| 140000321 |
Alameda County Medical Center D/P SNF |
020009261 |
A |
26-Apr-12 |
JJQW11 |
11692 |
483.25(c) TREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES Based on the comprehensive assessment of a resident, the facility must ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.Based on the comprehensive assessment of a resident, the facility must ensure that- (1) A resident show enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and (2) A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. The facility failed to assess, plan and provide care to one (Resident A) of one residents reviewed to ensure that he did not develop a pressure sore. Resident A developed a pressure sore on his left foot. Resident A left lower leg was amputated after the facility did not assess, plan care or provide care to Resident A's left foot in a timely manner to prevent infection and gangrene from a pressure sore. Definitions:Ankle foot orthosis or commonly known as AFOs are used in the treatment of disorders that affect muscle function ... (such as stroke) ... AFOs can be used to provide support to weak or wasted limbs or the ankle brace can position a limb ... into a more normal position."Gas gangrene is a type of moist gangrene that is commonly caused by bacterial infection. Once present in tissue, these bacteria produce gasses and poisonous toxins as they grow. Gas gangrene is a medical emergency because of the threat of the infection rapidly spreading via the bloodstream and infecting vital organs. [Reference: http://medical-dictionary.thefreedictionary.com/Gangrene] Record review on 12/16/11 showed the facility admitted Resident A on 7/13/11. Resident A had diagnoses that included diabetes and he had suffered a stroke that left him weakened on the right side of his body. Physician's orders for admission to the facility, dated 7/13/11, contained instructions for the facility to provide Physical Therapy and Podiatry (foot care) to Resident A.Resident A's plan of care, for Hyperglycemia/Hypoglycemia, with the 'problem date' of July 13, 2011, listed under "Approaches" the following intervention, "Observe lower extremity circulation, check skin integrity, provide foot care. Communicate with MD (medical doctor) if with findings." On 8/15/11, Resident A complained of stomach pains and then chest pains and was transferred to a local hospital for evaluation. Resident A was readmitted to the facility on 8/17/11. RN 3 completed a form, "Admission Database and Nursing Assessment." RN 3 recorded that Resident A was alert and oriented x 3, had, "weakness on the right side", and his skin was intact (had no wounds). The licensed nurse indicated that Resident A was not impaired for feeling pressure related discomfort and that he was at risk for developing pressure sores. According to the assessment instructions, "braces," were, "factors further increasing risk." Physician's orders for care of Resident A, dated 8/17/11, contained no instructions for the use of AFOs. An inventory of Resident A's personal property, dated 8/17/11, included, a "left foot brace."A facility Policy and Procedure, dated as revised on October 2011, contained instructions for use of assistive devices that included braces. Item 4 included the following information: "All braces are evaluated for appropriate fit, comfort ...Skin should be checked frequently to monitor for potential skin breakdown ..."A PT evaluation, dated 8/19/11, described Resident A as able to walk 16 feet within parallel bars while wearing AFOs on both feet/legs. PT planned to continue therapy for Resident A to further improve his functional ability.Dr. P, a podiatrist recorded a visit to assess and treat Resident A's feet, on 8/24/11. Dr. P described Resident A as having diabetes with neuropathy. "...neuropathy, a result of nerve damage, often causes numbness and pain in (the) hands and feet ... One of the most common causes is diabetes." [Reference:] Dr. P recorded that Resident A had, pedal pulses (pulsation of blood flow in the feet) on the right and left. Dr. P trimmed Resident A's toenails and instructed, "protect both feet, no tight shoes (secondary) to neuropathy ... " Dr. P made no mention of AFOs in his report of care and assessment.Review of the medical record showed no nursing or PT plans or interventions to ensure that Resident A's feet were protected and his footwear was not tight. Physician's orders, dated 9/15/11 and 10/14/11, showed no entries regarding the use of AFOs.The facility's comprehensive assessment of Resident A's condition, dated 10/11/11, showed that the facility had determined that Resident A had no pressure sores nor other wounds or skin problems, to include foot problems. The assessment indicated that Resident A had no splint or brace assistance provided by restorative nursing programs, however, Resident A had received services from Physical Therapy.Further review of PT records showed a review of Resident A's abilities that was dated 10/24/11. PT recorded additional progress by Resident A. With assistance, Resident A could now walk with a front wheel walker assistive device for a distance of 30 feet. Resident A wore AFOs on both feet/legs. PT's goal was for Resident A to further improve in his ability to walk with on-going therapy. Review of the, "Nursing Measures Record," with daily entries for the month of November, 2011, showed that Certified Nurse Aides (CNA) check- marked that Resident A's skin was observed at least every eight hours, "...inspected for red areas." There was a checkmark for each nursing shift, from 11/1/11 to 11/23/11. Additionally, there was a pre-printed care area field for information, "splints as scheduled," however, there were no corresponding checkmarks at all.The medical record contained no information as to who applied the AFOs to Resident A's feet/legs or when the devices were used.On 11/23/11 at 12 noon, Physician A recorded in a progress note the following: "New wound," Left lateral foot, "deep ulcer," positive for surrounding cellulitis (reddened area and inflammation around the wound). The wound was described as, "unstageable," deep, and the, "size of a nickel." Physician A ordered a topical antimicrobial dressing and a wound care evaluation.A licensed nurse's progress note, dated 11/23/11 at 12:30 p.m., recorded, "CNA assigned to the resident showed me his left lateral foot - scab is off and discoloration noted." Until this licensed nurse's entry, there was no record of any injury or scabbed area to Resident A's foot. The facility's color photographs of the wound were dated 11/23/11. A hand written notation next to the photo of Resident A's foot said that this was a, "dry scab and now it's off." In addition to the wound there was a band of reddened skin that crossed the bottom of Resident A's foot. Licensed nurses' progress notes, dated 11/27/11 and 11/28/11 contained entries that described Resident A as feeling weak. On 11/28/11, the licensed nurse recorded that the physician wished for Resident A to be transferred to the hospital for evaluation of his left foot's condition. Photographic record, dated 11/28/11, taken at the hospital on the date of admission, showed that Resident A now had an open wound on the bottom of his left foot. The picture of the open wound showed blackened tissue that was surrounded by deep red discoloration.A hospital wound care consultant documented an assessment of Resident A's left foot on 11/30/11. The consultant described the wounds as being filled with dead tissue and purulent fluid and they had, "strongly foul odors."An x-ray result, dated 11/30/11 recorded that x-rays were taken showing three different views of Resident A ' s left foot. The report of findings stated that there was, "soft tissue gas," next to the bones on the side of Resident A's left foot. The bone of the foot that led to Resident A's left small toe was eroded and "suspicious" for infection of the bone due to infection of the surrounding soft tissue. Physician B, a hospital vascular surgeon, evaluated Resident A on 11/30/11 and concluded that the wounds on Resident A's foot were, "pressure induced necrotic tissue with infection." Surgeons' reports, dated 12/ 1/12, 12/2/11, and 12/6/11, described the need for and actual amputation of Resident A's left leg below the knee. The left foot was not salvageable due to infection and resulting destruction of the bones in the feet and gas gangrene. The surgeons determined that Resident A had palpable pulses in his left leg. In an interview, on 12/16/11 at p.m., CNA 1 stated that CNAs caring for Resident A put the braces on in the morning and the evening shift CNAs take them off. CNA 1 stated that she had not cared for Resident 1 on days just prior to 11/23/11. On 11/23/11 she found the wound on Resident A's foot and had reported it to the charge nurse. CNA 1 described the wound as a sore that was purplish with redness leading to the bottom of the foot.In an interview on 1/15/12 at 4:15 p.m., the PT Manager stated that when assistive braces were needed for PT and walking, that a physician's order was required for the devices. The PT Manager confirmed that there was no physician's order for braces for Resident A.In an interview with PT, on 2/15/12 at 3:30 p.m., she stated that Resident A had a left side brace on admission to the facility and she had provided a right side brace. She stated that it would be the physician's role to instruct the facility in an order as to when to put on and take off the braces. In an interview with Resident A, on 2/15/12 at 3 p.m., he stated that facility staff put the braces on when he got up from bed and facility staff removed the braces at night. In an interview with Registered Nurse 1 (RN), on 3/9/12 at 12:10 p.m., she confirmed that nursing weekly summaries lacked information regarding the use of Resident A's AFOs. RN 1 located the PT evaluation document that contained information that the AFOs were used, but confirmed that there were no instructions for nursing staff. In an interview with RN 2, on 3/9/12 at 12:55 p.m., she confirmed that there were no care plan interventions for the use of AFOs for Resident A. There was, "just a note that says he has them." In an interview and concurrent record review with the facility ' s Podiatrist, Dr. P, on 3/9/11 at 1:05 p.m., he confirmed that he had evaluated and treated Resident A on 8/24/11. Dr. P stated that according to his progress notes that Resident A had no evidence of skin breakdown on his feet. Dr. P stated that Resident A had decreased sensation in his feet and so would not have felt discomfort from AFO pressure. When shown the facility's photo of Resident A's left foot wound, Dr. P stated, "that's a pressure point, it is the base of the fifth metatarsal." Dr. P stated that the wound was not likely to have developed overnight. Therefore the facility violated the regulation when the facility failed to: Assess Resident A's skin and plan his care to ensure that Resident A did not develop a pressure ulcer. Resident A developed a deep pressure sore, that was infected and gangrenous and his lower left leg was amputated.These violations presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 140000686 |
Alameda Hospital D/P SNF |
020010227 |
A |
21-Oct-13 |
W92N11 |
12595 |
483.25(l) DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Based on a comprehensive assessment of a resident, the facility must ensure that residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. On 10/5/12 at11 a.m., an unannounced visit was made to the facility to investigate an entity reported incident regarding an incident of alleged brain hemorrhage due to failure to monitor the clotting time of the resident (Resident 1). The facility violated the aforementioned regulation when it failed to monitor the necessary blood testing for Resident 1, who received a daily dose of Coumadin, a blood thinning medication that slows the clotting time so that the blood cannot clot as easily. Resident 1 had two antibiotics which when taken with Coumadin would increase the risk of bleeding.Prothrombin time and INR are two blood testings necessary to be monitored when a person takes Coumadin to determine the clotting time status and adjust or discontinue the dose of Coumadin according to the blood results. Prothrombin time (PT) is a blood test that measures how long it takes the blood to clot in patients receiving oral anticoagulation. The normal range is 11.1 - 13.1 seconds.International Normalized Ration (INR) is a calculation made to standardize prothombin time. INR is based on the ratio of the person's prothrombin and normal mean prothrombin time. A normal INR for a person who takes Coumadin is 2.0 to 3.0 times the normal PT. The staff interviews and records reviews showed that there were at least 14 different licensed nurses and a pharmacist over a six-week period of time who failed to ensure that Resident 1 had the necessary blood testing while on Coumadin. The failure to monitor the clotting time resulted in Resident 1 having an exaggerated effect from the Coumadin and an unrecognized delay in blood clotting resulting in brain hemorrhage and death after the removal of the breathing tube. A medical record review, on 10/5/12 at 11:00 a.m., showed that the facility admitted Resident 1 on 8/15/12 from a rehabilitation center, for failure to wean from the breathing machine. Resident 1's diagnoses included atrial fibrillation, (abnormal heart rhythm) and history of pulmonary embolism (blood clots in the lungs) that required the use of Coumadin, a drug to prevent blood clots.The Pulmonary Consultation Report, dated 8/15/12, indicated that Coumadin must be continued on admission and to monitor INR. The Pulmonary Consultation Report showed that on admission to the facility, Resident 1 had a tracheostomy tube or breathing tube through the throat and able to speak with the use of a special valve or, "talk leak." Resident 1 had a history of cardiopulmonary arrest (the heart and breathing stopped).During an interview on 11/7/12 at 4:05 p.m., RN A said that Resident 1 was alert, "a very nice lady," who communicated by talking and typing on the computer. Resident 1 communicated with a son by emails. The nurses notes, dated 9/26/12 at 12:15 p.m. to 12:46 p.m., showed that Resident 1 was discovered unresponsive with dilated pupils (sign of pressure on the brain) and had seizures. Emergency procedures were initiated. A lab report dated 9/26/12 at 12:25 p.m. showed a PT was 63.2 with an INR of 6.17. (PT, clotting time and INR were greater than six times the normal and no longer in therapeutic range for anticoagulation.) Resident 1 was transferred to the intensive care unit (ICU) of the acute care hospital at 12:46 p.m.Review of the Neurology Consult in the ICU, dated 9/26/12, 2 p.m. to 5:30 p.m., showed that Resident 1 remained unresponsive with no voluntary movements of her extremities. The neurologist wrote that the Cat Scan (CT scan is an x-ray from many angles) showed a large intracranial hemorrhage.On 9/27/12 the neurologist wrote that Resident 1 met criteria for brain death at 11:35 a.m. The hospital Discharge Summary Death Summary dated, 10/1/12, showed that Resident 1 was pronounced dead on 9/27/12 at 3:30 p.m., with a final diagnosis of "...Intracerebral hemorrhage secondary to over anticoagulation, felt to be adverse drug reaction secondary to fluconazole." Further review of the medical records showed that on 8/15/12 the admission orders included Warfarin (Coumadin) 10 mg daily. On 9/17/12 at 10 a.m., the physician ordered Fluconazole (an antibiotic to treat a fungal infection) 150 mg twice a day for seven days and Levaquin (an antibiotic to treat urinary tract infection 500 mg once a day for five days. According to Lexi-Comp ONLINE, a nationally recognized drug information source, both drugs multiply the effect of Coumadin that increase the risk of bleeding. Resident 1's MAR (Medication Administration Record) showed that Resident 1 received Flucanozole (antibiotic) for the full seven days and Levaquin (antibiotic) for three days while on Coumadin.The summary laboratory results of the blood drawn on 8/15/12 ( the day of admission), showed that Resident 1's PT was 22.1 seconds (normal range 9.6 - 12 seconds) with an INR of 2.09. The facility's INR goal for the treatment of pulmonary embolism and prevention of systemic embolism was 2.0 to 3.0. Resident 1's INR and PT results were within therapeutic range on admission. There was no written order for subsequent INR and PT after 8/15/12. Review of Resident 1's Anticoagulation Sheet from 8/15/12 to 9/25/12 where the licensed nurses would document the INR results and the Coumadin given showed that 14 different licensed nurses initialed that Coumadin was given. There was no INR documented on the Anticoagulation Sheet. There was no documentation to show that a licensed nurse called the physician to request an order to check Patient 1's INR and PT. Review of the facility's policy and procedure for Anticoagulation Management Program (No. 85, Reviewed 7/09) showed, III Medication Specific Therapeutic Procedures: A. Warfarin: 3. "Patients on warfarin will have a PT/INR drawn daily." Interviews of 11 facility staff that included the administrator, pharmacist, licensed nurses and physicians regarding Resident 1 showed that the facility failed to coordinate and follow the written guidelines on monitoring the INR and PT while Resident 1 was on Coumadin. During an interview, on 10/5/12 at 1:30 p.m., Administrator 1 stated that Patient 1's warfarin was dispensed by the acute care inpatient pharmacy. In an interview, on 10/11/12 at 9:25 a.m., the hospital's Director of Pharmacy (DOP) stated the pharmacist was to check the INR weekly for stable patients on Coumadin. The DOP stated that the facility did not have documentation that the pharmacist checked the INR from 8/15/12 to 9/26/12. During an interview on 11/8/12 at 3:30 p.m., Physician A could not remember whether he wrote or gave a verbal order for continued INR monitoring. He said he relied partly on the practice at the facility for routine monthly PT and INR monitoring. Physician A agreed that the Order Set was not used consistently in the subacute unit or the skilled nursing facility. During an interview and concurrent review of the Anticoagulation Flow Sheet for Resident 1, on 11/7/12 at 4:05 p.m., RN A said she administered the Coumadin on 9/18/12 and 9/19/12. RN G said the first time Coumadin was ordered there should be a special pre-printed order sheet used but since Resident 1 was on Coumadin already then the Order Set would not be used. RN A said that the practice at the facility was that once the baseline PT and INR were obtained the day shift nurse would call or fax the results to the physician and write a verbal order for future repeat lab work on the lab result record. The original lab record was missing from the chart. RN A said getting an ongoing order for PT and INR was overlooked for Resident 1. At 4:55 p.m., RN B said she administered Coumadin to Resident 1 on 9/7/12 through 9/9/12. She said that the policy in effect during that time period was that every second Wednesday of the month was the day for the subacute unit to have the PT/INR lab draws for all residents on Coumadin. RN B said she would automatically place any patient on Coumadin in her care on monthly lab work in the computer. RN B said nurses didn't need to have a doctor's order-"just automatically do it." She said that towards the end of every month an RN was assigned to go into the computer and update the physician order sheet. That would have been the time to catch that Resident 1 was on Coumadin without a lab order. The order sheet was then printed and placed in the chart for the physician to review and sign. RN B said the reason she didn't order the lab work when she administered Coumadin was that a month hadn't passed yet; she thought Resident 1 was due for the lab on 9/12/12 per the facility's practice. RN B said there was no written policy describing practice of obtaining monthly lab work. At 5:25 p.m., LVN C said she administered Coumadin eight times during 8/12 and none in 9/12. LVN C said that the day shift nurse caring for the Resident would call the doctor with lab results and get an order for further lab tests. LVN C said if there was no lab order she would continue to administer the Coumadin. At 5:45 p.m., RN D administered the Coumadin on 9/11/12 and 9/24/12. RN D said she wouldn't automatically enter an order in the computer; that there had to be a Doctor's order to check the lab work. RN D said there was a pre-printed order set for Residents on Coumadin which alerts staff to do lab orders every Monday. She said it was part of the admission packet and the nurse admitting the patient should initiate it.On 11/13/12 at 12:10 p.m., during a phone interview, RN E, who admitted the Resident 1 said that the Order Set was not in use at the time that Resident 1 was admitted. RN E said: "If I'm the one giving the medication then it's my responsibility to check the lab work," before administering the Coumadin.On 11/13/12 at 3:10 p.m., during a phone interview, RN F said she gave Coumadin to Resident 1 on 9/24/12 and 9/25/12. RN F said that on 9/25/12 Resident 1 had blood from the trachea upon suctioning. Review of the nurses notes dated 9/25/12 at 9:20 p.m. showed that Physician B was notified. RN F said that Physician B said to watch Resident 1 for further signs of bleeding and did not order a PT or INR. RN F said that the protocol on the unit was that there must be a Doctor's order for PT and INR, that nurses don't automatically order lab work.On 11/14/12 at 9:45 a.m., Physician B said he was on-call for Resident 1 on the evening of 9/25/12. Physician B said he knew that Resident 1 was on Coumadin and thought that the nurse said the last PT and INR was in a therapeutic range. Physician B said that many residents who have tracheostomies have blood tinged secretions. Physician B said: "In retrospect I wish I had done more." On 11/13/12 at 3:30 p.m. during a phone interview, LVN G said she gave Coumadin to Resident 1 on 9/20/12. LVN G said during 8/15/12 - 9/26/12, PT and INR lab work was done every month for residents on Coumadin. LVN G didn't know it was more than month since Resident 1 had lab work. LVN G said that she didn't notify Physician A that Resident 1 was due for follow-up lab work because Resident 1 had no side effect of bleeding from the Coumadin.The Neurology Consultation Notes dated 9/26/12 from 2 p.m. to 5:30 p.m. showed that the resident was not a candidate for neurological intervention because no surgery will change her clinical outcome. The neurologist recommended a DNR or do not resuscitate code status. On 9/27/12, the neurologist documented that the examination done on 9/27/12at 11:35 a.m. showed that the resident met all the clinical criteria for brain death. The brain death was due to cerebral or brain hemorrhage secondary to Coumadin. This failure presented an imminent danger to the resident and had a direct relationship to the cause of the death of the resident. |
| 020000043 |
Alameda Healthcare & Wellness Center |
020011701 |
B |
01-Sep-15 |
PLEU11 |
7677 |
F323 483.25(h): FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The facility violated the aforementioned regulation by failing to prevent hot water from being spilled onto Resident 1. A CNA placed a cup of very hot water on Resident 1's bedside table, which was cluttered with her items. While moving the clutter to make more room on the bedside table, the cup tipped over, spilling hot water onto Resident 1. As a result of this failure, Resident 1 received first degree burns (involves the upper layer of the skin and is usually red and very painful) and second degree burns (partial thickness burn which involves the entire outer layer of skin and upper layers of the dermis which contains the nerve endings. The burn will be pink or red in color, and painful.) Resident 1 experienced a pain level of 8 out of 10 (pain scale where zero is no pain and 10 is the worst pain imaginable,) and a delay in her rehabilitation therapy due to the location and extent of the burns.In an interview on 5/7/15 at 11:40 a.m., Resident 1 stated on 4/9/15, she was still in bed when Certified Nursing Assistant (CNA) 1 brought her breakfast tray into her room. Resident 1 stated she was on contact isolation precautions (used when a resident has a type of bacteria or virus that could be transmitted by touching contaminated areas). The meal was set up on disposable paper products. There was no room for the tray on the over bed table. CNA 1 put the cup of very hot water on the over bed table and began moving objects, when the hot water spilled onto Resident 1's upper, inner thighs and extended to her buttocks. Resident 1 stated after the hot water spilled on her the pain was, "Out of this world." Resident 1 stated as of 5/7/15, she was still having continuous pain on her upper thigh, especially during dressing changes, 29 days after the incident.Review, on 5/7/15, of Resident 1's admission documentation dated 1/15/15, showed Resident 1 was admitted to the facility on 1/15/15, with multiple diagnoses that included rehabilitation therapy to address a fall, lower leg injury, and generalized muscle weakness.Resident 1's Dietary Questionnaire form dated 1/15/15, as part of dietary's admission assessment, showed Resident 1 preferred not to have any hot drinks such as coffee, decaffeinated coffee, or tea served to her for breakfast, lunch, and dinner. There was no update to the assessment to show Resident 1 now preferred hot water with her meals.Record review of the Physician Assistant's notes, dated 4/9/15, showed, "Pt. (patient) had boiling water spilled on her legs this am. Multiple bullae (blisters) formed in medial (inner) thigh and have since ruptured ... significant pain of burn; uncontrolled with current pain rx (prescription medication)... Medial thigh burn: applying sulfadiazine 1% and cover with silvaderm (medications to control infection and promote healing) contact layer q (every) shift. Will increase Norco (narcotic pain reliever) prn (as needed) for pain." Review of the form used by nursing staff to facilitate an efficient and accurate communication between nurses and physicians, dated 4/9/15 at 8:30 a.m., showed Resident 1 had, "1st and 2nd degree burn, secondary to hot water spilled on upper inner bilateral thighs". At 10:00 a.m., "Noted Resident's c/o (complaint) of pain at site of second degree burn rated as 10/10 on pain scale. Medicated with 2 tablets Norco 5/325, as prescribed; will assess within one hour" (pain scale of 0 to 10; with 0 indicating no pain and a score of 10 on the pain scale, as the most severe pain imaginable.)Resident 1's Patient Wound Assessment dated 5/5/15, showed the following notation for her right inner thigh wound: "Burn had a measurement of "Length 21 centimeter (8-1/4 inches) X Width of 8.5 cm X Depth 0.2 cm (8-1/4 inches X 3-1/2 inches)." Left inner thigh wound burn had a measurement of "7.0 cm X 5.0 cm X .02 cm (2-3/4 inches X 2 inches)." Resident 1 complained of having pain at a level of 8 out 10, during the dressing change.During a dressing change observation and concurrent interview on 5/7/15 at 12:25 p.m., Licensed Vocational Nurse (LVN) 1 confirmed the wounds on Resident 1's left and right upper thighs were due to the scalding by hot water on 4/9/15. LVN 1 stated the wound was, "Better now; you should have seen it (wound) before it started healing. The right upper thigh wound extends all the way to Resident 1's buttock area."During an observation and concurrent interview of the Dietary Supervisor (DS), while in the presence of the Administrator on 5/7/15 at 12:50 p.m., she confirmed that once the hot water was poured into the cup, it would take 20 minutes until it was delivered to the resident in her room. The temperature of hot water immediately after it was poured from the hot water dispenser/coffee maker was 180 degrees Fahrenheit (F). Five minutes later (at 12:55 p.m.,) the water temperature was 163 degrees F; 10 minutes later the water temperature was 152.6 degrees, and by 20 minutes after pouring, the water temperature was 144.3 degrees F. According to the Burn Foundation, a hot water temperature of 140 degrees F. can cause a third degree burn (full thickness) in as little as 5 seconds of exposure to hot water. A hot water temperature of 149 degrees F can cause a second degree burn in as little as 2 seconds. (http://www.burnfoundation.org/programs/resource.cfm?c=1&a=3) During an interview and concurrent record review on 5/7/15 at 1:05 p.m., Licensed Vocational Nurse (LVN) 1 stated right after the accident on 4/9/15, she assessed Resident 1. LVN 1 stated nursing staff used a "Skin Sheet" to record the wound measurements. Nursing staff obtained a physician's order for wound treatment and pain medications because Resident 1 was having pain. LVN 1 was unable to locate Resident 1's "Skin Sheet" from 4/9/15 for Resident 1's initial burn wound measurement.In an interview on 5/7/15 at 1:25 p.m., Certified Nursing Assistant (CNA) 1 stated when she brought a disposable breakfast tray to Resident 1 on 4/9/15. Her bedside tray was cluttered with multiple items, so there was not room for the breakfast tray. She set the hot water cup on the bedside table, and began helping Resident 1 clear space on the tray. While she was assisting Resident 1 clear a space for the tray, her attention was diverted, and that was when the water spilled onto Resident 1. She did not see the cup tip over, or how it tipped over.There was no documentation to show a care plan for clutter on the bedside table. There was no documentation to show staff identified possible spill hazards due to clutter on the bedside table. In an interview on 5/7/15 1:55 p.m., the Occupational Therapist stated before Resident 1 suffered the hot water burn, she was able to walk along the hallway for up to 100 feet and she was getting stronger. When Resident 1 was put on contact isolation, she was able to do PT/OT activities in her room. Since the burn incident, she began doing her exercises mostly in bed two to three times per day. She had to learn to move her leg a certain way so it would not rub against the other injured leg while getting out of bed in order to avoid more pain. The Occupational Therapist stated the burn and the pain delayed Resident 1's recovery by at least one and a half months. Therefore, the facility failed to provide adequate supervision to prevent an accident. This failure had a direct or immediate relationship to the health, safety or security of patients. |
| 020000043 |
Alameda Healthcare & Wellness Center |
020011824 |
B |
04-Nov-15 |
6DJ511 |
10791 |
483.13(c) PROHIBIT MISTREATMENT/NEGLECT/MISAPPROPRIATIONThe facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property.The facility violated the aforementioned regulation by failing to follow their policy that prohibits neglect by failing to call 911 when Resident 1 had a change of condition and deteriorated on 1/18/15. Resident 1 experienced increased shortness of breath and staff notified Resident 1's son who told staff his mother belonged in a hospital. The respiratory therapist placed Resident 1 on a mechanical ventilator without physician's orders and facility Staff did not call 911 for one hour after they were unable to assess her blood pressure. As a result, Resident 1 did not have the benefit of acute hospital services when her heart stopped and she was pronounced dead, six and one half hours after her initial symptoms of shortness of breath first appeared.Record review showed Resident 1 was a 65 year old woman who was admitted to the facility on 1/9/15 from the acute care hospital. According to the hospital record "Critical Care" progress note dated 1/4/15, Resident 1 had a past medical history of atrial fibrillation (condition of the heart where the two upper chambers contract very fast and with irregularity causing a problem with the rate and rhythm of the heartbeat and can cause blood clots). Prior to hospitalization, Resident 1 was on Coumadin to prevent blood clots from forming but had stopped taking the medication three weeks before her admission to the hospital. Resident 1 had developed a blood clot in her right arm requiring surgery to remove the clot on 12/21/14. On 12/22/14, Resident 1 had a stroke (blood clot in the brain )and she was transferred to another hospital for a decompressive craniotomy, which is a neurosurgical procedure in which part of the skull is removed to allow a swelling brain room to expand without being squeezed. The resident also had a tracheostomy (trach) surgically placed to create an opening through her neck into the windpipe to provide an airway and to remove secretions from her lungs. Review of the physician's admission orders to skilled nursing facility (SNF), dated 1/9/15, showed Resident 1 was to receive oxygen at 5 liters per minute through her trach and the oxygen was to be adjusted to maintain an blood oxygen saturation (amount of oxygen in the blood) of greater than or equal to 92 percent. Resident 1 had an order for Duoneb nebulizer (aerosolized medication administered through the trach to open the air passages in the lungs) every four hours as needed for shortness of breath or wheezing (in the lungs) and Ambu bag (a hand-held self-inflating bag commonly used to provide positive pressure ventilation (push air into the lungs) of patients who are not breathing or not breathing adequately) at the bedside for emergency use. The physician orders for "Life-Sustaining Treatment" (POLST) dated 1/11/15, reflected the decisions made by the family as the legal decision makers, for, "Cardiopulmonary Resuscitation (CPR) and Full Treatment," which means staff were to provide manual heart compressions if Resident 1's heart stopped and prolong life by all medically effective means. In a telephone interview on 2/3/15 at 10:25 p.m., Resident 1's son stated that he received a phone call from RN 1, between 10 and 10:18 a.m., on 1/18/15, who told him his mother was having trouble breathing and had a fever. He asked RN 1 if she (Resident 1) had a stroke, and RN 1 told him, "No, but the doctor had ordered some tests." The son stated that he told RN 1 that his mother should be in a hospital, and RN 1 told him that they could take care of his mother there in the facility. He stated that an hour or two later he received a call from the doctor (MD) and he asked the MD why his mother was not in the hospital. When Resident 1's son arrived at the facility, he saw his mother was lying in the bed with one eye open, and one eye closed and the tubing was hooked up. He thought she was still alive, but she was dead. He stated that he was very upset that his mother was not sent to the hospital. During an interview on 1/18/15, RN 2 stated she was in charge of Resident 1 on 1/18/15 and during an interview on 2/4/15 at 1:30 p.m., RN 2 stated she did her first rounds at 6 a.m., on 1/18/15, and noted Resident 1 was having rapid breathing so she notified the respiratory therapist.RN 2 said Resident 1's breathing was labored by 10 a.m. she was sweating. RN 2 told RN 1 to call MD (the physician. RN 2's nurse's note written on 1/18/15 contained the following entries: At "6 a.m., Resident 1 had increased anxiety and mild shortness of breath. Her vital signs were, BP 157/85, (normal range 90-140 (systolic) over 60-90 (diastolic)), temperature 98.6 degrees Fahrenheit (without fever), pulse 100 beats per minute (normal rate 60 to 100 beats per minute), respirations 18 breaths per minute (normal 12 - 20 breaths per minute), blood oxygen saturation was 100 percent. At "7 a.m., Resident 1's trach was suctioned with a minimum amount of pale yellowish secretions and her oxygen saturation ranged from 97 to 100 percent." At "10 a.m., Resident 1 had labored breathing and the respiratory therapist (RT) was at the bedside. The nursing supervisor (RN 1) called the resident's physician, (MD) who said he was coming to the facility. RT placed the resident on a mechanical ventilator (a machine that generates a controlled flow of gas into the patient's airways) and administered the Duoneb nebulizer treatment via the tracheostomy. The oxygen saturation was 97-100 percent. The resident (1) was noted with diaphoresis (sweating) and her blood sugar at the finger was elevated at 315 milligrams per deciliter (mg/dl) (normal 60-100 mg/dl)."At "11:30 a.m., MD ordered a transfer to the acute hospital and the resident had, "Very weak palpable pulse on both wrist, by RN 1 and RT; despite all treatments administered and given and (she) even was placed on (mechanical ventilator), pt. (Resident 1) continues to have SOB (shortness of breath); RT started bagging (ambu bag) on portable tank with O2 (oxygen); RN 1 called 911...911 paramedics..here and take over." At "12:39 p.m., Pronounced dead by MD with 911 paramedics..."During an interview in the facility on 2/3/15 at 3 p.m., the RT stated that he started Resident 1 on mechanical ventilation and was with RN 2. He stated that RN 1 called MD and he wasn't sure which of the nurses, RN 1 or RN 2 said, "Put on mechanical ventilation per MD's orders; but he didn't see the written order. He agreed that he did not write progress notes in Resident 1's medical record, but provided a notebook containing a diary of notes regarding several residents titled "Weekly Notes" where he documented on Resident 1. According to RT's "Weekly Notes," on 1/18/15 there was an entry for Resident 1 at 9:15 a.m., that he gave a Duoneb treatment for shortness of breath, and "bagged" her, on and off, for 20 minutes. The entry further showed that Resident 1's heart rate was 109 beats per minute, and her respiration rate was 28 breaths per minute. The heart rate and respiration rates were both elevated above normal.In a telephone interview on 2/4/15 at 11:30 a.m., RN 1 stated that on that day (1/18/15) she called MD and he gave an order for mechanical ventilation, but RN 1 stated that she did not write it down, MD was "on his way."RN 1 stated that between 10 and 11 a.m., the vital sign equipment was not registering a blood pressure and she could not find a large enough blood pressure cuff needed to take Resident 1's blood pressure manually. She stated that Resident 1 had a pulse, but it was not documented in the medical record. RN 1 stated that she did not think that she needed to call 911 because MD was coming to the facility and, "We were working on trying to get a blood pressure."In a telephone interview on 2/4/15 at 10:15 a.m., the MD stated that he received a call from RN 1 on 1/18/15, that Resident 1 was having difficulty breathing. He told her he was going to finish rounds and then come to the facility. He did not recall giving a telephone order for mechanical ventilation or what the settings would be, he stated, "RT knows the standard settings." He did not recall telling the nurse to keep Resident 1 in the facility until he arrived as opposed to calling 911, because that would be "inappropriate." He further stated that the, "Nurses are competent. They should know there is no demand that they must keep her (Resident 1) there (at the facility)." MD wrote a progress note on 1/18/15, timed from 11:30 a.m. - 1 p.m., that showed Resident 1 had a decreased level of consciousness with stable vital signs at 11:30 a.m., but had no response and had to be ventilated. (MD's) discussion with family led to a decision to transfer to the hospital and 911 was called, but Resident 1's heart stopped beating and aggressive cardiopulmonary resuscitation was started. Called family, (they were) upset. Likely diagnosis was extended cardiovascular accident (stroke) or cardiac arrest (heart attack) with a rapid deteriorating course. The Nurse Manager (RN 3) of the Subacute Unit where Resident 1 was receiving care, stated in an interview on 2/3/15 at 3:10 p.m., that there were no written orders from the physician (MD) for mechanical ventilation or for what the settings should be, and that RN 1 did not write any progress notes. RN 3 stated that she would have called 911 when it became apparent that the ventilator and breathing treatments didn't have an impact. She also said she would send a resident out to the hospital at the request of the family. A review of the facility's policy and procedure for, "Change of Condition Notification" dated 1/1/12, showed that, "...In emergency situations ...the Licensed Nurse will: Call the Attending Physician STAT;...If the resident deteriorates, the symptoms are serious ...call 911 for transport to hospital..."A review of the facility's undated policy and procedure titled "Reporting Abuse to Administrator", which the Administrator provided on 2/24/15 at 2:30 p.m., showed the, "Purpose (was) To protect residents from...neglect...by ensuring that all Facility personnel...report any incident or suspected incident of resident neglect...to the Administrator." Under the heading of "Definitions, "Neglect is described as, "...Failure to provide medical care for physical and mental health needs..."Therefore the facility failed to provide emergency care according to their policy by failing to call 911 to have Resident 1 transferred to the hospital when Resident 1 had a change of condition.The above violation has a direct relationship to the health, safety or security of patients. |
| 140000003 |
Antioch Convalescent Hospital |
020011841 |
B |
16-Nov-15 |
WLO612 |
3777 |
483.25(h) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.The facility is in violation of the above regulation by failing to prevent Resident 1 from falling off the toilet and sustaining a fractured nose on 7/2/15. Record review showed Resident 1 was an 85 year-old, admitted on 6/25/15 with diagnoses including Alzheimer's disease, visual disturbance, chronic low back pain, unsteady gait and arthritis of both knees. Resident 1 had a history of falls and the "Minimum Data Set Assessment" (evaluation tool used to guide care), dated 7/16/15, showed Resident 1 had moderately impaired vision, considerable impairment in mental ability and was unsteady when moving from a seated to standing position. Review of the "Alas Fall Risk Evaluation", dated 6/25/15, showed a score of 18. A score of 10 or more indicated High Risk for falls. The Care Plan intervention for prevention of falls was, "Proper footwear for ambulation (walking or moving). Routinely assist the resident with toileting as needed." In a telephone interview on 7/16/15 at 8:43 a.m., CNA 1 stated she assisted Resident 1 to the toilet on 7/2/15. CNA 1 stated she sat Resident 1 on the toilet and left her to get the clothing. CNA 1 stated she heard the toilet seat move from outside the bathroom and proceeded to check what had happened and found Resident 1 on the floor, face down with blood coming from her nose. CNA 1 stated she was supposed to be with Resident 1 at all times and should not have turned her back on Resident 1 while she was on the toilet In an interview on 7/16/15 at 9:07 a.m., Registered Nurse (RN) 1 stated Resident 1's nose was bleeding and was not aligned after Resident 1 fell on 7/2/15. RN 1 confirmed Resident 1 should not have been left alone in the bathroom when using the toilet.In a telephone interview on 7/20/15 at 11:38 a.m., Licensed Vocational Nurse (LVN 1) stated she was on duty on 7/2/15, when Resident 1 fell. LVN 1 stated Resident 1 had problems with vision, did not have a steady gait and should not have been left alone on the toilet. LVN 1 stated Resident 1 did not have non-slip socks at the time of the fall and should have had non-slip socks on.In an interview on 7/16/15 at 10:35 a.m., the Director of Staff Development (DSD) stated CNA 1 should have had all the supplies gathered and ready for Resident 1, without having to leave her on the toilet without supervision.In an observation and concurrent interview on 7/16/15 at 10:55 a.m., Resident 1's closet was located in an area next to Resident 1's bathroom. When asked if CNA 2 could see into Resident 1's bathroom when she went to Resident 1's closet area, CNA 2 confirmed she could not see into the bathroom from that position. CNA 2 stated Resident 1 had pain and weakness in the right knee. CNA 2 further stated Resident 1 needed constant attention when she went to the bathroom, because she might get up quickly.In an interview on 7/16/15 at 11:15 a.m., the Director of Nursing (DON) stated CNA 1 should have never left Resident 1 in the bathroom alone, and Resident 1's fall was preventable.Review of Resident 1's x-ray report, dated 7/2/15, showed, "Multiple views of the nasal bone demonstrate fracture of nasal ridge with depression. There is associated soft tissue swelling." Therefore the facility is in violation of the above regulation by failing to ensure CNA 1 stayed with Resident 1 while she was on the toilet, resulting in Resident 1 falling off the toilet and sustaining a fractured nose on 7/2/15. The above violations had a direct relationship to the health, safety, or security of patients. |
| 140000574 |
Alhambra Convalescent Hospital |
020011913 |
B |
31-May-16 |
Q1NH12 |
5384 |
483.25(h) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICESThe facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.The facility violated the aforementioned regulation by failing to ensure Resident 1's safety when turning and repositioning the resident in bed, resulting in Resident 1 falling off the bed on 2/8/15 and sustaining a head injury leading to hospitalization for 3 days.Review of the admission record showed that Resident 1 was admitted to the facility on 9/4/14 with multiple diagnoses that included paraplegia (inability to move the lower part of the body). Review of the narrative notes, dated 2/8/15, showed Resident 1 fell off her bed when Certified Nursing Assistant (CNA) 1 repositioned her to provide incontinent care (care for lack control of bladder or bowel). Resident 1 was transferred to the emergency room and was diagnosed with a subdural hematoma (bleeding in the brain) and hospitalized until 2/11/15. Review of Resident 1's Minimum Data Set Assessment (MDS, an assessment tool used to direct resident care), dated 2/3/15, showed Resident 1 needed staff assistance with turning and repositioning when in bed and was totally dependent on staff assistance for toileting (how one uses toilet room, commode, cleanses self after elimination, changes pad, or adjusts clothes).In an interview on 2/17/15 at 2:18 p.m., Certified Nursing Assistant (CNA) 1 stated he provided incontinent care for Resident 1 on 2/8/15 at 8:45 p.m., CNA said he stood at the left side of Resident 1's bed while he changed the bed linen because it was wet. CNA 1 stated that when it was time to change the linen on the right side of the bed, he rolled Resident 1 to face the other direction, away from him to her right side. CNA 1 explained there were no bed rails attached to any part of the bed that Resident 1 could hold on to or to prevent her from falling off the bed. CNA 1 stated that he held Resident 1 on her left shoulder with one hand but when he needed to tuck the sheet under Resident 1, he had to release his hold of Resident 1's left shoulder so he could roll the linen with both hands. CNA 1 said that Resident 1 was not positioned at the center of the mattress, rather "was closer to the right edge of the bed". Resident 1 rolled over and fell off the bed. CNA 1 explained that at the time, Resident 1 was "irritated and moving a lot" and that he would have asked help from other CNAs but at that particular time, there was nobody to help him. Review of the narrative notes dated 2/8/15 showed that Resident 1 sustained laceration and swelling on the back of her head and an open wound on her right middle finger and that Resident 1 complained of pain following the fall. Resident 1 had to be transferred to the hospital. Review of the Hospital Emergency Department Provider Notes dated 2/8/15, showed a Computerized Tomography scan (CT scan, a procedure that combines a series of x-ray images from different angles and uses computer processing to create images of bones, blood vessels and soft tissues inside the body) was performed on 2/8/15 at 1:59 p.m. and showed a small acute subdural hematoma (pool of blood between the brain and its outer covering) because of the head injury that Resident 1 sustained from the fall. In an interview on 2/17/15 at 1 p.m., the Director of Staff Development (DSD) stated she talked to CNA 1 after the incident and CNA 1 told her that he may have positioned Resident 1 too close to the edge of the bed rather than at the center. DSD explained that when a staff turns a resident while in bed, staff had to turn the resident towards them and not away from where the staff is positioned. DSD said that one should ask for help if they feel that they could not do the task by themselves.In an interview on 2/17/15 at 3:05 p.m., CNA 2, who has worked with Resident 1, said that she always provided incontinent care to Resident 1 with help from another CNA because Resident 1 could not help with turning to her sides.In an interview on 2/17/15 at 2:50 p.m., Administrator (Adm) said the facility did not have a policy and procedure for provision of incontinent care to totally dependent residents. According to American Healthcare Association:-"When moving a resident to the side of the bed (when the resident is unable to help), "stand on the side to which you plan to move the resident, slide both your hands under the resident's head, neck, and shoulders and glide them toward you on your arms, slide your arms under the resident's hips and glide them toward you. When turning a resident from supine (lying on back) to side-lying for personal care, help the resident bend their knees up one at a time and place their feet flat on the bed, place one hand on the resident's shoulder farther away from you and the other hand on the hip farther from you, on the count of 3, help the resident roll toward you and continue personal care."[Reference:http://www.ahcancal.org/quality_improvement/howtobe/Documents/Chapter15.pdf]. Therefore the facility failed to ensure Resident 1 was turned and repositioned in bed safely on 2/8/15 resulting in Resident 1 falling off the bed and sustaining a subdural hematoma. The above violation has a direct relationship to the health, safety or security of patients. |
| 020000043 |
Alameda Healthcare & Wellness Center |
020012394 |
B |
24-Aug-16 |
IID511 |
4543 |
F309-Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility violated the aforementioned regulation by failing to ensure Resident 1 was provided the necessary foot care and services to maintain the highest physical well being. The facility did not provide podiatrist care for Resident 1 until after her toenails had grown to a length which caused the nails to circle and grow into the bottom of her feet. Resident 1 suffered unnecessary pain, and a decline in her ability to walk. On 4/4/16 at 10:40 a.m. Resident 1's record was reviewed at the facility. According to the face sheet Resident 1 was admitted to the facility on 10/14/15 with multiple diagnoses including diabetes and heart attack. Review of the nurses progress notes dated 3/18/16 reflected, "Resident transferred via w/c (wheelchair) to physical therapy at 9 a.m. Complained of pain on (R)(right) and (L)(left) feet. Assessed feet and noticed overgrown toenails extending to the rear of foot. Notified MD (medical doctor). 10:00 a.m. Resident sent to the acute hospital emergency room." Review of the Interdisciplinary Team Conference Record, dated 10/20/15, documented Resident 1 had requested to see a podiatrist (foot doctor). The record review revealed there was no physician's order for Resident 1 see a Podiatrist until 3/18/16. During an interview on 4/4/16 at 12:35 p.m., Resident 1 stated she had not seen a podiatrist since her request was made in October and no one had looked at her feet, "Until March." Resident 1 stated she had been in a lot of pain and kept telling the staff and, "No one did anything." During an interview on 4/4/16 at 10:10 a.m., with the LVN (Licensed Vocational Nurse) she stated Resident 1 had gone to Physical Therapy on 3/18/16, and the PT (Physical Therapist) came to her and said Resident 1 was in pain. LVN 1 stated she and the PT removed Resident 1's socks and found all of her toenails to be, "Extremely long, the toenails had been growing for so long that they were, the shape of the nails, curled around and wrapping (curled under) her feet." During an interview on 4/5/16 at 11:37 a.m., with Resident 1's Primary Physician, he said he had been at the facility on 3/18/16 when he was asked by staff to look at Resident 1's feet. The Primary Physician said Resident 1 had trouble standing because her nails were digging into her toes it was, "Bad, "and the Primary Physician had asked the charge nurse to call the Podiatrist for an appointment. Resident 1's Primary Physician said he wanted Resident 1 to be seen, "Urgently." The charge nurse said the podiatrist could see Resident 1 in, "A couple of weeks." The Primary Physician stated he did not think it was appropriate to wait that long and directed staff to send Resident 1 to the Emergency Department at the local hospital. Review of the acute hospital's Emergency Department Note dated 3/18/16 at 4:59 PM documented, "Presents to ED (Emergency Department) with complaint of foot problem. The main reason of her pain that her nails are long and curled over taking into the toes of her feet. She has no other complaints other than that she cannot do her physical therapy due to the pain related to this which is moderate in severity and with weightbearing/ambulation." During a telephone interview with the Director of Nurses on 4/14/16 at 2:53 p.m. she said, Resident 1 was able to walk 200 feet in November, 2015. She is now back in therapy and is walking two steps. During a telephone interview with C.N.A. (Certified Nursing Assistant) 4 on 4/20/16 at 11:10 a.m. he said, "I reported her (Resident 1) toenails to my charge nurse. I can't remember when I reported it to her." During a telephone interview with the charge nurse on 4/20/16 at 11:25 a.m. she said, "I didn't see her toes. No one reported to me about her toenails." Review of the facility's toenail care policy and procedure last revised 1/1/12 documented, "Nail care is given to clean the nail bed and keep the nails trimmed. Fingernails are trimmed by Certified Nursing Assistance, except diabetic residents or residents with circulatory impairments including all toenails except for high risk residents. (Note: a Licensed Nurse will trim those residents)." Therefore the facility failed to ensure Resident 1 was provided the necessary foot care and services to maintain the highest physical well-being. |
| 020000043 |
Alameda Healthcare & Wellness Center |
020012796 |
B |
8-Dec-16 |
PNZM11 |
6641 |
483.13(c) (1) (i) 483.13(c) DEVELOP/IMPLMENT ABUSE/NEGLECT, ETC POLICIES The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The facility violated the aforementioned regulation by failing to implement their abuse policies and procedures to: 1. Immediately remove from the care of the resident and suspend a staff member accused of physical abuse. 2. Immediately notify the Director of Nursing and the Administrator In a review of the clinical record on 10/17/16 showed Resident 1 was an elderly resident admitted on xxxxxxx with diagnoses that included cerebral vascular accident (stroke) and hemiplegia (paralysis on one side of the body). Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 9/17/16, showed Resident 1 required extensive assistance from the facility in bed mobility and transfers. The MDS also showed Resident 1 was cognitively intact (had the ability to think, reason, or remember clearly). During an observation and concurrent interview on 10/17/16 at 10:40 a.m., Resident 1 said on 10/6/16 at 4:45 a.m., she was in her bed and felt pain in her back. She wanted to get up and into her wheel chair where she felt she would be more comfortable. Resident 1 pushed her call light and CNA 1 entered her room. Resident 1 said she was sitting up in bed and CNA 1, "pushed," her down and then left the room. Resident 1 said she speaks a little English but was able to point at, and say the word, "wheel chair," to CNA 1. Resident 1 said she rang her call light a second time. Resident 1 said CNA 1 returned to her room and "hit" Resident 1 in the head. Resident 1 demonstrated how CNA 1 assisted her to the wheelchair. Resident 1 showed that CNA 1 grabbed her shirt sleeve in a rough manner to get her into the wheel chair. Resident 1 said CNA 1 did not take her hand or lift my arm to assist like they (CNAs) usually do. Resident 1 continued and said after CNA 1 hit her (Resident 1) she was "scared" and her "heart was racing." Resident 1 also said she was so scared she could not scream for help, so she banged her back scratcher on the bedside table in order to get the attention of other staff. Resident 1 said she wanted to tell other staff that this person (CNA 1) hurt her. Resident 1 further said when the charge nurse (LVN 1) entered the room and talked to her, she (Resident 1) could not understand what LVN 1 said. Resident 1 said she felt unable to verbally tell LVN 1 that CNA 1 hit her. Resident 1 said she tried to show LVN 1 that CNA 1 hit her by pointing to CNA 1 and then moving her (Resident 1's) fist against her forehead. In a telephone interview on 10/17/16 at 1:05 p.m., LVN 1 said on 10/6/16 between 4:30 and 5:00 a.m., Resident 1 told her CNA 1 had hit her in the head. LVN 1 stated she did not investigate, report the incident to the administrator or the director of nursing, call an interpreter, or send CNA 1 home at that time. In an interview on 10/17/16 at 10:00 a.m., LVN 2 said on 10/6/16, as she began her day shift, the night nurse (LVN 1) reported to her that CNA 1 hit Resident 1. LVN 2 said she went to check on Resident 1 and discovered a purplish discoloration on Resident 1's forehead. Resident 1 complained of pain, pointed to her forehead, and indicated that a staff member hit her. In an interview at 11:30 a.m., the Activities Assistant (AA) said she spoke to Resident 1 in her native language on 10/6/16 at approximately 8:30 a.m. The AA said Resident 1 had tears in her eyes when Resident 1 told her what happened (with CNA 1). The AA said Resident 1 told her that on 10/6/16 between 4:30-5:00 a.m., Resident 1 pushed her call light to call for CNA 1 to help her get up. The AA said Resident 1 also told her the first time CNA 1 went into the room, CNA 1 "slammed" Resident 1 back onto the bed "very hard" and told Resident 1 it was too early to get up. The AA said Resident 1 said she pushed her call light a second time and CNA 1 came into her room and punched her on the left side of her forehead and then left the room. The AA continued and said Resident 1 banged her backscratcher on the side table in order to get the staffs' attention. The AA said ever since the incident on 10/6/16, whenever Resident 1 sees her (AA) she (Resident 1) holds her hands and Resident 1 "Won't let me go." The AA said Resident 1 shakes and asks her to stay with her. In an interview on 10/17/16 at 12:00 p.m., the Administrator (ADM) said she was not notified that CNA 1 hit Resident 1 until 10:00 a.m. on 10/6/16. The ADM said CNA 1 worked with residents in the facility and finished her shift because she (the ADM) had not been told what had happened until 10:00 a.m. The ADM stated CNA 1 was suspended and then resigned from her position at the facility. In an interview at 12:30 p.m., the Director of Nursing, (DON) said when a resident communicates to staff that another staff person hit them, staff was to first assess the resident and notify the administrator. The DON stated Resident 1 was alert and oriented. The DON stated staff should have called for an interpreter and sent CNA 1 home right away. Review of the facility's policy and procedure titled, "Abuse-Reporting and Investigations", dated 11/18/15, showed the administrator or designee "will provide for a safe environment for the resident as indicated by the situation ...If the suspected perpetrator is an employee, remove the employee immediately from the care of the resident and immediately suspend the employee pending the outcome of the investigation in accordance with facilities (sic) policy." Review of the facility's policy and procedure titled, Alleged Abuse Investigation Checklist, dated 11/13/15, showed staff are expected to take the following steps when investigating alleged abuse: "Initiate investigation, suspend accused staff immediately, perform physical, psycho-social and mental assessment, notify attending physician, notify responsible party, notify administrator, notify the Director of Nursing, and initiate incident/accident reports." Therefore, facility failed to implement their abuse policies and procedures to: 1. Immediately remove from the care of the resident and suspend a staff member accused of physical abuse. 2. Immediately notify the Director of Nursing and the Administrator These violations had a direct relationship to the health, safety, or security of residents. |
| 100000089 |
Applewood Care Center |
030009001 |
B |
15-Feb-12 |
YEXM11 |
1453 |
Health & Safety Code 1418.91 a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. On 5/28/09 the Department made an unannounced visit to the facility to investigate two (2) Entity Reported Incidents numbers CA00179602 & CA00179611. The Department determined that the facility failed to report two alleged or suspected abuse incidents to the Department within 24 hours. On 3/2/09 the Department received a faxed report from the facility indicating that on 2/23/09 at 10:00 a.m. Patient B attempted to move Patient A's wheelchair. When Patient A turned to look at Patient B, Patient B then struck Patient A in the face. There was no documentation that this incident was reported to the Department until 3/2/09 at 3:28 p.m. Attached to the reporting fax was a facility follow-up investigation dated 2/27/09. Also received on 3/2/09 was a faxed report from the facility noting that on 2/24/09 Patient A struck Patient D on the side of the face without apparent provocation. A facility follow-up investigation was dated 2/26/09 and a handwritten date on the facility fax coversheet was 2/27/09. This fax was logged as received by the Department on 3/2/09 at 3:50 p.m.Failure to comply with this requirement shall be a class "B" citation. |
| 030000280 |
Auburn Oaks Care Center |
030009032 |
B |
27-Feb-12 |
D9SI11 |
6408 |
72315 Nursing Service - Patient Care (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. An unannounced visit was made to the facility on 12/10/09 to investigate complaints #CA00209698 and #CA00208673. Based on interviews and record reviews the facility failed to: 1) Ensure Patient A was free from physical abuse when Certified Nursing Assistant (CNA) 1 wrapped Patient A's call light cord around his hand several times and pulled it tightly.This failure resulted in Patient A being physically abused by CNA 1 causing Patient A pain.Patient A's clinical record was reviewed on 12/10/09 and his diagnosis included orthopedic aftercare, below knee amputation, hypertension, osteoarthrosis (a progressive degenerative joint disease, the most common form of arthritis), diabetes mellitus and acute kidney failure (an abrupt or rapid decline in renal filtration function). Patient A's Significant Change MDS (Minimum Data Set-an assessment tool), dated 9/21/09, documented Patient A as having no short or long term memory problems, modified independent cognitive skills for daily decision making, able to make himself understood and able to understand others. The MDS also documented Patient A as being dependent upon staff for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, personal hygiene and bathing and as being independent with eating. Review of the facility's investigation report, contained a written statement by CNA 2 with no date. CNA 2 documented that on 11/14/09, CNA 1 approached her several times to ask if she could help her find someone to work her p.m. shift (3:00 p.m.-11:00 p.m.). At 3:30 p.m., on 11/14/09, CNA 1 told CNA 2 that she couldn't work the whole p.m. shift. CNA 1 stated that she was "so tired" and didn't think she could work over 12 hours. CNA 1 stated that she was "tired and overwhelmed" from her workload. CNA 2 told CNA 1 she would start looking for a replacement for her. CNA 2 documented she reported to the charge nurse how CNA 1 was feeling and that CNA 1 wanted to go home early. A replacement was found for CNA 1 around 7:30 p.m. on 11/14/09.CNA 2 was interviewed on 12/10/09 at 9:48 a.m. She confirmed that the facility investigation report accurately depicted her account, as reflected. CNA 2 stated when CNA 1 left that evening she appeared "really agitated." The facility's investigation report contained a written statement by CNA 3 dated 11/16/09. According to CNA 3's statement, while giving care to Patient A, the patient mentioned that CNA 1 wrapped his hands together with the call light cord and yanked on it hard. Patient A stated that "she (CNA 1) hurt him." CNA 3 stated she examined Patient A's hands and observed "bruising and a red mark on both hands." CNA 3 stated she documented her findings on Patient A's ADL (Activities of Daily Living) sheet and reported the alleged incident to Licensed Vocational Nurse (LVN) 1.The facility's investigation report contained a written statement by LVN 1, dated 11/16/09. LVN 1 stated that CNA 3 reported to her that Patient A was abused by CNA 1. LVN1 told CNA 3 to document what she observed on the back of the ADL sheet. LVN 1 stated she reported the alleged incident to the oncoming a.m. shift. The facility's investigation report contained a statement, dated 11/16/09, that documented that the Administrator and Director of Nursing (DON) also had interviewed Patient A. Patient A "stated that an employee had wrapped the call light cord around his left hand and proceeded to tighten the cord." The statement also documented that the Administrator and the DON observed bruising on the inside of Patient A's left hand with a small spot of bruising on the back of his hand.Review of Patient A's Nurse's Notes, dated 11/15/09, documented that both the night nurse, LVN 1, and the oncoming a.m. nurse, LVN 2, interviewed Patient A regarding the alleged incident. Patient A stated that CNA 1 "tied the cord around my hands pulling it tight five times and then she gritted her teeth saying, here is your call light" and then left the room. A Nurse's Notes, dated 11/15/09 at 12:10 p.m., documented "small bruising" was noted to Patient A's left hand.LVN 1 was interviewed on 12/10/09 at 9:40 a.m. LVN 1 stated that CNA 3 came to her and reported to her that Patient A complained that something was wrong with his hands. LVN 1 stated she told CNA 3 to document what she found on the ADL sheet. LVN 1 stated when the a.m. nurse, LVN 2, came in she asked her to accompany her to look at Patient A's hand and talk with him to find out what happened.LVN 2 was interviewed on 12/10/09 at 9:44 a.m. She confirmed she went with LVN 1 to Patient A's room to look at his hand and to find out what happened. She stated Patient A told them that CNA 1 wrapped the call light cord around his hand/wrist and pulled it tight. Patient A's physician was notified and an x-ray was ordered of his left hand. Review of the x-ray results, dated 11/16/09, documented Patient A had mild osteoarthritis and no indication of a dislocation or fracture. Review of a Social Service Progress Note, dated 11/17/09, documented that the Social Service Director (SSD) interviewed Patient A about the alleged incident that happened over the weekend on 11/14/09. Patient A told SSD that his call light had fallen on the floor next to his bed. CNA 1 came into his room, picked up the call light and "wrapped it around his wrist and shook him." Patient A then stated CNA 1 walked out of the room. Patient A further stated to SSD that he didn't know why she did it but "she hurt him." Patient A was interviewed on 12/10/09 at 8:35 a.m. When asked regarding the alleged incident he stated CNA 1 wrapped the call light around his hand and then gestured that CNA 1 yanked on it several times. Patient A then stated that was "all you need to know. You don't need to know anything else." Patient A was asked if CNA 1 hurt him when she did this he replied, "Hurt at time, yes." The Department determined the facility failed to: Ensure Patient A was free from physical abuse when CNA 1 wrapped Patient A's call light around his hand several times and pulled it tightly, resulting in pain and bruising. This violation had a direct or immediate relationship to the health, safety or security of a long-term care facility patient or resident. |
| 100000089 |
Applewood Care Center |
030009263 |
B |
03-May-12 |
YCMX11 |
3841 |
72527 Patients' Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9)To be free from physical and mental abuse. (11) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. The following citation was written as a result of two unannounced visits to investigate a facility reported event, #CA00189866.As a result of the investigation, the Department determined the facility failed to: 1) Ensure Patient A was free from abuse 2) Ensure Patient A was treated with consideration, dignity and respect. Patient A, a 29 year old female, was admitted to the facility on 04/25/09 with diagnoses of closed fracture of vertebra, closed fracture of calcaneous (a large bone of the heel), chronic pain and unspecified personality disorder. In a Minimum Data Set (MDS), an assessment tool, dated 05/07/09, Patient A was noted to be independent in daily decision making with no memory problems. Resident A was frequently incontinent of urine and required limited assistance with personal hygiene. On 05/27/09, Patient A reported to the facility she was left naked and exposed on her bed following a shower approximately two weeks prior.In a review of a Report of Suspected Dependent Adult/Elder Abuse (SOC 341), completed by the Acting Director of Nursing (DON2) and the Administrator on 05/27/09, there was documentation Patient A had reported a staff member left her nude and exposed in her bed after a shower approximately two weeks prior.In a review of a facility Memorandum written by DON2 dated 05/29/09 there was reference to an interview between DON2 and Patient A in which Patient A reported concerns with a Certified Nursing Assistant (CNA1). Patient A stated CNA1 "rushes through my showers". Recently CNA1 left her lying in the bed "butt naked, seeping urine" while she attended to other residents. During that time Patient A stated she called the facility with her cell phone for assistance several times. Patient A stated no one came to her room for 45 minutes. In a review of the facility's Policy and Procedure titled Prevention of Abuse, revised 2/09, the following definitions are noted: a) Mental Abuse includes, but is not limited to humiliation, harassment, threats of punishment or deprivation. b) Neglect: Negligent failure to exercise that degree of care which a reasonable person would exercise, including failure to assist in personal hygiene. The Administrator, in a letter to the Department, written on 05/29/09, stated the investigation had been completed and the allegations of neglect were substantiated. He stated CNA1 admitted to leaving the resident exposed on the bed for an extended period of time after a shower. The Administrator revealed CNA1 also failed to provide Patient A with clean and dry linen when providing incontinent care. In an interview on 07/13/09 at 12:40 p.m., the Director of Nursing (DON1) stated CNA1 had been terminated for neglect on 05/27/09.The Department determined the facility failed to: 1) Ensure Patient A was not subjected to humiliation and deprivation when left naked and exposed on her bed for an extended period of time during a bath while CNA1 attended to other residents. and 2) Ensure Patient A was not subjected to neglect and a loss of dignity when she was not assisted with personal hygiene during a bath The above violations had a direct relationship to the health, safety and security of patients. |
| 100000089 |
Applewood Care Center |
030009264 |
B |
03-May-12 |
X87Z11 |
2863 |
1418.91 Health & Safety Code (a) A long term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately or within 24 hours. (b) Failure to comply with the requirements of this section shall be a Class B Citation. 72523 Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. The following citation was written as a result of two unannounced visits to investigate a facility reported incident of abuse #CA00190259. The Department determined the facility failed to: 1) Follow State Law requirements related to reporting allegations of abuse and2) Follow facility Policies and Procedures for alleged and suspected abuse reporting requirements. On 06/01/09 at 2:46 p.m., the Department received the following documents faxed from the facility regarding allegations of abuse: a) Letter written by the Administrator dated 05/26/09 referencing a Certified Nursing Assistant (CNA1) and an allegation of verbal abuse, no date of incident noted. b) Letter written by the Administrator dated 05/26/09 referencing a Certified Nursing Assistant (CNA2) and an allegation of verbal abuse, no date noted. c) Letter written by the Administrator dated 05/29/09 referencing the Director of Staff Development (DSD) and an allegation of verbal abuse, no date of incident noted.In an interview with the Social Services Director (SSD) on 07/16/09 at 8:25 a.m., she acknowledged she had completed three Reports of Suspected Dependent and Elder Abuse (SOC 341) for the above incidents and had passed them on to the Administrator.(a) The SOC 341 for CNA1's alleged verbal abuse was dated 05/24/09. (b) The SOC 341 for CNA2's alleged verbal abuse was dated 05/21/09. (c) The SOC 341 for the DSD's alleged verbal abuse was dated 05/27/09. The SSD was not aware of the requirements for reporting the incidents of abuse to the Department within 24 hours.In a review of the facility's Prevention of Abuse Policy, revised 02/09, there was the following statement: "All incidents of alleged abuse or suspected abuse will be reported to DPH as soon as practically possible not to exceed 24 hours (AB1731) and the results of the investigation to DPH within 5 working days of the incident". The Acting Administrator, in an interview on 7/16/09 at 8:40 a.m., did not know why there had been a delay in reporting the allegations of abuse. Therefore: The Department determined the facility failed to: 1) Follow State Law requirements related to reporting allegations of abuse and2) Follow facility Policies and Procedures for alleged and suspected abuse reporting requirements. Failure to meet the requirements of the Health & Safety Code 1418.91 shall be a Class B Citation. |
| 100000089 |
Applewood Care Center |
030009265 |
B |
03-May-12 |
Y5S911 |
6115 |
1418.91 Health & Safety Code (a) A long term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately or within 24 hours. (b) Failure to comply with the requirements of this section shall be a Class "B" Citation. 72523 Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are chieved. The following citation was written as a result findings made during the investigation of Complaint # 201109 initiated on 09/16/09. As a result of the investigation, the Department determined the facility failed to: 1. Follow California state law requirements related to reporting allegations of abuse, and 2. Follow facility Policies and Procedures for reporting alleged and suspected abuse. A review of Resident 1's clinical record was initiated on 09/16/09. She was admitted to the facility on 04/25/09 with diagnoses including a lumbar (lower back) spinal fracture accompanied by paraplegia (complete or partial paralysis of both legs), neurogenic bowel and bladder (dysfunction of the bowel and bladder caused by disease or trauma), and a right calcaneus (heel) fracture.The Minimum Data Set (MDS) (an assessment tool) dated 05/07/09, indicated Resident 1 displayed persistent anger "with self and others," and had "conflict(s) with" . . . and verbalized "repeated criticism of staff." Resident 1 also exhibited signs that she was "depressed, sad, or anxious." The MDS noted Resident 1's short term and long term memories were intact and that she was able to independently make decisions related to her daily life.The Resident Assessment Protocols (RAPs) (areas of concern triggered by the MDS to assist with care-planning) described problem areas including psychosocial well-being, mood state, and behavioral symptoms. Care plans for "Mood and Behavior", "Conflict with Staff", and "Psychosocial" were initiated on 04/25/09, and one for "Anxiety" on 06/23/09. CNA 1's undated, hand-written statement was reviewed on 09/23/09. In the statement, CNA 1 recounted two conversations she had with Resident 1 in which Resident 1 described two sexual encounters with facility administrative staff. An unsuccessful attempt was made on 09/17/09 at 11:28 a.m. to contact CNA 1 to validate her statement. Both her home and cell phone numbers had been disconnected and further confirmation of the allegations was not feasible. A transcript of an interview with Resident 1, conducted on 05/28/09 and signed by RN 1, was reviewed on 09/23/09.According to the transcript, Resident 1 denied having a "physical relationship" with administrative staff or telling anyone she'd had a sexual relationship with staff. A phone interview was conducted on 09/17/09 at 11:59 a.m. with Resident 1. When asked about the allegation, Resident 1 stated, "I don't want to deal with it. I don't want to talk about it." Resident 1 then ended the phone call.A transcript of an interview with the former DSD, conducted on 05/28/09 and signed by RN 1, was reviewed on 09/23/09. In the interview, the DSD stated that she had been told of the allegation by CNA 1 on "the morning of" 05/26/09. The DSD called the Corporate President that same day "because she wasn't sure what to do."An interview was conducted on 09/16/09 at 2:20 p.m. with the SSD, who has functioned as the Abuse Coordinator since 02/2009. The SSD stated she learned of the allegation from the DSD but could not remember the date that this occurred. She stated she did not report the allegation to the CDPH or the Ombudsman. During an interview with the SSD on 11/30/09 at 2:20 p.m., the SSD stated "there was no investigation; we didn't know what was going on." She also stated that the DSD had "called headquarters to find out what to do." During an interview on 09/21/09 at 10:52 a.m., RN 1 stated she was asked to investigate the allegation by the facility's Corporate President. She initiated and closed the investigation on 05/28/09. A review of the investigative report dated 09/28/09 disclosed that "it is our conclusion that this allegation (of sexually inappropriate behavior.. .is unfounded."During the interview on 09/21/09 at 10:52 a.m., RN 1 was asked why no report was made to CDPH. She stated there was "no need to report a false accusation." RN 1 was asked if she was familiar with the facility's Abuse Training and Reporting policy and California state laws and regulations related to abuse reporting. She replied she was not.During an interview on 10/14/09 at 9:35, the Ombudsman was asked if a verbal or written report of an allegation of sexual abuse by staff had been made to her; she stated, "No, no one reported the allegation to me." A review of the facility's Abuse Training and Reporting Policy dated August 2002 defines sexual abuse as "sexual harassment, sexual coercion, or sexual assault. Sexual abuse includes sexual battery, such as rape . . . sodomy, oral copulation or penetration with a foreign object." . . . If abuse is suspected, the Administrator and/or Abuse Coordinator must be immediately notified and an investigation initiated. The Abuse Coordinator will notify the (CDPH) that an investigation is in progress within 24 hours of the alleged abuse . . ."Review of in-service records for the former DSD and SSD determined that on 03/04/09 and 03/05/09, the SSD attended an "Abuse Training" in-service and watched a video titled "Your Legal Duty."The lecturer was listed as the former DSD. A review of CNA 1's personnel file disclosed that on 05/01/09 she signed a document stating the following: "I have viewed the film 'Your Legal Duty' and fully understand my responsibility of reporting adult resident abuse. I have also received and (sic) inservice (sic) on what to do and when to do it." The Department determined the facility failed to follow California Law and facility Policies and Procedures regarding alleged and suspected abuse reporting.A violation of Health & Safety Code Section 1418.91 shall result in a Class B Citation. |
| 100000089 |
Applewood Care Center |
030009278 |
B |
03-May-12 |
X87Z11 |
6681 |
72527 Patients' Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To be free from mental and physical abuse.The following citation was written as a result of unannounced visits initiated on 07/13/09 to investigate a facility reported event, #CA00190259. As a result of the investigation, the Department determined the facility failed to: Ensure Patient A's rights were not violated when she was verbally and mentally abused on 05/18/09 and 05/20/09.Patient A, a 29 year old female, was admitted to the facility on 04/25/09 with diagnoses of closed fracture of vertebra, closed fracture of calcaneus (a large bone of the heel), chronic pain and unspecified personality disorder. In a Minimum Data Set (MDS- an assessment tool) dated 05/07/09, Patient A was noted to be independent in daily decision making with no memory problems.In the Social Services Progress Note dated 05/21/09, the Social Services Director (SSD) documented Patient A reported she had been abused by the Charge Nurse (LN {Licensed Nurse} 1) and two nursing assistants (CNA{Certified Nursing Assistant}1 and CNA2) between 1:00 a.m. and 2:00 a.m. on the night shift of 05/20/09.In a review of a facility Grievance/Complaint Report dated 05/21/09, the SSD documented Patient A was standing at the nursing station and CNA1 was sitting at the desk "wrapped in a blanket" at 1:00 a.m. on 05/20/09. When Patient A asked CNA1 for her name, CNA1 said, "why do you want to know my name?" Patient A stated she wanted to know who her CNA was. CNA1 responded "rudely" with a fictitious name and stated "Don't put me in your mess".In a review of a Report of Suspected Dependent Adult/Elder Abuse (SOC 341), dated 05/27/09, the SSD documented the incident of verbal abuse by CNA1 on 05/20/09 at 1:00 a.m. In a review of a facility Grievance/Complaint Report dated 05/22/09, the SSD documented Patient A claimed she went to the nursing station and asked for a medication on 05/20/09 at 1:00 a.m. The nurse tried to hand her the medication and yelled out "Take your medication". Patient A responded she couldn't take it at the nursing station and asked LN1 to come to her room so she could take the pill sitting down. Patient A reported LN1 "tried to force the medication on me in my mouth". She said LN1 followed her to her room and the container with the medication had a bug inside. Patient A stated she took pictures of the bug in the cup with her camera phone. Patient A asked LN1 to give her another pill and Patient A put a mark on that pill so she would know if the nurse had changed it. Patient A went on to state LN1 brought back the same pill in a different cup and she refused to take the pill. Patient A stated the nurse then sent CNA2 into the room with my medication. She sat it on the table and left the room.In a review of a Report of Suspected Dependent Adult/Elder Abuse (SOC 341) dated 05/21/09, the SSD documented LN1 stated she had given a medication to CNA 2 to give to Patient A. In a review of the Licensed Nurse Progress Notes for 05/20/09 at 1:00 a.m., LN1 documented "Patient A walks to nursing station with walker and asks too many questions about her meds". She stated Patient A refused to take her meds at the nursing station and wanted her to bring the meds to her room. At 2:00 a.m., LN1 documented "pt requested meds, pain meds brought to room" and "pt used camera to take picture of the meds".In a review of a facility Grievance/Complaint Report dated 05/26/09, the Administrator documented Patient A reported CNA2 was very rude to her on 5/20/09 between 1:00 a.m. and 2:00 a.m. Patient A stated CNA2 was "screaming at me, what is it that you want from us now? I gave the medication to you. What do you want? You're never satisfied".In a review of a Report of Suspected Dependent Adult/Elder Abuse (SOC 341), dated 05/21/09, the SSD documented the incident of verbal abuse by CNA2 on 05/20/09 at 1:00 a.m. In a review of a Report of Suspected Dependent Adult/Elder Abuse (SOC 341), dated 05/27/09, the Administrator (A1) documented, "Patient reports that staff member was screaming outside the door for the patient to hear her inappropriateness. Making intentional inferences about the patient ".In a review of a Memorandum to the A1 dated 05/29/09, the Acting Director of Nursing (DON2) documented an interview with Patient A that occurred on 05/28/09. Patient A stated the Director of Staff Development (DSD) "screams at her and at the staff ". On 05/18/09, she overheard the DSD comment in the hallway, "If some people hadn't called Dr. ___" (Patient A's physician) "all weekend, some sick patient s could get care ". Patient A felt the comments were intentionally made loud enough for her to overhear and she felt intimidated. Patient A believed the DSD was talking about her as she had called her physician the evening of 05/17/09 to discuss her medications.In review of a documented interview between DON2 and the DSD on 05/28/09, the DSD would not comment on what Patient A had overheard. She did state Patient A's physician was upset because she (the DSD) had given Patient A the physician's phone number. The DSD reported that during a May 2009 Interdisciplinary Team Meeting she had told Patient A she was too "demanding and manipulative".In a review of the facility's Prevention of Abuse Policy, revised 2/09, it stated (in part) "each patient has the right to be free from verbal abuse." In Appendix A of the Prevention of Abuse policy, the following definitions were noted: c) Mental abuse includes humiliation and harassment. d) Verbal abuse is defined as the use of language that willfully includes disparaging and derogatory terms to patients within their hearing distance. The Acting Administrator (AA) confirmed the rude behavior and comments by the LN1, CNA1, CNA2 and the DSD in an interview on 07/16/09 and stated that they "constituted abuse."The Department determined the facility failed to: 1) Ensure Patient A was not subjected to mental abuse due to humiliation and harassment by LN1, CNA1 and CNA2 on the night shift of 05/20/09 2) Ensure Patient A was not subjected to verbal abuse from LN1, CNA1, CNA2 and the DSD on 05/18/09 and 05/20/09. These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 100000042 |
ACACIA PARK NURSING & REHABILITATION CENTER |
030009323 |
B |
25-May-12 |
GOT011 |
3051 |
Health and Safety Code 1418.91 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. The following citation was written as a result of an unannounced investigation of complaint # CA00175485. The complaint was initiated on 09/08/09 with additional on-site visits on 12/30/09, 01/27/10, and 01/29/10 regarding an allegation of physical and verbal abuse that involved Patient A during his stay in the facility. Based on interview and record review, the facility failed to report an allegation of abuse to the Department of Public Health within 24 hours as required. The facility reported the allegation on 01/22/09, which was 41 days after the allegation was made by Patient A to the facility. Patient A was admitted to the facility on 10/28/08. Review of the Admission Minimum Data Set (MDS-assessment and care screening tool) dated 11/04/08 revealed Patient A was independent regarding decisions of daily life. The MDS indicated Patient A was able to make himself understood and was able to understand others. Review of the Resident (Patient) Assessment Protocol (RAP-additional assessment based on problem identification) regarding cognition revealed Patient A " ... recognizes staff ... "Review of "REPORT OF SUSPECTED DEPENDENT ADULT/ELDER ABUSE" (form SOC 341) dated 12/12/08 at 9:45 a.m. revealed Patient A " ... reported the CNA [1] had hurt him during vital signs (cuff too tight) and when [Patient A] complained, CNA [1] swore at [Patient] repeatedly during care." The Report was sent to the Department via fax, but was date-stamped 01/22/09. Review of the facility's investigation of Patient A's allegation (undated) revealed "It appears most likely that CNA [1] did use profanity directed at [Patient A] and will be dismissed from the facility." Review of CNA 1's personnel file revealed a "PROGRESSIVE DISCIPLINE / TERMINATION NOTICE" dated 12/2008, which indicated Patient A reported CNA 1's actions to facility staff on 12/12/08. There was no documented evidence that the facility notified the Department within 24 hours of Patient A's allegation of abuse.Patient A was interviewed on 12/30/09 at 1:05 p.m. regarding the allegation of abuse perpetrated by CNA 1. Patient A stated "... I think he was having a bad day. He said some very bad things ..." The facility's Administrator was interviewed on 1/27/10 at 9:50 a.m. and was asked to provide information regarding the delay in reporting Patient A's allegation of abuse to the Department. The Administrator stated there was no other information or explanation regarding the delay in reporting the allegation to the Department. Therefore, the facility failed to report an allegation of abuse to the Department of Public Health within 24 hours as required. Failure to comply with the requirements of Health and Safety Code Section 1418.91 shall be a class B citation. |
