enteral feeding by failing to ensure the head of bed was elevated during feeding for one of one resident who received enteral feedings and who was observed during care (Resident #222). The sample size was 25. The census was 126.
Review of the facility's undated Policy and Procedure for Enteral Feedings with Gastrostomy tube (G-tube, a tube surgically inserted into the stomach through the abdomen for the purpose of providing liquid nutrition, hydration and medications), showed:
-Purpose: G-tubes are used to supply nutrition and hydration to residents unable to take liquid or food by normal means;
-General Guidelines:
1. Feedings are initiated and monitored by licensed nurses;
2. Feeding solution is hung by recommendation of manufacturer and how it is packaged;
3. Feeding tube is flushed and clamped between feeding if not continuous;
4. A physician order specifying type of solution, amount and frequency is required;
5. Change and label feeding set and equipment every 24 hours, unless indicated otherwise by manufacturer;
6. Head of bed must be elevated 30 to 45 degrees for all residents while receiving tube feedings.
Review of Resident #222's face sheet, showed:
-Originally admitted to the facility on [DATE], and readmitted from a local hospital on 4/19/19;
-Diagnoses included aspiration pneumonia, Alzheimer's disease, dementia, severe protein-calorie malnutrition, G-tube, stroke, dysphagia (difficulty swallowing), bacteremia (blood infection) and dependence on supplemental oxygen.
Review of the resident's electronic and hard copy physician order sheet (POS), dated 4/1/19 through 4/30/19, showed:
-An order dated 4/19/19, for staff to administer nothing by mouth (NPO) to the resident;
-An order dated 4/19/19, to administer oxygen at 2 to 5 liters a minute by nasal cannula continuously as need for shortness of breath;
-An order dated 4/20/19, to administer Teflaro (an antibiotic) 400 milligrams (mg) intravenously (IV) every 12 hours for 33 doses;
-An order dated 4/20/19, to flush the left upper peripherally inserted central catheter (PICC line, a thin, soft, flexible tube - an IV line), with heparin (blood thinner) flush 10 units in every milliliter (ml) every 12 hours;
-An order dated 4/23/19, to administer 2 Cal HN (a high nutritional liquid supplement that provides 2 calories for every cubic centimeter (cc) of formula) at 45 cc an hour through the G-tube for 22 hours out of 24 hours.
Review of the resident's care plan, dated 4/22/19, and in use during the survey, showed:
-Problem: Recreation/wellness. Resident is unable to communicate or get out of bed and cannot make wants and needs know;
-Goal: Placed on one on ones. Will have needs anticipated and met by staff;
-Interventions: Staff will anticipate needs, ask yes/no questions and be alert to nonverbal communications;
-The care plan did not address the G-tube or the tube feeding.
Observation on 4/22/19 at 9:50 A.M., showed the resident lay in bed sleeping, with the head of his/her bed elevated 30 degrees. The tube feeding of 2 Cal HN infused at 45 cc an hour by pump. Oxygen infused at 3 liters a minute through nasal prongs without any signs of respiratory distress.
Observation on 4/22/19 at 11:15 A.M., showed the resident lay flat in bed without the head of the bed elevated. The tube feeding infused at 45 cc an hour through the pump. Certified Nurse Assistants (CNAs) F and G came into the room, washed hands, put on gloves and provided the resident with care. At 11:30 A.M., both CNAs finished providing care, raised the head of the resident's bed and left the room. The resident had laid flat in bed during the care as the tube feeding infused at 45 cc an hour.
During an observation on 4/25/19 at 2:55 P.M., showed the resident not in his/her room. The tube feeding had been disconnected, turned off and remained in the room.
During an interview on 4/25/19 at 3:00 P.M., Nurse K said he/she had just sent the resident out to the emergency room due to having difficulty breathing and respiratory distress.
During an interview on 4/26/19 at 4:50 A.M., Nurse L said the resident had been admitted to the hospital due to his/her respiratory distress.
During an interview on 4/29/19 at 9:00 A.M., the Director of Nurses (DON) said it would never be appropriate for staff to provide care to a resident with the head of the bed flat while the tube feeding continued to infuse due to a high risk of aspiration the tube feeding (tube feeding going into the lungs).
CONCERN
(D)
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 that a resident who needs respiratory care, inc...
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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 a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice by failing to ensure an emergency tracheostomy tube was accessible in the resident's room and ensure an oxygen nasal cannula was secured properly under a resident's nose. In addition, the facility failed to obtain oxygen saturation (percentage of oxygen in the blood) and change oxygen tubing, bottles and masks as ordered, for four of 25 sampled residents (Residents #94, #110, #4, and #49). The census was 126.
1. Review of the facility's Policy and Procedure for Tracheostomy Care, dated August 2013, showed:
-General Guideline: A replacement tracheostomy tube must be available at the bedside at all times.
-Procedure Guidelines: Ensure there is an emergency tracheostomy set up at resident's bedside.
Review of Resident #94's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/13/19, showed:
-Diagnoses included quadriplegia (paralysis), tracheostomy (an opening through the neck into the trachea through which an indwelling tube maybe inserted), major depressive disorder, anxiety disorder and epilepsy (seizure disorder);
-Cognitively intact;
-No behaviors;
-Tracheostomy;
-Required total assistance from staff for transfers, dressing, eating, hygiene and bathing.
Review of the resident's care plan, dated 3/14/19, showed it did not address the resident's tracheostomy tube.
Observation on 4/22/19 at 10:39 A.M., 4/23/19 at 8:40 A.M., 4/24/19 at 9:19 A.M. and 4/25/19 at 12:30 P.M., showed the resident lay in bed with a tracheostomy tube inserted into his/her neck. No extra tracheostomy tube found in the room for the event of an emergency.
During an observation and interview on 4/23/19 at 8:40 A.M., Nurse K said when they change the resident's tracheostomy tube monthly as ordered, they get the tracheostomy tube and kit from central supply. He/she does not know if a tracheostomy tube is kept in the resident's room for an emergency. Nurse K asked the resident if he/she knew if there was an extra tracheostomy tube in his/her room, he/she said he/she did not know and to look in his/her drawers. Nurse K looked around the resident's room and in his/her drawers and did not find any extra tracheostomy tube.
During an interview on 4/25/19 at 12:45 P.M., the Director of Nurses (DON) said she would expect for staff to place at least one extra tracheostomy tube in the resident's room for emergency use, it should be taped to the wall above the head of the bed, or at least easily visible and readily accessible to staff in the event of an emergency and she would prefer to have 2 extra tracheostomy tubes in the room.
2. Review of the facility's undated oxygen administration policy, showed the following:
-Change tubing and cannula, mask or attachments every 7 days. Document on the resident's treatment administration record (TAR) or medication administration record (MAR) or label the tubing with date and staff initials;
-Change humidifier bottle at least weekly. Document on MAR or TAR or label bottle with date and initials.
3. Review of Resident #110 quarterly MDS, dated [DATE], showed:
-Cognitively impaired;
-Diagnoses included heart failure, high blood pressure, diabetes, non-Alzheimer's dementia, anxiety disorder, depression, morbid obesity and legal blindness;
-Total assistance required for transfers, dressing, toileting and hygiene;
-Extensive assistance required for bed mobility and eating;
-Receives oxygen therapy.
Review of the resident's care plan, dated 3/26/19, showed no documentation for continuous oxygen or a diagnosis that required continuous oxygen.
Review of the resident's POS, dated 4/1/19 through 4/30/19, showed:
-An order, dated 3/18/19, to check oxygen saturation every shift. Keep oxygen saturation above 90%;
-An order, dated 3/18/19, to change oxygen tubing weekly on Sunday night;
-An order, dated 3/18/19, for oxygen at 4 liters (L)/ minute via nasal cannula every shift;
-An order, dated 4/6/19, to obtain monthly vitals on the 6th of the month;
-An order, dated 4/25/19, to check water in humidifier oxygen every shift. Add distilled water if needed;
-An order, dated 4/25/19, to change oxygen tubing weekly on Sunday night;
-An order, dated 4/25/19, to change humidifier oxygen water container/tube weekly on Sunday night.
Review of the resident's MAR, dated 4/1/19 through 4/30/19, showed an order, dated 3/18/19, to check oxygen saturation every shift. Staff initialed the oxygen saturations obtained on 4/1/19 through 4/28/19, on the day and night shifts. The resident refused on 4/14/19 at 9:33 A.M. and 4/18/19 at 9:59 P.M.
Review of the resident's oxygen saturation (sats), dated 4/1/19 through 4/30/19, and reviewed on 4/28/19, showed:
-On 4/10/19 at 7:30 A.M., the resident's oxygen sats were 92%;
-On 4/10/19 at 10:57 A.M., the resident's oxygen sats were 92%;
-On 4/11/19 at 9:18 A.M., the resident's oxygen sats were 92%;
-On 4/12/19 at 5:26 A.M., the resident's oxygen sats were 98%;
-On 4/12/19 at 4:53 P.M., the resident's oxygen sats were 97%;
-On 4/13/19 at 6:08 P.M., the resident's oxygen sats were 97%;
-On 4/13/19 at 11:36 P.M., the resident's oxygen sats were 97%;
-No further documentation of the resident's oxygen sats.
Review of the resident's TAR, dated 4/1/19 through 4/30/19, reviewed on 4/28/19, showed:
-An order, dated 3/18/19, for oxygen at 4 L per nasal cannula every shift. Staff documented the administration of 4 L of oxygen on 4/1/19 through 4/29/19 on the day and night shifts;
-An order, dated 4/25/19, to change humidifier oxygen water container/tube weekly on Sunday night. Staff documented the water container/tube changed on 4/28/19, only;
-An order, dated 4/25/19, to change oxygen tubing weekly on Sunday night. Staff documented the tubing the changed on 4/28/19, only.
Observations of the resident, showed:
-On 4/22/19 at 8:50 A.M., the resident lay in bed. Oxygen set at 3 L per nasal cannula, but the oxygen tubing and cannula lay on the floor. No date on the oxygen tubing. The humidifier dated 3/9/19. At 11:50 A.M., the resident's oxygen set at 3 L per nasal cannula. The resident's nasal cannula secured under the resident's nose. The humidifier dated 3/19/19. The oxygen tubing was not dated;
-On 4/23/19 at 9:02 A.M., the resident lay in bed. The resident's oxygen set between 2-3 L per nasal cannula. The nasal cannula not secured under the resident's nose. At 12:01 P.M., the resident's oxygen set between 3-4 L. The nasal cannula not secured under the resident's nose. The nasal cannula on the resident's right cheek. The humidifier dated 3/9/19. The oxygen tubing not dated;
-On 4/24/19 at 9:58 A.M., the resident assisted with his/her meal by Certified Nurse Aide (CNA) W. Half of the nasal cannula secured under the resident's right nostril, and the other side was on the resident's cheek. At 1:04 P.M. and 3:37 P.M., the resident lay in bed. Half of the nasal cannula secured under the resident's right nostril. The other half lay on the resident's right cheek. The humidifier dated 3/19/19;
-On 4/25/19 at 7:53 A.M., the resident lay in bed. The oxygen set between 3-4 L. The nasal cannula lay on the resident's right cheek.
During observation and interview on 4/25/19 at 10:00 A.M., the DON entered the resident's room. The DON confirmed the humidifier was dated 3/9/19, and said it was not appropriate for it to be used for the resident's oxygen. She would expect it to be changed every week. She would expect staff to check the tubing to ensure the nasal cannula was secured under the resident's nose. The DON removed the nasal cannula, which was on the side of the resident's face with a tubing indention imprinted on the resident's face. The DON looked at the nasal cannula and said, that's gross. The nasal cannula had dried substance on it, and was slightly yellow. She confirmed that the tubing should have been changed by now. She was not sure of the process of how to date the tubing, but confirmed it was not being done.
Observation on 4/29/19 at 7:24 A.M., showed the resident lay in bed. The oxygen humidifier and tubing undated. The oxygen was set between 3-4 L. The nasal cannula was on the resident's right side of the face.
4. Review of Resident #4's quarterly MDS, dated [DATE], showed:
-Moderate cognitive impairment;
-Diagnoses included high blood pressure, multiple sclerosis (disease of the central nervous system), seizure disorder, anxiety disorder, depression and asthma;
-Received oxygen therapy.
Review of the resident's care plan, dated 3/7/19, showed no documentation for continuous oxygen or a diagnosis that required continuous oxygen.
Review of the resident's POS, dated 4/1/19 through 4/30/19, showed:
-An order, dated 9/4/18, for albuterol sulfate (used to treat asthma) solution for nebulization (liquid medication turned into an aerosol for inhalation), 2.5 milligram (mg) / 3 milliliter (ml). Administer one vial, three times a day;
-An order, dated 3/14/19, to change oxygen tubing weekly on Sunday night;
-An order, dated 3/14/19, for oxygen at 2 L per minute via nasal cannula every shift;
-No orders to check oxygen saturation or to change the nebulizer mask.
Review of the resident's MAR, dated 4/1/19 through 4/30/19, showed:
-An order, dared 9/4/18, for albuterol sulfate solution for nebulization, documented as administered three times a day;
-An order, dated 3/14/19, to change oxygen tubing weekly on Sunday night. Staff documented the oxygen tubing was changed on 4/7, 4/14, 4/21 and 4/28/19.
Review of the resident's TAR, dated 4/1/19 through 4/30/19, showed:
-An order, dated 3/14/19, for oxygen at 2 L per nasal cannula every shift. Staff documented the administration of 2 L of oxygen on 4/1/19 through 4/29/19 on the day and night shifts.
Review of the resident's documented oxygen saturation, dated 4/1/19 through 4/29/19, showed:
-On 4/17/19, the resident's oxygen saturation 96%;
-No further documentation of the resident's oxygen sats.
Observations of the resident, showed:
-On 4/23/19 at 9:12 A.M., the resident lay in bed. The undated oxygen tubing and nasal cannula lay on the floor. The resident picked it up and placed it under his/her nose. Oxygen set at 2 L. A nebulizer mask sat on the resident's night table, uncovered, and dated 3/9/19;
-On 4/24/19 at 9:49 A.M., the resident in bed. The oxygen machine turned on without oxygen tubing. The resident received oxygen from an oxygen tank. No date on the oxygen tubing with nasal cannula under the resident's nose. A nebulizer mask sat on the resident's night table, uncovered, and dated 3/9/19;
-On 4/25/19 at 7:56 A.M., the resident lay in bed. Oxygen set at 2 L. The oxygen tubing undated and the nasal cannula secured under the resident's nose. A nebulizer mask sat on the resident's night table, uncovered, and dated 3/9/19;
-On 4/29/19 at 7:22 A.M., the resident lay in bed. Oxygen set at 2 L. The oxygen tubing undated and the nasal cannula secured under the resident's nose. A nebulizer mask sat on the resident's night table, uncovered, and undated.
5. Review of Resident #49's face sheet, showed diagnoses included heart failure and coronary artery disease.
Review of the resident's POS, showed an order dated 3/21/19 for oxygen at 2-4 liters per minute, via nasal cannula, as needed. No documented order to change the resident's tubing, cannula or humidifier.
Observations on 4/22/19 through 4/26/19 and on 4/29/19, showed an oxygen concentrator next to the resident's bed, turned on and in use. The nasal cannula, oxygen tubing and the humidifier not labeled with any date.
Review of the resident's MAR, dated 4/1/9 through 4/29/19, showed no documentation of when the resident's oxygen tubing, cannula or humidifier were changed.
During an interview on 4/29/19 at 9:50 A.M., the DON said residents with oxygen should have a physician's order to change the concentrator bottle, tubing and cannula, weekly and staff should document this task on the resident's MAR/TAR. It is important to change the concentrator bottle, tubing and cannula, weekly to prevent bacteria build up.
6. During an interview on 4/29/19 at 9:00 A.M., the administrator said she would expect staff to follow physician's orders and change the oxygen tubing and humidifier. It should be changed weekly and as needed. It is important for the humidifier and tubing to be changed per physician's orders to prevent a build-up of bacteria. If a resident was on continuous oxygen and had orders to obtain oxygen sats every shift, she would expect staff to obtain them and document it. The CNAs and nurses are able to record the oxygen sats. It should be documented under vitals in the electronic medical record. She would expect staff to ensure the nasal cannula is secured under the resident's nose. The nebulizer mask should be dated and covered when it was not in use. She would expect the use of oxygen to be care planned, including the diagnoses that required the use of continuous oxygen.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed ensure that residents who require dialysis receive such services, consistent with professional standards of practice by failing t...
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Based on observation, interview and record review, the facility failed ensure that residents who require dialysis receive such services, consistent with professional standards of practice by failing to provide ongoing communication with the dialysis center for residents on dialysis. The facility also failed to obtain pre and post weights and have a system in place for not serving foods contraindicated for residents with kidney failure, including educating staff about limitations of tomatoes, potatoes, and orange juice for residents on dialysis. In addition, the facility failed to provide a dialysis policy. The facility identified two residents who received dialysis. Of those two, one was selected for a sample of 25 (Resident #72). The census was 126.
Review of Resident #72's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/28/18, showed:
-Cognitively intact;
-Diagnoses included high blood pressure and hyperlipidemia (high levels of lipids);
-Supervision required for transfers, dressing, eating, toileting and hygiene;
-Received dialysis (process for removing toxins from the blood for individuals with kidney failure);
-Weight of 191 pounds.
Review of the resident's dietary notes, showed:
-On 3/9/18, resident was admitted on 3/8 with a diagnosis of renal (kidney) failure. Diet order is regular and resident will consume meals in the main dining room;
-On 3/9/18, spoke with registered dietician at dialysis center today. Provided fax number for the current labs. Explained liberalized diets at facility. States his/her labs are normal today with potassium (K) being slightly higher but within normal limits (WNL). Will continue to monitor and follow up as needed (PRN);
-On 3/18/18, spoke to the resident today about his/her high potassium levels. This morning he/she had three glasses of orange juice. Spoke about high potassium foods like tomatoes, potatoes, melons, and oranges and to limit intakes of these items. He/she stated he/she did not have to limit potatoes because of his/her labs. Reminded him/her of his recent potassium level and encouraged decreased intake to help manage. Informed him/her of the risk associated with high potassium levels. Will continued to provide reminders and to educate PRN;
-On 5/15/18, spoke to nursing and dietary staff about limiting potassium at meals and snacks. Remind resident to limit orange juice at meals. Observed resident drinking water and no orange juice last week after speaking with the resident. Will continue to monitor and follow up;
-On 2/7/19, resident re-admitted on 2/6 with hypotension (low blood pressure). Diet order regular, and resident will consume meals in the main dining room. Will follow up at assessment.
Review of the resident's lab results, showed:
-On 9/5/18, the potassium level 5.0 (reference range 3.5-5.1);
-On 10/12/18, the potassium level 5.4. The level documented as high;
-On 11/7/18, the potassium level 5.5. The level documented as high;
-On 12/6/18, the potassium level 5.7. The level documented as high;
-On 12/19/18, the potassium level 5.8. The level was documented as high;
-Further review of the resident's medical record, showed no further lab tests or results.
Review of the resident's care plan, dated 2/14/19, showed:
-Problem: Resident is at increased nutritional risk secondary to end stage renal disease, dialysis and renal restrictions. He/she is meeting his nutritional needs at this time;
-Approaches: Regular diet;
-Encourage him/her to follow renal restrictions in place from his/her dialysis center;
-Encourage limited potassium intakes and phosphorous intake (yogurt/dairy) products;
-He/she goes to dialysis Monday, Wednesday, and Friday and receives a sack lunch on these days. He/she stated he/she enjoys ham or turkey sandwiches, applesauce, Cheetos, etc., in his/her sack lunch;
-He/she is blind and requires help during his/her meals for location of his/her food items. He/she is able to feed him/herself once he/she knows where the food is located;
-He/she likes to sleep in. He/she receives his/her breakfast at the facility prior to leaving for dialysis on Monday, Wednesday, and Friday;
-Staff to weigh him/her pre and post dialysis.
Review of the resident's dialysis communication worksheet, showed:
-On 3/8/19: Pre-dialysis report, showed:
-Patient is scheduled for dialysis today. Cath (shunt, dialysis access site) to left upper arm, no redness or bleeding noted;
-Fever in the last 24 hours: No;
-Falls: No;
-Shunt Thrill (a rumbling sensation that you can feel) present: Yes;
-Shunt Bruit (a rumbling sound you can hear) present: Yes;
-Vascular access site: No signs/symptoms of infection;
-Pre-dialysis skin assessment: Skin intact;
-Appetite: Normal;
-Post-dialysis report: Blank;
-On 3/11/19: Pre-dialysis report, showed:
-Fever in the last 24 hours: No;
-Falls: No;
-Shunt Thrill present: Yes;
-Shunt Bruit resent: Yes;
-Vascular access site: No signs/symptoms of infection;
-Pre-dialysis skin assessment: Skin intact;
-Appetite: Normal;
-Post-dialysis report: Blank;
-Further review of the resident's medical record, showed no further documentation of the communication between the facility and the dialysis center.
Review of the resident's physician orders sheet (POS), dated 4/1/19 through 4/30/19, showed:
-An order, dated 3/14/19, to record pre and post dialysis weight on Mondays, Wednesdays, and Fridays;
-An order, dated 3/14/19, for Dialysis on Monday, Wednesday, and Friday;
-An order, dated 3/20/19, for regular diet.
Review of the resident's weight record, dated 4/1/19 through 4/30/19, showed:
-On 4/12/19, the resident weighed 195 pounds;
-On 4/26/19, the resident weighed 194 pounds;
-No further documentation of the resident's weight including any pre and post dialysis weight.
Review of the resident's dietician progress notes, dated 4/24/19, showed:
-Diet: Regular
-Weight: 195.0;
-By mouth (PO) intake: 75-100% of most meals;
-Labs: Contacted dialysis center to fax over April labs;
-Resident is alert and able to make needs and preferences known. Resident is self-feeding and only needs assistance to set up plate/meals due to blindness. Resident has no difficulty chewing and swallowing. Resident is tolerating diet well and is meeting estimated nutrient needs. Resident is at risk for weight fluctuations related to need for dialysis due to end stage renal disease diagnosis. Resident receives dialysis every Monday, Wednesday, and Friday and takes a sack lunch with him/her. Registered dietician contacted dialysis center and they will be faxing over his/her April labs today. Will continue to monitor. Resident is on selvemar carbonate which has an interaction of binding phosphate to elevate serum Ca levels and decrease serum phosphorous levels. Resident is taking renal caps and vitamin D2 to help meet estimated nutrient needs. Resident is on fiber-lax which has an interaction of stimulating movement of the bowels. Encourage/offer fluids often. Continue to encourage good intake at meals and snacks for optimal nutrition. Will follow weight/labs/intake and will make nutritional recommendation as needed.
Observation on 4/23/19 at 12:43 P.M., showed the resident in the dining room. Staff served enchilada with sour cream and salsa, chopped lettuce, and fiesta corn. Red sauce observed on the enchilada. He/she consumed 100% of the meal.
Review of the resident's meal ticket, dated 4/23/19, showed:
-Regular;
-Enchiladas served with sour cream and salsa, chopped lettuce, and fiesta corn;
-Double portions;
-No shellfish i.e. shrimp;
-Limit orange juice, potatoes, tomatoes, and melon.
Observation on 4/23/19 at 1:33 P.M., showed the enchilada sauce pre-made in a container. The main ingredient was tomato puree.
During an interview on 4/25/19 at 1:19 P.M., Dietary Aide D said if a meal ticket said to limit a certain food, he/she was not sure what it meant, but it could mean the resident could not have double portions of the food.
During an interview on 4/25/19 at 1:25 P.M., Dietary Aide E said limit on a meal ticket meant the resident could not have it.
During an interview on 4/29/19 at 7:59 A.M., the nurse at the dialysis center said if the resident brought a communication sheet from the facility, the dialysis center staff would fill it out and send it back with the resident to the facility. There were concerns with the resident's diet. The dietician at the dialysis center spoke to the facility's dietician about the resident's consumption of tomatoes, potatoes, and orange juice. The nurse confirmed that the dialysis center obtains labs on a weekly basis and the resident's potassium levels were high.
During an interview on 4/29/19 at 9:00 A.M., the administrator said the facility does not offer a renal diet, so the staff are not educated on it, so they would not know what it was. If a resident had limit tomatoes, potatoes, and orange juice on the meal ticket, it is simply a suggestions. It is the resident's choice. There are alternates offered as well. The administrator would expect staff to obtain the resident's pre and post dialysis weight per physician's orders. The resident is sent with the form that the staff at the dialysis center fills out, but the administrator did not know about the return of the form or where it is located in the medical record. The dialysis center calls, but she would assume there is a communication or a progress note if the nurse spoke to the dialysis center. She would expect the facility to check the resident's potassium if the physician had an order for it. The dietician at the dialysis center would contact the facility's dietician if the parameters were out of whack. The dialysis center monitors the labs regularly.
During an interview on 4/29/19 at 2:00 P.M., the administrator said the facility's dialysis policy was not available to be given to the surveyor. The corporate office was reviewing it to ensure the facility had the most updated policy.
During an interview on 4/29/19 at 3:10 P.M., the assistant administrator said the administrator was still working on the policy and offered to fax it to the surveyor once it was completed.
During an interview on 5/1/19 at 9:37 A.M., the administrator at the dialysis center said they faxed the resident's labs to the nursing staff at the facility. The resident's potassium level were 5.4, which was considered high. The resident's phosphorous level was a 6.1 (normal 2.5 to 4.5). The dietician at the dialysis center speaks to the resident weekly regarding his/her diet. He/she was encouraged to not consume tomatoes, potatoes, and oranges. He/she was also encouraged not to consume cheese and yogurt. The administrator at the dialysis center read the dietician's notes. He/she confirmed that the resident had a banana in his/her sack lunch, but gave it to the bus driver. He/she would expect the facility to understand what a renal diet is and to offer it. It is important for the dietary staff to know what the resident can and cannot eat. There is an understanding that some residents are non-compliant with their diet; however, it is the facility's responsibility to monitor what the resident is consuming and have a system in place in case the resident is non-compliant. If the resident is non-compliant with their diet, it is also important for the facility to obtain and monitor the labs so they are aware if the resident's potassium or phosphorous levels are at a dangerous level.
As of 5/6/19, no dialysis policy provided by the facility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 34 opportunities observed, two errors occurred resulting in a 5.88% med...
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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 34 opportunities observed, two errors occurred resulting in a 5.88% medication error rate (Resident #122). The census was 126.
Review of Resident #122's electronic physician order sheet, showed:
-An order dated 4/12/19, for Meropenem (antibiotic) 1 gram reconstituted with sodium chloride 0.9% (salt water) 100 milliliter (ml), give intravenous (IV, into the vein) at 200 ml per hour, every eight hours, at 6:30 A.M., 2:30 P.M., and 10:30 P.M.
Review of the resident's care plan, dated 4/15/19, showed:
-Problem: Resident requires IV antibiotics related to wound infection;
-Goal: Resident will not exhibit signs of complications from the IV;
-Approach: Administer IV meds per physician orders.
Observations of medication administration, showed:
-On 4/22/19 at 1:50 P.M., Licensed Practical Nurse (LPN) P administered Meropenem to the resident. LPN P set the IV pump to administer the Meropenem at a rate of 100 ml per hour for 100 ml. LPN P failed to set the infusion rate to 200 ml per hour for 100 ml as ordered;
-On 4/24/19 at 8:50 A.M., Nurse A started the Meropenem infusion at a rate of 200 ml per hour for 100 ml. At 10:20 A.M., the IV alarm beeped and did not infuse. The alarm audible in the hall. At 10:43 A.M., Certified Nursing Assistant (CNA) Z entered the resident's room, left the room, and did not notify the nurse. At 11:07 A.M., Nurse A entered the room and restarted the pump. The Meropenem had 70 ml left to infuse. At 11:25 A.M., the infusion completed. The nurse failed to administer the antibiotic at the scheduled 6:30 A.M. timeframe and failed to assure the antibiotic infused within 2 hours.
During an interview on 4/29/19 at 10:35 A.M., the administrator said nurses are expected to follow physician orders.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to provide food that accommodates resident allergies, intolerances, and preferences, when staff served one resident fish, when he...
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Based on observation, interview and record review, the facility failed to provide food that accommodates resident allergies, intolerances, and preferences, when staff served one resident fish, when he/she had an allergy to fish. This affected one of 25 sampled residents (Resident #322). The census was 126.
Review of Resident #322's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/24/18, showed:
-Rarely/never understood;
-One staff person assist for eating;
-Diagnoses included Alzheimer's disease.
Review of the resident's current physician order sheet (POS), in use during the survey, showed allergies: Fish, fish oil and fish product derivatives.
Review of the resident's care plan, dated 4/2/19 and in use during the survey, showed the resident was not to receive fish product derivatives.
During an observation and interview on 4/22/19 at 12:26 P.M., Certified Nursing Assistant (CNA) X picked up two plates from the serving cart and carried the plates to the resident assisted dining room table. CNA X sat each plate in front of the residents and both meal tickets showed puree herbed butter baked fish as the entrée. As CNA X prepared to spoon the meat puree into Resident #322's mouth, the surveyor stopped CNA X and asked if the resident was allergic to fish. CNA X said he/she was not aware if the resident was allergic to fish and picked up the resident's meal ticket. At the bottom of the ticket in bold print, showed allergies: Fish product derivatives. The CNA removed the plate from the resident.
During an interview on 4/29/19 at 7:02 A.M., Nurse Y said he/she would expect the staff to read the meal ticket and check for allergies prior to serving the meal.
During an interview on 4/29/19 at 7:26 A.M., the administrator said she expected staff to follow the resident's care plan and also to read the meal tickets and check for allergies.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0808
(Tag F0808)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to assure that residents receive and consume foods in the appropriate form and/or the appropriate nutritive content as prescribed...
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Based on observation, interview and record review, the facility failed to assure that residents receive and consume foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician to support the resident's treatment and plan of care, in accordance with his her goals and preferences by failing to assure staff provided a meal for a resident who went off campus for physical therapy. This affected one of 25 sampled residents (Resident #15). The census was 126.
Review of Resident #15's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/9/18, showed:
-Cognitively intact;
-Two staff person assist for bed mobility and transfer;
-Eating, set up help only;
-Mobility: wheelchair;
-Diagnoses included multiple sclerosis (MS, often disabling disease of the central nervous system that disrupts the flow of information within the brain, and between the brain and body), diabetes, heart failure and high blood pressure.
Review of the resident's care plan, dated 2/17/17, and in use during the survey, showed off campus therapy not identified and no interventions listed to ensure meals are provided either before leaving the facility or to provide a sack lunch.
Review of the resident's physician order sheet (POS), dated 9/7/18, showed the following:
-An order for a Novolog (rapid acting) insulin. Administer by sliding scale three times daily, before meals and at bedtime (7:30 A.M., 11:30 A.M., 4:30 P.M., and 9:00 P.M.). Administer insulin units (u) based on blood glucose level (BGL) as follows:
-BGL less than 70, call the physician;
-BGL 151-200, give 1 u;
-BGL 201-250, give 2 u;
-BGL 251-300, give 3 u;
-BGL 301-350, give 4 u;
-BGL 351 to 400, give 5 u;
-BGL greater than 400, give 6 u;
-If BGL greater than 400, call the physician.
During an interview on 4/23/19 at 12:01 P.M., the resident said he/she goes to therapy at another facility per his/her preference. He/she attended therapy on Mondays and Wednesdays. He/she has to go down to the kitchen him/herself prior to leaving for therapy to get something to eat, if he/she has time. Otherwise, he/she gets his/her blood sugar checked, but no one provides anything to eat prior to his/her leaving.
During an interview on 4/23/19 12:09 P.M., Nurse Y said he/she was aware the resident goes to off campus for therapy. As far as meals, he/she was not aware if dietary provided a lunch prior to the resident leaving the facility. If the resident has his/her blood sugar tested and insulin administered prior to leaving, and did not eat, the potential harm could be hypoglycemia (low blood sugar).
During an interview on 4/23/19 at 12:30 P.M., the dietary manager said she only had two residents who leave the facility that would need meals prior to leaving. She provided the names of the two residents and Resident #15 was not included. The dietary manager said she was not aware Resident #15 left the facility and would need to either eat prior to leaving, or have a sack lunch sent with him/her.
During an interview on 4/29/19 at 7:18 A.M., the administrator said she was not aware the resident needed a sack lunch if he/she is not able to eat prior to leaving the facility. There should be communication between nursing and dietary and should be on the resident's care plan.
MO00154983
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
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 they maintained complete and accurate records when a residen...
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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 they maintained complete and accurate records when a resident expired in the facility, for one of three closed records reviewed. The resident's notes did not have documentation of vitals or reflect that the resident had expired (Resident #123). The census was 126.
Review of Resident #123's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following:
-Total dependence on staff for bed mobility, transfers, dressing, eating and hygiene;
-Incontinent of bowel and bladder;
-Diagnosis included anemia, arthritis, dementia, constipation, dysphasia (difficulty swallowing), anxiety and muscle weakness;
-Received hospice services.
Review of the resident's diagnostic problem list, dated [DATE], showed he/she received hospices services from [DATE] to [DATE].
Review of the resident's nurse's notes, showed:
-On [DATE] (no time noted), the physician ordered Compazine (used to treat nausea) suppository 10 milligram (mg), every 6 hours as needed for nausea and Imodium (used to treat loose stools) 2 mg every 4 hours as needed for diarrhea. Vital signs every shift for three days. Push fluids and call physician for oxygen levels less than 90%.