| 100000042 |
ACACIA PARK NURSING & REHABILITATION CENTER |
030009324 |
B |
25-May-12 |
GOT011 |
2418 |
72527. Patients' Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To be free from mental and physical abuse.Based on interview, record review and facility document review, the facility failed to ensure Patient A was not subjected to mistreatment by a Certified Nurse's Aide during care, which included rough handling during vital sign measurement and verbal abuse in response to Patient A's complaints. Patient A was admitted to the facility on 10/28/08. Review of the Admission Minimum Data Set (MDS-assessment and care screening tool) dated 11/04/08 revealed Patient A was independent regarding decisions of daily life. The MDS indicated Patient A was able to make himself understood and was able to understand others. Review of the Resident (Patient) Assessment Protocol (RAP-additional assessment based on problem identification) regarding cognition indicated Patient A " ... recognizes staff ... " Review of "REPORT OF SUSPECTED DEPENDENT ADULT/ELDER ABUSE" dated 12/12/08 at 9:45 a.m. revealed Patient A " ... reported the CNA [Certified Nurse's Aide 1] had hurt him during vital signs (cuff too tight) and when [Patient A] complained CNA swore at the [Patient] repeatedly during care." Review of the facility's investigation of Patient A's allegation revealed "It appears most likely that CNA [1] did use profanity directed at [Patient A] and will be dismissed from the facility." Patient A was interviewed on 12/30/09 at 1:05 p.m. regarding the allegation of abuse perpetrated by CNA 1. Patient A stated " ... I think he was having a bad day. He said some very bad things ... all just talk." Patient A denied any physical abuse or ill-effects related to CNA 1's treatment. The facility failed to ensure Patient A was not subjected to mistreatment by CNA 1 during care, which included rough handling during vital sign measurement and verbal abuse in response to Patient A's complaints. These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 100000025 |
Arden Post Acute Rehab |
030009332 |
B |
25-May-12 |
X86V11 |
11750 |
F323 - Free Of Accident Hazards/supervision/devices - CFR 42 483.25 (h) The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. F465 - Safe/functional/sanitary/comfortable Environment - 42 CFR 483.70 (h) The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. The following citation was written as a result of an unannounced monitoring visit. The monitoring visit was initiated on 9/16/10 with an additional on-site visit on 10/5/10. Based on observation, interview, and clinical record review, the Department determined the facility failed to: 1. Ensure Resident A received adequate supervision, physician-ordered and care planned devices to prevent accidents and minimize risk of injury. 2. Ensure wheelchairs used by residents were maintained to be safe, sanitary and comfortable.These failures resulted in Resident A sustaining a laceration to his leg during an unassisted transfer from bed to wheelchair, which required transfer to the General Acute Care Hospital emergency department for treatment. Resident A was originally admitted to the facility on 1/12/10 with diagnoses that included difficulty in walking. The Admission Minimum Data Set (MDS-assessment and care screening tool) dated 1/29/10 indicated Resident A's cognitive skills for daily decision making were independent, but that he required extensive assistance with transferring and locomotion. The MDS also indicated Resident A had fallen during the previous 30 days. The Resident Assessment Protocol (RAP- additional assessment based on problem identification) regarding falls indicated Resident A had fallen at home prior to admission to the facility, was at moderate risk for falls, and did not require further intervention "except star on door."A "CHANGE IN CONDITION REPORT - POST FALL/TRAUMA" dated 3/16/10 at 12:50 a.m. indicated Resident A was "found on the floor ... transferred to [emergency room]." Resident A was re-admitted to the facility on 3/18/10 with diagnoses that included subdural hematoma, subarachnoid hemorrhage (bleeding within the head) and muscle weakness. The facility developed a care plan regarding falls dated 3/18/10 with a goal to minimize risk. The care plan approaches included landing strip (impact-absorbing protection pad) and pressure tab alarm (a pressure sensitive pad that is connected to an audible alarm that alerts care givers when resident gets out of a chair or bed) in bed and wheelchair. Physician's orders dated 3/20/10 indicated Resident A was to have a pressure tab alarm in place when in bed or in wheelchair and a landing strip at beside. Nurse's notes dated 9/12/10 at 7 p.m. indicated Resident A " ... at [2:45 p.m.][Resident] put his call light on. When [Certified Nurses Aide] went into his room and found him in his [wheelchair][with] his [left] leg bleeding ... When asked what happened, the [Resident] replied that he hurt himself on the [wheelchair] when he was trying to transfer on his own from the [wheelchair] to bed ... sent to [General Acute Care Hospital] ... Laceration was deep and probably needs sutures." The "EMERGENCY PHYSICIAN RECORD" dated 9/12/10 indicated Resident A had an 8 centimeter (approximately 3 inches) laceration to the front of his left lower leg. The record indicated Resident A's injury was repaired with sutures.Resident A returned to the facility following repair of his left leg laceration. The facility developed a care plan regarding falls for Resident A on 9/12/10.The care plan concern was listed as "Actual/current fall." The goal was to minimize risk. The care plan did not include the previous approaches of alarms and landing strip. Review of physician orders for the month of September, 2010 revealed alarms and landing strip continued to be a current order for Resident A. Review of medication records dated August, 2010 and September, 2010 revealed orders for pressure tab alarm in place when in bed or up in wheelchair and landing strip at bedside. The orders were "INFO ONLY." There was no documentation of acknowledgement (e.g., nurse initials or signatures to increase accountability) by licensed nursing staff to ensure the devices were actually in place for Resident A. Resident A was observed in his room on 9/16/10 at 11:30 a.m. Resident A was seated in a wheelchair at his bedside. There were no alarms in place on his bed or wheelchair. There was no landing strip at the bedside. Resident A was interviewed at the time and stated he cut his leg when he transferred himself from his bed to the wheelchair. Resident A stated he cut his leg on the sharp metal edge of the wheelchair. Observation of the wheelchair revealed the front part of the wheelchair frame, at the top, had exposed sharp edges on both sides that had been covered with pieces of foam rubber approximately 2 inches thick and 4-5 inches square. The foam rubber was attached to the wheelchair frame with a zip-tie at one end, leaving the front part free. The foam rubber was not covered with a material that would allow cleaning. Certified Nurse's Aide (CNA) 1 was interviewed on 9/16/10 at 11:40 a.m. CNA 1 stated she was caring for Resident A while the assigned CNA was on a break. CNA 1 was asked about alarms and landing strip for Resident A. CNA 1 stated she was not aware that Resident A needed alarms. CNA 1 searched Resident A's room and found an alarm device in a drawer, but there were no pads or wires with which to attach the alarms. CNA 1 then stated she was "new"; CNA 1 stated she had been working in the facility for "two months." CNA 1 was asked what methods were used by the facility to ensure CNAs were kept informed about the needs of residents. CNA 1 stated she received information from the "nurse in the morning." CNA 1 was asked if there was any procedure in place, such as posting, to alert staff of resident needs. CNA 1 stated she was not aware of any posted information and had not received any training on any other ways to determine needs of residents. Licensed Nurse (LN) 1 was interviewed on 9/16/10 at 11:50 a.m. regarding safety devices for Resident A. LN 1 stated she was the nurse assigned to Resident A. LN 1 stated she was not aware that Resident A needed alarms or landing strip. Resident A's medication record, which included information regarding alarms and landing strip, was reviewed with LN 1. LN 1 stated, "Quite honestly" she did not check to see if alarms and landing strip were in place for Resident A when she was in the room.The facility's Director of Nursing (DON) was interviewed on 9/16/10 at 12:10 p.m. The DON was informed of the above observations and nursing staff interviews. The DON stated the facility had a system in place to ensure staff received information regarding care of residents. The DON stated a "Kardex" was posted in the residents' rooms, inside the closet. Observation of Resident A's room closet was then conducted with the DON. There was no Kardex posted inside Resident A's closet. The DON stated Resident A had been transferred from another room and that room was then inspected for presence of the Kardex. There was no Kardex posted. The DON was asked when Resident A was transferred to his present room. Review of Resident A's record revealed no documented evidence of a room change; there were no nurse's notes or social service notes regarding the room change. The DON stated, that based on the licensed nurse signatures, Resident A was transferred to his present room approximately 7/30/10-8/1/10 (one and one half months earlier), and that, potentially, Resident A's alarms and landing strip had not been in place since that time (including the day of the injury).In addition to the above Kardex procedure, the DON stated the facility had instituted another system after Resident A's injury on 9/12/10 to ensure resident needs were met. The DON stated that after a resident incident, the information was then communicated to department heads at the daily meeting, then to the Interdisciplinary Team (IDT), then to care planning, and then rounds were made by the IDT. The DON was asked what the responsibilities of the IDT were (i.e., as a result of the above described system) when rounds were made to ensure resident needs were met and accountability of facility staff. The DON stated the facility did not use any form of documentation regarding the IDT rounds. The facility's Administrator was interviewed on 9/16/10 at 12:30 p.m. regarding the above observations and interviews. The Administrator was informed of the facility's failures to ensure Resident A's needs regarding safety devices (alarms and landing strip) at multiple opportunities (i.e., three shifts per day of CNAs and LNs, and IDT). The Administrator stated there were no documentation or policies and procedures regarding the Kardex or IDT rounds. A follow-up interview was conducted with the DON on 10/5/10 at 8:30 a.m. The DON stated that "two weeks" prior to the Department's visit on 9/16/10, the facility's "QM" process, which involved unit supervisor observations of residents, noted that Resident A's alarms and landing strip were not in place. The DON stated the supervisor reported the observation to a CNA, but no further communication or follow-up to the LN or DON occurred. The DON stated there were "multiple system failures; we're working on them." The Administrator was interviewed on 10/5/10 at 10:15 a.m. regarding the facility's wheelchair maintenance program. The Administrator stated there were no formal program or policies and procedures in place regarding wheelchair maintenance. The Administrator stated staff report noted wheelchair problems to the maintenance supervisor for repair and cleaning was done by the housekeeping department. The Administrator was not able to say how the foam rubber on Resident A's wheelchair was cleaned.The facility's Maintenance Supervisor was interviewed on 10/5/10 at 10:25 a.m. regarding wheelchair maintenance. The Maintenance Supervisor stated his main source of information for needed wheelchair repairs was the repair request log located at each nurse's station and the housekeeping department's reports of problems noted during cleaning. The Maintenance Supervisor was asked about the foam rubber that was applied to Resident A's wheelchair, as opposed to a rubber plug/cover that would cover the sharp edges and allow cleaning. The Maintenance Supervisor stated the foam rubber was placed because the plugs are "hard" and that he spoke to a nurse at the time. On 10/5/10 at 10:45 a.m. the Administrator was requested to provide the facility's investigation regarding Resident A's injury that was sustained on 9/12/10 (i.e., how determination was made that foam rubber was the best solution to prevent further injury). The Administrator provided "CHANGE IN CONDITION REPORT - POST FALL/TRAUMA" dated 9/12/10. The Report indicated "IDT recommend pipe insulation tubing to wrap around ... leg rest top ... IDT - team feels the top of the leg rests caused the injury to resident ..." There was no documented evidence of further inspection of the wheelchair or bed, or involvement with therapy department or maintenance department.Therefore, the facility failed to:1. Ensure care planned and physician-ordered safety measure devices to minimize injury risk to Resident A were in place. 2. Ensure a program and policies and procedures were in place regarding wheelchair maintenance to ensure safe, sanitary, and comfortable conditions.These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 100000001 |
Asbury Park Nursing and Rehabilitation Center |
030009433 |
B |
16-Aug-12 |
MBNG11 |
7370 |
Patients' Rights -- 72527 (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (4) To consent to or refuse any treatment or procedure or participation in experimental research. This citation was written as a result of an unannounced visit on 3/27/09 to investigate complaint number CA00181582, a facility reported incident. The Department determined the facility failed to honor Patient A's right to refuse treatment when he expressed a desire to leave the facility against medical advice (AMA) on 3/14/09, and the facility failed to facilitate his discharge AMA, per their policy and procedure. A Physician's Orders for Life-Sustaining Treatment (POLST), a form completed by the physician, based on the person's medical condition and degree of treatment interventions desired by the patient, dated 3/6/09, included Patient A's signature with his chosen level of interventions based on his medical status.A History and Physical/Initial Nursing Home Visit form, dated 3/6/09, revealed, "...case was [discussed with Patient A], he does have full capacity to make decision." A Social Services admit note, dated 3/6/09, indicated Patient A was alert and oriented to person, place, and time and he had "some memory deficit" with modified independence for daily decision making. A Progress Note completed on an "[Acute care hospital affiliate] Geriatrics" form by the facility's Physician's Assistant (PA), dated 3/11/09, indicated Patient A had been experiencing persistent vomiting and diarrhea, had been "very anxious" lately about his spouse being ill, and he had a history of dementia.The plan portion of the progress note indicated, "Social Services to do [Mini Mental State Evaluation (MMSE)] (a screening tool used to assess cognitive skills). Need to determine if capable of making safe decisions..." A Physician's Telephone Orders sheet, dated 3/13/09, indicated, "Social Services - [please check] MMSE and place in chart..."Another Medical Doctor (MD)/PA progress note, dated 3/13/09, indicated "... [Patient] began packing his things - states he's going home [with] wife today." The physical examination portion of the note indicated, "awake, alert, [slightly] confused, walking all around facility." The plan portion of the progress note indicated, "... [Patient] agrees to stay to [re-check] labs on Monday, [March 16, 2009]..." Daily Skilled Nurses Notes, dated 3/14/09 at 2 p.m., indicated Patient A was alert and able to verbalize needs, but had intermittent confusion and was depressed over his wife's health decline. Daily Skilled Nurses Notes, dated 3/14/09, indicated, "[Patient] very confused and worried..." The note indicated Patient A told the nurse, "I have many things to take care of at home...I will go AMA." The MD and daughter of Patient A were contacted. "[Patient] watch hourly for [absence without leave (AWOL)]."There was no documented evidence the MMSE had been completed per the physician's order. There was no documented evidence the physician or other qualified clinician had made the determination that Patient A was no longer able to make informed choices regarding his stay in the facility and, therefore, could be held against his will. Activity Progress Notes, dated 3/14/09, indicated, "[Patient A] had an episode of confusion this evening, trying to leave and see his wife in the hospital. Spoke to him about staying for safety and referred him to the nurse."Daily Skilled Nurses Notes, dated 3/15/09, indicated, "No attempt to leave AMA today..."A Physician's Telephone Order, dated 3/16/09, indicated new orders including weekly weights, a re-check of laboratory tests and adjustments to Patient A's medication regimen. Daily Skilled Nurses Notes, dated 3/17/09, indicated, "Head of therapy department...discuss [with] nurse practitioner/[MD] regarding [patient] attempt to go AMA...social service [administered] the mental test and was agreed upon that he can leave..." The MMSE for Patient A, dated 3/17/09, had a score of 31, indicating intact cognition and the ability to make safe decisions. Four days had passed from the time Patient A expressed a desire to leave the facility AMA and the facility's implementation of the Physician's Order to conduct the MMSE.Patient A was interviewed on 3/27/09 at 1:05 p.m. He stated he felt his rights had been violated by the facility when he expressed a desire to be discharged from the facility and was not allowed to leave. The Social Services Director (SSD) was interviewed on 3/27/09 at 4:05 p.m. She stated, "If a resident wants to go, they can go. We don't hold anyone against their will." The SSD was interviewed again on 3/27/09 at 4:20 p.m. She stated, regarding Patient A, "My role was to make sure he was safe..." The PA was interviewed on 5/11/09 at approximately 11:30 a.m. regarding Patient A's desire to be discharged. The PA stated Patient A "was insistent on going home on a daily basis." The PA stated the MMSE was ordered to try and determine if Patient A had decision making capacity. The facility Director of Nursing (DON) was interviewed on 2/8/10 at 3 p.m. She stated if a resident insisted on leaving the facility, the physician was notified, the resident was asked to sign the AMA form, and arrangements were made for discharge. When asked if Patient A had the right to leave the facility, the DON stated, "Yes...He was able to make decisions for himself." When asked if she had been made aware that Patient A expressed a desire to be discharged from the facility on 3/14/09, the DON stated, "Not to my knowledge."The PA was interviewed again on 2/8/09 at 3:20 p.m. When asked why the facility waited four days before administering the MMSE, she stated, "Unfortunately" there had been a delay in implementing the MMSE. She also stated Patient A "had a right to make the decision to leave even though it wasn't wise" based on his health status. The PA confirmed that Patient A had decision making capacity regarding his care and stated Patient A should have been allowed to discharge AMA. Review of the facility's undated policy titled Discharging a Resident Without a Physician's Approval revealed the policy statement (in part), "A physician's order should be obtained for all discharges." Review of the Policy Interpretation and Implementation directed, "1. Should a resident, or his representative (sponsor) request an immediate discharge, the resident's attending physician must be promptly notified...5. Should the resident...insist upon being discharged without the approval of the attending physician, the resident and/or representative (sponsor) must sign a Release of Responsibility form..." The Department determined the facility failed to honor Patient A's right to refuse treatment when he expressed a desire to leave the facility AMA on 3/14/09, and the facility failed to facilitate his discharge AMA, per their policy and procedure. These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 100000001 |
Asbury Park Nursing and Rehabilitation Center |
030009564 |
B |
23-Oct-12 |
74CC11 |
7785 |
F224 - Prohibit Mistreatment / neglect / misappropriation 483.13(c) The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property F225 - Investigate/report Allegations/individuals 483.13(c)(1)(ii)-(iii), (c)(2) - (4) The facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. F499 - Employ Qualified FT/pt/consult Professionals483.75(g) The facility must employ on a full-time, part-time or consultant basis those professionals necessary to carry out the provisions of these requirements. Professional staff must be licensed, certified, or registered in accordance with applicable State laws. This citation was written as a result of an unannounced visit on 3/9/10 to investigate complaint number CA00219860. The Department determined the facility failed to: 1. Ensure that Certified Nursing Assistant 1 (CNA 1), who was employed as a CNA from 11/4/05 until promotion to another capacity on 10/19/07, a total of 23 months, had a valid and active issued State of California CNA Certificate. 2. Ensure CNA 2's certificate was clear and active prior to employment. 3. Ensure that facility staff responsible for obtaining clearances followed the facility's undated Abuse Prohibition policy and procedures when they did not "check licenses, certificates on hire and regularly thereafter." CNA 1's date of hire was 11/4/05. A Request for Live Scan Service (fingerprint background check), dated 11/1/05, was submitted for the background check. There was no confirmed background check clearance and there was no CNA certificate number in CNA 1's personnel file. An interview was conducted with the Director of Nursing on 3/9/10 at 2 p.m. She stated she was "unable to locate a CNA certificate number." Review of a California Department of Public Health L&C Verification Search Page document, dated 3/9/10, revealed CNA 1's certification status as "Certificate is denied, not employable." Review of the California Health and Safety Code, Section 1337, disclosed the following: (a) "The Legislature finds that the quality of patient care in skilled nursing and intermediate care facilities is dependent upon the competence of the personnel who staff its facilities. The Legislature further finds that direct patient care in skilled nursing and intermediate care facilities is currently rendered largely by certified nurse assistants. To assure the availability of trained personnel in skilled nursing and intermediate care facilities, the Legislature intends that all such facilities in this state participate in approved training programs established under this article. This article shall not apply to intermediate care facilities/developmentally disabled habilitative, intermediate care facilities/developmentally disabled-nursing, and intermediate care facilities/developmentally disabled continuous nursing which have staff training programs approved by the State Department of Developmental Services, general acute care hospitals, acute psychiatric hospitals, or special hospitals. (b) The requirement that certified nurse assistants obtain a criminal record clearance upon certification and biannually thereafter shall apply regardless of the setting in which the certified nurse assistant is employed." Review of the facility's undated Abuse Prohibition policy and procedure revealed in pertinent part, "...How the facility Prevents Abuse: Screening of potential hires,...Checks licenses, certificates on hire and regularly thereafter..." A telephone interview was conducted with the California Department of Public Health's Aide and Technician Unit representative on 3/9/10 at 12:15 p.m. The representative disclosed that CNA 1 was "never certified" in California, and "had a conviction" that prevented issuance of a California Nursing Assistant Certificate. An interview was conducted with the facility's Human Resources Representative 1 on 3/10/10 at 12:50 p.m. She stated the procedure is to "go in and check the background and certification status before employment." She stated, "We didn't know because [CNA 1] had been here so long" and "I didn't start in this position until 2008." When asked if CNA 1 should have been allowed to work without a clearance, she stated, "No."An interview was conducted with CNA 1 on 3/10/10 at 12:30 p.m. CNA 1 stated that he had an out of state certificate, did the California background fingerprint submission, received a number and "the Director of Staff Development" at the time said, "It was taken care of."An interview was conducted with the facility Administrator on 3/10/10 at 2:10 p.m. The Administrator stated he was unaware that CNA 1 did not have an active certificate.A written statement from Aide and Technician Unit staff Services Manager (SM) 1, dated 3/23/10 at 9:23 a.m., disclosed "[CNA 1] has never received a certificate from California...therefore it would have been illegal for him to work in California in a CNA capacity..." Follow up telephone interviews were conducted with SM 1 on 3/23/10 at 10:35 a.m. and 2:50 p.m. SM 1 stated that on 11/5/05 CNA 1's application status was "allowed pending criminal background check results." He stated that on 1/10/06, the pending status was changed to a "denial status" due to a positive criminal conviction and CNA 1's clearance to obtain a CNA Certificate was denied.CNA 2 had a hire date of 3/10/10. There was no documented evidence that CNA 2's certificate was clear and active prior to employment at the facility. An interview was conducted with the facility's staffing coordinator on 3/10/10 at 2 p.m. She stated that CNA 2 had a certificate number. When asked if the clearance check should have been done before hire, she stated, "Yes."The Department determined the facility failed to: 1. Ensure that CNA 1, who was employed as a CNA from 11/4/05 until promotion to another capacity on 10/19/07, a total of 23 months, had a valid and active issued State of California CNA Certificate. 2. Ensure CNA 2's certificate was clear and active prior to employment. 3. Ensure that facility staff responsible for obtaining clearances followed the facility's undated Abuse Prohibition policy and procedures when they did not "check licenses, certificates on hire and regularly thereafter." These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 100000042 |
ACACIA PARK NURSING & REHABILITATION CENTER |
030009574 |
B |
08-Nov-12 |
KQCC11 |
12061 |
72311 - Nursing Service - General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. 72311 - Nursing Service - General (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 72523 - Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. 72527 - Patient Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse. The following citation was written as a result of an unannounced visit on 9/11/09 to investigate complaint numbers CA00201562, CA00203994, CA00205387, and CA00215909, facility reported incidents. The Department determined the facility failed to: 1) Develop a plan of care for Resident B after Resident A exhibited sexually inappropriate behavior toward her on 9/11/09. 2) Develop a plan of care for Resident C after Resident A exhibited inappropriate behavior of disrobing in public which placed her at a potential risk of abuse. 3) Implement interventions in plans of care developed for Residents A, B, and C to prevent continued incidents of sexual abuse of Residents B and C by Resident A. 4) Ensure Residents B and C were kept free from physical abuse. 5) Notify the attending physician promptly of incident of sexual abuse involving Resident C in accordance with the facility's Abuse Investigations policy and procedure, dated December 2006. Resident A was admitted to the facility on 9/13/02. He had diagnoses including cognitive deficits related to the late effects of a cardiovascular disorder, mental disorder, and depressive disorder. A Social Service Progress Note, dated 9/10/08, indicated that Resident A was removed from "one to one" supervision with the stipulation that he "...keep his hands to himself and not touch any other person other than himself." An interview was conducted with the Director of Nursing (DON) on 2/8/10 at 1:15 p.m. She stated that approximately one year ago, Resident A had exhibited inappropriate sexual behavior toward a female resident. She stated Resident A had not exhibited any further behavior until September and October 2009, when he was observed exhibiting sexually inappropriate behavior toward Residents B and C. The DON indicated that Resident A was receiving medication to control his sexual behavior. She was asked about continued episodes of sexually inappropriate behavior by Resident A toward Residents B and C, after the 9/11/09 incident and the facility's notification to the Department at that time that it would maintain Resident A within "line of site" to prevent further incidents. The DON responded that Resident A leaves the dining room unsupervised, and is "...forgetful at times." The DON stated that Resident A knew his behavior was "wrong", and "...knows he's not supposed to touch female residents."Resident A's Minimum Data Set (MDS - an assessment tool), dated 10/8/09, indicated the resident had short and long term memory problems, his cognitive skills for daily decision making were moderately impaired, and the resident exhibited socially inappropriate behavior, such as sexually inappropriate behavior. Though Resident A had been observed exhibiting sexually inappropriate behavior toward Resident B on 9/11/09, a plan of care was not developed to address this incident until another incident of sexually inappropriate behavior by Resident A toward Resident B occurred on 10/5/09.Resident A's plan of care, dated 10/5/09, noted a problem of "Inappropriate Behavior: Sexual, evidenced by sexual advancement toward another female resident by touching her at inappropriate place on her body." Approaches to this identified problem included Resident A was to be monitored "...within eye distance while around other residents, [especially] in dining room and in hallway" and Resident A was not to be "...within arms reach distance to any female resident in the facility." The care plan did not address Resident A's problem of "forgetfulness" relative to his continuing problem of exhibiting sexually inappropriate behavior toward other residents. Because of the facility's failure to implement Resident A's plan of care, by ensuring that he was kept within line of sight to prevent further incidents of sexual abuse toward Resident B, two more incidents of sexual abuse by Resident A occurred. One incident was on 10/19/09 toward Resident C and another incident was on 11/21/09 toward Resident B. Resident B was admitted to the facility on 3/12/09. She had diagnoses including rehabilitation process, old cerebrovascular accident (stroke), and muscle weakness including right-sided paralysis. An MDS, dated 10/6/09, indicated Resident B had short and long term memory problems, severe cognitive impairment, was unable to walk, was unable to speak, and exhibited sad, tearful, and anxious behaviors. According to the information provided by Social Services Director (SSD) 1 who reported the 9/11/09 incident, SSD 1 observed Resident A grabbing and fondling Resident B by the breast. The report indicated that Resident B "...is understandably upset but is OK." SSD 1 reported that, during her conversation with the DON regarding the incident, Resident A had been placed on line of sight of staff and would be kept on it as long as he was in the facility. The second incident involving Residents A and B, which occurred on 10/5/09, was observed by Physical Therapist (PT) 1, who reported to the Department, "...[Resident A] had cut off [Resident B's] pathway in the hall. He had his hands on her chest feeling her breasts." A care plan was developed for Resident B, dated 10/5/09, which included a problem, "Resident touched by a male [resident] inappropriately." Approaches to this problem included, "Resident will not be placed within reaching distance with suspected resident,..." and "Resident will not be placed in hallway without any staff around/present..." Resident A's care plan for the problem of "Inappropriate Behavior: Sexual", updated 10/19/09, noted additional approaches of "Resident agrees to eat meals in room - OK to be in smoking area unsupervised if [no] females present or females present are alert [and] oriented [times] 3 - must be supervised in all [social activities]..." A "Nurses Note", dated 11/21/09 at 1:20 p.m., indicated Resident A had again been observed exhibiting sexually inappropriate behavior toward Resident B. The note indicated, "...entered in to female peer [room]...and was doing inappropriate sexually behavior towards peer - example, is rubbing her groin [and] private areas (breast) [and] rubbing legs. CNA reported this to [charge nurse]. [Physician] notified regarding [behavior] per [nursing] discretion. [Every] shift charting regarding [behavior] [times] 72 [hours]. Resident also to stay in room...not allowed to be in front [at] this time..." The facility failed to implement Resident B's care plan and failed to include any problem of the continued sexual abuse of Resident B by Resident A relative to the 11/21/09 incident. They failed to indicate what measures would be implemented to prevent further victimization of Resident B by Resident A. Resident C was admitted to the facility on 6/26/09. She had diagnoses including difficulty walking. Resident C's MDS, dated 11/26/09, indicated she had short and long term memory problems and her cognitive skills for daily decision-making were moderately impaired. The MDS also indicated Resident C exhibited socially inappropriate behaviors of disrobing in public and wandering. A Nurses Note, dated 10/19/09 at 2:15 p.m., indicated Resident C had been touched inappropriately between her thighs by a male resident. The complaint received by the Department from the facility on 10/19/09 (Complaint # CA00205387) indicated the male resident was Resident A. A plan of care was developed for Resident C on 10/19/09 relative to Resident C being touched inappropriately by Resident A on 10/19/09. Approaches to this problem included monitoring Resident C for any changes in behavior as a result of the incident and monitor her whereabouts each shift because the resident was prone to wandering around the facility in her wheelchair. The care plan also indicated that safety precautions in Resident C's environment were to be ensured, though the care plan did not specify what these safety precautions were. An Investigation Form for Resident Abuse, dated 10/19/09, was completed for the 10/19/09 sexual abuse of Resident C by Resident A. The Summary of Findings indicated, "[Resident A] continues to behave inappropriately towards incoherent female residents. This is the [third] case in a month that this behavior was observed." Despite Resident C's care plan specifically indicating that her whereabouts were to be monitored each shift, a second incident occurred on 1/24/10 when Resident A was observed in the hallway grabbing Resident C's crotch area.Because of the facility's failure to implement Resident A's care plan of 10/5/09 and Resident C's care plan of 10/19/09, Resident C was sexually abused by Resident A on 1/24/10. An interview was conducted with the DON on 2/8/10 at 1:15 p.m. She stated Resident C was "probably more at risk for being inappropriately touched, because she would frequently take her clothes off." There was no plan of care addressing Resident C's behavior of disrobing in public and how the facility would protect Resident C from potential abuse as a result of this behavior. The facility's policy and procedure for Abuse Investigation directed, "...The individual conducting the investigation will, at a minimum: ...Interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition." There was no evidence that Resident C's physician was notified of the 1/24/10 incident involving Resident A.An interview was conducted with the Administrator on 2/9/10 at 3 p.m. regarding the above findings. The Administrator acknowledged the continued incidents of inappropriate sexual behavior exhibited by Resident A toward Residents B and C constituted sexual abuse of Residents B and C. The Administrator was unable to provide an explanation as to why Resident C's physician was not notified of another occurrence of sexual abuse by Resident A toward Resident C on 1/24/10. The Department determined the facility failed to: 1) Develop a plan of care for Resident B after Resident A exhibited sexually inappropriate behavior toward her on 9/11/09. 2) Develop a plan of care for Resident C after Resident A exhibited inappropriate behavior of disrobing in public which placed her at a potential risk of abuse. 3) Implement interventions in plans of care developed for Residents A, B, and C to prevent continued incidents of sexual abuse of Residents B and C by Resident A. 4) Ensure Residents B and C were kept free from physical abuse. 5) Notify the attending physician promptly of incident of sexual abuse involving Resident C in accordance with the facility's Abuse Investigations policy and procedure, dated December 2006. The above violations had a direct relationship to the health, safety and security of the residents. |
| 030001004 |
American River Center |
030009588 |
B |
15-Nov-12 |
6NES11 |
4930 |
F323 - Free Of Accident Hazards/supervision/devices - 483.25 (h)The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.On 4/02/09, an unannounced onsite visit was conducted to initiate investigation of Complaint #CA00182723 and Entity Reported Incident #CA00182902. As a result of the investigation, the Department determined that the facility failed to ensure:Each resident receives adequate supervision and assistance devices to prevent accidents.The failures resulted in Resident A not having adequate supervision on 3/24/2009 when he was left unattended and unobserved in his wheelchair at the nursing station without a medically prescribed lap restraint device in place to prevent a fall. Resident A was found on the floor after a fall from his wheelchair. He had struck his head and sustained some skin tears and a small thumb laceration. He required transfer and admission to the General Acute Care Hospital (GACH). He was diagnosed with a minimal subdural hematoma (a bruising of the brain tissue) which necessitated overnight observation in the hospital and suturing of a laceration of his thumb. After the overnight observation, he was re-admitted to the facility.Clinical record review on 4/02/09 was conducted. Resident A was 95 years old, admitted to the facility on 9/05/08 with diagnoses including dementia and blindness related to glaucoma.The Minimum Data Set (MDS - a basic assessment tool) dated 10/10/08 documented the following characteristics. Resident A had short and long term memory deficits, and cognitive impairment requiring cues and decision making assistance. His vision impairment was documented. He had poor balance and required extensive assistance for all activities of daily living (ADL). He also had a documented history of falling.On 10/06/08 an "Interdisciplinary Progress Note" stated, "Found @ foot of roommate's bed with wheelchair on top of him.Sent to ER (Emergency Room) for laceration on back of head. Returned with three staples...no abuse or neglect suspected. CP (Care Plan) revisited..."the documented "Fall Follow-up" identified that the resident had poor safety awareness.On 9/12/08, the Physician's Orders revealed an order for "Lap Buddy on W/C (wheelchair) per family request secondary to unattended/unassisted transfer and ambulation." A lap buddy is a tray device that fits across the wheelchair and can be secured to prevent the resident from rising out of a sitting position or falling from a chair.An updated MDS on 1/07/09 reflected evidence of repetitive physical movements and restlessness. It was noted that the resident had increased dependence on staff for all ADL care and physical locomotion.Nursing documentation on 3/24/09 at 8:30 p.m. noted, "Found resident lying down on his left side, and his left hand under his side...patient denied hitting head...called 911 came and took to (GACH)..." The Interdisciplinary Progress Note dated 3/25/09 included an entry by the Director of Social Services stating, "Found on floor @ nursing station laying on left side...hand under side...with bleeding. Pressure dressing applied, resident alert and verbally responsive. Res (resident) denies hitting head. Res declines pain, MD and RP (Responsible Party) notified. Res transferred to hospital for evaluation and treatment. Res had attempted to get up out of wheelchair unassisted. Resident will have lap buddy in place when in wheelchair."On 4/02/09 an interview was conducted with the Administrator and Director of Nursing. They indicated that on 3/24/09, C.N.A. 1 (Certified Nursing Assistant) had just assisted the resident in the bathroom and wheeled him to the front of the nursing station and left him while he assisted another resident. C.N.A. 1 had forgotten to place the lap buddy and clip alarm prior to leaving the resident unsupervised.The Administrator provided a copy of C.N. A. 1's counseling record that reflected C.N.A.1's failure to implement the lap buddy and the resultant fall.The C.N.A. was also interviewed on 4/20/09 and confirmed that he/she was in a hurry and forgot to apply the lap buddy, an intervention intended to reduce Resident A's risk for a fall.The GACH Progress Note for 3/24/09 documented Resident A was admitted due to a fall from a wheelchair and sustained a small subdural hematoma and thumb laceration that required suturing. It was also noted on the Skin/wound form that Resident A had additional skin tears. Resident A was discharged back to the facility on 3/26/09 following observation related to his head injury.Therefore the facility failed to ensure:Each resident receives adequate supervision and assistance devices to prevent accidents.These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 100000042 |
ACACIA PARK NURSING & REHABILITATION CENTER |
030009674 |
B |
14-Dec-12 |
U08X11 |
6693 |
Nursing Service -Staff 72329.1 (a) Nursing service personnel shall be employed and on duty in at least the number and with the qualifications determined by the Department to provide the necessary nursing services for patients admitted for care. The staffing requirements required by this section are minimum standards only. Skilled nursing facilities shall employ and schedule additional staff as needed to ensure quality resident care based on the needs of individual residents and to ensure compliance with all relevant state and federal staffing requirements. The Department may require a facility to provide additional staff as set forth in Section 72501(g). (f) Each facility shall employ sufficient nursing staff to provide a minimum of 3.2 nursing hours per patient day. The following citation was written as a result of an unannounced investigation of entity reported incident #CA00182926. The investigation was initiated on 9/8/09 with additional on-site investigation on 12/30/09, 1/27/10 and 1/29/10 regarding a fractured leg that involved Patient A during her stay in the facility. The Department determined that the facility failed to ensure adequate nursing staff levels were maintained to provide for appropriate care and services for Patient A and as required by State law.The failure resulted in inadequate nursing staff during the period of 3/8/09 through 3/28/09. The failure to ensure adequate nursing staff during this period contributed to Certified Nursing Assistant (CNA) 1's inability to provide appropriate services, which lead to Patient A suffering a fractured leg during provision of care on 3/26/09. Review of the clinical record revealed Patient A was 93 years old and was admitted to the facility on 11/11/05. The annual Minimum Data Set (MDS-assessment and care screening tool) dated 2/1/09 indicated Patient A resisted care daily, which was not easily altered. The Resident [Patient] Assessment Protocol (RAP-additional assessment based on problem identification) related to the MDS indicated Patient A continued "to present daily refusal of meds ... [continued] to require max level of assistance with most ADLs [activities of daily living]." Nurse's notes dated 3/26/09 at 6:30 a.m. indicated "CNA reported that while changing [Patient A] she rolled her on her [left] side to pull up her pants & then when she went to roll her over [Patient A] straightened her leg out & it got stuck in side rail as she rolled her over & CNA said she heard a pop. [Patient complained of] severe pain to [left] upper leg close to hip." The nurse's note indicated Patient A was transferred to the hospital at 7:15 a.m. Review of the History and Physical dated 3/26/09 revealed Patient A had a displaced left femur (thigh bone) fracture (break in bone) and osteoporosis (a loss of bony substances that produces brittleness and softness of bones).Review of "FACILITY REPORTED EVENT" dated 3/27/09 revealed Patient A "... suffered a fracture during ADL care at approximately 6:30 am on 3/26/09 [CNA 1] was dressing [patient]. [Patient's] leg was caught in side rail. [CNA 1] did not notice and turned [patient] resulting in fracture of left upper leg." Review of the facility's investigation of the incident revealed "... Although the injury appeared to be the result of [Patient] resisting care, CNA should have asked for assistance ..." The facility's policy and procedure titled "Abuse Training and Reporting Policy" dated August, 2002 indicated the facility "... will continually monitor ... systems, etc., ... p. Striving to maintain adequate staffing on all shifts to ensure that the needs of each [patient] are met." Review of "INTERDISCIPLINARY [PATIENT] RESIDENT SAFETY INVESTIGATION AND INTERVENTION - IDT TEAM" dated 3/27/09, and related to the incident involving Patient A, revealed the incident was best attributed to "Poor safety judgment" and "Non-compliance to instructions." Facility staffing levels were not indicated to be a factor related to the incident. There was no documented evidence the facility "continually monitor[ed] ... systems, etc., ... p. Striving to maintain adequate staffing on all shifts to ensure that the needs of each [patient] are met."Review of the Quarterly MDS dated 5/1/09 revealed Patient A's physical functioning had declined as compared to the annual MDS dated 2/1/09. The Quarterly MDS indicated Patient A did not engage in locomotion on or off the unit, required extensive assistance with eating, and was totally dependent with bathing. CNA 1 was interviewed on 12/30/09 at 10:35 a.m. regarding the incident that involved Patient A on 3/26/09. CNA 1 stated she remembered the incident. CNA 1 stated, "We have certain time to get [patients] dressed ... Some are feeders and need to go to assigned dining rooms ... trying to get [Patient A] up and she was pinching me ... she was trying to grab side rail, left side rail ... trying to pull her towards me and get her hand loose ... she all of a sudden let go and grabbed my shirt ... when trying to turn her, she put the leg on the side rail and I heard that it popped. I got really, really scared and I ran to the charge nurse ... called 911 and they came right away ... I was by myself ..." CNA 1 was asked what training she had received related to working with patients who exhibited the types of behaviors as Patient A. CNA 1 stated, "Get some help from somebody ... chart it on ADL and talk to charge nurse ... [on that day] we're short staffed ... went to get help ... really busy ... I remember [waiting] half hour [nobody came], tried to do it myself." CNA 1 added, "[Patient A] went down after that." Review of facility payroll records for the period 3/8/09 through 3/28/09 revealed the following: (PPD = nursing hours per patient day) Date: PPD: Census: 3/8/09 2.30 86 3/9/09 2.75 85 3/10/092.88 86 3/11/092.63 85 3/12/092.43 86 3/13/092.65 84 3/14/092.37 84 3/15/092.52 85 3/16/092.87 85 3/17/092.40 85 3/18/092.46 86 3/19/092.53 86 3/20/092.41 87 3/21/092.45 87 3/22/092.28 87 3/23/092.29 87 3/24/092.41 86 3/25/092.44 85 3/26/092.50 86 3/27/092.69 87 3/28/092.36 85 Depending on the census, the above represented nursing staff shortages that ranged from 27.5-80 hours per day. On 3/26/09, the day of the incident that involved Patient A, the facility's nursing hours PPD was 2.5, which equaled a nursing staff shortage of 60.2 hours for the day.Per the calculations, the facility failed to ensure adequate staffing levels were maintained to provide for appropriate care and services for Patient A and as required by State law.These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 100000030 |
Alderson Convalescent Hospital |
030009730 |
B |
07-Feb-13 |
VBC511 |
4708 |
72527(a)(9) Patient Rights -- (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To be free from mental and physical abuse. The following citation was written as a result of an unannounced visit on 11/16/10 for the investigation of complaint number CA00249040, a facility reported incident. The Department determined the facility failed to ensure Patient A did not suffer physical abuse from a staff member on 11/8/10.This failure resulted in Patient A sustaining bruises on her arms. Patient A was admitted to the facility on 6/18/10. Her diagnoses included a history of a stroke. Her clinical record was reviewed on 11/16/10. A quarterly Minimum Data Set (MDS - an assessment tool), dated 9/15/10, was reviewed. The MDS indicated Patient A had no short or long term memory deficits. She had some difficulty with cognition in new situations only. She was able to both understand and be understood by others. Physician Orders, dated 6/18/10, identified Patient A was capable of understanding rights and responsibilities and /or participating in the treatment process. Nurse's Notes, dated 11/9/10 at 1:30 p.m., indicate Patient A had complained of a missing cell phone. Licensed Nurse (LN) 1 went to her room to question her about the phone. While talking with her, Patient A told LN 1 that a certified nurse assistant (CNA), "grabbed her arms and held her down stating you're not getting out of bed. [Patient A] has numerous bilateral bruises on forearm and upper arms."A Social Service note, dated 11/9/10, was reviewed. The documentation in the note described, "It was reported to this writer that [Patient A's] cell phone was stolen and that resident held down by CNA. Went and talked to [Patient A] she stated that a [CNA] on pm shift held her down by her arms and told her she could not get up, there is bruising on the upper forearms."An interview was conducted with Patient A on 11/16/10 at 3:30 p.m. She was sitting in her wheelchair wearing a long sleeved shirt. Patient A stated CNA 1 had come into her room and "grabbed my arm and started to wring it like a towel, she held me down on the bed. I could see she was mean. I was yelling at her and then she left. The next night she was back again around 4 a.m. She was admiring my cell phone. I thought it was going to start again. I told her get your ass out of here. I haven't seen her since." On 11/16/10 at 3:45 p.m., Patient A was asked to remove her long sleeved shirt. Her left arm had bruising on the forearm in two different spots approximately 1.5 inches in diameter. Her upper arm also had two different areas of approximately 1.5 inches in diameter. The bruises were blueish/reddish in color. Patient A stated her arm was "still sore." The facility policy titled Abuse, Prevention of, dated 6/22/09, was reviewed. The policy identified, in part: "Each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion. Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals." An interview was conducted with LN 1 and the Director of Nurses (DON) on 11/16/10 at 4:30 p.m. Both acknowledged the bruising on Patient A's arm was indicative of having been "grabbed with some force." They stated the facility was still in the process of investigating.The facility investigation of the abuse allegation, undated, was reviewed on 11/29/10. The documentation indicated when LN 1 went into Patient A's room on 11/9/10, he noticed "a couple of bruises." LN 1 asked Patient A how she acquired the bruises. She stated, "A caregiver grabbed my arm and held me down and said no, you're not getting out of bed."The documentation in the investigation explained Patient A had stated, "if you bring that lady here I will identify her." On 11/16/10 at 5:30 p.m. Patient A identified CNA 1 as the caregiver who held her down, causing bruising to her arms. The Department determined the facility failed to ensure Patient A did not suffer physical abuse from a staff member on 11/8/10.These failures had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 100000022 |
Arbor Rehabilitation & Nursing Center |
030009761 |
B |
07-Mar-13 |
579G11 |
7779 |
72311 Nursing Service (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. 72301 Required Service (f) The facility shall ensure that all orders, written by a person lawfully authorized to prescribe, shall be carried out unless contraindicated. An unannounced visit was made on 6/21/10 to initiate an investigation of complaints concerning injuries sustained by Patient 1. The report identified allegations of multiple falls with injuries sustained and a lack of supervision of the patient. As a result of the investigation, the Department determined the facility failed to: 1. Update the patient's care plans for falls to include new measures and increased supervision to prevent further falls and injuries; 2. Follow doctor's orders for dressing changes for a laceration sustained after a fall. Patient 1 was a 95 year old admitted to the facility on 11/2/09 with diagnoses which included dementia and osteoporosis. A Minimum Data Set (MDS- an assessment tool) dated 5/12/10, described the patient as having severely impaired cognitive skills and memory loss. The patient was described as requiring staff assistance for most activities of daily living, and as being unable to walk or move independently from her wheelchair to the bed. A Fall Risk Assessment form for Patient 1 indicated on 3/7/10, a fall risk score of 13; on 3/14/10, a fall risk score of 13 and a subsequent fall risk assessment, completed on 5/2/10, indicated a score of 14. The form contained the following guideline: "Total score of 10 or above represents HIGH RISK." Review of a "Fall Risk Care Plan" dated 3/7/10, indicated "At risk for falls and injuries [related to]...medication...osteoporosis, unsteady gait, pain...dementia, poor safety awareness, weakness and history of falls..." The "Goal" indicated, "No injuries from falls in 90 days." Interventions included, "Monitor for unsteady gait and balance, assess toileting needs, provide verbal safety cues, keep personal belongings within reach..." Review of the clinical record for Patient 1 revealed a physician's order, dated 3/7/10, for a "Self Release, Seat belt with alarm for safety and promote independence." Review of a Resident Assessment Protocol (RAP) Assessment, date 5/12/10, under the heading for Falls included "(Patient 1) is at risk for falls related to episode of falls in the past 30 days. She is at risk for falls related to poor safety awareness." Review of an "Episodic Care Plan: Post Fall" dated 5/26/10, indicated Patient 1 had a fall that resulted in a bruise to her mid-back. Interventions included monitoring vital signs, assessing for pain, and notification of the physician and Responsible Party. Review of another "Episodic Care Plan: Post fall" dated 6/2/10, indicated Patient 1 had another fall that resulted in a skin tear to the right elbow. Interventions included monitoring vital signs, assessing for pain, notification of the physician and the Responsible Party and first aid instructions for the skin tear. A Change of Condition Report, dated 6/18/10 at 7:30 p.m., indicated, "Resident found on floor face first, right index finger inside of hole in wheelchair that connects to wheel. Laceration to right index finger and right eyebrow." A note in the right margin of the report indicated, "Self release belt removed but it was found off." The report indicated the patient was sent to the emergency room at 8:25 p.m. Review of a physician's order, dated 6/19/10, indicated "Keep wound clean and dry and change dressing daily until healed, right eye brow lacerated wound and right index finger." An IDT (interdisciplinary team) Post-Occurrence Review form, dated 6/21/10, which reviewed the fall on 6/18/10, indicated under the heading "Recommendations/Target Plan to Prevent Recurrence" was a description of the resident's lack of memory of the fall. No recommendations were made by the IDT. Review of the Treatment Record for Patient 1 revealed an order, dated 6/19/10, to "Keep wounds clean and dry. Change dressing daily until healed, right eyebrow and right index finger." The blocks for 6/19/10, 6/20/10 and 6/21/10 dressing changes were all blank. Nurse's notes for 6/19, 6/20, and 6/21 did not indicate that Patient 1 had refused any dressing changes. Patient 1 was observed on 6/21/10 at 12:40 p.m. to be up in her wheelchair in her room. The right side of her face had extensive bruising and her right outer eyebrow had steri-strips with dried blood. Patient 1's right index finger had a splint and was covered in a dirty bandage with dried blood and it was generally soiled. The right hand was bruised. In an interview with Licensed Nurse 1 (LN 1) on 6/21/10 at 12:45 p.m. he stated Patient 1 had been "found face down on the floor, her right index finger was caught inside a pipe on the wheelchair that normally held the foot rests." In an interview with Responsible Party 1 (RP 1) on 6/21/10 at 2:10 p.m. she stated Patient 1 "was pretty banged up after the fall Friday night." RP 1 accompanied Patient 1 to the emergency room on 6/18/10. She stated, "The finger dressing on her right hand is the same one as she had Friday night at the hospital."In an interview with Licensed Nurse 1 (LN 1) on 6/21/10 at 3 p.m. LN 1 stated he did not know when the last dressing change was for Patient 1's brow and finger dressings. LN 1 stated he "did not change the dressing yesterday or today." He reviewed the treatment record and stated dressing changes were not documented. Review of the facility policy titled Dressing Change, dated 2006, revealed under the heading Documentation Guidelines: "Documentation may include date, time, dressing change, signature and title of nurse changing dressing." In an interview with LN 2 on 6/21/10 at 3:30 p.m. he stated he was the nurse on duty caring for Patient 1 when she fell on 6/18/10. He stated, "I heard a thud and a scream. The self releasing seatbelt alarm was not on, but the seat alarm was on and sounding. There was blood on the floor, she hit her head face first and her finger was caught in a hole in the wheelchair. I pulled out her hand and she tried to get up by herself, she thinks she can walk." LN 2 stated, "She needs to be supervised more closely, other nurses agree. I'd like to see a 1:1 to protect her from more falls." LN 2 stated after the fall on 6/18/10 additional measures were not put in place to protect the resident from further injury, "just keep a close eye on her." Review of a Fall Risk Care Plan, dated 3/7/10 and last updated on 6/10/10, showed it was not updated to include interventions following the patient's fall on 6/18/10. Review of two Episodic Care Plans: Post Fall, dated 5/26/10 and 6/2/10 were reviewed. There was no evidence the care plans for falls included new measures or increased supervision, to prevent further falls and injury. In an interview with the Director of Nursing (DON) on 7/22/10 at 11:25 a.m. DON reviewed the nurse's notes for Patient 1 from 6/18/10 to 6/21/10 and stated there was "no documentation she refused dressing changes."Therefore, the Department determined the facility failed to: 1. Update the patient's care plans for falls to include new measures and increased supervision to prevent further falls and injuries; 2. Follow doctor's orders for dressing changes for a laceration sustained after a fall. These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or patients. |
| 100000089 |
Applewood Care Center |
030009910 |
B |
17-May-13 |
7QZ211 |
9854 |
72311Nursing Service - General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. The following citation was written as a result of an unannounced visit to the facility on 8/16/11 for the investigation of complaints CA00279216 and CA00282332. As a result of this investigation, the Department determined the facility failed to assess and consult with appropriate health professionals to ensure Patient A could be safely transferred using an appropriate lift device, based on her physical condition. This failure increased the potential for injury to Patient A during transfers when her weight bearing status was not assessed, a specific plan of care was not developed, and lift manufacturer's specifications for the sit to stand lift were not followed. Patient A was an 83 year old admitted to the facility 9/4/05 with diagnoses including quadriplegia, severe osteoporosis (weakening of the bones), dementia and adult failure to thrive. Review of Patient A's clinical record revealed a document titled "Impaired Mobility Care Plan", dated 4/15/09. The care plan indicated the patient had impaired mobility issues related to stroke, contractures, pain, weakness/paralysis, osteoporosis and quadriplegia. "Approaches" included "Handle resident gently during turning and repositioning" and "Assist resident with transfer..." There was no documented evidence the facility had identified the specific method of transfer for Patient A at that time.Further review indicated a care plan titled, "Potential for falls and injury" due to osteoporosis, immobility, weakness and quadriplegia" dated 3/2011. Under "approaches" the care pan reflected the patient requires maximum assistance with Activities of Daily Living (ADLs) and "Assist resident to bed when he/she is fatigued." There was no specific indication of the method of transfer for Patient A.Review of a Minimum Data Set (MDS- an assessment tool), dated 4/19/11, indicated Patient A required extensive assistance with bed mobility, transfers and dressing. It was noted Patient A did not walk in her room or in the hallways of the facility. Review of the physician's History and Physical for Patient A, dated 6/12/11, indicated Patient A had quadriplegia (inability to move or bear weight to all extremities) secondary to brain surgery for the repair of a ruptured artery. It also indicated she had contractures (tightening of the muscles causing a decrease in range of motion and use of the extremity affected) of the hands and feet, and a history of osteoporosis (weakened bones). There was no documented evidence the care plan had been updated to reflect how Patient A would be transferred from one surface to another safely, based on her physical condition at this time. Review of Nurses Notes, dated 8/9/11 at 9:45 p.m., noted Patient A's right knee was swollen with no discoloration noted. Patient A's Responsible Party (RP) was notified of the swelling. The staff attempted to notify the Medical Doctor 1 (MD 1), but was not able to contact him.Review of Nurses Notes, dated 8/10/11 at 3:30 a.m., noted the right knee had increased swelling and was warm to the touch, but no discoloration was noted.An untimed entry on 8/10/11 indicated the staff notified MD 1 of Patient A's knee swelling, and MD 1 did not order an x-ray at this time. The RP was notified of the increase in swelling.Another attempt was made to contact MD 1 at 2 p.m. and he was not available. The note, timed 2:30 p.m., indicated MD 2 was notified and orders were given for laboratory tests and x-rays. The RP was notified at this time.Review of the x-ray report, dated 8/10/11, indicated the patient had a "displaced distal femur metadiaphyseal fracture...", a fracture of the thigh bone at the knee. The report indicated there was an "associated joint effusion [swelling at the knee joint]" and "Osteoporosis is present." Review of the Acute Hospital "Orthopedic ER Consult" report, dated 8/11/11, indicated "Moderate soft tissue swelling. No ecchymosis [bruising]" and "No areas of redness or breakdown" to Patient A's right knee. X-ray results from the hospital, dated 8/11/11, confirmed the diagnosis of right distal femur fracture. In a review of "Physician's Progress Notes" dated 8/16/11, MD 1 indicated, "I believe that she [Patient A] sustained a "spontaneous" Fx [fracture] of distal R[ight] femur during the lift due to severe osteoporosis." Review of an MDS, dated 8/10/11, indicated Patient A had functional limitations to both her upper and lower extremities, and she used a wheelchair when out of bed. The MDS indicated Patient A was totally dependent and required full staff performance with her ADLs (including transferring, eating and hygiene activities).Further review of the "Potential for falls and injury" care plan indicated the plan had been updated on 8/12/11 to include "Hoyer Lift [full body sling lift] for transfer per Rehab [Rehabilitation] evaluation" (as opposed to the standing lift) This care plan was implemented after the swelling and the knee fracture were identified. During an interview with the Physical Therapist (PT) on 12/5/11 at 2:40 p.m., she stated that Patient A had limited Range of Motion (ROM) to her upper extremities that were 25% of normal. The PT stated that Patient A had contractures to her shoulders and hands. The PT indicated Patient A's hands would not open up enough to hold on to a sit-to-stand lift. PT further stated Patient A had limited ROM to her lower extremities, and a left foot contracture. The PT indicated Patient A required 2 persons to assist her to transfer from the bed to the chair and stated the patient could not use a sit-to-stand lift even prior to obtaining the distal femur fracture. During an interview on 12/27/12 at 11:48 a.m. with Patient A's family member (FM 1), she stated she had observed a CNA transfer Patient A from her bed to a wheelchair with a sit to stand lift. She stated Patient A was "hanging in the air with her feet dangling" around the wheels of the lift. During an interview with the Director of Nursing (DON) on 12/27/12 at 12:28 p.m., she stated a CNA used the sit to stand lift 2 days before the swelling was noticed. She stated when she interviewed the CNA who used the sit to stand lift, the CNA told her the patient was not able to grab the handles of the lift. She stated the CNA described to her the method of transfer with the standing lift. The CNA told the DON that she placed the sling around the patient's upper back, under her arms and lifted her up with the CNA supporting some of her weight and guided her to the chair. The DON stated that sounded reasonable to her.Review of a document titled "Stand-Up Lifts Frequently Asked Questions", retrieved from the manufacturer's web site (www.invacare-cc.com) on 12/28/12, answered the question "Should a stand-up lift be used for all residents?" The document indicated the stand-up lift should only be used for residents "who can bear some of their own weight." Further review of this document indicated "the standing sling is proper to use for transferring residents who are partially dependent, have at least 60% weight bearing capacity, have head and neck control, can sit up on the edge of the bed...and are able to bend at the hips, knees and ankles." (Patient A was quadriplegic and completely dependent on others due to decreased mobility).During an observation on 1/30/13 at 2:20 p.m. Certified Nursing Assistant (CNA) 1 and CNA 2 demonstrated how to use a sit to stand lift. The CNA's described that the sit to stand lift was designed to lift a patient from the sitting position to a standing position using a sling that is secured around the patient's waist, and securing the sling under the patient's arms, and attaching it to the lift. The patient is instructed to hold on to hand grips located on the frame of the lift. The feet are placed on a non-skid platform and the knees are secured to knee pads. The controls to the hydraulic system are activated and the lift assists the patient to a standing position, supporting some of the patient's weight.During an interview with the DON on 1/30/13 at 2:30 p.m., she stated the facility did not have a policy regarding the sit-to-stand lift and it had not been the facility practice to have a resident evaluated by Physical Therapy prior to using the sit-to-stand lift with a resident. The DON stated the CNAs are instructed on how to use the standing lift at orientation, but no further training is done. During an interview with MD 1 on 2/8/13 at 11:11 a.m., he stated that he felt the fracture was a result of the patient's contractures, twisting and osteoporosis.During an interview with MD 3 on 2/21/13 at 9:25 a.m., he stated the type of fracture Patient A sustained was caused by a "fair" amount of trauma, usually from twisting injuries. He stated that an injury of this nature could potentially be caused by extreme hyperextension of the knee, or if her leg was in a fixed position during an awkward transfer. He stated it would have been obvious right away that something was wrong with the knee. Therefore, the Department determined the facility failed to assess and consult with appropriate health professionals to ensure Patient A could be safely transferred using an appropriate lift device, based on her physical condition.These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 030001829 |
ACC Care Center |
030009946 |
AA |
03-Jul-13 |
T51C11 |
8858 |
72315 Nursing Service - Patient Care (g) Each patient requiring help in eating shall be provided with assistance when served, and shall be provided with training or adaptive equipment in accordance with identified needs, based upon patient assessment, to encourage independence in eating. The following citation was written as a result of an unannounced visit, made on 3/19/12, to initiate an investigation of Complaint #CA00302503 concerning a patient who choked on a piece of meat while on a facility outing and subsequently died. The report identified allegations the facility failed to protect the patient from the risk of eating food of a texture she could not safely consume due to her difficulty with swallowing.The Department determined the facility failed to: Provide meal assistance to Patient A, including cutting her meat into smaller pieces during a facility sponsored outing, to ensure Patient A ate foods in a form she could safely swallow.This failure resulted in Patient A consuming a large piece of meat which blocked her airway and resulted in her death. Patient A was an 86 year old female, originally admitted to the facility on 2/8/08 with diagnoses which included dementia with behavior disturbances, diabetes, and stroke.Review of the clinical record for Patient A revealed a "Mental Status Examination" dated 5/5/09 which indicated a score of 25. The "Scoring" section was highlighted on the score range for patients who have a high school education, a score of "27-30 Normal; 20-27 MCI [mild cognitive impairment], 1-19 Dementia." Review of a physician progress note, dated 5/13/09, under the heading "Dementia" indicated, "Although [Patient A] scored a 25 on the MSE [mental status examination] but she dramatically documented she could not comprehend directions and has abnormal spatial orientation, I believe the patient is able to compensate to a certain point. However with this recent examination of the clock drawing, this demonstrates the patient is unable to make sound decisions on her own." Further review of the clinical record indicated the following physician's orders:10/31/11, "May go on LOA [leave of absence]/outings for therapeutic reasons with the responsible party and/or staff, special instructions: and/or designee or recreational therapy assistants;" 6/4/11, "[Patient] has no mental capacity to make health decisions;" 6/4/11, "May deviate from therapeutic diet for planned activities;" 6/4/11, "May participate in activities not in conflict with treatment plan;" 6/6/11, "Mechanical soft, NAS [no added salt], NCS [no concentrated sugar] diet." A "Dysphagia Evaluation" (dysphagia means trouble swallowing) dated 6/7/11, reflected Patient A had moderate impairment with the oral phase of swallowing. The recommendations were for intermittent meal supervision, with a diet of soft chopped solids. A care plan for mechanically altered diet, dated 6/13/11, included the following interventions: "Encourage to eat slowly and chew food...observe for chewing problems." A Progress Note, dated 1/9/12 at 12:28 p.m., reflected "Received phone call from activities director in regards to a change in condition....patient noted to be choking and then became unconscious... Spoke with paramedic via telephone with orders to send resident to [hospital name] for further evaluation. " In an interview with Certified Nursing Assistant 1 [CNA 1] on 3/15/13 at 2:25 p.m. CNA 1 verified that she was on the facility's activity department outing to a market on 1/9/12, along with 2 other staff members and 1 volunteer. CNA 1 confirmed 5 residents were in the van and [Family Member 2 -FM 2] met the group and took [Patient A] shopping. CNA 1 confirmed the group had started eating when Patient A and FM 2 arrived at the table. CNA 1 stated she saw that Patient A "had noodles and meat." In another interview with CNA 1 on 4/19/12 at 3:28 p.m. CNA 1 stated she opened Patient A's food container to look at it, "...For sharing, we're friends." CNA 1 denied she was looking at Patient A's food as part of her responsibilities as a facility employee. In an interview with Activities Director 1 [AD 1] on 4/20/12 at 8:50 a.m. she stated, "We were already sitting...[FM 2 and Patient A] came with some food, when I saw the food I said [Patient A] you can't eat that...she was adamant about what she wants to eat...that wasn't her diet, mechanical soft, I said, 'Is that what you should have?' and she put her head down...[FM 2] told her to slow down, he moved her food away...[Patient A] was an alert resident, she knew her diet, she still insisted on that food...everyone knows that about her...When [FM 2] came back he said 'she's choking' I swept her mouth...just noodles came out...I did the Heimlich, nothing but noodles came out...[FM 2] called 911 and I called the facility." AD 1 stated she had seen meat in the patient's food and stated, "It was so much food." Review of a staff education sign-in sheet, dated 5/25/11, titled, "Choking Prevention," revealed both CNA 1 and AD 1 had attended the training. The class materials included, "Choking prevention. What can be done to prevent the injury? In many cases, choking can be prevented by: cutting food into small pieces and chewing slowly..."Review of the General Acute Care Hospital [GACH] clinical record included: A "Prehospital Care Report Summary" from the fire department crew, dated 1/9/12. The report documented the fire department arrived at 11:14 a.m. and found Patient A in "Cardiac arrest [without a heartbeat], airway [breathing] obstruction." The record included "...complete airway obstruction, no pulse. CPR initiated. Suction brought up large chunks of food, intubation [insertion of a breathing tube] [no] success...attempted intubation 2 [times without] success. Suction continued to remove chunks of food, CPR [cardiopulmonary resuscitation] maintained...to ER [emergency room]." Dictated physician notes, dated 1/9/12, titled, "Cardiopulmonary arrest" included, "Given history of choking, we attended to the airway primarily...We were able to visualize a large piece of what appeared to be meat obstructing the airway when we looked with direct laryngoscopy [a tool used for visual examination of the airway]. This was removed with a [brand name] forceps and the patient was easily intubated [artificial airway]...There was some food material/vomit coming from the endotracheal tube [artificial airway] and this was suctioned." An "Admission/Discharge Information" form, dated 1/10/12, included, "Disposition Died-expired 1/10/12...Principal Diagnoses: 1. Asphyxiation due to choking on meat; 2. Acute respiratory failure...6. Coma due to anoxic encephalopathy..." The report included, "...20 minutes had elapsed between her collapse and her arrival in the ER. The ER physician was able to remove the giant piece of meat sitting on top of the patient's glottis with forceps..." Review of the "Certificate of Death" for Patient A identified the, "Cause of Death Asphyxiation due to choking on food." During an interview with MD 1 on 4/24/12 at 10:47 a.m. MD 1 stated that when she wrote an order allowing Patient A to deviate from her therapeutic diet for activities, her goal was for the patient to have, "Foods to her liking, to get her more interested in food, but also with precautions." During an interview with Speech-Language Pathologist 1 [SLP 1] on 4/27/12 at 8:30 a.m. SLP 1 reviewed the Dysphagia Evaluation, dated 6/7/11, and stated the patient "had challenges with chewing chopped meat..." When asked if facility staff needed to cut Patient A's food, SLP 1 stated, "Yes." During an interview with Registered Dietician 1 [RD 1] on 4/27/12 at 9:05 a.m. RD 1 stated the facility's mechanical soft diets included, "chopped meat." RD 1 reviewed the picture of Patient A's food from the market, which had been taken by facility staff during the outing, and stated, "This picture is not chopped [meat]." In an interview with the Administrator and the Director of Nurses on 1/17/13 at 12:35 p.m. they stated staff meal supervision involved a, "Staff member eyeballing the [patient] to make sure they don't need help." The facility failed to provide meal assistance to Patient A, including cutting her meat into smaller pieces during a facility sponsored outing to ensure Patient A ate foods in a form she could safely swallow. This failure resulted in Patient A consuming a large piece of meat which blocked her airway and resulted in her death. These violations presented either (1) imminent danger that death or serious harm to the patients or residents of the long-term health care facility would result therefrom, or (2) substantial probability that death or serious physical harm to patients or residents of the long-term health care facility would result therefrom and were a direct proximate cause of the death of the patient or resident. |
| 030000280 |
Auburn Oaks Care Center |
030009992 |
B |
08-Jul-13 |
9YSD11 |
13096 |
72311 Nursing Services - General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition.72311 Nursing Services - General (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 72523 Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved.72527 Patients' Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (11) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. On 6/2/10 at 10:15 a.m. an unannounced visit was made to the facility to initiate an investigation of Entity Reported Incidents (# CA00196509, CA00221549 and CA00227829) regarding alleged resident abuse(s). As a result of the investigation, the Department determined that the facility failed to protect the dignity of 3 female residents or to fully implement the abuse policy when: 1. A male resident made repeated sexual assaults on female residents of the facility.2. The care plan for the sexual aggressor was not revised to provide additional security measures to protect the female residents. 3. The original care plan measures of placing a stop sign at the door to prevent female residents from wandering in was not implemented.4. The facility failed to investigate one of the allegations of abuse that was reported to the Department.Resident 1 was an 86 year old male admitted to the facility on 2/11/05. Current diagnoses included dementia with behavioral disturbances.A facility investigation report dated 8/3/09 indicated that on 7/27/09, Resident 1 had been observed in his wheelchair in the hallway next to a female, (Resident 2) who was sitting in her wheelchair. Resident 1 reached for Resident 2's hand and placed her hand in his lap. The report noted Resident 1 had been attending an activity where he was supposed to have been supervised by the staff. Resident 1 left the activity and the activity staff was unaware he had left the room. The report also indicated the staff was instructed that they must know the whereabouts of Resident 1 at all times.On 2/22/10, the facility reported Resident 1 had been found in the Activities area fondling the breasts of Resident 3. He also had one of his hands down in her pants. The follow up facility investigation indicated there were no additional findings as a result of the investigation and the facility staff was to continue to frequently observe Resident 1. On 3/15/10, the facility reported to the Department that on 3/13/10 at 9:45 p.m., Resident 4 wandered into Resident 1's room where an aide witnessed them. Resident 1 had placed one of his hands in Resident 4's blouse and was holding her breast. His other hand was holding her hand onto his penis. The follow up facility investigation dated 3/24/10 indicated there were no additional findings. The report further noted the facility staff was to continue to frequently monitor Resident 1. On 5/5/10, the facility reported to the Department that on 5/4/10 at 6:45 a.m. Resident 1 was observed to be next to Resident 2. He had placed her hand down his pants. A follow up investigation dated 6/3/10 indicated Resident 2 was witnessed with her hand in Resident 1's pants, and Resident 1 was controlling Resident 2's hand. The report further noted the Interdisciplinary Team recommended continued use of a Stop Sign at Resident 1's door. The clinical record for Resident 1 included the following information: 1. An undated Interdisciplinary Progress Note (between 9/25/09 and 1/7/10) documented that Resident 3 had been seen in Resident 1's room and Resident 1 was holding Resident 3's hand to his stomach. The staff attempted to separate the two residents, but Resident 1 would not release his grip until the staff told him they were going to get the charge nurse. The note further documented "Will place a STOP SIGN barrier on doorway to prevent wandering residents from entering this room." 2. Social Service Progress Note dated 9/30/09 indicated Resident 1 had grabbed a female resident when she entered the dining room. 3. Social Service Progress Note dated 1/5/10 noted the Executive Director had met with Resident 1 to discuss the inappropriate comments the resident made to the daughters visiting the roommate of Resident 1. The note indicated Resident 1 was being monitored for his behaviors. 4. Social Service Progress Note dated 1/6/10 documented Resident 1 was calling another resident over to give him a kiss. The unnamed resident began to cry and was removed from Resident 1's line of sight. 5. Social Service Progress Note dated 2/7/10 documented Resident 1 grabbed an unnamed female resident and was asking for a kiss. 6. Care plan for socially inappropriate behavior dated 2/11/10, "Resident has long history of making sexually inappropriate remarks to staff and other residents as well as inappropriately touching other residents and grabbing them and forcing them to touch his groin." The care plan interventions indicated the resident was to be placed in areas where constant supervision was possible. As a result of the 5/4/10 occurrence the care plan was updated to include "Monitor all activity in and out of the room, and continue use of stop sign on the door." During an interview with the Director of Nursing and the Executive Director on 6/2/10 at 3:45 p.m., they reported they were unaware a staff member had reported the 5/4/10 incident to the Department and had not investigated the allegations.In an interview with the Executive Director on 6/4/10 at 9:30 a.m., he reported Resident 1 was to be separated from the other residents while he was in public areas of the building. He reported this plan of care was implemented prior to his employment in September 2009. He reported he did not know when the use of the stop sign was first implemented. When asked what additional measures were put into place as a result of the repeated sexual assaults on the female residents, he reported the facility continued to monitor Resident 1 and use a stop sign to discourage other residents from entering the room.In an interview with the Director of Staff Development on 6/4/10 at 9:40 a.m., she reported the only changes to Resident 1's care plan for sexually inappropriate behavior after the 2/21/10 incident was to remove the resident from public places when he was sexually inappropriate. She reported she was unaware of when the use of the stop sign was first initiated, but it had been in use for awhile. She also reported Resident 1 would himself remove the stop sign, and Resident 3 had also been observed removing the stop sign.In an interview with CNA (Certified Nursing Assistant) 4 on 6/4/10 at 10:15 a.m., she reported she had witnessed the event of 5/4/10. She reported "I was walking down the hall and I saw the sign was down and I went in and I saw Resident 2 in there. Both his (Resident 1's) hand and her hand were in his pants and he was holding her hand in there. I tried to separate them. Resident 1 got mad at me. He was aggressive and he was saying she had to stay and that I shouldn't take her away. I pulled Resident 2 out of the room and went to tell the charge nurse. Resident 1 sometimes takes the sign down."In an interview with CNA 1 on 6/4/10 at 11:40, she reported she witnessed the event of 3/13/10 involving Resident 1 and Resident 4. She reported she walked past the room and she saw "Resident 4 had wandered into Resident 1's room. Resident 1 was in his bed and Resident 4 was standing next to the bed. Resident 1 had one hand down Resident 4's blouse and he had removed his brief, and grabbed her hand and held her hand on his groin area.When Resident 1 saw he was being observed he let go of Resident 4." In an interview with CNA 2 on 6/4/10 at 2:35 p.m., she reported that on 2/21/10 she was bringing a resident to the dining room where Resident 1 and Resident 3 were attending Activities. Resident 1 was sitting next to Resident 3. Resident 1 had one of his hands in Resident 3's pants and the other hand was grabbing her breast. CNA 2 reported she tried to pull Resident 3 away from Resident 1 and Resident 1 threatened CNA 2 would lose her job if she separated the two residents. CNA 2 further reported she called for assistance, as there were two activity staff members in the room both with their backs to Resident 1.In an interview with CNA 3 on 6/10/10 at 3:30 p.m., she reported she witnessed the event of 7/27/09. She reported she saw Resident 1 going down the hallway towards the dining room. Resident 2 came from the other directions and Resident 1 began to talk to Resident 2, then grabbed her hand and stuffed her hand down his pants and began to masturbate himself with her hand. CNA 3 reported a second CNA heard her calling for assistance and ran to the two residents. She heard Resident 1 tell the second CNA he wasn't doing anything.During a 1:15 p.m. observation of Resident 1 in his room on 6/2/10, with the Executive Director in attendance, the "Stop Sign" was observed hanging down along one side of the doorway, rather than being stretched across the doorway to discourage entry.The Executive Director reported the stop sign should not have been left down.The facility policy for Elder Abuse, most recently updated on 1/18/05 included the following information (In Part): 1. Page 1, #1, "No individual shall be subjected to violent, abusive, humiliating, or neglectful behaviors." 2. Page 1, #2, "This facility will fully protect the rights of each resident (regardless of physical or mental condition), for whom we provide care and treatment against all forms of physical, verbal, sexual, mental abuse, neglect, financial abuse..." 3. Page 1, #4, "The facility will enforce a policy of non-tolerance of any form of behavior that might be construed as abuse by any individual, (including resident to resident abuse of any type) family member, staff member, visitor, volunteer, student or other person(s)." 4. Page 2, #13, "The facility has internal procedures to assure that all 'alleged' or known instances of any type/form of abuse that are reported to the authorities are also reported to the Administrator or his/her designee so that each may be thoroughly investigated, the resident is properly protected during the investigation and corrective actions are implemented to prevent reoccurrences." 5. Under Guidelines, Page 6, #4, "All alleged violations will be thoroughly investigated and reported to the Administrator...or other officials in accordance with state law, within five (5) working days of an incident. 6. Page 6, #7 "The facility investigates singular events, patterns/trends that may constitute abuse...such as...sexual exploitation." 7. Procedures Section, Page 9, #1 It is the responsibility of the Director of Nurses and the Administrator to immediately investigate any allegations of abuse, received from any source.8. Under the heading of "Resident to Resident Altercations" the guidelines indicated the staff was to assess the residents involved in the altercation to determine if there were any similarities to previous events, and to determine actions needed to prevent a reoccurrence, and update the resident's care plan to reflect needs based on the assessment. 9. Under the heading of "Screening and Training of Employees" the guidelines included "The facility will ensure that "there is sufficient staff on each shift to meet the needs of the residents." Therefore, the facility failed to prevent abuse and protect the dignity of 3 female residents or to fully implement the abuse policy when: 1. A male resident made repeated sexual assaults on female residents of the facility.2. The care plan for the sexual aggressor was not revised to provide additional security measures to protect the female residents. 3. The original care plan measures of placing a stop sign at the door to prevent female residents from wandering in was not implemented.4. The facility failed to investigate one of the allegations of abuse that was reported to the Department. These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 030000280 |