Review of the resident's medication administration record (MAR) and treatment administration record (TAR) dated [DATE] through [DATE], showed the only documented vitals recorded were on [DATE], which were his/her temperature, pulse and blood pressure. Staff did not document anything under the push fluids order.
Further review of the resident's nurses notes, showed:
-On [DATE] at 6:15 A.M. (next note after [DATE]/9) Nurse called to residents room at about 5:10 A.M., resident lying in bed, oxygen at 4 liters with an oxygen saturation (amount of oxygen in the blood) at 87% (normal 95-100%), temperature 99 (normal 97.9-99.1 degrees Fahrenheit (F)), respirations 44 (normal 12-18), pulse 116 (normal 60-100) and dropping, blood pressure 80/58 (normal 120/80). Resident noted just lying in bed with his/her mouth open, no distress noted, skin warm to touch. Call placed to physician at 5:25 A.M. and received new order for Roxanol (narcotic pain medication) 20 mg per milliliter (ml), give 10 mg (0.5 ml) every hour for respirations greater than 26 or for pain. Give Lorazepam (used to treat anxiety) intensol 2 mg/ml, given 1 mg/0.5 ml every hour for restlessness. Hospice to treat and evaluate. Call placed to hospice. Call placed to family. Staff gave the resident Roxanol at 5:50 A.M., will continue to monitor and note any changes;
-On [DATE] at 7:10 A.M., staff noted night supervisor made aware of change in condition at 5:30 A.M.;
-No further documentation in the residents nurses notes.
Review of the hospice plan of care, dated [DATE] (no time noted), showed the resident was actively dying at time of visit and resting comfortably. He/she passed shortly after visit.
During an interview on [DATE] at 12:25 P.M., the director of nursing (DON) said the resident was declining the last month and had decreased intake with eating. The nurses should have charted his/her condition and document changes. The DON was not familiar with the paper charting for vitals but the newly implemented computerized charting has a vital sign tab and the order will pop up. The nurse who wrote on [DATE] was an agency nurse. She would expect there to be complete charting on the day the resident expired. She does not know why there was not complete charting.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0917
(Tag F0917)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to provide residents with a comfortable mattress when the low air loss (LAL) mattress was set on the incorrect weight setting, re...
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Based on observation, interview and record review, the facility failed to provide residents with a comfortable mattress when the low air loss (LAL) mattress was set on the incorrect weight setting, resulting in the mattress being hard for one of 25 sampled residents (Resident #272). The census was 126.
Review of the Resident #272's quarterly Minimum Data Set (MDS), a federally mandated assessed instrument completed by facility staff, dated 4/8/19, showed:
-Rarely understood;
-Total dependence with bed mobility;
-Weight of 207 pounds.
Review of the resident's physician order sheet (POS), dated 4/1/19 through 4/30/19, showed:
-An order, dated 3/14/19, for ¼ side rails for positioning and bed mobility;
-An order, dated 3/14/19, for a LAL mattress.
Review of the resident's weight record, showed a weight of 207 obtained on 4/8/19.
Observations on 4/22/19 at 9:11 A.M. and 11:45 A.M., and 4/23/19 at 8:55 A.M. and 12:05 P.M., showed the resident lay in bed. The LAL machine located at the foot of the bed beeped continuously. The low pressure light flashed. The weight on the LAL machine set for a weight 290 pounds. Other weight setting options available on the bed, closer to the resident's actual weight, included 200, 230, and 260. The mattress felt hard to the touch.
Observations on 4/24/19 at 7:51 A.M. and 9:43 A.M., and 4/25/19 at 7:57 A.M., showed the resident lay in bed. The LAL machine located at the foot of the bed beeped continuously. The low pressure light flashed. The weight on the LAL machine set for a weight of 350 pounds. Other weight setting options available on the bed, closer to the resident's actual weight, included 200, 230, 260, 290, and 320. On 4/25/19 at 10:00 A.M., the resident lay in bed. The Director of Nursing (DON) confirmed the LAL was set at 350 pounds. The low pressure light flashed and the bed alarm beeped. The DON said she could hear it beep and she would expect staff to address it. It was possible that the LAL needed to be reset. The DON was not aware of where to find the manual for the LAL. She would expect the weight setting to be accurate or set per physician orders if specified. The DON checked the firmness of the mattress. She pressed down on the lower and upper part of the mattress and said it was pretty firm.
During an interview on 4/29/19 at 9:00 A.M., the administrator said she would expect staff to check the settings on the resident's LAL mattress to ensure it was on the correct weight setting. If the machine continued to beep and the low pressure light flashed, she would expect staff to report it and address it. She would expect staff to have access to the brand manual. The administrator confirmed that a company comes in once year to check if the LAL mattresses are properly functioning, but the facility staff are expected to check if the LAL mattresses are working on a regular basis.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff treated residents in a manner to maintain...
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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 treated residents in a manner to maintain their dignity when staff used their cell phone while assisting residents with care, failed to provide privacy for residents with indwelling urinary catheters, knock on residents' doors before entering their rooms and failed to answer call lights in a timely manner for eight residents (Residents #323, #109, #56, #272, #21, #111, #96 and #87). The census was 126.
1. Review of Resident #323's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/12/19, showed:
-Rarely/never understood;
-No behaviors;
-Required assistance from one staff person for bed mobility, dressing, personal hygiene, dressing and toilet use;
-Wheelchair for mobility;
-Diagnoses included Alzheimer's disease, schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly), heart failure, high blood pressure and depression.
Observation on 4/24/19 at 8:42 A.M., showed the resident sat in the dining room. He/she had removed his/her top, leaving his/her breast exposed. Two certified nurse aides (CNAs) sat at the adjacent table, assisting residents with their meals. Both CNAs sat with their heads down with their focus on their phones, neither CNA realized the resident had disrobed. Nurse X walked over to the resident and started to assist the resident with his/her shirt. One CNA looked up from his/her phone, saw the resident and said, Oh my!
During an interview on 4/29/19 at 7:08 A.M., Nurse N said staff should be focused on the residents during meals, encouraging those at risk for weight loss to eat.
2. Review of Resident #109's quarterly MDS, dated [DATE], showed:
-Rarely/never understood;
-No behaviors;
-Required assistance from one staff person for dressing and personal hygiene;
-Diagnoses included dementia, stroke, coronary artery disease, high blood pressure, anxiety and depression.
Observation on 4/22/19 at 9:26 A.M., showed the resident sat in the dining room. The resident stood from his/her seat and walked out of the dining room. His/her urinary catheter leg bag hung below his/her shorts and not in a privacy bag. The contents of his/her catheter bag was visible as he walked past residents seated in the dining room.
During an interview on 4/29/19 at 7:01 A.M., Nurse N said he/she expected the resident's catheter be covered, without covering the bag, it would be a dignity issue.
During an interview on 4/29/19 at 7:25 A.M., the administrator said staff should make an effort to cover the resident's catheter bag to respect the resident's dignity.
3. Review of Resident #56's quarterly MDS, dated [DATE], showed:
-Rarely/never understood;
-No behaviors;
-Required assistance from one staff for hygiene, toileting, dressing and eating (supervision, cueing, and set-up);
-Diagnoses included dementia and high blood pressure.
Observation on 4/25/19 at 8:19 A.M., showed the resident sat in the dining room and dropped a knife on the floor while staff walked around the dining room and served residents their meals. The audible sound of a utensil hitting the floor was heard throughout the dining room. The resident then leaned over, slowly in an attempt to reach his/her knife. As he/she leaned and stretched out his/her hand to reach his/her knife, CNA X walked past the resident's table, looked back at the resident, then continued out of the dining room. CNA X returned to the dining room and assisted another resident to his/her table. The resident, without assistance by staff, picked up his/her knife and used the same knife to put jelly on his/her bread.
During an interview on 4/29/19 at 7:08 A.M., Nurse N said staff should be focused on the residents during meals and get them a new utensil if one drops.
4. Review of the Resident #272's quarterly MDS, dated [DATE], showed:
-Rarely understood;
-Diagnoses included multiple sclerosis (a neurological disease) and anxiety;
-Total dependence of staff for bed mobility, transfers, dressing, eating, toileting and personal hygiene;
-Range of motion impairment to both sides of the lower and upper extremity.
Observation on 4/23/19 at 2:31 P.M., showed Restorative Aide U entered the resident's room and closed the door. Restorative Aide U removed the resident's blanket. A housekeeper opened the door, without first knocking, and entered the room. The housekeeper said, I need to hang this curtain. Restorative Aide U said, we really need this room, give us just a minute. The housekeeper left the room and closed the door.
5. Review of Resident #21's quarterly MDS, dated [DATE], showed:
-Diagnoses included quadriplegia (paralysis), depression, bipolar disease (major mental disorder with mixed moods) and high blood pressure;
-No cognitive impairment;
-No behaviors;
-Required total assistance from staff for transfers, dressing, hygiene and bathing.
During an interview on 4/23/19 at 1:30 P.M., the resident said when he/she turns on the call light at night, it takes staff so long to answer that he/she falls back asleep and staff turn off the call light without taking care of his/her needs. When he/she wakes up again, he/she will turn the call light back on and the process repeats itself. Staff will come into the room to answer his/her call light and will be talking on their cell phone while providing care to him/her.
6. Review of Resident #111's quarterly MDS, dated [DATE], showed:
-Diagnoses included high blood pressure, heart failure and chronic kidney disease;
-No cognitive impairment;
-No behaviors;
-Independent with transfers, ambulation, dressing, hygiene and bathing.
During an observation and interview on 4/25/19 at 9:50 A.M., the resident sat in his/her room with the window opened approximately 4 inches and a cool wind blew into the room. The resident said the night shift staff take a really long time to answer his/her call light at night. The staff come into his/her room to provide care for his/her roommate, talking on their cell phones the entire time they are in the room. He/she said gets cold very easily and likes the room on the warmer side. Staff will come into the room, turn off the heater, turn on the air conditioner or open the window without asking permission. When they leave the room, they do not close the window or turn the heater back on as he/she had it set. He/she did not and does not open his/her window and asked for it to be closed due to his/her being cold. He/she understands staff get hot while providing care, but they need to turn the heater back on or close the window before they leave the room.
7. Review of Resident #96's MDS, dated [DATE], showed:
-Cognitively intact;
-Diagnosis included dementia, anxiety and depression.
Observation on 4/22/19 at 4:20 P.M., showed the resident sat in his/her recliner and talked with the surveyor with the room door closed. A staff person entered the room without knocking, stood in the doorway just inside the resident's room and did not announce his/her presence. The resident's chair was out of view of the doorway. The resident stopped talking to the surveyor and said hello, can I help you? The staff person said he/she just wanted to check if the resident was ready for dinner, did not wait to hear the resident's response and left the room. The resident said staff enter his/her room frequently without knocking.
8. Review of Resident #87's quarterly MDS, dated [DATE], showed:
-Diagnoses included heart failure, high blood pressure, depression, respiratory failure, chronic kidney disease, difficulty walking and muscle weakness;
-Cognitively intact;
-Required total assistance from staff for transfers and toilet use.
Observation on 4/22/19 at 9:06 A.M., showed a staff member entered the resident's room without first knocking. He/she asked a resident in the room if they were done with their food tray, took the tray and exited the room.
During an interview on 4/22/19 at 8:50 A.M., the resident said a few weeks ago, his/her call light was on for seven hours before someone came in and answered it. Other times, he/she has waited an hour and a half for staff to come in and respond to his/her call light. Staff go to their breaks and no one covers for them. Sometimes he/she will have to holler to get a staff person to come in his/her room. The resident's roommate will propel him/herself out into the hallway to find a staff person. Staff come in the resident's room when his/her call light is on, turn it off and say they will come back in a little bit but they do not. Staff come in and turn the call light off without helping. Sometimes he/she will have to call the front desk to get a staff person to come to his/her room. The resident was concerned what might happen if he/she was seriously hurt and staff did not respond to his/her call light. Staff do not always knock before entering his/her room.
9. Observation on 4/24/19 at 10:00 A.M., showed CNA M walked down the hall on the unit with a personal cell phone in his/her hand. CNA M looked down at his/her phone and nearly bumped into the surveyor. At 10:15 P.M., a CNA walked around and talked on his/her phone in the dining room.
10. Observation on 4/23/19 at 5:35 P.M., showed the call light for room [ROOM NUMBER] sounded with two staff located on the hall and two at the nurse's station as the notification alarm sounded. At 5:37 P.M., both room [ROOM NUMBER] and 509 alarmed. A staff person walked up the hall and past both rooms with the call indicator lights on as he/she looked at his/her cell phone. He/she then exited the unit and continued to look at his/her cell phone.
11. Observation of the 500 hall, on 4/23/19 at 1:32 P.M., showed the call light for room [ROOM NUMBER] alarmed and audible at the nurse's station. A staff person sat in a chair in the lobby area outside the elevators and did not respond to the light. A staff person exited a room, looked at the call system that indicated the room with the call light on, shook his/her head and said now what? He/she continued down the hall but failed to respond to the light. A certified medication technician (CMT) stood at the medication cart and prepared medications. At 1:56 P.M., a staff member answered the call light.
12. Observation of the 500 hall on 4/23/19 at 5:15 P.M., showed the call light for room [ROOM NUMBER] and audible at the nurse's station upon the surveyor's arrival to the floor. A staff person passed dinner trays. Three staff were located at the nurses station. One on the facility phone, one on the facility computer and one flipped through papers on a clip board. Observation from down the hall, looking towards room [ROOM NUMBER] from the nurse's station, showed the light indicator above the door not visibly on. As the surveyor got closer to the room, the call light became visible and was dim. Several staff were observed to be in the halls, stood at the nurse's station and/or at the medication carts. The staff did not respond to the call light. At 5:34 P.M., staff responded to the call light.
13. During an interview on 4/24/19 at 10:30 A.M., all 14 residents present at the resident meeting said there was a problem with staff using their cell phones. Some staff may have a Bluetooth in their ear. Sometimes they do not know if they are talking to them or on their phone. Staff are heard speaking to their significant others or making plans. They feel like they are less than a person and it is rude. Staff are on their phone when they are providing care. Sometimes they stop assisting the resident and finish their conversation on the phone. Sometimes staff knock on their door before entering, but not all the time.
14. During an interview on 4/29/18 at 9:00 A.M., with the administrator, Director of Nursing and assistant administrator, the administrator said staff should knock and announce their presence when entering the resident's room. Everyone can answer a call light, even if the resident is not on their assignment. Residents have voiced concerns regarding staff not answering the call lights. This concern is mentioned in the all partners meetings (staff meetings). No other interventions have been put into place to resolve this issue. She was aware of resident complaints that staff use their cell phones. The facility has not implemented any interventions to resolve this concern.
MO00153371
MO00153511
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure the facility's Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and ...
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Based on interview and record review, the facility failed to ensure the facility's Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation policy and procedure required exercising caution in handling potential evidence, required identifying and interviewing all involved persons of an allegation and failed to identify steps to protect residents during the investigation if the alleged abuser is a visitor or another resident. The policy and procedure failed to identify when, how, and by whom determinations of capacity to consent to sexual contact will be made and where this documentation will be recorded. In addition, the facility failed to follow their policy by not investigating an injury of unknown origin for one resident (Resident #26). The census was 126.
1. Review of the facility's Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation policy and procedure, revised 9/14/17, showed:
-The patient has the right to be free from abuse, neglect, misappropriation of patient property and exploitation;
-The policy failed to identify when, how and by whom determination of capacity to consent to a sexual contact will be made and where this documentation will be recorded;
-The policy failed to require exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence);
-The policy failed to require identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations;
-The policy failed to identify steps to protect residents during the investigation if the alleged abuser is a visitor or another resident.
During an interview on 4/25/19 at 11:41 A.M., the administrator said the facility does not have a policy to address capacity to consent to sexual contact.
During an interview on 4/29/19 at 9:00 A.M., with the administrator, assistant administrator and Director of Nursing (DON), the administrator said she would expect all required elements of the abuse and neglect policies and procedures be included in the facility policies and procedures.
2. Review of Resident #26's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/3/18, showed:
-Diagnoses included Alzheimer's disease, dementia, high blood pressure, diabetes and urine incontinence;
-Severe cognitive impairment;
-No behaviors;
-Incontinent of bowel and bladder;
-No wounds;
-Required maximum assistance from staff for transfers, dressing, hygiene and bathing.
Review of the resident's weekly skin assessments, showed:
-On 4/17/19, Skin tear to left shoulder;
-No further skin assessments found.
Review of the resident's progress notes, showed:
-On 4/26/19 at 7:09 A.M. - Open area to left upper back. Area cleansed and dry dressing applied. No complaints of pain or discomfort at this time;
-No documentation found of the skin tear to the left shoulder on 4/17/19, how the skin tear occurred if known, investigation into the cause if not known, any treatment orders or of the physician or responsible party notification as late as 4/29/19.