Auburn Oaks Care Center |
030010045 |
A |
01-Aug-13 |
Z75H11 |
16200 |
72311(a) (1) (A) Nursing Service - General Nursing service shall include, but not limited to, the following: Planning of patient care, which shall include at least the following: Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and completed within seven days after admission.72523 Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure patient related goals and facility objectives are achieved.On 3/9/10 at 7:20 a.m., an unannounced visit was conducted at the facility to initiate an investigation of Complaint (#CA00218518).As a result of the investigation, the Department determined the facility failed to:1. Provide a comprehensive on-going assessment of Patient (Resident) A's right leg with input from health professionals involved in the care of the patient to ensure early detection of abnormal findings and provide for appropriate physician updating and timely medical interventions. 2. Ensure facility policy regarding assessment by licensed and registered nursing staff was implemented.These failures delayed the diagnosis and treatment of a major blood clot, which could have avoided the amputation of Patient A's right leg. Patient A, an 84 year old was admitted to the facility on 7/29/08 with diagnoses that included late effects of cerebral vascular disease (CVA, stroke) and atrial fibrillation (irregular and often rapid heart rhythm). The effects of the CVA lead to full loss of function for Patient A's left arm and leg. Patient A was able to use her right arm and leg.On 3/9/10 at 7:45 a.m., Patient A's clinical record was reviewed. The quarterly MDS (Minimum Data Set - an assessment tool) dated 11/4/09 documented Patient A as having no memory problems, was understood when speaking as well as being able to understand others. Patient A's functional limitation described full loss of voluntary movement on one side of her body involving her arm, hand, leg and foot. Patient A's pain was described as occurring less than daily and was usually moderate in intensity.Patient A's care plan with an onset date of 7/29/08 and target date of 2/11/10 contained the following problems: "Actual pain due to depression; atrial fibrillation; osteoarthritis (long term non-inflammatory joint disease); muscle spasm; generalized muscle weakness; osteoporosis (thinning of bone tissue and loss of bone density over time.); and debility."The approaches for these problems included the following: "Assess location, frequency, duration and intensity of pain [scale 1-10]. Document assessment. Report increased pain trend to physician." The time interval for this approach was to be done "Q (every) shift." The individual responsible for the approach as listed under "Role(s)" was "CN (charge nurse)." In this facility, a charge nurse could be a Registered Nurse (RN) or Licensed Vocational Nurse (LVN).Review of Patient A's Nurse's Notes dated 1/16/10 included the following information.LVN 3 documented at 2 p.m., "Resident (Patient A) c/o (complained of) pain 10/10 (intensity) to right leg. Norco scheduled given as ordered @ 2p.m. the time of c/o - MD (medical doctor) notified order to monitor + continue pain meds. No swelling or redness to right leg." 2:35 p.m., "Pain level decreased 3/10 resident in bed with call bell in reach." LVN 4 documented an untimed noted, "Res (resident) cont (continued) c/o pain. Last shift reported Res c/o right leg pain. Res now c/o left knee pain. Informed MD. NO (new order) Ativan (medication used for anxiety) 0.5 mg (milligrams - unit of measure) 1 po (by mouth) X (times) 1 dose TO (telephone order) PA (physician's assistant)." No time. "Res cont. to c/o pain. When asked where pain is located in left knee, then c/o pain goes to back, then to her arm. Res has no complain (sic), when being re-positioned or when staff is in the room. Ativan 0.5 mg has slight effect. Res still in room - will inform noc (night) nurse." No time. "Res right leg, left knee, arm no edema no disfiguration. Res did not c/o pain when area is palpated. Cont (continue) to c/o pain when left alone in the room."1/17/10 Nurse's Notes did not contain any information concerning Patient A's pain except to indicate the narcotic medication (Norco) for pain was administered "as scheduled" every 6 hours. Assessments of the source of Patient A's pain, such as body tenderness, discoloration, warmth swelling, range of motion and circulation were not documented. The 1/17/10 nurse's notes did not contain any notification of the physician or physician assistant (PA).1/18/10 untimed Nurse's Notes, the LVN 1 documented, "Resident c/o increased pain right leg. MD here (PA). Orders to transfer for eval (evaluation) of right leg ischemia (inadequate blood supply due to a blockage). Left message with family. (Ambulance Company) called." The above nurses' notes for 1/16/10, 1/17/10 and 1/18/10 were written by Licensed Vocational Nurses (LVNs). According to the 2010 State of California Department of Consumer Affairs Board of Vocational Nursing & Psychiatric Technicians, LVNs "provide basic bedside nursing care to clients under the direction of a physician or registered nurse. Duties within the scope of practice of an LVN typically include, but are not limited to, provision of basic hygienic and nursing care; measurement of vital signs; performance of prescribed medical treatments; administration of prescribed medications' implementation of behavioral management techniques; crisis intervention; sensory and perceptual development assessment; social and vocational training; and, the facilitation of individual and group therapeutic activities."The facility's 2/10/10 policy "Assessment and Care Planning" indicated (in part) the responsible disciplines include RN (Registered Nurse) and LVN with the following responsibilities, "The Licensed Nurse interviews, obtains data and determines needs of the resident. The RN is responsible for the analysis and synthesis of the data." According to the DON (Director of Nursing) on 6/20/11 at 1:04 p.m., this policy was the only one addressing patient assessment and responsibilities of the RN and LVN. The facility had RN staff on duty on each shift 1/16, 1/17 and 1/18/10. There was no documented evidence of RN assessment of Patient A during that time period.On 3/9/10 at 8:25 a.m., an interview was conducted with LVN 1. LVN 1 stated she provided care for Patient A on the day she was sent to the General Acute Care Hospital (GACH), 1/18/10. When questioned about Patient A, LVN 1 stated Patient A was "doing a lot of hollering and a CNA told her, she (Patient A) was having a lot of pain and was medicated and medication wasn't working." LVN 1 stated the doctor was called and she was told to transfer Patient A to the hospital. "She (Patient1) hollered out a lot but that was more than usual." Patient A "usually responds to medication." stated LVN 1. LVN 1 stated she "did not look at Patient A's leg, but I know her leg hurt."On 3/9/10 at 8:50 a.m., an interview was conducted with the MDSC (Minimum Data Set Coordinator). The MDSC stated on 1/18/10, she heard "(Patient1) screaming and crying and she asked (LVN 1) what was wrong." The MDSC stated, "That's not like her."The MDSC stated when she went into Patient A's room; the Physical Therapist Aide (PTA) was there. "Therapist was checking for capillary refill, pushing on her leg." stated the MDSC. The MDSC stated "Usually you could give (Patient A) something for pain and in a 1/2 or 1 hour she was okay. I haven't heard her cry like that in a long time." The MDSC stated she went to Patient A's room because of the crying at "somewhere between 7 and 8 in the morning." The MDSC stated she told LVN 1 to, "medicate her (Patient A), she was having severe pain in her leg." When asked if Patient A's leg was examined or viewed by a Registered Nurse, the MDSC stated, "No." On 3/10/10 at 2:09 p.m., a telephone interview was conducted with the Physician's Assistant (PA). The PA was on call for Patient's 1 physician. The PA stated he received a call from the facility on Saturday (1/16/10) "between 2 and 3 p.m." concerning Patient A's "right knee and leg pain." The PA stated the call was from LVN 3. The PA stated he asked LVN 3 if there was any "discoloration or swelling in the leg. (LVN 3) stated no." The PA stated the next call from the facility was about "3 or so hours later." The PA stated this call was from LVN 4. LVN 4 told the PA that pain was decreased and Patient A was anxious. The PA was told by LVN 4 that he inspected both of Patient A's leg and there was "no discoloration or swelling." The PA stated he did not receive any calls on Sunday (1/17/10).The PA stated when he went into the facility on Monday, 1/18/10, he examined Patient A's right leg. Patient A's right foot was "cold to touch, ischemic (inadequate supply of blood to a body part caused by partial or total blockage of an artery). Vascular surgery consult needed...Probably developed some ischemia either Sunday afternoon or evening." The PA stated Patient A's family told him there was purple discoloration of her right leg" on Sunday. The PA stated when he asked LVN 4 (on Saturday) to look at Patient A's leg and tell him what he saw, the PA stated he was told that the "pain increased with movement."Review of the 1/18/10 fax concerning Patient A sent to MD 1, time stamped 11:19 a.m., indicated the following: "Resident has been yelling out more frequently with pain. PRN (as needed) pain Rx (treatment) given. C/o (complained of) burning in R (right) leg would you please evaluate her when you come in next or you (your) PA." The response on the fax written by the PA dated 1/18/10 untimed indicated the following, "See order, ER (emergency room)."Review of Patient A's clinical record revealed a progress note written by the PA at 1:10 p.m. on 1/18/10 which included the following: "... R (right) LE (lower extremity) cool, purplish in color about mid-calf down (which per nursing is new today). Pedal pulses very weak in bilat (bilateral) feet,A/P (Assessment/Plan): leg pain bilat but physical finding concerning for R LE ischemia so will send pt (patient) out to ER (emergency room) for eval (evaluation)." Review of Patient A's 1/18/10 History and Physical from the General Acute Care Hospital (GACH) indicated: "Chief Complaint: Right lower extremity pain and discoloration. History of Present Illness: Most of the history is obtained by reviewing the records talking to the daughter over the phone. The patient is unable to provide any history and according to the records the patient had been complaining of pain in her right lower extremity and subsequent discoloration thereafter for the past 2 days and the patient said the pain was getting worse. The patient was transferred from the skilled nursing facility to GACH and from there over to (another) GACH because of a concern for a right lower extremity arterial occlusion. Physical Examination: Both extremities are cool but right lower extremity is cooler than left... Assessment and Plan: Right lower extremity blue discoloration secondary to arterial occlusion. MD presented various options including AKA - above knee amputation, versus extensive vascular surgery versus comfort care..."Review of Patient A's "Diagnostic Imaging Report" conducted at the bedside on 1/18/10 contained the following: "Clinical Indication: Possible arterial occlusion of the lower extremities. Findings: Right System: No flow identified within the common femoral artery (large artery in the thigh), profunda (deep artery in the thigh) femoral artery, or proximal superficial femoral artery. [Arteries that provide blood supply to the thigh, knee and foot.] Heterogeneous (different) but predominantly hypo-echoic material (appears dark on an ultrasound) is identified within the lumen of the common femoral and profunda femoral artery, concerning for thrombosis/clot. (Incidental notation is made of non-occlusive [not causing obstruction of a vessel] thrombosis in the right common femoral vein (DVT - deep vein thrombosis)... No flow is identified within any of the run-off vessels in the right calf." Review of Patient A's "Operative Report" dated 1/19/10 indicated: "Preoperative Diagnosis: Gangrenous (death and decay of soft tissue as a result of lack of blood to the area) right leg. Postoperative Diagnosis (after): Gangrenous right leg. Operation: "Above-knee amputation right leg and thrombectomy (surgical removal of a clot from a blood vessel) of the right femoral iliac (the chief vein in the thigh) vessels."The "Consultation Report": "Physical Examination (1/18/10): The patient had a nonviable (not capable of living) right lower extremity. It appears that the degree of ischemia is too great for too long a time... Plan: Given the condition of the right foot, the patient should undergo amputation and simultaneous attempt at reperfusion (return blood supply to the tissue) of that extremity. I (MD 3) believe reperfusion of that extremity with the degree of ischemia in the leg and foot would be a life-threatening event for her given her cardiac status, and unfortunately the patient currently is not willing to consider amputation. I spoke with the daughter eventually, as well as the granddaughter, and it was felt that this could be scheduled for the following day and they are going to attempt to come see the patient... The plan would be an above-knee amputation with femoral artery reconstruction, possible within 24 hours."On 3/29/10 at 11:16 a.m., an interview was conducted with MD 2. MD 2, a cardiologist (specialized in heart problems) stated he provided care to Patient A concerning her atrial fibrillation condition. MD 2 stated he reviewed the information of Patient A's right leg and stated "if acute occlusion occurred pain would have started then discoloration. Severe pain is associated with occlusion." MD 2 stated that the "patient examination should have included checking the temperature, color and pulses of the leg." MD 2 also stated the "gangrene means that it was going on for a while." On 8/11/11 at 8:54 a.m., a telephone interview was conducted with RN 1. RN 1 was working in the facility on 1/17/10 and 1/18/10. RN 1 stated she was able to recall Patient A, but was not able to recall any LVNs coming to her for evaluation of Patient A's condition. RN 1 also stated if there had been an evaluation conducted she would have documented the results in Patient A's clinical record.When RN 1 was questioned about the type of assessment she would have provided for Patient A's right leg, RN 1 stated the assessment would have included the "temperature, color, quality of the pulses and capillary refill."The Lippincott Manual of Nursing Practice 7th Edition 2001, states (in part) that assessment of possible arterial vascular impairment includes, "pain at rest...color changes...numbness or tingling of the toes...changes in temperature and check both extremities for similarities...pulses decreased or absent." The facility failed to: 1. Provide a comprehensive on-going assessment of Patient (Resident) 1's right leg with input from health professionals involved in the care of the patient to ensure early detection of abnormal findings and provide for appropriate physician updating and timely medical interventions. 2. Ensure facility policy regarding assessment by licensed and registered nursing staff was implemented.The failures put Patient A at risk for delay in recognition of a major blocked leg artery and missed opportunity to treat promptly and to preserve function of Patient A's only functional leg and to avoid a right leg amputation.These violations presented either (1) imminent danger that death or serious harm to the patients or residents of the long-term health care facility would result therefrom, or (2) substantial probability that death or serious physical harm to patients or residents of the long-term health care facility would result therefrom.1 |
| 030000280 |
Auburn Oaks Care Center |
030010068 |
B |
13-Aug-13 |
0B8711 |
4463 |
72527. Patient Rights - (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies and procedures available to the patient and any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To be free from mental and physical abuse. The following citation was written as a result of an unannounced visit on 1/25/11 for the investigation of complaint number CA00255452 and entity reported incident number CA00253677. The Department determined the facility failed to ensure Patient A was free from physical abuse when she was purposefully sprayed with cold water by a staff member. This failure resulted in Patient A being physically abused. Patient A was a 69 year old admitted to the facility on 7/3/10. She had diagnoses including muscle weakness, chronic pain, and difficulty walking. Patient A was self-determined and able to make her own decisions. Patient A was observed in her room on 1/25/11 at 9:30 a.m. She was alert and oriented to person, place, time, and purpose. An interview was conducted with Patient A on 1/25/11 at 9:30 a.m. She stated she had "a hard time" with certain things, such as breathing, and she moves very slowly. She indicated it was difficult to get out of bed and move much. She stated Certified Nurse Assistant (CNA) 1 came into her room and told her it was time for her shower. She told CNA 1 "all right" if she could go slowly since she didn't do well when she first got up.Patient A stated CNA 1 took her into the shower room, turned the water on, and sprayed her entire body with "ice cold water" using a hand held shower device. She stated she told CNA 1 to stop because of the cold water. She told CNA 1 the cold water spray was "on purpose" and he replied, "Maybe." Patient A stated after the incident took place several staff members told her to report the incident. She indicated after she reported the incident CNA 1 came into her room and told her "they are going to investigate" and asked her to tell everyone the incident had not occurred. Patient A stated she told CNA 1 again that it had been done "on purpose" and he again replied, "Maybe." Nurses' Progress Notes, dated 12/22/10 and 12/29/10, indicated Patient A was alert and oriented to time, place, and purpose. Documentation indicated Patient A had no memory deficits and was independent with decision making. Nurses' Notes, dated 12/26/10 (no time), indicated a staff member had reported to the Licensed Nurse (LN) that Patient A complained she had received a "very cold shower" from CNA 1. The LN documented she went into Patient A's room to talk with her. Patient A told her, "He gave me a very cold shower. He even sprinkled the cold water in my face. It kept me freezing. He is so mean." The LN notified the supervisor of the incident.An interview was conducted with the Director of Nurses (DON) on 1/25/11 at 11:45 a.m.The DON was asked if she was aware of the incident with Patient A. She stated she was informed of CNA 1 spraying Patient A with cold water while giving her a shower. The DON stated the incident was investigated and CNA 1 was terminated for abuse. She was asked for the facility policy and procedure pertaining to abuse and neglect prohibition. The policy was located in the Administrative Manual. The policy titled Elder/Dependent Adult Abuse, revised 1/18/05, was reviewed. The policy directed the following, in part: 1. "No individual shall be subjected to violent, abusive, humiliating or neglectful behavior." 2. "This facility will fully protect the rights of each resident (regardless of physical or mental condition), for whom we provide care and treatment against any and all forms of abuse or neglect." 3. "The facility will enforce a policy of non-tolerance of any form of behavior that might be construed as abuse by any individual, (including resident to resident abuse of any type) family member, visitor, volunteer, student, or other person(s)." The Department determined the facility failed to ensure Patient A was free from physical abuse when she was purposefully sprayed with cold water by a staff member. These failures had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 030000280 |
Auburn Oaks Care Center |
030010113 |
B |
29-Aug-13 |
BU0H11 |
2429 |
1418.91 Health & Safety Code (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the Department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. The following citation was written as a result of an unannounced visit to the facility on 4/6/11 to investigate complaint number CA00264448. The Department determined the facility failed to report alleged or suspected abuse to the Department within 24 hours as required by law. Patient A was re-admitted to the facility on 12/5/10. Her diagnoses included congestive heart failure and difficulty walking. Her clinical record was reviewed on 4/6/11.The quarterly Minimum Data Set (an assessment tool), dated 3/15/11, indicated Patient A had no cognitive deficits. She was able to understand and she was understood by others. She required extensive assistance with transfers and was totally dependent on staff for toileting and personal hygiene. She was always incontinent of urine and frequently incontinent of bowel. Nurse's Notes, dated 3/21/11 at 1:15 p.m., indicated Patient A had "[complained of] possible [Certified Nurse's Aide] neglect over the weekend." A Care Plan, dated 3/21/11, indicated Patient A was being monitored for "psychological harm due to resident feeling that her needs were not met timely." The Approaches section of the Care Plan included notifying the physician, family, social services, and the Ombudsman. There was no documented evidence the facility notified the Department of this allegation of abuse. An interview was conducted with the Director of Staff Development on 4/6/11 at 10:45 a.m. She stated when she arrived at work on Monday, 3/21/11, there was a note under her door from the night shift Registered Nurse regarding Patient A's allegation of neglect. She stated, "I began the investigation, completed the SOC341 (official notification form) and notified the Ombudsman. I was not aware [the Department] was supposed to be notified. The [Director of Nursing (DON)] does that part and we didn't have [a DON]." The Department determined the facility failed to report alleged or suspected abuse to the Department within 24 hours as required by law. These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 030000280 |
Auburn Oaks Care Center |
030010115 |
B |
29-Aug-13 |
BU0H11 |
4612 |
72315(b) Nursing Service - Patient Care (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. The following citation was written as a result of an unannounced visit to the facility on 4/6/11 for the investigation of complaint number CA00264448. The Department determined the facility failed to protect Patient A from neglect and physical abuse by Certified Nurse's Aide (CNA) 1. Patient A was re-admitted to the facility on 12/5/10. Her diagnoses included congestive heart failure and difficulty walking. Her clinical record was reviewed on 4/6/11. The quarterly Minimum Data Set (an assessment tool), dated 3/15/11, indicated Patient A had no cognitive deficits. She was able to understand and she was understood by others. She required extensive assistance with transfers and was totally dependent on staff for toileting and personal hygiene. She was always incontinent of urine and frequently incontinent of bowel. Nurse's Notes, dated 3/21/11 at 1:15 p.m., indicated Patient A had "[complained of] possible CNA neglect over the weekend." An interview was conducted with Patient A on 4/6/11 at 10:20 a.m. She stated she had been a patient at the facility for "about a year." She stated CNA 1 had cared for her in the past and "she had an attitude." She stated she had asked not to have CNA 1 care for her and had not had her for "a while." She stated she remembered asking CNA 1 to change her brief and CNA 1 told her, "I'll get to you when I can." Patient A stated she kept calling for assistance and "3 1/2 hours later she came back." Patient A stated when she asked CNA 1 for the bed control, "she threw it at me and it hit my shoulder. Then she threw the call light at me. It didn't hit me, but I don't know why she had to throw things. I would rather lie here and die than have her take care of me." The facility investigation of Patient A's allegation of neglect was reviewed. The written statement from the Registered Nurse (RN) on the night shift of 3/20/11 indicated Patient A had turned on her call light at 11 p.m. and told CNA 1 that she needed to be changed. Patient A complained that CNA 1 told her she had "just been changed by the PM shift and you have to wait two hours. [Patient A] said the CNA threw the call light and she said she is rough with me. [Patient A] asked the CNA if she can talk to the nurse, CNA said he's taking his break. [Patient A] was upset and she doesn't want to have that CNA back. She said this is not the first time [CNA 1] has done this to her."A written statement by CNA 1, dated 3/22/11, was reviewed. The written statement confirmed CNA 1 was assigned to Patient A on the night shift of 3/19/11. Her statement indicated Patient A put her call light on around 11:30 p.m. to 12 a.m. Patient A stated, "I am wet and need my diaper changed." CNA 1 indicated she checked Patient A's Attend (diaper) and "had all yellow lines only two lines were blue, but they were in the front of the Attend. I believe it was not necessary to change her Attend at that time. Also the PM shift CNA had changed her Attend around 10 p.m. I let [Patient A] know her Attend was not 'wet' and that I would return later to check her Attend." The facility investigation included a review of CNA 1's "previous complaints. The complaints included the residents requesting [CNA 1] not be assigned to care for them. During those complaints [CNA 1's] schedule was changed to day shift to provide increased supervision and training. Due to the present allegations and history of complaints, [Director of Staff Development (DSD)] advised [CNA 1] she would need to be on a Monitoring Program for at least two weeks. The Monitoring Program would be on day shift Monday through Friday." The investigation indicated CNA 1 did not accept the plan and resigned on 3/28/11. An interview was conducted with the DSD on 4/6/11 at 10:45 a.m. She stated the facility felt Patient A was alert and oriented and "wouldn't make up a story." She stated the facility had offered CNA 1 a position on day shift where there would be more supervision, but she declined and then resigned." The facility Elder/Dependent Adult Abuse policy, dated 3/2/11, was reviewed. The policy directed that "no individual shall be subjected to violent, abusing, humiliating, or neglectful behavior." The Department determined the facility failed to protect Patient A from neglect and physical abuse by CNA 1. These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 030000012 |
Avalon Health Care - San Andreas |
030010160 |
B |
04-Oct-13 |
UM5711 |
5183 |
F323 - Free of Accident Hazards/supervision/devices 483.25(h) The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The following citation was written as a result of an unannounced visit on 12/28/10 for the investigation of a facility reported incident number CA00242479. Resident 1 suffered a fall that occurred while being transported in the facility van in his wheelchair. The fall resulted in Resident 1 hitting the back of his head on the floor of the van and sustaining a laceration. He required two days of hospitalization for evaluation. The Department determined the facility failed to ensure Resident 1's wheelchair was properly restrained in the van while the van was in motion. Resident 1 was admitted to the facility on 10/27/08 with diagnoses including dementia. The Minimum Data Set, an assessment tool, dated 8/17/10, indicated Resident 1 required extensive assistance with bed mobility and with moving around in and out of the facility in his wheelchair. Resident 1 was totally dependent in transferring from his chair to his bed and he did not walk. On 9/10/10 the Department received a report from the facility that Resident 1 had been injured on 8/30/10 while being transported in the facility van to an appointment. The report indicated Resident 1 had sustained a laceration to the back of his head and he had bitten his lip. The report also indicated Resident 1 had been sent to an acute care hospital near the facility. From there he had been transferred to a larger regional hospital for evaluation. Resident 1 returned to the facility on 9/2/10. The Facility Verification of Investigation Report, dated 8/30/10, included a detailed description of the event. "Resident was being transported in facility van to a clinic appointment. Employee was stopped at a red light on an incline. When light turned green employee accelerated abruptly due to the incline and the wheelchair fell backwards onto the floor." The Incident Log note, dated 8/3/10, indicated, "[Driver 1] called to report an accident during a transport of [Resident 1]. She stated they were on an incline at a stop light in Sonora. When the light turned green she had to accelerate abruptly due to the incline and she noticed the wheelchair fall backwards and the resident fell hitting his head on a metal piece on the floor of the bus. She called 911 for transport to the [emergency room]." The Incident Log note, dated 9/10/10, indicated, "[Driver 1] was asked to demonstrate in the bus (van) what had occurred. She stated that she used a three (3) point tie-down (immobilizing technique to prevent a wheelchair from rolling while in the van) of a wheelchair, both back legs of the chair and the left front. When questioned why she didn't tie the right front she stated it wasn't necessary. 'I've been driving for years and never restrained four (4) points.'" A Performance Review for Driver 1, dated 9/15/10, indicated, "[Driver 1] failed to follow tie-down requirements as outlined in the 'QRT' training for transport of resident in the facility van. [Driver 1] acknowledges she watched the 'QRT' training video upon hire." The Performance Review indicated Driver 1 had committed a "violation of the safety rules." An Investigation Checklist, dated 8/30/10, indicated Supervisor 1 for Driver 1 had noted, "[Driver 1] failed to do a four point tie-down." The Facility Verification of Investigation Report, dated 8/30/10, identified the causal contributing factor to the fall as "Employee failed to use a four (4) point tie-down of the wheelchair." The outcome of the investigative findings was "[Driver 1] did in fact violate safety rules." An interview was conducted with Supervisor 1 on 12/28/11 at 12:55 p.m. She stated she had originally trained Driver 1. She stated the van transportation training material included a video that directed the driver's to use a tie-down on all four corners of the wheelchair when being transported in the van. She stated she was "surprised" to learn Driver 1 had only been using 3 tie-downs when immobilizing the wheelchairs. She indicated that was not how she had trained Driver 1 to immobilize the wheelchairs. An interview was conducted with the Administrator on 1/3/12 at 2 p.m. He stated he had asked Driver 1 to demonstrate how she had immobilized the wheelchair. Driver 1 had demonstrated she had tied the wheelchair on three of the corners. At the time of the demonstration Driver 1 had told him it was her common practice to use only three tie-downs when immobilizing the wheelchairs. He stated facility practice and manufacturer's recommendations required wheelchairs be immobilized by four ties. He stated Driver 1 had not followed the facility practice when she had only used three ties to immobilize the wheelchair. The Department determined the facility failed to ensure Resident 1's wheelchair was properly restrained in the van while the van was in motion. This violation had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 030000012 |
Avalon Health Care - San Andreas |
030010381 |
B |
16-Jan-14 |
FJ5H11 |
3888 |
F323 - 483.25 -- Free Of Accident Hazards/supervision/devices (h) The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. On 5/18/12 at 9:30 a.m. an unannounced visit was made to the facility to investigate an entity reported incident number CA00301391, of a resident who sustained a fractured right ring finger when a Certified Nursing Assistant (CNA) did not verify the resident's hand was free from the wheelchair wheels prior to pushing the wheelchair.The Department determined the facility failed to ensure Resident 1 was protected from accidental injury when his finger became caught in the wheel of the wheelchair as the CNA pushed it. This failure resulted in a fractured finger that required emergency treatment. Resident 1 was admitted to the facility on 2/13/12 for rehabilitation following a hip fracture. The Admission Minimum Data Set (an assessment tool) completed on 2/20/12, indicated he had short and long term memory problems and had some cognitive difficulties in new situations.The clinical record for Resident 1 contained the following information: A nurse's note, dated 2/26/12 at 4:58 p.m., indicated Resident 1 had sustained an injury to the right ring finger, with skin and nail appearing torn. The resident reported it was painful but declined pain medication. Physician orders were received to send Resident 1 to the acute hospital for an evaluation. A 2/26/12 X-ray report from the acute care hospital identified the presence of a fracture of the end of Resident 1's right ring finger. A 2/26/12 care plan provided care instructions relating to Resident 1's fractured right ring finger.Physician orders, dated 2/26/12, directed nursing staff to administer 500 milligrams of Keflex, an antibiotic, every 6 hours for 7 days for Resident 1's open wound to finger. Physician orders, dated 2/28/12, directed nursing staff to clean Resident 1's right ring finger and apply dressing daily.Physician orders dated 2/28/12 directed nursing staff to remove sutures from Resident 1's right ring finger on 3/10/12. The investigation report included the following: A documented interview with CNA 1 noted she had been attending to Resident 1 when his hand became caught in the spokes of the wheelchair, she reported Resident 1 was in his wheelchair up against his dresser and she went to turn the wheelchair from the dresser. "I went to turn it away from the dresser, not realizing his fingers were in the wheel. He pulled his hand up and looked down and saw that it was injured". A 2/28/12 Huddle Attendance Form indicated CNA 1 had been provided additional training for "Procedures when moving resident in wheelchair". The document indicated the Director of Staff Development (DSD) had met with CNA 1 and instructed her, "When moving residents in wheelchair-check position of hands and feet. That feet are elevated and hands in lap or resting on arms of wheelchair." In an interview with the DSD on 5/18/12 at 11:30 a.m. she reported it was a standard of practice for CNA staff to check to make sure residents' hands are free from the wheels of the wheelchair before moving the wheelchair. In an interview with CNA 1 on 5/29/11 at 3:30 p.m. she reported she recalled the incident and verified she had not checked to ensure Resident's 1's hands were free from the wheel before she repositioned the wheelchair. Therefore, the Department determined the facility failed to ensure Resident 1 was protected from accidental injury when his finger became caught in the wheel of the wheelchair as the CNA 1 pushed it. This failure resulted in a fractured finger that required emergency treatment.These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 030001829 |
ACC Care Center |
030010383 |
B |
29-Jan-14 |
YS9P11 |
3752 |
72523 Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved An unannounced visit was made on 4/19/12 to initiate an investigation of facility reported event # CA00300015, concerning a fall resulting in a fractured hip.As a result of the investigation, the Department determined the facility failed to:Follow its policy which required the use of a gait belt (a seatbelt like device secured around a patient's waist, which is held by the staff member during a transfer to help steady a patient) while walking with Patient 1, who fell and sustained a hip fracture requiring surgery. Patient 1 was admitted to the facility on 9/3/11 with diagnoses which included dementia and a prior hip fracture. A full Minimum Data Set (MDS, an assessment tool) dated 9/3/11 described the patient as needing extensive assistance from 1 staff member to transfer and to walk. In an observation of Patient 1 on 4/19/12 at 4:10 p.m., Patient 1 was sitting in her wheelchair in the hallway. She wore skin protective sleeves on both arms. During a concurrent interview with Patient 1 on 4/19/12 at 4:10 p.m., Patient 1 was alert and responded to questions. She denied being in pain, and did not recall having experienced a fall or injury. Review of the clinical record for Patient 1 revealed: -A "Fall Risk Assessment" dated 12/2/11 which documented Patient 1's fall risk score was "13." The form included: "A Resident whose score is over 9 is at risk for falls. Consider environmental risk factors in the resident's interventions. Consider addition or removal of balance mobility devices." -A "Fall Risk Assessment" dated 2/14/12 documented the patient's fall risk score was "15," indicating higher risk for falling than the prior quarter. -A Nurse's Note dated 2/16/12 at 6:15 a.m. documented the patient fell and bumped her head and complained of right hip pain. -A Nurse's Note dated 2/16/12 at 11:03 a.m. documented "Fall was an assisted fall" which occurred while a Certified Nursing Assistant (CNA) was walking the patient to the bathroom. -A Nurse's Note dated 2/16/12 at 6 p.m. documented the patient was transferred to a general acute care hospital (GACH) following fracture of her right hip. During an interview with CNA 1 on 4/25/12 at 9:45 a.m., CNA 1 stated "I went to get [Patient 1] up to the bathroom, she took her first step, didn't complete it and fell to the right, away from me. I didn't have my gait belt, that was the biggest mistake." Review of the GACH "History and Physical" report dated 2/17/12 included "She has an impacted femoral neck fracture ["hip fracture"] on the right...needing an ORIF [surgical repair of the hip] for this." Review of facility policy titled "Gait Belts" dated 8/94 included: "To ensure optimum safety of residents and nursing personnel, gait belts will be used for each resident transfer or ambulation requiring assistance, unless contraindicated by the resident's medical condition...The Nursing Assistant will apply the gait belt around the waist of a resident before transferring or ambulating." Review of a facility "Written Warning" for CNA 1, dated 2/17/12, included, "It was determined that on Thursday February 16, 2012 you failed to use gait belt when transferring [Patient 1]. Failure to use gait belt as trained resulted in the resident falling and sustaining a fractured hip." Therefore, the Department determined the facility failed to: Follow its policy which required the use of a gait belt while walking with Patient 1, who fell and sustained a hip fracture requiring surgery. This failure had a direct relationship to the health, safety, or security of patients. |
| 030000012 |
Avalon Health Care - San Andreas |
030010495 |
A |
26-Feb-14 |
VH1H11 |
26153 |
F323 Free of Accident Hazards/Supervision/DevicesThe facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The following citation was written as a result of an unannounced visit on 5/18/12 for the investigation of entity reported incident number CA00301630. The Department determined the facility failed to provide adequate supervision and interventions to prevent Resident 1 from falling on 2/28/12, resulting in a left hip fracture.Resident 1 was a 93 year old admitted to the facility on 10/6/11. He had diagnoses including fainting, abnormality of gait, adult failure to thrive, a history of temporary stroke, a history of falls, and Alzheimer's disease. Resident 1 fell 22 times between admission on 10/6/11 and his transfer to the hospital on 2/28/12 for the fracture of his left hip. He also placed himself on the floor on an additional 4 occasions.A Fall Risk Assessment, dated 10/19/11, listed Resident 1's score as 18. The form indicated, "Score - 10 or more indicates higher risk for falls." Also indicated was, "Score - 10 or more must be care-planned." A Fall Risk Assessment, dated 1/16/12, listed Resident 1's score as 21.Resident 1 had a "New Admit" care plan initiated after his admission to the facility. One of the problems listed was "Potential for Fall." The Approaches included, "Assist resident with transfers/[activities of daily living (ADL's)] as needed" and "Assist resident to the restroom..."Departmental Notes by a Licensed Nurse (LN), dated 10/7/11 at 2:50 p.m., indicated Resident 1 "needs constant monitoring and observation due to poor safety awareness and Alzheimer's [diagnosis]."Departmental Notes by a LN, dated 10/7/11 at 8:22 p.m., indicated Resident 1 "does not follow directions. Noncompliant with transfers and ambulation. Noted multiple times by staff ambulating without assistance...requiring extensive staff supervision due to constant attempts to stand and ambulate. Tabs alarm in place." A Tabs alarm is an alarm box with a string that attaches from a stationary object, such as a chair or bed, to the clothing of the resident. If the string becomes detached from the alarm box, an alarm sounds. Departmental Notes by a LN, dated 10/9/11 at 5:49 p.m., indicated Resident 1 "continues to stand, attempt to [ambulate] without assist from staff. Reeducated constantly to use call light. Unable to comprehend due to [diagnosis] of Alzheimer's." Departmental Notes by a LN, dated 10/11/11 at 6:31 p.m., indicated Resident 1 "continues to require extensive assist and [one to one (1:1)] care." 1:1 care is the assignment of one staff person to continuously attend to a resident to ensure their safety or the safety of others.Departmental Notes by a LN, dated 10/19/11 at 6:13 p.m., indicated Resident 1 "was found on the floor in front of his [wheelchair]...No injuries noted." The "New Admit" care plan was updated to include "Bilateral 1/4 bedrails used for mobility." There were no updates to specifically address Resident 1's fall from his wheelchair. There was no documented evidence a Fall Trend Investigation Report was completed following this fall. Departmental Notes by a LN, dated 10/23/11 at 9:05 p.m., indicated, "At 8:10 PM called to lobby by Certified Nurse Assistant (CNA) Resident noted to be laying on the ground by wheelchair. States he stood up and staggered and then fell...No injury noted...Alarms in place." There were no updates to the care plan for falling. A Fall Trend Investigation Report was completed on 10/28/11. The report was reviewed by the Fall Committee. The report indicated Resident 1 was identified as a fall risk prior to the time of the fall. Measures taken after the fall to reduce risk of a repeat fall included, "Frequent observation." There was a recommendation to add "Autolock Brakes" to the wheelchair, which was added to the "New Admit" care plan on 10/28/11. Autolock Brakes lock the wheelchair automatically when a person rises from the wheelchair. They disengage when the person sits down. Departmental Notes by a LN, dated 11/7/11 at 4:03 a.m., indicated, "Resident was sitting in [wheelchair] at nurses station when he attempted to stand up. CNA saw him starting to stand and rushed to his side. Resident fell on left hip and left shoulder...Required extensive assistance through night. Residents alarm sounded throughout the night and could not give any answers as to what the problem was." No injury was found. There was no documented evidence a Fall Trend Investigation Report was completed following this fall. Departmental Notes by a LN, dated 11/7/11 at 9:43 p.m., indicated, "At 7:00 PM tonite, alarm sounded from wheelchair, CNA ran to help but resident was already on the floor." No injury was found. There was no documented evidence a Fall Trend Investigation Report was completed following this fall. Departmental Notes by a LN, dated 11/8/11 at 2:53 p.m., indicated, "Resident found laying on his right side in room 26 in front of his [wheelchair]. He states he hit his head...No [complaint of pain]...Sustained a skin tear to his right upper back." There was no documented evidence a Fall Trend Investigation Report was completed following this fall. Departmental Notes by a LN, dated 11/11/11 at 4:44 a.m., indicated, "Resident alarm was sounding and CNA found resident kneeling next to bed...No injuries or pain/discomfort." A Fall Trend Investigation Report was completed on 11/11/11. Measures taken after the fall to reduce risk of a repeat fall included, "Mats [at] bedside." There were no additional interventions documented in light of the additional three falls from the wheelchair that had occurred since the prior Fall Trend Investigation Report on 10/28/11. The "New Admit" care plan was updated to include, "Mats on floor [at] bedside." Departmental Notes by a LN, dated 11/11/11 at 10:53 p.m., indicated, "Multiple persistent attempts to stand and walk unassisted. Alarm sounding, staff approached resident as he tried to stand and fell to his knees in front of his [wheelchair]. No apparent injuries...[Physician] ordered lap buddy or seat belt, whichever is effective for resident's safety. Lap Buddy applied, resident removed lap buddy within one hour of application to [wheelchair]. Resident has bed alarm and Tabs alarm in place at all times. Resident becomes very agitated with multiple requests for him to stay seated. Toileted and offers of food and drinks with each attempt to stand." A lap buddy is a soft device that attaches to the wheelchair and fits snugly between the resident and the wheelchair frame to prevent leaning forward and to remind residents not to stand up.There was no documented evidence a Fall Trend Investigation Report was completed following this fall. Departmental Notes by a LN, dated 11/17/11 at 5:19 a.m., indicated, "Resident had fall X 2 this shift. Resident is extremely combative during evening shift that carried on through the [night] shift...Resident taken to restroom on multiple occasions...Resident unable to state that he wants or needs anything...Extensive 1:1 care needed this shift at all times." A Fall Trend Investigation Report was completed on 11/17/11. Measures taken after the fall to reduce risk of a repeat fall included, "Scheduled toileting program." The "New Admit" care plan was updated to include a scheduled toileting program, despite the information provided in the Departmental Notes indicating the resident's restlessness was not an indication of his need to use the toilet. Departmental Notes by a LN, dated 11/17/11 at 5:19 a.m., indicated, "New order Ativan 0.5 [milligrams (mg) orally every] 8 hours for anxiety." Departmental Notes by a LN, dated 11/20/11 at 12:18 p.m. as a late entry for 11/17/11, indicated, Resident 1 "displays ongoing anxiousness and agitation. He is restless on a daily basis, with multiple restless episodes throughout the day...He reaches for objects that do not belong to him, and goes into other residents' belongings. When this occurs, staff assesses for toileting needs, assesses for hunger and thirst, offer activities such as simple games. These attempts are not successful...One on one interaction has been provided during these episodes of agitation...Agitation continues despite these interventions." Departmental Notes by a LN, dated 11/22/11 at 10:31 p.m., indicated, "Saw resident standing and walking towards door, ran to assist could not get there in time Resident lowered self to floor sitting on bottom between bed one and bed two...No injury...Requires extensive one to one care." A Fall Trend Investigation Report was completed on 11/23/11. Measures taken after the fall to reduce risk of a repeat fall included, "Frequent observations...Move closer to the nurses station...reclining wheelchair." The notes did not address the rationale for the use of a reclining wheelchair. The "New Admit" care plan was updated to include moving closer to the nurse's station and a reclining wheelchair. Departmental Notes by a LN, dated 11/30/11 at 4:19 p.m., indicated, "Speech therapist was walking past residents room & noticed him on the floor up against the wall in the doorway of his room...[No] injuries noted. Alarm not sounding." A Fall Trend Investigation Report was completed on 12/2/11. Measures taken after the fall to reduce risk of a repeat fall included, "Resident doesn't like to be alone. Attempt to keep in group setting." The "New Admit" care plan was updated to include, "[Increased] involvement in activities. Attempt to keep in group settings." Departmental Notes by a LN, dated 12/4/11 at 12:25 a.m., indicated, "Resident attempted to stand out of [wheelchair] in room with wife present. He fell back on his butt as his head hit the foot of his bed...Residents wife stated that she 'does not feel safe leaving him here with the staffing the way it is. There is not enough staff here to take care of him!'...Nurse got OK from administrator to have a 1:1 staff member with him all night due to the fact that he would not settle down and stay in his [wheelchair] or bed."A Fall Trend Investigation Report was completed on 12/10/11. Measures taken after the fall to reduce risk of a repeat fall included, "Family education to call for help. 1:1 care provided by nursing day of fall." The "New Admit" care plan was not updated. Departmental Notes by a LN, dated 12/4/11 at 12:10 p.m., indicated, "New order for Ambien 5 mg [orally at hour of sleep]. Resident is unable to sleep at [night]. All attempts to help him sleep, provide calm, quiet room, assess pain, offer food, drink, offer back rub, were unsuccessful...Resident is very confused, has no safety awareness, attempts to stand and [ambulate] without assist. He does not understand how to use call light or ask for assist. Tabs alarm on bed, [wheelchair]...He requires total care for meals, dressing, oral care, grooming, toileting, transfers." Departmental Notes by a LN, dated 12/5/11 at 1:12 p.m., indicated, "New order Ritalin 5 mg orally every eight hours for anxiety." Departmental Notes by a LN, dated 12/6/11 at 9:48 p.m., indicated, "Constantly trying to climb out of [wheelchair] removing Tabs alarm, increased supervision provided." Departmental Notes by a LN, dated 12/10/11 at 5:26 a.m., indicated, "Resident extremely agitated. Kicking, hitting, squeezing and trying really hard to stand up (very unbalanced). Resident has been very combative for no reason as far as we can tell. Multiple attempts at food, fluids and bathroom attempts. 1 time Haldol (psychotropic medication) 0.5 mg [injection] from [physician's assistant], and 1 hour after initial Haldol to administer 0.5 mg [injection] again." This was a one-time order. Departmental Notes by a LN, dated 12/10/11 at 1:43 p.m., indicated, "No attempts at this time to stand or transfer without assist." Departmental Notes by a LN, dated 12/11/11 at 12:10 p.m., indicated, "Resident cheerful and cooperative with staff." Departmental Notes by a LN, dated 12/12/11 at 1 a.m., indicated, "Resident was found in hall from his bed on his knees pushing his [wheelchair] down the hall. No injuries noted...Requiring 1:1 almost all night." A Fall Trend Investigation Report was completed on 12/12/11. Measures taken after the fall to reduce risk of a repeat fall included, "Add [reclining wheelchair]." A reclining wheelchair had previously been recommended by the Fall Committee on 11/23/11. The "New Admit" care plan was not updated. Departmental Notes by a LN, dated 12/23/11 at 1:24 p.m. as a late entry for 12/19/11, indicated, Resident "was sitting in his wheelchair in the day room, moving himself down in the chair by sliding his feet, as he slid from his chair onto his buttocks onto the floor...no injuries noted." A Fall Trend Investigation Report was completed on 12/23/11. Measures taken after the fall to reduce risk of a repeat fall included, "Research purchase of [reclining wheelchair]." This was the third time the Fall Committee had recommended the use of a reclining wheelchair. An additional note written on the Report, dated 12/28/11, indicated, "[Reclining wheelchair] would not allow [resident] to have [independent wheelchair] mobility, as this device would [decrease] functional ability."An Interdisciplinary Resident Care Plan - Falls was initiated as an update on 12/27/11. The care plan indicated approaches including, "Post 'fall alert' symbol on resident door; Implement falling star program; Assist with transfers and ambulation as needed; Assist resident to the rest room; Personal alarm to bed/wheelchair as ordered; and, Scheduled toileting [every 2 hours] while awake [every 4 hours at night]."Departmental Notes by a LN, dated 12/27/11 at 9:40 p.m., indicated, Called to room by CNA Resident noted to be sitting on bedside mat. Bed in low position. Per [CNA] Resident's alarm sounded and by the time she got in the room she found him sitting on the floor." There was no documented evidence a Fall Trend Investigation Report was completed following this fall. Departmental Notes by a LN, dated 1/3/12 at 1:34 p.m., indicated, "At 0600, resident's alarm was heard from room, upon entering room, resident found on floor...No injuries noted."There was no documented evidence a Fall Trend Investigation Report was completed following this fall. Departmental Notes by a LN, dated 1/5/12 at 1:11 a.m., indicated Resident 1 was "extremely anxious this shift." An order was received from the Physician's Assistant to give Haldol 2.5 mg now and then 2 mg twice a day orally. Departmental Notes by a LN, dated 1/6/12 at 1:28 a.m., indicated the Haldol order was changed to 4 mg twice a day orally. Departmental Notes by a LN, dated 1/6/12 at 5:08 a.m., indicated, "Unwitnessed fall. Resident was sitting in [wheelchair] in solarium and said 'The floor looked more comfortable.' Resident stated that he lowered himself to the floor from [wheelchair] to lay down...No injuries found." A Fall Trend Investigation Report was completed on 1/6/12. Measures taken after the fall to reduce risk of a repeat fall included, "Increase ambulation with CNAs." Departmental Notes by a LN, dated 1/9/12 at 4:17 p.m., indicated, "CNA's heard residents alarm sounding & when they entered the room he was sitting on the floor next to his bed." There was no documented evidence a Fall Trend Investigation Report was completed following this fall. Departmental Notes by a LN, dated 1/13/12 at 7:28 p.m., indicated, "Resident found on lobby floor next to wheelchair, alarm going off. No known injuries noted." A Fall Trend Investigation Report was completed on 1/16/12. Measures taken after the fall to reduce risk of a repeat fall included, "Staff education [regarding] toileting program." Departmental Notes by a LN, dated 1/17/12 at 3:56 p.m., indicated, "Resident was [ambulating] without assist at 7 am, fell in hallway, landed on the floor on his buttocks and tried to break his fall by using his left arm causing a skin tear 4 [centimeters] long." The skin tear was on his elbow. There was no documented evidence a Fall Trend Investigation Report was completed following this fall. Departmental Notes by a LN, dated 1/19/12 at 3:21 p.m., indicated, "Noncompliant with transfers, ambulation. Unable to comprehend to use call lite due to his Alzheimer's. Requires constant 1 on 1 assist." Resident 1 had a Physician's Order, dated 1/26/12, for Haldol 4 mg twice a day. The order was changed on 1/31/12 to once a day. Departmental Notes by a LN, dated 2/5/12 at 5:56 p.m., indicated, "Per wife resident was reaching for something on the floor and slid to the floor onto his knees to look for the object. Wife also stated that resident did not fall but [got] onto his knees . No injuries noted." A Fall Trend Investigation Report was completed on 2/6/12. Measures taken after the fall to reduce risk of a repeat fall included, "Evaluation by therapy for use of [enclosed] walker" and "Staff education [and] toileting program." An enclosed walker is a walker/chair combination with a framework around it to prevent falls, but allow for independent ambulation. The Falls care plan was updated to include, "Evaluation by therapy for use of a [enclosed] walker." Departmental Notes by a LN, dated 2/8/12 at 2:30 p.m., indicated, "[Patient] found on floor in front of recliner chair. [Patient] sitting in chair prior to incident." A Fall Trend Investigation Report was completed on 2/9/12. Measures taken after the fall to reduce risk of a repeat fall included, "[Occupational Therapy evaluation] for use of [enclosed] walker." The Falls care plan was updated to include, "Working [with Occupational Therapy] for use of [enclosed] walker." Resident 1 had a Physician's Order, dated 2/13/12, for Occupational Therapy 5 times a week for 1 week, then 3 times a week for 1 week for training to ambulate in [enclosed] walker and establish RNA (Restorative Nursing Assistant) ambulation program. Departmental Notes by a LN, dated 2/13/12 at 7:37 p.m., indicated, "[Patient] was found next to [wheelchair] on floor. Unwitnessed fall. [Patient] alert [patient] talking [patient] stated he was trying to go around the hall when his foot got stuck." A Fall Trend Investigation Report was completed on 2/14/12. Measures taken after the fall to reduce risk of a repeat fall again included, "[Occupational Therapy evaluation] for use of [enclosed] walker." The Falls care plan was not updated. Departmental Notes by a LN, dated 2/16/12 at 7:28 p.m., indicated, "[Patient] found on floor in front of [wheelchair] in [patients] room...no injuries noted...states he was trying to open drawer." A Fall Trend Investigation Report was completed on 2/17/12. Measures taken after the fall to reduce risk of a repeat fall again included, "Social Service Interventions - schedule care conference [with] family" and "Evaluation by therapy - continues on [Occupational Therapy] treatment for use of [enclosed] walker." The Falls care plan was not updated.A Care Plan for "Abnormality of Gait" was developed on 2/17/12. The care plan indicated approaches including, "Place resident close to nurses station; Use reclining wheelchair; Increase involvement in activities, attempt to keep in group setting to encourage interaction with others; Autolock brakes on wheelchair; Mattress on the floor at bedside when resident is in bed; Assist with transfers and ambulation, as needed; Ensure call-light is in reach and answered promptly. Encourage resident to await assistance; Orient/Re-orient to time of day/tasks and surroundings, as needed; Scheduled toileting; RNA ambulation; [Occupational Therapy evaluation] for use of a [enclosed] walker; Care conference (social service intervention)." An Occupational Therapy Progress Summary, dated 2/18/12, indicated, "[Patient] trying to get out of wheelchair - sliding underneath lap buddy - [maximum assist with 2] to pull him up in chair. Unsafe & confused in [wheelchair] - not safe to be in [enclosed] walker [without] constant 1 on 1 assistance." Resident 1 had a Physician's Order, dated 2/22/12, to discontinue the Haldol. Departmental Notes by a LN, dated 2/24/12 at 1:56 p.m., indicated, "Attended a meeting this afternoon regarding physical restraints for resident. Wife, daughter and local ombudsman was in attendance. Wife is requesting a lap buddy. Administrator notified wife and daughter of negative affects from using a restraint such as a lap buddy, including skin breakdown, decrease mobility, possible injury from tipping over. Reviewed all other measures attempted including pain assessment, frequent toileting, redirection and repositioning in [wheelchair]. However these measures were not effective. A [enclosed] walker was suggested for the resident to use. As it is a less restrictive measure, when he is anxious or wanting to walk. Family agreed that was a good plan. Resident is no longer on therapy. He is working with the RNA program. Spoke with CNA from restorative program. She states that even with the [enclosed] walker resident needs two person assistance with ambulation due to tendency to cross both feet every few steps. Resident will continue to work with RNA program and we will continue to monitor results." Departmental Notes by a LN, dated 2/26/12 at 9:49 p.m., indicated, "CNA responded to wheelchair alarm and found resident lying on his left side in hallway." There was no documented evidence a Fall Trend Investigation Report was completed following this fall. Departmental Notes by a LN, dated 3/1/12 at 11:03 a.m., indicated a fall occurred on 2/28/12 with no time specified. The note indicated, "Nurse called down to B wing solarium. [Resident] was found by housekeeper lying on floor on his left side...expressed pain and unable to move left lower extremities. Transported to [Emergency Room] by ambulance."A History and Physical form from the acute care hospital, dated 2/29/12, indicated Resident 1 had sustained an acute left hip fracture. The Discharge Summary from the acute care hospital, dated 3/8/12, indicated Resident 1 underwent a left hip hemiarthroplasty (surgery to replace the upper portion of the femoral bone of the upper leg) on 3/3/12. He also developed left wrist drop during the hospitalization of new onset, "likely secondary to peripheral nerve syndrome, maybe brachial plexus injury." The brachial plexus is the network of nerves in the upper spinal that control the muscles of the chest, shoulder, arm, and hand. Brachial plexus injuries are caused by damage to those nerves. A left wrist x-ray was negative for fracture. Payroll records for the period of time Resident 1 was in the facility were reviewed. The records indicated 1:1 staff had been provided to Resident 1 on only 4 days; 12/3/11, 1/8/12, 1/11/12, and 1/17/12. No records were provided to validate the days the Departmental Notes indicated 1:1 care was provided. An interview was conducted with the Director of Nursing (DON) on 5/30/12 at 12:15 p.m. She confirmed the payroll records reviewed identified all the days Resident 1 had a staff assigned to him. She stated there was no indication 1:1 staffing had been provided on other days, despite the Departmental Notes indicating 1:1 staffing was provided.An interview was conducted with the DON on 8/7/12 at 4 p.m. She verified there were no other payroll records demonstrating 1:1 staff had been provided to Resident 1 on any days other than the 4 days identified in the records. She verified the facility staff had implemented a variety of fall prevention measures which had proven to be ineffective, leaving the alarms as the primary manner of preventing falls. She verified Resident 1 had fallen from his wheelchair a "significant number of times" despite the use of the personal alarms.An interview was conducted with LN 1 on 5/18/12 at 1:15 p.m. She stated Resident 1 needed extensive assistance with ambulation. He had a chair alarm and a bed alarm and they would go off constantly, so the staff tried to keep him at the nurses' station. An interview was conducted with CNA 1 on 6/21/12 at 10:15 a.m. She stated Housekeeper 1 had reported to her that Resident 1 had fallen on 2/28/12. She stated the alarm was in place on the wheelchair; however, the tab was not clipped to the resident's clothing. An interview was conducted with LN 2 on 6/21/12 at 10:35 a.m. She stated Resident 1 had an alarm, but he would stand up so fast he would fall before anyone could reach him. She stated the alarm would go off constantly and was not very effective. An interview was conducted with CNA 2 on 6/21/12 at 10:50 a.m. She stated Resident 1 fidgeted with the Tabs alarm and he could take it off. An interview was conducted with CNA 3 on 6/21/12 at 11:30 a.m. She stated another resident had removed Resident 1's tab alarm in the past. She stated Resident 1 would try to get up so fast the alarms were ineffective because staff could not get to him before he fell. She stated she had notified the charge nurse and the administrator the alarms were ineffectual at preventing falls. An interview was conducted with CNA 4 on 6/21/12 at 3:10 p.m. She stated Resident 1 would be left at the nurse's station since staff was usually there; however, he was fast when he attempted to stand and staff could not always get there in time.An interview was conducted with Housekeeping Staff 1 on 6/21/12 at 3:30 p.m. She stated she was walking down the hallway when she saw Resident 1's legs on the floor sticking out into the hallway. She stated she did not hear the alarm go off and she was the first person to find him after he had fallen from his chair. The Department determined the facility failed to provide adequate supervision and interventions to prevent Resident 1 from falling on 2/28/12, resulting in a left hip fracture.These violations presented either (1) imminent danger that death or serious harm to the patients or residents of the long-term health care facility would result therefrom, or (2) substantial probability that death or serious physical harm to patients or residents of the long-term health care facility would result therefrom. |
| 100000001 |
Asbury Park Nursing and Rehabilitation Center |
030010988 |
B |
17-Sep-14 |
055Z11 |
3571 |
Health and Safety Code 1418.91 (a) A long-term health care facility shall report all incidents of alleged or suspected abuse of a Patient of the facility to the Department immediately or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. An unannounced visit was made on 07/24/14 to investigate three complaint numbers CA00405022, CA00405052, and CA00405037 regarding allegations of abuse. The Department determined the facility failed to report three allegations of abuse to the Department immediately or within 24 hours. This failure put all patients in the facility at risk for abuse. Patient 1 was admitted to the facility with diagnoses that included: Dementia (a mental illness that causes someone to be unable to think clearly or to understand what is real or not real).The most recent quarterly Minimum Data Set (MDS) (an assessment tool) dated 6/25/14, indicated Patient 1 had Brief Interview for Mental Status (BIMS) score of 1 indicating severe impairment. She had displayed no behavior problems. Patient 1 was totally dependent for Activities of Daily Living (ADL) with one person physical assistance. On 6/26/2014, it was reported to the Ombudsman, that a Certified Nursing Assistant (CNA 1) yelled multiple abusive statements ("Your nasty") then proceeded to stuff toilet tissue in Patient's hand and told her to "Wipe yourself, you can do it"! This allegation was reported to the Administrator by the Ombudsman on 6/26/14 at 12:35 p.m. Patient 2 was admitted to the facility with diagnoses that included: Infantile Cerebral Palsy (disorder affecting posture and movement). The most recent quarterly MDS dated 5/3/14, indicated Patient 2 had a BIMS score of 6 indicating severe impairment. She had displayed no behavior problems. Patient 2 was totally dependent for ADL's with one person physical assistance.On 6/25/14, it was reported to the ombudsman that CNA 1 was saying inappropriate comments ("you always stink") to Patient 2 regarding cleanliness. This allegation was reported to the Administrator by the ombudsman on 7/9/14. Patient 3 was admitted with diagnoses that included: Dementia (a mental illness that causes someone to be unable to think clearly or to understand what is real or not real). The most recent quarterly MDS dated 5/4/14, indicated Patient 3 had a BIMS score of 13 indicating cognitively intact. Patient 3 has displayed no behavior problems. Patient 3 needed extensive assistance with ADL's with one person physical assistance, except for eating, Patient 3 needed set up only. On 6/25/14, it was reported to the Ombudsman that a CNA 1 was heard yelling and scolding Patient 3 to "Calm down" repeatedly until she was so upset she was shaking. This allegation was reported to the Administrator by the Ombudsman on 7/9/14. During an interview on 7/28/14 at 2:45 p.m., the Administrator/Abuse Coordinator was asked to provide the investigations for the abuse allegations for Patients 1, 2 and 3. The Administrator stated that he had reported the abuse to the Ombudsman for Patient 1, but since the allegations for Patient 2 and 3 were erroneous, he did not report them.As of 7/30/14 at 12:30 p.m., the Administrator was unable to provide evidence that the allegations of abuse for Patients 1, 2 and 3 were reported to the Department as required.The Department determined the facility failed to report three allegations of abuse to the Department immediately or within 24 hours. These violations had a direct relationship to the health, safety or security of the patients.. |
| 100000001 |
Asbury Park Nursing and Rehabilitation Center |
030010989 |
B |
17-Sep-14 |
ZH5211 |
2864 |
Health and Safety Code 1418.91 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the Department immediately, or within 24 hours.(b) A failure to comply with the requirements of this section shall be a class "B" violation. An unannounced visit was made to the facility on 8/1/14 to investigate two complaint numbers CA 00407089 and CA 00407552 regarding allegations of abuse.The Department determined that the facility failed to report two allegations of abuse to the Department immediately or within 24 hours. This failure put all patients in the facility at risk for abuse.Patient 4 was admitted to the facility with multiple diagnoses including a cognitive disorder. According to the most recent quarterly Minimum Data Set (MDS, a resident assessment tool), Patient 4 was "rarely/never understood."On 7/19/14, the allegation of an abuse involving Patient 4 was reported to the Ombudsman (in-charge with representing the interests of the public), that on 7/19/14 Patient 4 was fighting off a worker lady and she sustained the discoloration to her left forearm..."On 7/25/14, the Ombudsman informed the Department of the allegation of abuse for Patient 4. The Department did not receive any information from the facility regarding this allegation of abuse for Patient 4. Patient 5 was admitted to the facility with multiple diagnoses including a chronic disorder of the mental processes.On 7/24/14, the allegation of an abuse was reported to the Ombudsman that the "[Patient] has right hand swelling and bluish discoloration; left hand [sustained] a bluish discoloration also. Patient stated that somebody twisted her hand..." On 7/30/14, the Ombudsman informed the Department of the allegation of abuse for Patient 5.A review of Patient 5's clinical record revealed that an x-ray to the right hand was done on 7/24/14 and indicated that the patient sustained a "fracture involving the second metacarpal (a bone of the palm of the hand)..." Further review of the clinical record revealed that a completed investigation report of the alleged abuse was done on 7/25/14.The Department did not receive any information from the facility of this allegation of abuse for Patient 5. During an interview with the Administrator/Abuse Coordinator on 8/1/14 at 3:20 p.m., he was asked to present any documentation that both of these allegations of abuse (involving Patients 4 and 5) were reported to the Department. He stated, "I was informed by the previous Ombudsman that she would be the one to inform the Department...I have not been informing the Department."The Department determined that the facility failed to report two allegations of abuse to the Department immediately or within 24 hours.These violations had a direct relationship to the health, safety and security of the patients. |
| 100000025 |
Arden Post Acute Rehab |
030011076 |
B |
24-Oct-14 |
9U8111 |
4084 |
Health & Safety Code 1418.91(a) A long term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately or within 24 hours. (b) Failure to comply with the requirements of this section shall be a Class B Citation. The following citation is written as a result of the investigation of complaint #CA00414422. Unannounced visits were made to the facility to investigate the allegation of abuse reported to the facility on 4/11/13.The Department determined the facility failed to follow California Law regarding alleged and suspected abuse reporting requirements. It was determined that the facility failed to report the allegation of abuse reported to them on 04/11/13.Complaint CA00414422 was filed with California Department of Public Health Licensing and Certification District Office on 9/24/14 by the California Department of Public Health Licensing and Certification Professional Certification Branch. This complaint contained an allegation of abuse involving Certified Nursing Assistant 1 (CNA 1).On 10/2/14 at 11:45 a.m. the Administrator 1 was asked to provide documentation of their investigation of an allegation of staff to resident abuse involving Patient 1 and CNA 1. Administrator 1 was informed the allegation was reported to the facility on 4/11/13 by Patient 1's [Family Member 3]. On 10/3/14 at 10 a.m. Administrator 1 stated they did not have a record of alleged abuse occurring on 4/11/13 involving Patient 1.On 10/3/14 at 12:45 p.m. Family Member 1 was interviewed. She stated she spoke to her [Family Member 2] who recalled that during a visit with Patient 1 in April 2013, Patient 1 had been incontinent of bowel; [Family Members 1 and 2] told the nurse and the nurse stated that she had just changed Patient 1 and was too busy. She stated she could not remember any names of the people they reported it to. On 10/3/14 at 1 p.m. CNA 1 was interviewed. She stated that she was assigned to and took care of Patient 1 on 4/11/13. She stated she and another CNA provided incontinence care for Patient 1. She stated that neither of them scolded Patient 1. She stated the complaint was made by the wife and daughter to the facility. She stated the Director of Staff Development (DSD) interviewed her about the allegation. She stated she was terminated because of the allegation.Review of un-titled DSD document dated 4/11/13 revealed "I was called to the admissions office so that [family members 1 and 2] could discuss some care issues that have come to their attention. Per report: On the evening of 4/11/13 [Patient 1's Family Member 3] was here to visit he noticed Patient 1 had been inc. [incontinent] of stool and requested his father be changed. [CNA 1] told him she had just changed him and that she was busy... so again he went to [CNA 1] who then stated she would come in after she had taken the other residents out to smoke... [CNA] 1 has been noted to come into resident's room and just grab his arm to check blood pressure, or to uncover him to change him without any explanation or introduction which the resident has shared with the family makes him feel uncared for [sic]." Review of "SEPARATION NOTICE" for CNA 1 dated 4/15/13 revealed the document was signed by the DSD and Administrator 2. CNA 1 signed the document of 4/17/13. Review of facility policy "ALLEGED ABUSE AND ELDER JUSTICE ACT" revised Sept. 2011 revealed "The Administrator of the facility shall report all "alleged" or "suspected" abuse of a resident to the Dept. of Health Services immediately, or within 24 hrs (Ca. H&S Code 1418.91a)." The Department's records do not include evidence the facility reported the allegation of abuse on or within 24 hours of 4/11/13. The Department determined the facility failed to follow California Law regarding alleged and suspected abuse reporting requirements. It was determined that the facility failed to report the allegation of abuse reported to them on 04/11/13.The above violations had a direct relationship to the health, safety, or security of patients. |
| 030000280 |
Auburn Oaks Care Center |
030011094 |
B |
13-Nov-14 |
KQCE11 |
7854 |
72527 Patients' Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To be free from mental and physical abuse. The following citation was written as a result of an unannounced visit on 5/21/14 to investigate entity reported incident CA00399121 and CA00399185 regarding sexual abuse.The Department determined the facility failed to: Ensure Patient 1 was not sexually abused by CNA 1 in the shower on five occasions. Patient 1's Admission Minimum Data Set (MDS, an assessment tool) indicated Patient 1 was moderately impaired cognitively. She was not steady, only able to stabilize with staff assistance. The patient required extensive assistance with bed mobility, transferring, dressing and personal hygiene. She was frequently incontinent of bowel and bladder. The resident did not have a poor appetite, ate with limited assistance, and did not have hallucinations or delusions. Patient 1 usually understands and was understood during conversations. She was deemed as her own responsible party upon admission. A review of Patient 1's clinical record indicated CNA 1 had provided showers on the following dates: 4/5/14 at 16:39 (4:39 p.m.) shower was given. 4/9/14 at 16:53 (4:53 p.m.) shower was given. 4/9/14 at 21:07 (9:07 p.m.) shower was given (second shower was given during the same evening). 4/30/14 at 17:31 (5:31 p.m.) shower was given. 5/7/14 at 20:20 (8:20 p.m.) shower was given. Patient 1 was interviewed on 5/21/14 8:30 a.m. The patient 1 stated she had been "assaulted" by CNA 1 on five separate occasions. She stated CNA 1 "assaulted" her by exposing himself and forcefully kissing her against her will. She said, "I gave up fighting back because I was scared of him." She further stated she requested another CNA to take care of her and when the new CNA was assisting her, she reported the abuse. Patient 1 said, "I was afraid of what would happen to me if I told anyone. He really scared me." Patient 1 further stated, "He [CNA 1] assaulted me each time he assisted with my showers." An interview was conducted on 5/21/14 at 10:26 a.m. with CNA 1. The CNA said, "I know why you called me in here for this interview." Without prompting or mentioning any specific patients, CNA 1 again said, "I know why you called me in for an interview. [Patient 1] complained about me, right?" Upon further interview about what had happened with Patient 1, CNA 1 stated, "I pulled my pants down and showed [Patient 1] my penis. I kissed her and told her not to tell anyone because I would lose my job and my kids couldn't go to school." When asked about how many times this had happened, CNA 1 stated, "I showered her about five times and kissed her every time. I showed her my penis one time." When asked if he had an erection, CNA 1 said, "Yes, I had an erection. I told her to look and [Patient 1] said 'no' and I pulled my pants up."The Director of Staff Development (DSD) was interviewed on 5/21/14 at 10:47 a.m. She stated CNA 1 often volunteered to do the "showers only" on the assignment sheets on his shift if staff needed help with their assignments. An interview was conducted with Licensed Nurse (LN) 1 on 5/21/14 at 3:38 p.m. LN 1 was in charge of the evening shift when CNA 1 was on duty. LN 1 was responsible for the oversight of provision of care performed by CNA 1. The LN was questioned about CNA 1 providing two showers to Patient 1 during the same shift on 4/9/14. She stated, "I didn't know that happened."Review of a facility policy titled "Preventing Resident Abuse" revised December 2006 included: "Policy Interpretation and Implementation: 1. The facility's goal is to achieve and maintain an abuse-free environment. i. Monitoring staff on all shifts to identify inappropriate behaviors toward residents... k. Assessing residents with signs and symptoms of behavior problems and developing and implementing care plans to address behavior issues; n. Identify areas within the facility that may make abuse and/or neglect more likely to occur (e.g., secluded areas) and monitoring these areas regularly..." Review of the medical record for Patient 1 indicated changes in her behavior: 4/14/14 progress note included, "...Pt [patient] declining in self-feeding... Pt observed with... gagging at times (appears to be behavioral)... On 4/11/14 Resident [Patient 1] was attempting to harm herself by attempting to induce emesis and not eating..."4/15/14 progress note included, "...Pt continues to exhibit several behaviors during lunch meal requiring 1:1 assist/redirection for initiation, task completion... consuming about 20% of meals..." 4/16/14 progress note under Nursing Services: "Nursing is monitoring behaviors as resident is noted to have some anxiety, crying episodes and recently attempting to make herself vomit."The 4/21/14 progress note contained the following information: "When pt [patient] was first admitted, she was self-feeding on mechanical soft [diet], then she started complaining on [sic] not able to eat. For the past 2 weeks she has become increasingly agitated and had been refusing to eat... Alert. Tearful at times... Often speaking like a young child..."Significant weight loss was noted on the 4/21/14 progress note, 13.6 pounds in nearly a month. Review of a progress note dated 5/7/14 at 11:48 a.m. with Patient 1's medical record included the following: "Reason for visit: lab review... Pt [patient] with noted psych issues. Has difficulty swallowing which has been determined to be psych related. Poor po (oral) intake..."A review of a progress note dated 5/27/14 at 14:04 (2:04 p.m.) included a follow up visit from a Nurse Practitioner (NP) with Patient 1. The following information was contained in the document: "Date of visit: 5/22/14, Reason for visit: Request to evaluate patient's status post sexual encounter involving a male staff at the facility. Patient 1 started to get upset and hyperventilate...The patient stated that in the last few days she told the CNA that she was going to tell about his encounter with her and the CNA told her he had a similar incident like this one three or four years ago and it had never been resolved..."A physician visit for Patient 1 was documented on 6/2/14 at 20:59 (8:59 p.m.) which included, "...Pt (patient) with poor po (oral) intake, eating less than 50 percent meals including if husband brings in food... appears confused and lethargic with childlike voice..."Review of a facility policy titled Recognizing Signs and Symptoms of Abuse/Neglect revised April 2011 included the following: "Policy Interpretation and Implementation: 1. Abuse is defined as willful infliction of ... intimidation...with resulting...mental anguish. c. Possible signs/symptoms of psychological abuse/neglect: (3) Depression, (4) New or increasing confusion or disorientation, (5) Withdrawal, (8) Anger..."Review of a facility's policy titled Reporting Abuse to Facility Management, revised April 2011 included the following: "2.a. Abuse is defined as the willful infliction of ...intimidation... with resulting... mental anguish...c. Sexual abuse is defined as, but is not limited to, sexual harassment, sexual coercion, or sexual assault..." The Department determined that the facility failed to: Ensure Patient 1 was not sexually abused by CNA 1 in the shower on five occasions. These violations caused or are under circumstances likely to cause significant humiliation, indignity, anxiety or other emotional trauma to the patients or residents of a long term health care facility. |
| 100000025 |
Arden Post Acute Rehab |
030011834 |
B |
06-Nov-15 |
SWE911 |
9603 |