Observation on 4/26/19 at 5:45 A.M., showed the resident lay in bed on his/her right side with his/her back exposed. An approximate 2 centimeter (cm) round, black/brown colored scabbed area surrounded by an approximate ½ cm red area observed on his/her left shoulder blade area. No dressing covered the area or was found in or around the resident's bed. Certified Nursing Assistant (CNA) I and Nurse J provided the resident with care, repositioned the resident onto his/her back using the cloth incontinence pad underneath him/her, turned him/her onto his/her right side and revealed the scab had been peeled off of the area and fresh blood oozed from the wound.
During an interview on 4/29/19 at 7:00 A.M., the Director of Nurses (DON) said she could not find any investigation into the wound on the resident's left shoulder and no investigation had been done.
Review of the facility's Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation policy and procedure, revised 9/14/17, showed:
-Injuries of unknown source: An injury should be classified as injury of unknown source when both of the following conditions are met:
-The source of the injury was not observed by any person or the source of the injury could not be explained by the patient; and
-The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time;
-The investigation is conducted immediately under the following circumstances:
-When it is identified that an alleged incident may have occurred;
-As soon as any partner has knowledge and reports an alleged event;
-When there is a question as to whether to conduct an investigation, it is best to do so;
-The results of all investigations will be completed within five working days of the incident.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0638
(Tag F0638)
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 assess residents using the quarterly review instrument specified by...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess residents using the quarterly review instrument specified by the State and approved by the Centers for Medicare and Medicaid Services (CMS) not less frequently than once every 3 months for 34 of 39 residents reviewed for resident assessments (Residents #272, #19, #5, #15, #33, #11, #12, #23, #41, #37, #39, #32, #8, #119, #31, #22, #14, #35, #34, #10, #18, #4, #30, #36, #17, #29, #20, #25, #27, #38, #21, #7, #26 and #42). The census was 126.
1. Review of Resident #272's medical record, showed admitted on [DATE].
Review of the resident's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, records, showed:
-An admission MDS, dated [DATE];
-A quarterly MDS, dated [DATE];
-No quarterly MDS completed January 2019.
2. Review of Resident #19's medical record, showed admitted on [DATE].
Review of the resident's MDS records, showed:
-An annual MDS, dated [DATE];
-No quarterly MDS completed February 2019.
3. Review of Resident #5's medical record, showed admitted on [DATE].
Review of the resident's MDS records, showed:
-An annual MDS, dated [DATE];
-No quarterly MDS completed January/February 2019.
4. Review of Resident #15's medical record, showed admitted on [DATE].
Review of the resident's MDS records, showed:
-An annual MDS, dated [DATE];
-A quarterly MDS, dated [DATE];
-No quarterly MDS completed February 2019.
5. Review of Resident #33's medical record, showed admitted on [DATE].
Review of the resident's MDS records, showed:
-An admission MDS, dated [DATE];
-No quarterly MDS completed February/March 2019.
6. Review of Resident #11's medical record, showed admitted on [DATE].
Review of the resident's MDS records, showed:
-An annual MDS, dated [DATE];
-A quarterly MDS, dated [DATE];
-No quarterly MDS completed February 2019.
7. Review of Resident #12's medical record, showed admitted on [DATE].
Review of the resident's MDS records, showed:
-An annual MDS, dated [DATE];
-No quarterly MDS completed February 2019.
8. Review of Resident #23's medical record, showed admitted on [DATE].
Review of the resident's MDS records, showed:
-A significant change MDS, dated [DATE];
-No quarterly MDS completed February 2019.
9. Review of Resident #41's medical record, showed admitted on [DATE].
Review of the resident's MDS records, showed:
-An admission MDS, dated [DATE];
-No quarterly MDS completed January or February 2019.
10. Review of Resident #37's medical record, showed admitted on [DATE].
Review of the resident's MDS records, showed:
-An annual MDS, dated [DATE];
-No quarterly MDS completed March 2019.
11. Review of Resident #39's medical record, showed admitted on [DATE].
Review of the resident's MDS records, showed:
-An admission MDS, dated [DATE];
-No quarterly MDS completed March 2019.
12. Review of Resident #32's medical record, showed admitted on [DATE].
Review of the resident's MDS records, showed:
-An admission MDS, dated [DATE];
-No quarterly MDS completed February/March 2019.
13. Review of Resident #8's medical record, showed admitted on [DATE].
Review of the resident's MDS records, showed:
-An annual MDS, dated [DATE];
-No quarterly MDS completed January/February 2019.
14. Review of Resident #119's medical record, showed admitted on [DATE].
Review of the resident's MDS records, showed:
-An entry MDS, dated [DATE];
-No admission MDS completed;
-No quarterly MDS completed February 2019.
15. Review of Resident #31's medical record, showed admitted on [DATE].
Review of the resident's MDS records, showed:
-An annual MDS, dated [DATE];
-No quarterly MDS completed February/March 2019.
16. Review of Resident #22's medical record, showed admitted on [DATE].
Review of the resident's MDS records, showed:
-An annual MDS, dated [DATE];
-No quarterly MDS completed February 2019.
17. Review of Resident #14's medical record, showed admitted on [DATE].
Review of the resident's MDS records, showed:
-An annual MDS, dated [DATE];
-No quarterly MDS completed February/March 2019.
18. Review of Resident #35's medical record, showed admitted on [DATE].
Review of the resident's MDS records, showed:
-A significant change MDS, dated [DATE];
-No quarterly MDS completed March 2019.
19. Review of Resident #34's medical record, showed admitted on [DATE].
Review of the resident's MDS records, showed:
-An admission MDS, dated [DATE];
-No quarterly MDS completed February/March 2019.
20. Review of Resident #10's medical record, showed admitted on [DATE].
Review of the resident's MDS records, showed:
-An admission MDS, dated [DATE];
-A quarterly MDS, dated [DATE];
-No quarterly MDS completed February 2019.
21. Review of Resident #18's medical record, showed admitted on [DATE].
Review of the resident's MDS records, showed:
-An admission MDS, dated [DATE];
-A quarterly MDS, dated [DATE];
-No quarterly MDS completed February 2019.
22. Review of Resident #4's medical record, showed admitted on [DATE].
Review of the resident's MDS records, showed:
-An annual MDS, dated [DATE];
-No quarterly MDS completed January or February 2019.
23. Review of Resident #30's medical record, showed admitted on [DATE].
Review of the resident's MDS records, showed:
-A significant change MDS, dated [DATE];
-No quarterly MDS completed February 2019.
24. Review of Resident #36's medical record, showed admitted on [DATE].
Review of the resident's MDS records, showed:
-A significant change MDS, dated [DATE];
-A quarterly MDS, dated [DATE];
-No quarterly MDS completed March 2019.
25. Review of Resident #17's medical record, showed admitted on [DATE].
Review of the resident's MDS records, showed:
-A significant change MDS, dated [DATE];
-No quarterly MDS completed February 2019.
26. Review of Resident #29's medical record, showed admitted on [DATE].
Review of the resident's MDS records, showed:
-An annual MDS, dated [DATE];
-No quarterly MDS completed February 2019.
27. Review of Resident #20's medical record, showed admitted on [DATE].
Review of the resident's MDS records, showed:
-An admission MDS, dated [DATE];
-A quarterly MDS, dated [DATE];
-No quarterly MDS completed February 2019.
28. Review of Resident #25's medical record, showed admitted on [DATE].
Review of the resident's MDS records, showed:
-An admission MDS, dated [DATE];
-A quarterly MDS, dated [DATE];
-No quarterly MDS completed February/March 2019.
29. Review of Resident #27's medical record, showed admitted on [DATE].
Review of the resident's MDS records, showed:
-A significant change MDS, dated [DATE];
-No quarterly MDS completed February 2019.
30. Review of Resident #38's medical record, showed admitted on [DATE].
Review of the resident's MDS records, showed:
-An annual MDS, dated [DATE];
-A quarterly MDS, dated [DATE];
-No quarterly MDS completed March 2019.
31. Review of Resident #21's medical record, showed admitted on [DATE].
Review of the resident's MDS records, showed:
-An admission MDS, dated [DATE];
-A quarterly MDS, dated [DATE];
-No quarterly MDS completed February 2019.
32. Review of Resident #7's medical record, showed admitted on [DATE].
Review of the resident's MDS records, showed:
-An admission MDS, dated [DATE];
-No quarterly MDS completed January/February 2019.
33. Review of Resident #26's medical record, showed admitted on [DATE].
Review of the resident's MDS records, showed:
-An admission MDS, dated [DATE];
-No quarterly MDS completed February 2019.
34. Review of Resident #42's medical record, showed admitted on [DATE].
Review of the resident's MDS records, showed:
-An admission MDS, dated [DATE];
-A quarterly MDS, dated [DATE];
-No quarterly MDS completed February 2019.
35. During an interview on 4/24/19 10:40 A.M., the MDS coordinator said she is the only MDS coordinator for the facility. She has been in her position since 12/26/18. The position was open before that. She is responsible for all MDS in the facility and is aware that she is behind on MDS. MDS assessments are completed quarterly, on admission, annually, on discharges and on reentry.
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 develop a comprehensive care plan based on the assess...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to develop a comprehensive care plan based on the assessment of the resident's conditions, needs, and behaviors, and consistent with the resident's goals and preferences for 11 residents out of 25 sampled residents (Residents #98, #22, #15, #373, #86, #119, #322, #49, #101, #43,and #1). The census was 126.
1. Review of Resident #98's face sheet, showed the facility admitted the resident on 1/16/14, with diagnoses which included hemiplegia (paralysis of part of the body) following stroke affecting the right dominant side, epilepsy (seizure disorder), type 2 diabetes, heart disease, dependence on other enabling machines and devices, urge incontinence, vascular dementia, obesity, muscle weakness and chronic embolism (blocked artery) and thrombosis (blood clot) of lower extremity.
During an interview on 4/24/19 at 8:38 A.M., the resident said staff often can't find the equipment they need to transfer him/her. He/she requires the use of a special pad and they only have one of the kind he/she prefers. He/she needs at least two on days he/she takes a shower because it gets wet when he/she showers. Sometimes he/she soils the pad and they are not able to get him/her another one. If they don't have the pad, they can't get him/her out of bed.
Review of the resident's care plan, updated 3/19/19, showed the resident was a two person assist with a Hoyer (mechanical lift) for transfers. The care plan did not address the need for a specialized Hoyer pad when transferring the resident and did not address the resident's preference for a certain type of lift pad.
During an interview on 4/29/18 at 10:20 A.M., the Director of Nursing (DON) said any special equipment needed to transfer a resident should be documented on the care plan. The resident did prefer a certain type of pad.
2. Review of Resident #22's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/16/18, showed:
-Cognitively intact;
-No behaviors listed;
-Psychosocial well-being triggered as a care area and indicated by the facility it would be care planned.
Review of the resident's face sheet, showed the facility admitted the resident on 3/21/14, with diagnoses which included congestive heart failure, chronic obstructive pulmonary disease (COPD, lung disease), sleep apnea (condition where breathing stops when sleeping), bipolar disorder (a mood disorder characterized by manic highs and depressed lows), vascular dementia, anxiety disorder, major depressive disorder, type 2 diabetes, legal blindness and osteoarthritis of the knee.
Observation on 4/22/19 at 9:23 A.M., showed the resident cried as he/she talked to the surveyor. The resident said he/she did not know why he/she was crying.
Observation on 4/24/19 at 8:22 A.M., showed the resident tearful as he/she sat alone in his/her room. The resident said he/she had pains all over.
Observation on 4/25/19 at 9:11 A.M., showed the resident started to cry as he/she talked to the surveyor. The resident said he/she was upset with him/herself because he/she screamed at a staff member the night before.
Review of the resident's care plan, dated 4/16/19, showed:
-Psychotropic drug use: Resident receives anxiety medication related to anxiety and antidepressant medication related to depression;
-No documentation of the resident's behavior of crying or becoming tearful;
-No services/interventions listed to address the resident's depression, mood or crying episodes.
During an interview on 4/29/19 at 10:20 A.M., the DON said the resident's behaviors should have been addressed on the care plan.
3. Review of Resident #15's quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-Two staff person assist for bed mobility and transfers;
-Eating: set up only;
-Mobility: wheelchair;
-Diagnoses included multiple sclerosis (MS, often disabling disease of the central nervous system that disrupts the flow of information within the brain, and between the brain and body), diabetes, heart failure, and high blood pressure.
Review of the resident's physician order sheet (POS), dated 9/7/18, showed the following:
-An order for a Novolog (rapid acting) insulin. Administer by a sliding scale three times daily, before meals and at bedtime;
-No order for the resident to attend physical therapy or go to an outside company for therapy services.
During an interview on 4/23/19 at 12:01 P.M., the resident said he/she goes to therapy at another facility per his/her preference. He/she attended therapy on Mondays and Wednesdays. He/she goes down to the kitchen prior to leaving for therapy to get something to eat, if he/she has time. Otherwise, he/she gets his/her blood sugar checked, but no one provides anything to eat prior to his/her leaving.
During an interview on 4/23/19 12:09 P.M., Nurse Y said he/she was aware the resident goes to off campus for therapy, as far as meals, he/she was not aware if dietary provided a lunch prior to the resident leaving the facility. If the resident has his/her blood sugar tested prior to leaving, and did not eat, the potential harm could be hypoglycemia (low blood sugar).
During an interview on 4/23/19 at 12:30 P.M., the dietary manager said she only had two residents which leave the facility that would need meals prior to leaving. She provided the names of the two residents and Resident #15 was not included. She was not aware the resident left the facility and would need to either eat prior to leaving, or have a sack lunch sent with him/her.
Review of the resident's care plan, dated 2/17/17 and in use during the survey, showed no off campus therapy identified and no interventions ensuring meals to be provided either before leaving the facility or to provide a sack lunch.
During an interview on 4/29/19 at 7:18 A.M., the administrator said she was not aware the resident needed a sack lunch if not able to eat prior to leaving the facility. There should be communication between nursing and dietary and should be on the resident's care plan.
4. Review of Resident #373's annual MDS, dated [DATE], showed:
-Brief interview of mental status (BIMS) score of 15 out of a possible score of 15, showing the resident understands and is able to make self-understood;
-Total dependence with assist of two staff members for bed mobility, transfers and toileting;
-Impairment of both legs;
-Indwelling catheter (a sterile tube inserted into the bladder to drain urine);
-Medical diagnoses included: Neurogenic bladder (the bladder does not empty properly due to a neurological condition), paraplegia (paralysis that affects all or part of the trunk, legs and pelvic organs), multiple sclerosis, osteoporosis (condition that causes bones to become weak and brittle), fracture, and cataract (clouding of normally clear lens of the eye);
-Care plan areas triggered included: visual function, activities of daily living (ADLs) function/rehab potential, catheter, falls, nutritional status, and pressure ulcer (injury to the skin and/or underlying tissue, as a result of pressure or friction).
Review of the resident's electronic and paper care plan, showed the care plan dated 4/22/19, failed to address visual function and falls.
5. Review of Resident #86's quarterly MDS, dated [DATE], showed:
-BIMS score of 15 out of a possible score of 15, showed the resident understands and is able to make self-understood;
-Total dependence with assist of two staff members for transfers and locomotion;
-Extensive assistance with one staff member for toileting and personal hygiene;
-Indwelling catheter;
-Colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall);
-At risk for pressure ulcers, no other skin problems;
-Active diagnoses included: diabetes mellitus, depression, asthma, respiratory failure (condition in which not enough oxygen passes into the blood stream from the lungs), Fournier gangrene (rare and potentially life threatening infection of the genitalia area), osteomyelitis (infection of the bone);
-Care plan areas triggered: ADL function/rehab potential, catheter, falls, nutritional status, pressure ulcer, and psychotropic drug use.
Review of the resident's physician progress note, dated 4/18/19, showed:
-Medical diagnoses included diverticulosis (inflammation of the colon) with colostomy and rectal fistula (an opening that develops between the colon and skin).
Review of the resident's electronic and paper medical record during time of survey, showed the following physician orders:
-An order dated 3/14/18, for Peri-ostomy (skin around colostomy), change wafer and bag as needed. Cleanse peri-ostomy with soap and water, pat dry and apply new wafer and bag;
-An order dated 1/9/19, for escitalopram oxalate (medication to treat anxiety and depression) 10 milligram (mg), give once a day;
-An order dated 3/14/19, to change indwelling/suprapubic catheter as needed;
-An order dated 3/18/19, for nystatin cream (used to treat fungal infections). Apply to skin around perineal (the surface area between the thighs, extending from the pubic bone to the tail bone) wound and right abdominal fold every shift;
-An order dated 4/9/19, for clotrimazole cream 1 % (used to treat skin infections). Apply to genitals twice a day until healed.