F203 42 CFR 483.12(a)(4)-(6) Notice Requirements before Transfer/Discharge Before a facility transfers or discharges a resident, the facility must notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand; record the reasons in the resident's clinical record; and include in the notice the items described in paragraph (a)(6) of this section. Except as specified in paragraph (a)(5)(ii) and (a)(8) of this section, the notice of transfer or discharge required under paragraph (a)(4) of this section must be made by the facility at least 30 days before the resident is transferred or discharged. Notice may be made as soon as practicable before transfer or discharge when the health of individuals in the facility would be endangered under (a)(2)(iv) of this section; the resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (a)(2)(i) of this section; an immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (a)(2)(ii) of this section; or a resident has not resided in the facility for 30 days. The written notice specified in paragraph (a)(4) of this section must include the reason for transfer or discharge; the effective date of transfer or discharge; the location to which the resident is transferred or discharged; a statement that the resident has the right to appeal the action to the State; the name, address and telephone number of the State long term care ombudsman; for nursing facility residents with developmental disabilities, the mailing address and telephone number of the agency responsible for the protection and advocacy of developmentally disabled individuals established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act; and for nursing facility residents who are mentally ill, the mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals established under the Protection and Advocacy for Mentally Ill Individuals Act. F205 42 CFR 483.12(b)(1)&(2) Notice of Bed-Hold Policy/upon Transfer Before a nursing facility transfers a resident to a hospital or allows a resident to go on therapeutic leave, the nursing facility must provide written information to the resident and a family member or legal representative that specifies the duration of the bed-hold policy under the State plan, if any, during which the resident is permitted to return and resume residence in the nursing facility, and the nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (b)(3) of this section, permitting a resident to return.At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and a family member or legal representative written notice which specifies the duration of the bed-hold policy described in paragraph (b)(1) of this section. An unannounced visit was made to the facility on 10/7/15 at 11:30 a.m. to investigate complaint number CA00459728. The Department determined the facility failed to: 1. Provide Resident 1 a written notice of discharge, which included the reasons for discharge, information regarding the right to appeal the discharge, and the required contact information, when Resident 1 was involuntarily discharged to the general acute care hospital (GACH) on 9/18/15; 2. Provide Resident 1 written information that specifies the duration of the bed-hold policy, and; 3. Allow Resident 1 to return to the nursing facility from the GACH when he was determined to be stable on 9/18/15. Resident 1's clinical record revealed he was admitted to the facility on 9/16/15 for rehabilitation services following surgical repair of a fractured right hip in July 2015. Other diagnoses included dementia, anxiety, insomnia, and depression. Resident 1 was transferred from the facility to the GACH on 9/18/15, 44 hours after admission.A Nurse's Notes, dated 9/16/15 at 10:30 p.m., indicated Resident 1 was admitted to the facility from the hospital via a gurney. The note described Resident 1 as calm, pleasant, and able to verbalize his needs to the staff. A Resident Transfer Record, dated 9/18/15, indicated Resident 1 was sent to the GACH for being "Dangerous to staff, choke staff, grabbing co-residents, hitting."A Final Licensed Nurses Progress Note and Discharge Summary, dated 9/18/15 at 6:30 p.m., approximately 44 hours after admission, indicated Resident 1 was sent to the GACH. His mental status was documented as "alert." The section of the form titled "Resident's Stay (Reason for admission, interventions, course of staff and outcome)" contained only the statement "Long term care." The Physician's Discharge Summary, dated 9/20/15, indicated Resident 1 "continued to exhibit problems related to [his] diagnoses during their stay." The Resident's Discharge Diagnoses was documented as traumatic hip fracture, osteoporosis, and dementia. An interview was conducted with Resident 1's Case Manager (CM) at the GACH on 10/7/15 at 10:30 a.m. The CM stated Resident 1 was admitted to the GACH on 9/18/15. The CM stated on 9/18/15 Resident 1 received treatment in the emergency room and they attempted to send him back to the facility. The facility refused to take him. On 9/19/15 the CM stated she contacted the facility to advise them Resident 1 was stable and ready to return to the facility. The CM stated she was informed by the admissions office staff that the facility would not take Resident 1 back. The CM stated they tried to send Resident 1 back, contacting the facility daily. On 9/23/15 the facility advised the CM that under no circumstances would they take him back due to aggressive behaviors. The CM stated Resident 1 was still at the GACH. An interview was conducted with the Facility Administrator (FA) on 10/7/15 at 11:30 a.m. The FA stated on 9/18/15 Resident 1 began to get violent. He stated the Resident was trying to hit staff and choke staff. The FA stated Resident 1's physician was notified and the Resident was sent to the GACH. The FA stated two hours later, the GACH called and wanted to send Resident 1 back. The FA stated he refused to take him back. The FA stated Resident 1's listed responsible party had not signed the admission paperwork. The FA was asked to provide a copy of the admission agreement that would have been completed for Resident 1.A second interview was conducted with the FA on 10/7/15 at 1:10 p.m. He stated no admission paper work or discharge paper work had been completed for Resident 1. The FA provided a copy of the California Standard Admission Agreement. There was no documentation in Resident 1's clinical record that the facility had provided a written notice of discharge, with the right to appeal and the required contact information as required by law. There was no documentation that the facility had agreed to readmit Resident 1 to the facility. The admission agreement directed, under section VI. Transfers and Discharges, the following, in part: "Our written notice of transfer to another facility or discharge against your wishes will be provided 30 days in advance. However, we may provide less than 30 day's notice if the reason for the transfer or discharge is to protect your health and safety or the health and safety of other individuals, if your health allows for shorter notice, or you have been in our facility for less than 30 days. Our written notice will include the effective date, the location to which you will be transferred or discharged and the reason the action is necessary." "The only reasons that we can transfer you to another facility or discharge you against your wishes are: 3) Your presence in our Facility endangers the health and safety of other individuals." "In our written notice, we will advise you that you have the right to appeal the transfer or discharge to the California Department of Health Care Services and we will also provide the name, address and telephone number of the State Long-Term Care Ombudsman." "If you are transferred or discharged against your wishes, we will provide transfer and discharge planning as required by law." The admission agreement directed, under section VII. Bed Holds and Readmission, the following, in part: "If you must be transferred to an acute hospital for seven days or less, we will notify you or your representative that we are willing to hold your bed. You or your representative will have 24 hours after receiving this notice to let us know whether you want us to hold your bed for you." "If we do not follow the notification procedure described above, we are required by law (Title 22 California Code of Regulations Sections 72520(c) and 73504(c)) to offer you the next available appropriate bed in our Facility." Therefore, the Department determined the facility failed to: 1. Provide Resident 1 a written notice of discharge, which included the reasons for discharge, information regarding the right to appeal the discharge, and the required contact information, when Resident 1 was involuntarily discharged to the general acute care hospital (GACH) on 9/18/15; 2. Provide Resident 1 written information that specifies the duration of the bed-hold policy, and; 3. Allow Resident 1 to return to the nursing facility from the GACH when he was determined to be stable on 9/18/15. These violations had a direct relationship to the health, safety or security of patients. |
| 030001615 |
Avalon Care Center - Sonora |
030012183 |
AA |
20-Apr-16 |
IY5E11 |
10777 |
F323 483.25 Free of Accident Hazards/Supervision/Devices (h) The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The following citation was written as a result of an unannounced visit to the facility on 9/2/2014 to investigate entity reported incident CA00410834 and complaint CA00411801. The Department determined the facility failed to ensure adequate supervision and direct assistance with a meal for one of three sampled residents (Resident 1) and failed to ensure his meal was provided in a texture Resident 1 could safely swallow. This failure resulted in an obstruction of Resident 1's airway and death due to choking. Resident 1 was a 90 year old admitted to the facility on 12/26/13 with diagnoses which included food/vomit pneumonitis (lung inflammation due to inhaling food or vomit), encephalopathy (brain disease, damage or malfunction) and dementia. Review of the Minimum Data Set (MDS - an assessment tool), dated 6/26/14, indicated Resident 1 had long and short term memory problems and some difficulty in daily decision making in new situations. The MDS indicated Resident 1 needed extensive assistance with meal setup and one person physical assistance while eating. Resident 1 ate in the dining room. Review of the clinical record for Resident 1 identified a physician's order for a "Mechanical Soft with Ground Meat" diet dated, 12/26/13.Review of the facility Dietary Food Preferences, completed by the Dietary Manager (DM) and Resident 1's Responsible Party, indicated in the section for food dislikes, both wheat and white bread were circled.Review of the clinical record indicated a Dietary Memo/Diet Order form, dated 12/26/13, indicated as New Orders the following: mechanical soft and "ground meat" written on the form. A Dietary Memo/Diet Order form, dated 6/2/14, indicated handwritten notes, "extra sauce/gravy" and "ground meat" underlined.Review of the Diet Manual, dated May 2012, page 17, titled Mechanical Soft (Ground), indicated, "All meat (such as beef, fish, poultry and pork) should be ground or chopped. Gravy or sauces should be added to moisten dry ground and chopped meats ...for lubrication." Under definitions of terms, ground was described as "1/8" (inch) or less - consistency of ground meat." Another form titled, Mechanically Altered/Texture Modified Diets, declared the intended use was for "residents with chewing and/or swallowing problems." The form indicated the facility provided, "Two levels of mechanically altered diets on the Menu Spreadsheets ...Puree and Mechanical Soft Ground."Record review revealed Resident 1's "Dysphagia" (difficulty swallowing) care plan. There was no problem onset date. The plan indicated, "Resident is at risk for choking." Goals were "No choking episodes" and "Diet texture as ordered." The Approaches (what the facility would do to assist the resident to reach the goals) were listed as "ST [Speech therapy] screens as appropriate, Follow recommendations from therapy, To dining room for all meals," and "Assistance/supervision with all meals." Review of the "Dysphagia" care plan, dated 12/19/2013, for nutritional status, indicated as the Goal, "Resident food preferences will be honored through next review." The facility approaches were, "Encourage resident to consume 100% of breakfast, 75% of lunch, 50% of dinner and 100% of afternoon snack, Determine food preferences" and to "Give food that is easily swallowed."Review of the Speech Video Swallow Study done 1/16/14 indicated Resident 1's aspiration (breathing in food or fluid into lung) risk as moderate. The Speech Diet recommendations were for the National Dysphagia Diet (NDD) II-Ground, Liquids-Nectar thick. In the summary, a recommendation indicated NDD II (moist with extra gravy).Review of the Speech Language Pathologist (SLP - a specialist who evaluates and treats patients with speech, language, cognitive-communication and swallowing disorders in individuals of all ages) treatment note, dated 1/31/14, revealed the resident had a coughing/choking event: "Arranged for 1:1 [one to one] assistance w/ [with] meals." The SLP recommendations for Resident 1, dated 5/28/14, indicated, "In order to facilitate safety with oral intake, caregivers will assist patient in use of rate moderation [encourage resident to eat slower], bolus size modification [smaller bites], alternation of liquid/solids, second dry swallow [swallowing without food in mouth]...in order to decrease risk of choking and aspiration." Under, "Caregiver goals: Keep him from choking to death."Review of the SLP treatment note dated 6/2/14 revealed, "Pt seen @ [at] dining room ....and dining room CNAs [Certified Nursing Assistants] present for training. Upon arrival, tray had dry chopped meat [with] no gravy and dry rice. Removed immediately and replaced [with] correct diet order." The SLP note for 6/6/14 indicated, "Pt needed consistent cues to take small/single sips and go at a slow rate." A treatment note, dated 6/10/14, confirmed "Instructed caregivers SSP [Swallow/Strategies/Positions: to facilitate safety and efficiency, it is recommended the patient to use the following strategies and/or maneuvers during oral intake: general swallow techniques/precautions]...to improve safety [with] oral intake, focused on the following-rate and bolus size modifications, alternation of consistencies, cough/re-swallow, single sips, double swallows and frequent breaks." Further review indicated that on 6/9/14, "Educated staff on SSP and supervision needed to prevent choking and decrease risk of aspiration w/ verbalized understanding demonstrated." A comprehensive review was done on the SLP notes and on 1/3/14, 1/10/14, and 2/6/14, the SLP noted either wrong food consistency or wrong liquid consistency on the resident's diet tray. Review of the facility incident reports indicated Resident 1 experienced choking events on food that was not indicated on a mechanical soft, ground meat diet or per the food preference form completed on admission by the Dietary Manager. On 5/27/14, Resident 1 choked on cake which caused him to become "limp and cyanotic [skin turned blue from lack of oxygen]" and then on 6/21/14 Resident 1 choked on a dinner roll which caused him to become distressed and cyanotic."Review of the Facility Reported Event, dated 8/23/14, revealed that Resident 1 "...began choking at 12:15 PM," 911 was called and the Resident 1 was transported to the emergency department. Review of the Pre-hospital Care Report, dated 8/23/14, completed by the ambulance crew who responded to the 911 call, indicated the Field Clinical Impression as "Respiratory and cardiac arrest secondary to foreign body obstruction." The "Comments" section included, at 12:31, "Rice was suctioned form [sic] airway revealing a large foreign body obstructing [patient] airway." At 12:32, "A large piece of chicken approximately the sized [sic] of a fifty cent piece [30.6 millimeter or 1.2 inches] was removed form [sic] airway." The Call Summary indicated, "PT was found unresponsive, pulseless and apneic [not breathing] while lying on the floor...staff indicated that he started chocking [sic] while eating lunch...Pt was found to have a large piece of chicken completely blocking his airway. After removal of foreign body and pt ventilated no improvement was noted and DNR [Do not resuscitate] was followed."Review of the emergency department reports, dated 8/23/14, in the History of Present Illness section, indicated "...They [EMT] were able to suction out the rice and remove the piece of chicken from his esophagus in the ambulance." Resident 1 was pronounced dead at the emergency department at 12:48 p.m.During an interview on 9/2/14 at 1 p.m., the SLP stated she had trained the family and the CNA's to encourage the resident to sit up when eating, slow down between bites, take smaller bites, and to swallow between bites.During an interview with Licensed Vocational Nurse 1 on 9/2/14 at 3:10 p.m., she stated she checked the lunch trays on 8/23/14. She stated she saw a "layered enchilada" cut in pieces on Resident 1's tray. An interview was conducted on 9/5/14 at 2 p.m. with the Dietary Manager (DM); she described how the chicken quesadilla was made. She said the frozen, precooked chicken pieces were thawed, heated and placed in food processor to be chopped "fine". The processed chicken was then placed in the oven until lunch. The cook placed a tortilla on a plate, put cheese and then the ground chicken on it, then folded the tortilla over the filling. Review of the lunch menu for 8/23/14 indicated Chicken Quesadilla, Spanish rice, and seasoned black beans.During an interview on 9/19/14 at 12:17 p.m., Certified Nursing Assistant 1 (CNA 1) stated on 8/23/14 she was in the West dining room passing lunch trays alone. She stated that usually there were at least two CNA's in the dining room during meals but the other CNA was called out to care for a resident. CNA 1 said she served Resident 1 his meal, then went back to get the lunch tray for another resident at the same table. She heard a noise and looked at Resident 1, who looked "scared." She asked if he needed the choking maneuver and he nodded his head. She called for help and attempted to help the resident.During an interview with the Coroner on 9/19/14 at 9:15 a.m., he stated the ambulance crew removed a large piece of chicken from the patient's airway. He examined the piece of chicken, took pictures, and described it as a "single piece of chicken... not chopped... approximately the size of a quarter or 50 cent piece size." In his professional opinion Resident 1's death was consistent with choking due to a large piece of chicken in the airway.Review of the Certificate of Death, issued 9/19/2014, indicated the, "IMMEDIATE CAUSE" of death for Resident 1 as, "AIRWAY OBSTRUCTION" and "FOOD BOLUS." Under the description of how the injury occurred indicated, "CHOKED ON A PIECE OF FOOD." Therefore, the facility failed to ensure adequate supervision and direct assistance with a meal for one of three sampled residents (Resident 1) and failed to ensure his meal was provided in a texture Resident 1 could safely swallow. This failure resulted in an obstruction of Resident 1's airway and death due to choking. These violations presented either (1) imminent danger that death or serious harm to the patients or residents of the long-term health care facility would result therefrom, or (2) substantial probability that death or serious physical harm to patients or residents of the long-term health care facility would result therefrom and were a direct proximate cause of death of the patient or resident. |
| 100000030 |
Alderson Convalescent Hospital |
030012495 |
B |
9-Aug-16 |
ETHU11 |
10614 |
F223 Free from Abuse/Involuntary Seclusion 483.13(b), 483.13(c)(1)(i) The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. The following citation was written as a result of an unannounced investigation of entity reported incident # CA00481986. The investigation was initiated on 4/12/16 regarding the sexual abuse of Resident 2, perpetrated by Resident 1 on 3/26/16. The Department determined that the facility failed to protect Resident 2 from sexual abuse by Resident 1. The facility's failure to provide protection for Resident 2 resulted in Resident 2 being sexually assaulted by Resident 1. This failure resulted in Resident 2 developing psychosocial distress (the way situations affect a person's interaction with others). Resident 1 was admitted to the facility on 12/15/09 with diagnoses that included schizoaffective disorder (a mental disorder characterized by the presence of schizophrenia, a generally continuous psychotic illness, plus intermittent mood episodes). The Minimum Data Set (MDS, an assessment tool), dated 3/4/16, indicated Resident 1 had no memory problems or disorganized thinking. Resident 1 was independent in all of his self-care needs, including walking. Resident 1 had a care plan, dated 3/25/14, that indicated he was at risk for developing an alteration in mood/behavior as a result of his diagnosis of schizophrenia and secondary to his inappropriate sexual behaviors. The interventions included encourage resident to express feelings, administer medications as ordered, calm resident down when he gets verbally aggressive, speak slowly and clearly, intervene when needed, have social service staff speak with resident if behaviors continue to be offensive, notify physician if behaviors worsen, and provide 1 to 1 interventions. Resident 1's care plan was not updated until 3/29/16, three days after the incident with Resident 2. Resident 1 had a physician order, dated 7/14/15, that directed licensed nurses to administer 1 milligram of Abilify (a medication used to treat schizophrenia) each evening. The targeted behavior for the Abilify was "impulsivity sexual disinhibition and verbal aggression/yelling out." Resident 1's Medication Administration Record (MAR) for May, June, and July 2015 indicated nursing staff had documented Resident 1 displayed no episodes of sexual disinhibition during those months. Resident 1's MAR for August 2015 noted 2 episodes of sexual disinhibition that month. Resident 1's MAR for September 2015 noted 3 episodes of sexual disinhibition that month. Resident 1's MAR for October 2015 noted 6 episodes of sexual disinhibition that month. Resident 1's MAR for November 2015 noted 0 episodes of sexual disinhibition that month. Resident 1's MAR for December 2015 noted 13 episodes of sexual disinhibition that month. Resident 1's MAR for January 2016 noted 33 episodes of sexual disinhibition that month. Resident 1's MAR for February 2016 noted 25 episodes of sexual disinhibition between 2/1/16 and 2/21/16. The monthly total of sexual disinhibition behaviors was 45. A nursing note, dated 2/21/16 and written by Licensed Nurse (LN) 2, indicated a Nurse Supervisor had approached LN 2 to inform the LN that Resident 1 had exposed himself outside the facility. The LN noted he spoke with Resident 1 about the incident and Resident 1 had told him he was sorry and would not do it again. LN 2 noted he would continue to monitor Resident 1's behavior. There were no additional nursing notes to demonstrate facility staff, in general, was aware of a need to monitor Resident 1 after he exposed himself outside. A Social Service Director (SSD) note, dated 2/22/16, indicated the SSD had spoken to Resident 1 about an inappropriate sexual behavior that occurred outside of the facility. The SSD note indicated Resident 1 stated, "He couldn't quite explain why he did what he did, but that 'there's something that just builds up inside of me and before I know it, I'm already unable to control myself.'" The SSD indicated Resident 1 was apologetic and agreed to not go outside anymore. Resident 1 would limit his walking to inside the facility. The SSD further indicated he explained to Resident 1 that he could be arrested for indecent exposure if neighbors called the police. The SSD reminded Resident 1 not to make unnecessary stops in front of other resident rooms, so as not to appear intrusive. The SSD indicated he would continue to monitor and outside mental health services would follow up with Resident 1's case. There was no other documentation demonstrating Resident 1's plan of care had been updated as a result of the escalated sexual behaviors and the reported indecent exposure incident of 2/21/16. Resident 1's Annual Activity Note, dated 3/4/16 and written by the Activity Director (AD), indicated, "When the weather is nice he sits outside... ambulates and is able to know when his programs take place." An Annual Social Service Review, dated 3/9/16, indicated Resident 1 had a history of exposing himself outside the confines of his privacy area and this continued to happen occasionally. There was no indication in the note that the SSD had identified an escalating pattern of sexual disinhibition as evidenced by the 25 incidents that occurred in February prior to his exposing himself outside of the building. There was no indication in the SSD note that alternate interventions had been put into place when it was identified that Resident 1's behaviors had escalated when he exposed himself outside the facility and the resident himself reported his behaviors were beyond his own control. Resident 1's care plans were updated on 3/29/16 to include a care plan for Alterations in behavior related to schizoaffective disorder. The care plan indicated Resident 1's behaviors included standing in front of his open window while stroking his penis and pulling down his pants, exposing his penis, to allow staff to administer insulin injections. The care plan also indicated Resident 1 removed pants and underwear while in his room and would watch to see who was looking at him and made inappropriate comments to staff, such as, "I'm the best [derogatory description of female anatomy] licker around here... I want you to see me get hard," while wiggling his penis with his hand. The care plan identified Resident 1 would open privacy curtains while masturbating and engage in sexually inappropriate touching of others without consent. The updated interventions included offer stimulating activities in room if resident refuses to socialize outside of room and notify social services for intervention if escalation of behaviors occur. Resident 2 was admitted to the facility in 2014 and her diagnoses included age-related bone disease, muscle weakness, and anxiety disorder. Resident 2's MDS, dated 2/12/16, indicated she had no memory problems or disorganized thinking. Resident 2 had a care plan, dated 3/26/16, that identified Resident 2's potential for psychosocial decline related to being touched by a male peer on her private parts without her consent. The care plan further identified this issue was compounded by Resident 2's diagnosis of anxiety disorder. A Social Service Note, dated 3/28/16, indicated Resident 2 was upset that a male was able to go into her room. On 4/1/16 the facility provided an investigation summary of the incident that occurred between Residents 1 and 2 on 3/26/16. The summary indicated Resident 2 had notified staff on 3/26/16 at 9:50 p.m., a man walked into her room while she was sleeping and woke her up when he touched her vagina. Resident 2 was found "frantic and upset." Resident 2 reported she recognized the man who had touched her as being the man who came to her room several times a week to deliver empty soda cans to her roommate. Resident 2 expressed a desire to press legal charges. The summary indicated the staff had confirmed Resident 1 had been the only man seen walking through the facility that night and Resident 1 admitted touching Resident 2's vaginal area. An interview was conducted with LN 1 on 4/12/16 at 11:20 p.m. He stated he was one of the nurses that monitored Resident 1's sexually inappropriate behaviors. LN 1 stated Resident 1 would walk around naked and masturbate in his room. LN 1 stated this was something Resident 1 did in front of nursing staff, but he was unaware of Resident 1 exhibiting this behavior in front of other people. An interview was conducted with Resident 2 on 4/12/16 at 11:45 p.m. Resident 2 stated she was traumatized by the incident perpetrated by Resident 1, but stated, "I don't want to go over it again." She stated she generally stayed in her room, but the prior day she had to leave the facility for a doctor visit and she saw Resident 1 sitting outside as she left the building. She stated it was very distressing to her that he appeared to be free to walk around the facility and she wished she never had to see him again. An interview was conducted with the SSD on 6/27/16 at 12:30 p.m. He reported the facility learned about the 2/21/16 indecent exposure incident when a neighbor reported to a staff member he had seen Resident 1 expose himself at the perimeter of the building property. The neighbor had reported there was a children's party going on at the time and he was concerned about Resident 1's indecent exposure. The SSD reported there were no other witnesses to the event. An interview was conducted with the SSD on 7/11/16 at approximately 11 a.m. The SSD stated there were no additional care plan interventions put into place at the time Resident 1's behaviors escalated in number and severity on 2/21/16. The SSD reviewed the annual note he wrote on 3/9/16. The SSD confirmed the annual review did not demonstrate facility staff had used the behavior monitoring records to identify or address the escalation of behaviors by Resident 1 to prevent the abuse of Resident 2, when Resident 1 had himself stated the behaviors were beyond his control. Therefore, the Department determined that the facility failed to protect Resident 2 from sexual abuse by Resident 1. The facility's failure to provide protection for Resident 2 resulted in Resident 2 being sexually assaulted by Resident 1. This failure resulted in Resident 2 developing psychosocial distress. These violations caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients. |
| 100000025 |
Arden Post Acute Rehab |
030012787 |
B |
2-Dec-16 |
Z5JU11 |
5379 |
483.12(b)(3) Policy To Permit Readmission Beyond Bed-hold A nursing facility must establish and follow a written policy under which a resident whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, is readmitted to the facility immediately upon the first availability of a bed in a semi-private room if the resident requires the services provided by the facility; and is eligible for Medicaid nursing facility services. The following citation is written as a result of complaint #CA00483684. An unannounced visit was made to the facility on 4/21/2016 to investigate an allegation of refusal to readmit. The Department determined the facility failed to: 1. Readmit Resident 2 after an emergency department (ED) visit at the General Acute Care Hospital (GACH). This failure had the potential to cause emotional distress and/or harm to Resident 2, who wished to return to the facility and who resided in a room at the facility with a family member. Resident 2 was admitted to the facility with a stroke causing paralysis on one side and chronic pain. Resident 2 had a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS) test dated 3/1/2016, meaning his memory and ability to think was intact. During a telephone interview on 4/21/2016 at 8:15 a.m. with Resident 2, he indicated on 4/9/2016 the facility refused to call an ambulance for him to be transferred to the GACH when he requested it. Resident 2 stated he went to the GACH on 4/9/2016 and he wanted to return to the facility where he resided with his family member, but the facility refused to allow him to return. Resident 2's nurses notes, dated 4/9/2016 at 5:08 a.m., indicated at 4:45 a.m. he complained his urinary catheter (a flexible tube inserted into the bladder through the penis to drain urine) was uncomfortable and he wanted it changed. The note indicated the Licensed Nurse (LN) told Resident 2 she was unable to change the catheter because there was no order to replace it. The note indicated Resident 2 stated he would get the catheter changed at the GACH and he intended to call an ambulance to transport him to the GACH. The nurse's note, dated 4/9/2016 at 5:08 a.m., further indicated an ambulance arrived to transport Resident 2 to the GACH at 4:50 a.m. GACH ED notes, dated 4/9/2016 at 5:31 a.m., indicated Resident 2 was "...brought from SNF [skilled nursing facility] with complaint of recurrent suprabubic [lower abdomen] abdominal pain...admitted 3/31-4/1/16 for pyelonephritis [kidney infection]...came back to ED on 04/07/16 with similar complaints,...Today he complained of similar suprapubic pain...called EMS [emergency medical services] himself and came to ED. In ED UA [urinalysis-a lab test to detect urinary infection] still positive [infection present]. When ED tried to send him back to the SNF, the facility refused to take him back..." Resident 2's nurses notes, dated 4/9/2016 at 9 a.m., indicated the nurse called the facility administrator (ADM) to inform him of Resident 2's self-transfer to the GACH. The note indicated the ADM stated Resident 2 left the facility AMA (against medical advice) and the facility would not allow Resident 2 to be readmitted. The note indicated the ADM instructed the writer that if the resident returned to the facility he was to be sent back to the GACH. During an interview with the Administrator (ADM) on 4/26/2016 at 11:33 a.m. the ADM stated, "It is facility practice not to accept back residents who leave AMA." Resident 2's clinical record had no documented evidence a notice of discharge or bed hold was given to Resident 2 when he left the facility via ambulance on 4/9/2016. In an interview with the ADM on 10/28/2016 at 1:35 p.m. he confirmed neither a notice of discharge nor a bed hold notice was given to Resident 2. He further stated those documents would not be given to a resident the facility considered leaving AMA. The facility policy titled, Transfer or Discharge Notice, version 1.3, indicated "...Except as specified below, a resident and/or his or her representative (sponsor) will be given a thirty (30)-day written notice of an impending transfer or discharge...a.....resident's needs cannot be met in the facility; b....resident's health has improved...so the resident no longer needs the services of the facility...c. The safety of individuals in the facility is endangered; d. The health of individual in the facility would otherwise be endangered; e. The resident has failed...to pay for a stay at the facility; f. An immediate transfer or discharge is required by the resident's urgent medical needs; g. The resident has not resided in the facility for thirty (30) days; and/or... h. The facility ceases to operate." The facility policy titled, Preparing a Resident for Transfer or Discharge, version 1.1, indicated "Our facility shall prepare a resident for a transfer or discharge...The business office will be responsible for:...Informing the resident, or his or her representative (sponsor) of our facility's readmission appeal rights, bed-holding policies, etc..." Therefore, the Department determined the facility failed to: Readmit Resident 2 after an emergency department (ED) visit at the General Acute Care Hospital (GACH). These violations had a direct or immediate relationship to the health, safety, or security of Long Term Care patients or residents. |
| 040001378 |
Allen-Florer Family Home - Wheeler |
040009896 |
B |
13-May-13 |
F86J11 |
5347 |
Each person with a developmental disability, as defined by this subchapter, is entitled to the same rights, protections, and responsibilities as all other person under the laws and constitution of the State of California, and under the laws and the Constitution of the United States. Unless otherwise restricted by law, these rights may be exercised at will by any person with a developmental disability. These rights include, but are not limited to the following:(a) Access Rights (5) A right to prompt and appropriate medical care and treatment. The facility failed to ensure Client A was provided prompt and appropriate medical treatment when Client A sustained physical injury (fractured left femur), was in physical pain and was not sent promptly to the emergency room for assessment and medical treatment.A review of Client A's clinical record revealed Client A was admitted to the facility on 1/26/13. Client A's history included a fracture of the left tibia and a fracture of the right femur. Client A was dependent on staff for most activities of daily living due to his complex health needs. Client A was non-verbal and dependent on staff for all of his physical and medical needs. A review of Client A's "Nursing Notes" dated 2/24/13 at 10:40 a.m., indicated while Licensed Vocational Nurse (LVN) 1 pulled up Client A's pants, she heard a loud pop from his left knee. Client A started crying and flinched when LVN 1 touched the area or move the left leg. LVN 1 notified Registered Nurse (RN) 1 and was instructed to give Tylenol and Motrin, and to "keep an eye on it." Client A's "Nursing Notes" dated 2/24/13 at 2:00 p.m., written by LVN 1, indicated Client A displayed facial grimacing when left leg was moved. Client A's "Nursing Notes" dated 2/24/12 at 5:30 p.m., written by LVN 3, indicated Client A's (left) knee was swollen and painful to move.Client A's Nursing Notes dated 2/24/12 at 7:30 p.m., written by LVN 3, indicated Client A had cried off and on and the prescribed range of motion had been held due to his pain. Client A's Nursing Notes dated 2/24/12 at 8:00 p.m., written by LVN 3, indicated Client A's left knee had discoloration and slightly swollen. At 8:05 p.m. LVN 3 called RN 1 to notify her of Client A's condition and was instructed to call RN 2. Client A's Nursing Notes dated 2/24/13 at 8:15 p.m., written by RN 2, indicated she had received a call from LVN 3 with a report of Client A crying and appeared in pain whenever she would move him. Client A's left knee was redden, swollen and warm to the touch. RN 2 arrived at the facility at 8:30 p.m. and found Client A crying out and moaning. Client A cried out when RN 2 moved his left knee. Client A's "PRN (as needed) MEDICATION CHART" dated 2/13, indicated Client A received Tylenol (pain medication) 160 milligrams (mg) on 2/24/13 at 10:45 a.m., 2:45 p.m., 7:00 p.m., and 10:40 p.m. due to pain. Client A received Ibuprophen (anti-inflammatory and pain medication) 300 mg on 2/24/13 at 10:45 a.m. and 5:30 p.m. due to pain.On 3/13/13 at 4:15 p.m., during an interview, LVN 1 stated she had notified RN 1 regarding the incident with Client A's knee on 2/24/12 around 10:30 a.m. RN 1 had instructed her to give Client A both Tylenol and Ibuprophen and call if there was any change in his condition. Client A stayed in bed after the incident due to any movement of his left leg caused him pain. LVN 1 stated she did not feel that was a change in condition as she had already reported to RN 1 that Client A showed signs of pain when his left leg was moved.On 3/22/13 at 4:37 p.m., during an interview, LVN 3 stated on 2/24/13 at 4:30 p.m., when she arrived on shift and LVN 1 gave her the report of the incident with Client A. At 5:00 p.m., LVN 1 assessed Client A and he showed signs of pain by crying when his left leg was moved. LVN 1 stated Client A required frequent prn medications to maintain some comfort. On 2/24/13 at 10:30 p.m., LVN 3 was unable to maintain Client A's comfort and placed a call to RN 1. She was told RN 1 was no longer on-call and was instructed to call RN 2. RN 2 arrived at the facility at 10:30 p.m. and Client A was sent to the emergency room at 11:00 p.m. (12 hours and 20 minutes after the incident occurred).Client A's discharge instruction dated 2/24/12, indicated Client A had a lower extremity fracture and a soft splint was applied to left leg. An order to give Vicodin (medication for moderate pain) every 6 hours as needed for pain was received.On 4/22/13 at 1:28 p.m., during an interview, RN 1 stated she expected to be notified when a client required continued prn (as necessary) medications to control pain, not to exceed eight hours. LVN 1 and LVN 3 should have notified RN 1 when Client A demonstrated pain when his left leg was moved.Therefore, the facility failed to provide prompt and appropriate medical treatment when Client A sustained physical injury (fractured left femur), was in physical pain and was not sent promptly to the emergency room for assessment and medical treatment. Client A sustained the injury on 2/24/13 at 10:40 a.m. and sent to the emergency room at 11:00 p.m. (12 hours and 20 minutes after the incident occurred).The above violation had a direct relationship to the health and well-being of the client. This violated Client A's rights and therefore constitutes a Class "B" Citation. |
| 040000225 |
Anberry Nursing and Rehabilitation Center |
040012209 |
B |
27-Apr-16 |
BC8Z11 |
10717 |
Before a nursing facility transfers a resident to a hospital or allows a resident to go on therapeutic leave, the nursing facility must provide written information to the resident and a family member or legal representative that specifies the duration of the bed-hold policy under the State plan, if any, during which the resident is permitted to return and resume residence in the nursing facility, and the nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (b)(3) of this section, permitting a resident to return.At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and a family member or legal representative written notice which specifies the duration of the bed-hold policy described in paragraph (b)(1) of this section.On 10/20/15 at 10 a.m., an unannounced visit was made to Skilled Nursing Facility (SNF) 1 to investigate complaint CA 00462040 regarding alleged violation of transfer and discharge rights. SNF 1 failed to ensure Resident 1 and a family member were provided with a written notice of the facility's bed-hold policy (notice informing residents of their right to request the facility hold their bed for up to seven days if transferred to the hospital) upon Resident 1's transfer to the hospital during an acute (sudden onset) illness. This failure resulted in Resident 1's inability to request a bed-hold due to illness and the family member unable to request a bed-hold in Resident 1's behalf. As a result, Resident 1 was not provided a bed-hold; Resident 1's bed was released for admission of another resident and Resident 1 was not afforded the opportunity to return to SNF 1 upon discharge from the hospital. Upon discharge from the hospital Resident 1 was transferred to SNF 2 which was located more than one hundred miles from her home, family, and friends. As a result, Resident 1 suffered significant psychological and emotional distress and loneliness. Review of Resident 1's clinical record titled, "Face Sheet" indicated Resident 1 was admitted to SNF 1 on 9/8/15. Review of Resident 1's clinical record titled, "Transfer Report" dated 9/15/15 indicated Resident 1 had diagnoses that included pneumonia (lung infection), septicemia (infection that has traveled to the bloodstream), chronic obstructive airway obstruction (lung disease that causes difficulty breathing) that required use of supplemental oxygen, pain, anxiety, depressive disorder and bipolar disorder (disorder with recurring episodes of mania and depression). The "Transfer Report" indicated Resident 1 required rehabilitation (physical therapy and occupational therapy) while in SNF 1. Resident 1's "Transfer Report" indicated Resident 1 was sent the hospital emergency room on 9/15/15 for evaluation and treatment of chest pain and decreased oxygen levels.On 10/16/15 at 9 a.m., during a telephone interview, Resident 1's Family Member (FM) 1 stated Resident 1 had been admitted to Skilled Nursing Facility (SNF) 1 on 9/8/15 for physical therapy and rehabilitation after a stay in the acute care hospital. FM 1 stated on 9/15/15 Resident 1 had become very ill and required transport back to the acute care hospital. FM 1 stated Resident 1 wanted to return to SNF 1 when she had been ready for discharge from the hospital on 9/17/15. FM 1 stated she had called SNF 1 and had been told they could not take Resident 1 back as there was no bed available. FM 1 stated she had called several other facilities in the area seeking placement for Resident 1 and had been told by a nurse at another facility that Resident 1 should have been offered a seven day bed-hold by SNF 1. FM 1 stated she had never been informed about a bed-hold either verbally or in writing and had called SNF 1 to ask why Resident 1's bed had not been held for seven days. FM 1 stated she had been told by the Admissions Nurse (AN) that beds are released at midnight on the day of transfer if the facility has not received a written request to hold the bed within 24 hours of transfer. FM 1 stated she had never received a bed-hold notice in writing or verbally at the time Resident 1 had been transferred to the hospital and had not been aware of the bed-hold policy. FM 1 stated she resided out of state and a nurse had called her on the telephone on 9/15/15 to inform her Resident 1 had been transferred to the hospital but had never mentioned the requirement to request a bed-hold in writing. FM 1 stated Resident 1 was responsible for her own medical and financial decisions but she (FM 1) was the person the facility would contact concerning any change in Resident 1's condition. FM 1 stated she did not think Resident 1 had received a written bed-hold notice when transferred, but had been too sick at the time of transfer to have been able to read or respond to the notice even if she had received it. FM 1 stated no other family members had received a bed-hold notice. FM 1 stated SNF 1 would not take Resident 1 back after discharge from the hospital and as a result she was placed in SNF 2 which was over 100 miles away from her home, family and friends. FM 1 stated Resident 1 had become very lonely and sad at SNF 2 as family and friends were unable to visit her due to the distance required to travel.On 10/20/15 at 1:15 p.m., during an interview at SNF 1, the Director of Staff Development (DSD) stated the SNF 1 practice was to provide a notice of the bed-hold policy when a resident was transferred to the hospital. The DSD stated the bed-hold notice is sent with the resident's transfer papers to the hospital. The DSD stated the facility does not send a notice to family members. The DSD stated Resident 1's bed-hold notice upon transfer would have gone with her paperwork to the hospital, but she was not able to find a photocopy of the notice or record of the notice having been issued in Resident 1's clinical record.On 10/20/15 at 2:10 p.m., during an interview with the AN in the SNF 1 business office, the AN stated she had released Resident 1's bed at 12:01 a.m. on 9/16/15. The AN stated residents have a right for a seven day bed-hold, but if they do not request one in writing within 24 hours of transfer the bed is released for admission of another resident. The AN stated Resident 1 had not provided a written request for the seven day bed-hold within 24 hours of her transfer to the hospital. On 10/23/15 at 1:45 p.m., during a telephone interview, the acute hospital Program Manager (PM) stated a request to discharge Resident 1 back to SNF 1 had been sent on 9/17/15. The PM stated on 9/18/15 SNF 1 responded to the request to re-admit Resident 1 as unable to readmit due to the facility had no available beds.On 11/4/15 at 1:30 p.m., during a telephone interview, Resident 1 stated she had gone to SNF 1 on September 8, 2015 for rehabilitation and therapy. Resident 1 stated she had chest pain and difficulty breathing on 9/15/15 and had been sent by ambulance to the hospital for evaluation and treatment. Resident 1 stated she did not recall receiving a notice of the facility bed-hold policy when transferred to the hospital. Resident 1 stated, "They were trying to push papers at me - trying to get me to sign papers. I couldn't do it. I was sick. I was sinfully sick. I was really out of it." Resident 1 stated she had not been aware of any notice of bed-hold policy included with her papers when she was transferred and had been too sick at that time to read any papers or to respond to anything in writing. Resident 1 stated she wanted to go back to SNF 1 when ready for discharge from the hospital but they would not take her back. Resident 1 stated she had been transferred to SNF 2 when discharged from the hospital. Resident 1 stated, "I have no idea why I had to go there." Resident 1 stated she had no family or friends within several hours drive of SNF 2 and had been very lonely and unhappy. Resident 1 stated, "I felt trapped. I was stressed. I was depressed. It was really bad. I didn't want to be there."On 11/6/15 at 3 p.m., during a telephone interview, FM 2 stated she resided in the same town as Resident 1. FM 2 stated she had not been notified of SNF 1's bed-hold policy either verbally or in writing when Resident 1 had been transferred to the hospital on 9/15/15. Review of facility document titled, "Attachment E Authorization for Disclosure of Medical Information" indicated "[Resident's Name] hereby authorize the Facility, [SNF 1], to provide information regarding my medical history, mental or physical condition, care, or treatment as specified below: This authorization is limited to disclosure to the following persons: 1. [FM 1]...3. [FM 2]." The facility document was signed by Resident 1 and dated 9/10/16. Review of Resident 1's clinical record titled, "Progress Notes" dated 9/15/15 at 12 p.m., indicated "Pt [patient] breathing hard and labored. O 2 cannula [oxygen tubing] in place...co [complained of] cp [chest pain] to left chest...O 2 85-89 % [a measurement of oxygen level in the blood, normal level is 95% or greater] upon initial assessment with HR of 105 - 126 [ heart rate of 105 to 126 beats per minute, normal range is 60 - 100 beats per minute ]...Called MD [Medical Doctor] at 12:30 who stated to send to ER [emergency room] for further eval [evaluation] and tx [treatment]. Called [ambulance], pt [patient] left building at 1246." Review of undated facility policy titled, "Bed Hold Informed Consent" indicated, "You have the option of requesting a seven (7) day bed hold to keep a bed vacant and available for return to this facility...If you desire this option, the facility must be notified with written confirmation and to the Business office within 24 hours of transfer. " Review of facility policy titled, "California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities" dated 5/2011, indicated "VII. Bed Holds and Re-admission. If you must be transferred to an acute hospital for seven days or less, we will notify you or your representative that we are willing to hold your bed. " Review of website www.mapquest.com indicated SNF 2 was located 110.2 miles and two hours and twelve minutes driving time from Resident 1's home. Therefore, the facility failed to honor and protect Resident 1's transfer and discharge rights. Resident 1 and her family were not provided written or verbal notice of the bed-hold policy upon Resident 1's transfer to the hospital. This violation resulted in significant emotional and psychological distress and loneliness for Resident 1. These violations had a direct relationship to Resident 1's health, safety and security and thus constitute a Class B Citation. |
| 040000225 |
Anberry Nursing and Rehabilitation Center |
040012299 |
B |
01-Jun-16 |
UISX11 |
14428 |
Each resident must receive and the facility must provide the necessary services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. On 5/6/15 at 8:15 a.m., an unannounced visit was made to the facility to investigate Complaint CA00440945 regarding Quality of Care/Treatment. The facility failed to ensure Resident 1 received services to attain and maintain the highest practicable physical and psychosocial well-being when: 1. Resident 1's handwritten physician's order for administration of pain medication was carried out for moderate pain and no order was carried out for severe pain. Resident 1 had 20 episodes of severe pain managed with pain medication prescribed for moderate pain (in the Numeric Pain Rating Scale of zero- to- ten, 0/10 indicated no pain, 1/10-3/10 indicated mild pain, 4/10-6/10 indicated moderate pain, 7/10-10/10 indicated severe pain, and 10/10 was the worst pain imaginable). This resulted in inadequate pain control for Resident 1. 2. Resident 1's recurrent episodes of severe unrelieved pain were not communicated to the physician. 3. Resident 1's pain management was not reviewed for effectiveness in managing the resident's pain as indicated in Resident 1's care plan. Resident 1's handwritten physician's order for administration of pain medication was not clarified to determine dosage indication for moderate pain and dosage indication for severe pain prior to transcribing orders onto the electronic medical record. As a result of these failures, Resident 1 suffered physical and psychological distress limiting the resident's ability to attain and maintain her highest practicable physical and psychosocial well-being. Resident 1 was a 73 years old female who was readmitted to the facility on XXXXXXX. She had diagnoses that included Aftercare-Internal Right ORIF (Open Reduction Internal Fixation - a surgical procedure to fix a severe bone fracture) of the hip, muscular wasting and disuse, cellulitis (a bacterial infection of the skin and the tissues underneath) and abscess (a confined collection of pus in an infected body part) of leg, acute post-op (immediately after the operation) pain, personal history of falls, and dual chamber pacemaker. The Minimum Data Set (MDS) assessment (a standardized resident assessment tool) dated 3/6/15, indicated Resident 1 had a BIMS (Brief Interview of Mental Status) (an assessment tool to determine a resident's cognitive status pertaining to memory, judgement and reasoning) score of 15/15 (indicated Resident 1 had no cognitive deficits). On 5/6/15, at 8:20 a.m., during a concurrent observation and interview in Resident 1's room, Resident 1 appeared anxious, grimaced and her eyebrows furrowed. Resident 1 stated she had a current pain scale of "...12/10 (12 out of 10 on a scale of one to 10 with 10 being the worst pain imaginable)." Resident 1 stated she had received a pain medication that morning and it "took a while to work... (it) was only good for two hours (looked at the wall clock facing the bed), then comes back again... (I) tell the nurse... (They) tell me (I) have to wait another 2 hours... (I) can't take it (referring to the pain pill) right away... by the time I get it, pain is too much... (I) can't bear it and it (pain pill) takes a while to work..." Resident 1's handwritten physician prescription for controlled substance (a medication restricted by law and may be dispensed only under a physician's prescription), dated 4/4/15 indicated "...Hydrocodone 5 mg/325 (generic name Norco, a narcotic pain reliever) (mg) (milligram) (a unit of measurement)... 1 tab (tablet) PO (by mouth) Q (every) 4 hours for mod (moderate)/severe pain/ (No more than 2 pills Q 4 hrs) (sic)..." Resident 1's "Order Summary Report" (a summary of orders that have been entered into the resident's electronic or computerized clinical record), printed 5/6/15, indicated an active order dated 4/5/15, "... Norco Tablet 5-325 MG... Give 1 tablet by mouth every 4 hours as needed for moderate pain 4-6 ([moderate pain identified by] pain scale of 4/10-6/10)..." There was no active physician order in the clinical record by which nursing staff were to manage severe pain. There was no documentation in the clinical record to indicate the handwritten physician prescription for Norco dated 4/4/15 was clarified with the physician on what was meant by "mod/severe pain... no more than 2 pills every 4 hours" prior to the order transcription in the electronic clinical record. Resident 1's April 2015, "Medication Administration Record" (MAR) indicated a pain medication was ordered on 4/5/15. The order indicated "Norco Tablet 5-325 MG... give 1 tablet... every 4 hours as needed for moderate pain 4-6 (pain scale of 4/10-6/10) ..." This MAR indicated Resident 1 had 13 episodes of severe pain (a value to evaluate severe pain on a pain scale of 7/10-10/10) over several days and was managed with this dosage. These episodes of pain occurred on: 4/14/15 (7/10 at 12:33 p.m.) 4/15/15 (7/10 at 12:28 p.m. and 7/10 at 5:54 p.m.) 4/18/15 (7/10 at 8:15 a.m.) 4/19/15 (8/10 at 7:47 a.m.) 4/24/15 (8/10 at 1:22 p.m. and 7/10 at 7:23 p.m.) 4/25/15 (7/10 at 1:30 p.m.) 4/27/15 (8/10 at 10:23 a.m., 7/10 at 2:36 p.m. and 7/10 at 7:21 p.m.) and 4/29/15 (7/10 at 9:02 a.m. and 8/10 at 12:57 p.m.) Resident 1's Nursing Note, dated 4/30/15 at 9:32 a.m., indicated "...During this time family member called (Company's name) Ambulance to come to facility and take resident to the hospital. Resident was taken by (Company's name) Ambulance at (8:37 a.m.) for c/o (complaint of) abdominal pain..." Resident 1's Emergency Room (ER) Report, dated 4/30/15, indicated she complained of pain "...described as severe, sharp, cramping, non-radiating... states she has had this pain for 4 weeks and 'they were not doing nothing (sic)' and she is not getting answers..." Resident 1's May 2015 pain medication MAR for moderate pain indicated Resident 1 had 7 episodes of severe pain from 5/1/15-5/6/15 managed with one tablet of Norco 5-325 mg which was ordered for moderate pain of 4 to 6 on a scale of 0 to 10. These occurred on: 5/1/15 (7/10 at 11:36 a.m.) 5/3/15 (7/10 at 9:36 a.m. and 7/10 at 5:19 p.m.) 5/4/15 (7/10 at 11:39 a.m.) 5/5/15 (9/10 at 8 a.m. and 10/10 at 12:13 p.m.) 5/6/15 (10/10 at 8:13 a.m.) Resident 1's e (electronic) MAR Note, dated 5/4/15 at 6 a.m., indicated "... PRN (as needed) administration was: Ineffective resident is still c/o (complaining of) pain and discomfort..." Resident 1's May 2015 MAR, indicated on 5/4/16 at 11:39 a.m., abdominal pain was 7/10. There was no documentation in the clinical record to indicate the physician was notified of Resident 1's unrelieved pain and ineffective pain medication. There was no documentation in the clinical record to indicate the physician was informed that the current pain medication dosage indicated for moderate pain was used to manage Resident 1's episodes of severe pain. Resident 1's MAR, dated 5/5/15 at 8:00 a.m., indicated Resident 1's abdominal pain was 9/10. At 12:13 p.m., four hours after the 8 a.m. dose, Resident 1's abdominal pain was 10/10. A fax communication sheet to the physician, dated 5/5/16 at 11:50 a.m., indicated "...Continue with abdominal pain. Resident states 1 tablet of norco ineffective... Pain level:10/10... May we have a stronger medication..." Resident 1's e (electronic) MAR - Medication Administration Note , dated 5/5/15 at 12:13 p.m., indicated "Norco tablet 5-325 MG Give 1 tablet... every four hours as needed for moderate pain 4-6 (4/10-6/10)... resident stated 10/10 pain in abdomen... given 1 tab of Norco..." Resident 1's MAR, dated 5/6/15 at 8:13 a.m., indicated her abdominal pain was a 10/10. Resident 1's eMAR - Medication Administration Note, dated 5/6/15 at 8:13 a.m., indicated"... Norco Tablet 5-325 MG... Give 1 tablet by mouth every 4 hours as needed for moderate pain 4-6... resident c/o (complained of) abdominal pain 10/10... 1 tab Norco given..." Review of the clinical record on 5/6/15 visit indicated there was no documentation to confirm the physician replied to the faxed communication on 5/5/15-5/6/15. There was no documentation to indicate the facility followed up with the physician about Resident 1's unrelieved severe pain on 5/5/15 until the 5/6/15 survey. On 5/6/15 at 9:52 a.m., an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated Resident 1 had complained of pain. LN 1 stated Resident 1 received "PRN Norco only, not routine" for pain management. LN 1 stated, "She (Resident 1) does not need it (routine pain med)... (she is) not in constant pain..." LN 1 stated the physician was notified through fax of Resident 1's pain on Monday (5/5/15) and did not respond. LN 1 stated there was no follow up done for this notification when the physician did not respond. Review of the clinical record indicated there was no documentation to verify pain management was evaluated by the facility for the onset of severe pain on 4/4/15 until the 5/6/15 survey. On 5/6/15, at 11:50 a.m., an interview was conducted with LN 2. LN 2 stated the facility pain management protocol was to notify the physician if pain management was ineffective. On 5/6/15 at 11:56 a.m., an interview was conducted with LN 1. LN 1 stated the facility's pain management protocol was to evaluate the pain administration for effectiveness. If the medication was ineffective, the nurse should notify the physician for pain medication re-evaluation. On 5/6/15 at 12:20 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated pain was evaluated per the facility scale as moderate pain of 4/10-6/10 and severe pain was 7/10-10/10. The DON confirmed Resident 1 had no current orders for severe pain. The DON stated there was no documentation in Resident 1's clinical record to indicate a clarification was done for the handwritten controlled pain medication prescription dated 4/4/15. The DON stated there was no documentation in the clinical record to indicate the physician was notified of episodes of recurring severe pain. The DON was unable to answer if the physician had been notified of Resident 1's severe pain. The DON stated there was no recent pain assessment for Resident 1. The DON stated the last pain assessment was done on 2/18/15 for Resident 1's readmission. The DON stated there was one pain care plan dated 2/17/15 which had not been revised to address Resident 1's current complaints of severe pain. The DON was unable to answer if the current pain management was evaluated by the facility for effectiveness. Review of Resident 1's pain care plan, initiated 2/17/15 indicated "... Interventions/Tasks... Evaluate the effectiveness of pain interventions. Review for... resident satisfaction with results, impact on functional mobility and impact on cognition... Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents (sic) past experience of pain..." The facility Nursing Policy and Procedure titled, "Physician's Orders" effective 01/01/15 revised 05/01/15, indicated " ...Policy: it is the policy of this facility to maintain a system of transcribing and noting physician orders at the time received that minimizes the chance of errors... Procedure: 1. Orders written by a physician during their visit to the facility will be transcribed into the electronic medical record (PCC) [facility term for electronic medical record] by the licensed nurse or unit clerk... 11. All orders are to be verified as being accurate before being signed in the PCC." The facility Nursing Policy and Procedure titled, "Pain Management" effective 1/01/10 and reviewed 9/25/14, indicated, "PURPOSE: To assure an accurate assessment of the resident's pain and respond in a timely manner with administration of pain medication... PROCEDURE... 7. If pain... changed in nature, or not relieved with current medication, the licensed nurse will notify the physician for a review of medications..." The article titled, "Errors in Transcribing and Administering Medications" from Safety First Alert published on January 2001 by (c) The Massachusetts Coalition for the Prevention of Medical Errors indicated "... Transcription, the transfer of information from an order sheet to nursing documentation forms, is a source of many medication errors... In addition to errors associated with transcribing the drug name, there is also opportunity for errors when transcribing the dose, route or frequency..." The National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) defined medication error as "...any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional... Such events may be related to professional practice... and systems..." (c) 2016 National Coordinating Council for Medication Error Reporting and Prevention. The article titled, "Nursing Standard of Practice Protocol: Pain Management in Older Adults" by A.L Horgas, et.al. from the Hartford Institute for Geriatric Nursing updated July 2012, indicated "... Standard. All older adults will either be pain free, or their pain will be controlled to a level that is acceptable to the patient and allows the person to maintain the highest level of functioning possible... Significance 1. Pain has major implications for older adults' health, functioning, and quality of life... Expected outcome... Patient...1. Will be either pain free or pain will be at a level that the patient judges acceptable. 2. Maintains highest level of self-care, functional ability, and activity level possible..." The facility failed to ensure Resident 1 received and was provided necessary services for pain management. Resident 1's pain medication order was not clarified with the physician for the correct dosage at varied levels of pain which resulted in inadequate pain control. Resident 1's care plan for pain management was not carried out as indicated. These violations resulted in Resident 1's physical and psychological distress limiting the resident's ability to attain and maintain her highest practicable physical and psychosocial well-being. These violations had direct or immediate relationship to Resident 1's health, safety and security and thus constitute a Class B violation. |
| 040000073 |
Avalon Health Care - Madera |
040012802 |
AA |
9-Dec-16 |
CDX811 |
26109 |
F 333: 483.25(m) (2) Residents Free of Significant Med Errors The facility must ensure that residents are free of any significant medication errors. On 9/1/16 at 2 p.m., an unannounced visit was made to the Skilled Nursing Facility (SNF) to investigate Entity Reported Incident CA 00501186 and Complaint CA 00501384 regarding an alleged violation of medication administration. The facility failed to ensure Resident 1 was free of a significant medication error when Dilaudid (hydromorphone is the generic name for Dilaudid which is an opioid narcotic used to treat severe pain) was not administered according to the physician order. Resident 1 was prescribed 4 milligrams (mg) of Dilaudid to be given sublingually (placed under the tongue) for pain control. Instead, Resident 1 was administered 80 mg of Dilaudid in error, 20 times the ordered dose, on eight separate occasions, within three consecutive days by four different skilled nursing facility licensed nurses. As a result of these failures Resident 1 developed opioid neurotoxicity (adverse reaction affecting the central nervous system due to high amount of opioids) from the overdose along with increased physical and emotional distress and pain. Resident 1's health rapidly declined and Resident 1 expired two days after the Dilaudid overdose was discovered and the medication was withdrawn. Resident 1's clinical record face sheet (resident profile information), indicated Resident 1 was a 63 year old diagnosed with acute renal failure (abrupt loss of kidney function), psoriasis (a red, peeling rash that can itch or burn intensely), and cirrhosis of the liver (disease of the liver in which the liver fails to function). Resident 1 was transferred from the acute care hospital to the facility for hospice (end of life care) services on 8/14/16. Resident 1's clinical record titled, "Progress Notes" dated 8/14/16 at 2:09 p.m., indicated, "Received resident at 10:45 a.m., via [by] ambulance ...Resident is alert and oriented x 3 [coherent awareness of person, place and time]..." Resident 1's progress note indicated vital signs (clinical measurements of pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) were "temperature (T) 98.4, heart rate...82, respiratory rate...15, blood pressure (B/P) 160/72 ... " Review of Professional Reference, " Fundamental Nursing Skills and Concepts," Ninth Edition; Barbara K. Timby; c. 2009; indicated normal range for vital signs include; Temperature 96.6 to 99.3 degrees Fahrenheit (F), heart rate (pulse) 60 to 100 beats per minute, respiratory rate 14 to 20 breaths per minute, blood pressure 120/80. Resident 1's clinical record titled, "Progress Notes" dated 8/16/16, at 5:34 p.m., and electronically signed by Licensed Nurse (LN) 1 indicated, "...Resident currently resting in bed...is adjusting well to facility and routine. Resident continued on hospice care. No indications of pain or discomfort..." Resident 1's clinical record titled, "Minimum Data Set (MDS) (a resident assessment tool which directs care planning decisions) assessment, dated 8/21/16, indicated Resident 1 had no cognitive (pertaining to short and long term memory) impairment. Resident 1's MDS assessment indicated he was able to make himself understood and could understand others. Resident 1's MDS assessment indicated he had no behaviors of agitation, aggression or anxiety. The MDS assessment indicated he was able to feed himself with supervision. Resident 1's MDS assessment revealed he experienced frequent pain, requiring the use of PRN (as necessary) pain medication. Resident 1's clinical record titled, "Weekly Assessment" dated 8/22/16, at 3:21 a.m., indicated Resident 1 was alert and oriented to person, place, time and situation and had no noted mood or behavior changes. The document indicated Resident 1 verbalized complaints of pain but the document had not indicated the intensity or location of Resident 1's pain. Review of Resident 1's clinical record titled, "[name] Hospice Physician's Order Sheet" dated 8/25/16, indicated the following order by the hospice physician (HMD), "Dilaudid 1 mg/ml (milligram) [per](milliliter, a liquid measure) give 4 mg = (equals) 4 ml...q [every] 4 hours routine for pain management..." A second "[name] Hospice Physician's Order Sheet " dated 8/25/16 indicated, "Dilaudid 2 mg/0.1 ml give 4 mg =0.2 ml...q 4 hours routine for pain...Dilaudid 2 mg/0.1 ml give 2 mg= 0.1 ml every 4 hours as needed for breakthrough pain." The time the orders were written was not recorded on the physician orders. Review of professional reference, "Saunders Nursing Drug Handbook 2015 c. Elsevier, Saunders, 2015" indicated, "hydromorphone...High Alert...Black Box Alert. Indications/Routes/Dosage...PO [orally] Adults, Elderly: 2-4 mg every 3-4 hours...Range: 2-8 mg/dose" Saunders Nursing Drug Handbook indicated, "High Alert drugs with a blue icon [High Alert] are considered dangerous by The Joint Commission [an accrediting agency for healthcare facilities] and the Institute for Safe Medication Practices (ISMP) because if they are administered incorrectly, they may cause life-threatening or permanent harm to the patient. The entire High Alert generic drug entry sits on a blue-shaded background so that it's easy to spot...Black Box Alert. This feature highlights drugs that carry a significant risk of serious or life-threatening adverse effects. Black box alerts are ordered by the FDA [Food and Drug Administration]." On 9/1/16 at 2 p.m., during an inspection of the facility's medication cart with the Director of Nursing (DON), a bottle of liquid Dilaudid 2 mg/0.1 ml, dated 8/25/16 and labeled for Resident 1 was observed. The dosage directions on the bottle matched the second physician order dated 8/25/16 for treatment with Dilaudid in a concentration of 2 mg/0.1 ml for routine and breakthrough pain. On 9/1/16 at 2:01 p.m., during an interview, the DON stated Resident 1 was administered multiple incorrect doses of Dilaudid beginning 8/28/16. The DON stated Resident 1 had an order dated 8/25/16 for Dilaudid 4 mg in a concentration of 1 mg/ml (4 mg = 4 ml). The DON stated there was a second order for Dilaudid 4 mg at a higher concentration of 2 mg/0.1 ml (4 mg = 0.2 ml) also ordered on 8/25/16. The DON stated the content in the bottle of the less concentrated Dilaudid ran out on 8/28/16. The DON stated the nurses began to use the bottle which contained a concentrated solution of 2 mg /0.1 ml but continued to administer 4 ml (80 mg) rather than 0.2 ml (4 ml of concentrated solution equals 80 mg or 20 times the ordered dose) in error. The DON stated Hospice Licensed Nurse (HLN) 2 reviewed Resident 1's clinical record on 8/30/16 and informed the DON medication errors had been made. The DON stated LN 1 entered the first order for Dilaudid into the electronic record system but had not entered the second order. The DON stated the second physician order, dated 8/25/16, should have been entered into the electronic health record. The DON stated the practice was for the LN to input the physician order into the electronic system, and then the unit manager would audit the order either the same day or the day following the input. The DON stated LN 1 should have followed facility protocol for entering the order into the electronic clinical record. The DON stated the licensed nurses who administered the concentrated solution of Dilaudid had not checked the medication label on the bottle for the concentration before they administered the medication. The DON stated protocol for medication administration had not been followed. On 9/1/16 at 2:52 p.m., during an interview, LN 1 stated the hospice nurse handed her a physician order for Dilaudid for Resident 1 on 8/25/16. LN 1 stated about an hour later the hospice nurse handed her a second physician order for the administration of Dilaudid. LN 1 stated the second order had not been entered into Resident 1's clinical record. LN 1 stated, "I screwed up. The second order wasn't entered [in the clinical record]. It didn't get done the correct way." LN 1 stated another nurse called HLN 1 on 8/28/16 and left a voice message to let him know they were running low on Resident 1's Dilaudid. LN 1 stated HLN 1 came to the facility on 8/30/16 and told her they should not be running low on the Dilaudid ordered for Resident 1. LN 1 stated she checked on the Dilaudid doses administered and realized the nurses gave the wrong amount of Dilaudid to Resident 1. LN 1 stated she informed HLN 1 on 8/30/16 of the medication error. Resident 1's clinical record titled, "Progress Notes" dated 8/25/16 at 1:52 p.m., indicated, "Hospice nurse in to see resident, new orders written..." The progress notes were electronically signed by LN 1. On 9/1/16 at 3:52 p.m., during an interview, LN 2 stated on 8/28/16 she administered 80 mg of Dilaudid to Resident 1 during the night shift instead of the ordered 4 mg. LN 2 stated she looked at the physician order on the computer and it indicated 4 ml was to be administered to Resident 1. LN 2 stated she located the bottle of Dilaudid with Resident 1's name and administered 4 ml (80 mg) of Dilaudid without reading the concentration of the medication. LN 2 stated, "I'll be honest with you I did not see the dose amount...It's a mistake that I made...the DON told me there was a med error." On 9/1/16 at 4:15 p.m., during an interview, LN 3 stated she administered 80 mg of Dilaudid to Resident 1 instead of the 4 mg that had been ordered by the physician. LN 3 stated she looked at the computerized physician order and the order indicated the LN was to give 4 ml of Dilaudid. LN 3 stated she looked at the bottle of medication (Dilaudid) and Resident 1's name was on the bottle. LN 3 stated she had not read the medication label to determine the dosage or concentration written on the bottle. LN 3 stated she had not compared the label on the medication bottle with the physician order entered into the computer. LN 3 stated she administered the Dilaudid dosage from the bottle containing a different concentration than the physician's order had prescribed. LN 3 stated, "That was a mistake that I made. I didn't realize it was a different concentration." LN 3 stated the Dilaudid bottle had a 1 ml syringe attached to the bottle and she filled the syringe full four times to administer one dose of Dilaudid to Resident 1 without comparing the label on the bottle to the physician's order on the computer. Review of Resident 1's "Controlled Drug Medication Record" (CDR) indicated, "[Resident 1], Hydromorphone 2 mg/0.1 ml solution, date 8/29, Time 1600 [4 p.m.], Dose 4 ml, Amount Given 4 ml, Nurse Signature [LN 3]." LN 3's signature was repeated on the CDR record for 8/29/16 at 8 p.m. to signify LN 3 had administered the same amount of medication to Resident 1 as she had at 4 p.m. On 9/1/16 at 5:10 p.m., during an observation, Resident 1 was lying in bed with the head of the bed elevated, and his eyes and mouth were open. Resident 1 wore a nasal cannula (tube placed into the nose to supply oxygen). Resident 1 was breathing heavily through his open mouth. Resident 1 stared at the ceiling and had not responded to the presence of visitors in his room. On 9/12/16 at 3:30 p.m., during an interview, HLN 1 stated she made a visit to Resident 1 at the facility on 8/25/16. HLN 1 stated Resident 1 was having significant pain on 8/25/16. HLN 1 stated she handed two physician orders to LN 1 for Resident 1 at the same time and informed her that the physician orders were for two different concentrations of Dilaudid. HLN 1 stated the first concentration was based on the Dilaudid bottle the facility had on hand, in which the concentration was Dilaudid 1 mg/1 ml. HLN 1 stated the second physician order was for Dilaudid 2 mg/ 0.1 ml. HLN 1 stated the second bottle of Dilaudid with the higher concentration was supplied with a 1 ml syringe and there was a dark black line on the syringe to indicate the correct (dosing) amount. HLN 1 stated there were directions on the bottle which indicated the correct dose as well. HLN 1 stated, "They [nurses] kept going above the line." HLN 1 stated when she visited Resident 1 on 8/26/16 he was awake and feeding himself. HLN 1 stated when she visited Resident 1 on 8/31/16 he was agitated, combative and twitching all over. HLN 1 stated the hospice doctor's note indicated Resident 1 had been given an overdose of Dilaudid and had symptoms of the overdose exhibited by nonstop jerking movements of his body. HLN 1 stated Resident 1 expired on 9/1/16. On 9/12/16 at 4:25 p.m., during an interview, HLN 2 stated the facility staff had left two messages for him over the weekend of 8/27/16 indicating a refill was needed for Resident 1's Dilaudid. HLN 2 stated on 8/30/16 he reviewed Resident 1's clinical record with LN 1 and found Resident 1 had been receiving the incorrect dose of Dilaudid for eight doses. HLN 2 stated he informed the DON on 8/30/16 of Resident 1's Dilaudid medication errors. HLN 2 stated the DON told him there was only one physician order given and he informed her there were two orders for the Dilaudid. HLN 2 stated he and the DON went into the back room of the nursing station and found the second physician order for the Dilaudid on the bottom of a pile of stacked papers. HLN 2 stated he notified the hospice agency's medical director (HMD) and HLN 1 immediately after identifying the medication errors of Resident 1's Dilaudid administration. HLN 2 stated when he called the HMD on 8/30/16 the HMD gave an order not to administer Dilaudid for 24 hours. Resident 1's hospice clinical record titled, "Hospice routine visit on 8/30/16," indicated Resident 1's vital signs were recorded at 12:02 p.m. on that date. The vital signs included an axillary (armpit) temperature of 98.8 Fahrenheit, pulse of 120 beats per minute (high), respiratory rate was 24 breaths per minute and shallow. Resident 1's blood pressure was 90/64. The hospice clinical record indicated, "Symptoms: unresponsive, noisy and moist breathing, dyspnea (difficulty breathing), pain, jerking, twitching..." The entry was electronically signed by HLN 2. On 9/15/16 at 4:06 p.m., during an interview and concurrent clinical record review, the DON reviewed Resident 1's CDR. The physician order dated 8/25/16, indicated the following dose instructions: "Dilaudid 2 mg/0.1 ml, [2 mg is equal to 0.1 ml] take 0.2 ml (4 mg) every 4 hours... and 0.1 ml (2 mg)...every 4 hours as needed [additionally] for breakthrough pain [Pain unrelieved by the first dose]." The DON verified Resident 1 had been administered 80 mg (20 times the ordered dose) instead of 4 mg by four different licensed nurses on eight separate occasions as follows: 8/28/16 at 8 a.m. by LN 1 8/28/16 (time not recorded) by LN 2 8/29/16 at 8 a.m. by LN 1 8/29/16 at 12 noon by LN 1 8/29/16 at 4 p.m. by LN 3 8/29/16 at 8 p.m. by LN 3 8/30/16 at 12 a.m. by LN 8 8/30/16 at 4 a.m. by LN 8 On 11/8/16 at 8:35 a.m., during a telephone interview, the DON confirmed the overdoses of Dilaudid recorded on Resident 1's CDR were administered by LN 1, LN 2, LN 3, and LN 8. On 10/12/16 at 8:40 a.m., during a telephone interview, LN 7 stated Resident 1's goal in hospice care was to maintain an adequate level of comfort for the end of life care. LN 7 stated prior to 8/29/16 Resident 1 was alert and oriented to self, time and situation, engaged in conversation and had the physical ability to grip a cup of water from the bedside table and drink independently. LN 7 stated on 8/29/16, following the medication errors, Resident 1 was confused and no longer spoke coherently. On 10/12/16 at 9:25 a.m., during a telephone interview and concurrent clinical record review, HLN 1 stated she initially saw Resident 1 on 8/15/16. HLN 1 stated Resident 1's primary goal while under hospice was for pain management and the promotion of his comfort. HLN 1 stated on 8/15/16 Resident 1 had been able to feed himself, was awake, alert and able to make his needs known. HLN 1 stated at that time Resident 1 had the ability to engage in a meaningful conversation. On 10/12/16 at 10:15 a.m., during a telephone interview and concurrent clinical record review, HLN 1 stated she made a 24-hour follow up visit to Resident 1 on 8/26/16 after the adjustment in the physician orders for pain medication was made. HLN 1 stated Resident 1 appeared to be in good spirits, was talking, feeding himself and requested to speak with his wife. HLN 1 stated on 8/26/16 the correct dosage of Dilaudid had been given and was effective as Resident 1 was no longer in pain. HLN 1 stated the facility called the hospice agency to request a refill for Resident 1's Dilaudid on 8/30/16. HLN 1 stated the request made to refill the bottle of medication by the facility concerned her and she requested HLN 2 visit the facility the same day the request was made. HLN 1 stated she visited Resident 1 on 8/31/16 at 9:20 a.m., and saw Resident 1 was very agitated and in a lot of pain. HLN 1 stated Resident 1 was screaming, dry heaving (experiencing the reflex of vomiting), and twitching throughout his entire body. HLN 1 stated on 8/31/16 she called the HMD to notify him of Resident 1's condition. HLN 1 stated the HMD gave an order for the administration of lorazepam (medication used for anxiety) 0.5 mg, and an order for the administration of methadone (medication used as a pain reliever), 2.5 mg every 8 hours for pain. HLN 1 stated the HMD discontinued the Dilaudid order altogether. HLN 1 stated Resident 1 had still exhibited signs of anxiety not relieved after he received the lorazepam. HLN 1 stated the HMD was called again regarding the severe symptoms of anxiety. The HLN gave an order to discontinue the lorazepam and start Haldol (antipsychotic medication used for extreme agitation) 5 mg once, then to repeat the dose one time if the initial dose was ineffective. HLN 1 stated methadone 2.5 mg was administered and taken by Resident 1 at 12:20 p.m. HLN 1 stated Resident 1 was unable to take the Haldol by mouth and required the HMD order a "Macy rectal catheter (tube inserted into the rectum for the purpose of giving medications) for the administration of Haldol. HLN 1 stated she administered Resident 1's ordered dose of Haldol through the rectal catheter. HLN 1 stated the HMD arrived to the facility on 8/31/16 around 1:45 p.m., and assessed Resident 1. HLN 1 stated the HMD spoke with Resident 1's spouse initiating "palliative sedation" (practice that provides a relief from pain and suffering in terminally ill patients). HLN 1 stated Resident 1 was no longer able to communicate or feed himself on 8/31/16 and passed away on xxxxxxx at 11 p.m. Resident 1's hospice clinical record titled, "Charts/Clinical Notes," dated 8/31/16 and electronically signed by HLN 2 at 8:06 p.m., indicated, "[HMD and HNL 1] with family at bedside ...[rectal] cath inserted for med [medication] administration Patient dosed at 2 p.m., with 5 mg of Haldol... Staff gave methadone 2.5 mg also at that time via [by way of] [rectal] cath...2:30 p.m...patient remains with extreme anxiety, yelling and striking out if touched Vitals B/P 100/50, P [pulse]108, R[respirations] 22 shallow...3 p.m., patient remains with high anxiety yelling out and screaming patient was dosed with another 1 time dose of 5 mg Haldol via rectal tube at this time patient does not allow anyone to touch him-strikes out not able to do vitals due to extreme anxiety...4 p.m., patient seems a little more calm...Vitals B/P 104/54 P 128 R 30 will push away and strike out at times...4:30 p.m., Facility staff nurse gave 2 mg Haldol routine order via [rectal] cath [catheter] patient anxiety remains the same yelling, striking out... pulse rate 112 at this time, hit [by the resident] when B/P attempted. Respiratory rate 30...5:15 p.m., RN...arrived with Versed [medication used in terminally ill patients to relieve pain and suffering and promote sedation] dose and pump [for intravenous medication administration] to be started...Vitals B/P 102/50, P 134 R 30, still thrashing in the bed striking out ...7 p.m., Vitals B/P 108/54 P126 R 30 patient comfortable. Patient not striking out or yelling..." Resident 1's clinical record titled, "Hospice Physician Exam" dated 8/31/16 and signed by HMD indicated "Opioid Neurotoxicity...The patient's wife and I had an extensive conversation...Versed pump discussed in detail...Haldol has not helped..." On 10/12/16 at 11:15 a.m., during a telephone interview, the HMD stated Resident 1's "neurotoxicity was essentially irreversible. You could potentially dialyze [procedure to remove drugs and waste products from the blood stream using an artificial kidney] a patient but this resident [Resident 1] was severely agitated and restless. The dialysis would not have been an option for him; he may have not even survived the dialysis." The HMD stated during his visit on 8/31/16, Resident 1 was severely agitated, restless, and with increased confusion. The HMD stated the nurses were unable to touch the resident without Resident 1 becoming more agitated. The HMD stated Resident 1 was going through a state called "hyperalgesia" (an abnormal sensitivity to pain) the HMD stated pain was experienced even by the touch of clothing. The HMD stated Narcan (medication used to reverse the effects of opioids) was not considered for Resident 1 because the medication could have made Resident 1's situation worse by causing a "pain crisis" (pain that is severe and causing increased distress). The HMD stated, "I didn't want him to experience anymore distress..." The HMD stated the use of Narcan was a practice used to treat residents with decreased respiratory rate from the use of opioids but Resident 1's respiratory rate was not low. The HMD stated there were limited options to treat Resident 1's pain and anxiety given Resident 1's medical condition. The HMD stated, "His [Resident 1's] final days were agonizing with severe distress." The HMD stated this distress led him to speak to Resident 1's spouse about starting a Versed pump to administer palliative sedation. The HMD stated the overdoses of Dilaudid precipitated the neurotoxicity that increased Resident 1's level of distress and caused Resident 1 to suffer. The HMD stated Resident 1 signed up for hospice care to be comfortable. On 10/13/16 at 11:15 a.m., during a telephone interview, HNL 2 stated he saw Resident 1 on the morning of 8/30/16 after he had received the multiple overdoses of Dilaudid. HNL 2 stated Resident 1 was not coherent and was experiencing symptoms resulting from the Dilaudid overdose. HNL 2 stated, "[Resident 1] was completely different, he was screaming, yelling out and thrashing in his bed." HLN 2 stated Resident 2 required use of a rectal catheter for the administration of the Haldol because he was spitting out everything from his mouth. Review of professional reference, "10 Strategies for Preventing Medication Errors 2008" http://minoritynurse.com/10 strategies-for-preventing-medication-errors/ indicated, "1. Ensure the five rights of medication administration. Nurses must ensure that institutional policies related to medication transcription are followed. It isn't adequate to transcribe the medication as prescribed, but to ensure the correct medication is prescribed for the correct patient, in the correct dosage, via the correct route, and timed correctly (also known as the five rights) ...3. Double check or even triple check procedures. This is a process whereby another nurse on the same shift or an incoming shift reviews all new orders to ensure each patient's order is noted and transcribed correctly on the physician's order and the medication administration record (MAR) or the treatment administration record. Some institutions have a chart flag process in place to highlight charts with new orders that require order verification ..." The facility policy and procedure titled, "Medication Administration General Guidelines" dated 3/11, indicated under Procedures, "2. Medications are administered in accordance with written orders of the attending physician. If a dose seems excessive ...the nurse calls the physician for clarification prior to the administration of the medication...16. Read medication label and compare with medication administration record before pouring..." The facility policy and procedure titled, "Preparation for Medication Administration" dated 3/11, indicated, "Policy: Medications are administered as prescribed in accordance with good nursing principles and practices...Procedures...5. Prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label. If the label and MAR are different and the container is not flagged indicating a change in directions, or if there is any other reason to question the dosage or directions, the physician's orders are checked for clarification. 10. When administering potent medications in liquid form or those requiring precise measurements...devices provided by the manufacturer or obtained from the provider pharmacy are used to allow accurate measurement of doses." Review of facility policy titled, "Orders, Receiving and Transcribing" Revised February 2014, indicated, "1 ...Orders must be reduced to writing by the person receiving the order, and recorded in the resident's medical record." Therefore, the facility failed to ensure Resident 1 was free from significant medication errors. Resident 1 was administered 20 times the ordered dose of the narcotic pain reliever, Dilaudid, on eight separate occasions. This violation resulted in significant physical and emotional distress and pain and materially contributed to a rapid decline and death of Resident 1. These violations either jointly or separately, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and was a direct proximate cause of the death of Resident 1 and therefore constitute a Class "AA" Citation. |
| 040000025 |
ALICE MANOR CONVALESCENT HOSPITAL |
040012956 |
B |
8-Feb-17 |
8IH211 |
18815 |
F 309 483.25
Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
On 6/13/16 at 10:20 a.m., an unannounced visit was made to the Skilled Nursing Facility (SNF) to investigate Entity Reported Incident CA 00491420 regarding the alleged violation of quality of care and treatment. The facility failed to provide adequate assessment, care planning and psychotherapeutic services needed to treat Resident 1's depression and repeated suicide attempts. The facility failed to provide the necessary services to protect Resident 1's physical and psychosocial health and to ensure Resident 1 maintained her highest physical, mental and psychosocial well-being.