Review of the resident's care plan, dated 3/14/19, showed the facility failed to address:
-Psychotropic drug use (any drug capable of affecting the mind, emotions, and behavior);
-Pressure ulcer risk or presence of, with treatment goals and interventions;
-Falls, history or risk;
-The resident's rectal fistula with treatment goals and interventions;
-The resident's depression;
-The diagnosis of Fournier gangrene with treatment goals and interventions.
6. Review of Resident #119's electronic and paper medical record, showed:
-admit date [DATE];
-Medical diagnoses included: Spastic quadriplegic cerebral palsy (difficulty controlling movements in arms and legs, jerking motions in limbs), seizures, gastrostomy (G-tube, a tube surgically inserted into the stomach to provide hydration, nutrition and medications), obstructive sleep apnea (sleep disorder that causes breathing to repeatedly stop and start during sleep), neurogenic bladder, dysphagia (difficulty swallowing foods and liquids);
-Braden scale (used for predicting pressure ulcer risk), dated 4/17/19, showed a score of 9, indicating a very high risk for developing pressure injury;
-An entry MDS, dated [DATE], no comprehensive MDS completed.
Review of the resident's electronic and paper physician orders, showed:
-An order dated 12/1/18, for Diazepam (a sedative used to treat anxiety, muscle spasms, and seizures) 7.5 mg, rectal, once a day as needed;
-An order dated 3/7/19, for Lorazepam (a sedative used to treat anxiety and seizures) 2 mg, take every 8 hours as needed for seizures;
-An order dated 3/14/19, for Jevity 1.2 (a therapeutic liquid nutrition), run at 45 ml for 22 hours via g-tube.
Review of the resident's physician progress note, dated 3/28/19, showed:
-Incontinent of bowel and bladder, with an intervention of scheduled toileting;
-Ataxia (impaired balance or coordination), bedfast.
Review of the resident's electronic and paper medical record, showed the care plan, dated 3/14/19 consisted the following:
-Problem: Bowel elimination:
-Goal: Will have a bowel movement at least every 3 days for 120 days since update/last review, and/or will not experience any complications related to colostomy for 120 days from update/last review, and/or will not experience any stomach/intestinal complications and/or will remain clean, dry between incontinent episodes thru 120 days from update/last review;
-Approach: Bowel protocol. Monitor absence/presence of bowel movement daily;
-Problem: Needs assistance in performing, improving, and maintaining some ADLs:
-Goal: ADL approaches will meet the resident's needs to enhance ability, maintain abilities, or provide quality;
-Approaches include: Total lift (Hoyer) with the assist of two. NPO and can have nothing by mouth;
-The care plan failed to address the resident's seizures, obstructive sleep apnea, spastic quadriplegic cerebral palsy, incontinence of bowel and bladder, and G-tube with treatment goals and care approaches.
7. Review of Resident #322's quarterly MDS, dated [DATE], showed:
-Rarely/never understood;
-No behaviors;
-One staff person assist for bed mobility, transfers, eating, dressing, toilet use and personal hygiene;
-Diagnoses included Alzheimer's disease, high blood pressure and arthritis.
Review of the resident's current POS, in use during the survey, showed allergies: Fish, fish oil, and fish product derivatives.
Review of the resident's care plan, dated 4/2/19, showed the resident was not to receive fish product derivatives.
During an observation and interview on 4/22/19 at 12:26 P.M., Certified Nursing Assistant (CNA) X picked up two plates from the serving cart and carried the plates to the resident assisted dining room table. CNA X sat each plate in front of residents, both meal tickets showed puree herbed butter baked fish as the entrée. As CNA X prepared to spoon the meat puree to the resident's mouth, the surveyor stopped CNA X and asked if the resident was allergic to fish. CNA X said he/she was not aware if the resident was allergic to fish and picked up the resident's meal ticket. At the bottom of the ticket, in bold print, showed, allergies, fish product derivatives. The CNA removed the plate from the resident.
During an interview on 4/29/19 at 7:26 A.M., the administrator said she expected staff to follow the resident's care plan and also to read the meal tickets and check for allergies.
8. Review of Resident #49's face sheet, showed the facility admitted the resident on 1/30/19, with diagnoses which included heart failure, chronic kidney disease, coronary artery disease, atrial fibrillation (rapid heart rate), dysphagia (difficulty swallowing), malnutrition and stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dead or dying tissue) may be present on some parts of the wound bed. Often includes undermining and tunneling) to the sacrum (triangular-shaped bony structure located at the base of the lumbar vertebrae).
Review of the resident's admission MDS, dated [DATE], showed the following:
-One or more unhealed pressure ulcers at stage I (an observable, pressure-related alteration of intact skin) or higher;
-One 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) pressure ulcer, one stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough (dead tissue) may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) pressure ulcer and one unstageable (slough, (dead tissue) is present, the actual base and condition of the ulcer cannot be determined) pressure ulcer;
-Treatment: Pressure reducing device for chair and bed. Pressure ulcer care;
-Frequently incontinent of bowel.
Review of the facility's wound report, dated 4/19, showed the following wounds listed for the resident:
-Stage IV pressure ulcer to the sacrum;
-Unstageable pressure ulcers to the right shoulder and right shin;
-Stage III to the right iliac (uppermost and largest part of the hip bone);
-Stage IV to the right trochanter (femur near its joint with the hip bone).
Observation on 4/22/19 at 10:10 A.M., showed a rectal tube (tube used to contain and drain liquid stool into a collection bag) in place and in use by the resident. The resident's bed featured a low air loss/pressure reducing mattress.
Review of the resident's care plane, updated 4/16/19, showed:
-No documented needs or services related to the resident's pressure ulcers. No documented treatments or interventions to promote pressure ulcer healing;
-Bowel protocol did not document the presence of a rectal tube.
During an interview on 4/29/19 at 10:20 A.M., the DON said if a resident has a wound, wound care and treatment should be documented on the care plan. The resident's rectal tube should have been addressed on the care plan.
9. Review of Resident #101's quarterly MDS, dated [DATE], showed:
-Rarely/never understood;
-No behaviors;
-One staff person assist for dressing, toilet use and personal hygiene;
-Diagnoses included dementia, anemia, anxiety and depression.
Review of the resident's care plan, in use during the survey, located inside the paper chart, showed staff were to assist the resident when he/she has difficulty sitting in a chair.
Observations of the resident, showed the following:
-On 4/22/19 at 8:57 A.M., he/she sat in the dining room in a Geri chair (medical reclining chair) and appeared to be asleep. His/her upper torso hung over the right side of the Geri chair;
-On 4/22/19 at 9:22 A.M., he/she sat in the dining room, appeared to be asleep, his/her upper torso hung over the side of the Geri chair, his/her head hung backward and his/her right arm dangled behind him/her;
-On 4/22/19 at 11:49 A.M., he/she sat in the dining room, appeared to be asleep, his/her upper torso hung over the side of the Geri chair, his/her head hung down;
-On 4/22/19 at 11:52 A.M., he/she sat in the dining room and appeared asleep. The resident's pillow fell on floor from his/her lap, three staff were in the dining room, no one picked up the pillow or attempted to reposition the resident;
-On 4/23/19 at 8:58 A.M., he/she sat in the dining room, appeared asleep, his/her upper torso hung over the side of the Geri chair. Two staff were present in the in dining room, neither staff attempted to reposition the resident;
-On 4/23/19 at 2:27 P.M., he/she sat in the dining room, appeared asleep, leaning back in recliner, his/her head hung off the side of the chair. Three staff were present, no one attempted to reposition the resident;
-On 4/24/19 at 2:09 P.M., he/she sat in the dining room, appeared asleep, covered with a blanket. His/her upper torso leaned over the side of the Geri chair and his/her head hung downward;
-On 4/24/19 at 2:20 P.M., he/she sat in the dining room, appeared asleep, his/her head hung off the chair, three staff were in the dining room. No staff attempted to reposition the resident;
-On 4/25/19 at 10:18 A.M., he/she sat in the dining room, his/her Geri chair reclined and he/she appeared asleep. His/her upper torso hung over the side of the Geri chair, his/her head hung over the side of the chair. A pillow positioned next to his/her hip. Two staff present in the dining room and neither staff attempted to reposition the resident's pillow and/or the resident.
During an observation and interview on 4/26/19 at 5:09 A.M., showed the resident sat in the dining room. His/her upper torso hung over the side of the Geri chair, his/her head not supported by the chair. He/she said he/she would appreciate something to help him/her not lean, he/she had difficulty sitting upright in the chair.
During an interview on 4/29/19 at 7:03 A.M., Nurse Y said staff usually have the resident seated in a Geri chair with a pillow to help so he/she did not lean. He/she was aware the resident has had difficulty sitting in the chair for approximately the last month and a half and the resident had not been evaluated by therapy for the leaning.
During an interview on 4/29/19 at 7:35 A.M., the therapy director said he was aware the resident leans in the chairs. Staff should put the resident in his/her bed when they notice him/her leaning, it would be a safer place for him/her. The leaning is not good for his/her back and neck. A high back chair with lateral (side) support would be the best alternative for the resident's leaning.
During an interview on 4/29/19 at 7:21 A.M., the administrator said she expected staff to notify the resident's physician and obtain a physician's order for a therapy evaluation to address the resident's leaning.
Further review of the resident's paper care plan, showed a high back chair with lateral support not listed. The use of pillows to assist the resident to sit up not listed.
Review of the resident's electronic care plan, showed positioning not indicated as a problem.
10. Review of Resident #43's paper and electronic POS, showed:
-An order dated 7/26/18, to apply skin prep (protective barrier wipe) to the coccyx (tailbone area) and dermaLevin (water proof adhesive foam dressing) once daily on the 7:00 A.M. through 7:00 P.M. shift;
-An order dated 9/19/17, for weekly skin assessments on Mondays.
During an interview on 4/25/19 at 2:31 P.M., the wound nurse said the resident originally had an order for skin prep and a protective dressing because he/she had a history of having a wound and it had healed. The skin prep was for protection and not treatment of a wound.
Review of the resident's weekly wound assessment record, showed on 2/3/19, no new or concerning skin issues noted. Skin is dry and intact and warm. On 2/15/19, sacral unstageable, wound measured 5 by 3.5. No exudate (drainage). Wound base moist, no odor or signs and symptoms of infection, no eschar (hard dead tissue) or slough, granulation (new tissue growth) tissue present, periwound (skin around wound opening) redness and maceration (skin deterioration caused by moisture). NOTE: Wound noted with 100% slough mild periwound maceration. Mild odor noted. No redness or warmth noted, air loss mattress replaced. Staff educated to provide 2 hour position changes. Resident noted with non-compliance, at times resident noted change position to back after turned on side. Education provided and resident agrees to comply to position changes. Treatment completed.
Further review of the resident's POS, showed:
-An order dated 2/22/19, for sacral area treatment, cleanse with wound cleanser, apply Santyl, apply Mepilex (occlusive absorbent dressing) or Allevyn (adhesive absorbent dressing) daily and as needed;
-An order dated 3/10/19, please refer to medical center wound clinic as soon as possible (ASAP);
-An order dated 3/21/19, for Santyl ointment 250 unit/gram topical once a day, 7:00 A.M. through 7:00 P.M. shift. Cleanse wound with wound cleanser, apply Santyl, pack and cover with saline moistened 2 by 2 (gauze) and cover with dry dressing. Order discontinued 3/25/19;
-An order, dated 3/25/19, for Biostep AG (collagen dressing with silver targets and deactivates excess matrix metalloproteinase (MMPs, a group of enzymes that are responsible for the degradation of most extracellular matrix proteins during growth and normal tissue) to optimize wound closure for chronic wounds) bandage 4 by 4 (gauze) topical once a day on the 7:00 A.M. through 7:00 P.M. shift. Cleanse area with normal saline or wound cleanser before applying dressing.
Review of the resident's paper care plan, located in the hard chart, dated 12/20/18, showed:
-The care plan did not address pressure ulcer with goal and interventions;
-The care plan did not identify a behavior of refusing to be repositioned in the bed with goals and interventions.
Review of the resident's electronic care plan, last reviewed/revised 4/16/19, showed:
-Diagnoses included hemiplegia and hemiparesis (muscle weakness or partial paralysis) after stroke. No diagnosis for pressure ulcers;
-Problem: Assistance required in performing, improving and maintaining some ADLs:
-Total Hoyer with assist of two;
-Prefer showering during the evening on Wednesday/Saturday;
-Incontinent undergarments;
-Provide perineal care following incontinent episodes. Apply moisture barrier cream as needed. Incontinent of bowel and bladder;
-The care plan did not address pressure ulcer with goal and interventions;
-The care plan did not identify a behavior of refusing to be repositioned in the bed with goals and interventions.
During an interview on 4/29/18 at 9:00 A.M., with the DON, administrator and assistant administrator, they said the MDS coordinator is responsible to update care plans, but any disciplines can update the care plan as needed. Care plans should address the resident's care needs. It should be person centered. A resident with a stage III pressure ulcer should have this identified on the care plan with goals and interventions. If the resident is resistant to be repositioned in bed, this should be included in the care plan with interventions to help guide staff.
11. Review of Resident #1's face sheet, showed the resident admitted to the facility on [DATE], with diagnoses which included hemiplegia following stroke affecting left non-dominant side, coronary artery disease, atrial fibrillation, cardiomyopathy (heart disease), dementia with behavioral disturbance, displaced intertrochanteric (upper part of thigh bone) fracture of right femur (thigh bone), restlessness and agitation, anxiety disorder, osteoarthritis and diabetes.
Review of the resident's discharge MDS assessment, dated 3/30/19, showed the resident did not have a pressure ulcer but was at risk for pressure ulcers.
Review of the resident's 14-day readmission assessment dated [DATE], showed the following:
-Stage I pressure ulcer or greater;
-Unhealed pressure ulcer;
-Pressure ulcer care;
-At risk of pressure ulcer.
Review of the facility's wound report dated 4/2019, showed the resident had a stage II pressure ulcer but staff did not document the wound acquired date, site and treatment.
Review of the resident's care plan, updated 4/12/19, showed the following:
-The resident's care plan not updated to include his/her need for pressure ulcer treatment;
-No services listed to address prevention of future pressure ulcers or to promote healing of current pressure ulcer.
Observation on 4/22/19 at 10:30 A.M., showed the resident cried out help me, help me, help me over and over again while he/she lay on his/her back in his/her bed.
During an interview on 4/22/19 at 10:30 A.M., the resident's roommate said the resident cried out for help, repeatedly, most of the day, while he/she was awake.
Observation on 4/23/19 at 5:40 P.M., showed the resident in bed on his/her back and cried out help, help, help. Staff entered the resident's room and attempted to feed the resident his/her uneaten food, from his/her room tray. The resident cried out it's hot and asked the staff person for water. The resident continued to cry out help, help, help and please, medicine. Staff reminded the resident he/she already got his/her medication. The staff person asked the resident if he/she was in pain and he/she said his/her whole body hurt. The resident cried out please medicine, pain medicine, pain medicine, pain medicine repeatedly.
Observation on 4/24/19 at 8:45 A.M., showed the resident sat in her wheelchair in the third floor common area and he/she cried out help me, help me, help me.
Observation on 4/26/19 at 7:52 A.M., showed staff propelled the resident to his/her room as he/she cried out help me, help me, help me.
Further review of the resident's care plan, updated 4/12/19, showed no behavioral needs or services listed to address the resident's behavior of repeatedly crying out.
During an interview on 4/29/18 at 10:20 A.M., the DON said the resident's behaviors and staff interventions should have been addressed on the resident's care plan. The resident's wound and wound treatment also should have been documented.
12. During an interview on 4/29/19 at 10:00 A.M., the administrator said comprehensive care plans should include transfers, diet, incontinence care, G-tubes, wounds, behaviors, and any other issues identified for the individual resident. Care plans should be person centered such that staff can properly care for the resident and best meet their needs.
CONCERN
(E)
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 ensure a resident who is unable to carry out activities o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene by failing to provide proper perineal (the surface area between the thighs, extending from the pubic bone to the tail bone) care and failed to provide adequate personal hygiene for six out of 25 sampled residents (Residents #97, #222, #71, #26, #110, and #4). The census was 126.
Review of the facility's Perineal Care policy, revised October 2010, showed:
-Purpose: To provide cleanliness and comfort to the resident, to prevent infections and skin irritation and to observe the resident's skin condition;
-Wash hands;
-Place gloves on;
-Wash the perineal area, wiping front to back, rinse thoroughly and dry;
-Wash the rectal area thoroughly. Do not reuse the same washcloth or water to cleanse the genitals;
-Rinse thoroughly and dry.
1. Review of Resident #97's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/29/18, showed:
-Severe cognitive impairment;
-Impairment on one side of upper body and one side of lower body;
-Total dependence of one staff member for toileting;
-Always incontinent of bowel and bladder;
-Medical diagnoses included dementia.
Observation on 4/22/19 at 12:53 P.M., showed Certified Nursing Assistant (CNA) M provided incontinence care to the resident in the resident's bathroom. CNA M donned gloves without cleansing hands first, helped the resident out of his/her wheelchair, pulled down the resident's pants, removed the urine soaked brief, and threw it in the trash can. CNA M then guided the resident to sit on the toilet by placing his/her hands around the resident's hips. The resident stood up from the toilet and CNA M took a wet, soapy towel and wiped the resident's buttocks and anus free of bowel movement, using a left to right and front to back motion with the same area of the towel. CNA M then used a new area of the towel and wiped the resident's rectum again, removing bowel movement in a front to back motion. After throwing the soiled towel in the trash bag, CNA M grabbed a clean brief, secured to the resident and pulled the resident's pants up. CNA M assisted the resident to his/her wheelchair. CNA M failed to cleanse the resident's inner thighs, genital region, and lower abdomen where the urine potentially touched the skin, and failed to dry the resident's skin after wetting it. CNA M failed to change his/her gloves after removing the soiled brief and before assisting the resident to stand, and failed to use a new section of the towel after cleansing one area, before cleansing the next.
Review of the soap bottle used on the resident, showed to place a small amount on a wet washcloth, rinse clean and dry the skin.
2. Review of Resident #222's face sheet, showed diagnoses included Alzheimer's disease, gastrostomy tube (G-tube, a tube surgically inserted into the stomach through the abdomen for the purpose of providing liquid nutrition, hydration and medications) and stroke.
Observation on 4/22/19 at 11:15 A.M., showed the resident lay in bed. CNAs F and G came into the room, washed hands, put on gloves and provided the resident with care. CNA F removed a wet with urine adult incontinence brief from the resident, washed the resident's genital area with perineal wash, turned him/her onto the left side, washed and dried the resident's right buttock and rectal area. The CNAs placed a clean adult incontinence brief on the resident, repositioned him/her on his/her right side, and covered the resident, removed gloves, washed hands and left the resident's room. Neither CNA washed the resident's left buttock and hip to ensure all of the urine had been removed from the resident's skin prior to leaving the resident's room.
3. Review of Resident #71's significant change MDS, dated [DATE], showed:
-Diagnoses included stroke, vascular dementia, high blood pressure, diabetes and major depressive disorder;
-Severe cognitive impairment with short and long term memory problems;
-No behaviors;
-Incontinent of bowel and bladder;
-Required total assistance from staff for transfers, dressing, hygiene and bathing.
Review of the resident's laboratory test, showed:
-On 1/3/19 - Urinalysis (UA, urine test used to aid in the diagnosis of disease or to detect the presence of infection) with culture and sensitivity (C & S, lab test to detect the identification of antibiotics that kill the specific bacteria) - Slightly cloudy yellow urine (Normal is clear), [NAME] blood cells (WBC, can indicate infection) - too numerous to count (Normal is 0 to 4), bacteria - many (normal is none). Greater than 100,000 colonies per milliliter (ml) of urine of Klebsiella pneumonia (bacteria found in soil and the intestinal tract of humans and animals);
-On 1/29/19 - UA with C & S - 50,000 to 100,000 colonies per ml of Staphylococcus aureus (bacteria).
Observation on 4/22/19 at 9:57 A.M and at 11:32 A.M., showed the resident sat in his/her Broda chair (medical reclining chair) in his/her room with his/her slacks wet from the crotch down to the knees. At 12:09 P.M., the resident sat in his/her Broda chair in the division dining room. His/her slacks had been changed. At 1:14 P.M., the resident sat in his/her Broda chair in his/her room. CNAs F and H provided the resident with care. Both CNAs transferred the resident into bed, removed his/her slacks and wet with urine adult incontinence brief and turned the resident onto his/her left side. CNA H washed and dried the resident's right buttock, back of thighs and rectal area, placed a clean adult incontinence brief on the resident and covered the resident. Both CNAs removed their gloves, washed their hands and left the resident's room. Neither CNA washed the resident's entire genital area and left buttock and hip to ensure all of the urine had been removed from the resident's skin prior to leaving the resident's room.
4. Review of Resident #26's admission MDS, dated [DATE], showed:
-Diagnoses included Alzheimer's disease, dementia, high blood pressure, diabetes and urine incontinence;
-Severe cognitive impairment;
-No behaviors;
-Incontinent of bowel and bladder;
-Required maximum assistance from staff for transfers, dressing, hygiene and bathing.
Observation on 4/26/19 at 5:45 A.M., showed the resident lay in bed. CNA I and Nurse J provided the resident with care. CNA I put on gloves, removed a wet with urine adult incontinence brief from the resident, washed the resident's genital area with body wash and water, turned the resident onto his/her right side, cleaned the resident's left buttock and rectal area with body wash and water, and placed a clean adult incontinence brief on the resident. CNA I positioned the resident on his/her back and covered the resident. He/she removed his/her gloves, washed hands and left the resident's room. Neither the CNA or the nurse rinsed the soap off of the resident's skin, dried the resident's skin, or washed the resident's right hip and buttocks to ensure all urine and soap had been removed from the resident's skin prior to leaving the resident's room.
Review of the body wash bottle used on the resident, showed to place a small amount on a wet washcloth, rinse clean and dry the skin.
During an interview on 4/29/19 at 9:00 A.M., the Director of Nurses (DON) said she would expect staff to wash all areas of the skin that may have come in contact with urine and/or stool to prevent odors and skin breakdown. Staff should rinse the soap off of the skin and pat dry and wash both buttocks and the genital areas.
5. Review of Resident #110 quarterly MDS, dated [DATE], showed:
-Cognitively impaired;
-Diagnoses included non-Alzheimer's dementia, malnutrition, anxiety disorder, depression, manic depression, schizophrenia (brain disorder that affects the ability to understand reality), morbid obesity and legal blindness;
-Has delusions;
-Total assistance required for transfers, dressing, toileting and hygiene;
-Extensive assistance required for bed mobility and eating;
-Range of motion impairment on both sides of extremities;
-Always incontinent of bowel and bladder;
-Weight of 212 pounds.
Review of the resident's care plan, dated 3/26/19, showed:
-Problem: Needs assistance in performing, improving, and maintaining some Activities of Daily Living (ADLs);
-Approach: Prefers bathing/showers during the day on Tuesdays and Fridays;
-Total lift (Hoyer, mechanical lift) with the assist of two;
-Please provide perineal care following incontinent episodes. Apply moisture barrier cream as needed (PRN).
Review of the facility's shower book on the resident's hall, for April 2019 and reviewed on 4/25/19, showed:
-The resident's showers scheduled on Tuesday and Friday on the day shift;
-No documentation the resident received showers or bed baths.
Review of the resident's progress notes, dated 4/12/19, showed the resident yelling out, refusing care and all medications. Offered a snack, refused that as well. Will continue to monitor for any acute changes.
Observation of the resident, showed:
-On 4/22/19 at 1:35 P.M., resident in bed. An odor in the room that became stronger, closer to the resident. The resident's hair appeared oily and disheveled;
-On 4/23/19 at 12:01 P.M., resident in bed. A strong body odor noted, dirt under his/her fingernails. The resident's hair appeared oily. The resident's nasal cannula (used to deliver oxygen) dirty and on the side of his/her right cheek;
-On 4/24/19 at 9:58 A.M. and 1:04 P.M., staff assisted the resident with a meal. Urine smell observed in the room and near the resident. The resident's hair combed back and appeared oily. The resident's nasal cannula dirty and on the side of his/her right cheek;
-On 4/25/19 at 7:53 A.M., resident in bed. He/she had a faint body odor that could be smelled when closer to the resident. The resident's hair appeared oily. The resident's nasal cannula dirty and on the side of his/her right cheek;
-On 4/29/19 at 7:24 A.M., the resident in bed. His/her hair matted and oily. He/she had a faint body odor that could be smelled when closer to the resident. The resident's nasal cannula dirty and on the side of his/her right cheek.
During an interview on 4/24/19 at 10:09 A.M., Hospice Nurse AA said the resident receives ADL care from hospice. The health aide comes in twice a week. Hospice Nurse AA did not know what the facility provided as far as hygiene and grooming, but the hospice care provided is supposed to be extra.
During an interview on 4/29/19 at 7:25 A.M., Nurse XX said everyone is responsible for the resident's bath. Hospice gives the resident a bath twice a week and facility staff gives the resident a bath twice a week.
6. Review of Resident #4's quarterly MDS, dated [DATE], showed:
-Moderately impairment cognition;
-Diagnoses included multiple sclerosis (disease of the central nervous system), seizure disorder, anxiety disorder, depression and asthma;
-Always incontinent;
-Received oxygen therapy.
Review of the resident's care plan, dated 3/7/19, showed:
-Problem: Needs assistance in performing, improving, and maintaining some ADLs;
-Approach: Continent of bowel and bladder, but may need some assistance at times;
-Prefers bathing/showers during the evenings on Monday and Friday.
Review of the facility's shower book on the resident's hall, for April 2019 and reviewed on 4/25/19, showed:
-The resident's showers scheduled on Monday and Friday during the evening shift;
-A shower sheet, dated 4/19/19, showed the resident received a bed bath;
-No further documentation the resident received a bath or shower in April.
Observations of the resident, showed:
-On 4/22/19 at 12:55 P.M. and 2:04 P.M., the resident with body odor. A urine odor in the room. He/she said he/she did not receive showers. He/she could not remember the last time he/she received a bath or shower, but felt he/she needed one. The resident's visitor said staff do not provide the resident with baths or showers. He/she often has an odor;
-On 4/24/19 at 9:49 A.M., 4/25/19 at 7:56 A.M., and 4/29/19 at 7:22 A.M., the resident's hair appeared disheveled. He/she had a body odor that smelled throughout the room.
During an interview on 4/29/19 at 7:20 A.M., Nurse XX said the resident often refuses care, but he/she comes to the nurse's station and complains he/she did not receive it. He/she had behavior issues and likes to play the victim. Nurse XX did not know if the resident received his/her showers during the day or night. He/she checked the shower book and confirmed that the resident is scheduled to receive his/her showers at night. Nurse XX said he/she would not know if the resident received his/her showers because he/she works the day shift.
7. During an interview on 4/29/19 at 9:00 A.M., the DON said staff is expected to change their gloves during incontinence care when going from a dirty to clean task, before touching clean surfaces, and before applying ointment. Staff is expected to change the area of a cloth after cleansing an area before cleansing another area. It is not appropriate to use the same area of cloth when wiping outer buttocks and then rectum. Staff is expected to clean all areas in which urine has touched. When a resident is incontinent of bowel and/or bladder, staff is expected to cleanse from front to back, rinse soap off of the skin, dry the skin and wash all areas of skin in which stool or urine has come in contact. This is to prevent skin breakdown and odors, infections, and meet basic hygiene needs. The administrator said she would expect staff to document the resident's baths and showers. If a resident refused it, staff are expected to document it in the progress notes and on the shower sheet. It is the responsibility of the CNA to provide the baths and showers, but the nurse has to follow up. If the resident was observed with body odor and oily and matted hair, she would expect staff to address it, but continue to document it if the resident refused. Hospice care is above and beyond what the facility provides. Any ADL care that hospice provided, she would expect it to be documented.
MO00155068
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
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 have nursing staff with the appropriate competencies a...
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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 have nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment, by failing to ensure a process for determining competencies for agency staff, failing to ensure resources to direct resident care was readily accessible to the staff providing direct care to the residents, and failing to ensure certified nursing assistance (CNAs) were trained in the prevention of pressure ulcers. In addition, the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for resident needs regarding documentation and follow-up after a change in condition and when providing wound care. The census was 126.
1. Review of the facility's agency nursing staff contracts, showed the facility contracted through seven nurse staffing agencies to fulfill staffing needs.
During an interview on [DATE], the assistant administrator said the facility uses several agency's to fulfill staffing needs, they use Nurse Staffing Agency DD the most.
Review of the training materials provided to contracted agency CNAs, showed instructions to describe how to log into the computer. No further information provided.
Review of the training materials provided to contract agency licensed nursing staff, showed:
-Instructions on how to log into the computer;
-A guide to describe the facility's culture and expectations;
-A navigation guide to the electronic health record;
-No further information provided.
Review of Resident #123's nurse's notes, showed on [DATE] (no time noted), the physician ordered Compazine (used to treat nausea) suppository 10 milligram (mg), every 6 hours as needed for nausea and Imodium (used to treat loose stools) 2 mg every 4 hours as needed for diarrhea. Vital signs every shift for three days. Push fluids and call physician for oxygen levels less than 90%.
Review of the resident's medication administration record (MAR) and treatment administration record (TAR), dated [DATE] through [DATE], showed the only documented vitals recorded were on [DATE], which were his/her temperature, pulse and blood pressure. Staff did not document anything under the push fluids order.
Further review of the resident's nurses notes, showed:
-On [DATE] at 6:15 A.M., Nurse called to residents room at about 5:10 A.M., resident lying in bed, oxygen at 4 liters with an oxygen saturation (amount of oxygen in the blood) at 87% (normal 95-100%), temperature 99 (normal 97.9-99.1 degrees Fahrenheit (F)), respirations 44 (normal 12-18), pulse 116 (normal 60-100) and dropping, blood pressure 80/58 (normal 120/80). Resident noted just lying in bed with his/her mouth open, no distress noted, skin warm to touch. Call placed to physician at 5:25 A.M. and received new order for Roxanol (narcotic pain medication) 20 mg per milliliter (ml), give 10 mg (0.5 ml) every hour for respirations greater than 26 or for pain. Give Lorazepam (used to treat anxiety) intensol 2 mg/ml, given 1 mg/0.5 ml every hour for restlessness. Hospice to treat and evaluate. Call placed to hospice. Call placed to family. Staff gave the resident Roxanol at 5:50 A.M., will continue to monitor and note any changes;
-On [DATE] at 7:10 A.M., staff noted night supervisor made aware of change in condition at 5:30 A.M.;
-No further documentation in the resident's nurses notes.
Review of the hospice plan of care, dated [DATE] (no time noted), showed the resident was actively dying at time of visit and resting comfortably. He/she passed shortly after the visit.
During an interview on [DATE] at 12:25 P.M., the Director of Nursing (DON) said the resident was declining the last month and had decreased intake with eating. The nurses should have charted his/her condition and document changes. The DON was not familiar with the paper charting for vitals but the newly implemented computerized charting has a vital sign tab and the order will pop up. The nurse who wrote on [DATE] was an agency nurse. She would expect there to be complete charting on the day the resident expired. She does not know why there was not complete charting.
During an interview ion [DATE] at 9:00 A.M., the administrator said competency for agency staff is evaluated by exception. There is no process but if concerns are identified, the facility will address them. Staff hired by the facility are provided training by the nurse educator. The facility utilizes a computer training system for staff competencies. Agency staff do not have access to this program. Agency staff are not trained on facility care policies but may ask to see them if needed.
2. Review of the facility's resource binder, showed:
-Information on abuse and neglect;
-Contact information for a variety of companies and individuals;
-Weight protocol;
-Instruction on what to do if a resident is transferred, discharged , or expires;
-Instructions on how to print forms from the computer system;
-No resident care policies.
Observation on [DATE], of the 500 hall nurses station, showed the resource binder available to the staff. No further care policies.
During an interview on [DATE] at 8:02 A.M., Nurse SS said he/she is the nurse on the 500 hall. There are policy manuals at the nurse's station and staff can ask the house supervisor to find a policy if needed.
Observation on [DATE], of the 300 hall nurses station, showed the resource binder available to the staff. No further care policies.
During an interview on [DATE] at 8:13 A.M., Certified Medication Technician (CMT) Q on the 300 hall said if he/she needed to view a policy and procedure that was not at the nurse's station, he/she would ask the nurse. Otherwise, he/she did not know how to find them.
During an interview on [DATE] at 8:17 A.M., Nurse A on the 300 hall, said the DON has the book of policies. If he/she needed to view care policies and procedures, he/she would get them from DON's office. If the office was locked, he/she would need to get the house supervisor, who would have the keys.
Observation on [DATE], of the 100 hall nurses station, showed:
-The resource binder;
-The Skin Integrity Manual;
-No further care policies.
During an interview on [DATE] at 8:27 A.M., House Supervisor TT said he/she is the nurse for the 100 hall and is the house supervisor. There is a resource binder at the nurse's station. There may also be policies in other binders, but he/she would have to look. If he/she needed care policies and they were not located in the binders at the nurse's station, he/she was not sure where to find the policies.
Observation on [DATE], of the 400 hall nurses station, showed the resource binder available to the staff. No further care policies.
During an interview on [DATE] at 9:01 A.M., CNA G on the 400 hall said he/she knew how to care for residents by looking in the care plan. Everything staff need to know is in the care plan. There is no need for policies.
Observation of the 200 hall, showed no residents resided on this hall.