As a result of these failures, Resident 1 suffered psychological distress from untreated depression and risk of physical harm from repeated suicide attempts. Resident 1 was hospitalized for suicidal attempts on multiple occasions and expressed anxiety, distress, and fear that the suicidal behaviors would continue due to lack of appropriate therapy.
Resident 1's clinical record face sheet (resident profile information) indicated, Resident 1 was admitted to the facility on XXXXXXX15 with diagnoses that included anxiety disorder (a mental health illness characterized by a feeling of fear and anxiety about current and future events) and schizophrenia (a serious mental disorder characterized by bizarre behavior and an altered perception of reality). Resident 1's Minimum Data Set (MDS)(a resident assessment tool used to guide care planning decisions) assessment, dated 4/29/16, indicated Resident 1 was oriented to time and place, was able to understand others and communicate her needs.
Resident 1's MDS assessment dated 1/28/16, Section D0300 (section for depression symptoms) indicated a score of "2" which indicated Resident 1 was feeling bad about herself and depressed. Resident 1's MDS dated 4/29/16, Section D0300 indicated a score of "8" which indicated Resident 1 was feeling increasingly bad about herself and depressed. Review of Resident 1's clinical record indicated Resident 1's care plan was not revised on 4/29/16 and no new interventions were planned to address Resident 1's worsening mood.
Resident 1's MDS Section V, titled, "Care Area Assessment" (portion of the MDS assessment that identifies areas to be care planned based upon the findings of the assessment) dated 7/28/16, indicated a care plan for Resident 1 should have been developed in the areas of "Psychosocial Well-Being, Behavioral Symptoms and Psychotropic Drug Use." There was no documented evidence the care plans for the Psychosocial Well Being and the Behavioral Symptoms were developed and implemented.
On 7/28/16 at 10:52 a.m., during an interview, the Assistant Director of Nursing (ADON) stated Resident 1 was transferred to the emergency department (ED) for an attempted suicide (ingestion of a large number of pills) on 5/11/16. The ADON stated there was no care plan developed for the 5/11/16 suicide attempt. The ADON stated a care plan for Resident 1's behaviors that triggered the attempted suicide should have been initiated by the Licensed Nurse (LN) upon readmission on XXXXXXX16. The ADON stated a care plan triggered by the MDS assessment should have been initiated by the Director of Nursing (DON) or the ADON.
Review of Resident 1's Primary Medical Doctor's (PMD) progress notes titled, "Adult Progress Notes," dated 6/7/16 had not indicated any documentation of Resident 1's suicide attempt of 5/11/16 or any orders for psychotherapy follow up after this incident.
Review of Resident 1's, "Psychologist Consultation/Follow Up," dated 6/8/16 indicated diagnoses of depression, schizophrenia and anxiety disorder. The note indicated Resident 1's complaints/symptoms were depression, anxiety, aggression, self-destructive thoughts or gestures, excessive sleep, health concerns and attempted history of suicide. The note indicated the treatment plans/recommendations were a continuation of the current treatment regime (which included medications and behavior monitoring as appropriate).
Review of Resident 1's clinical record titled, "Transfer Form" dated 6/10/16, indicated Resident 1 was transferred to the acute hospital emergency department (ED) on XXXXXXX16 for a suicide attempt due to an ingestion of pills.
On 6/16/16 at 5 p.m., during a telephone interview, Certified Nursing Assistant (CNA) 1 stated on 6/10/16 at 10:45 p.m., she heard Resident 1 at the nurses' station telling LN 1 she had ingested some pills. CNA 1 stated, "[Resident 1] told [LN 1] she did not know how many pills she took." CNA 1 stated they [CNA 1, LN 1, Resident 1] walked back to Resident 1's room where Resident 1 handed them [LN 1 and CNA 1] an empty bottle of Vitamin C. CNA 1 stated Resident 1 told them [LN 1 and CNA 1] she did not feel well after taking the pills and LN 1 had called the paramedics to transport Resident 1 to the acute care hospital. CNA 1 stated the paramedics transported Resident 1 right after midnight (6/11/16).
On 6/22/16 at 3:30 p.m., during a telephone interview, the Director of Staff Development (DSD) stated Resident 1 had a history of suicidal ideations. The DSD stated he was not sure if there were written care plans that addressed Resident 1's behaviors resulting from suicidal ideations such as the two incidents of Vitamin C ingestion. The DSD stated the licensed nurses were responsible for initiating care plans.
On 6/22/16 at 4 p.m., during a telephone interview, LN 1 stated Resident 1 had come to the nurses' station on 6/10/16 and stated she wanted to kill herself. LN 1 stated Resident 1 had taken some vitamin C pills. LN 1 stated this was the same situation that happened in May 2016 [suicide attempt by taking vitamin C pills]. LN 1 stated she had not remembered seeing a care plan in the chart for suicide attempts. LN 1 stated she initiated a care plan for suicidal ideations that night (6/10/16) after Resident 1 was transported to the hospital.
Resident 1's care plan initiated by LN 1 on 6/10/16 indicated, "The Resident has a behavior problem as evidenced by having suicidal thoughts related to depression." The goal indicated the Resident would have no behavior problems related to suicidal thoughts. The interventions listed included, "Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes." There was no documented evidence of interventions to follow up with psychotherapy, monitoring of behaviors, or identification of triggers to the suicidal ideations.
Resident 1's discharge orders from the acute care hospital dated XXXXXXX16, indicated, "Discharge Plan: Follow up with... Behavioral Health regarding medication management, psychotherapy, and aftercare support." There was no documented evidence an appointment was made by the facility to the Behavioral Health center after the 6/10/16 through 6/13/16 hospital stay.
Review of Social Service Notes dated 6/13/16 indicated the Social Services Director (SSD) spoke to Resident 1 upon readmission to the facility from the acute care hospital regarding the facility policy for residents to keep over the counter medications in their rooms. There was no documented evidence a referral was made for psychotherapy services. There was no documentation which indicated the SSD spoke to Resident 1 about her suicidal ideations and triggers or the need to meet with a therapist.
Review of Resident 1's Interdisciplinary Team (IDT) (a resident care team that includes nurses, dietician, social services, activities and medical staff) notes dated 6/13/16 indicated the IDT team met regarding the 6/10/16 suicide attempted by Resident 1. The IDT team note indicated the care plans should have been updated to reflect interventions to prevent reoccurrence following the attempted suicide. The IDT recommendations included monitoring the resident every 15 minutes and if appropriate a psychology referral to evaluate Resident 1. The ADON was unable to provide documentation of updated care plans related to the 6/10/16 incident. Review of the care plan titled, "Behavior-suicidal thoughts" dated 6/10/16 and developed by LN 2 did not reflect a revision upon Resident 1's return to the facility to include discharge recommendations from the acute care hospital. Resident 1's discharge orders from the acute care hospital dated XXXXXXX16, indicated, "Discharge Plan: Follow up with... Behavioral Health regarding medication management, psychotherapy, and aftercare support. Other Resource Instructions: 24 hour Suicide Hotline..." There was no documented evidence of a referral to behavioral health or follow-up as recommended by the acute care hospital.
Resident 1's "Transfer Form" dated 7/10/16, indicated Resident 1 was transferred to the ED on XXXXXXX16 for a suicide attempt.
On 7/28/16 at 4:48 p.m., during an interview LN 2 stated she had been passing medications to other residents on 7/10/16 when she was approached by Resident 1. LN 2 stated Resident 1 had made statements to [LN 2] that included Resident 1 not wanting to, "live anymore," and she [Resident 1] was thinking of hanging herself. LN 2 stated she had not called the physician at the time Resident 1 made the statements on 7/10/16 because she was busy passing medications to other residents. LN 2 stated later that morning, around 9 am, she saw Resident 1 in her room with the call light cord wrapped around her neck. LN 2 had observed Resident 1 trying to tighten the call light cord with the cord wrapped around her neck. LN 2 stated she then sent Resident 1 to the acute care hospital and then phoned Resident 1's medical doctor and her conservator. LN 2 stated she did not recall an update to the care plan after the 7/10/16 incident. There was no documented evidence of any care plan revisions following the 7/10/16 attempted suicide incident.
Review of Resident 1's care plan titled, "Behavior-suicidal thoughts" originally dated 6/10/16, indicated under "Focus, Goals, and Interventions," that no updates or revisions were made to the plan following the suicidal attempt and subsequent transfer to the acute care hospital on XXXXXXX16. The care plan remained in place without revisions once Resident 1 was readmitted to the facility on XXXXXXX16.
Review of the IDT note dated 7/11/16 indicated the IDT met after Resident 1 was transferred to the acute care hospital following the suicide attempt on 7/10/16. The IDT note indicated they had plans to meet upon Resident 1's readmission to the facility. No documented evidence was provided the IDT met after Resident 1 was readmitted to the facility to plan care for Resident 1 related to the XXXXXXX16 attempted suicide.
On 7/28/16 at 4:15 p.m., during an interview, Resident 1 stated, "I don't have the right therapy or care here. I need somewhere I can get help. My husband died a year ago, I need help... I can't keep trying to kill myself... I'm still trying to kill myself." Resident 1 stated she saw a psychologist when she was admitted to the acute care hospital. Resident 1 stated the psychologist [psychology evaluation 7/17/16] told her she needed to have therapy when she returned to the facility. Resident 1 stated the SSD at the facility told her they did not have a psychologist available to see residents. Resident 1 stated, each time she asked the SSD for therapy he [SSD] said not to keep asking the same thing over and over about therapy. Resident 1 tearfully referenced the suicide attempt of 7/10/16 and stated LN 2 and CNA 2 found her with the call light cord wrapped around her neck. Resident 1 stated, "I was pulling on it tight, I couldn't breathe... I remember passing out. I was in the hospital for two weeks the last time. You guys need to help me. I am going to end up hurting myself. I just want to transfer to a psychiatric unit and get therapy to get help and stop thinking of ways to kill myself. Recently, I just started sleeping all day. No one comes to talk to me about my problems..." Resident 1 stated the activities staff did not visit her in her room. Resident 1 stated no one came to talk to her about her problems after the last suicide attempt on (7/10/16).
On 8/1/16 at 5 p.m., during an interview, the Primary Medical Doctor/Medical Director (M.D.) (the physician in charge of caring for the resident) was asked about the care of Resident 1 and concerns regarding the lack of follow-up interventions after each suicidal attempt. The PMD/MD stated he was aware of the need to treat Resident 1 with a psychologist and/or a psychiatrist. The PMD/MD explained that the facility had difficulty finding available psychologists or psychiatrists to treat Resident 1. The PMD/MD stated he was aware the acute care hospital recommended records for Resident 1 included plans and recommendations to treat the ongoing depression and suicide attempts. The PMD/MD was aware the acute care hospital records needed to be reviewed for continuity of care. The PMD/MD was made aware that according to his physician progress notes for Resident 1 there was no documentation of Resident 1's suicide attempts, no referrals to mental health providers such as psychologist or psychiatrist and no directions to the staff on how to deal with Resident 1's ongoing depression and suicidal attempts. The PMD/MD stated he was in charge of the care of Resident 1 and ultimately in charge of the clinical component as the Medical Director for the facility.
On 8/3/16 at 3:55 p.m., during an interview, the ADON stated in response to unusual occurrences and MDS triggers the role of the IDT was to initiate plans of care. The ADON stated an attempted suicide was considered an unusual occurrence. The ADON stated there was no IDT meeting after the 5/11/16 incident upon readmission on XXXXXXX16 and there was no care plan initiated to address specific interventions following the suicide attempt of Resident 1 to prevent further occurrences.
On 8/3/16 at 6:40 p.m., during an interview, the Administrator stated when a resident returned from a hospital visit which resulted from an incident that occurred at the facility there should be a plan for a follow-up action to address the incident the next morning at the daily stand up meetings (informal meeting held to share important information among nursing staff). The Administrator stated there should be an IDT meeting following the event of an unusual occurrence, such as occurred with Resident 1. The Administrator stated the information regarding Resident 1's hospitalization was not passed on to the nursing staff after the 5/11/16 incident.
Review of Resident 1's PMD's (Primary Medical Doctor) progress note titled, "Adult Progress Note" dated 7/15/16, indicated no documentation of Resident 1's suicide attempt on 7/10/16 or any orders for psychotherapy follow up care.
Resident 1's Transfer form dated 8/1/16 indicated; Resident 1 was transferred to the ED for suicidal ideations (thoughts about committing suicide) on XXXXXXX16.
Resident 1's discharge orders from the acute care hospital dated 8/3/16, indicated, "Follow up with your primary care provider and therapist..." and "Suicide Prevention for Adults: Call 911 if ...is at immediate risk of suicide...Instructions: ...Suicide Hotline..." There was no documented evidence of the discharge instructions being integrated into a plan of care by the IDT or follow up for the referral to a psychology therapist.
On 8/9/16 at 2 p.m., during an interview and concurrent record review, the ADON stated when the MDS was completed and the care area assessments (CAA) triggered "Behaviors," a care plan for Resident 1's behaviors should have been developed and initiated. The ADON reviewed the care plan titled; "Resident Care Plan- Behaviors/Psychotropic Med [medication] Use." The document indicated the Care Plan was initiated on 7/24/15. The ADON stated the care plan appeared to be a care plan for behavior/psychotropic medication use and was not updated for the problem of behaviors. The ADON stated a care plan should have been developed to address the services and interventions needed to prevent the behaviors of suicidal attempts.
On 8/17/16 at 10:45 a.m. during a telephone interview the DON stated Resident 1 was again transferred to the ED for an attempted suicide on 8/10/16.
Review of Resident 1's care plan titled, "Resident Care Plan- Behaviors/Psychotropic Med Use" and "Mood" had not included dates or timetables related to the goals care planned for Resident 1's psychological needs. The "By Date" section of the care plan reserved for the projected achievement of the goals was left blank.
The facility policy and procedure titled, "Care Plan" undated indicated, "Our facility develops a comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing and psychological needs... Care plans are revised as changes in the resident's condition dictate."
The facility policy and procedure titled, "Care Planning-Interdisciplinary Team" dated December 2008, indicated, "Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident."
The facility policy and procedure titled, "Suicide Threats" dated Revised December 2007, indicated, "Resident suicide threats shall be taken seriously and addressed appropriately ...5. All nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the resident's behavior immediately. 6. As indicated, a psychiatric consultation or transfer for emergency psychiatric evaluation may be initiated. 7. If the resident remains in the facility, staff will monitor the resident's mood and behavior and update care plans accordingly, until a physician has determined that a risk of suicide does not appear to be present."
Therefore, the facility failed to ensure Resident 1 maintained her highest physical, mental and psychosocial well-being. Resident 1 was not provided with the necessary assessments, care planning or psychotherapy needed to adequately treat her depression and multiple suicide attempts. These violations resulted in significant physical, emotional and psychological distress for Resident 1.
These violations had a direct relationship to Resident 1's health, safety and security and thus constitute a Class B Citation. |
| 040000025 |
ALICE MANOR CONVALESCENT HOSPITAL |
040013232 |
B |
30-May-17 |
IHLJ11 |
28510 |
F 201 483.15(c) Transfer and Discharge
1. Facility requirements
(i) The facility must permit each resident to remain in the facility, and not transfer to discharge the resident from the facility unless-
(A) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility;
(B) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility;
(C) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident;
(D) The health of individuals in the facility would otherwise be endangered;
(E) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or
(F) The facility ceases to operate.
(ii) The facility may not transfer or discharge the resident while the appeal is pending, pursuant to 431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to 431.220(a)(3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose.
F 203 483.15(c)(3) Notice Before Transfer
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer of discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.
483.15(c)(4) Timing of the notice
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered, under paragraph (c)(1)(ii)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c) (1)(ii)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(ii)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (C)(1)(ii)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.
483.15(c)(5) Contents of the notice.
The written notice specified in paragraph (C)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone of the Office of the State Long Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000; and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.
483.15(c)(6) Changes to the notice
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.
F 204
483.12 (a) (7) Preparation For Safe/Orderly Transfer/Discharge
A facility must provide sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This orientation must be provided in a form and manner that the resident can understand.
On 10/27/16, an unannounced visit was made to the facility to investigate Complaint CA00508510 regarding an allegation of unsafe discharge from the facility.
The facility failed to plan and provide a safe discharge, for Resident 1 when Resident 1 was discharged on XXXXXXX16 to the home of his elderly Responsible Party (RP) who indicated to facility staff she was incapable of caring for Resident 1. Resident 1 was diagnosed with psychiatric/mental health illnesses and exhibited frequent episodes of aggression and violent behavior. Resident 1 was discharged without the necessary medications for his mental health illnesses, without adequate notice to the RP and without medical justification of a discharge to a lower level of care.
These failures resulted in Resident 1's unsafe discharge to his RP's home where he did not receive the medically prescribed services, became progressively agitated and left the home within a day of discharge and wandered the streets. Resident 1 exhibited aggressive behavior while wandering the streets and was taken to a mental health treatment center by the local police and from there was transported to the acute care hospital under a Welfare and Institutions Code 5150 (involuntary psychiatric hold for suspected danger to self or others).
The clinical record titled, "Admission Record" (document containing resident profile information) indicated Resident 1 was a 64 year old male admitted on XXXXXXX16 with diagnoses of dementia (a decline in mental ability severe enough to interfere with daily life), schizophrenia (a disorder marked by severely impaired thinking, unpredictable emotions, and bizarre behaviors), kidney failure and Parkinson's disease ( a progressive neurological disease characterized by weakness, tremor (uncontrollable shaking of extremities) and rigidity (stiffness of body movements). Resident 1 was discharged on XXXXXXX 16.
Resident 1's Physician Orders dated 9/1/16, indicated Resident 1's medications included: Abilify (a medication to treat schizophrenia) 10 milligrams (mg) (a unit of measurement) once daily, Aricept (medication to treat dementia) 10 mg daily at bedtime, Depakote (anti-seizure medication also used as a mood stabilizer) 500 mg two tablets daily at bedtime, Seroquel (medication to treat schizophrenia) 300 mg daily and Trazadone (medication to treat depression) 300 mg daily at bedtime.
Resident 1's clinical record titled, "Minimum Data Set (MDS) ( a resident assessment tool used to plan care)" dated 6/13/16, indicated Resident 1 had moderate cognitive (pertaining to memory, reasoning and judgement) impairment.
On 10/27/16 at 1:35 p.m., during an interview, the Director of Nursing (DON) stated Resident 1 had a history of verbal and physical altercations with staff and with other residents while in the facility. The DON stated Resident 1 had been discharged from the facility (on XXXXXXX 16) and his RP and his Family Member (FM) 1were upset Resident 1 had been discharged.
On 10/27/16 at 2 p.m., during an interview, the Social Service Director (SSD) stated Resident 1 had behavior problems prior to discharge from the facility. The SSD stated Resident 1 had aggressive behavior, hit a staff member and displayed threatening behavior to staff. The SSD stated the Interdisciplinary Team (IDT, team of facility staff that includes nursing, dietary, social services, activities staff and other healthcare providers that meet to review resident needs and plan individualized care) met 9/19/16 after Resident 1 struck a staff member. According to the SSD the IDT decided to discharge Resident 1 because of his aggressive behavior and frequent refusal of medication. The SSD stated she called Resident 1's RP on Monday 9/19/16 and told her Resident 1 would be discharged from the facility and for the RP to start looking for placement for Resident 1. The SSD stated she called the RP on Tuesday 9/20/16 and Wednesday 9/21/16 and the RP stated she did not have any transportation to pick up Resident 1. On 9/22/16 the SSD stated she accompanied the Assistant Administrator (AA) and dropped Resident 1 off at the RP's home. The SSD stated the AA returned to the facility to get Resident 1's medication and then brought those to the RP's home. The SSD stated she did not know if the RP was provided any discharge instructions. The SSD stated Resident 1's discharge (on XXXXXXX16) was not a safe discharge because Resident 1's RP was elderly (84 years old) and Resident 1 had a history of aggressive behavior and violent outbursts.
On 10/28/16 at 9:50 a.m., during an interview, the SSD stated she was newly hired by the facility when Resident 1 was discharged on XXXXXXX16. The SSD stated she did not know how to go about the discharge process and had asked a SSD at another facility what she should do to discharge Resident 1. The SSD stated she did not determine Resident 1's needs at discharge and did not plan any care for Resident 1's discharge home.
On 10/28/16 at 1:30 p.m., during an interview, Licensed Nurse (LN) 1 stated she was the nurse on duty when Resident 1 was discharged (on XXXXXXX16). LN 1 stated she did not know the reason for Resident 1's discharge. LN 1 stated Resident 1's Primary Care Physician (PCP) wrote the order for discharge and she (LN1) followed the order. LN 1 stated the physician did not include a reason for Resident 1's discharge in the order.
On 10/28/16 at 2:20 p.m., during a telephone interview, Resident 1's RP stated she was unable to provide care for Resident 1 at her home. The RP stated Resident 1 had a history of violent outbursts and she was too old to take care of him. When asked if she had agreed to take Resident 1 home upon discharge from the facility on XXXXXXX 16, the RP stated she was 84 years old and had difficulty understanding what was going on or what documents the facility wanted her to sign. The RP repeated she could not take care of Resident 1. The RP stated she was worried about what would happen to Resident 1. The RP stated he (Resident 1) had been in and out of her home since discharge from the facility on XXXXXXX 16.
On 11/1/16 at 2:50 p.m., during a telephone interview, Resident 1's RP stated Resident 1 was discharged to her home (on XXXXXXX 16) and he had become agitated the same day. The RP stated Resident 1 left the home about 5 a.m. the following morning (9/23/16). The RP stated since the discharge to home on XXXXXXX 16 Resident 1 left the home for two or three days at a time and then would return briefly only to leave again. The RP stated during this period of time she had reported Resident 1 missing to the local police department. The RP stated Resident 1 had been taken to the Acute Care Hospital (ACH) sometime during the previous weeks but had left the hospital. The RP stated on 10/31/16 Resident 1 came home and told her he needed to go back to the hospital. The RP stated she called an ambulance and Resident 1 was taken to the ACH.
On 11/2/16 at 2:23 p.m., during a telephone interview, FM 1 stated Resident 1's RP was unable to care for Resident 1. FM 1 stated, "We (the family) take care of her (RP)." FM 1 stated the RP was elderly and required assistance from family members for her own activities of daily living (ADLs) and provision of meals. FM 1 stated the RP did not have a bed available for Resident 1 nor could she provide food and meals for him. FM 1 stated the family received no warning from the facility Resident 1 was being discharged. FM 1 stated a phone call on 9/21/16 was made to the RP to pick him [Resident 1] up from the facility. FM 1 stated the RP had told the SSD she [RP] could not provide care for Resident 1 and had no transportation to pick him up from the facility. FM 1 stated the facility made no attempts to place Resident 1 in another setting other than the RP's home. FM 1 stated Resident 1 was dropped off by facility staff on 9/22/16 without any notice, consent or discharge instructions. FM 1 stated Resident 1 did not have important medications with him at discharge. FM 1 stated Resident 1 needed Seroquel (medication to control symptoms of schizophrenia) and did not have that medication upon discharge. FM 1 stated the only paperwork given to the RP on 9/22/16 was an inventory list to sign to indicate she (the RP) had received Resident 1's personal belongings from the facility. FM 1 stated, "At [RP's] age, she didn't understand [what was happening]." FM 1 stated she phoned the SSD and told her the facility failed to give the RP and FM 1 the opportunity to find placement for Resident 1. FM 1 stated, "We would have looked for another place." FM 1 stated Resident 1 had been roaming the streets "dirty and hungry" since discharge. FM 1 stated another family member had seen Resident 1 on the street the previous week and took him home. FM 1 stated Resident 1 became violent at home and she [FM 1] called police. FM 1 stated the RP never requested for Resident 1 to come home.
On 11/3/16 at 10:32 a.m., during an interview, Resident 1's RP stated she was not given a thirty day notice letting her know Resident 1 was going to be discharged. The RP stated she received a phone call on 9/19/16 from the SSD asking her to pick up Resident 1. The RP stated she told the SSD she was unable to pick up Resident 1. The RP stated a man (Assistant Administrator) and a woman (SSD) came to her home on 9/22/16 and dropped off Resident 1. The RP stated, "They didn't bring any medicine, so I called them [the facility] and they dropped it off. A man dropped it [the medicine] off with no instructions but he did make me sign for them. On the slip of paper there was a medicine named Seroquel, but it was missing. That's the one I remember because he has taken that for years. If he [Resident 1] doesn't take it [Seroquel] he doesn't sleep. He gets irritable. Others [medications] were missing but I can't remember... I told them I couldn't care for him. They didn't ask me if I could care for him. No instructions were given to me on anything." The RP stated "[Resident 1] gets really bad without his medication [Seroquel] because he has been mentally ill for 42 years and now he has dementia along with the schizophrenia." The RP was asked if she had agreed to take Resident 1 home and the RP stated she told the facility she was not able to take care of Resident 1.
On 11/4/16 at 3:30 p.m., during an interview, the AA stated he and the SSD discharged Resident 1 to the RP's apartment on XXXXXXX16. The AA stated he dropped Resident 1 off at the RP's home and made a second trip to drop off Resident 1's medications. When asked about whether or not discharge instructions were provided, the AA stated he went over how to match the medications to the doctor's order with the RP. The AA stated it was not in his job description as an assistant administrator to provide medication instruction but he did review the medications with the RP "as a favor." When asked if the AA was a nurse, he stated "no." The AA stated "in small facilities you have to be ready to all pitch in"
On 11/4/16 at 3:45 p.m., during an interview, the facility Administrator (Adm) stated if there had been a nurse available to review Resident 1's medications with the RP (at discharge on XXXXXXX16) they would have done that. The Adm stated there was not a nurse available and the AA reviewed the medications.
The request was made to the facility to provide any discharge instruction documents and none were provided.
On 11/4/16 at 4 p.m., during an interview, Resident 1's PCP stated he was informed there was an attempt to discharge Resident 1 to home on XXXXXXX16 but on that day Resident 1 was transferred to the acute care hospital (ACH) for an evaluation for altered mental status [change in cognitive status]. The PCP stated he understood the family wanted to take Resident 1 home with them and that was the reason for discharge on XXXXXXX16. The PCP stated he did not know if Resident 1's condition had improved or if he no longer required skilled nursing care. The PCP stated in retrospect, he should have spoken to the family himself. The PCP stated he was not sure if the IDT met to plan Resident 1's discharge. The PCP stated the discharge on XXXXXXX16 was ultimately his responsibility because he wrote the discharge order and he did not have all of the information regarding Resident 1.
On 11/4/16 at 4:30 p.m., during an interview, the Adm stated she was not certain if an IDT meeting was held to plan for Resident 1's discharge. The Adm stated nursing and the SSD discussed Resident 1's discharge. The Adm stated the reason for Resident 1's discharge was Resident 1 wanted to go home with the RP and the RP wanted to care for Resident 1 in her home. When asked whether the Adm spoke directly to the RP about taking Resident 1 home the Adm stated she thought the RP told the SSD she wanted to take Resident 1 home.
On 3/22/17 at 2:40 p.m., during a telephone interview, the DON stated Resident 1 was discharged to home with the RP on Thursday, XXXXXXX16. The DON stated Resident 1 was readmitted to the facility from the ACH on XXXXXXX16. Resident 1 was not an admitted resident of the facility from XXXXXXX16 to XXXXXXX16.
Resident 1's "Social Services New Admit Assessment" dated 6/21/16 indicated, "Discharge Plan: Because of the assistance on ADL's no discharge is planning for this resident [Resident 1]. Prior living arrangements: Convalescent facility. Family's expectations and feelings regarding discharge and availability for support: Family will be available for support... Plan: long term care anticipated."
Review of Resident 1's clinical record did not indicate evidence of any documentation related to an IDT meeting to develop or discuss Resident 1's discharge plan. The DON was unable to produce an IDT note related to discharge planning for Resident 1 by the end of the abbreviated survey.
Resident 1's "Notice of Transfer/Discharge" signed by the Adm and dated 9/19/16, indicated the discharge was to become effective 9/22/16. The notice indicated Resident 1 was being discharged to the RP's residence. The notice indicated the decision to discharge Resident 1 was made by the IDT. There was no evidence provided that documented an IDT meeting or discussion of the decision to discharge. The Notice of Transfer/Discharge indicated the reason for the discharge was "Responsible Party wishes to take him home with her."
Resident 1's clinical record titled "Resident Transfer Form" dated 9/19/16 indicated Resident 1 was transferred to the ACH Emergency Department (ED) on 9/19/16 at 9:25 p.m. for evaluation of "altered mental status." The Resident Transfer Form indicated "Diagnoses: unspecified dementia without behavioral disturbances, mental disorders due to known condition, Reason for Transfer: Altered Mental Status-striking staff." The Resident Transfer form indicated, "Behavior...disruptive, belligerent, combative, suspicious..."
Resident 1's clinical record from the ACH ED dated 9/19/16, titled, "History of Present Illness (HPI)" indicated "...male presents on psychiatric hold for alleged aggressive behavior. He reports that he ate his meal and then got mad at the SNF when they wouldn't let him go outside and smoke. Does have a history of dementia and schizophrenia, lives at a SNF and has baseline GCS [Glasgow Coma score - tool to evaluate level of consciousness measured between 0-15, with zero being coma and 15 being normal) 14. Per EMS [emergency medical services] form, apparently he allegedly got angry and hit another SNF resident yesterday as well. Currently he has no complaints, and is denying SI/HI (Suicidal Ideation/Homicidal Ideation), AH/VH (Auditory Hallucinations/Visual Hallucinations). Appears well... Impression: Well adult examination; alleged aggressive behavior; medical clearance for psychiatric care... Plan of Care: ...would like patient returned to [SNF] in the morning..."
Resident 1's "Weekly Summary" dated 9/22/16, indicated "Resident have increased altered mental status, resident very aggressive."
Resident 1's Progress Notes [Nurse's Note] dated 9/22/16 and signed by LN 1 indicated, "Telephone order from [PCP] stating it is appropriate for resident to be discharged with RP."
Resident 1's unsigned "Transfer/Discharge Report dated 9/22/16, indicated "Discharge to home and with responsible party."
Resident 1's "Physician's Summary" indicated, "Discharge date: 9/22/16, Rehabilitation Potential: limited -Schizophrenia, unspecified dementia without behavioral disturbance, Prognosis: home with family." The Physician's Summary was signed and dated 10/1/16 by the PCP. There was no medical justification documented for Resident 1's discharge home.
Resident 1's "Progress Notes" [Nurse's Note] documented by the DON, dated 9/22/16, indicated "Resident was discharged home to [RP] today... Resident was taken to [RP's] residence with all belongings (inventory list reviewed and signed by RP); he was accompanied by SSD and Assistant Administrator."
Resident 1's ACH clinical record titled, "Physician's Discharge Summary" dated 10/28/16, indicated Resident 1 was admitted to the ACH on XXXXXXX16. The Discharge Summary indicated "[Resident 1]... presents with altered mental status... He was sent here from [a Psychiatric Health Facility (PHF)] at which point 5150 (involuntary psychiatric hold) was initiated. ... He was apparently found verbally harassing people at a local business facility. He was subsequently taken to the PHF from which he came here for further neurological evaluation... When I spoke to the patient he was alert only to person but not to time and place. He did not know why he was here...Placement was pending at which time patient eloped [left without the knowledge or permission of the ACH staff]. Discharge date: XXXXXXX16. Discharge diagnoses: eloped."
Review of Resident 1's care plan indicated, "Focus: Resident to be discharged to home with his Responsible Party to her residence... Date initiated 9/22/16, Date created 10/28/16. Goal: Resident to have a safe discharge to RP's residence. Interventions: Complete Nursing Assessment... Obtain Physician's Order... Provide current medications to RP... Provide MD orders... Provide Transportation... " There was no documented evidence the care plan addressed Resident 1's mental disorder or behaviors to ensure a safe discharge to the RP's home. The care plan was created 37 days after the discharge of XXXXXXX16.
The facility's policy and procedure titled, "Documentation of Transfers/Discharges" dated 4/7/98, indicated "1. When the facility anticipates a resident's discharge to a private residence... a post -discharge plan will be developed which will assist the resident to adjust to his or her new living environment... 2. The post discharge plan will be developed by the care plan team with the assistance of the resident and his/her family... 4. As a minimum the post-discharge plan will include: d. the identity of specific resident needs after discharge... i.e., medications... Appropriate referrals, when necessary are made by Social Services... 5. Social services will review the plan with the resident and the family before the discharge is to take place." There was no documented evidence of a post - discharge plan being developed or provided to the RP.
The facility's policy and procedure titled, "Documentation of Transfers/Discharges" dated 4/7/98, indicated "When a resident is transferred or discharged, his or her medical records shall be documented as to the reasons why such action was taken. 2. Should the resident be transferred or discharged for the following reasons, the basis for the transfer or discharge must be documented in the resident's clinical record by the resident's attending physician: b. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility. 4. Documentation from the care planning team concerning all transfers or discharges must include, as a minimum and as they may apply: The reasons for the transfer or discharge; b. That an appropriate notice was provided to the resident and/or representative; c. ... d. The date and time of the transfer or discharge; f. The mode of transportation; g. A summary of the resident's overall medical, physical and mental condition; i. Disposition of medications."
The facility's policy and procedure titled, "Notice of Transfers and/or Discharge" dated 4/7/98, indicated "Our facility shall provide a resident and/or the resident's representative with a thirty day notice written notice of an impending transfer or discharge. 2. The resident, and/or representative will be provided with the following information. a. The reason for the transfer or discharge; b. The effective date of the transfer or discharge; c. the location to which resident is being transferred or discharged; the name, address, and telephone number of the state long-term care ombudsman; e. The name, address and telephone number of each individual or agency responsible for the protection and advocacy of mentally ill... f. The name address and telephone number or the state health department agency that has been designated to handle appeals of transfers and discharge notices."
The facility's policy and procedure titled, "Preparing a Resident for Transfer or Discharge" dated 4/7/98, indicated "Our facility shall prepare a resident for a transfer or discharge. 2. e. Nursing services will be responsible for preparing the discharge summary; f. Preparing medications as permitted by law."
The facility's policy and procedure titled, "Discharge Summary" dated 4/7/98, indicated "A discharge summary shall be prepared for each resident discharged from our facility. 2. As a minimum the discharge summary will contain a summary of the resident's status to include a description of the resident's: a. medically defined condition...g. Mental and psychosocial status (the resident's ability to deal with life, interpersonal relationships and goals, make health care decisions, and indicators of resident behavior and mood); m. Drug therapy (all prescription and over-the-counter medications taken by the resident including dosage, frequency of administration, and recognition of significant side effects that would be most likely to occur in the resident). 4. A copy of the discharge summary will be filed in the resident's medical record."
Therefore the facility failed to provide sufficient preparation to ensure a safe discharge for Resident 1. As a result of this failure, Resident 1 was discharged without necessary medications, adequate notice or medical justification. Resident 1 was discharged to the home of his elderly RP who could not provide care for him and Resident 1wandered the streets until placed under an involuntary psychiatric hold by local police to protect the safety of Resident 1 and others.
This violation had a direct or immediate relationship to Resident 1's health, safety and security and thus constitutes a class "B" citation. |
| 040000025 |
ALICE MANOR CONVALESCENT HOSPITAL |
040013417 |
B |
8-Aug-17 |
BIFB11 |
9152 |
F 365 483.60(d) (3) Food - Meet Individual Needs
Food prepared in a form designed to meet individual needs.
On 8/12/16 an unannounced visit was made to the Skilled Nursing Facility (SNF) to investigate the Entity Reported Incident (ERI) CA00496941.
The facility failed to verify, prepare and serve a physician ordered mechanical soft diet (foods blended, pureed, ground, or finely chopped to be made easily chewed and swallowed) to meet Resident 1's individual needs. Resident 1's meal tray was not verified to determine if Resident 1's diet was prepared in a manner consistent with Resident 1's physician ordered diet. Resident 1 was served chunks of meat too large for Resident 1 to swallow.
As a result of these failures, Resident 1 choked on his food, developed difficulty breathing, and required the Heimlich Maneuver (placing pressure with the fist in hard, quick thrusts against the resident's abdomen to cause food to be dislodged and ejected from the throat) to clear his throat and restore normal breathing and was transported by ambulance to the acute care hospital for assessment.
Resident 1's clinical record titled, "Admission Record" (record containing resident personal information) indicated, Resident 1 was admitted to the Skilled Nursing Facility (SNF) on XXXXXXX 11 with diagnoses that included Type 2 Diabetes Mellitus (disorder which causes high blood sugar due to insufficient production of the hormone insulin which regulates blood sugar), Dementia ( disorder resulting in decline in memory, reasoning and judgement), Anxiety Disorder (disorder characterized by feelings of uneasiness, apprehension and dread), Schizophrenia (disorder resulting in disorganized thinking and loss of contact with reality) and Muscle Weakness.
Resident 1's clinical record titled, "Minimum Data Set" (MDS) (a resident assessment tool used to plan resident care) dated 7/8/16, indicated Resident 1 had no teeth or tooth fragments, required a mechanically altered diet (mechanical soft) and required staff supervision during meals.
Resident 1's clinical record titled, "Order Summary Report" dated 2/28/17, indicated a physician order for "...MECHANICAL SOFT texture, THIN consistency" diet with start date of 6/25/15.
Resident 1's clinical record titled, "Progress Notes [Nursing Notes]" dated 7/26/16, at 12:54 p.m., indicated, "Resident noted with choking episode during lunch unable to cough and difficulty breathing, start hemuleich [Heimlich] maneuver. Advise CNA [certified nursing assistant] to call 911 [emergency response phone number]. Resident hemuleich maneuver took over by the DSD [Director of Staff Development] and ADON [Assistant Director of Nursing] present with the patient too. Resident [Resident 1] coughed up and threw up food come out. Applied O 2 [oxygen] 2 liter [flow rate of 2 liters (measure of volume) per minute] via NC [nasal cannula, tubing placed into the nose to deliver oxygen]. No further episode noted of difficulty breathing or respiratory distress...Paramedic arrived at 12:27 p.m...resident awake alert verbally response to care...left in stable condition transfer to [acute care hospital] for further evaluation." The progress note was signed by Licensed Nurse (LN) 1.
Resident 1's acute care hospital emergency department (ED) record titled, "Patient Progress" 7/27/16 dated at 6:18 p.m. indicated, "... Clinical Impression : Choking episode, Inappropriate diet."
Resident 1's acute care hospital report titled, "Emergency Department Discharge Instructions" dated 7/26/16, indicated, "...diagnosis today is choking episode... maintain a SOFT NO CHEW DIET. You will need an evaluation by a speech therapist for a swallow evaluation."
On 8/12/16 at 8:40 a.m., during a concurrent observation and interview in Resident 1's room, the Director of Social Services (DSS) asked Resident 1 if he had teeth. Resident 1 opened his mouth and moved his head side to side. There were no teeth visible in Resident 1's mouth. The DSS stated Resident 1 did not have teeth or dentures to chew his food and that was why Resident 1 was on a mechanical soft diet.
On 8/12/16 at 10 a.m., during a telephone interview, the Director of Staff Development (DSD) stated on 7/26/16 at 12:30 p.m., other staff members (didn't recall who) in the dining room alerted the DSD Resident 1 was choking on food served during the lunch meal. The DSD stated he performed abdominal thrusts (Heimlich Maneuver) and dislodged a piece of meat "larger than the size of a quarter" from Resident 1's mouth. The DSD stated the dislodged piece of meat was too large to swallow for Resident 1 who had a physician ordered mechanical soft diet. The DSD stated the size of meat expelled from Resident 1 was "not appropriate for a mechanical soft diet...choking was directly related to the size of the chunk of meat."
On 8/12/16 at 10:20 a.m., during an interview, the Dietary Services Supervisor (DSS) stated a quarter size piece of meat was not consistent with a mechanical soft diet. The DSS stated the meat should have been chopped or ground up. The DSS stated the cook who prepared Resident 1's meal should have checked the food card (card with resident's diet order and description that accompanies the resident's meal tray) to ensure the food was the right consistency for Resident 1. The DSS stated CNAs and LNs were responsible for checking all the residents' meal trays for physician ordered diets before meals were served to residents.
On 3/10/17 at 3:20 p.m., during a telephone interview, LN 1 stated on 7/26/16, she was responsible for verifying Resident 1's lunch meal tray was consistent with the meal card and physician ordered mechanical soft diet. LN 1 stated she was aware Resident 1 did not have natural teeth or dentures. LN 1 stated on 7/26/16 she was in the back hallway of the facility and had not verified Resident 1's lunch meal tray matched his diet card. LN 1 stated verifying Resident 1's lunch meal tray would have alerted her the meal was not consistent with Resident 1's diet and could have prevented Resident 1 from choking. LN 1 stated nursing staff were responsible for verifying resident meal trays match their diet cards. LN 1 stated she did not assign another staff member to verify resident meal trays match their diet cards even though facility policy indicated she could have assigned the task to other facility staff.
On 3/14/17 at 3:50 p.m., during a telephone interview, CNA 1 stated she had worked at the facility for five years. CNA 1 stated LNs had not checked the meal trays at any time during the time she had worked at the facility. CNA 1 stated it was the practice in the facility for CNAs to check meal trays prior to serving to ensure residents were getting the correct diet. CNA 1 stated she checked meal trays during the lunch meal on 7/26/16 but did not recall if she was the CNA who checked Resident 1's tray to ensure it was consistent with Resident 1's physician ordered mechanical soft diet. CNA 1 stated she knew Resident 1 should have been served ground and chopped foods because he did not have teeth. CNA 1 stated Resident 1 would not have choked if he had been served chopped or ground food.
The facility document titled, "Modified Diets" undated, under heading, "Mechanical Soft (Dental Soft) Diet" indicated, "Changes the consistency of the regular diet when there is difficulty with chewing or swallowing... Foods are modified in texture by chopping, dicing, and grinding. Menu should be based on ground meats and chopped fruits and vegetables."
The facility policy and procedure titled, "Policy and Procedure for Monitoring Dining Room" dated 1/1/08, indicated, "...Charge Nurse will be present during mealtimes at Dining Room and will assist with the following: 1. Verify that resident's trays correspond to their diet cards. 2. Supervise meal intake documentation. 3. Monitor behaviors... 4. P.M. and Weekend Charge Nurse may delegate to a C.N.A her responsibilities at the Dining Room during meal times if there's a medical emergency elsewhere in the building."
Review of professional reference, "Edentulous [without teeth] Patient Diet" , indicated, "Soft, liquid, blended, chopped or ground foods comprise most of an edentulous diet... Being edentulous poses serious problems in receiving adequate nutrition from the foods you can eat, in addition to concerns centered on decreased chewing efficiency and increased risk of choking."
Therefore, the facility failed to verify, prepare and serve a physician ordered mechanical soft diet to meet Resident 1's individual needs. Resident 1 was served food that had not been prepared in accordance with his physician ordered mechanical soft diet and facility staff failed to verify the food was properly prepared prior to serving the meal. Resident 1 choked, experienced difficulty breathing and was transported by ambulance to the acute hospital.
These violations had a direct or immediate relationship to the health, safety, or security of the resident and therefore constitute a class "B" citation. |
| 050000064 |
Atterdag Care Center |
050010901 |
A |
11-Sep-14 |
XQ6Q11 |
3492 |
CFR 483.25 (h) ACCIDENTS- The facility must ensure that: (2) Each resident receives adequate supervision and assistance devices to prevent accidents.The Department determined the facility failed to provide adequate supervision and assistive devices to prevent an injury related to Resident A falling in a bathroom. The facility failed to provide the assessed necessary supervision while toileting Resident A. As a result, Resident A fell and sustained a hip fracture. Resident A was 96 year old admitted with diagnoses including dementia, muscle weakness, difficulty walking and fractured vertebrae. Resident A's fall risk assessment dated March 15, 2014 identified Resident A as "HIGH RISK" for falls due to: intermittent confusion, being bed bound and requiring assistance with toileting, inability to balance on both feet without holding onto something, medications and predisposing diseases. A comprehensive assessment dated March 17, 2014 indicated Resident A required extensive physical assistance of one person for activities of daily living including transferring, dressing and toileting. Review of subsequent fall risk assessments dated from January 2013 through June 4, 2014 indicated Resident A had multiple falls while at the facility. A care plan titled "At risk for fall or injury" dated January 23, 2013 indicated Resident A was a fall risk and interventions included: monitoring Resident A's location especially in the bathroom, alarms and an antiroll back device for the wheelchair when Resident A attempted to transfer without assistance, nonskid socks, and keeping Resident A near the nurses' station. On March 27, 2013 the facility revised and updated the care plan with the intervention "Don't leave [Resident A] alone on the toilet."Review of the nurse progress notes June 3, 2014, indicated Resident A fell after being assisted to the bathroom and left unsupervised at 10 p.m. Resident A fell while attempting an unassisted transfer. Two hours later (at 12:10 a.m.) Resident A complained of severe back pain radiating to the pelvis. A physician ordered Resident A to be transferred to an acute care hospitals' emergency room via ambulance. The results of Resident A's x-rays on June 4, 2014 revealed Resident A sustained a fractured left hip. During an interview on July 1, 2014, at 12:35 p.m., the director of staff development (DSD) stated that the facility trains staff to never leave cognitively impaired residents alone in the bathroom. In a subsequent interview at 2:05 p.m., the director of nursing (DON) confirmed the facility's policy is to not leave cognitively impaired residents alone in the bathroom.The facility policy and procedure titled "Toileting" dated September 1, 2011 indicated: "Provide particular patient centered assistance [while toileting] required for the individual resident while maintaining safety."During an interview on 7/1/14, at 11:45 a.m., a certified nurses' assistant (CNA 1) stated that she did leave Resident 3, who she knew was cognitively impaired, alone in the bathroom on June 3, 2014, stating "It was my fault [that she fell and fractured her leg] for leaving her [Resident 3]." The facility's failure to provide the necessary supervision while toileting Resident A, as previously identified in Resident A's care plan, resulted in Resident A's fractured hip.These failures presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 050000064 |
Atterdag Care Center |
050012055 |
B |
24-May-16 |
X5RD11 |
2153 |
California Health and Safety Code 1418.91 (a) (b)-Failure to Report (a) A long-term care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation.During an annual Recertification Survey, the Department determined the facility was in violation of the above statute by its failure to report to the Department an allegation of abuse immediately or within 24 hours. During an interview on 2/24/16 at 12:15 p.m., the director of nursing (DON) stated, Resident A, who was Resident B's wife/roommate, alleged a "male aide was spending too much time in areas they did not belong" when a male nurse was cleaning Resident A. The DON said, she and the social service director (SSD) met with the family in January 2016 to discuss the allegation. The DON confirmed, the facility failed to report this allegation of abuse to the Department at the time the facility had knowledge.Review of Resident B's "Social Service Notes" dated 1/28/16 at 5:25 p.m. indicated, Resident B had been verbalizing fear that his wife/roommate [Resident A] was being touched by a male staff.Review of Resident B's "Social Service Notes" dated 1/25/16 at 1:45 p.m., indicated, Resident B's family met with the facility to discuss the care of his wife [Resident A] and indicated there would be no more male staff.During an observation of Resident A and consecutive interview with Resident B on 2/14/16 at 2:10 p.m., Resident A was lying in bed and did not respond to her name. Resident B indicated, he had reported to staff that a male certified nursing assistant (CNA) had spent too much time "face to face with her [Resident A's] private parts", and "He [CNA] seemed to be enamored with her [Resident A] as opposed to normal procedure." Resident B indicated, Resident A had memory problems and was not interviewable.The facility should know or should have known, they have to report to the Department immediately, or within 24 hours, the allegation of sexual abuse by an employee towards a resident. |
| 050000064 |
Atterdag Care Center |
050012197 |
B |
24-May-16 |
2ZXU11 |
2421 |
California Health and Safety Code 1418.21(a) A skilled nursing facility that has been certified for purposes of Medicare or Medicaid shall post the overall facility rating information determined by the federal Centers for Medicare and Medicaid Services (CMS) in accordance with the following requirements: (1) The information shall be posted in at least the following locations, in the facility: (A) An area accessible and visible to members of the public. (B) An area used for employee breaks. (C)An area used by residents for communal functions, such as dining, resident council meetings, or activities. (2) (C) The most recent overall star rating given by CMS to that facility, except that a facility shall have seven business days from the date when it receives a different rating from the CMS to include the updated rating in the posting. The star rating shall be aligned in the center of the page. The star rating shall be expressed as the number reflects the number of stars given to the facility by the CMS. The number shall be in a clear and easily readable font of at least 2 inches print.The Department determined the facility was in violation of the above statute by failure to post its overall facility rating (Five-Star Quality Rating) in areas accessible and visible to the public, residents, and employees.During a Relicensing survey, observations on 2/22/16 beginning at 9:50 a.m., on 2/23/16 at 9:50 a.m., and 2/24/16 at 8:25 a.m., the facility star rating was not posted in any area accessible to the public, in any area used by residents for communal functions (dining rooms, living rooms, activities, and hallways), and in any area used for employee breaks. During an interview on 2/24/16 at 4 p.m., the administrator's secretary (AS) acknowledged the facility's star rating was not currently posted. On 2/25/16 at 8:45 a.m., the AS confirmed, previously star posting was located solely at the bulletin board in front of the nursing station and nowhere else.The Five-Star Quality rating System was created by CMS to help consumers, their families, and caregivers compare nursing homes more easily. The ratings are based on health inspection rating, staffing, and quality measures. The facility's failure in posting its star rating deprived consumers, their families, and caregivers valuable information in determining sound decisions for nursing home placement and continued stay in the nursing home. |
| 050000007 |
Alto Lucero Transitional Care |
050013045 |
A |
8-May-17 |
CCDB11 |
6052 |
Title 42 of the Federal Code of Regulations 483.25 (d) (2) Accidents and Supervision
(h) The facility must ensure that -
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
The Department determined the facility was in violation of the above regulation when it failed to ensure Resident A, who was assessed upon admission to the facility as a high risk for elopement (leaving the facility unnoticed) with recent history of elopement, received adequate supervision to prevent elopement. As a result of this failure, Resident A eloped from the facility on 01/21/17 and sustained right 5th and 6th rib fractures, shattered right humeral head (shoulder) fracture, and mild dependent atelectasis (collapsed lung).
Review of admission record on 3/2/17 indicated, Resident A was admitted to the facility on XXXXXXX 17 with diagnoses including, alcoholic cirrhosis of liver (scaring of liver tissue causing damage to the healthy liver cells), and alcohol-induced persisting dementia (a condition which causes problems with memory and cognitive functioning).
Review of Resident A's "Comprehensive Nursing Observations Upon Admission" assessment dated 1/16/17 indicated, Resident A was alert, responsive, with periods of confusion and forgetfulness. Resident A presented with a behavior of wandering and attempted to elope from the facility on the day of admission. Resident A needed limited assistance with one person with bed mobility and transfers. Resident A had reduced strength to legs, ambulated with assistance, with unsteady gait.
Review of Resident A's "Elopement Risk Evaluation" dated 1/16/17 indicated, Resident A was at risk for elopement because the Resident A had:
a. history of elopement,
b. attempted to leave a residence or other place unescorted that placed him in danger,
c. poor decision-making skills, and ability to walk independently,
d. verbalized intent to leave facility,
e. wandered and sought to find family,
f. wandered aimlessly, and
g. exhibited exit-seeking behavior.
Review of Resident A's "Care Plan Report," undated, included intervention for the use of Wanderguard bracelet (an alarming device that alerts the facility staff when the resident attempts to elope from the facility).
Review of a "Clinical Notes Report" dated 1/21/17, timed at 8:15 p.m., signed by a Registered Nurse (RN), indicated, at approximately 10:30 a.m, Resident A was seen in the doorway of his room standing and observing the hallway. The resident was last seen by a CNA at 11:45 a.m. At approximately 12:15 p.m, during medication administration, Resident A was not in his room.
Review of "Clinical Notes Report" dated 1/21/17, timed at 8:16 p.m., and signed by RN indicated, at 12:15p.m, Resident A was noticed by a charge nurse to be missing from his room. Staff checked interior and exterior perimeter of the building without locating the resident. Last visualization of the Resident A by staff was approximately 11:45 a.m. in his room.
Review of the "Interdisciplinary Team Conference/Care Plan Review," dated 1/23/17, indicated an acute care hospital contacted the facility on 1/22/17 that Resident A was admitted on XXXXXXX17 at 12:19 a.m.
Review of the acute care hospital's "Emergency Department (ED) Provider Notes" dated 1/22/17 at 12:19 a.m., indicated Resident A was brought in by an ambulance to the emergency room. This was approximately 12 hours after Resident A eloped from the facility. The notes indicated Resident A was found "staggering" on the street, approximately five (5) miles away from the facility. Resident A fell after leaving the facility and sustained multiple abrasions and bruising to extremities and upper chest. Resident A had a medical bracelet on and was covered with stool. Resident A's CT scan (computer aided X-ray) revealed right 5th and 6th rib fractures and shattered right humeral head (shoulder fracture).
Review of the acute care hospital's "Discharge Summaries" dated 2/16/17 indicated Resident A sustained "Traumatic comminuted (R) humeral head fracture (shoulder fracture) s/p (past) repair now displaced." The patient underwent surgery (ORIF- open reduction and internal fixation on 1/22/17) due to the shoulder fracture. "X-ray showed complete failure of previous right shoulder repair."
During a concurrent interview and a review 3/3/17 at 10:55 a.m., of the facility's "Wanderguard Tract Form" dated 1/21/17, the facility's Lead CNA (CNA 1) and the Administrator provided a list of residents who were wearing Wanderguard bracelets. The record indicated Resident A was part of the list, and had the monitoring device to his left wrist. CNA 1 indicated Resident A's Wanderguard bracelet was checked on 1/21/17 at the beginning of the morning shift; however, there was no documentation to indicate what time the device was checked. The facility was unable to provide documentation to indicate it provided adequate supervision, or an effective intervention to prevent Resident A from elopement.