During an interview on [DATE], the DON said her office is locked when she is not at the facility. The nursing supervisor has a key if needed.
During an interview on [DATE] at 8:54 A.M., the corporate staff said there are several binders in the DON's office to direct staff on how to provide care.
During an interview on [DATE] at 9:00 A.M., the administrator said anyone can ask for policies and they are provided upon hire.
3. Review of the facility's Resident Census and Conditions of Residents form, dated [DATE], showed:
-Indicate the number of resident's with pressure ulcers (injury to the skin and/or underlying tissue, as a result of pressure or friction): Six;
-Of the total number of residents with pressure ulcers, excluding stage I, how many residents had pressure ulcers on admission: One.
Review of a list of facility employees, showed 26 CNAs employed at the facility for more than a year. Of those 26, a sample of 10 were selected. Review of the CNA training records for the past year, from hire date to hire date, showed 6 of the 10 with no in-service provided on skin care/pressure ulcer prevention:
-CNA B- date of hire (DOH) [DATE]= 12.16 in-service hours provided, no training on skin care/pressure ulcer prevention;
-CNA W- DOH [DATE]= 16.83 in-service hours provided, no training on skin care/pressure ulcer prevention;
-CNA UU- DOH [DATE]= 13.33 in-service hours provided, no training on skin care/pressure ulcer prevention;
-CNA V- DOH [DATE]= 16.8 in-service hours provided, no training on skin care/pressure ulcer prevention;
-CNA VV- DOH [DATE]= 13.33= in-service hours provided, no training on skin care/pressure ulcer prevention;
-CNA WW- DOH [DATE]= 12.83 in-service hours provided, no training on skin care/pressure ulcer prevention.
During an interview on [DATE] at 9:00 A.M., the administrator said she would you expect all staff to know how to care for residents and know the needs of the residents they care for. The nurse educator is responsible for CNA training. She is no longer employed at the facility.
4. Review of Resident #122's care plan, dated [DATE], showed:
-Problem: Resident was admitted with an infected stage III pressure (full thickness tissue loss, subcutaneous fat may be visible but the bone, tendon or muscle is not exposed) Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) ulcer to sacrum (tail bone area);
-Approach: Administer treatment as ordered. Assess condition of surrounding skin. Assist/encourage resident to turn and reposition to alleviate pressure to sacrum. Institute antibiotic therapy as ordered. Record the amount, type, and odor of drainage from the wound.
Review of the resident's physician order sheet, showed an order, dated [DATE], to flush sacral wound with normal saline once a day. Dakin's solution (used to cleanse wounds to prevent infection), Special Instructions: Wet Kerlix (absorbent, woven gauze used for wound care) with Dakin's and pack sacral wound once a day. Cover sacral wound with dressing once a day. Turn every two hours, keep off back.
Observation on [DATE] at 1:45 P.M., showed Licensed Practical Nurse (LPN) N gathered supplies from the treatment cart and entered the resident's room to change the dressing on the resident's Stage IV (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure ulcer located at his/her sacrum. After setting the treatment supplies on a barrier on top of the resident's bedside table, LPN N washed his/her hands and donned gloves and then removed the bowel movement filled brief from the resident. Bowel movement visible on the wound dressing. LPN N removed the dressing from the wound and exposed the wound bed. Bowel movement visible underneath the wound dressing. No Kerlix packed inside the wound. LPN N took off his/her gloves, cleansed his/her hands and donned new gloves. He/she then took a wet, soapy wash cloth and wiped the rectum, buttocks and the wound bed free of bowel movement. LPN N measured the wound and verified the pressure ulcer measured approximately 8 centimeters (cm) long and 9 cm wide with a depth of approximately 2 cm. The resident's vertebrae visible, located at the top of the wound, with slough (moist dead tissue) present at the 12 o'clock to 3 o'clock position (as compared to the face of a clock) and covered approximately 40% of the wound base. Eschar (dry dead tissue) present at the top of the wound and covered approximately 5% of the wound base. Hyper granulated tissue (an overly large amount of reddish connective tissue) located at the sides of the wound base. After cleansing the wound with normal saline, without changing gloves, LPN N took Dakin's soaked Kerlix and began packing the wound base by unrolling the gauze and using a cotton tipped applicator to push the gauze into the wound bed. LPN N continued packing the gauze into the wound base, pressing it into the wound, causing the gauze to spill out, back into LPN N's hand. The skin around the edges of the wound bed bulged out due to the tightly packed gauze. After removing his/her gloves, cleansing hands and donning new gloves, LPN N placed an absorbent dressing against the wound and pressed it firmly with the palm of his/her hand. LPN N took medical tape and attempted to tape down the dressing to the resident's skin. The tape only adhered to the resident's skin on two sides, leaving two sides of the dressing opened with a gap of approximately 3 inches between the wound base and the dressing. As LPN N and CNA O turned the resident back over to his/her back, the wound base was visible.
During an interview on [DATE] at 10:30 A.M., the administrator said:
-Treatment orders for wound care should be followed to prevent to wounds from getting worse;
-Nursing staff are expected to tape all areas of a wound bandage to prevent contamination of the wound and to make sure the dressing stays in place;
-Nurses are expected to know how to properly treat a wound according to professional standards.
5. Review of the facility's Facility Assessment, dated as last reviewed [DATE], showed:
-Staff training/education competencies: Manuals are available, such as administrator manual, director of nursing manual, skin integrity manual, documentation guidelines, nursing policies and procedure manual, infection control manual, volume 1 and 2 pharmacy manual, resident assessment instrument manual or electronic health record manual, each discipline specific manual, quality assurance manual, updates for manuals are sent annually;
-Mandatory training is completed upon hiring and annual through the facility electronic training program in-services;
-Attached Orientation Handout/Staff Competency Check List: Included the name of the department heads and a list of information provided to the new hire;
-The facility assessment failed to address an evaluation of the facility's training program to ensure any training needs are met for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles.
During an interview on [DATE] at 9:00 A.M., the administrator said the department heads, administrator and medical director were involved in the development of the facility assessment.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on interview, and record review the facility failed to establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliatio...
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Based on interview, and record review the facility failed to establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation when the controlled substance shift change count check sheets were missing documentation for five of the seven facility medication carts. The facility census was 126.
Review of the facility's Controlled Substance policy, dated June 2016, showed:
-Policy: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility, in accordance with federal and state laws and regulations;
-Accurate accountability of the inventory of all controlled drugs is maintained at all times.
1. Review on 4/23/19 at 7:30 A.M., of the facility's controlled substance shift change count check sheet, dated April 2019, for the certified medical technicians (CMT) cart for 300 Terrace, showed:
-21 out of 51 shifts with one nurse initial;
-8 out of 51 shifts without a nurse initial;
-15 out of 51 shifts without the count of narcotics that remained documented.
2. Review on 4/23/19 at 8:00 A.M., of the facility's controlled substance shift change count check sheet, dated April 2019, for the nurse's cart for 300 Long, showed:
-11 out of 45 shifts with one nurse initial;
-18 out of 45 shifts without a nurse initial;
-21 out of 45 shifts without the count of narcotics that remained documented.
3. Review on 4/23/19 at 8:23 A.M., of the facility's controlled substance shift change count check sheet, dated April 2019, for the nurse's cart for 300 Terrace, showed:
-29 out of 49 shifts with one nurse initial;
-12 out of 49 shifts without a nurse initial;
-22 out of 49 shifts without the count of narcotics that remained documented.
4. Review on 4/23/19 at 12:15 P.M., of the facility's controlled substance shift change count check sheet, dated April 2019, for the nurse's cart for 200 Terrace, showed:
-29 out of 45 shifts with one nurse initial;
-7 out of 45 shifts without a nurse initial;
-25 out of 45 shifts without the count of narcotics that remained documented.
5. Review on 4/23/19 at 12:16 P.M., of the facility's controlled substance shift change count check sheet, dated April 2019, for the CMT cart for 200 Terrace, showed:
-23 out of 47 shifts with one nurse initial;
-11 out of 47 shifts without a nurse initial;
-19 out of 47 shifts without the count of narcotics that remained documented.
6. During an interview on 4/29/19 at 10:30 A.M., the administrator said:
-The oncoming and off going nursing staff are expected to count the narcotics together before starting and ending their shifts and document their findings on the controlled substance shift change count sheet found in the narcotic binder on each medication cart;
-Unit managers should follow up to ensure the controlled substance shift change count sheets are filled out appropriately;
-If a narcotic was missing, the facility would use the controlled substance shift change count sheet to investigate;
-Nurses are not to leave their assignment if there is a discrepancy in the narcotic count;
-Due to the missing information on the controlled substance shift change count sheets, they are not sufficient to obtain an accurate reconciliation of the facility's controlled substances.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional standards in two out o...
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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 in two out of three medication storage rooms and in five out of seven medication/treatment carts. The census was 126.
Review of the facility's medication storage policy dated 2001 and revised April 2017, showed:
-Policy: The facility shall store all medications and biologicals in a safe and orderly manner;
-Drugs and biologicals shall be stored in packaging, containers, or other dispensing systems in which they are received from pharmacy;
-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;
-Compartments containing drugs and biologicals shall be locked when not in use;
-Medications requiring refrigeration must be stored in a refrigerator in the drug room located at the nurse's station or at another secured location.
1. Observation of the 300 Long Certified Medical Technician (CMT) medication cart, on 4/23/19 at 7:30 A.M., showed:
-Several nebulizer vials (medications used to treat complications with breathing) loose in the cart, not in pharmacy boxes and without labels;
-One open vial of eye drops, loose in the cart, not labeled, and not in a box;
2. Observation of the 300 Long medication storage room, on 4/23/19 at 7:50 A.M., showed:
-A bag of fast food on the counter;
-The freezer located in the narcotic refrigerator covered with thick ice;
-Approximately 24 urine sample cups, expired on 2/23/19;
-In the bottom cabinets:
-Enteral feeding pump (used to administer nutrition through a tube placed into the stomach or bowel), not in a bag;
-Bilevel positive airway pressure machine (BIPAP, used to treat lung and respiratory disease), not in bag;
-Three dirty food containers.
3. Observation of the 300 Long nurse's medication cart, on 4/23/19 at 8:05 A.M., showed:
-One vial of Novolog (short acting insulin) open, without a date;
-One vial of unopened Novolog (not in a refrigerator) without a date.
Review of the Novolog product information, showed store unopened vials in the refrigerator. After first use, store in the refrigerator or room temperature. Discard after 28 days.
4. Observation of 300 Terrace CMT medication cart, on 4/23/19 at 8:45 A.M., showed:
-Cooked bacon, a roll and an apple placed on a napkin in the top drawer amidst medications;
-A personal water cup in the bottom drawer amidst medications.
5. Observation of the 200 Terrace treatment cart, on 4/23/19 at 12:10 P.M., showed:
-The cart unlocked and unattended;
-Betadine (antiseptic solution commonly used to treat wounds) bottle, opened and covered with sticky, spilled betadine solution;
-BIPAP mask, expired on 6/13/18.
6. Observation of the 200 Terrace medication storage room, on 4/23/19 at 12:30 P.M., showed:
-On the counter:
-Suction machine, in a ripped open bag;
-Staff purse;
-The sink had white substance splattered on the sides and an unidentifiable brown sticky substance covered the drain;
-In upper cabinets:
-Two open bottles of hot sauce, one without a lid;
-Enteral feed pump not in bag;
-A radio, dirty crumpled trash bag, dentures, and a copy of a physician order;
-Nebulizer machine (used to administer medication in a form of a mist inhaled into the lungs), not in bag;
-One bottle of beer, not labeled with a resident's name;
-Two open packs of cigarettes, not labeled with a resident's name;
-The refrigerator that contained narcotics was unlocked.
7. Observation of the 200 Terrace CMT medication cart, on 4/23/19 at 12:44 P.M., showed:
-A plastic cup full of pills, not labeled;
-Several nebulizer vials loose in cart, not in pharmacy boxes, without labels.
8. During an interview on 4/29/19 at 10:40 A.M., the administrator said:
-Unit managers are ultimately responsible for maintaining medication storage rooms and medication/treatment carts;
-It is important to maintain cleanliness and order in storage rooms and carts for infection control, to prevent cross contamination, and so staff can find items when needed.
-Staff should store their personal belongings and food in lockers or in the break room;
-It is not appropriate for staff to store personal belongings or food in medication storage rooms or medication/treatment carts due to infection control. It brings in filth, food borne illness, and can contaminate sterile supplies and medications;
-Clean equipment is stored in the central supply room. Dirty equipment is brought to the dirty hold room, and once it is sanitized, it is placed in a bag and stored in the central supply room;
-Medications are stored in their pharmacy packaging. It is not appropriate to store medications in a plastic cup, without a label;
-Staff should discard expired medications or medical supplies according to procedure;
-Medication carts, treatment carts and refrigerators with narcotics are to be locked when not in use.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0838
(Tag F0838)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both...
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Based on interview and record review, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies by not identifying a resource of agency staff used to fulfill staffing needs; address an evaluation of the facility's training program to ensure any training needs are met for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles; and include an evaluation of any contracts, memorandums of understanding, including third party agreements, for the provision of goods, services or equipment to the facility during both normal operations and emergencies. The census was 126.
1. Review of the facility's agency nursing staff contracts, showed the facility contracted through seven nurse staffing agencies to fulfill staffing needs.
During an interview on 4/24/19, the assistant administrator said the facility uses several agency's to fulfill staffing needs, they use Nurse Staffing Agency DD the most.
Review of the facility's Facility Assessment, dated as last reviewed 12/27/18, showed:
-When there are vacancies, calls are made to all PRN (as needed) and part time partners to get vacancies covered. At that time, if no one is available, then we will call full time partners that are off to see if they can come in to work. When overtime is needed, we look at what hall needs to be covered and we will ask partners if they can work over or come in early for that hall to have consistence in staff. Unit managers fill in on the floor to ensure proper staffing;
-The assessment failed to identify the resource of agency staff used to fulfill staffing needs.
2. Review of the training materials provided to contracted agency certified nursing assistants (CNAs), showed instructions that described how to log into the computer. No further information provided.
Review of the training materials provided to contract agency licensed nursing staff, showed:
-Instructions on how to log into the computer;
-A guide to describe the facility's culture and expectations;
-A navigation guide to the electronic health record;
-No further information provided.
During an interview ion 4/29/19 at 9:00 A.M., the administrator said competency for agency staff is evaluated by exception. There is no process but if concerns are identified, the facility will address them. Staff hired by the facility are provided training by the nurse educator. The facility utilizes a computer training system for staff competencies. Agency staff do not have access to this program. Agency staff are not trained on facility care policies but may ask to see them if needed.
Review of the facility's Facility Assessment, dated as last reviewed 12/27/18, showed:
-Staff training/education competencies: Manuals are available, such as administrator manual, director of nursing manual, skin integrity manual, documentation guidelines, nursing policies and procedure manual, infection control manual, volume 1 and 2 pharmacy manual, resident assessment instrument manual or electronic health record manual, each discipline specific manual, quality assurance manual, updates for manuals are sent annually;
-Mandatory training is completed upon hiring and annually through the facility electronic training program in-services;
-Attached Orientation Handout/Staff Competency Check List: Included the name of the department heads and a list of information provided to the new hire;
-The facility assessment failed to address an evaluation of the facility's training program to ensure any training needs are met for all new and existing staff, individuals providing services under a contractual arrangement and volunteers, consistent with their expected roles.
3. Review of the facility's nursing agency staff contracts, showed the facility contracted through the following agency's to fulfill staffing needs:
-Nurse Staffing Agency DD;
-Nurse Staffing Agency EE;
-Nurse Staffing Agency FF;
-Nurse Staffing Agency GG;
-Nurse Staffing Agency HH;
-Nurse Staffing Agency II;
-Nurse Staffing Agency JJ.
Review of a list of dialysis residents, provided by the facility, showed two residents received dialysis services provided by a contracted dialysis company.
Review of a list of residents who receive hospice services, provided by the facility, showed eight residents receive hospice from two different contracted hospice companies.
During an interview on 4/22/19 at 8:45 A.M., the administrator said dialysis is provided by an outside vender. The facility does not provide dialysis onsite at the facility. Pharmacy Company MM is the pharmacy contracted to provide residents with ordered medications.
Review of the facility's Facility Assessment, dated as last reviewed 12/27/18, showed:
-Resource Services:
-Dental: Dental Company PP and Dental Company QQ;
-Barber/Beauty shop;
-Pharmacy: Pharmacy Company MM;
-Radiology: Radiology Company RR;
-Therapy: Occupational, physical and speech therapy;
-Religious Services;
-Recreational Music;
-The facility assessment failed to identify dialysis as a resource service;
-The facility assessment failed to identify nursing agency services as a resource service;
-The facility assessment failed to identify hospice as a resource service;
-The facility assessment failed to include an evaluation of any contracts, memorandums of understanding including third party agreements for the provision of goods, services or equipment to the facility during both normal operations and emergencies.
4. During an interview on 4/29/19 at 9:00 A.M., the administrator said the department heads, administrator and medical director were involved in the development of the facility assessment. She would expect all required elements be included in the facility assessment.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
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's quality assessment and assurance committee failed to develop a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility's quality assessment and assurance committee failed to develop and implement action plans to correct identified quality deficiencies related to answering call lights timely, staff use of personal phones on duty and prevention, identification, and treatment of wounds. The census was 126.
Review of the Centers for Medicare and Medicaid Services (CMS) State Operations Provider Certification manual, showed:
-Corrective Action: A written and implemented plan of action for correcting or improving performance in response to an identified quality deficiency;
-Quality Assurance and Performance Improvement (QAPI): Nursing home QAPI is the coordinated application of two mutually-reinforcing aspects of a quality management system: Quality Assurance (QA) and Performance Improvement (PI). QAPI takes a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families, and all nursing home caregivers in practical and creative problem solving.
1. Review of the facility's Quality Improvement Program Manual, dated 2/1/07, showed:
-Purpose: To promote and facilitate the provision of excellent care to our patients. To promote and facilitate the highest possible quality of life for our patients;
-Objectives: Identify quality deficiencies, determine and implement improvements;
-The administrator has the ultimate responsibility for the committee's functioning in compliance with Federal and State regulations.
2. Review of Resident #21's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/16/18, showed:
-Diagnoses included quadriplegia (paralysis), depression, bipolar disease (major mental disorder with mixed moods) and high blood pressure;
-No cognitive impairment;
-No behaviors;
-Required total assistance from the staff for transfers, dressing, hygiene and bathing.
During an interview on 4/23/19 at 1:30 P.M., the resident said when he/she turns on the call light at night, it takes staff so long to answer that he/she falls back asleep and staff turn off the call light without taking care of his/her needs. When he/she wakes up again, he/she will turn the call light back on and the process repeats itself.
2. Observation of the 500 hall, on 4/23/19 at 1:32 P.M., showed the call light for room [ROOM NUMBER] alarmed and was audible at the nurse's station. A staff person sat in a chair in the lobby area outside the elevators and did not respond to the light. A staff person exited a resident room, looked at the call system that indicated the room with the call light on, shook his/her head and said now what? He/she continued down the hall but failed to respond to the light. A certified medication technician (CMT) stood at the medication cart near by, prepared medications and did not respond to the call light. At 1:56 P.M., a staff member answered the call light.
3. Observation of the 500 hall on 4/23/19 05:15 P.M., showed the call light indicator on for room [ROOM NUMBER] and audible at the nurse's station upon the surveyor's arrival to the floor. A staff member passed dinner trays. Three staff were located at the nurses station. One on the facility phone, one on the facility computer and one flipped through papers on a clip board. Observation from the nurse's station, looking towards room [ROOM NUMBER], showed the light indicator above the door not visible. As the surveyor walked closer to the room, the call light became visible and appeared dim. Several staff were observed to be in the halls, stood at the nurse's station and/or at the medication carts. The staff did not respond to the call light. At 5:34 P.M., staff responded to the call light.
4. Observation on 4/23/19 at 5:35 P.M., showed the call light for room [ROOM NUMBER] on and sounded. Two staff were located in the hall and two at the nurse's station as the notification alarm sounded. At 5:37 P.M., both rooms [ROOM NUMBERS] alarmed. A staff person walked up the hall and past both rooms with the call indicator lights on as he/she looks at his/her cell phone. He/she then exited the unit and continued to look at his/her cell phone.
5. Observation on 4/24/19 at 8:42 A.M., showed a resident sat in the dining room. The resident had removed his/her top, leaving his/her breast exposed. Two Certified Nurse Aides (CNAs) sat at the adjacent table and assisted residents with their meals. Both CNAs sat with their heads down, their focus on their phones, neither CNA realized the resident had disrobed. Nurse X walked over to the resident and started to assist the resident with his/her blouse. One of the CNAs looked up from his/her phone, saw the resident and said, Oh my!
6. During an interview on 4/24/19 at 10:30 A.M., all 14 residents present at the resident meeting said there was a problem with staff using their cell phones. Some staff may have a Bluetooth in their ear. Sometimes residents do not know if staff are talking to them or on their phone. Staff are heard speaking to their significant others or making plans. They feel like they are less than a person and it is rude. Staff are on their phone when they are providing care. Sometimes they stop assisting the resident and finish their conversation on the phone.
7. During an interview on 4/29/19 at 9:00 A.M., the administrator said she was aware of resident complaints that staff use their cell phones and residents have voiced concern regarding staff not answering the call lights. The concern regarding call lights has been mentioned in the all partners meetings (staff meetings). No other interventions have been put into place to resolve the issues.
8. Review of the facility's Resident Census and Conditions of Residents form, dated 4/23/19, showed:
-Indicate the number of resident's with pressure ulcers (injury to the skin and/or underlying tissue, as a result of pressure or friction): Six;
-Of the total number of residents with pressure ulcers, excluding stage I, how many residents had pressure ulcers on admission: One.
Review of the facility's wound tracking reports, showed no wound tracking completed for residents at the facility the last two weeks in January 2019 and the first week in February.
During an interview on 4/25/19 at 2:31 P.M., the wound nurse said she measures wounds weekly and tracks wounds on the wound on the wound reports. She was on maternity leave during the timeframe the wound reports were not completed.
Review of Resident #43's medical record, showed:
-Progress note on 1/17/19, skin: No rash or skin breakdown;
-Weekly wound assessment record:
-On 2/3/19, no new or concerning skin issues noted. Skin is dry and intact and warm;
-On 2/11/19, no new skin issues noted;
-On 2/15/19, sacral (located at the bottom of the spine and lies between the fifth segment of the lumbar spine and the tailbone) unstageable (depth unable to be determined), wound measured 5 by 3.5. No exudate (drainage). Wound base moist, no odor or signs and symptoms of infection, no eschar (hard dead tissue) or slough (moist dead tissue), granulation tissue (new tissue growth) present, periwound (skin around wound edges) redness and maceration (skin deterioration caused by moisture). NOTE: Wound noted with 100% slough, mild periwound maceration. Mild odor noted. No redness or warmth noted, air loss mattress replaced. Staff educated to provide 2 hour position changes. Resident noted with non-compliance at times resident noted change position to back after turned on side. Education provided and resident agrees to comply with position changes. Treatment completed.
-Physician order sheets, no treatment order obtained for the wound identified on 2/15/19 until 2/21/19.
During an interview on 4/25/19 at 2:31 P.M., the wound nurse said Resident #43 originally had an order for skin prep and a protective dressing because he/she had a history of having a wound and it had healed. The skin prep was for protection and not treatment of a wound.
During an interview on 4/29/19 at 9:00 A.M., the administrator said when it is identified that a resident has a wound, the resident's specific concerns are discussed as part of the QAPI meeting. Interventions are implemented individually for each resident. There are no facility wide interventions implemented to prevent, identify or treat wounds. Interventions are only set in place for the individual resident after a wound has been identified.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to implement policies and procedures to include providing resources and instructions for performing hand hygiene in or near lobby...
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Based on observation, interview and record review, the facility failed to implement policies and procedures to include providing resources and instructions for performing hand hygiene in or near lobby areas or entrances and provide conveniently-located alcohol-based hand rub and supplies for hand washing where sinks are available, when the alcohol-based hand rub in the 500 hall elevator lobby remained empty for several days of observation and no hand washing sink available to visitors. In addition, the facility failed to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. The census was 126.
1. Review of the facility's Cover your Cough information, provided by the facility as materials used to educate staff, showed:
-Cover your mouth and nose with a tissue when you cough or sneeze, or cough or sneeze into your upper sleeve, not your hands;
-Put your tissue in the waste basket;
-Clean your hands after coughing or sneezing;
-Wash hands with soap and warm water for 20 seconds or clean with alcohol-based hand cleaner.
During an interview on 4/22/19 at 3:23 P.M., the administrator said the Cover your Cough sign is what the facility used teach staff, but she did not believe the facility had policies and procedures to address cough etiquette/respiratory hygiene.
Review of the facility's undated infection control and prevention program, showed:
-Infection Control: Respiratory Hygiene/Cough Etiquette is a component of Standard Precautions. It is important to ensure that all person with symptoms of respiratory infection adhere to respiratory hygiene/cough etiquette;
-Restrictions for visitors and health-care personnel: Adherence to respiratory hygiene/cough etiquette and the importance of perform frequent hand hygiene should be reinforced.
The facility failed to have policies and procedures to:
-Provide resources and instructions for performing hand hygiene in or near lobby areas or entrances;
-Provide conveniently-located dispensers of alcohol-based hand rub and supplies for hand washing where sinks are available;
-During times of increased prevalence of respiratory infections in the community, the process to have facemasks available and that staff should offer face masks to coughing or sneezing visitors and other symptomatic persons;
-Specify that symptomatic visitors should wear a facemask or maintain at least a 3 feet separation from others in common areas.
Observation of the alcohol-based hand rub dispenser on the 500 hall elevator lobby showed the bottle empty. The Director of Nursing (DON) said there is a bottle on the medication cart for use. Observation of the medication cart alcohol-based hand rub bottle, showed the bottle empty. No alcohol-based hand rub available at the 500 hall nurses station or on the treatment cart, accessible to visitors. No hand washing sink accessible to visitors. Observations on 4/24/19 at 2:28 P.M., 4/25/19 at 7:18 A.M., and 4/29/19 at 7:49 A.M., showed the alcohol-based hand rub dispenser on the 500 hall elevator lobby empty. No alcohol-based hand rub available at the 500 hall nurses station, on the medication cart or treatment cart, accessible to visitors. No hand washing sink accessible to visitors.
During an interview on 4/29/19 at 9:00 A.M., the administrator said housekeeping is responsible to make sure alcohol-based hand rub is filled. If staff become aware that the hand rub is empty, they should contact housekeeping.
2. Review of the Centers for Medicare and Medicaid Services (CMS), Center for Clinical Standards and Quality, Safety and Oversight Group memo QSO-17-30, revised 7/6/18, showed:
-Requirement to reduce Legionella risk in healthcare facility water systems to prevent cases and outbreaks of Legionnaires' disease (LD);
-For skilled nursing facilities and nursing facilities: Policies must include a system for identifying, reporting, investigating and controlling infections and communicable disease of patients and personnel;
-Medicare and Medicaid certified healthcare facilities are expected to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. Facilities must have water management plans and documentation that, at a minimum, ensure each facility:
-Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system;
-Develops and implements a water management program that considers the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) industry standard and the Centers for Disease Control (CDC) toolkit;
-Specifies testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained;
-Maintains compliance with other applicable Federal, State and local requirements.
Review of the facility's, Legionella Monitoring Plan and Schedule, showed:
-A list of high risk locations for the growth of water pathogens;
-Water sampling directions for each high risk location;
-Testing protocols;
-The facility failed to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems;
-The facility failed to have water management plans and failed to develop and implement a water management program, that:
-Considers the American Society of Heating, Refrigerating and Air Conditioning Engineers (ASHRAE) industry standard and the CDC toolkit;
-Policies and procedures that include a system for identifying, reporting, investigating and controlling infections and communicable disease of patients and personnel.
During an interview on 4/22/19 at 3:23 P.M., the administrator said the facility does not have policies and procedures to reduce the risk of opportunistic pathogens in water systems and they do not have a water management program. The facility does test for Legionella and has a contract with a vender to do this.
During an interview on 4/24/19 at 3:28 P.M., the maintenance director said the facility does test for Legionella bi-annually but they do not have a water management team or a description of the water management system using text or a flow diagram.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0943
(Tag F0943)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to train their staff on freedom from abuse, neglect and exploitation; activities that constitute abuse, neglect, exploitation, and misappropri...
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Based on interview and record review, the facility failed to train their staff on freedom from abuse, neglect and exploitation; activities that constitute abuse, neglect, exploitation, and misappropriation of resident property; procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property; and dementia management and resident abuse prevention, for nursing staff contracted through nursing agencies. The facility identified seven nurse staffing agencies utilized by the facility. The census was 126.
Review of the Centers for Medicare and Medicaid Services (CMS) State Operations Provider Certification manual, showed staff includes for the purposes of the training guidance, all facility staff, (direct and indirect care and auxiliary functions) contractors and volunteers.
Review of the facility's agency nursing staff contracts, showed the facility contracted through the following agency's to fulfill staffing needs:
-Nurse Staffing Agency DD;
-Nurse Staffing Agency EE;
-Nurse Staffing Agency FF;
-Nurse Staffing Agency GG;
-Nurse Staffing Agency HH;
-Nurse Staffing Agency II;
-Nurse Staffing Agency JJ.
During an interview on 4/24/19, the assistant administrator said the facility uses several agency's to fulfill staffing needs, they use Nurse Staffing Agency DD the most.
Review of the training materials provided to contracted agency certified nursing assistants (CNAs), showed:
-Instructions to describe how to log into the computer. No further information provided;
-No training or information on the facility's abuse, neglect misappropriation and exploitation policies and procedures;
-No dementia management training.
Review of the training materials provided to contract agency licensed nursing staff, showed:
-Instructions to describe how to log into the computer;
-A guide to describe the facility's culture and expectations;
-A navigation guide to the electronic health record;
-No training or information on the facility's abuse, neglect misappropriation and exploitation policies and procedures;
-No dementia management training.
During an interview on 4/29/19 at 9:00 A.M., the administrator said she would expect outside agency staff be aware of general expectations regarding abuse and neglect, but she cannot say she expects agency staff to be aware of the facility's specific policies. Agency staff are not trained on the facility's abuse and neglect procedures.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0577
(Tag F0577)
Minor procedural issue · This affected most or all residents
Based on observation, interview and record review, the facility failed to maintain survey reports with respect to all surveys and complaint investigations, including any plan of correction in effect, ...
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Based on observation, interview and record review, the facility failed to maintain survey reports with respect to all surveys and complaint investigations, including any plan of correction in effect, available for review for the prior year. The census was 126.
Observation on all days of the survey, from 4/22/19 through 4/26/19 and 4/29/19, showed the facility's previous survey results maintained in a binder on the wall near the front entrance to the building.
Review of the survey binder, showed the survey binder did not include any information regarding complaint investigations that resulted in a statement of deficiency and the plans of corrections for the last year.
During an interview on 4/29/19 at 9:10 A.M., the administrator said she was aware the most recent survey and last three years of survey results should be maintained in the survey binder, but was not aware results of complaint investigations should also be in the binder.
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?"
- "What safeguards are in place to prevent abuse and neglect?"
- "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: Federal abuse finding, 3 life-threatening violation(s), 2 harm violation(s), $281,231 in fines, Payment denial on record. Review inspection reports carefully.
- • 125 deficiencies on record, including 3 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $281,231 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 has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is Athene Nursing And Rehabilitation's CMS Rating?
CMS assigns ATHENE NURSING AND REHABILITATION an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Missouri, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Athene Nursing And Rehabilitation Staffed?
CMS rates ATHENE NURSING AND REHABILITATION's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 57%, which is 11 percentage points above the Missouri average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 56%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Athene Nursing And Rehabilitation?
State health inspectors documented 125 deficiencies at ATHENE NURSING AND REHABILITATION during 2019 to 2025. These included: 3 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 2 that caused actual resident harm, 117 with potential for harm, and 3 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 Athene Nursing And Rehabilitation?
ATHENE NURSING AND REHABILITATION is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by VERTICAL HEALTH SERVICES, a chain that manages multiple nursing homes. With 282 certified beds and approximately 157 residents (about 56% occupancy), it is a large facility located in TOWN AND COUNTRY, Missouri.
How Does Athene Nursing And Rehabilitation Compare to Other Missouri Nursing Homes?
Compared to the 100 nursing homes in Missouri, ATHENE NURSING AND REHABILITATION's overall rating (1 stars) is below the state average of 2.5, staff turnover (57%) 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 Athene Nursing And Rehabilitation?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "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?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the substantiated abuse finding on record, the facility's high staff turnover rate, and the below-average staffing rating.
Is Athene Nursing And Rehabilitation Safe?
Based on CMS inspection data, ATHENE NURSING AND REHABILITATION has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 3 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Missouri. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Athene Nursing And Rehabilitation Stick Around?
Staff turnover at ATHENE NURSING AND REHABILITATION is high. At 57%, the facility is 11 percentage points above the Missouri average of 46%. Registered Nurse turnover is particularly concerning at 56%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Athene Nursing And Rehabilitation Ever Fined?
ATHENE NURSING AND REHABILITATION has been fined $281,231 across 11 penalty actions. This is 7.8x the Missouri average of $35,891. 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 Athene Nursing And Rehabilitation on Any Federal Watch List?
ATHENE NURSING AND REHABILITATION is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.