During an interview and a concurrent record review on 3/6/17 at 1:25 p.m., the facility's Administrator stated, "maybe between the times the Wandergaurd bracelet was checked to have been activated/functional and the time the resident left, the Wandergaurd had become deactivated. This is the only way that I can think of how it happened."
The facility knew Resident A had multiple factors putting him at high risk of elopement, manifested by wandering behavior, history of elopement, and attempted elopement during admission to the facility. The facility failed to provide adequate supervision to prevent Resident A from elopement. As a result of these failures, Resident A eloped from the facility and sustained right 5th and 6th rib fractures, shattered right humeral head (shoulder) fracture, and mild dependent atelectasis (collapsed lung).
The facility's failure presented either an imminent danger that death or serious harm would result or a substantial probability of death or serious physical harm would result. |
| 060001245 |
ALL STAR HOME |
060009506 |
B |
20-Sep-12 |
UOVX11 |
5840 |
Title 22, Section 76876 (g) No medication shall be administered to or used by any client other than the client for whom the medication was prescribed.(h) Medication errors and adverse drug reactions shall be recorded and reported immediately to the practitioner who ordered the drug or another practitioner responsible for the medical care of the client.The above regulations were NOT MET as evidenced by:On 4/27/12, the facility reported a medication error incident to the Department. On 5/2/12, an unannounced visit was conducted to the facility to investigate the above incident. Based on interview and review of clinical record and facility documents, the facility failed to ensure Client 1 did not receive another client's medication. On 5/2/12 at 0930 hours, the lead staff was asked what happened on the day that Client 1 was given the wrong medication. The lead staff stated a direct care staff (DCS 1) was passing medications on 4/17/12 around 0630 hours and asked her for help. The lead staff asked DCS 1 who she had given medications to and DCS 1 told her she had given Client 1 his medications. However, when the lead staff looked at Client 1's medication bubble packs, the medications for that morning were still in them. The lead staff informed DCS 1 that Client 1's medications were still in the bubble packs. DCS 2, who was standing nearby turned and asked DCS 1 whose medication she had given him to give to Client 1. DCS 1 realized she had punched out Client 2's medications and had given it to DCS 2 to give to Client 1 by mistake.Client 1 was given the medications for Client 2 which were Tegretol (antiseizure drug) 200 mg and Cogentin 1 mg (common uses include treating Parkinson's disease and certain movement disorders). In addition, Client 1 was also given his routine medications which consisted of docusate sodium (stool softener), Tab-a-vite (multivitamins), Artane 1 mg (used to treat the stiffness, tremors, spasms, and poor muscle control of Parkinson's disease), and Baclofen 10 mg (a muscle relaxer used to treat muscle symptoms caused by multiple sclerosis, including spasm, pain, and stiffness.)The lead staff further stated that she told DCS 1 to call the RN and inform the RN that a medication error had occurred. The lead staff stated she went to give another client a shower and after giving the shower she was informed that DCS 1 had not called the RN.When asked about Client 1's condition on 4/17/12 after the medication error, the lead staff stated Client 1 was okay and at 0815 hours, he went to the day program. The lead staff also stated that at 0900 hours, she called and notified the licensee of the medication error. The lead staff stated the licensee said she would notify the RN.When asked what was supposed to be done when a medication error occurred, the lead staff stated the RN should be notified. At 1040 hours, the RN was asked what time was she notified of the medication error on 4/17/12. The RN stated she was notified at 1130 hours. When asked what was done regarding Client 1 taking the wrong medication, the RN stated she and Client 1's primary physician were present at the facility at approximately 1600 hours when Client 1 returned from the day program. Client 1's primary physician examined him.At 1140 hours, the day program's Administrator stated during an interview that Client 1 usually needed help getting off the bus and when walking; however, on 4/17/12, Client 1 required more help than usual. The Administrator also stated Client 1 had increased shaking that day. The Administrator stated she called the facility at the end of the day to inform them of Client 1 having a difficult time getting off the bus and requested to have a facility staff present when the bus arrived at the facility to help Client 1 get off the bus. When asked if anyone from the facility called the day program to inform them of Client 1 being given the wrong medication or to see how Client 1 was doing, the day program's Administrator stated no one had called to check on Client 1 and she did not find out about the medication error until she spoke with the RN the next day.Review of the day program's incident report dated 4/17/12, showed the job coach documented Client 1 was shaking more than usual and it made Client 1 tired and weak. Review of the RN's documentation of the incident showed the client's physician was notified of the medication error on 4/17/12 at approximately 1230 hours.On 5/3/12 at 0930 hours, the QMRP was asked to provide a copy of the facility's policy and procedure (P&P) for medication errors. Review of the facility's undated P&P for medication errors showed medication errors and adverse drug reaction shall be recorded and reported immediately to the physician, and the RN consultant; medication errors include, but are not limited to, the failure to administer a drug, giving wrong medication, wrong time, wrong client, wrong route of administration, and incorrect labeling of medication. Even though the medication error was identified by the lead staff, DCS 1 and DCS 2 on 4/17/12 at 0630 hours, Client 1 was sent to the day program and the day program staff was not made aware of the medication error. Client 1 presented with increased weakness and shaking while at the day program. Also, the physician and the RN consultant were not notified immediately of the medication error. Client 1 was not assessed by the physician and the RN consultant until after he came back to the facility from the day program at approximately 1600 hours.The failure of the facility to ensure that no medication was administered to or used by any client other than the client for whom the medication was prescribed and the failure to immediately report the medication error to Client 1's physician had a direct relationship to the health, safety, or security of patients. |
| 060001245 |
ALL STAR HOME |
060009903 |
B |
17-May-13 |
GH0K11 |
7759 |
W&I 4502. Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following:(d) A right to prompt medical care and treatment.On 4/12/13, an unannounced visit was made to the facility to investigate an entity reported incident (ERI) involving Client A sustaining a fractured right hip. Based on interview, and review of clinical record and acute care hospital record, the facility failed to ensure Client A's pain in her right leg and hip area was evaluated by the registered nurse (RN) after the pain medication failed to relieve the client's pain.Review of the clinical record showed Client A is non-verbal and deaf, but is able to understand simple to moderate requests and is able to make her needs known. Client A is ambulatory, able to transfer and walk without assistance. On 4/12/13 at 1500 hours, the qualified mental retardation professional (QMRP) was interviewed and the following scenario was disclosed: - Client A arrived at the facility from the day program on 3/28/13 at approximately 1430 hours.- The direct care staff (DCS 1 and DCS 2) informed the QMRP during her investigation that Client A was fine when she arrived from the day program and sometime between 1430 hours and 1600 hours, Client A began to point to her right thigh and indicated she was in pain. The DCSs also observed Client A to limp when walking.On 4/12/13, DCS 3 came to work at the facility at 1600 hours. Interview with DCS 3 was conducted and the following was disclosed: - On 3/28/13, when DCS 3 realized Client A was in pain, he gave Client A Tylenol, which she had ordered for arthritis. - When Client A was still complaining of pain at approximately 1900 hours, DCS 3 called the QMRP. The QMRP told DCS 3 to call the facility RN. DCS 3 then called the RN (RN 1) but RN 1 did not answer at that time. RN 1 returned the call approximately 30 minutes later, and told DCS 3 that she was unavailable and that she would call the substitute RN (RN 2).- Per DCS 3, neither RN 1 nor RN 2 called back the facility.- DCS 3 gave Client A another Tylenol at 2000 hours. At this time, Client A was having difficulty getting up from a sitting position without help. DCS 3 got concerned because the Tylenol had always worked in the past to relieve Client A's arthritis pain. - Client A fell asleep at approximately 2030 hours. At approximately 2400 hours, Client A asked for help to get out of bed to go to the bathroom and that was not like her to ask for help. DCS 3 and the night shift DCS got Client A up to go to the bathroom. Client A was still complaining of pain but DCS 3 did not give her more Tylenol nor did he call the RN or the QMRP to inform them of Client A's continued pain and inability to get out of bed and walk to the bathroom independently.- DCS 3 stated Client B told him that Client A had fallen earlier in the house while walking down the hall leading from the kitchen area to the living room. The QMRP stated during further interview the information disclosed by DCS 3 was the same information she obtained from DCS 3 during her own investigation. The QMRP stated that as part of her investigation she interviewed Client B and asked the client if she had seen anything happened to Client A. The QMRP stated Client B told her Client A had fallen on the floor right by the kitchen, and DCS 1 and DCS 2 had to help Client A to get up from the floor. The QMRP stated she interviewed DCS 1 and DCS 2, and both denied that Client A had fallen on 3/28/13. When asked if she interviewed Client A, the QMRP stated, no, and no one had asked Client A what happened. The QMRP also stated she had called Client A's job coach to find out if anything had happened to Client A while at the day program on 3/28/13. The job coach informed the QMRP that Client A was fine during the time she was with her and the client had not complained of any pain nor had she noticed Client A limping when walking.On 4/12/13 at 1600 hours, Client B was interviewed. When asked if she had seen anything happened to Client A, she stated, "she fell." When asked where Client A fell, Client B stated, "right here" and pointing to the hallway area by the kitchen. When asked if she knew what caused Client A to fall, Client B stated, "No." On 4/12/13 at 1615 hours, DCS 4 was interviewed. She stated she arrived at the facility the morning of 3/29/13 and Client A was crying and pointing to her hip. DCS 4 stated she called RN 2, who asked DCS 4 to take a picture of Client A's hip and leg, and to send the pictures to him over the phone. DCS 4 stated she got Client A up in a wheelchair so she could eat breakfast. DCS 4 then called the QMRP at 0700 hours, who instructed DCS 4 to send Client A to the ER. DCS 4 stated she did not send pictures to RN 2 as requested. DCS 4 also stated she did look at Client A's hip and leg, and there was no redness or bruising.On 4/12/13 at 1630 hours, RN 2 was interviewed via telephone. RN 2 stated RN 1 called him around 2330 hours on 3/28/13, since RN 1 is out of the country that night and up to the present time. RN 2 stated RN 1 told him Client A was complaining of pain in her right leg/hip area. RN 2 also stated RN 1 assured him it was Client A's arthritis and that he could handle it in the morning. When asked if he called the facility that night to check on Client A, RN 2 stated he never called the facility or went to the facility to check on Client A. However, review of the clinical record for Client A showed the following documentation: "3-29-13 N.N. received call from _____ (facility name) DCS client c/o (complaining of) rt (right) hip pain. DCS denies observing hip dissymmetry, redness or swelling. States client is in pain and Tylenol given was ineffective. Advised to send to ED (emergency department) for further evaluation per MD (medical doctor) orders."On 4/18/13, the emergency room report from the acute care hospital was reviewed. Documentation showed Client A arrived at the emergency room on 3/29/13 at 0905 hours. Documentation showed Client A was unable to move her leg due to pain. X-rays were obtained and showed Client A had a mildly comminuted right femoral (the femur or the thighbone is a bone in the human leg extending from the pelvis to the knee, that is the longest, largest, and strongest in the body) neck fracture. A comminuted fracture is a crush or splintered fracture where the bone is splintered or crushed into more than two pieces, typically caused by direct crushing energy or force to tissues and bone. The x-ray results showed no osteoporosis was noted. Further review of the record showed Client A required surgery to repair the fracture and the surgery was performed on 3/30/13.The facility failed to ensure: 1. The RN assessed Client A after being told of the client's pain. 2. The DCS notified the RN and the QMRP, in a timely manner, when the client continued to complain of pain after being medicated with Tylenol, and had difficulty getting up and walk due to pain.The facility's failure had resulted to Client A having to suffer pain for at least 17 hours before she was transferred to an acute care hospital.This violation either jointly, separately, or in any combination had a direct or immediate relationship to client health, safety, or security. |
| 060001375 |
ARTEMIA HOUSE |
060012801 |
B |
14-Dec-16 |
PD0T11 |
11365 |
W331 - The facility must provide clients with nursing services in accordance with their needs. On 10/3/16, the California Department of Public Health (CDPH) received a complaint indicating Client 1 was not taken to the physician to refill his medication for his spinal pump. As a result, the client suffered back spasms and had to be hospitalized. On 10/11/16 at 0740 hours, an unannounced visit was made to the facility to investigate the above complaint. Client 1 was observed sitting in his wheelchair waiting for the bus to come to pick him up for his day program. He was observed to be calm. No shaking or spasticity (a movement disorder characterized by hyperexcitable stretch reflexes, increased muscle tone, and involuntary movements) was observed. Review of Client 1's clinical record was initiated on 10/11/16. Client 1 was admitted to the facility on xxxxxxx, with diagnoses including profound intellectual disability (a person with an IQ score of less than 25) and spastic quadriplegia (spasticity of all four limbs of the body). Client 1 was nonverbal and unable to communicate his needs. Client 1 was completely dependent on facility staff for all of his medical needs. The facility's undated policy and procedure (P&P) titled Physician Services showed in part: the Nurse Consultant or licensed vocational nurse (LVN) will monitor the physician visits and assure all orders are carried out as prescribed. Review of the Nurses Notes form showed an entry from the LVN dated 9/27/16 at 0700 hours. The LVN documented Client 1's upper extremities were shaking and the lower extremities were stretching. The LVN documented acetaminophen (pain medication) 15 milliliters was administered for Client 1's discomfort. On 10/11/16 at 0740 hours, an interview with the LVN was conducted. The LVN stated she was at the facility on 9/27/16 at 0730 hours, and noticed Client 1 was shaking. The LVN stated she wondered about Client 1's baclofen (muscle relaxant medication) pump so she looked on the appointment calendar kept by the staff. The LVN stated she saw Client 1 had an appointment at the pain specialist clinic on 9/7/16 (20 days ago), to get his baclofen pump refilled. The LVN stated she called the pain clinic on 9/27/16, and the receptionist informed the LVN the client had missed his appointment on 9/7/16. The receptionist at the pain clinic informed the LVN they could see Client 1 on 9/28/16 (the next day), to get his pump refilled, but the LVN did not feel comfortable so she took Client 1 to the general acute care hospital's (GACH) Emergency Room (ER). The LVN stated she informed the Registered Nurse (RN), Qualified Intellectual Development Professional (QIDP), and the client's conservator prior to transporting the client to the ER. The LVN stated Client 1 was administered the oral baclofen in the ER and was sent back to the facility the same day (9/27/16). The LVN stated the baclofen pump was not filled in the ER. The LVN stated Client 1 started shaking 30 minutes after he returned to the facility from the ER and was not stable so 911 was called. Client 1 was taken back to the ER where he was given intravenous fluids, oral baclofen, and stayed overnight at the hospital. He was discharged from the hospital on xxxxxxx, and was taken directly to the pain clinic to get his baclofen pump refilled. The LVN stated Client 1 had no signs or symptoms of shaking or spasticity since 9/28/16. When asked how the baclofen pump was managed, the LVN stated Client 1's baclofen pump was refilled every four months at the pain clinic and his appointment was listed on the calendar and the LVN's cell phone. The LVN stated Client 1's appointment for 9/7/16, was listed on the calendar; however, it was not on her cell phone. The LVN stated she must have deleted Client 1's appointment on her cell phone by accident. When asked for their tracking system regarding the baclofen pump, the LVN stated the facility had no other way to keep track of when the baclofen pump was due for refills other than the doctor's notes from the previous visit. The LVN stated when Client 1 was taken to get his pump refilled, the clinic would schedule the client's next appointment ahead in four months, from the current appointment date to have the baclofen pump refilled again. The LVN stated Client 1 had an appointment on 9/7/16; however, it was overlooked until 9/27/16 (20 days later), when she observed Client 1 had shaking and spasticity. Review of the paperwork from the pain clinic showed Client 1's baclofen pump was replaced on 5/29/12. Client 1 was seen at the pain clinic to refill his baclofen pump on 5/11 and 9/8/15, and 1/5 and 5/10/16. Review of the event log from the pain clinic visit on 9/28/16, showed Client 1's baclofen pump had an empty reservoir (did not contain any baclofen medication) from 9/17/16 at 2243 hours, until it was filled on 9/28/16 at 1140 hours. Client 1 had not received the baclofen for more than 10 days, causing his spastic quadriplegia to be uncontrolled. On 10/11/16 at 0900 hours, an interview with the RN was conducted. The RN stated the LVN called on 9/27/16, to tell her Client 1 was shaking and having spasticity. The RN stated she told the LVN to take Client 1 to the ER. Client 1 was sent back to the facility from the ER; however, after being home for 30 minutes, the client started having spasticity so 911 was called and Client 1 was taken back to the ER and spent the night at the hospital. The RN stated when Client 1 was discharged from the hospital, he was taken to the pain clinic where he had the baclofen pump refilled. The RN stated Client 1 had not had any shaking or spasticity since he was discharged from the hospital on 9/28/16. The RN stated she had seen the appointment for the pain clinic on the appointment calendar on 9/7/16, to refill the baclofen pump and thought the LVN had taken Client 1 on the scheduled appointment date. The RN further stated she gave an in-service to all staff on 9/27/16, informing them of the baclofen withdrawal symptoms, such as high fever, change in mental status, muscle rigidity, and might result in loss of function of many vital organs and death. When the RN was asked for the facility's P&P regarding the baclofen pump therapy, the RN stated the facility had no P&Ps. On 10/18/16 at 1500 hours, the RN was interviewed via telephone. The RN stated a care plan was developed addressing Client 1's baclofen pump. The RN stated the staff had not routinely documented the status of the baclofen pump; however, the pain clinic had given them a read out to identify when they had the pump refilled. The RN stated Client 1 was observed by the LVN daily. Review of the care plan addressing Client 1's use of the baclofen pump dated 1/18/12, showed the following approaches: - Assess for decrease or increase of spasticity. - Baclofen refill every four months or as specified by the physician. - Encourage activity participation. - Monitor adverse reaction of baclofen. - Laboratory works as ordered. The care plan did not include the instructions for the staff to monitor the pump alarm (a signal indicating the pump needs to be replaced or filled with baclofen, or if there is a problem with the pump). Also, the care plan did not list what adverse reactions were to be monitored, i.e. for overdose (drowsiness, lightheadedness, dizziness) or underdose (increase or return of spasticity, low blood pressure, lightheadedness, tingling). On 10/19/16 at 0830 hours, the RN was interviewed via telephone. When asked where she documented Client 1's spasticity, the RN stated this was documented on Client 1's seizure record. Review of the facility's Seizure Observation Record showed Client 1 had no documented seizures for August 2016 and had a seizure activity with shaking of arms and legs on 9/27/16. On 10/28/16 at 1145 hours, the RN was interviewed via telephone. When asked how the staff monitored the baclofen pump and if the monitoring was documented in the Medication Administration Record (MAR), the RN stated the staff did not document anything in the MAR. The RN stated a flowsheet that listed what the staff needed to monitor for the baclofen pump was attached to the MAR. The RN was asked for a copy of their P&P regarding care of the client with Baclofen pump and copy of Client 1's MAR for September 2016. On 10/28/16, a copy of the facility's undated P&P titled Baclofen Pump, Client 1's MAR for September 2016, and flowsheet for the baclofen monitoring were received via fax from the RN. Review of the undated P&P titled Baclofen Pump showed the RN Consultant was to check the client's appointments monthly and remind the licensed staff. Review of the flowsheet titled Monitoring Tool for Baclofen Pump showed the pump will sound an alarm when the pump needed to be replaced or filled with baclofen, or if there was a problem with the pump. Review of the MAR for September 2016 confirmed no documentation was made regarding the baclofen pump monitoring. On 11/9/16 at 0750 hours, Direct Care Staff (DCS) 1 was interviewed via telephone. He stated he worked at the facility with Client 1 six days a week. DCS 1 said he gave Client 1 all his personal care needs. When asked if he was trained regarding the signs and symptoms to look for regarding the baclofen pump, or the alarm that would sound when the pump needed to be filled with baclofen, DCS 1 stated he was never in-serviced regarding signs and symptoms to look for regarding the pump, or the alarm that would sound when the pump needs to be filled with baclofen before Client 1 went to the hospital on 9/27/16. DCS 1 stated the RN gave an in-service regarding the baclofen pump two days after Client 1 went to the hospital. On 11/9/16 at 0800 hours, DCS 2 was interviewed via telephone. She stated she worked at the facility daily. She further stated DCS 1 took care of Client 1. DCS 2 stated she gave Client 1 his medications daily. DCS 2 said she knew Client 1 had a baclofen pump, but she was never in-serviced regarding signs and symptoms to look for regarding the pump, or the alarm that would sound when the pump needed to be filled with baclofen before Client 1 went to the hospital on 9/27/16. DCS 2 stated the RN gave an in-service regarding the baclofen pump two days after Client 1 went to the hospital. The facility's RN failed to check Client 1's appointment with the pain clinic and failed to remind the licensed staff of the appointment as per the facility's P&P. The facility's RN failed to provide an in-service to the staff and revise the care plan to include monitoring Client 1's baclofen pump when the pump needed to be replaced or filled with baclofen, or if there was a problem with the pump; monitoring for adverse reactions to baclofen i.e. overdose or underdose. The facility's RN failed to ensure the staff had monitored Client 1's baclofen pump when the pump needed to be replaced or filled with baclofen. The facility's RN failed to ensure Client 1 was seen at the pain clinic for a scheduled baclofen pump refill. These failures resulted in Client 1 not receiving the baclofen for 10 days causing the client to suffer shaking and spasticity, and the client being sent to the GACH's ER two times for treatment. The above violations, either jointly, separately, or any combination had a direct or immediate relation to the client's health, safety, or security. |
| 070000096 |
Amberwood Gardens |
070008939 |
B |
25-Jan-12 |
PWOR11 |
8144 |
Title 22 72311(a)(1)(C) Nursing Service ? General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition.The facility failed to update the care plan to maintain the highest practicable physical well-being for Patient 1 when her 10/2011 minimum data set (MDS, an assessment tool) indicated she had a significant decline in activities of daily living (ADLs) and could no longer drink fluids without full staff assistance. Patient 1's care plans for hydration and ADLs were not revised to reflect the change. Inadequate fluid intake may put a patient at increased risk of dehydration (a condition resulting from loss of body fluid). Patient 1 was admitted to the acute care hospital on 12/18/11 and diagnosed with hypernatremia (elevated sodium, an electrolyte) in the blood. Patient 1 was admitted to the facility with diagnoses including dementia (a loss of brain function that affects memory, thinking, language, judgment and behavior).The clinical record for Patient 1 was reviewed on 1/9/12. The MDS dated 10/10/11 indicated a change in Patient 1's condition. It indicated she was totally dependent on staff for eating and drinking. The MDS also indicated Patient 1's ability to make decisions regarding tasks of daily life were poor and supervision was required. During an interview on 1/9/12 at 4 p.m., certified nurse assistant A (CNA A) stated Patient 1 needed assistance for the past month to take a drinking glass in her hand and drink fluids. A physician's order dated 7/5/11 indicated Patient 1 was to receive Lasix (a diuretic, increases urine secretion) 20 milligrams (mg) for edema (an excessive amount of fluid in body tissue). It carries a black box warning (an alert that indicates Lasix can lead to profound water and electrolyte depletion). A "Nutritional Assessment" progress note authored by the registered dietician (RD) dated 9/2/11 indicated staff "still" needed to encourage fluid intake to maintain hydration for Patient 1. A physician's order dated 9/7/11 indicated encourage fluids every shift. Then again a physician's order dated 9/10/11, indicated encourage fluids for Patient 1.The "Nutritional Assessment" dated 10/13/11 indicated Patient 1 had a change of condition, a decline in ADLs. The RD indicated daily fluid needs for Patient 1 should be decreased to 1662 - 1995 ml (milliliters) daily. During an interview on 1/9/11 at 2 p.m., the director of nursing (DON) stated if Patient 1 was on fluid restriction, intake and output should be recorded. She further confirmed there were no intake and output (I&O) records after Patient 1 had a change of condition in October 2011. She further stated all fluids that are taken with meals and Medpass (a liquid protein supplement) should be included in the 24 hour I&O if done. A "Care Plan on Dehydration" dated 7/5/11, indicated Patient 1 was at risk for dehydration possibly due to "decline in mental status" "use of diuretics" and "fluid restriction." The care plan further indicated interventions to monitor dehydration were to "Assess causative factors of potential fluid volume deficit. . . Monitor and record I&O as needed? Administer adequate amounts of fluid." However, review of Patient 1's clinical record indicated the above dehydration care plan interventions to prevent dehydration were not revised to ensure Patient 1 received the amount of daily fluids recommended by the RD on 10/13/11. A "Care Plan on ADL Function" dated 7/5/11, indicated "Eating" (how a patient eats and drinks) was coded at a one (1). This indicated only oversight, encouragement, or cueing was needed by staff. However, an MDS dated October 10, 2011, indicated it was initiated due to an change in Patient 1's condition. Patient 1's MDS indicated Patient 1 was fully dependent on staff for eating and drinking and could no longer drink fluids without full staff assistance. Patient 1's clinical record indicated her ADL care plan for physical functioning was not revised to reflect an increased need for staff support. During an interview on 1/9/12 at 2:45 p.m., licensed nurse B (LN B) stated she was aware Patient 1's care plan for ADL function was not revised despite Patient 1's decline. Review of Patient 1's "Intake and Output Record" dated 12/3/11 indicated the average 24 hour fluid intake between 11/26/11 and 12/2/11 was 834 ml. There were no I&O records for October 2011. Patient 1 was admitted to the acute care hospital on 12/18/11 and diagnosed with sepsis (a condition in which the body is fighting a severe infection), acute urinary tract infection (germs getting into the bladder and kidneys and the tubes that connect them), and hypernatremia (elevated sodium, an electrolyte) in the blood.A history and physical note dated 12/18/11 and labs collected 12/18/11 at 9:50 a.m. at the acute care hospital indicated Patient 1's urea nitrogen (BUN - a kidney function test ) was 75 (reference values were 7 - 17) and creatinine (also a kidney function test)was 1.57 (reference value was <= (less than or equal to) 1.11. A lack of adequate hydration can cause an elevated BUN to creatinine ratio (www.webmd.com/a-to-z-guides/blood-urea-nitrogen).Laboratory results collected on the above date and time indicated Patient 1's sodium was increased to 159 (reference values were 137 - 145). The medical doctor (MD) noted on the assessment dated 12/18/11 the patient appeared dehydrated. The facility's policy and procedure, "Change in Patient's Condition or Status" revised 2011, indicated, "A significant change" of condition is a decline?that Requires interdisciplinary review and/or revision to the care plan." The facility's policy and procedure, "Hydration - Clinical Protocol" revised October, 2010 indicated "staff will identify individuals with a significant risk for subsequent fluid and electrolyte imbalance; for example, those?who are taking diuretics?and who are not eating and drinking well." It further indicated staff will provide supportive measures such as providing fluids. The facility's policy and procedure "Care Plans - Comprehensive" revised October, 2010, indicated, "Our facility's Care Planning/Interdisciplinary Team, in coordination with the patient?develops and maintains a comprehensive care plan for each patient that identifies the highest level of functioning the patient may be expected to attain. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS. Each patient's comprehensive care plan is designed to incorporate identified problem areas; Incorporate risk factors associated with identified problems...Reflect treatment goals, timetable and objective in measurable outcomes; Identify the professional services that are responsible for each element of care; Aid in preventing or reducing declines in the patient's functional status and/or functional levels...Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the patient are...processes that require careful data gathering." The policy and procedure further indicated, "The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans, When there has been a significant change in the patient's condition; When the desired outcome is not met." The facility failed to update Patient 1's care plan when she had a change of condition in 10/2011 and needed assistance to take fluids. The patient's intake and output was not consistently monitored to ensure she received the daily amount of fluids recommended by the RD. On 12/18/11 Patient 1 became less responsive and was transferred to the acute care hospital. Patient 1 was diagnosed with a urinary tract infection, sepsis and dehydration.The above violation had a direct or immediate relationship to the health, safety or security of Patient 1. |
| 070000095 |
A GRACE SUB ACUTE & SKILLED CARE |
070008956 |
B |
30-Jan-12 |
RX1611 |
4253 |
F323 - 483.25(h) Free of Accident Hazards/Supervision/Devices The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to provide adequate supervision to prevent an accident when one of four sampled residents (1) fell out of bed on 1/7/12. A certified nurse assistant (CNA) repositioned Resident 1 in bed. The CNA rolled Resident 1 away from her. According to the CNA, the side rail fell down and the resident rolled off the bed onto the floor. Resident 1 sustained multiple lacerations to his face and right elbow, and a subdural hematoma (the collection of blood below the dura mater [one of the tissue layers covering the brain]).The facility's policy and procedure also failed to follow nursing practice to prevent accidents when their policy indicated to roll a resident away from oneself.Record review was conducted on 1/10/12 and 1/11/12. Resident 1 was admitted with diagnoses including stroke, respiratory failure and a tracheostomy (insertion of a tube through the neck into the airway to make it easier to breathe). A review of the 10/12/11 Minimum Data Set (MDS) assessment indicated Resident 1 had both short and long-term memory problems and severe cognitive impairment. Resident 1 required total assistance with his activities of daily living, including turning and repositioning. During an interview with the director of nursing (DON) on 1/10/12 at 2:10 p.m., she stated as certified nurse assistant A (CNA A) started to turn the resident away from her, Resident 1 moved slightly and proceeded to roll out of bed onto the floor, sustaining lacerations of the head. According to the DON, the side rail was up prior to turning the resident but then suddenly went down. At the hospital it was determined he had sustained a subdural hematoma as a result of trauma. The DON stated the resident was a "one staff assist" (only required one person for turning and repositioning). The DON also stated the maintenance staff could not find anything wrong with the side rail.During a telephone interview with CNA A on 1/12/12 at 9:30 a.m., she stated prior to turning Resident 1, he was lying in the middle of the bed and the left side rail was up. She was standing on the right side of the bed. When she started to turn the resident toward his left side, without first moving him closer to her, the side rail suddenly fell down and the resident rolled out of bed falling onto the floor. The CNA stated she was alone at the time. During the morning of 1/11/12, six CNAs were randomly interviewed regarding how they would reposition a resident by themselves. One CNA forgot to move the resident to one side of the bed before turning him. On 1/23/12 at 9:05 a.m., a CNA was observed turning and repositioning a resident as follows: After removing the pillows from under the resident's left side and legs, and using the draw sheet already under the resident, the CNA rotated the resident away from himself.Review of the facility's 2004 policy and procedure, "Turning a Resident On His/Her Side Away From You" indicated to slide the resident toward the staff turning the resident, then "Gently turn the resident away from you." However, "Assisting With Moving and Positioning Clients in Bed -- Moving a dependent client to a side-lying position" Nursing Interventions & Clinical Skills, ed 3, St. Louis, 2004, Mosby indicated to move the resident to the side of the bed opposite to the one toward which the resident will be turned. Raise the side rail and go to the opposite side of the bed. Lower the side rail and assist the resident to roll on their side toward the staff. "Turning the client toward you promotes the resident's sense of security." It was noted the two turning procedures were the exact opposite of each other. The facility failed to ensure Resident 1 was turned safely in his bed when the CNA rolled him off the bed. Resident 1 was transferred by ambulance to an acute care hospital on 1/7/12 for examination and observation. Resident 1 was diagnosed with a subdural hematoma.The above violation had a direct relationship to the health, safety, or security of residents. |
| 070000096 |
Amberwood Gardens |
070011398 |
B |
29-Apr-15 |
6YIR11 |
4628 |
F226 - 483.13(c) Develop/Implement Abuse/Neglect, Etc. Policies The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The facility failed to implement their abuse policy for one of three residents (1) when an alleged abuse allegation was not investigated or reported. The facility also failed to thoroughly investigate injuries of an unknown origin (skin tears) for two of three sampled residents (2 and 3) to determine whether the residents were being mishandled. These failures had the potential to prevent the implementation of corrective actions to protect the residents. Findings: 1. Review of Resident 1's clinical record indicated he had diagnoses including total blindness and dementia. Resident 1's minimum data set (MDS, an assessment tool) dated 1/23/15, indicated he had severe cognitive impairment and required one person extensive assistance for walking.The social service progress note, dated 3/18/15, indicated Resident 1 alleged a male staff member "slapped him in the face" twice when he was assisted to the bathroom. On 3/21/15, a care plan was developed indicating Resident 1 had a skin tear on the bridge of his nose.The social service progress note, dated 3/24/15, indicated Resident 1 also alleged a staff member "scratched him" during incontinence care resulting in a skin tear to his nose. There was no documentation indicating an investigation was conducted after the 3/24/15 allegation to determine if Resident 1 was mistreated. During an interview on 4/2/15 at 10:45 a.m., the administrator (ADM) confirmed the second allegation was not investigated or reported to the California Department of Public Health (CDPH) or the ombudsman's office. During an interview on 4/6/15 at 10:15 a.m., the director of nurses (DON) stated there was a meeting on 4/2/15 with the ADM where Resident 1's skin tear and the second allegation of staff mistreatment were discussed. The facility did not take any further action to investigate or report the incident to the CDPH or the ombudsman's office. Review of the facility's 8/2011 policy, "Reporting Abuse to State Agencies and Other Entities/Individuals," indicated all suspected violations of abuse were to be immediately reported to the appropriate state agencies and other entities/individuals as required by law. 2. Review of Resident 2's clinical record indicated she had diagnoses including dementia. The MDS, dated 3/4/15, indicated Resident 2 had memory problems. The general nurses notes, dated 4/5/15 at 1:10 p.m., indicated Resident 2 had a skin tear on her right knee and was unable to explain what happened.During an interview on 4/13/15 at 4:10 p.m., licensed vocational nurse (LVN) C stated she interviewed two certified nurse assistants (CNAs) about the skin tear but did not ask the staff members from the various shifts to determine the potential cause. LVN C stated there was a recent inservice reminding the staff to interview the staff from the different shifts when conducting an investigation.3. Review of Resident 3's MDS, dated 3/28/15, indicated she did not have memory problems, did not walk, required two persons total assistance with transfer and did not have a recent fall. A general nurses note on 2/27/15 at 12:05 a.m. indicated Resident 3 had a skin tear on his right hip. There was no investigation indicating who reported the incident and no staff members were interviewed about the skin tear. During an interview on 4/13/15 at 5:35 p.m., the DON confirmed the facility had provided all of the available documentation concerning the investigations. A review of the facility's 8/2011 policy, "Abuse Investigations," indicated all reports of resident abuse and injuries of unknown source were to be thoroughly investigated. The investigation at a minimum was to include interviewing the person(s) reporting the incident and the staff members (on all shifts) who had contact with the resident during the period of the alleged incident and to review all of the events leading up to the alleged incident.The facility failed to implement their abuse policy for one of three sampled residents (1) when an alleged abuse allegation was not investigated or reported to the appropriate state agencies and other entities as required by law and when they failed to thoroughly investigate injuries of an unknown origin (skin tears) for two of three sampled residents (2 and 3) to determine whether the residents were being mistreated. These violations had a direct relationship to the health, safety or security of residents. |
| 070000096 |
Amberwood Gardens |
070011620 |
B |
16-Jul-15 |
IRVY11 |
3631 |
F206 - 483.12(b)(3) POLICY TO PERMIT READMISSION BEYOND BED-HOLD A nursing facility must establish and follow a written policy under which a resident whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, is readmitted to the facility immediately upon the first availability of a bed in a semi-private room if the resident requires the services provided by the facility; and is eligible for Medicaid nursing facility services. The facility failed to follow the facility's policy on readmission for one of three sampled residents (1) when the facility did not readmit Resident 1 following hospitalization which exceeded the bed-hold period. Resident 1 was discharged to the acute hospital on 12/10/14 and remained in the acute hospital up to the time of the complaint investigation. Resident 1 had a tracheotomy tube (a surgical opening through the neck to allow passage of air) and a gastrostomy tube (a surgical opening through abdominal wall into the stomach for feeding).Review of Resident 1's clinical records on 7/6/15, the Minimum Data Set (MDS, an assessment tool) dated 10/3/14 indicated Resident 1 was totally dependent in decision making. The same MDS indicated Resident 1 needed two-person total assistance with activities of daily living (ADLs). During an interview on 7/6/15 at 9:15 a.m., the hospital staff stated they had contacted the facility several times for Resident 1's readmission. The facility had stated multiple reasons why they could not readmit the resident including no male bed available and no physician would accept the resident. Review of hospital staff inquiries regarding male bed availability in the facility dated 7/9/15 indicated on 1/7/15, 1/13/15, 2/5/15, 2/9/15, 2/11/15, 2/20/15, 2/23/15, 3/5/15, 3/12/15, 3/18/15, 3/26/15, 5/26/15, 5/28/15, and 6/11/15, the facility stated no male bed was available. Review of the facility's daily census on 7/9/15 indicated a male bed was available on 2/20/15 and 2/23/15. Resident 1 was not readmitted. During an interview on 7/6/15 at 11:05 a.m., the admission coordinator (AC) stated referrals would be reviewed and approved by the admission committee. The committee would make sure the bed would be available and the physician would accept the resident. During an interview on 7/6/15 at 11:50 a.m., the case manager (CM) admitted there had been multiple conversations with hospital staff regarding Resident 1's readmission to the facility including male bed availability. He also admitted there were some male beds available at times but stated the bed may already be reserved for an admission. CM was unable to provide documentation and evidence of inquiries.During an interview on 7/6/15 at 1:45 p.m., the administrator (ADM) stated he was willing to accept Resident 1 if the bed was available and if he could find a primary physician (PP) to take care of the resident while the resident was in the facility. During an interview on 7/8/15 at 10:40 a.m., ADM stated his decision not to accept Resident 1 remained the same as he could not find a PP for him. During an interview on 7/8/15 at 11:00 a.m., the medical director (MD) stated he could not accept any resident since MD was already full throughout the year. During an interview on 7/8/15 at 12:20 p.m., PP stated she could not accept Resident 1 due to a professional reason. The facility failed to follow the facility's policy on readmission for Resident 1 which resulted in violation of the resident's right to readmission as required by law. The above violation has a direct or immediate relationship to the health, safety, or security of the resident. |
| 070000043 |
Almaden Health and Rehabilitation Center |
070012378 |
B |
30-Jun-16 |
QLEL11 |
3439 |
F226--483.13(c) Develop/Implement Abuse/Neglect, Etc. Policies The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. Resident 1's clinical record was reviewed. His 5/2016 Minimum Data Set (MDS, an assessment tool) indicated he was cognitively intact. His 5/11/16 Grievance and Complaint Report indicated he had a complaint against Resident 3 and requested a room transfer. His nurses notes, dated 5/11/16, also indicated he requested a room change. Resident 3's clinical record was reviewed. His 5/16 MDS indicated he was cognitively intact. The clinical records for Residents 1 and 3 did not contain any documentation regarding a verbal altercation and there was no documentation indicating the incident was reported to the CDPH. During an interview on 5/20/16, at 12:45 p.m., certified nurse assistant B (CNA B) stated she was not working at the time of the incident but in the past she had heard Resident 1 make racial comments when he was referring to Resident 3. Although Resident 3 did not hear the comments, she reminded Resident 1 not to say those words because they were offensive. She stated the licensed nurse was aware of Resident 1's behavior. During an interview on 5/20/16, at 2 p.m., Resident 1 stated he had an argument with Resident 3. Resident 1 stated they exchanged words when he said bad things about Resident 3 and he responded with racial comments. He could not stand Resident 3 and he requested a room change. During an interview on 5/20/16, at 4 p.m., Resident 3 stated he felt so bad and upset when he heard Resident 1 make racially derogatory comments about him. He stated they had a big argument, he was defending himself, and he would not tolerate abuse. He stated if both of them could have gotten up, they would have had a fist fight. During an interview on 5/20/16, at 4:25 p.m., registered nurse A (RN A) stated on 5/11/16 Residents 1 and 3 had an argument and both of them were calling each other names. After the incident, Resident 1 requested a room change. She stated she informed the administrator and was instructed to report the incident to the state if the residents experienced any psychosocial effects. She stated she did not report the incident to the state because she did not see any psychological distress. During an interview on 6/27/16, at 1 p.m., CNA C stated on 6/12/16 Resident 3 was upset. He told her he had an argument with Resident 1 and bad words were said to him. During an interview on 6/27/16, at 4 p.m., the director of nurses (DON) stated there was no documentation, or investigation regarding the verbal altercation, and the incident was not reported to the CDPH. She stated if the incident happened, it should have been investigated and reported to the CDPH, the ombudsman, and the law enforcement agency. Review of the facility 5/2013 policy, "Abuse and Neglect Prohibition", indicated the facility will report all allegations and substantiated occurrences of abuse to the state agency and law enforcement officials. Abuse could be verbal which was defined as oral language that was willfully disparaging and derogatory to the residents within their hearing distance. The facility failed to report an allegation of abuse to the CDPH as required. This violation had a direct or immediate relationship to the health, safety, or security of the residents. |
| 070000043 |
Almaden Healthcare and Rehabilitation Center |
070012848 |
B |
29-Dec-16 |
JDTL11 |
6782 |
F223--483.12 FREE FROM ABUSE/INVOLUNTARY SECLUSION The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms. The facility failed to ensure Resident 1 was free from verbal and mental abuse when the regional workers compensation administrator (RWCA) used threatening words towards Resident 1. This failure had the potential to affect the resident's self-esteem and cause emotional and psychological pain or distress. Resident 1 was admitted to the facility on xxxxxxx with diagnoses including multiple sclerosis (a progressive disease that could affect the brain, spinal cord, and the nerves in eyes and cause problems with vision, balance, muscle control, and other basic body functions), depression, and muscle weakness. The Minimum Data Set (MDS, an assessment tool) dated 10/11/16, indicated the resident was cognitively intact and required assistance with activities of daily living. Review of Resident 1's care plan dated 9/12/16, indicated the resident hoarded items in her room. The intervention indicated to assist and encourage the resident to organize her belongings, keep only the things she needed, and remove her old belongings. Review of Resident 1's social service progress notes dated 12/5/16, indicated the resident reported to the social service director (SSD) an occurrence of verbal abuse from a staff member when a male staff went to the resident's room and informed the resident to arrange her stuff within 24 hours or else she would be kicked out. During an interview on 12/14/16 at 12:46 p.m., the director of nursing (DON) stated on 11/29/16 at around 1:30 p.m., she made room rounds with the facility's RWCA to inspect the resident's room. The DON stated RWCA saw Resident 1's room was cluttered and identified it as a "safety issue." The DON stated RWCA spoke with the resident and informed the resident she had 24 hours to clean her items in her room or she had to look for another place. The DON stated the words used were direct, straightforward and could have been expressed in a subtle way. She stated if there were identified problems during room rounds, the RWCA would bring the identified problems to the administrator. During an interview on 12/14/16 at 2:31 p.m., the SSD stated on 12/5/16, Resident 1 informed him a male staff entered her room and she was told if she did not clean her items in her room within 24 hours, she would be kicked out. SSD stated Resident 1 expressed feelings of being threatened by the RWCA. During an interview on 12/14/16 at 1:30 p.m., Resident 1 stated the DON and RWCA came into her room a couple of days before the interview and she was told by RWCA that her room was cluttered with lots of items. Resident 1 stated the RWCA informed her if she did not clean the clutter within 24 hours she had to leave and look for another place. Resident 1 stated she could not respond to the RWCA's approach because she was in "shock" and in a "panic." She stated she was "hurt and felt threatened." She also stated a family member was present when RWCA spoke to her about the clutter in her room. During an interview on 12/14/15 at 3:30 p.m., and 12/20/16 at 3:20 p.m., RWCA stated on 11/29/16, he made room rounds with the DON to inspect the residents' rooms. RWCA stated Resident 1 had a lot of items in her room, he identified the hazards and informed the resident of the safety violation in her room. RWCA stated he told Resident 1 she had a lot of things on and around her bed and people could slip, trip, or fall from her items. When asked about his involvement with resident issues, he stated after conducting his inspection he would usually report to the department head/administrator and present his report to them. RWCA stated he saw hazards in the resident rooms and if the resident was noncompliant he would talk to the resident. RWCA stated he took it for granted when the facility administrator informed him they did everything to assist the resident to pick up the clutter in her room. He stated he should have informed the facility to call and involve the ombudsman in addressing the problem in the resident's room. During an interview on 12/19/16 at 1:05 p.m., the facility administrator (FA) stated RWCA was not supposed to talk to the resident when issues or concerns arose. FA stated when the DA inspected the resident rooms, he had to report to the administrator, and the administrator or DON had to address the issues with the resident. During an interview on 12/19/16 at 11:59 a.m., a family member (FM) stated she was present at the time when RWCA spoke to Resident 1 about the clutter in her room. FM stated RWCA had no compassion for the resident saying "sorry to be rough on these, you have 24 hours. If I come back and you do not comply, you have to leave." FM stated DA spoke very fast standing in front of the resident who was in a wheelchair and not appreciative of the resident's situation. FM stated "we were shocked with his approach and it was not said in a nice way." She stated Resident 1 did her job to arrange her items that day, sat for a couple of days to clear her emotions, and informed the SSD staff afterwards. FM also stated the 24 hour notice was very short. She stated it should have been said, "If you need more time we could work it out" and it would have been nicer. FM further stated she did not think DA could legally say those words. She said, "It was threatening and very upsetting" to the resident. Review of the facility's 12/18/12 policy "Resident Rights" indicated the facility protects and promotes the rights of the resident. The resident had a right to a dignified existence, self-determination, and communication with access to persons and services inside and outside of the facility. Review of the facility's 6/08 policy "Abuse and Neglect Prohibition" indicated each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. Verbal abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents of families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Mental Abuse includes but is not limited to humiliation, harassment, and threats of punishment or deprivation. The facility failed to ensure Resident 1's right to be free from verbal and mental abuse. The violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or emotional trauma to the resident. |
| 090000102 |
Amaya Springs Health Care Center |
090011000 |
B |
12-Feb-15 |
WIWM11 |
17452 |
Class B Citation _ T-22 _ 72349 (d)(1) - Dietetic ----- Equipment and Supplies (d) Food supplies shall meet the following standards: (1) At least one week's supply of staple foods and at least two days' supply of perishable foods shall be maintained on the premises. Food supplies shall meet the requirements of the weekly menu including therapeutic diets ordered. The facility failed to maintain sufficient food supplies, to ensure the planned menus would be followed as developed by the RD (Registered Dietitian), to meet the nutritional needs of 46 residents. In addition, the facility failed to maintain the facility's planned par level of disaster food supplies, to meet the nutritional needs of the residents and staff, in the event of a disaster or emergency resulting in the loss of gas or electricity. As a result, the lack of sufficient food supplies posed an immediate threat to the health and safety of the facility residents. The facility staff would not have the means to meet the resident's nutritional needs in day to day meal planning. The lack of sufficient emergency food supplies could also result in not meeting the nutritional needs of the residents during a disaster. The facility failed to have a system in place to ensure adequate food supplies, to implement the facility's planned menus in order to meet the nutritional needs of the residents. The lack of guidance and monitoring of the facility staff to direct, prepare recipes and the quantities of food to serve to the residents, impeded the staff's ability to ensure that the planned amount of calories, proteins, vitamins and minerals, were provided to the residents on a daily basis for approximately 10 days. The lack of planning and food supplies had the potential to impact the nutritional status of the residents. In addition, there was inadequate guidance of dietary staff to ensure that therapeutic diets as ordered were provided, in terms of modified textures. Dietary staff were not provided sufficient guidance, and were not following recipes and planned menus.On 6/26/14 at 8:53 A.M., the Department received an anonymous complaint that the facility had insufficient food to feed the residents. On 6/26/14 at 10:15 A.M., an on-site investigation was conducted. Joint observations and interviews were conducted with facility Staff 1. Joint observations of the facility's food storage included all areas of the kitchen in which foods were stored: refrigerators, freezers, dry food storage and disaster/emergency food supplies. Three refrigerators in the kitchen area were jointly observed. Refrigerator 1: contained,1 pan with a clear plastic bag that contained a grey colored substance. Staff 1 identified the grey substance as 5 pounds of hamburger for dinner. Staff 1 stated that, "Refrigerator 1 was normally stocked with fresh produce, such as vegetables and fresh fruit." Staff 1 continued to state that, "Staff were going to the (warehouse store) today for more meat." Refrigerator 2: contained, 5 gallons of milk on the bottom shelf. Staff 1 stated refrigerator 2 normally was stocked with dairy products, such as, yogurts, cottage cheese, sour cream and milk shakes. Refrigerator 3 was empty. Staff 1 stated, refrigerator 3 normally stored eggs and assorted cheeses. Six cabinets with shelves were observed with Staff 1 who stated, the cabinets were used to store canned goods and dry food products.The cabinet's contents were:Cabinet 1- One 8-pound can (#10 can) mixed fruit, two #10 cans of Mexican sauce, two #10 cans of tomatoes, three #10 cans refried beans, four #10 cans of mashed potatoes, and one #10 can pears. The above items were all on one shelf, the other two shelves were empty. Cabinet 2 - One commercial box of cream of wheat, one commercial box of cream of rice, one box of cocoa, one box of tea. The above items were all on one shelf, the other two shelves were empty. Cabinet 3- Contained paper products, paper plates, and napkins.Cabinet 4- Contained 1 #10 can cranberry sauce, and additional paper goods.Cabinet 5- Contained three 40 ounce bags of dry cereal.Cabinet 6 - Contained paper cups, plates on one shelf.Staff 1 stated, "All the cabinet selves should be full with canned goods, coffee, a variety of hot and cold cereals, and different types of pasta to accommodate the daily menus." Three freezers located in the dietary office were jointly observed with Staff 1: Freezer 1- Contained one, 3-gallon container of ice cream.Freezer 2 - Contained 6 unidentified objects wrapped in foil. Staff 1 stated that freezer 2 usually contained frozen vegetables.Freezer 3 was empty. Staff 1 stated that freezer 3 usually contained frozen meat. Staff 1 stated: "the routine for ordering food was two times a week." Staff 1 further stated, "The dietary supervisor quit June 6 and we [dietary staff] were told to order food only once a week." Today the kitchen staffs were told not to order food supplies. Instead we need to make a list of the food and give it to the Administrator in Training (AIT). He would then have a facility staffs go to the (warehouse store). Sometimes the facility staff person would go to the (grocery store)." Staff 1 stated that, "This (practice) has been happening for about 3 weeks." On 6/26/14 at 10:30 A.M. a joint observation and interview with Staff 1, of the emergency food supplies, was conducted. The shelves were empty. Staff 1 stated that, the emergency supply had been rotated out to the daily food supply, to accommodate the menu and provide meals for the residents. Staff 1 stated that, the AIT was told about the shortage of the food supply yesterday (6/25/14), and he said he would call in an order. On 6/26/14 at 11:05 A.M., a telephone interview was conducted with the facility's food vendor. The food vendor stated that he had not received a food order from the facility for today. He continued to state his deliveries for (city name) today had been completed and the facility was not on the list for deliveries.On 6/26/14 at 11:10 A.M., an interview was conducted with the AIT. The AIT stated he was not aware the of a food shortage. He stated the kitchen staff would give him a list of what food would be needed and he would order from the vendor.On 6/26/14 at 11:20 A.M., an interview was conducted with Staff 2. Staff 2 stated that the refrigerators had been empty "but not as bad as today." Staff 2 stated that Staff 1 used to order after the dietary supervisor left but now the AIT was doing the ordering.On 6/26/14 at 12:24 P.M., facility staff 3 (FS 3) said that he assisted facility staff with a grocery run to the (warehouse store) and brought the food to the facility's dietary office. FS 3 said the AIT had provided him and facility staff 4 (FS 4), with the grocery list for the food purchases at the (warehouse store) for 6/26/14. According to the (warehouse store) receipt, dated 6/26/14 at 11:26 A.M., the following items were purchased: waffles, buns, veggies, fruit cocktail, Splenda, Sweet ' N Low, ground beef and sausage. On 6/26/14 at 12:25 P.M., a lunch observation was conducted in the dining room. According to the posted menu, located on a wall in the dining room, the following should have been served: Chopped Lettuce/Tomato, Enchilada Casserole, Salsa Mexicana, Sour Cream/Salsa, Mexican Corn, Refried Beans, and Fresh Fruit in Season. Instead of the posted menu, the following food items were observed for lunch: barbequed chicken, mashed potatoes, mixed canned vegetables, and pudding. The lunch alternate was a grilled cheese sandwich. The planned alternate for 6/26/14 should have been cheeseburger, per the posted menu. On 6/26/14 at 12:27 P.M. an interview was conducted with Staff 1. Staff 1 stated that the facility had not served the planned menu for lunch because the food items needed were not available in the facility. On 6/26/14 at 12:30 P.M., The Administrator (Admin) stated the dietary services supervisor (DSS) abruptly left on June 9th or 10th. The Admin stated that she had asked the facility's consultant Registered Dietitian (RD) to work full-time until the DSS position could be filled, and the RD said "no". The Admin said, "to my knowledge, the dietary services supervisor (DSS) was working her full-time hours. It was sometimes difficult to track because she said she would need to work on weekends or very early hours." The Admin said she was aware that the dietary department was without a qualified full-time Food Service director. The Admin said that she was aware that there were food shortages occurring "to some extent." The Admin said, "What I do know is they (staff) would ask me to make short runs [grocery runs]." The Admin acknowledged that the request to make grocery runs was an unusual occurrence.During the same interview, the Admin stated that she was unaware that the planned meals were not being provided to residents as per the posted menus. The AIT said, "I'm not sure if the planned menus were served or not. I didn't check" The Admin and AIT acknowledged that the leadership staff provided insufficient oversight of the nutritional services during a time in which they were aware that sudden "grocery runs" were necessary, and while knowing the facility was without a qualified full time food service director.The Admin said that she asked the RD to increase her hours to monitor the status of the foodservice operation. The Admin said, "I believe by 4-8 hours two times a week, and it used to be only one time a week, on Sundays." The Admin stated that the RD had not reported any significant concerns to date (6/26/14). The record review, of "Consultant Dietitian Report", dated 6/15/14, indicated: Concerns: "The food stock for this coming week is below the stock standard limit. Pls (please) see attached List to Order food and supplies - to be given to manager/Admin by head cook, discussed with cook the food substitutions due to insufficient food supplies L (low). Disaster Supply - Insufficient - need to refill & Order to standard supply or Par Level."On 6/26/14 at 1:20 P.M., an interview was conducted with Staff 2. Staff 2 stated that, there were numerous occasions in June, in which the cooks had to prepare what food was on hand, as the food needed for the planned menu was not available. Staff 1 was asked what was served when the menu indicated "Fresh Fruit in Season?" and Staff 1 stated, "all we have are bananas every day. Bananas are the only fresh fruit we have. We have been serving canned fruit." On 6/26/14 at 2:14 P.M., inventory of the facility's planned Emergency and Disaster Menu was jointly conducted with Cook 1. Cook 1 verified that the following food items from the "3 days disaster food supplies" inventory list were missing: 2 cans of low sodium canned mixed vegetables, 2 cases of canned pureed chicken, 1 case of canned pureed carrots, 2 # 10 cans of ravioli, 4 tubs of peanut butter, 4 #10 cans of chili beans, 4 #10 cans of prepared macaroni & cheese, 1 case canned beef stew and 2 #10 cans of beef stew, 2 cans #10 of mixed vegetables, 4 #10 cans of 3 bean salad, 1 case of canned diced carrots, 1 #10 can of sliced beets, 1 case of canned green beans, 1 case of canned fruit cocktail, 5 cases of apple juice, 1 case of grape juice, and 48 CTS 5 1/2 oz. cans of cranberry juice, and 2 cases of graham crackers. Cook 1 verified that food items were missing as they had to pull from the disaster food to meet the day to day food service operations for the residents. On 6/26/14 at 3:00 P.M., the Admin and the AIT said they were unaware that the facility had not maintained the planned par level of disaster food supply.According to the planned dinner menu posted in the kitchen, for 6/26/14 was: Spaghetti with meatballs, parmesan cheese, fruit garnish, zucchini tarragon, whole wheat roll/margarine, and lemon bars.On 6/26/14 at 5:08 P.M., Cook 1 said the following was prepared for dinner for 6/26/14: "Hamburger, a handful of grapes, 1/3 cup of fruit cocktail, 5 ounces of juice and 5 ounces of milk."At the time of the interview, Cook 1 verified that the residents had already been served dinner.Cook 1 was asked why the planned menu was not served, and Cook 1 said, "Didn't have menu items to serve the planned menu." Cook 1 stated that, "what was prepared for dinner was what was on hand, so hamburgers were prepared."An interview with a confidential resident (CR) was conducted on 6/26/14 at 5:20 P.M. CR stated that administration told him to say that there was no problem with the food or meal service. CR further stated that the meals severed were not what was on the menu. CR continued to state "we have had a lot of hamburger for dinner." The consultant RD had identified the insufficient day to day operation food supply, and the insufficient disaster food supply in her written consultation reports, 11 days previously to the immediate jeopardy situation that was identified on 6/26/14. Per the Consulting Agreement between the contracted RD and the facility: "9. Provide written records to the Administrator, DON (Director of Nursing) and Director of Dietetics for job performed." On 7/3/14 at 11:00 A.M, an interview was conducted with the RD. The RD stated that she wanted to make corrections to her statement she made on 6/26/14, and 6/27/14. The RD stated that, the Administrator was crying and begging her to lie on 6/26/14, and 6/27/14. The RD said, "So I stupidly did not tell the truth." During the same interview The RD said the following: 1. The Admin never asked her to work full-time when the DSS had no longer worked at the facility since 6/9/14. The Admin had not asked the RD to increase her hours to provide oversight over the foodservice operation when the Admin knew there was no DSS. The RD said, "In fact, [name of Admin] gets upset if I increased my hours, she likes me to stay to 4 hours a week."2. The RD said the Admin had known that the DSS was not working full-time at the facility as the Admin had instructed the DSS to "split her time" between the Admin's two skilled nursing facilities that she administered because one of the facilities did not have a DSS. The RD said the DSS told the RD that she had been splitting her time between the two facilities since 2/28/14. 3. The Admin asked me to change my 6/15/14 Consultant Dietitian Report, to take out the part of shortage of food and disaster supplies because the Admin said, "I will be in trouble if you submit your report." 4. The RD said the following was the reason for the shortage of food, "The regular order for food supplies was completed by the DSS on 6/5/14 before she resigned but that order was cancelled by the AIT with the approval of the Admin. Imagine there was a shortage of food supplies for 10 days, so the cooks had no choice but to start using the disaster [food] supplies." 5. The RD said, "Then on 6/15/14, I was very angry and asked the Cook to submit all the written food supplies that the kitchen needed to [name of AIT]. The following day 6/16/14, delivery came." The RD verified the food order was for only 4 days. 6. The RD said, "On 6/19/14, Thursday - the cook reported to me that [name of food vendor] the food vendor company called to check if the order still stands [routine order] ,and the AIT told the vendor "no", and that's how all the food in the freezer and disaster [food] supplies were exhausted." The facility's policy and procedure entitled "Food Ordering" (last revised June 01, 2014) indicated: "Purpose; To ensure that the Facility maintains an adequate supply of food to meet the nutritional needs of the residents. Policy: The Dietary Manager, under the supervision of the Administrator, is responsible for ordering food and non-food supplies necessary to adequately maintain dietary services to meet local, state and federal requirements and the nutritional needs of the residents. The facility will maintain an adequate supply of food and non-food items. The Dietary Manager will only order supplies through designated, contracted vendors of the facility. Procedure II. The Dietary Manager will utilize the guidelines for ordering food and non-food supplies as established by the menu purchase guide IV. Under normal operating conditions the following minimum inventory should be available at the facility for both regular and therapeutic diets: A. Staples: 7 days, B. Perishables: 2 days." According to the facility's job description for "Cook", "Responsibilities: 5. Follows instructions of the DSS in the preparation of meals" The Cook did not have a spread sheet readily available to follow instructions to ensure portions were served in accordance to the planned menu, to ensure the nutritional needs of residents were met." The facility's Emergency and Disaster Procedures (undated) indicated: "Policy; To provide a planned menu with simplified nutritious meals to be used during an emergency or disaster. Procedure: In case of emergency, a 3-day menu will be used, A. Food items designated in the emergency menu must be available at all times." The lack of sufficient food supplies posed an immediate threat to the health and safety of the residents. The staff would not have the means to meet the resident's nutritional needs in their day to day meal planning. The lack of sufficient emergency food supplies could also result in not meeting the nutritional needs of the residents during a disaster.A violation of these regulations had a direct or immediate relationship to the health, safety or security of the patient. |
| 090000020 |
Avocado Post Acute |
090012723 |
B |
21-Dec-16 |
KMB011 |
7836 |
Federal Regulation, Long Term Care Facilities 483.13 Resident Behavior & Facility Practice, F 223 Free of Abuse - Verbal, Sexual, Physical, Mental. The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. Federal Regulation, Long Term Care Facilities 483.13 Resident Behavior & Facility Practice, F226 Abuse Policy & Procedures, Develop & Implement. The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The facility failed to ensure that Resident 1 was kept free from abuse, when Licensed nurse (LN) 1 dragged Resident I and put LN 1's fist on Resident 1's neck and stated to Resident 1 that if he will not behave, LN 1 "will kick his ass." This failure compromised Patient 1's safety, which resulted in an increased risk for mental and physical stress. Furthermore, the facility failed to ensure staff implemented facility policy and procedure related to abuse reporting. This failure had the potential to put Resident 1's health, safety, and security at risk. Resident 1 was not protected from physical and verbal abuse by a LN 1 when two of the certified nursing assistants (CNA 1 and CNA 2) did not report the incident immediately to the administrator or the charge nurse as the facility's abuse policy indicated. As a result, CNA 1 and CNA 2 witnessed the physical and verbal abuse on 10/18/14 and this abuse incident was not reported to the licensed nurse supervisor (LNS) until the following day on 10/19/14. This failure compromised Resident 1's as well as other residents', safety and psychosocial welfare of another possible abuse incident. Findings: Resident 1 was admitted to the facility on xxxxxxx with diagnoses that included chronic obstructive pulmonary disease (COPD- lung disease) per the History and Physical (H&P) dated 10/16/14. The Minimum Data Set (MDS) assessment dated 10/20/14 indicated that Resident 1's brief interview for mental status (BIMS) scored 13/15 (15 was cognitively intact). On 10/20/14, Monday at 8:53 A.M., the California Department of Public Health (CDPH) received a faxed entity reported incident from the facility indicating a witnessed abuse by a licensed nurse. On Monday, 10/20/14 at 2:38 P.M., an interview was conducted with the assistant administrator (AA). The AA stated that an incident happened on 10/18/14 and was reported to LNS on 10/19/14 by the two certified nursing assistants (CNA 1 and CNA 2). The AA stated that CNA 1 and CNA 2 witnessed the incident during the morning shift on 10/18/14. On 10/20/14 at 3:00 P.M., an interview was conducted with Resident 1. Resident 1 stated that he remembered that LN 1 grabbed him by the neck and threw him to the floor in the hallway by the room. Resident 1 stated that CNA 1 witnessed the incident. Resident 1 also stated that he did not verbalize or question anything. On 10/20/14 at 3:45 P.M., an interview was conducted with the LNS. The LNS stated on 10/18/14 around 12 noon, CNA 1 approached LNS to report a witnessed incident. The LNS stated that according to CNA 1, another CNA (CNA 2) witnessed the incident and stated that LN 1 pushed Resident 1 on the floor. LNS also stated that according to CNA 1, LN 1 dragged the resident and put LN 1's fist on Resident 1's neck and stated to Resident 1 that "if you will not behave, I will kick your ass." On 10/23/14 at 1:35 P.M., an interview was conducted with CNA 1. CNA 1 stated that the incident started on 10/18/14 at breakfast time in the dining room when Resident 1 "started a behavior to the charge nurse." CNA 1 stated that LN 1 was checking the trays, "irritated" and commented "We gonna have a good day today, I'm gonna beat that man's ass...get him in his room and f--k him up." LN 1 went back to the station and CNA 1 stayed and helped another resident to the bathroom. CNA 1 stated that LN 1 was observed at the hallway station and continued to say "We ain't having this today, I'm gonna kick his ass" repeatedly saying it over and over. CNA 1 stated "I didn't take it seriously" and LN 1 stated to her, "We don't see, hear, or say nothing." CNA 1 stated that LN 1's comments were not reported to any staff or supervisor by CNA 1 and CNA 2. CNA 1 stated that Resident 1 was observed to enter his room and looked at LN 1, with LN 1's hands on his hips. LN 1 continually stated "You don't see, hear or say nothing" then took the stethoscope off and threw it to the other CNA (CNA 2), and gave the medication. LN 1 then pushed Resident 1 twice in the chest and Resident 1 fell to the ground. LN 1 grabbed Resident 1 by the collar of his shirt, had his arm around resident's neck, other hand on top of resident's head, and dragged Resident 1 halfway to his room. CNA 1 stated that Resident 1 was not fighting but kept saying to LN 1, "Kill me, kill me." CNA 1 stated that LN 1 repeatedly stated to both CNAs "Don't say nothing." CNA 1 acknowledged that she was a mandated reporter but the incident was reported the following day. On 10/23/14 at 2:35 P.M., an interview was conducted with CNA 2. CNA 2 stated that on 10/18/14 in the morning, Resident 1 was heard shouting out derogatory comments. CNA 2 stated that LN 1 was antagonizing Resident 1 and LN 1 stated "I will get him good today," and told both CNA 1 and CNA 2 that "You hear, see, or say nothing." Resident 1 was observed walking toward his room then LN 1 took off his stethoscope, gave it to CNA 2, pushed Resident 1 twice, took him down to the floor, and dragged him from the floor. LN 1 then told Resident 1, with fist in his neck, that if he kept acting up, that "he's going to kick his ass." CNA 2 stated that both of them (CNA 1 and CNA 2) were told again by LN 1 "You hear, see, or say nothing." CNA 2 stated that the incident was not reported to anyone that day because he was scared. CNA 1 acknowledged it should have been reported on the day of incident and "It was a mistake." CNA 1 and CNA 2 both wrote a declaration of the incident. The written declarations were reviewed and statements matched. On 11/2/16 at 3 P.M, the administrator was interviewed, and acknowledged that the facility failed to ensure that Resident 1 was kept free from abuse, and the facility failed to ensure staff implemented facility policy and procedure related to abuse reporting. A review of the facility's policy and procedure (P&P), dated 9/04, titled "Abuse Reporting" was conducted. The P&P indicated, "It is the policy that all facility staff...promptly notify the administrator of any allegation of resident abuse or neglect. Abuse includes but is not limited to physical, mental, verbal..." The facility failed to ensure that Resident 1 was protected from physical and verbal abuse by LN 1. Because the incident was not immediately reported to supervisor staff, LN 1 was allowed to continue work and complete his shift on 10/18/14. In addition, he returned to work the following day and was not sent home until 10/19/16 around 12:00 P.M. when the supervisor was informed. This failure compromised Resident 1's safety, as well as other residents' safety which resulted in an increased risk for mental and physical stress. Furthermore, the facility failed to ensure staff implemented facility policy and procedure related to abuse reporting. Facility staff failed to report an abuse incident within the required time frame as indicated by state law. This violated state law and had the potential to put Resident 1's health, safety, and security at risk. The above violations jointly, separately, or in any combination had a direct or immediate relationship to health, safety, or security of patients. |
| 090000020 |
Avocado Post Acute |
090012881 |
B |
13-Jan-17 |
83Y211 |
4955 |
Health and Safety Code - ?1418.91(a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a Patient of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. Welfare and Institutions Code Article 3 15630(a) indicated: "Any person who has assumed full or intermittent responsibility for care or custody of an elder or dependent adult, whether or not that person receives compensation, including administrators, supervisors, and any licensed staff or a public or private facility that provides care or services for elder or dependent adults, or any elder or dependent adult care custodian, health practitioner, clergy member, or employee of a county adult protective services agency or a local law enforcement agency, is a mandated reporter." The facility staff failed to report an abuse incident within the required time frame as indicated by state law. This violated state law and had the potential to put Patient 1's health, safety, and security at risk. Patient 1's medical record was reviewed on 10/3/16, during the facility's Annual Re-certification survey in 10/2016. Patient 1 was re-admitted to the facility on XXXXXXX with diagnoses which included history of falling, muscle weakness, and difficulty walking per the facility's Face Sheet. A review of the nurse progress note, dated 6/17/16, indicated that at 2:20 A.M., Patient 1 was found lying on the floor by Patient 2's room. Per the note, Patient 2 stated that Patient 1 would not leave her alone, so she pushed Patient 1 out of her room. Per the same note, at 2:25 A.M., Patient 1 was assessed, "noted contusion hematoma with 1 cm (centimeters) x 1.5 cm abrasion on left eyebrow....able to move extremities without pain." The note also indicated that at 5:25 A.M., a nurse practitioner (NP), who was covering for Patient 1's physician, was informed about the incident. The NP ordered an x-ray. A review of the physician's order sheet, dated 6/17/16 at 6 A.M., indicated an order for, "Skilled x-ray STAT (immediately)." A review of Patient 1's x-ray result, dated 6/17/16, indicated, "Acute left hip fracture." A review of Patient 1's History and Physical from (name of hospital), dated 6/18/16, was conducted. This record indicated, "...The patient... was taken to the Emergency Room from (name of facility) earlier last night after having a mechanical fall. The patient fell to the floor, was unable to get up. X-Ray was obtained that showed what appeared to be a left hip fracture..." An interview with Licensed Vocational Nurse (LVN) 1 was conducted on 10/3/16 at 9:20 A.M. LVN 1 stated that the incident happened during the night shift. LVN 1 stated that Patient 1 went inside Patient 2's room. Per LVN 1, Patient 2 told Patient 1 to go, but Patient 1 did not understand Patient 2. Patient 2 pushed Patient 1 causing her to fall. An interview with the administrator (Admin), who was also the abuse coordinator, was conducted on 10/4/16 at 5 P.M. The Admin stated she remembered this particular incident. The Admin stated, "It wasn't noted until later in the afternoon, so we dropped the ball. We probably should have investigated more." The Admin acknowledged all resident to resident physical altercations should have been investigated thoroughly and reported to the California Department of Public Health (CDPH) and the police department. The altercation between Patient 1 and Patient 2 on 6/17/16, which resulted in Patient 1's hip fracture, was not reported to the CDPH. The CDPH became aware of the incident while conducting a review of Patient 1's medical record during the facility's Annual Re-certification survey on 10/2016. A review of the facility's policy titled, Abuse Prevention, dated February 2016, was conducted. This policy did not provide specific guidelines and timeframes for reporting alleged and/or suspected abuse. The facility staff failed to report an abuse incident within the required time frame as indicated by state law. Per the Welfare and Institutions Code, the facility staff were mandated reporters and should have reported the abuse incident. According to Health and Safety Code, the facility were required to report alleged or suspected abuse within 24 hours. Despite knowledge of an incident of patient-to-patient abuse occurred, staff did not report this incident within the required time frame. The facility did not report the abuse to the CDPH which was not in accordance with the Health and Safety Code 1418.91(a) and the Welfare and Institutions Code Article 3 15630(a). These violations of the state law had the potential to delay the response and investigation process from CDPH putting the patient's health, safety, and security at risk. The above violations either jointly, separately, or in any combination had a direct or immediate relationship to health, safety, or security of patients. |
| 090000020 |
Avocado Post Acute |
090012882 |
B |
13-Jan-17 |
83Y211 |
5189 |
Health and Safety Code - ?1418.91(a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a Patient of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. Welfare and Institutions Code Article 3 15630(a) indicated: "Any person who has assumed full or intermittent responsibility for care or custody of an elder or dependent adult, whether or not that person receives compensation, including administrators, supervisors, and any licensed staff or a public or private facility that provides care or services for elder or dependent adults, or any elder or dependent adult care custodian, health practitioner, clergy member, or employee of a county adult protective services agency or a local law enforcement agency, is a mandated reporter." The facility staff failed to report an injury of unknown origin within the required time frame as indicated by state law. This violated state law and had the potential to put Patient 1's health, safety, and security at risk. A review of Patient 1's medical record was conducted on 10/4/16, during the facility's re-certification survey. Patient 1 was readmitted to the facility on 10/11/15 with diagnoses which included cerebrovascular disease (brain damage) and bed bound per the facility's History and Physical, dated 10/13/15. Per the same record, Patient 1 did not have the capacity to understand and make decisions. A review of Patient 1's nurses progress notes, dated 4/6/16, was conducted. This note indicated, that on 4/6/16 at 2:40 P.M., "Noted...purplish discoloration on left posterior (back) thigh & (and) left hip... Claimed he fell but unable to state when..." The note also indicated that the patient's physician was notified and gave an order for "STAT (immediately) x-ray." There was no other documentation to help determine when the incident happened or what caused the patient's injury. A review of the x-ray result, dated 4/6/16, indicated, "Minimally displaced fracture of the base of the femoral neck." A review of Patient 1's nurses progress note, dated 4/6/16, indicated that at 5:25 P.M., a message was left with the patient's physician regarding the x-ray result. Per the same note, at 6 P.M., the patient's physician ordered the patient to be transferred to the hospital. A concurrent interview and record review with Licensed Vocational Nurse (LVN) 1 was conducted on 10/4/16 at 1:25 P.M. LVN 1 stated that she went to see Patient 1 after the CNA reported the purple bruise on the patient's left hip. LVN 1 stated, "(Patient) 1 was alert but confused; he complained of pain and had facial grimacing. LVN 1 also stated, "He is non ambulatory." An interview with LVN 1 was conducted on 10/4/16 at 2:15 P.M. LVN 1 stated, "I remember investigating the incident and asking the nurses what happen, but I don't remember the result of that investigation." There was no other documentation found in Patient 1's medical record regarding this incident. LVN 1 stated that Patient 1's injury of unknown origin should have been reported to the abuse coordinator and should have been investigated thoroughly, but was not. A concurrent interview and record review with the facility's administrator (Admin), who was also the abuse coordinator, was conducted on 10/4/16 at 4:25 P.M. The Admin stated all injuries of unknown origin should be investigated. The Admin reviewed records of abuse allegations in the facility. The Admin acknowledged that there was no record or documented evidence that Patient 1's injury of unknown origin was reported to the California Department of Public Health (CDPH) or the police in accordance with state law. The Admin stated, "l know I didn't report it and looking back, we probably should have." Patient 1's injury of unknown origin was identified by the facility on 4/6/16. The facility did not report the injury of unknown origin to the CDPH. The CDPH became aware of the patient's injury while conducting a review of Patient 1's medical record during the facility's Annual Re-certification survey on 10/2016. The facility staff failed to report an injury of unknown origin incident within the required time frame as indicated by state law. Per the Welfare and Institutions Code, the facility staffs are mandated reporters and should have reported the alleged or suspected abuse. According to the Health and Safety Code, all incidents of alleged or suspected abuse should be reported within 24 hours. As mandated reporters, the facility staff did not report Patient 1's injury of unknown origin, which was not in accordance to the Welfare and Institutions Code Article 3 15630(a). The facility did not report suspected abuse within 24 hours to the CDPH, which was not in accordance with the Health and Safety Code 1418.91(a). These violations of the state law had the potential to delay the response and investigation process from CDPH putting the patient's health, safety, and security at risk. The above violations either jointly, separately, or in any combination had a direct or immediate relationship to health, safety, or security of patients. |
| 010000026 |
Apple Valley Post-Acute Rehab |
110009217 |
B |
30-May-12 |
Q99K11 |
2815 |
72601(a) Alterations to Existing Buildings or New Construction (a) Alterations to existing buildings licensed as skilled nursing facilities or new construction shall be in conformance with Chapter 1, Division 17, Part 6, Title 24, California Administrative Code and requirements of the State Fire Marshal. 72605 Notice to Department The Department shall be notified in writing, by the owner or licensee of the skilled nursing facility, within five days of the commencement of any construction, remodeling or alterations to such facility. The facility violated the regulation by failure to notify California Department of Public Health and failure to ensure alterations to the skilled nursing facility were in conformance with Chapter 1, Division 17, Part 6, Title 24, prior to installing an Ansul system (fire suppression system). These failures resulted in the potential for unsafe installation of the Ansul system and risk of re-ignition of fuel without chemical fire suppressant to extinguish fire and the potential failures of a fire alarm system leaving the residents in the facility at risk. During an observation and staff interview on 3/12/12 at 1:36 p.m., a fire suppression system was observed over the stove in the facility kitchen. The Dietary Supervisor (DS) stated the suppression system was installed, "About two years ago."During a joint interview and concurrent document review on 3/12/12 at 2:14 p.m., the Area Compliance Officer for the Office of Statewide Health Planning and Development (OSHPD) and the facility Administrator reviewed a letter to the facility from OSHPD, dated 3/12/12, which indicated the construction project (#SS110447-0) for the installation of the Ansul system was closed due to inactivity. The Area Compliance Officer stated the construction project for the installation of the Ansul system expired on 3/12/12. The facility Administrator stated he was not aware of a construction plan for the installation of the Ansul system. During an interview on 3/12/12 at 2:25 p.m., the Administrator stated the facility did not notify CDPH, L&C prior to installing the Ansul fire suppression system. Therefore, the facility violated the regulation by failure to notify California Department of Public Health and failure to ensure alterations to the skilled nursing facility were in conformance with Chapter 1, Division 17, Part 6, Title 24, prior to installing an Ansul system (fire suppression system). These failures resulted in the potential for unsafe installation of the Ansul system and risk of re-ignition of fuel without chemical fire suppressant to extinguish fire and the potential failures of an fire alarm system leaving the residents in the facility at risk. The violation of these regulations had a direct relationship to the health, safety, and security of patients. |
| 010000026 |
Apple Valley Post-Acute Rehab |
110009218 |
B |
30-May-12 |
Q99K11 |
4929 |
72601(a) Alterations to Existing Buildings or New Construction (a) Alterations to existing buildings licensed as skilled nursing facilities or new construction shall be in conformance with Chapter 1, Division 17, Part 6, Title 24, California Administrative Code and requirements of the State Fire Marshal. 72605 Notice to Department The Department shall be notified in writing, by the owner or licensee of the skilled nursing facility, within five days of the commencement of any construction, remodeling or alterations to such facility. The facility violated the regulation by failure to notify California Department of Public Health and failure to ensure alterations to the skilled nursing facility were in conformance with Chapter 1, Division 17, Part 6, Title 24, prior to installing eight HVAC (heating, ventilation, and air conditioning) units. This failure resulted in the potential for unsafe installation of a new roof without the benefit of a permit and eight HVAC units on the roof without the benefit of a permit. The following installations were made: 1) Eight HVAC units without known size and capacity that had the potential to overload the electrical service causing a fire hazard; 2) Eight HVAC units were improperly mounted on the roof causing hazard of falling during a seismic event; 3) Eight HVAC units lacked an automatic shutdown upon smoke detection that would allow the spread of smoke to all areas of the building in the event of a fire; 4) A new roof and eight improperly installed HVAC units that negatively impacted smoke barriers and fire integrity of the roof causing smoke and fire to rapidly spread through the attic and roof joists thus putting residents at risk; and 5) The unknown reliability of electrical service may leave the residents with no heat for extended periods of time. During an interview on 3/12/12 at 3:46 p.m., the Area Compliance Officer for the Office of Statewide Health Planning and Development (OSHPD) stated the facility currently had eight HVAC units on the facility roof, but did not have a permit for the installation of all of the HVAC units. During an interview on 3/12/12 at 2:25 p.m., the Administrator stated the facility did not notify CDPH, L&C prior to installing the HVACs on the roof of the facility. Document review dated 3/19/12, revealed the Regional Compliance Officer for OSHPD, indicated the following: 1) "A new roof without benefit of a permit. This is violation of H&S Code 129875 and CBC 105.1." The code requirements require rated construction with a one hour roof to ensure that staff have time to relocate residents safely in the event of a fire: 2) "Up to eight separate HVAC units have been installed without benefit of a permit." The document from OSHPD regional compliance officer confirmed installation of eight HVAC units without known size and capacity that had the potential to overload the electrical service causing a fire hazard. Eight HVAC units were improperly mounted on the roof causing hazard of falling during a seismic event. Eight HVAC units lacked an automatic shutdown upon smoke detection that would allow the spread of smoke to all areas of the building in the event of a fire. A new roof and eight improperly installed HVAC units that negatively impacted smoke barriers and fire integrity of the roof causing smoke and fire to rapidly spread through the attic and roof joists thus putting residents at risk. The unknown reliability of electrical service may leave the residents with no heat for extended periods of time. Therefore, the facility violated the regulation by failure to notify California Department of Public Health and failure to ensure alterations to the skilled nursing facility were in conformance with Chapter 1, Division 17, Part 6, Title 24, prior to installing eight HVAC (heating, ventilation, and air conditioning) units. This failure resulted in the potential for unsafe installation of a new roof without the benefit of a permit and eight HVAC units on the roof without the benefit of a permit. The following installations were made: 1) Eight HVAC units without known size and capacity that had the potential to overload the electrical service causing a fire hazard; 2) Eight HVAC units were improperly mounted on the roof causing hazard of falling during a seismic event; 3) Eight HVAC units lacked an automatic shutdown upon smoke detection that would allow the spread of smoke to all areas of the building in the event of a fire; 4) A new roof and eight improperly installed HVAC units that negatively impacted smoke barriers and fire integrity of the roof causing smoke and fire to rapidly spread through the attic and roof joists thus putting residents at risk; and 5) The unknown reliability of electrical service may leave the residents with no heat for extended periods of time. The violation of these regulations had a direct relationship to the health, safety, and security of patients. |
| 010000026 |
Apple Valley Post-Acute Rehab |
110009220 |
B |
30-May-12 |
Q99K11 |
3301 |
72601(a) Alterations to Existing Buildings or New Construction (a) Alterations to existing buildings licensed as skilled nursing facilities or new construction shall be in conformance with Chapter 1, Division 17, Part 6, Title 24, California Administrative Code and requirements of the State Fire Marshal. 72605 Notice to Department The Department shall be notified in writing, by the owner or licensee of the skilled nursing facility, within five days of the commencement of any construction, remodeling or alterations to such facility. The facility violated the regulation by failure to notify California Department of Public Health and failure to ensure alterations to the skilled nursing facility were in conformance with Chapter 1, Division 17, Part 6, Title 24, prior to installing a resident Care Tracker system (a software system for tracking resident care) with monitors which were mounted to the wall in the facility hallways. These failures had the potential for unsafe installation of equipment that may result in: 1) Overloading the electrical circuits and electrical panel creating a fire hazard and loss of electricity; 2) Monitors contain combustibles and may obstruct the exit paths causing slowed emergency evacuation and hazard to the residents.During an observation on 3/12/12 at 2:28 p.m., monitors for the Care Tracker system were mounted to walls in three facility hallways. During an interview on 3/12/12 at 2:56 p.m., the Area Compliance Officer for the Office of Statewide Health Planning and Development (OSHPD) stated the facility did not have a permit for the installation of the Care Tracker system. During an interview on 3/12/12 at 2:25 p.m., the Administrator stated the facility did not notify CDPH L&C prior to installing the Care Tracker system. Document review dated 3/19/12, from the Regional Compliance Officer for OSHPD, indicated the following: "The installation requires a large amount of cabling through the building, this cable penetrates fire and smoke walls a number of times." The holes allow the fire and smoke to spread throughout the facility resulting in ineffective smoke compartments. The power supply to the circuits is unknown, thus possible overloading the electrical circuits and electrical panel creating a fire hazard and loss of electricity. The patient care tracking monitors contain combustibles and may obstruct the exit paths causing slowed emergency evacuation and hazard to the residents. Therefore, the facility violated the regulation by failure to notify California Department of Public Health and failure to ensure alterations to the skilled nursing facility were in conformance with Chapter 1, Division 17, Part 6, Title 24, prior to installing a resident Care Tracker system (a software system for tracking resident care) with monitors which were mounted to the wall in the facility hallways. These failures had the potential for unsafe installation of equipment that may result in: 1) Overloading the electrical circuits and electrical panel creating a fire hazard and loss of electricity; 2) Monitors contain combustibles and may obstruct the exit paths causing slowed emergency evacuation and hazard to the residents. The violation of these regulations had a direct relationship to the health, safety, and security of patients |
| 010000998 |
Able |
110010047 |
A |
17-Dec-13 |
H2SR11 |
3066 |
A008 W&I 4502(h) Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following: (h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect. The facility failed to prevent Client 1 from receiving second-degree burns to 3-4% of her body when Direct Care Staff A (DCS) left Client 1 unattended in the bathtub with hot running water. The facility is a 10 bed Intermediate Care Facility for the Intellectually Disabled licensed to provide care and services to people with varying degrees of developmental and intellectual disability. Client 1 was dependent upon the facility for her activities of daily living, which included bathing. Client 1 was a female with intellectual disabilities and used a walker for ambulating. During an interview, on 6/6/11 at 9:40 a.m., in the lobby of the California Department of Public Health's District Office Santa Rosa, DCS A stated that on the day of the incident Client 1 went to toilet herself independently as usual. She went to check on Client 1, as she was taking longer than usual in the bathroom. Client 1 had soiled her clothes with feces, had removed her clothing and was sitting inside the bathtub. DCS A turned on the water and checked the temperature from the faucet with her hand, which she states, "felt ok". DCS A then diverted the water to the hand held showerhead and gave it to Client 1. Then she proceeded to take the soiled linen out of the bathroom "because it smelled really bad". When she returned, she noticed that the water was hot and adjusted it. When drying Client 1, DCS A noticed that the skin on Client 1's thighs was very red.DCS A stated that she called in another staff member to check Client 1's skin. DCS called the nurse who gave instruction to take Client 1 to the hospital. Record review of hospital visit indicated that Client 1 received treatment for partial thickness burns (second-degree burns) to her groin, thighs and buttocks on 6/1/11. Review of Client 1's "Personal Living Skills" last updated 6/25/10, indicated that she required staff presence for safety during showering. The facility's failure to provide proper supervision during bathing of Client 1 resulted in Client 1 suffering pain from partial thickness burns over 3-4 percent of her body and having to stay home from her day program for pain control and to receive treatment to burn areas. The violation of this regulation had a direct and immediate relationship to the health, safety and security of Resident 1 |
| 010000998 |
Able |
110012237 |
A |
24-May-16 |
VKL711 |
6484 |
W&I 4502(b)(8) W&I 4502 (b) It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following: (8) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect. The facility is a ten bed Intermediate Care Facility for the Developmentally Disabled - Habilitative, licensed to provide care and services to people with varying degrees of developmental disability. Client 1 was dependent upon the facility for all basic needs including safety. The facility failed to protect one client (Client 1), with a history of impulsive behavior and poor safety awareness, from harm when: Client 1 was left unattended, released her wheelchair brake, attempted to transfer herself into a facility van, and overshot the loading platform, losing control of her wheelchair on the facility's steep driveway. This failure resulted in Client 1 falling over, hitting her head, and sustaining facial lacerations that required 15 stitches. The facility's "Special Incident Report," dated 12/28/15, indicated Client 1 was a wheelchair dependent client, living at a group home. One staff member had placed Client 1 at the [passenger] side of the van, and secured her brakes, while assisting another dependent resident in the van. The incident report indicated Client 1 released her brakes in an attempt to load herself onto the van's lift, and lost control on the steep driveway, tipping over onto her left side approximately 20 feet down. The report indicated paramedics transferred Client 1 to the Emergency Room (ER), where hospital staff assessed Client 1 to have facial lacerations requiring 15 stitches across her left eyebrow, and down the bridge of her nose. Other abrasions and lacerations, not requiring stitches were evident on Client 1's left cheek, forehead, left shoulder, and knee.During an interview, on 12/29/15 at 7 a.m., Licensed Staff A stated Client 1 had a history of lack of impulse control, and diminished safety awareness. Licensed Staff A stated Client 1 had released her brake while waiting to be loaded onto the facility van. Licensed Staff A stated Client 1 lost control when her wheelchair went down the driveway and hit a crack that caused her to tip over, shattering her glasses and causing facial lacerations. Licensed Staff A stated Client 1 is hydrocephalic, and especially vulnerable to any head trauma. (Hydrocephalus is a rare medical condition in which there is an abnormal accumulation of fluid in the brain. This causes increased pressure inside the skull and may cause seizure disorders, poor vision, mental disability, and poor muscle control.)The facility's "Resident Face Sheet," dated 4/15/15, indicated Client 1 diagnosis included hydrocephalus, seizure disorder, muscular weakness, developmental delay, and glaucoma.An observation of the facility driveway on 12/29/15 at 7:56 a.m., indicated a steeply inclined driveway leading up to the facility from the level street below. The driveway's surface was lifted in areas, and had some open seams/cracks. The facility's front door led out to a gated front yard. The gate opened up onto a flat surface that accommodated one vehicle parked for loading, but then declined sharply at a 45-60? angle for approximately 50-60 feet to the level street below. Daily "RN [Registered Nursing] Notes," dated 12/27/15, indicated Client 1 "...ended up rolling about 20 feet [down the] driveway, which has a considerable incline, and the wheelchair tipped over after hitting a 'crack'." During a concurrent observation and interview on 12/29/15 at 8:05 a.m., Client 1 had two black eyes. When asked for her version of the incident, Client 1 stated she became impatient waiting for assistance, and tried to independently load herself on the facility van's lowered lift, located at the back of the van. Client 1 stated she released her wheelchair's brakes, overestimated the distance to the van's lift, and shot past the lowered lift and down the driveway, tipping part way down. During an interview, on 12/29/15 at 8:10 a.m., Direct Care Staff B stated she had verbally told Client 1 to remain buckled in her wheelchair, on the level side of the van, while she loaded an ambulatory resident through the passenger side door. Direct Care Staff B stated the van's loading lift, located at the rear of the van, and had been lowered in advance. As she buckled the other resident in the van's seat, Direct Care Staff B stated she heard "Help me." Direct Care Staff B stated she turned to where she had left Client 1, and did not see her. Direct Care Staff B exited the van, ran to the back of the van, and saw Client 1 had rolled partially down the steep driveway, and fallen over onto her left side. When asked if Client 1 had attempted to load herself onto the van in the past without waiting for staff, Direct Care Staff B stated she had, and that she had discussed Client 1's impulsiveness with management. During an interview, on 12/2915 at 8:25 a.m., Administrative Staff AC and Management D indicated Client 1 tried to be helpful and independent, but denied being aware of Client 1's past attempts to independently load herself. The facility's "Nursing Care Plans for Chronic Confusion," dated 6/1/15, indicated Client 1 had impaired memory and an altered interpretation to stimuli (environment). Nursing interventions, number "4.," indicated the facility ensured Client 1 was in a safe environment by removing potential hazards because of her loss of ability to make good judgements, which could potentially result in harm to herself or others. The facility's care plans for Client 1 did not include a specific care plan for safe transfer from the facility driveway into the facility van, taking into account Client 1's impulsive behavior and the potentially dangerous incline of the facility's driveway.Therefore, the facility failed to protect Client 1 from harm during transportation, when Client 1 was left unattended, released her wheelchair brake, attempted to transfer herself into a facility van, and overshot the loading platform, losing control of her wheelchair on a sharp decline. This failure resulted in Client 1 falling over, hitting her head, and sustaining facial lacerations that required 15 stitches. This violation presented either imminent danger that death or serious harm would result, or a substantial probability that death or serious physical harm would result. |
| 010000026 |
Apple Valley Post-Acute Rehab |
110012748 |
B |
13-Dec-16 |
HH2D11 |
3885 |
Health and Safety Code 1418.91(a) (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. Health and Safety Code 1418.91(b) (b) A failure to comply with the requirements of this section shall be a class "B" violation. The Facility failed to ensure that all alleged incidents, involving mistreatment or abuse of a resident, were reported, in accordance with State law, including to the State survey and certification agency. Resident 1 was admitted to the facility on xxxxxxx with diagnoses including Cerebral Vascular Accident and Vascular Dementia The facility reported, to the Department on 07/12/16, that during a survey conducted by the facility on 7/11/16, Resident 1's spouse reported that, in the last one to two years, Resident 1 received bruises from care and that one staff person spoke mean to him. They submitted the confidential report documenting the allegations to the Ombudsman on 7/12/16. During an interview, on 7/12/16 at 4 p.m., the resident's spouse stated that she had not reported the bruising to the facility when it was observed. She stated that Staff A had allegedly spoken mean to the resident. She also stated, at that time, she had written a letter to the facility regarding her concerns. When the facility was requested to provide that letter, they complied. The letter was dated 12/01/14 and included the concern that the resident was unhappy when cared for by Staff A because she talked down to him. The spouse stated Staff A was observed to be negative and angry. The letter also noted that the spouse had not reported sooner because she feared retaliation, but the treatment had escalated. A fax was sent to the physician, dated 11/30/13, contained the note "False accusations of injury" during transfers and care. A care plan entry, dated 3/28/14, documented a concern that the resident had reported that a Certified Nursing Assistant (CNA) made faces at him when passing the room. A message sent to the physician regarding the accusation, on the same date, included a notation that resident is also being monitored for "falsely" accusing staff of hurting him during transfers. Facility staff was unable to find evidence that this had been reported to the Department. Staff A was identified by spouse (in her letter to the facility as being negative and angry and talking down to the resident). A review of Staff A's employee history, on 7/12/16, revealed a Discipline Form, dated 12/02/14, which stated that residents, families and employees had complained to the Director of Nurses about Staff A.s behaviors. A second Discipline Form, dated 4/25/16, documented that a resident had complained that Staff A was rude and short with her. There were no performance evaluations in the file and facility staff were unable to locate any evaluations. During a telephone interview on 7/26/16 at 4 p.m., Staff A stated that when she was given the Discipline Form, she was told "it" was never reported and she was not aware that she had to report the allegation to anyone outside of the facility. She said she was told just to sign the form. The facility was aware of the four (4) documented allegations (11/30/13, 12/01/14, 3/28/14 and 04/25/16), as evidenced by documentation, but failed to report them to the required agencies (State survey and certification, Ombudsman and Law Enforcement). Therefore, the Administrator failed to ensure that all allegations of mistreatment or abuse were reported to the State survey and certification agency in accordance with policy and State law. Failure to report allegations of mistreatment does not provide the State or Law Enforcement the opportunity to conduct an independent investigation of the incidents and may place all residents in the facility at risk of recurrence of the behaviors. |
| 010000998 |
Able |
110013134 |
A |
12-May-17 |
UWMS11 |
6660 |
W & I 4502(b)(8)
(b) It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following:
(8) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect.
The facility failed to prevent Client 1 from harm when the gate from the yard to the driveway was not maintained in such a way that it securely closed at all times. The facility did not check that the gate was securely latched before Client 1, who had a prior history of a fall outside the gated area, went outside the house to walk in the yard as was his preference. Client 1 opened the gate and started down the steep driveway, which had a considerable incline, fell and broke his left arm which required surgical repair.
The facility is a ten bed Intermediate Care Facility for the Developmentally Disabled - Habilitative, licensed to provide care and services to people with varying degrees of developmental disability. Client 1 was dependent upon the facility for all basic needs including safety.
XXXXXXX/16 the facility submitted a Special Incident Report to the Department which documented on 11/1/16 at 5:30 p.m., Client 1 had been found at the top of their driveway outside of the gate and appeared to have fallen. Facial abrasions were noted on the client's forehead, eyebrow, upper lip and a fresh bite mark to his lower lip. Client 1 was taken to an urgent care center on 11/2/16 for x-rays. The facility reported on 11/4/16 that Client 1 had sustained a fracture to the left distal radius, (the forearm near the wrist). The report documented that due to a mechanical deficiency in the gate mechanism, a new latch had been ordered to allow the gate to effectively close.
Client 1's Annual IDT (Interdisciplinary Team) Review, dated 8/22/16, documented Client 1 had diagnoses that included moderate intellectual / developmental disability, deafness. The IDT documented Client 1 had shown signs of confusion at times, was ambulatory, with an unsteady gait at times.
During an interview on 11/7/16 at 3:15 p.m., QIDP (Qualified Intellectual Disabilities Professional) stated the latch to the gate was fine but the gate did not always swing fast enough to catch the latch. The QIDP stated on 11/1/16 at about 5:30 p.m., the Massage Therapist came for an afternoon treatment and found Client 1 lying on his side near the top of the steep driveway. Client 1 was helped back to the house and given first aid.
During an interview on 11/7/16 at 3:30 p.m., House Manager stated Client 1 liked to walk in the yard, go to the gate and touch the top of the wood, and liked to look out. House Manager stated Client 1 did not reach over the gate to work the latch.
During a telephone interview on 11/10/16 at 9:15 a.m., QIDP stated staff realized the gate was not closing and latching on its own after Client 1 had the fall.
During an interview on 1/5/17 at 3:20 p.m., QIDP stated Client 1 had proven to be safe and steady walking outside in the yard. QIDP stated Client 1 was able to push on doors but had not been observed to use doorknobs or gate latches. The facility assessed Client 1 was safe behind the closed gate before the steep driveway.
During the same interview, QIDP stated he monitored the gate 2-3 times a week and the House Manager monitored the gate daily. QIDP stated this was done informally and was not documented when done. Signs were put up to keep the gate closed and staff were instructed to keep the gate closed.
During an interview on 1/5/17 at 3:35 p.m., DCS A (Direct Care Staff) stated he usually helped Client 1 get into the house after day program. Client 1 usually used the restroom, had a snack and then went outside to walk. "Client 1 is free to go out by self: he goes in and out by himself until dinner." DCS A stated Client 1 did not know how to operate the gate.
DCS A stated he had been in the laundry room on 11/1/16 when Client 1 was found down outside. DCS A stated he last closed the gate that day when they had returned from Day Program around 3 p.m. DCS A stated he did not know when Client 1 had last gone outside and did not check to see if the gate was secured.
Review of a Memo to the staff from the QIDP dated 3/30/16 noted that Client 1 "fell recently on the driveway near the hill, because someone left the front gate open....." This Memo documented for staff to, "Please remember to close the gate at all times. The front gate should only be open when you are taking a client through it..."
The facility checklist titled Client Transportation: Loading/Unloading the van, dated 6/3/16, was used by the House Manager to monitor this process. The checklist included item 2, "The gate is kept closed except when clients are coming through." The monitoring was scheduled to be one time a week between 8/28/16 to 11/28/16. The House Manager documented that the gate had been left open the following times: 9/28/16 at 3:15 p.m., 9/29/16 at 8:17 a.m., and 10/11/16 at 9:15 a.m.
During a telephone interview on 1/19/17 at 11 a.m., the QIDP stated he did not know if anyone checked the gate before Client 1 walked in the yard after snack time. During the interview, the QIDP asked the House Manager if the gate was checked when Client 1 went outside. The House Manager responded the gate was checked from a distance and those checks were not documented. The QIDP stated prior to the fall he had not made checking the gate part of the monitoring requirements for Client 1.
Review of Client 1's Operative Report, from the outpatient surgery center, dated 11/11/16, indicated Client 1 had a diagnosis of Left Distal Radius Fracture (the arm bone near the wrist was broken). Client 1 had an Open Reduction and Internal Fixation (a surgical procedure to realign the broken bone into the normal position by use of steel rods, screws or plates to stabilize the bone) of the Left Wrist fracture to repair the injury.
The facility failed to prevent Client 1 from harm when the gate from the yard to the driveway was not maintained in such a way that it securely closed at all times. The facility did not check that the gate was securely latched before Client 1, who had a prior history of a fall outside the gated area, went outside the house to walk in the yard as was his preference. Client 1 opened the gate and started down the steep driveway, which had a considerable incline, fell and broke his left arm which required surgical repair.
This failure presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 240000700 |
ASISTENCIA VILLA REHABILITATION AND CARE CENTER |
240008918 |
B |
18-Jan-12 |
LDE211 |
3651 |
REGULATION VIOLATION: Title 22 72311 Nursing Service-General (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's car shall be based on this plan.The facility failed to implement Patient 1's plan of care pertaining to two-person assist for transfers. This failure resulted in Patient 1 falling on October 15, 2009 and hitting her head on the bedside table resulting in Patient 1 needing 7 staples to her forehead, as well as a skin tear to her left elbow. On November 6, 2009 at 1:00 PM, an unannounced visit was made to the facility to investigate an entity reported incident pertaining to patient care. Patient 1 was a 93 year old female, who was admitted to the facility on September 9, 2003, with diagnoses which included anemia, status post cerebrovascular accident, and organic psychotic dementia. Documentation revealed Patient 1 was diagnosed with blindness. Patient 1's quarterly Resident Assessment Instrument (RAI) completed on September 16, 2009, under the heading "mobility" that Patient 1 required, "2 person assist for transferring at all times."A plan of care dated September 18, 2009, addressed the patient's need for staff assistance for all ADLs (activity of daily living), due to her "progressive dementia and blindness." Physician's orders dated September 19, 2003, included, "Side rails up bilaterally while in bed due to poor safety awareness secondary to dementia. An interview with the Director of Nurses (DON), on November 6, 2009 was conducted. The DON stated that on October 15, 2009 at approximately 10:30 AM, Certified Nurse Assistant 1 (CNA 1) was helping Patient 1 out of bed. The DON stated that Patient 1 was a patient that required two person assist and a Hoyer lift for transferring. The DON stated that CNA 1 sat Patient 1 up in bed then went outside the patient's door to retrieve the Hoyer lift. The DON stated that when CNA 1 went to get the Hoyer lift from outside the room, Patient 1 "somehow lost her balance, fell forward unto the floor, hitting her head on the bedside table on the way down, causing a laceration to her forehead." The DON stated that Patient 1 was transferred to the emergency room the same day.On November 6, 2009 at 2:00 PM, CNA 1 stated that on October 15, 2009, she was attempting to get Patient 1 out of bed. CNA 1 stated that she sat Patient 1 up on the side of the bed, asked her if she was alright, and then stepped outside the room to get the Hoyer lift. CNA 1 stated that as she was getting the Hoyer lift, she heard someone behind her say "Ouch." CNA 1 stated that she turned and saw Patient 1 on the floor between the bedside table and the bed. CNA 1 stated she called for help to get Patient 1 back in bed. A review was conducted on November 6, 2009 of the Emergency Room Discharge Report. The report indicated that Patient 1 received 7 stitches. A review was conduced on November 6, 2009 of Patient 1's Resident Assessment Instrument (RAI), which was initiated on September 18, 2009. Under the heading "transfers," documentation indicated Patient 1 needed a two person assist for transferring. However, on October 15, 2009, staff failed to ensure Patient 1 was assisted by two staff. CNA 1 left Patient 1 seated on the edge of her bed while she left the room to get a Hoyer lift.As a result, Patient 1 fell, hit her head, sustained a laceration and required 7 sutures (stitches) to repair the affected area. This facility failure had a direct or immediate relationship to the health, safety, or security of long-term health care facility patient or residents. |
| 240001011 |
Apple Valley Post Acute Center |
240009002 |
B |
15-Feb-12 |
6N0P11 |
4167 |
REGULATION VIOLATION: Health and Safety Code 1418.91 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours.(b) A failure to comply with the requirements of this section shall be a class "B" violation.The facility failed to report an incident of alleged abuse to the Department as required. On May 30, 2011, Patient A was observed with a bruising around his left upper eye lid. According to an anonymous report obtained by the Department, Patient A had been physically abused. On June 21 2011 an unannounced visit was made to the facility to investigate an injury of unknown cause, which had been reported to the Department as "abuse" by an anonymous caller. Patient A was an 87 year old male admitted to the facility on April 20, 2011, with the following diagnoses: history of falls, generalized pain and chronic kidney disease. The clinical record for Patient A was reviewed on June 21, 2011. The MDS (Minimum Data Set, an assessment of Patient A's health.) dated May 15, 2011, indicated that Patient A did not have a memory deficit. The "Nurse's Notes" dated May 30, 2011, indicated, "Patient has bruising around left upper eye lid. PT (patient) does not know where it came from." The "Nurse's Note" dated May 30, 2011, at 10 PM, indicated, "On observation for bruising to left eye of unknown origin." During an interview with LVN 1 (Licensed Vocational Nurse), on June 21, 2011 at 10:30 AM, she stated, "I remember his black eye, I got a report of the change of condition. He was not confused but he was not aware of how it happened. I asked Patient A how it happened, he said I don't know. When his eye was open you could see the red area, about one third to one half of the eye lid dark red and purple." During an interview with CNA 1 on June 21, 2011 at 10:40 AM, she stated, "Yes I remember his black eye. I was off on the 30th and the day before, on the 28th he had no eye problem. I observed bruising reddish/purple over most of his eye lid and above the eye was bruised. He said he did not remember how it happened. He was not combative during cares." The DON (director of nurses) reviewed the clinical record and was unable to find documentation that Patient A's physician had been notified of his black eye. The facility's policy and procedure titled "Change of Condition/Notification" dated April 2005 included the following. "Licensed Nurse will notify MD/legal representative or an interested family member when there is an: a. incident/accident." On June 21, 2011 at 10:00 AM, the DON stated, "No I didn't investigate it. I didn't get an incident report and I was unaware of any bruise.' The policy and procedure titled "Incident and Accident Reporting" dated April 2005, stipulated the following. "It is the policy of this facility, that all accidents/incidents involving resident...will be accurately and completely reported on the facility incident report form, documented, investigated and analyzed." The policy included the following instructions. "When resident...incident occurs, the employee making the discovery shall initiate the completion of the incident report form." "Staff member making the discovery shall notify his/her immediate supervisor." "Supervisor will notify the director of nurses and/or administrator of any serious injury." "Licensed Nurse will document when physician and responsible party was notified." During an interview with the Administrator on June 21, 2011 at 10:00 AM, she stated, "I didn't know about it, so it wasn't reported. If after an investigation if we couldn't find out why, we would have reported it, but no investigation was done because we didn't know about it." The policy and procedure titled "Abuse, Protection from and Reporting" dated April 2005, also stipulated, "INVESTIGATION: 1. Any incident of unknown cause or origin will initiate notification to the Department of Health within 24 hours." Based on the information obtained, the facility failed to notify the Department of Patient A's black eye, even though the injury was secondary to an alleged abusive incident. |
| 240001011 |
Apple Valley Post Acute Center |
240009279 |
B |
04-May-12 |
TKIP11 |
5652 |
REGULATION VIOLATION: Title 22 72527 Patient's Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse.The facility failed to protect a patient from abuse, by employing a staff member who had previously been terminated for substantiated complaints of abuse and had seven allegations of abuse between January 3, 1999 and January 7, 2011.An unannounced visit was made on April 11, 2011 at 11:55 AM to investigate an entity reported event.A review of Patient 1's record, conducted on April 11, 2011 at 2:50 PM, revealed that Patient 1 was a 94 year old female admitted to the facility on October 13, 2010 with diagnoses of cellulitis (a deep tissue infection) and chronic kidney disease. Patient 1 was discharged home on January 21, 2011.Further review of the record revealed that Patient 1's responsible party, and power of attorney was her son. Review of the minimum data set (a standardized assessment tool), dated December 13, 2010, revealed that the patient was independent with daily decision making, and cognitively intact.On April 11, 2011, review of the facility's investigation report revealed that on January 8, 2011, Patient 1 complained to the day shift nurse that her night shift CNA (certified nursing assistant) threw her pajamas at her when she requested a different pair. Review of "Termination of Employment" documentation dated January 13, 2010 (other dates state 2011), showed the employee was terminated for, "inappropriate physical approach or response to residents" and, "failure to follow facility policy and procedures, failure to follow state and/or federal regulations".On April 11, 2011, review of the employee file for the CNA revealed an "Employee Counseling Notice" dated February 22, 2001 for leaving a patient on a bedpan for long periods of time, leaving a "bright red indentation".Further review revealed that the employee had been terminated on July 12, 2001 for, "disrespectful behavior" and that the patient's allegations that included the employee waving a glove in her face and telling her to go to sleep, had been corroborated by the patient's roommate.Further review of the CNA's employee file revealed an absence slip for a sick day dated September 15, 2001. On August 30, 2011 at 10:20 AM, per request, the Director of Nurses (DON) was unable to provide the facility's payroll information for 2001.The CNA's employee file contained a Job Description for a Certified Nursing Assistant, signed and dated (December 20, 2001) by the CNA that included responsibilities and duties including, "always being mindful of Resident's rights", and, "provid[ing] care...in a respectful manner".On April 11, 2011, review of the employee file for the CNA revealed an "Employee Counseling Notice" dated December 11, 2003 for putting multiple pads on patient's beds and putting a sheet between their legs, putting patients at risk for skin breakdown.Furth review of the employee file for the CNA revealed an "Employee Counseling Notice" dated December 17, 2003 for handling the patients in a "rough" manner. The employee was moved to day shift, so that supervisory staff could monitor her care and train her on how to handle patients.On April 11, 2011, review of the employee file for the CNA revealed an "Employee Counseling Notice" dated January 6, 2004 for failure to clean patient's nails or do good oral care. The facility's expectations were that the CNA would provide care according to company standards.A "Suspicion and Investigation Notice" dated February 9, 2009 was reviewed in the employee's personnel file on April 11, 2011. The document revealed an allegation of abuse reported by a patient's family member. The document showed that the employee was reinstated on February 10, 2009 because the facility could not substantiate the claims. The facility was unable to provide documentation that described the specific allegations.An interview with the DON on August 30, 2011 revealed that there was no paperwork in the employee's file that explained why she was still employed at the facility after being terminated in 2001. She also stated that the alleged substantiated allegations against the employee at that time would be considered physical abuse.On October 11, 2011, and interview with the Administrator confirmed that there was no documentation as to why the employee was still employed at the facility following her termination in 2001. She stated that there were no employees who would know, and the management team had changed. The administrator stated that the last DON, "really cleaned house".On October 11, 2001, review of the facility's policy and procedure titled, "Abuse, Protection from and Reporting", dated April, 2005, revealed: "It will be the policy of this facility to fully protect the rights of the individuals for whom we provide care and treatment; and form of abuse and neglect will not be tolerated"."The facility will enforce a policy of non-tolerance of any form of behavior that might be construed as abuse by any resident, family member, staff member, visitor, volunteer, student, or other persons."The violation was determined to cause or under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to the patient. |
| 240000106 |
Arrowhead Healthcare Center, LLC |
240012702 |
A |
31-Oct-16 |
None |
9766 |
REGULATION VIOLATION: Title 22 72311(a)(3)(G) (a)Nursing shall include, but not limited to, the following: (3) Notifying the attending physician promptly of: (G) The facility?s inability to obtain or administer, on a prompt and timely basis, drugs, equipment, supplies, or services as prescribed under conditions which present a risk to the health, safety or security of the patient. The facility failed to ensure that Patient A who had a history of, ?jumping in front of a moving vehicle,? and sustaining a fractured right ankle at her previous skilled nursing facility (SNF 1) was provided with services to include ongoing monitoring and reassessment to ensure Patient A did not elope from the facility, or engage in self-harming behaviors. This failure resulted in one sampled patient (Patient A) eloping from the facility and not being located for (4) four days and when found, being admitted to a General Acute Care Hospital (GACH). During a phone interview with the Assistant Administrator (AA) on April 12, 2016 at 5:00 PM, to investigate an entity reported incident of a patient elopement, she stated on April 11, 2016 at 8:30 PM, a License Vocational Nurse (LVN 1) was taking nourishments and medications to Patient A's room and discovered Patient A was missing. The facility staff searched for Patient A inside and outside the facility, but were unsuccessful. The AA stated local law enforcement was contacted and a missing person's report was made. During a follow up phone interview with the AA on April 14, 2016 at 2:24 PM, she stated Patient A still had not been located and her whereabouts were unknown, a total of three (3) days after elopement. The AA stated Patient A was admitted to the facility for treatment of an open area to the right shin after Patient A sustained a right leg fracture, as a result of jumping in front of a car, at a prior facility placement. Patient A had a soft cast (flexible fiberglass casting material that is molded to the patient's injured limb), cam boot (brace in the form of boot) and walker, but the cam boot and walker were left behind when Patient A eloped from the facility. An unannounced visit was made to the facility on April 14, 2016 at 4:45 PM, to investigate an entity reported incident of an elopement for Patient A. During a review of the clinical record for Patient A, the face sheet (contains patient demographics) indicated Patient A was admitted to the facility from a general acute care hospital (GACH 1) on February 24, 2016, with diagnoses which included manic episode (moods that are beyond reason and cause major distress and life impairment), with severe psychotic symptoms (is a serious mental disorder characterized by thinking and emotions that are so impaired, that they indicate that the person experiencing them has lost contact with reality). Patient A was under conservatorship. A review of the physician?s admission history and physical from GACH 1, dated January 19, 2016, indicated, ??Apparently the patient (Patient A) had sustained a fracture of the medial malleolus (ankle) about one month ago. Apparently, she (Patient A) has provoked accident by jumping in from of a moving vehicle?? Under the section titled,? Plans and recommendations,? the physician documented: ? The patient will have a sitter at all times.? A further review of the skilled nursing facility (SNF 2) clinical record for Patient A was conducted. Under the section entitled, ?History and Physical," the record indicated Patient A did not have the capacity to understand and make decisions due to psychosis. A review of an unnamed document provided by the General Acute Care Hospital regarding attempts to place Patient A from January 19, 2016 through February 24, 2016, reflected the General Acute Care Hospital discharge planner had documented each time she had attempted to find placement for Patient A. An entry dated February 24, 2016 at 4:36 PM, by the General Acute Care Hospital discharge planner reflected she had received a call from (used first name only, no title was provided from the staff [Staff 1] at a sister long term care facility). The General Acute Care Hospital discharge planner documented Staff 1 requested ?Inter-facility form state that the patient (Patient A) does not have a one to one sitter, case manager made aware.? During an unannounced visit to the facility on April 14, 2016 at 4:45 PM, an interview with the AA was conducted. During the interview, the AA stated she was not aware that Patient A was an elopement risk at the time of admission and an elopement risk assessment was not done. The AA stated from the day of admission, Patient A had informed staff she wanted to leave the facility, and would tell the staff she knew what she had to do to leave the facility, such as jump in front of a car. The AA stated Patient A had a previous elopement attempt at the facility on March 30, 2016. The AA stated that after Patient A's elopement attempt on March 30, 2016, Patient A was placed on a one-to-one (1:1) observation (increased level of observation and supervision in which includes continuous one-to-one monitoring of the patient by facility staff). Patient A was on 1:1 observation from March 30, 2016 through April 11, 2016 at 10:13 AM, (a total of 11 days). The AA stated Patient A's 1:1 observation was discontinued and that routine every (2) two hour rounding was implemented. The AA stated there was no elopement risk assessment completed after Patient A's elopement attempt on March 30, 2016, and could not explain the reason an elopement risk assessment was not done. During an interview with a License Vocational Nurse (LVN 2) on April 14, 2016 at 6:51 PM, LVN 2 stated she was Patient A's nurse on March 30, 2016, when Patient A attempted to elope from the facility. LVN 2 advised that on March 30, 2016, Patient A had stated she did not want to be at the facility and was inquiring about how to leave the facility. LVN 2 stated, ?Patient A was found at the front gate attempting to elope from the facility and was brought back inside by the facility staff. LVN 2 stated after the elopement attempt, Patient A became aggressive and attempted to swallow a zipper head on March 30, 2016, following her elopement attempt from the facility. Patient A was then placed on 1:1 observation. LVN 2 was unable to verbalize the facility's protocol for continued observations of a patient after a 1:1 observation was discontinued. During an interview with the AA on April 14, 2016, at 7:41 PM, the AA stated there was no policy and procedure in place for staff to follow when a patient is being placed on a 1:1 observation which included the following information: a. What criteria will be used to place a patient on a 1:1 observation; b. What criteria will be used to discontinue a 1:1 observation; c. What would be the next level of observation to implement after a patient was removed from 1:1 observation. During an interview with the Director of Nurses (DON) on April 15, 2016 at 9:38 AM, she stated an Interdisciplinary Team meeting (involves clinical department heads) was not done or an elopement risk assessment completed after Patient A's elopement attempt on March 30, 2016. [The DON stated she did not know why an IDT meeting or elopement risk assessment were not completed and that, "I should have followed up." During an interview with the DON on April 15, 2016 at 1:23 PM, the DON stated Patient A was found around the corner from the facility at approximately 11:30 AM on April 15, 2016 (a total of 4 days from elopement). The DON stated Patient A was sitting on the sidewalk against a building, was delusional (having false ideas or beliefs that are caused by mental illness) and Patient A stated she could not walk. The DON stated 9-1-1 was called and Patient A was transported to the nearest hospital for medical treatment. The facility policy and procedure entitled, "Wandering Patients" dated August 2006, indicated: ?1. All patients who are at risk for harm because of wandering (elopement) will be assessed by the interdisciplinary care planning team...3. The patient?s care plan will be modified to indicate the resident is at risk for elopement episodes. Staff will be informed at shift change of the modifications in the patient?s care plan?6. If a resident repeatedly wanders off the unit, a monitoring schedule will be implemented to ensure safety. The patient?s care plan will be documented as to the implementation of the monitoring schedule?? The facility policy and procedure entitled, "Change in a Patient's Condition or Status," dated April 2007, indicated: ?1. The Nurse Supervisor or Charge Nurse will notify the patient?s Attending Physician or on- call Physician when there has been: a. An accident or incident involving a resident?2. A significant change of condition is a decline or improvement in the patient's status that a. Will not usually resolve itself without interventions by staff...c. requires interdisciplinary review and revision of the care plan..." The facility?s failure to ensure that Patient A who had a history of, ?jumping in front of a moving vehicle,? and sustaining a fractured right ankle at her previous skilled nursing facility (SNF 1) was provided with services to include ongoing monitoring and reassessment to prevent further elopement attempts resulted in Patient A eloping from the facility and not being located for (4) four days, requiring hospitalization when she was found. This facility failure presented either (1) imminent danger that death or serious harm to the patients or residents of the long-term health care facility would result therefrom or (2) substantial probability that death or serious physical harm to patients of the long-term care health care facility would result therefrom. |
| 240000106 |
Arrowhead Healthcare Center, LLC |
240012766 |
B |
30-Nov-16 |
CQRD11 |
9600 |
REGULATION VIOLATION: 72527. Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse. The facility failed to protect Patient A from verbal and sexual abuse when a facility staff member, a certified nursing assistant (CNA 1) was overheard to state, "He (Patient A) is hung like a horse," and was witnessed by CNA 4 to stroke Patient A's penis when Patient A did not have the physical or mental ability to give consent or the ability to move CNA 1's hand off his penis. On September 28, 2016 at 2:15 PM, an unannounced visit was made to the facility to investigate an entity reported incident regarding verbal and sexual abuse towards Patient A. During an interview with a Licensed Vocational Nurse (LVN 1) on September 28, 2016 at 2:15 PM, she stated that on September 22, 2016, it was reported to her that the facility Psychologist overheard a conversation between two Certified Nurse Assistants' (CNA 2 and CNA 5) on the 3-11 shift who stated that CNA 1 was being sexually inappropriate with Patient A and CNA 1 had made a statement, "He (Patient A) is hung like a horse." LVN 1 stated CNA 1 was suspended pending investigation of alleged abuse against Patient A, per the facility policy. During an interview and concurrent record review with LVN 1 on September 28, 2016 at 2:30 PM, she reviewed the personnel file for CNA 1 and was not able to find documentation to show the abuse training as being completed in 2015, and was not able to find a completed criminal back ground check prior to CNA 1 being hired. On September 28, 2016, a review of Patient A's clinical record indicated on the Admission Face sheet a 60 year old male with an admission date of July 23, 2015, and diagnoses that included: bipolar disorder (a mental disorder with periods of depression and periods of elevated moods), mild cognitive disorder (a mental disorder) and unspecified dementia (a chronic or persistent disorder of the mental process) without behaviors. The Annual Assessment Form, dated July 31, 2016, indicated Patient A did not have the capacity to understand and make decisions. During an Interview with CNA 2 on September 28, 2016 at 3:30 PM, when asked about the event that happened to Patient A, CNA 2 stated, I think it was on a Tuesday or Wednesday a few weeks ago on the 3-11 shift. I was walking down the hall when CNA 1 opened the door of Patient A's room screaming for another aide to come down and help her. When I went over towards that room CNA 3 was coming out of the room shaking her head. I asked her what is wrong and she said, "it's ok." I then looked into the room and saw CNA 4 holding Patient A's hands and heard CNA 1 say "He (Patient A) is hung like a horse." CNA 2 then stated, "I was scared to report overhearing the statement by CNA 1 so I did not say anything; I should have reported it to the Charge Nurse, the Director of Nursing, or Administrator." During an Interview with CNA 5 on September 28, 2016 at 3:45 PM, when asked about the event that happened to Patient A, she stated, I think it was on a Sunday a few weeks ago on the 3-11 shift. CNA 5 said I was in the patient's room taking care of the patient assigned to me when I heard CNA 1 laughing and saying to CNA 4 "He [Patient A] is hung like a horse and started to stroke his penis." CNA 5 said I yelled "Stop, I was shocked." CNA 5 stated, I did not report it right away because I was afraid of CNA 4 and the other aide, might retaliate against me. On September 29, 2016 at 3:25 PM, Patient A was observed located next to the bed in his room. Patient A was sitting in his wheel chair, leaning over a lap buddy (a safety device that hooks into the arms of a wheel chair across a residents lap to prevent him/her from standing unassisted), with his eyes closed. The Licensed Vocational Nurse (LVN 1) called his name and Patient A was observed to open his eyes and sit up straight in the wheel chair. The surveyor asked Patient A, "Are you ok? He did not respond. The surveyor then asked Patient A if there was anything he needed, he again did not respond. During an Interview with CNA 4 on September 30, 2016 at 4:30 PM, when asked have you ever been assigned to take care of Patient A, she stated, "Yes, he is very quiet and he does not say much." CNA 4 said, he is not too difficult to take care of, but it helps if someone "holds his hands" because it keeps him from walking around the room as we are changing him (changing the adult brief). When asked about the event that happened to Patient A, CNA 4 stated, "I was on vacation from August 23, 2016, to August 31, 2016, I returned to work on September 1, 2016, a Tuesday." She stated, I just do not remember holding his (Patient A) hands. CNA 4 said I never heard CNA 1 say anything derogatory towards him (Patient A). CNA 4 stated that when she was helping change Patient A she usually stands in front of him and holds his hands. During an interview with the Assistant Administrator (AA) on September 30, 2016 at 4:45 PM, she stated that CNA 1 was terminated due to the result of the facility investigation of abuse. When asked about the staff abuse training not being completed in 2015, she stated she was not aware that the training had not been completed for 2015. The AA stated that she was not aware that the back ground check for CNA 1 had not been done. During a phone interview with the Psychologist on October 28, 2016 at 3:00 PM, she stated that she was informed of the event that happened to Patient A, by CNA 5. She said CNA 5 was upset that CNA 1 was stroking Patient A's large penis. The Psychologist said CNA 5 told her that she was afraid to report it due to CNA 1 having a large family of gang members. She further stated that CNA 5 also told her that she was afraid of some kind of retaliation by CNA 1. The Psychologist stated she immediately reported the event to the Director of Staff Development (DSD) but did not remember the date. On November 2, 2016, the personnel file for CNA 2 was reviewed and indicated the last abuse training was provided and competed on June 30, 2016. There was no documented evidence to show that a criminal back ground check for CNA 2 had been completed prior to hire. During an interview with the DSD on November 2, 2016 at 11:00 AM, she stated the "Abuse training is completed once a year and during orientation for new employees." The DSD stated, "The back ground checks are completed when hired and annually thereafter." During an interview with the DSD on November 2, 2016 at 11:40 AM, she reviewed the personnel file for CNA 2 and was able to find documentation for completion of abuse training as being completed in 2016. She was not able to find a completed criminal back ground for CNA 2 prior to being hired. On November 2, 2016, the personnel file for CNA 5 was reviewed and indicated the last abuse training was provided and competed on September 2, 2014, however there was no evidence to show a criminal back ground check for CNA 5 had been completed prior to hire. During an interview with the Director of Staff Development (DSD) on November 2, 2016 at 11:40 AM, the personnel file for CNA 5 was reviewed. The DSD confirmed there was no documentation to show that the abuse training was completed in 2015, and no completed criminal back ground check prior to CNA 5 being hired in 2001. A review of the facility policy and procedures entitled, "Reporting Abuse", undated, indicated, "Procedure I. Mandatory Reporters: i. Facility owners, operators, employees, managers, agents, and contractors are obligated by the Elder Justice Act and California Abuse and Dependent Adult Civil Protection Act to report known or suspected incidents of abuse of elder or dependent adults." Section VI. Notice to facility staff, "Facility staff members will annually, receive a notice of their obligations to comply with the law and the facilities policy and procedures." CNA 1 and CNA 3 have signed documented training for mandated reporting requirements in their employee file. CNA 2 and CNA 5 have no currently signed documented evidence of training for mandated reporting requirements in their employee file. A review of the facility's policy and procedures entitled, "Patient Abuse and Prevention", indicated, "I. Screening: Prior to hiring of an employee, facility shall ensure provisions covering employment screening for potential history of abuse, neglect or mistreatment of residents....making appropriate inquires to applicable licensing boards and registries, criminal background check for those offered a position in direct patient care." Section (S), "If the suspected perpetrator is a staff member, immediately place the staff member under administrative leave for three days or more..." Because the facility failed to implement their abuse policy and procedures Patient A's rights to be free from abuse were violated. Patient A was subjected to sexual abuse by CNA 1 and had the potential to be subjected to further abuse when the incident was not reported promptly. This violation has a direct or immediate relationship to patient health, safety, or security and produced a situation likely to cause significant humiliation, indignity, anxiety or other emotional trauma. |
| 240000106 |
Arrowhead Healthcare Center, LLC |
240013150 |
A |
26-Apr-17 |
CBC811 |
12954 |
REGULATION VIOLATION TITLE 22 72311 Nursing Service - General
(a) Nursing service shall include, but not be limited to, the following:
(3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of:
(B) Any sudden and /or marked adverse change in signs, symptoms or behavior exhibited by a patient.
TITLE 22 72523 Patient Care Policies and Procedures
(a). Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved.
The facility failed to provide timely care and services in accordance with facility policy and procedure for two (2) of 13 sampled patients (Patient 9 and 12) when:
1. For Patient 12, the charge nurse failed to notify the physician, endorse to the next shift, and document a fall incident. Patient 12 was diagnosed with a left hip fracture six (6) days after the fall incident occurred.
2. For Patient 9, the charge nurse failed to notify the physician and the Director of Nursing when the patient reported that her right knee was bumped into by another patient's wheelchair. There was no documented evidence to show that an incident report or investigation was completed. Patient 9 was diagnosed with a right femur fracture nine (9) days after the incident occurred.
1. During an interview with Licensed Vocational Nurse (LVN 3) on March 9, 2017 at 3:20 PM, she stated that last January 24, 2017 at 7:51 PM, she went to Patient 12's room to give her medications. Patient 12 was sitting at the edge of her bed. LVN 3 went to put on gloves and noticed Patient 12 began to slip from her bed. LVN 3 said she assisted her (Patient 12) in going down to the floor and she then alerted the closest Certified Nurse Assistant (CNA 7) and they both assisted Patient 12 back to bed.
During another interview with LVN 3 on March 9, 2017 at 3:30 PM, she stated she made assessments and Patient 12 did not have any pain or injury. She further stated that the next shift was notified but no documentation was shown to indicate the assessment or notification to the Director of Nursing (DON) and the staff on the next shift was done at the time of the incident. She confirmed that lowering Patient 12 to the floor is considered an assisted fall and must be reported immediately to the Director of Nursing (DON).
During a phone interview with Licensed Vocational Nurse (LVN 1, incoming shift 11:00 PM to 7:00 AM charge nurse on January 24, 2017) on March 10, 2017 at 10:15 AM, she stated that she was not aware of the incident and no endorsement was made.
A review of the departmental (nurses' notes) notes, dated January 30, 2017 and January 31, 2017, indicated the following:
a. A late entry of the fall incident for January 24, 2017, was entered on departmental notes on January 30, 2017.
b. Patient 12 was transferred to an acute care hospital on XXXXXXXX 2017 at 5:30 PM, due to the swelling of her left upper leg.
A review of acute hospital's physician notes, dated January 31, 2017, indicated, "1.The patient has suffered a mechanical fall in which there was no loss of consciousness, resulting in a left hip intertrochanteric fracture (fracture of the upper part of the thigh bone) with dislocation."
A review of another facility's departmental notes revealed that "?Resident is post-surgery for left hip intramedullary rodding (a metal rod placed in the long bone to stabilize or treat a fracture)" prior to her return to the facility on XXXXXXXX 2017 at 10:54 PM.
A review of the clinical record of Patient 12 indicated that she was admitted to the facility on XXXXXXXX 2015, which included the diagnosis (identification of an illness) of aged related osteoporosis (thinning or weakening of the bones).
The facility policy and procedure titled, "Falls - Clinical Protocol", not dated, indicated that "Assessment and Recognition ? 5. The staff will evaluate and document falls that occur while the individual is in the facility."
A review of a facility policy and procedure titled, "Dealing with a Fall," undated, indicated that "Any fall needs to be investigated immediately (lowering a resident to the ground is considered a fall). You must do the fall risk assessment and post fall assessment. Slide the completed incident report under the DON office door."
A review of the facility's "Charge Nurse - "RN/LVN (Registered Nurse/Licensed Vocational Nurse)" specific job function of a charge nurse includes "? Gives thorough report to oncoming charge nurse and details changes in conditions, incidents, new orders etc."
2. A review of Patient 9's clinical record indicated Patient 9 was admitted to the facility on XXXXXXXX 2015, with diagnoses that included osteoarthritis (a form of arthritis involving the cartilage of the knee joint causing a gradual wearing away of the cartilage), schizophrenia (a mental disorder in which a person experiences symptoms, such as hallucinations or delusions, and mood disorders) and a history of right total knee replacement date of surgery 2002.
During an observation of Patient 9 on March 9, 2017 at 1:30 PM, Patient 9 was observed lying in bed with a leg immobilizer (an apparatus to prevent movement) on her right leg and a wound dressing over the right knee. Patient 9 was alert and oriented to place and person, answered questions appropriately, and was able to make needs known.
During an interview with Patient 9 on March 9, 2017 at 1: 35 PM, when asked what happened to her leg, she stated that someone bumped her knee with their wheelchair.
During an interview with Patient 9's family member on March 9, 2017 at 7:30 PM, she stated that no one informed her of the incident that happened on February 11, 2017, when Patient 9 was bumped on the right knee by another patient's wheelchair. The family member stated that when she visited her mom on February 19, 2017, she found the resident in bed with two (2) CNAs trying to help her up to a wheelchair. Her right knee was swollen and she was complaining of pain. The family member stated that the last time she saw her mother was about two weeks ago and she was able to stand with assist to a wheelchair. According to the family member, one of the CNAs told her, "I don't want to lie to you; but your mom was hurt on the right knee when it got bumped."
A review of the nurse's note for Patient 9, dated February 11, 2017 at 7:14 AM, by Licensed Vocational Nurse (LVN 1), indicated that the patient was complaining of right knee pain. Upon further assessment the resident stated that she was hit by another patient's wheelchair. Swelling was present.
During an interview with a Licensed Vocational Nurse (LVN 1), on February 14, 2017 at 10:30 AM, LVN 1 stated that she was the LVN on duty on February 11, 2017 at 7:14 AM, when the patient complained of pain in her right knee. LVN 1 said the patient stated that another patient's wheelchair bumped her on the right knee. The incident was unwitnessed. LVN 1 said the patient (Patient 9) complained of pain, and the right knee had more swelling than usual when she did the assessment. The patient was medicated for pain and she was placed in bed. LVN 1 stated that she did not initiate an incident report and further stated, "Now I know that I should have initiated one."
An interview was conducted with the Assistant Director of Nursing (ADON) on March 10, 2017 at 10:50 AM. The ADON stated that there was no investigation or incident report done for Patient 9 because the patient kept changing her story and giving conflicting stories. I did not know or I am not aware that we called and notified anybody when the incident happened.
A review of the physician's order for Patient 9, dated February 14, 2017 at 7:30 AM, indicated; "Resident may have x-ray (digital image of the internal composition of something) of knee two (2) views for pain." Result of x- ray reading on February 15, 2017 taken by {name of Laboratory facility} on February 15, 2017 indicated, "Right knee 2V (two views) there is a prosthetic right femoral in proper alignment ? There is no fracture or acute dislocation. "
There were no nurse's notes to review from February 15, 2017 at 6:18 PM through February 19, 2017. On February 20, 2017 at 2:36 PM, the nurse's note for Patient 9 indicated, Patient was having right knee pain 10/10 (pain level indicating severe pain). Patient's right knee was swollen and warm to touch. MD (Medical Doctor) notified. MD advised to send her out. Called AMR (Transport ambulance) and they transferred her to {name of hospital}.
A review of the acute hospital's Emergency Department (ED) notes for Patient 9, dated February 20, 2017 at 12:05 PM, indicated, "Chief complaint: right leg swelling, pain to touch and movement. Per EMS (Emergency Medical Services) patient's knee was bumped by another wheelchair at the facility."
A review of the ED physician's note for Patient 9, dated February 21, 2017, indicated, "X-ray of the right knee showed, fracture of the distal diaphysis of the femur with angulation at the fracture site, displacement and override of the fracture fragments as well" (Fracture of the thighbone that occur just above the knee joint). Surgery was advised but the resident's daughter declined at that time."
A consult interview was conducted with the Radiologist (a medical doctor that specializes in diagnosing and treating diseases and injuries using medical imaging techniques) at {name of laboratory facility} on March 14, 2017 at 12:15 PM, who stated, "That it is possible that the fracture could have been blocked by the right knee prosthesis (artificial body part) on the first x- ray, that's why the fracture was not seen on the x-ray taken on February 15, 2017, and there was no follow up x-ray done for comparison."
A review of the nurse's notes for Patient 9, dated February 22 to February 27, 2017, showed the patient continued having pain and was medicated with routine MS Contin (an extended release form of morphine, a narcotic used for pain) 15 mg (milligrams), and Tylenol 650 mg, added as a new medication for pain. Patient was dependent with transfer.
An interview was conducted with a Restorative Nursing Assistant (RNA 1) on March 14, 2017 at 3:15 PM. RNA 1 stated, "Before February 11, 2017 the patient was not complaining of pain during RNA, but starting on the 11th of February 2017, she was complaining of pain in her right leg, so I did not perform exercises on the lower extremities. I only perform exercises on the upper part of the body."
Patient 9 was taken to {name of Ortho. Clinic} accompanied by a staff member on February 28, 2017 for appointment. A review of physician's progress notes dated February 28, 2017, indicated, "Long spiral fracture extending along the distal diaphysis (the shaft of a long bone) to the prosthesis. Surgery was recommended STAT (as soon as possible) ORIF (An open reduction internal fixation- refers to a surgical procedure to fix a severe bone fracture) was performed at {name of hospital} on February 28, 2017.
An interview was conducted with the facility Administrator in the presence of the Director of Nursing on March 10, 2017 at 4:30 PM. The Administrator stated that the incident of fracture did not occur in the facility, that's why there was no investigation done and there was no incident report generated. The Administrator further stated that the fracture could have happened in the ambulance or at the hospital. The DON stated that there was no assessment done upon return to the facility from {name of hospital} because the patient (Patient 9) came back to the facility in less than 24 hours.
A review of the facility's policy and procedure titled, "Unexplained Injuries- Investigation," dated January 1, 2012 indicated, "Purpose: to protect the health and safety of our residents by ensuring that all unexplained injuries are promptly and thoroughly investigated and addressed. Procedure: 1. If a resident is observed with unexplained injuries, the Charge Nurse on duty will complete AN-08-Form A-Incident & Accident Report Form and record such information into the resident's medical record. II. Documentation must include information relevant to risk factors and conditions that causes or predisposes someone to similar signs and symptoms (e.g. receiving anticoagulants, having osteoporosis, having movement disorder ?). III. The nursing staff will discuss the situation with the Attending Physician or Medical Director to consider whether medical conditions or other risk factors could account for the findings."
Based on the information obtained, the facility failed to provide timely care and services when the facility did not follow their policy and procedure regarding a fall and an injury of unknown origin.
This facility failure had a direct or immediate relationship to the health and safety of the patients. |
| 240000106 |
Arrowhead Healthcare Center, LLC |
240013280 |
A |
15-Jun-17 |
None |
8434 |
REGULATION VIOLATION
A Citation-ERI-CA00510652
Title - 22 72523(a) ? Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved.
On November 15, 2016 at 2:00 PM, an unannounced visit was made to the facility to investigate an entity reported incident regarding a patient elopement from the facility.
The facility failed to provide adequate supervision to prevent 1 of 2 sampled patients (Patient A) elopement as evidenced by not implementing the every 15 minute observation checks as per the facility policy and procedure for patients who are at risk for elopement. This failure contributed to the patient eloping from the facility and placing him at risk for serious harm.
During an interview with the Assistant Director of Nursing (ADON) on November 15, 2016 at 2:15 PM, she stated, they did not know how he [Patient A] exited. She said the Licensed Vocational Nurse (LVN 1) said she locked the doors at 5:00 PM, but stated that the patient [Patient A] was gone prior to that. Patient A was not found when the dinner trays were passed at 5:00 PM.
A review of Patient A's clinical record showed he was admitted to the facility on XXXXXXX 2016, with diagnoses which included epilepsy (seizure disorder), hypertension (high blood pressure), Type II diabetes mellitus (blood glucose levels above normal), dementia (gradual decrease in the ability to think and remember), COPD (a group of respiratory diseases of the lungs), and muscle weakness.
A review of Patient A's History and Physical dated November 14, 2016, showed the patient has fluctuating capacity to understand and make decisions, but can make immediate needs known.
A review of the Nurse's Notes for Patient A, dated October 13, 2016 at 18:45 [6:45 PM], documented Patient A stated, "Can't I just walk to my mom's from here, she lives right here," patient continued to repeat "My mother is dead" and stated, I live in her house. I have to go see her house now.
A review of the Nurse's Notes for Patient A, dated November 11, 2016 at 7:11 PM, reflected at 5 PM the charge nurse went to lock the doors and check on all patients with Q (every) 15 (minutes) checks. The nurse found out that the patient was not in his room. Staff then spread out to look for the Patient A and could not find the patient.
During an interview with the Director of Nursing (DON) on November 15, 2016 at 3:10 PM, when asked why Patient A was placed on Q 15 minute (every 15 minutes) observation checks beginning November 2, 2016, she stated, we had the LVNs complete an elopement risk assessment on all of the patients. She said we started the Q 15 minute checks for the ones deemed at risk.
During an interview with Certified Nurse Assistant (CNA 3), on November 15, 2016 at 4:25 PM, who worked the afternoon shift on November 11, 2016, CNA 3 stated, "I did see him when we were passing out waters at 3:45 PM, he [Patient A] was in his room standing by the window."
During an interview with Certified Nurse Assistant (CNA 4), on November 15, 2016 at 4:30 PM, who worked the afternoon shift on November 11, 2016, CNA 4 stated, "..dinner trays were already out and were being passed. . . I personally did not see him . . he was the type of person to be on heightened alert, he had not tried to leave prior, but would stand at the doors watching during the change of shifts."
During an interview with the Certified Nurse Assistant (CNA 5), on November 16, 2016 at 11:00 AM, who worked the afternoon shift on November 11, 2016, CNA 5 stated, Patient A's dinner time was 5:15 PM, and it was noticed then that he was not in his room. CNA 5 further stated, Patient A is always in the hallway and she did not see him that afternoon.
During an interview with LVN 2, on November 17, 2016 at 11:30 AM, who worked the afternoon shift on November 11, 2016, LVN 2 stated, " . . I had not seen him that day . . .normally he follows someone asking to leave at least every other day . . . he also carried around an envelope that had an address, and said his mom was passed away and wanted to go there. . ."
A review of Patient A's "Elopement Risk Assessment" dated October 31, 2016 at 8:08 PM, showed the assessment was not done until 18 days after Patient A?s admission. The Elopement Risk Assessment listed Patient A?s diagnoses and had items to check off for specific patient behaviors. Under the behavior section, ?ANGER REGARDING FACILITY PLACEMENT? was checked. The nurse answered ?YES? to the question? BASED ON ASSESSMENT, DOES RESIDENT (Patient) PRESENT AN ELOPEMENT RISK? There was no specific guideline on what constitutes an elopement risk.
A review of Patient A's "Wandering Care Plan" (not dated and not signed) indicated the following approaches: Place patient in area where constant observation is possible. Do not allow patient to leave facility. Place patient on Q 15 minute observation.
In an interview with LVN 1 on April 12, 2017 at 1:35 PM, she stated that it was the "CNA?s responsibility to do the Q 15 minute checks and it is the LVN?s responsibility to make sure the CNA does them.?
A review of the "Resident Q 15 Minute Observation Record" for Patient A, showed the 15 minute observation checks were done by the staff of Patient A's presence in the facility beginning November 9, 2016 at 6:30 AM and ending November 10, 2016 at 6:15 AM, and November 10, 2016 beginning at 6:30 AM ending November 11, 2016 at 3:40 PM. There was no documentation to show the 15 minute check observations were done after 3:40 PM on November 11, 2016.
In an interview with LVN 1 on April 12, 2017 at 1:35 PM, she stated that (name) CNA 5 was assigned to Patient A and she did not do them (the Q 15 minute checks). She stated it was the CNA?s responsibility to do the Q 15 minute checks. She stated the LVN does not do them, it is the LVN?s responsibility to make sure the CNA does them. She stated she checks the CNA?s Q 15 minute form at the end of the shift. She did not explain why she did not sign the CNA?s Q 15 minute check form on November 15, 2016.
In an interview with ADON on April 12, 2017 at 1:35 PM, she stated she did not know why the Q 15 minute checks were not done. She stated, ?I wasn?t here.? She stated it was the CNA?s responsibility to do the Q 15 minute checks. She stated ?I don?t do them [the Q 15 minute checks], The LVNs don?t do them.? When shown the Q 15 minute check sheet for November 15, 2016, and asked why her initials for the Q 15 minute checks from 11:30 AM to 3:30 PM and signature were on the sheet, she stated she signed her initials for the checks because she ?Knew where he (Patient A) was.? A request was made to review the facility?s Policy and Procedure for the Q 15 minute checks. The policy was received. The ADON stated that the Admission Policy is the one they use for the Q 15 minute checks.
A review of the facility policy and procedure titled, ?Admission Elopement Risk Policy and Procedure,? undated, showed the following:
?Procedure:
The steps the facility will take to identify residents at risk for elopement on admission will include:
An Elopement Risk Observation report will be completed upon admission by admitting nurse.
Residents will be put on a Q (every) 15-minute watch for the first 72 hours of placement in the facility per MD (physician)/PSYCH (Psychiatrist) order. This will be documented on the Q 15-minute observation form and signed off at the end of shift by the charge nurse??
Patient A was last seen by a CNA (CNA 3) at 3:45 PM, and was not noticed to be missing until 5:00 PM, one (1) hour and 15 minutes after the last Q 15 minute check was done.
During an interview with the ADON on February 24, 2017 at 5:45 PM, she stated that the patient has not been found.
Therefore the facility failed to implement their policy and procedure for ?Admission Elopement Risk? by failing to conduct the elopement risk assessment upon admission and did not do the every 15 minute watch (checks) after 3:40 PM, and the patient was not noticed missing until the dinner trays at 5:00 PM, were being passed, one (1) hour and 15 minutes after the last Q 15 minute check was done.
These violations presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 250000673 |
AFVW HEALTH CENTER |
250010258 |
A |
14-Nov-13 |
TPEP11 |
11558 |
Class A Citation 72311 (a) (1) (A) - Nursing Service-General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission.During the investigation of a complaint, initiated on July 31, 2008, it was determined the facility failed to develop a comprehensive plan of care based on a continual assessment of the care needs for Patient A. The facility failed to individualize Patient A's plan of care, and to incorporate input from the therapy services that were providing care and therapy to Patient A for the patient's fractured hip. This failure resulted in Patient A being left alone and unattended in the bathroom, falling and re-fracturing her right hip.Patient A, a female 85 years of age, was admitted to the facility on June 26, 2008, with diagnoses including: 1. Rehabilitation; 2. Aftercare for Internal Fixation Device of the Right Hip; 3. Aftercare for Traumatic Fracture of the Hip 4. Joint Replaced Hip; 5. Difficulty in walking; 6. Alzheimer's Disease; and, 7. Dementia without Behaviors.Patient A had previously sustained a fall at home and fractured her right hip, which required surgical repair and an acute care hospital stay of six days, prior to being admitted to the facility for physical and occupational therapy rehabilitation.On July 16, 2008, at 7:15 p.m., Patient A was assisted to the bathroom for toileting by a certified nursing assistant (CNA 1). CNA 1 placed Patient A on the toilet, then left Patient A alone and unattended in the bathroom while she provided care to other patients. Prior to leaving Patient A alone, CNA 1 directed Patient A to use the call light when finished and to just wait on the toilet until CNA 1 returned to assist her. When CNA 1 returned to the bathroom, she found Patient A lying on the floor. Patient A verbalized she had pain in her right hip. Patient A's condition was assessed and her rightleg was observed to be shorter in length. Patient A was not able to move her right leg. The physician was notified and Patient A was transferred to the General Acute Care Hospital for evaluation. Patient A was diagnosed as having a right periprosthetic subtrochanteric fracture (a fracture around the previous right hip replacement), which required surgical repair under general anesthesia and an acute care hospital stay.A review of the facility health record for Patient A noted a "Fall Risk Assessment" form, completed on June 26, 2008, that included the following: A. Level of Consciousness/Mental Status -- Disoriented x 3 at all times B. History of Falls (Past 3 months) -- 3 Or More Falls in past 3 months C. Ambulation/Elimination Status -- Chair Bound - And/or assist with elimination E. Gait/Balance -- N/A - not able to perform function G. Medications -- Takes 1 - 2 of these medications currently and/or within last 7 day(Anesthetics, Antihistamines, Antihypertensives, Antiseizure, Benzodiazepines, Cathartics, Diuretics, Hypoglycemics, Narcotics, Psychotropics, Sedatives/Hypnotics.) H. Predisposing Diseases -- 1 - 2 Present (Hypotension, Vertigo, CVA, Parkinson's disease, Loss of limb(s), Seizures, Arthritis, Osteoporosis, Fractures.)Patient A had a total score of 14 on the fall risk assessment. The instructions on the form directed, "If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. A prevention protocol should be initiated immediately and documented on the care plan."A facility "Resident Care Plan" was initiated on June 26, 2008, addressing Patient A's right hip fracture and surgical repair. The goal was documented as, the hip fracture will heal without complications and the patient will be able to go home. The "Approach/Plan" was listed as follows:* Provide a well lit environment to reduce anxiety of new place * Keep all personal belongings within reach on bedside table, ie: books, and telephone * Remind resident to use call light and ask for assist prior to transfers * Assess for side effects of medications * Keep bed in lowest position * Keep call light within reach at all times The only staff discipline listed on the care plan to implement the approaches was "Nursing". There were no interventions included that indicated it was permissible for the staff to leave Patient A alone or unassisted when Patient A was toileted.A "Nurse's Note" dated June 30, 2008, at 2100 hours contained documentation stating, "Resident found lying on floor near bathroom. Awake and alert. C/O (complaining of) mild - mod. (mild to moderate) pain. VS (vital signs) 99.4 (temperature) - 109 (pulse) -- 21 (respirations) - 94/59 (blood pressure). Large ecchymosis on outer mid (middle) (r) (right) thigh. Dark ecchymotic area noted 6" (six inches) below surgical incision on (r) hip. Resident states she lost her balance & (and) fell directly on (r) hip. Limited movement of (r) lower leg. No rotation displacement of foot Proximal (word crossed out) externally or internal noted. pt. (patient) transported as a unit by 4 staff back to bed. Dr. (Name) notified / Daughter notified. pt. sent to Riverside County Hospital ER for further assessment & treatment if indicated."A "Nurse's Note" dated July 1, 2008, at 0200 hours, contained documentation that Patient A was returned to the facility with no evidence of any new fractures, and included an order to follow up with orthopedics for evaluation of her hip surgery.Following Patient A's fall on June 30, 2008, the facility initiated a revised "Resident Care Plan" dated July 1, 2008. The "Problem" was listed as "Actual fall 6/30/08, found on the bathroom floor." The goal was listed as, "Resident will be free of injury QD x 90 days (daily times 90 days)".The Care Plan Approach/Plan listed the following: * Bowel and Bladder retraining program * Tabs mobility while in bed and wheelchair - (an alarm system that alerts the nursing staff when the resident tries to rise from the bed or wheel chair) * Lap buddy while in wheelchair (a soft padded device placed across the resident's mid-section that helps to position the upper body in an upright position) * Continue Rehab therapy * Encourage to attend and participate in daily group activities * Out of bed as tolerated * 1:1 (one to one) sitter per daughters request at night * Out of room as tolerated * Bed lowest position * Encourage family to sit with patientThe Minimum Data Set (MDS) Assessment initiated after Patient A's admission to the facility, dated July 7, 2008, described Patient A's cognitive skills for daily decision making as being severely impaired, and included short and long term memory problems, with memory recall ability being impaired. Patient A was assessed as being easily distracted and her mental functioning was noted to vary over the course of the day.Patient A's ability to understand others was assessed as "Sometimes Understands - responds adequately to simple, direct communication." Patient A was noted to require extensive assistance with her activities of daily living and had limited range of motion to one leg, including the hip or knee with a partial loss of voluntary movement.Registered Nurse 1 (RN 1) was interviewed on July 31, 2008, and stated she was on duty working the desk the night Patient A fell. RN 1 stated, CNA 1 was not the regular CNA on that unit and was covering for another CNA who was on her break. RN 1 further stated that CNA 1, "Really didn't know the patient very well, and she left her (Patient A) alone in the bathroom. It was a mistake." RN 1 stated, CNA 1 already had two other patients in the bathroom, so when Patient A put her light on to use the bathroom, CNA 1 responded quickly and put her on the toilet. RN 1 stated, CNA 1 told Patient A to use the call light because the patient "would use the call light a lot of the time". During the interview, RN 1 was asked if Patient A should have been left alone. RN 1 stated "No." RN 1 was asked what the process was when a CNA goes on break, do they share information with the CNA covering the assigned area? RN 1 replied, "You would think they would give each other a report, but I don't think that happened in this case."The Director of Nursing (DON) was interviewed on October 9, 2008. The DON was asked to provide a facility policy and procedure on Bowel and Bladder training, and a policy regarding the CNA care for a patient needing toileting assistance. The DON provided two policies for review: "Bowel and Bladder Training", and, "Assisting Resident to walk to the bathroom." Neither of the policies included any information addressing leaving a patient alone in the bathroom. The DON stated, "It's our responsibility for patient safety. I told them to never leave a resident alone in the bathroom. It's the expectation, especially for someone who has a history of falls and fractures."The Director of Rehabilitation (DOR) was interviewed on October 9, 2008. The DOR was asked how the therapy services communicated with the CNA's regarding a patient's limitations and level of care needs.The DOR stated, "We don't do in-services with all of the staff for each individual patient. If the CNA has questions on how to transfer, etc... then we will do individual training." The DOR was asked how the CNA's know not to leave a patient alone. The DOR responded, "I don't know. We rarely leave any patient alone in the bathroom." The DOR stated Patient A required assistance and he would never leave her alone. He stated Patient A was always going to be a fall risk because of her poor safety awareness. The DOR did not know how this type of information was communicated with the nursing staff.Patient A was admitted to the facility for rehabilitation therapy after sustaining a fractured hip from a fall at home. Patient A sustained another fall at the facility four days after being admitted. The facility identified that Patient A was a risk for falls and injury on the admission Fall Risk assessment form and the MDS assessment form. A care plan was initiated on Patient A's admission to the facility, and was revised after Patient A's fall in the facility on June 30, 2008. Neither of these care plans addressed not leaving Patient A alone and unattended when being toileted, due to her physical limitations and her decreased cognitive status. The facility did not provide training or communicate to the CNA staff the proper provision of care and safety concerns for individual patients identified with safety awareness issues.Patient A sustained a second fracture to her right hip due to being left unattended in the bathroom and falling. Patient A suffered increased pain, and the risk of complications including infection, skin breakdown, uncontrolled bleeding, respiratory failure, adverse drug reactions, and possibly death, due to the need for surgical repair of her fractured hip under general anesthesia. Patient A's level of independence, activities of daily living, and mobility were diminished by the fall and the repeat fractured hip, and her hospital stay and rehabilitation was prolonged.The violation of these regulations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 250000010 |
ALTA VISTA HEALTHCARE & WELLNESS CENTRE |
250010391 |
B |
30-Jan-14 |
SHYY11 |
4242 |
Health & Safety Code: 1418.91 (a) A long term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" citation. Title 22: 72527(a) Patients have the rights enumerated I this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To be free from mental and physical abuse. The facility failed to report immediately or within 24 hours to the California Department of Public Health (CDPH) that Patient 1 had allegedly touched Patient 2 and 3 inappropriately, and failed to protect and keep Patient 2 and Patient 3 free from Patient 1's inappropriate touching as reportedly happened on 8/6/10. On 8/13/10, the Facility Administrator (FA) reported to CDPH that Patient 1 had allegedly touched Patient 2 and 3 inappropriately on 8/6/10. On 8/17/10, at 2:45 p.m., an interview with the FA was conducted. He stated the facility staff reported to the Abuse Coordinator (AC) that Patient 1 had allegedly touched Patient 2 and Patient 3 inappropriately on 8/6/10, on separate occasions. On 8/17/10, at 3:35 p.m., the AC was interviewed. The AC stated Certified Nursing Assistant (CNA) A told the Housekeeping Supervisor (HS) that Patient 1 allegedly touched Patient 2 and Patient 3 inappropriately on 8/6/10. The HS reported the incident to the AC, the FA and the Director of Nursing (DON) three days after the incident had occurred.A follow up visit was conducted at the facility on 10/1/10. At 9:45 a.m., the FA was interviewed. The FA stated that after the incident's investigation was done, he believed Patient 1's alleged inappropriate touching on Patient 2 and Patient 3 had happened. The FA stated, "Why did the staff come forward and risk being suspended at work, if the incident did not happen? It did not make sense." On 10/1/10, at 10:10 a.m., the DON was interviewed. The DON stated the AC interviewed the facility staff who witnessed the incident. The DON stated CNA A observed Patient 1 touching Patient 2 on her thigh. On another occasion, CNA A saw Patient 1 touching Patient 2 on her crotch area. The DON stated CNA B saw Patient 1 touched Patient 3 on her crotch area. The DON further stated the Housekeeper saw Patient 1 touching Patient 3 on the chest, and then on the crotch area while in the dining room. Patient 2's record was reviewed. Patient 2 was admitted to the facility on 4/6/10, with diagnoses that included dementia (memory problems) and depressive disorder. The Minimum Data Set (MDS), an assessment tool, dated 7/26/10, indicated Patient 2 had short and long term memory deficits and cognitive skills for daily decision making was moderately impaired. Patient 3's record was reviewed. Patient 3 was admitted to the facility on 9/26/08, with diagnoses that included Alzheimer's disease, dementia, and depressive disorder. Further review of Patient 3's care plans included "Altered thought processes as manifested by impaired short and long term memory, impaired decision making, and dementia. Approaches plan included "provide reorientation to surroundings." On 9/6/11, a review of the facility's policy and procedure, "Responding to and Investigating an Abuse Allegation," read "For all Abuse Allegations...4. Report the alleged abuse to the appropriate state agencies in accordance with the law." Therefore, the facility failed: 1. To report immediately or within 24 hours to the CDPH's office that Patient 1 allegedly touched inappropriately Patient 2 and Patient 3 on 8/13/10, seven days after the incident. 2. To protect and keep Patient 2 and Patient 3 free from Patient 1's inappropriate touching as reportedly happened on 8/6/10. The above violations caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety or other emotional trauma to Patients 2 and 3. |
| 250000015 |
ARLINGTON GARDENS CARE CENTER |
250010606 |
B |
10-Apr-14 |
TYCS11 |
6576 |
T-22 72311 Nursing Service (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. The facility failed to implement Patient A's care plan for falls when staff did not assist Patient A to get out of bed. When Patient A attempted to get out of bed independently, the bed alarm (a device that sounds an alarm when a patient changes position from lying down to sitting or standing) did not work properly to produce an alarm to alert staff that Patient A attempted to get out of bed. These failures resulted in Patient A?s fall that caused the patient?s neck fractures. The fractures caused the patient to have an increase in pain and weakness and require assistance to go from a minimum one person assist to a maximum two person assist after the fall.On June 7, 2011, an unannounced visit was made to the facility for the purpose of investigating an entity reported incident that indicated a patient had fallen getting out of bed and sustained a neck fracture. Patient A's record was reviewed. The record indicated Patient A, an 89 years old male, was admitted to the facility on January 8, 2010, and readmitted on September 16, 2010. Patient A had diagnoses including congestive heart failure (the heart cannot pump enough blood), muscle weakness, and osteoarthrosis (arthritis of the joints).The physician orders, dated September 16, 2010, indicated that a bed sensor alarm was to be used while Patient A was in bed due to a history of falls.The functional skills instruction sheet, dated February 10, 2011, indicated Patient A required one-person assistance for transfers. The care plan for falls, initiated on September 16, 2010, had approaches (interventions) including, "Encourage resident to ask for assistance ....[and] Bed alarm sensor alarm."The record further indicated that the patient was capable of making decisions. A nurse's note, dated April 25, 2011, at 4:45 a.m., indicated Patient A was found on the floor in his room. Patient A was bleeding from lacerations (torn skin) on his nose and forehead. Patient A was transferred to the hospital. The emergency room treatment summary, dated April 25, 2011, indicated Patient A sustained head and cervical (neck bones) trauma with a fracture of the C1, C2 (C--cervical; C1--connects the skull and backbone; C2--the part of the neck that allows head movement) vertebrae.On June 7, 2011, at 9:30 a.m., Patient A was interviewed, with a staff member translating from Spanish to English. Patient A said that he did stand a little before the fall, but does not stand up now. He said he does work with physical therapy, and that it is "hard," but he "does it." Regarding the fall, Patient A stated he was sitting on the edge of the bed, bending down trying to get his shoes that were on the floor when he fell. Patient A stated, "There is nobody here at night." An interview was conducted with the Director of Nursing (DON) at 9:25 a.m. The DON stated the staff had reported responding to a "thump." She said that later on the same morning, the bed alarm was tested by maintenance and was found to be functioning. At 10:35 a.m., physical therapy (PT) was interviewed. PT stated that Patient A had required minimal assistance with transfers prior to the fall but required maximum assistance with a two person assist on April 29, 2011, when Patient A returned to the facility from the hospital. The facility clinical policy, entitled "Fall Policy and Procedure Manual Protocol," was reviewed on June 7, 2011. The policy indicated, "The nursing function in fall prevention includes, but is not limited to...H. Providing timely intervention to minimize risk." On September 1, 2011, at 2:34 p.m., the certified nursing assistant (CNA 1) on duty at the time of the incident was interviewed. CNA 1 stated, "I was in there [Patient A's room] about 15 minutes before checking him ....He wanted to get up. I said to him, ?Give me some more time. I'm doing my rounds checking on everybody. I'll be back in a few minutes." CNA 1 stated the light on the bed alarm was blinking, indicating it was on. CNA 1 stated she continued checking on everybody, and she said that in "5-15 minutes" she heard "a boom, like a fall," coming from Patient A's room. CNA 1 stated that she "ran to his room" and found Patient A lying on the floor. CNA 1 stated, "He disobeyed me. He did not want to wait for me to get him up. He usually doesn't get up by himself without assistance [when I'm working]." CNA 1 stated, "I didn't hear the alarm. I just heard the boom ...." At 3:14 p.m., the licensed vocational nurse (LVN 1) on duty at the time of the incident was interviewed. LVN 1 stated, Patient A "was awake, and he was trying to get out of the bed. It was too early, so he went back to sleep. Then, after 30 minutes, we heard a loud noise. The CNA called me. We found him on the floor ....There was blood all over his face." LVN 1 stated, "There was a bed alarm. I don't know what happened ....it doesn't go off ....but it was on ....The other nights, the alarm went off."According to "Early Morbidity and Mortality Associated with Elderly Odontoid (the peg-shaped process projecting from the second neck bone ? C2, on which the first neck bone ? C1 moves and rotates) Fractures" (June 2012; France, Power, Emery, and Jones; Orthopedics, 48.6% of 37 patients experienced complications, including three deaths. According to "Mortality in Elderly Patients After Cervical Spine Fractures" (March 2010, Harris, Reichmann, Bono, Bouchard, Corbett, Warholic, Seim, Schoenfeld, Maciolek, Corsello, Losina, and Katz; Journal of Bone and Joint Surgery), who analyzed 640 patients, 19% died within three months, and 28% died the first year. Therefore, the facility failed to implement Patient A's care plan for falls when staff did not assist Patient A to get out of bed. When Patient A attempted to get out of bed independently, the bed alarm (a device that sounds an alarm when a person changes position from lying down to sitting or standing) did not work properly to produce an alarm to alert staff that Patient A attempted to get out of bed. These failures resulted in a fall that caused Patient A?s neck fractures. The fractures caused the patient to have an increase in pain and weakness and to require increased assistance level from a minimum one person assist to a maximum two person assist after the fall. The following violation had a direct relationship to the health, safety, or security of Patient A. |
| 250000673 |
AFVW HEALTH CENTER |
250010610 |
B |
10-Apr-14 |
None |
3686 |
Class B Citation Title 22: 72315 (b) Title 22: 72315 Nursing Service-Patient Care. (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind.The facility failed to ensure Patient A was free from verbal and physical abuse by failing to ensure CNA 1 (Certified Nursing Assistant) did not verbally and physically abuse the patient, when CNA 1 stated "Nice a..(Actual word used) baby, and slapped the patient on the buttocks. An unannounced visit was made to the facility on April 24, 2013, at 2:20 p.m., to investigate an entity reported incident that Patient A had been verbally and physically abused by CNA 1. The record for Patient A was reviewed on April 24, 2013. Patient A was a 91year old female who was admitted to the facility on September 26, 2003, with diagnoses that included stroke and dementia (a deterioration of mental functioning). The facility document entitled "History and Physical Examination" dated April 9, 2013, indicated that Patient A was non-verbal (unable to speak) and dependent on staff for transfers, dressing, personal hygiene and bathing.An interview was conducted with the Director of Staff Development (DSD) on April 24, 2013, at 2:50 p.m. He stated that on April 17, 2013, at approximately 4 p.m., the instructor of the college students informed him that two students had witnessed CNA 1 "Spank the patient's (Patient A) buttocks," and made a comment, "Nice a.. (Actual word used) baby." The facility's investigative report indicated there was a written statement from Student 1. The undated statement indicated the following, "As I was holding the patient (Patient A) who was facing me and was on her side. ...(Student 2) was cleaning the patient who had her brief off and I had one hand on the patients back. The other hand was on her hip. ...(CNA 1) then stated " She has a nice butt" and then slapped the patients buttox. That made a loud slap sound and made the patient jerk, tense up, and tighten her hands... Then ...(CNA 1) upon slapping her buttock grabbed her buttock and squeezed it saying "Don't you baby". I noticed the patient getting tense, grinding her teeth ...(I) asked her are you ok?" On April 24, 2013, at 4:40 p.m., an interview was conducted with CNA 2. CNA 2 stated that she was "Partnered" with CNA 1 (to care for patients) "Cause I am new," on April 17, 2013. CNA 2 stated that around 2 p.m., she went into Patient A's room with two students and CNA 1. CNA 2 stated "We had the resident's (Patient A) diaper off and she was turned on her side. ...(CNA 1) came by and slapped the resident on her bare butt. The resident said "Ouch" so I knew that he hurt her. ....The next day I went and spoke to the DSD around 6 a.m. and told him what happened."During a review of CNA 1's personnel file on April 24, 2013, the document titled "Disciplinary Action Form" dated December 17, 2010, indicated "On December 15, 2010,...School Instructor (stated) 1 of her female students was not comfortable around (CNA 1) due to touching her on the hip..." CNA 1 was witnessed by two students and one CNA (CNA 2) slapping Patient A on the buttocks.CNA 1 was heard by two students and one CNA (CNA 2) making the derogatory statements "Nice butt baby", and "Don't you baby" when referring to the patient's buttocks. Therefore, the facility failed to ensure Patient A was free from verbal and physical abuse by failing to ensure CNA 1 did not verbally and physically abuse the patient, when CNA 1 stated "Nice a..(Actual word used) baby, and slapped the patient on the buttock. These violations had a direct relationship to the health, safety, or security of Patient A. |
| 250000010 |
ALTA VISTA HEALTHCARE & WELLNESS CENTRE |
250011865 |
B |
24-Nov-15 |
Y7DP11 |
13203 |
Code of Federal Regulations ? 483.13 (b), (F223) The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. On September 15, 2015, an unannounced visit was conducted at the facility to investigate a complaint of verbal abuse of a patient by a staff. During the course of the investigation, it was determined that the facility failed to provide for Patients B, C, D, E, and F an environment free from verbal abuse, harassment, and intimidation from Patient A. This failure resulted in emotional distress and fear of Patient A by Patients B, C, D, E and F. On September 15, 2015, Patient A's record was reviewed. Patient A, a 64 year old male, had diagnoses that included paranoid schizophrenia (person with false beliefs that people are plotting against them). Patient A's record indicated the patient was able to move about the facility in a wheelchair and transfer from wheelchair to bed and toilet. Patient A was observed sitting in a high back wheelchair and was able to independently wheel himself around the facility hallways. He was observed stopping at patients' rooms and talking to patients from outside their doorway. Patient A was interviewed and stated that on September 2, 2015, "I was in the dining room and was being harassed by (name of Patient F) when (name of Social Services Director) harasses me." Patient A stated he called the local Police Department's non-emergency number to report the harassment. Patient A stated the verbal harassment from the Social Services Director (SSD) was recorded by the Police Department dispatch. Review of the physician's progress note for Patient A, dated July 2, 2015, indicated "...S (subjective): you leave before I kill you and call the police to pick your body up...O (observation): very verbally abusive, yelling and get very belligerent, anxious, irritable angry with very expansive mood (easily annoyed, provoked to anger)...S/H (suicidal/homicidal): pt (patient) is homicidal...Plan: Transfer pt to acute inpt (inpatient) psychiatric hospital for evaluation..." The document titled "IDT" (Interdisciplinary Team) dated July 31, 2015, indicated, "The IDT has convened this meeting due to resident's (Patient A) escalating behavior that has started to negatively impact other residents...(name of Patient A) is noted to be verbally aggressive and harassing other residents causing altercations and emotional distress to the other residents. (One female resident (Patient D) had complained of having stomach distress after she was harassed by (name of Patient A))..." An additional physician's progress note, dated August 19, 2015, indicated "O...continue to be hostile, aggressive and verbally abusive to others. Pt (patient) is suspicious and paranoid, and belligerent...P (plan): Pt will require hospitalization for evaluation and treatment of his paranoid state..." There was no documented evidence that indicated Patient A was transferred to an acute inpatient hospital for evaluation from July 2, 2015 to August 19, 2015.Review of Patient A's "Behavioral" care plan initiated on March 11, 2015 indicated: ?Problem/Need: Behavioral symptom directed toward: Others, Self Manifested by: ?Suspiciousness, paranoia, refusal of care, non-compliance, false accusations, misinterprets actions of others, manipulation Approaches: ?Maintain consistency in routine across all shifts, determine triggers and de-escalation techniques and educate staff, involve resident in decisions regarding care and routine, encourage expression of feeling of anger, frustration and guilt, encourage resident to attend social activities, utilize diversion, distraction, or redirection to limit reoccurrence, assess for pain or discomfort, speak and move calmly when assisting or treating resident, explain paranoia are not real and provide reality orientation, psychiatric consult, provide praise for acceptable behavior, assess resident's understanding of the situation, provide education to resident, responsible party, and staff regarding special care needs?" The behavioral care plan problems were updated and indicated: 1. March 11, 2015, "Refused to be seen by psychiatrist." 2. May 11, 2015, "Accused a staff member of poisoning him." 3. June 13, 2015, "Accused staff of giving him a wrong medication." 4. July 14, 2015, "Accused supervisor of violating resident quality of life." 5. July 16, 2015, "Verbally abusive tried to hit staff." 6. July 21, 2015, "Threatens staff (suing, calling DHS (Department of Health), DOJ (Department of Justice), etc.)" 7. July 27, 2015, "Verbally inappropriate towards other residents." 8. Sept 2, 2015, "Inappropriate comments towards other residents." The behavioral care plan approaches were updated and indicated: 1. March 11, 2015, "Explain risks and benefits, monitor behavior every shift...social services to reassure and follow up as needed." 2. May 11, 2015, "Report to ombudsman, IDT (Interdisciplinary Team) meeting with ombudsman." 3. May 20, 2015, "Report to DHS, 2 staff to care all the time, in service staff." 4. July 14, 2015, "Explanation given out but never listen...SSD notified." 5. July 21, 2015, "Listen to resident concerns, reality orientation as needed." 6. July 27, 2015, "Encourage resident to verbalize needs and concerns, explain to resident that inappropriate behavior towards other resident is not acceptable." 7. September 2, 2015, "Frequent visual checking of resident...close supervision with resident during meal time in the dining room." Further review of Patient A's record indicated: 1. September 2, 2015, Patient A initiated a verbal argument with a male patient (Patient F) in the dining room during breakfast time. 2. September 9, 2015, Patient A kept following around and harassing Physical Therapist (PT) while in the middle of walking (therapy) another patient (Patient E). PT said Patient E ended up not wanting to continue ...due to (name of Patient A's) unpleasant behavior and comments..." 3. September 10, 2015, Patient A was "...ranting in the hallway around residents and staff..." using expletive language. On September 15, 2015, Patient B, Patient F, and Facility Staff 1 (FS 1) were interviewed. Patient B stated he witnessed Patient A's behavior on September 10, 2015. Patient B stated Patient A would tell him (Patient B) every day he needed to be gone the next day, and he (Patient B) would be thrown out of the facility. Patient B further stated Patient A was constantly (verbally) abusing him and others. Patient B stated he did not feel safe in the facility because of Patient A. Patient B's record was reviewed. Patient B's history and physical dated July 21, 2015, indicated Patient B had the capacity to understand and make decisions. Patient B's Minimum Data Set (MDS - assessment tool) dated July 31, 2015, indicated a BIMS (screening examination for mental and cognitive status) score of 15 (a score of 13-15 means cognitively intact). Patient F stated during breakfast time on September 2, 2015, he and Patient A had an argument. Patient F stated Patient A was "going on and on" about the difference in their "background." Patient F stated the SSD intervened and "handled the situation professionally." Patient F's record was reviewed. Patient F's history and physical dated, August 30, 2015, indicated Patient F had the capacity to understand and make decisions. Patient F's MDS dated September 26, 2015, indicated a BIMS score of 15. FS 1 stated on September 10, 2015, Patient A was in the hallway banging and yelling on the door of the Administrator's office. FS 1 stated Patient A kept on yelling and, "Started calling us (staff) every name on the book. Like no brain, you have fungus on your toes, etc." FS 1 stated other patients and visitors were around. FS 1 further stated, "We were afraid he (Patient A) was going to throw his cell phone and other residents may be hurt." FS 1 stated the facility had to call the (name of the local) Police Department. The Police Department dispatch recording of Patient A's call on September 2, 2015 was reviewed by both the HFEN (Health Facilities Evaluator Nurse) and HFES (Health Facilities Evaluator Supervisor) on September 29, 2015. The recording did not indicate any verbal abuse or harassment towards Patient A by any staff. On September 29, 2015, Physical Therapist 1 (PT 1) was interviewed.PT 1 stated on September 9, 2015, while in the middle of walking Patient E, Patient A started following her around and talking loudly. PT stated Patient E got upset and bothered with Patient A's tone of voice and did not want to walk anymore. PT stated this was the only time Patient E did not finish her walk. On Sept 30, 2015, Patient E, Patient C, and Patient D were interviewed. Patient E was unable to remember the incident and appeared confused. Patient C stated she witnessed Patient A arguing with another patient. Patient C stated she got scared. Patient C stated the verbal altercations made her anxious and feel unsafe. Patient C's record was reviewed. Patient C's history and physical dated February 11, 2015, indicated Patient C had the capacity to understand and make decisions. Patient C's MDS, dated October 3, 2015 indicated a BIMS score of 14. Patient D stated that on July 29, 2015, Patient A started yelling loudly at her through her doorway, "I'm sorry about your problem!" Patient D stated Patient A would not stop yelling about her "problem." Patient D stated she felt scared and embarrassed. Patient D stated the incident was "emotionally distressing" and facility staff was aware. Patient D stated she could not get out of her room that day. Patient D further stated, after the incident Patient A had been coming to her door every single morning and would sing "Home on the Range" in a "creepy voice.? Patient D stated Patient A also followed her around if she was out in the hallway speaking in a low tone to intimidate her. Patient D stated when she was in the dining room, Patient A would stare at her. Patient D stated Patient A "Makes me want to stay in my room." Patient D stated "I do not turn my back on him. I don't trust him, and I do not feel safe when he's around." Patient D stated, "Please, please help us get him out of here." Patient D's record was reviewed. Patient D's history and physical dated February 5, 2015, indicated Patient D had the capacity to understand and make decisions. Patient D's MDS, dated July 31, 2015, indicated a BIMS score of 15. On October 6, 2015, FS 2, Registered Nurse 1 (RN 1), and FS 3 were interviewed. FS 2 stated she witnessed Patient A saying things to Patient D. FS 2 stated that Patient D did not want to leave her room anymore because of Patient A. FS 2 stated she had been encouraging Patient D to get up every day. FS 2 further stated when Patient D was out of her room, FS 2 would keep her by her side to keep Patient A away from Patient D. FS 2 stated, "It is not right for other residents, such as (Patient D's name), to feel uncomfortable leaving their rooms." FS 2 stated "This is also the other residents' home and they should feel comfortable to go out and do normal things." FS 2 stated Patient A "scares" her and tells her every day "You're going down. You're going to jail." RN 1 stated she was the supervisor on July 29, 2015. RN 1 stated she was aware of the incident between Patient A and Patient D. RN 1 stated Patient D had complained of stomach upset due to the emotional distress Patient D experienced from Patient A's actions. RN 1 stated they monitored Patient D for 72 hours after the incident.FS 3 stated Patient A has been telling her every day, "I'm going to report you to the Health Department. You will get fired." FS 3 further stated Patient A tried to hit her, "He told me he was going to punch me so I had to lock myself in a room." FS 3 stated Patient A "Makes me feel scared. He's always yelling." On October 8, 2015, Patient C, the Administrator and Director of Nursing (DON) were interviewed.Patient C stated Patient A was still "terrorizing" them. Patient C stated, "We just try to stay away from him." The Administrator and DON stated Patient A was reported to have kicked Licensed Vocational Nurse 1 (LVN 1) on October 7, 2015. The Administrator stated Patient A cornered LVN 1 into Nurses' Station 3 and blocked the exit with his wheelchair. Patient A was accusing LVN 1 of poisoning him. The Administrator stated that on the same day Patient A was asked about the incident. Patient A stated he could not recall what happened.The facility's undated policy and procedure titled, "Abuse - Prevention Program" indicated "...The facility does not condone any form of resident abuse, neglect and/or mistreatment...The facility is committed to protecting residents from abuse by anyone, including but not limited to Facility Staff, other residents..." Therefore, it was determined that the facility failed to provide an environment free from verbal abuse, harassment and intimidation from Patient A by Patients B, C, D, E, and F. This failure resulted in emotional distress and fear of Patient A by Patients B, C, D, E and F.This violation had direct or immediate relationship to the health, safety, or security of patients. |
| 250000673 |
AFVW HEALTH CENTER |
250011983 |
B |
27-Jan-16 |
D0VL11 |
5270 |
F226 Abuse 483.13 (c) The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. On March 11, 2014, at 10:00 a.m., an unannounced visit was made to the facility to investigate an entity reported incident involving Resident A that occurred on February 22, 2014. The allegation was reported to the California Department of Public Health (CDPH) on March 7, 2014 (13 days later). Based on interview and record review, the facility failed to ensure that staff followed the facility's policy and procedure for reporting an allegation of abuse timely to the facility Administrator for one resident (Resident A) that was allegedly abused by a Certified Nursing Assistant (CNA 2). This failure resulted in a delayed investigation, no immediate nursing assessment of the resident for injuries, and had the potential for Resident A to be subjected to continued abuse for 13 days until the abuse allegation was investigated. Review of Resident A's record indicated the resident was a 86 year old female admitted to the facility on August 5, 2013, with diagnoses that included severe dementia (impairment of memory, judgment, and thinking) diabetes mellitus (lack of insulin), and urinary tract infection (bladder infection).Review of the resident's initial "History And Physical" form dated August 7, 2013, indicated she did not have the capacity to understand and make her own decisions. Resident A's assessment and screening indicated she had short and long term memory problems.Review of the most recent Minimum Data Set (MDS - a comprehensive assessment) with an assessment reference date of January 29, 2014, indicated Resident A had unclear speech, sometimes understood simple direct communication, and had memory deficits.Resident A was interviewed on March 11, 2015, at 10:20 a.m. When Resident A was asked if she knew who CNA 2 was, or if she was hit by CNA 2 she stated, "No." An interview was conducted with CNA 1 on March 11, 2014, at 10:33 a.m. CNA 1 stated the incident occurred on February 22, 2014. CNA 1 stated Resident A would become combative during care so she (CNA 1) asked CNA 2 to assist her with getting Resident A up into the wheelchair. CNA 1 stated CNA 2 was in a hurry so CNA 2 grabbed Resident A's left arm very aggressively without telling Resident A what she was doing. Resident A became combative and hit CNA 2's arm. CNA 2 then got upset and slapped Resident A on the side of the resident's face. When CNA 1 was asked by the surveyor why she did not report the incident right away after it occurred she stated she did not report it because, "I did not trust anyone," and she stated she didn't think anyone would do anything about it. CNA 1 further stated she reported the incident to the Director of Nursing (DON) on March 7, 2015. In an interview with Licensed Vocational Nurse 1 (LVN 1) on March 11, 2014, at 11:02 a.m., she stated CNA 1 had reported the incident to her on March 6, 2014. LVN 1 stated she then reported the incident to the Director Of Staff Development (DSD) on March 7, 2014. In an interview with the DSD on March 11, 2014, at 11:20 a.m., he stated employees were supposed to report abuse right away. He further stated, "It's on the video titled, "Your Legal Duty, Reporting Elder and Dependent Adult Abuse," that employees watch two times before they start working with the residents. In an interview with the DON on March 11, 2014, at 12:18 p.m., she stated that she told CNA 1, "You need to report it to us right away," and further stated CNA 1 waited too long to report the incident.In another interview with the DSD on April 7, 2014, at 9:55 a.m., he stated CNA 2 denied the abuse allegation, and the facility was not able to substantiate that Resident A was slapped by CNA 2. Review of the facility's written investigative report revealed the investigation was conducted on March 7, 2014, 13 days after the allegation of abuse occurred.A facility policy and procedure titled, "ABUSE PREVENTION AND REPORTING ACKNOWLEDGMENT," (undated) was reviewed. The policy indicated, "WHEN REPORTING IS REQUIRED...Any employee at (name of facility), who is in his/her professional capacity or within the scope of his/her employment, either has observed, or has knowledge of an incident that reasonably appears to be abuse,...shall report the known or suspected instance of abuse to his/her supervisor and to the Administrator of the Skilled Nursing Facility. The Administrator of the Skilled Nursing Facility or his designee, will conduct an investigation into the authenticity of the allegation..." A facility form titled, "In Case of Accusation of Resident Abuse," (undated) was reviewed. The form indicated "Within 2 hours...1. Report to your Supervisor. 2. Supervisor to report to Administrator and Director of Nursing. Suspend the accused employee(s) from any resident care during the investigation..." Therefore, the facility failed to ensure CNA 1 reported the abuse allegation to her supervisor timely so that an immediate investigation could be done, and Resident A would be protected from further abuse. The above violation had direct or immediate relationship to the health, safety, or security of Resident A. |
| 920000280 |
ANTELOPE VALLEY CARE CENTER |
920009827 |
A |
13-Nov-13 |
LOBQ11 |
8904 |
Title 22 CCR SectionSection 72315(j)(1)(2)(A) (j) Fluid intake and output shall be recorded for each patient as follows: (1) If ordered by the physician. (2) For each patient with an indwelling catheter. (A) Intake and output records shall be reevaluated at least weekly and each evaluation shall be included in the licensed nurses? progress notes. Based on interview and record review, the facility failed to implement Patient 1?s care plan and follow the physician?s order by failing to: 1. Monitor the patient?s fluid intake and output (I & O) by measuring and documenting all fluid intake and output volumes in the patient record during a 24-hour period) and then re-evaluating the documentation in those records weekly for a patient who had urinary retention (inability to empty the bladder completely).2. Monitor the patient for signs of urinary retention as indicated in the care plan. During a complaint investigation that was completed on November 16, 2010 at 8:10 a.m., the Admission Information Sheet in the patient?s medical record indicated Patient 1 was admitted on July 27, 2004, with diagnoses that included Alzheimer's disease, urine retention, recurrent urinary tract infection (UTI), and dysphasia (difficulty speaking). The Minimum Data Set (MDS) assessment, dated March 2, 2010, indicated Patient 1 had severely impaired cognitive skills for daily decision-making, was totally dependent on staff for mobility and activities of daily living, was incontinent of bowel and bladder, and received nutrition through a gastrostomy tube (GT) feeding. Patient 1 had the following physician's orders (dates indicated): (1) Flush GT tube with a minimum of 100 cubic centimeters (cc) of water every shift and 50 cc water pre and post medication administration, (dated March 22, 2010) (2) GT feeding of Jevity (a nutritional feeding product) at the rate of 65 cc/hour for 20 hours, (dated June 15, 2010) (3) Rocephin (antibiotic medication) 1 gram every 24 hours for 7 days intravenously for UTI, (dated July 14, 2010)(4) Foley catheter to gravity drainage due to urinary retention, and monitor I&O every shift for four weeks, (dated July 15, 2010) A review of the Visit and Information Progress Notes, written by Nurse Practitioner (NP) 1, dated July 15, 2010, indicated Patient 1 exhibited abdominal distension (bulging of the stomach) on the left lower quadrant and the abdomen was firm to touch without obvious rebound or guarding (which is an indication of urinary retention) . In addition, the notes indicated a Foley catheter had been inserted and more than 400 cc of urine had returned. A care plan was initiated on July 15, 2010, for the problem of alteration in urinary elimination manifested by urinary retention. According to the care plan, the goal was for the patient?s bladder to be adequately emptied without any complications as evidenced by no bladder distention, no pain, and no fever daily for 90 days. The approaches included to monitor for signs and symptoms of urinary tract infection such as pain during urination, abdominal distension (bulging), elevated temperature, and change in level of consciousness. Another care plan goal dated the same day indicated the problem of indwelling catheter ? at risk for urinary tract infection (UTI). The approaches included to monitor fluid intake and output volumes and monitor the patient for signs and symptoms of UTI such as pain or fever and the following urine characteristics: hematuria (blood in the urine) cloudy and foul odor. The medical record did not include any documentation that Patient 1?s abdomen had been assessed for signs and symptoms of urinary distension. A review of the Intake and Output Record indicated the information recorded in the medical record was inconsistent and incomplete. On July 16 - 24, 2010, the output was recorded as number of times (indicated by x?s) the Patient 1 was incontinent, instead of the volume of urine output. The weekly evaluation for the period July 11 ? 17, 2010, indicated an average intake of 1624 and an average output of ?X6.? The 30 days evaluation indicated to continue monitor I & O to determine adequate output towards the intake times 4 weeks. However, the adequacy of the output volume could not be determined as it was not measurable. The weekly evaluation for the period of July 18 ? 24, 2010, indicated an average intake of 1929 and average output of times ?X5.? The 30 days evaluation indicated to continue monitor I & O. From July 25 - 30, 2010, according to the documentation, the average intake was 2531 cc and the average output was 1470 cc. The average intake exceeded the average output by 1061 cc and the urine was described as clear, yellow with a musty odor. An accurate average measurement could not be obtained for the month since I & O record keeping was inconsistent.There was no documentation in the Licensed Personnel Progress Notes that I & O records were evaluated on a weekly basis. According to the Interdisciplinary Team Notes, dated July 31, 2010, page 3, the patient was at risk for urinary tract infection (UTI) due to indwelling Foley catheter use, and the patient was at high risk for abdominal distention secondary to actual urine retention/poor urine output. According to the Licensed Personnel Progress Notes, dated July 31, 2010 at 9:45 a.m., Patient 1 had a temperature of 99.7 degrees Fahrenheit, heart rate of 130 beats per minute, respirations of 30 per minute, normal heart impulse rate paces between 60 and 100 times per minute (The Lippincott Manual of Nursing Practice, 5th edition, page 362), had labored breathing, wheezing lung sounds, her abdomen was distended and had hypoactive bowel sounds in all four quadrants of the abdomen, and the Foley catheter was patent, draining dark amber urine. Patient 1 was noted with uncontrollable body twitching and movement on two occasions, five minutes apart lasting about one minute. Patient 1 was transferred to an acute care hospital at 10 a.m. for further evaluation due to respiratory distress and tachycardia (increased heart rate) according to the physician's order dated July 31, 2010. During a review of the medical record with the Director of Nursing (DON) on November 16, 2010 at 3:25 p.m., he stated that I&O should have been completed as ordered by the physician. He also stated that he could not provide documentation that the licensed staff was monitoring I & O differences to determine if Patient 1 had fluid deficit and intervened before symptoms appeared. According to a History and Physical (H&P) examination report from the acute care hospital dated July 31, 2010, Patient 1 was intubated, and the emergency room doctor indicated that the bladder was distended up to the belly button which was relieved with a newly inserted Foley catheter. The H&P also indicated that a Foley catheter that was inserted at least a couple of weeks prior at the nursing facility, had either been placed at the urethra (a canal that carries urine from the bladder to the outside of the body) level or had been clogged. The blood urea nitrogen (BUN) level was 60 milligram/deciliter with a reference range of 5-20 mg/dL[BUN is an end product of protein and amino acid metabolism removed from the body as a waste by the kidneys], and creatinine (Cr) level was 30 milligram/deciliter with a reference range of 0.7-1.5 mg/dL (Cr is a non-nitrogenous compound important in muscle metabolism because it acts as the storage site for high-energy phosphate, excreted by the kidneys because the body has no use for it), and glucose 433 mg/dL (blood sugar, reference range in adults is 70 - 150 mg/dL). Both BUN and Cr are chemistries that reflect renal function. The assessment section of the acute care hospital H&P indicated the following: Altered mentation, possible seizure activity, was most likely due to dehydration and a urinary tract infection.Renal insufficiency was most likely due to bladder distention or may have been obstructive as well as pre renal from dehydration.A pulmonary consult was called. Patient 1 was given intravenous fluid for hydration, antibiotic therapy, insulin, and strict I & O's were to be maintained. Based on interview and record review, the facility failed to implement Patient 1?s plan of care by failing to: 1. Monitor the patient?s fluid intake and output (I & O) by measuring and documenting all fluid intake and output volumes in the patient record during a 24-hour period) and re-evaluating the documentation in those records weekly for a patient who had urinary retention (inability to empty the bladder completely).2. Monitor the patient for signs of urinary retention as indicated in the plan of care. The violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 920000292 |
ARARAT NURSING FACILITY |
920010473 |
B |
13-Feb-14 |
YDYK11 |
3611 |
42CFR ?483.13(b), Free From Abuse F 223 The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusionThe Department received a complaint alleging that a Certified Nursing Assistant (CNA) slapped a patient in the face for objecting to the CNA putting two disposable briefs on the patient. There were no witnesses to the incident. On November 21, 2012, an unannounced complaint investigation was conducted. Based on interview and record review the facility failed to: 1. Ensure that a patient was free of physical abuse by allowing a CNA to slap Patient 1, when the resident told the CNA not to use two briefs and to be gentler.Findings: According to the admission information Patient 1 was admitted to the facility on April 6, 2012, with diagnoses that included dementia, incontinence of urine, hypothyroidism, degenerative joint disease, anemia and osteoporosis. The Minimum Data Set (MDS - a standardized comprehensive assessment of the patient's problems and conditions), dated September 26, 2012, indicated the patient had clear speech, was understood and understands and had adequate vision. There was no documentation in the MDS or the Care Plan to show that the patient lies or fabricates.According to the Investigation Report, dated October 30, 2012, on the night of the incident CNA 1 was changing Patient 1's disposable brief and she was rough with the resident. Patient 1 told CNA 1 not to use two diapers, and be gentler. CNA 1 got angry, slapped the resident's face and said be quiet. The resident did not know the CNA's name but described her to the Director of Nurses (DON). The DON asked the resident's primary caregiver to come to the facility and the resident identified CNA 1 when she walked into the patient's room. The CNA denied slapping the patient. The report also indicated there were no witnesses to the alleged incident. CNA 1 was terminated according to the report.On November 21, 2012, at 2 p.m., during an interview with Patient 1 through an interpreter (the DON), she said on the night of the incident she was asleep on her back. CNA 1 came in Patient 1's room, opened her legs to put two disposable diapers on her instead of one. Patient 1 told CNA 1 not to put two diapers on because it hurts her. CNA 1 told her to be quiet and slapped her face. The patient did not know the CNA's name but was able to pick her out from a photograph. The patient was visibly upset while describing the incident to the evaluator. A review of CNA 1's employee file indicated on March 12, 2011, she was warned for being rude and rough with two patients who did not want CNA 1 to be their care giver anymore. On December 18, 2012, at 9:45 a.m., during an interview, CNA 1 denied slapping Patient 1. The CNA went on to say she was not working the day of the incident and the facility found out they made a mistake. CNA 1 went on to say Patient 1 makes up lies. During an interview on December 18, 2012, at 9:55 a.m., the administrator said the facility did not make a mistake. CNA 1 was working that day. The administrator also said they verified everything before terminating CNA 1.The facility failed to:1. Ensure that a patient was free of physical abuse by allowing a CNA to slap Patient 1, when the patient told the CNA not to use two briefs and to be gentler.The above violation had a direct or immediate relationship to the health, safety, or security of Patient 1. |
| 920000001 |
All Saints Healthcare |
920011523 |
A |
28-Jul-15 |
K5KD11 |
12302 |
F323 CFR 42 483.25(h) ACCIDENTS The facility must ensure that ? ?483.25(h)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. F328 CFR 42 483.25(k) SPECIAL NEEDS The facility must ensure that residents receive the necessary care and treatment including medical and nursing care and services when they need the specialized services as listed below. ?483.25(k)(4) Tracheostomy Care ?483.25(k)(6) Standard: Respiratory CareThe facility failed to ensure a resident who had a tracheostomy (a hole made in the neck and windpipe used as an opening to allow airflow and permit the removal of secretions) tube, remained in the visual field of the "Sitter" (person assigned to provide direct visual supervision to assigned residents) at all times for safety as indicated in the facility's policy and procedure. As a result, staff who were in the room but were not in visual sight of Resident 17, were not immediately alerted by a flashing or sounding alarm on respiratory monitors, when the resident stopped breathing. Resident 17 was found unresponsive and was purple in color from the face to the fingertips. Cardiopulmonary resuscitation (CPR - life saving measures) was started and the resident was transferred to the general acute care hospital (GACH) where she was diagnosed with diffuse anoxic brain injury (damage caused by a lack of oxygen to the brain). She was hospitalized for 21 days, and did not return to this SNF per the request of the responsible party.On July 15, 2014, the Department received a complaint which alleged on July 7, 2014, the physical therapist (PT) found the resident not breathing. The resident was transferred to the GACH where a brain scan showed no activity. The report alleged that the resident's tracheostomy tube was not in the right place, the resident stopped breathing but the machine alarms attached to the resident did not alarm. The admission record, a one-year old, Resident 17, was originally admitted to the facility on April 16, 2013, with diagnoses that included Treacher Collins syndrome (birth defect that alters the development of the bones and tissues of the face and skull), and had a tracheostomy tube in place.A review of the physician's orders, dated February 8, 2014, indicated the following: 1. Apnea monitor (a machine that alarms when a resident stops breathing) continuously.2. Apnea monitoring parameters as follows: low respiratory rate (RR) of 10 breaths per minute, apnea period of 15 seconds (sec), low heart rate (HR) of 60 beats per minute and high HR of 200 beats per minute.3. Pulse oximetry (a machine that measures the percentage of oxygen in the blood) continuously. 4. Baseline FiO2 (Fractional of Inspired Oxygen) per liter flow of 28 percent (%).5. May use an increase of supplemental oxygen to maintain saturation equal or above 95% and notify the physician if more than 28% FiO2 is required for more than 15 minutes.6. Xopenex (medication to open airways to ease breathing) 0.63 milligrams via a hand held nebulizer (breathing apparatus and machine to administer medication).7. Physical therapy (PT), therapeutic exercise three times a week times 12 weeks dated March 4, 2014.There was a Resident Care Plan, dated October 2013 and re-evaluated July 2014, for ineffective airway clearance, ineffective breathing pattern, and inadequate oxygenation related to medical diagnoses. The goal was to achieve adequate oxygenation by maintaining patent (open) airways and unlabored respirations as reflected by oxygen saturation (amount of oxygen in the blood) equal to or greater than 95% daily. The approaches included to assess and monitor character of respirations, assess resident's skin color, breath sounds, oxygen saturation every shift and PRN (as necessary), secure trach at midline, keep resident on monitors as ordered, and refer any abnormal findings or change in resident's baseline to the physician accordingly. The disciplines responsible for this care plan were the Respiratory Therapist (RT) and Nursing. A review of the Annual Child Life Development Assessment dated April 17, 2014, indicated Resident 17 was able to go from sitting to standing independently, maintains stance by holding onto external support and walks along/cruises with unstable gait. Eye-hand coordination had improved with excellent sustained eye contact and visually tracked objects well. Resident 17 responded to auditory (heard) stimuli 50% of the time despite diagnosis of being deaf; was very alert, loved to be held and rocked, was very active with surroundings and engaged in solitary play.The Minimum Data Set (MDS) assessment dated April 21, 2014, indicated Resident 17's cognitive skills for daily decision-making was severely impaired. The resident needed limited assistance (one person physical assist) from staff for bed mobility, and total dependence (with one person assist) from staff members for moving on and off the unit, dressing, eating, toilet use, personal hygiene, and bathing. The resident did not have functional limitation in movement to the upper and lower extremities (arms/legs).The staff "Pediatrics Daily Assignment Sheet" dated July 7, 2014, on the 7 a.m. to 7 p.m. shift indicated the persons assigned to Resident 17 were LVN 1 and CNA 1. In an interview with CNA 1 on April 20, 2015, at 1:45 p.m. via phone, she said that she and LVN 1 were assigned as "Sitters". She stated LVN 1 was on break when the incident occurred. A review of the Therapy Treatment Flowsheet dated July 7, 2014, at 8:10 a.m., indicated Resident 17's heart rate was 113 beats per minute before breathing treatment of Xopenex. After the breathing treatment, the resident had a heart rate of 116 beats per minute, and had an oxygen saturation of 98%. A review of the Respiratory Therapy Treatment Flowsheet dated July 7, 2014, at 10:05 a.m., indicated Respiratory Therapist 4 (RT 4) responded to "RT" (code) called by PT. RT 4 found Resident 17 unresponsive with dusky color and immediately grabbed the bag valve mask (BVM) to provide supplemental oxygen, along with lead RT 1.Due to low heart rate, chest compressions were started by RT 2. Resident 17 remained unresponsive. 911 (emergency) paramedics were called. Epinephrine was given by the registered nurse (RN). Chest compressions and bagging continued by RT 2 and RT 1. A second dose of epinephrine was given to the resident because of low heart rate. RT 3 changed the trach tube, and it was documented that no plugs found, airway was patent (clear) and secure. The paramedics arrived and took over chest compressions and bagging.According to the SNF Nursing Narrative Notes, dated July 7, 2014, the paramedics arrive at 10:13 a.m. and took over CPR. Resident 17 was transferred to the GACH at 10:32 a.m. The paramedics' Conversion Record dated July 7, 2014, indicated they arrived at the facility at 10:17 a.m., and was with Resident 17 by 10:18 a.m. Upon arrival, the paramedics found Resident 17 pulseless (no heart beat) and apneic (no breathing), and started CPR [(cardiopulmonary resuscitation). They got a low heartrate of 63, with no breathing, and left the facility at 10:37 a.m. A review of the Emergency Department (ED) Clinical Summary (Final Report) dated July 7, 2014, at 11:56 a.m., indicated upon arrival to the ED, Resident 17 had some spontaneous breaths but was non-responsive. After about five to ten minutes, Resident 17 had some response to stimuli and had spontaneous movements.A review of the History and Physical Final Report from the GACH dated July 7, 2014 at 2:46 p.m. indicated Resident 17 had a trach and suspected dislodging; episode may have been due to dislodged trach.A review of the Neurology Progress Note dated July 28, 2014 at 12:53 p.m., indicated Resident 17's complications included confirmed acute diagnoses of cardiac arrest, mechanical complication of tracheostomy, and anoxic (absence of oxygen) brain injury.According to a written Declaration provided by the Physical Therapist (PT) dated April 3, 2015, and a follow-up phone interview on April 20, 2015, on the morning of the incident, she went to check if Resident 17 was ready to be seen for physical therapy treatment. She found Resident 17 sleeping on her stomach. She left to provide treatment to another resident. When she returned to provide treatment to Resident 17, she saw the resident was limp and lying face up, and was purple in color from the face to her arms and hands. She went to Resident 17's bed and called out "RT", which meant an emergency. She stated the monitors were flashing and sounding on bed A. The pulse oximeter reading was 28%. There was a privacy curtain between bed A and bed B drawn to the foot of the bed. A staff person was working with the resident in bed C, with the privacy curtain completely drawn. The certified nursing assistant (CNA) was sitting against the closet, facing bed B, and there was a shower bed to the left of the CNA blocking the view to bed A (Resident 17). When the PT called "RT", RT 4 opened bed B's curtain, and that was how the PT knew RT 4 was connecting the machines and monitors for bed B.The PT stated she did not see any LVN in the room at this time.On April 6, 2015, at 10:15 a.m., during an interview with RT 4, he stated that the day of the incident, he was the primary respiratory therapist, and CNA 1 asked him if he would assist her to get the resident in bed B ready for the shower. Bed B had a ventilator (breathing machine) attached, which was alarming while they were working on the resident. RT 4 heard a PT shout, "Oh my God, she's purple!" He turned around, moved the curtain and visualized Resident 17, and she was purple.RT 4 stated he did not hear the pulse oximeter or apnea monitor alarms for Resident 17, even though they were connected. RT 4 stated the PT got his attention when she shouted, "RT!"On April 20, 2015, at 1:45 p.m., during a telephone interview with CNA 1 regarding the incident on July 7, 2014, she stated that she was the sitter for Resident 17's room on that day, and there were three active residents in the room. The primary nurse for Resident 17 was LVN 1.CNA 1 said she was in the room between Resident 17 (who was in bed A) and bed B as she was also assigned to bed B.She stated LVN 1 took a break for 15 minutes and she covered for her as a sitter. CNA 1 was with bed B, preparing the resident for a shower and called RT 4 for help. The shower bed was next to bed B with the curtain pulled for privacy, and RT 4 was inside the curtain with bed B. According to CNA 1, she did not hear any alarms for bed B or bed A (Resident 17).The facility's policy and procedure titled, "Resident Sitters" dated March 2013, indicated the sitter will provide support and monitoring for safety. Sitters will monitor and observe assigned residents "at all times". The Sitters should interact with each resident on a continuing basis throughout the shift but all residents must remain in their field of vision "at all times". Examples included talking with one or more but continuously monitoring or viewing all three. Never leave the residents unattended. Sitters may be assigned between one to three residents in a given room depending on the need.Therefore, the facility failed to ensure a resident who had a tracheostomy tube, remained in the visual field of the "Sitter" at all times for safety as indicated in the facility's policy and procedure. As a result, staff who were in the room but were not in visual sight of Resident 17, were not immediately alerted by a flashing or sounding alarm on respiratory monitors, when the resident stopped breathing. As a result, Resident 17 was found unresponsive and was purple in color from the face to the fingertips. Cardiopulmonary resuscitation (CPR) was started and the resident was transferred to the general acute care hospital where she was diagnosed with diffuse anoxic brain injury (damage caused by a lack of oxygen to the brain). She was hospitalized for 21 days, and did not return to this SNF per the request of the responsible party.These violations posed imminent danger of death or serious harm to Resident 17. |
| 920000001 |
All Saints Healthcare |
920011703 |
B |
08-Sep-15 |
None |
5218 |
F223 42 CFR. 483.13 (b) Abuse The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.42 CFR 483.13 (c)Staff Treatment of Residents The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. 42 CFR 483.13 (c)(1)(i) Staff Treatment of Residents (1) The facility must-- (i) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion.Based on interview and record review, the facility failed to ensure that Resident 1 was free from physical and verbal abuse, and failed to implement its policy on Reporting Suspected Crimes under the Federal Elder Justice Act. Certified Nursing Assistant (CNA) 1 slapped Resident 1 on the head and called her a "bitch? while providing care. On November 15, 2011, the Department received an entity reported incident that alleged CNA 1 slapped Resident 1 on the head and called her a ?bitch? during a diaper change on November 6, 2011, sometime between 1 p.m. to 2.00 p.m. There were two witnesses in the room when the incident took place. On December 2, 2011, at 1:40 p.m., an unannounced complaint investigation (entity reported) was conducted to investigate an entity reported incident of an alleged patient abuse. According to the admission record Resident 1 was admitted to the facility on December 22, 2002, with admitting diagnoses which included chronic respiratory failure, bronchomalacia (weak cartilage in the walls of the bronchial tubes), and a gastrostomy tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach). A review of the Alleged Abuse Investigation report done by the Vice President of Operations/Abuse Coordinator dated November 11, 2011, revealed the following: On November 11, 2011 at 7:30 a.m., CNA 3 reported to the Pediatric Manager (PM) that she heard CNA 1 hit Resident 1 on the head on November 6, 2011, but did not know the time of incident. The PM immediately reported the allegation to the Vice President of Operations/Abuse Coordinator.A head to toe body and skin assessment for Resident 1 was conducted by a licensed nurse and found no bruises and/or reddened areas. There was no change in Resident 1?s behavior with no signs of fear towards any staff members.Staff witnesses were interviewed by the Vice President of Operation/Abuse Coordinator, PM, Director of Staff Developer and the law enforcement officers as follows:On November 11, 2011, at 11:20 a.m., CNA 4 stated that she did not see directly what happened but she heard a slapping sound and heard CNA 1 calling Resident 1 a ?bitch?. CNA 4 stated she did not know why she did not report this incident right away.On November 11, 2011, at 11:29 a.m., CNA 2 stated that CNA 1 was getting ready to go on break after she changed Resident 1?s diaper. CNA 1 finished washing her hands and she was told by CNA 4 that Resident 1 had another bowel movement and needed to be changed again. She stated CNA 1 was mad and slapped Resident 1?s head and called the resident a ?stupid bitch?. CNA 4 stated it was a disciplinary soft slap and did not know why she did not report the incident right away. On November 11, 2011, at 11:37 a.m., during an interview the activity aidee saidee that she was behind the privacy curtain working with another resident when she heard a ?smack? and CNA 1 saidee ?Bitch I just changed you?. The activity aidee did not know who and/or what was smacked and she did not report the incident to anyone.On November 11, 2011, at 11:47 a.m., CNA 1 was interviewed and she described her interaction with Resident 1 and stated the resident was active and a difficult resident to work with. CNA 1 stated, ?I did not do anything wrong to her?. CNA 1 stated that her actions may have seemed rough to others, or that she beat her or whatever, but she did not mean anything. CNA 1 stated the enforcement officer had asked her if she hit Resident 1. CNA 1 stated she hit Resident 1 but did not know why she did it or maybe she was stressed. According to the conclusion of the facility?s investigation report, CNA 1 slapped Resident 1 and called her a ?bitch.? The CNA admitted that she slapped Resident 1 on the head and called her a derogatory name which is also a swear word. CNA 1, CNA 2, and CNA 4 were terminated and were referred to their Certification Board.A review of the facility policy on Reporting Suspected Crimes under the Federal Elder Justice Act stipulates, ?Staff must report the suspicion of an incident immediately to the Abuse Coordinator (Vice President of Operations), Director of Nursing, or Director of Staff Developer.?Therefore, the facility failed to ensure that Resident 1 was free from physical and verbal abuse, and failed to implement its policy on Reporting Suspected Crimes under the Federal Elder Justice Act. Certified Nursing Assistant 1 slapped Resident 1 on the head and called her a ?bitch? while providing care.This violation had a direct relationship to the health, safety or security of all residents. |
| 920000002 |
ASTORIA NURSING AND REHAB CENTER |
920012339 |
B |
29-Jun-16 |
MVFV11 |
8060 |
Title 22, Division 5, Chapter 3, Article 6 ? 72601 (a) Alterations to existing buildings licensed as skilled nursing facilities shall be in conformance with Chapter 1, Division 17, Part 6, Title 24, California Administrative Code and requirements of the State Fire Marshall. On June 18, 2014 at 1:20 p.m., an unannounced visit was made to the facility to investigate an entity reported incident (ERI) that the generator has failed and it has been replaced with a temporary emergency generator. The ERI indicated the Office of Statewide Health Planning and Development (OSHPD) had been contacted. Based on observation, interview, and documentation review, the facility failed to comply with the requirements for alteration and construction work and ensure the temporary generator project was reviewed and approved by OSHPD, the authority having jurisdiction for alteration and construction work in healthcare facilities. During a tour of the facility on June 18, 2014, accompanied by Employee 1, the temporary generator was observed outside of the facility. According to Employee 1, the temporary generator was acquired on February 25, 2014. During an interview on June 25, 2014, at 1:05 p.m., Employee 2 said the temporary generator project had been approved by OSHPD. However he was unable to provide documentation of the approval. Employee 2 said he would contact OSHPD for the documentation that the temporary generator project had been approved, and then forward it to the Department. On October 8, 2014, during an interview with the Fire Marshall from OSHPD, he said the temporary generator project had not been approved. According to the Fire Marshall the generator project was opened on August 4, 2014, but no plan, submittals or any other documentation has been received by OSHPD for review or approval. He said he gave the facility until October 13, 2014 to submit the paperwork. During another interview with the Fire Marshall from OSHPD on December 17, 2014, at 9:45 a.m., he said the facility had not submitted any paperwork for the generator project. During the Life Safety Code Survey on April 21, 2016, accompanied by the Administrator and the maintenance staff members, the evaluators observed the untested and unapproved temporary generator still in operation outside of the facility. According to the documentation, the temporary generator was acquired on February 25, 2014. According to the documentation from the OSHPD Fire Marshall dated May 15, 2015, the generator project was technically void because the 180 day maximum long term temporary use has exceeded and the installation should now be considered as permanent. During an interview on April 21, 2016, at 2 p.m., the Administrator was unable to provide current documentation of the approval of the temporary generator by the OSHPD. A review of the Field Visit (FV) report from OSHPD dated May 24, 2016, with no changes noted were as follows: 1. 4/28/14 ? Noted the installation of apparent replacement water piping and valves without required review, permits or approvals from OSHPD. No changes or progress noted. 2. 4/28/14 ? The OSHPD Fire Marshall reviewed the trailer mounted emergency generator placed into service at the rear of the building by the facility without required inspection, review, temporary permits or approvals from OSHPD, apparently due to failure of emergency generator #1. 4/24/16 ? No changes or progress noted. OSHPD Project #S141669-19-00 was issued for the temporary generator, however, the installation has not been approved or accepted by OSHPD and no progress has been made in over one year since the last field visit of 5/5/15. 3. 4/28/14 ? Noted new louvered vents have been installed in the exterior wall directly adjacent to the existing generator #2 without required review, permits or approvals from OSHPD. No changes noted. 4. 4/28/14 ? Noted the installation of new floor covering in several areas without required review or approvals from OSHPD. No changes or progress noted. 5. 5/24/16- Noted installation in progress of exterior lighting and other electrical alterations by Nite Owl Alarm without required authorization, permits or approvals from OSHPD. 6. Noted the installation of magnetic door lo9cking devices and automatic door operators on various doors in the means of egress without required authorization, permits or approvals from OSHPD. 7. 1/19/13 ? Noted the installation of wall-hung flat panel televisions in several locations, some of which appear to weigh over 20 pounds such as the large TV installed in the Activity Room, as well as, flat panel TVs of articulating arms in patient rooms with new electrical receptacles and appurtenances without OSHPD plan approval, inspection, testing or approvals. No changes or progress noted. 8. 1/19/13 ? Noted installation, upgrade and/or alteration of the fire alarm system without apparent required permits, plan approval, inspection, testing or approvals. No changes or progress noted. 9. 1/9/13 ? Noted various penetrations of the bottom membrane of the fire resistive roof-ceiling assembly, such as apparent room exhaust fans and ducting for portable air conditioning (AC) appliances that were missing the required fire damper and/or smoke/fire damper and appears to have been altered without required review, permits or approval from OSHPD. No changes or progress noted. 10. 1/19/13 ? Noted installation of new, added and/or altered electrical circuits, including the non-compliant use of non-metallic sheathed cable (?Romex?), excessive lengths of unsecured flexible metal conduit, unsecured/unsupported boxes and the use of unapproved ?Tiger-Grip? boxes without required review, permits or approvals from OSHPD. No changes or progress noted. 11. 1/9/13 ? Noted the installation of an apparent security surveillance system and other electrical cabling in the exit access corridor that penetrates the fire resistive roof/ceiling assembly without required review, permits or approvals from OSHPD. No changes or progress noted. 12. 1/9/13 ? Noted various areas where fire resistive assemblies appear to have been disassembled, altered, patched or otherwise not been maintained and the fire resistance diminished or reduced. The bottom membrane of the roof/ceiling assembly in the corridor, for example, was noted as having been retextured and with patches without review, knowledge or approvals from OSHPD Fire Marshall. No changes or progress noted. 13. 1/18/13 ? Review of Project Status files for the facility revealed that at least three projects have expired permits include: Remove and replace generator and transfer switch, Laundry Remodel, and Laundry Equipment Replacement. The facility is hereby informed that if these projects were completed and placed into service, the work appears to have been performed without required review and approval from OSHPD and was not in compliance. 4/28/14 ? No changes noted. 5/24/16 ? No changes noted. 14. 4/24/14 ? Noted the installation of several replacement water heaters that have already been placed in service without required permits, plan approval, inspection, testing or approvals. No changes noted. 15. 4/28/14 ? Noted the installation of several new and/or replacement rooftop HVAC (heating, ventilation and air conditioning) equipment or systems without required permits, plan approval, inspection, testing or approvals from OSHPD. No changes or progress noted. 16. 1/29/14 ? In addition to the unauthorized HVAC equipment installation, appurtenances and related ducting have been replaced and/or altered without required inspection, review, permits or approvals from OSHPD. Replacement ductwork was noted incorrectly installed with excessive lengths of factory-made flexible ducting and noted missing dampers at several penetrations in the ceiling membrane of the fire resistive roof-ceiling assembly. No changes or progress noted. These violations had a direct relationship to the health, safety, and security of all patients of the facility. |
| 970000003 |
ALEXANDRIA CARE CENTER |
920012749 |
A |
14-Dec-16 |
24Z411 |
13975 |
42 CFR? 483.25 (h) ACCIDENTS The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to ensure Resident 9 received adequate supervision and assistance devices to prevent accidents by failing to: 1. Develop and implement a plan of care with effective and useful interventions to prevent a fall, based on individual needs for Resident 9, who had a history of falls and was assessed at risk for falls. 2. Continuously monitor and supervise Resident 9, who was at risk for falls due to difficulty maintaining a sitting balance, poor safety awareness, and attempted to stand unassisted, while sitting in a wheelchair. As a result, Resident 9 fell from her wheelchair, sustaining a laceration (cut) to the forehead and a nasal (nose) bone fracture. Resident 9 was transferred to the general acute care hospital (GACH) and received suture repair to the laceration of the forehead. Resident 9 also had a potential to develop undetected injuries from head trauma, as a result of incomplete provision of neurochecks (neurological evaluation performed to make sure an individual?s nervous system functions aren?t impaired or non responsive after an injury), in accordance with the facility?s Fall Management policy. According to the admission record, Resident 9 was a XXXXXXX year-old female admitted to the facility on xxxxxxx, and readmitted on xxxxxxx, with diagnoses that included high blood pressure, muscle weakness, dementia (a disorder of mental processes caused by brain disease or injury and marked by memory disorder, personality changes, and impaired reasoning), and seizure disorder (a sudden disruption of the brain?s electrical activity accompanied by altered consciousness). Resident 9's Annual Minimum Data Set [MDS- a comprehensive assessment and care screening tool] dated June 23, 2015, indicated she was severely impaired in cognition, required extensive one-person assist with transfers, toilet use, and personal hygiene, bathing, and when moving between locations in her room and the adjacent corridor on the same floor, and self-sufficiency once in the wheelchair. The MDS indicated Resident 9 was not steady, was only able to stabilize with staff assistance when moving from a seated to a standing position, walking, moving on and off the toilet, and transferring between the bed and chair or wheelchair. The MDS failed to indicate that Resident 9 had a history of falls. The Care Area Assessment (CAA) dated June 23, 2015, indicated Resident 9 had difficulty maintaining a sitting balance, had cognitive impairment, and had seizure disorder. The decision was to proceed with care planning. A review of the care plan initiated on August 11, 2015, indicated Resident 9 was at risk for falls due to cognitive loss, lack of safety awareness, and a diagnosis of seizures. The care plan did not address how to ensure the resident would maintain her sitting balance while in a wheelchair. The interventions indicated to provide resident/caregiver education for safe techniques and to remind the resident to use the call light when attempting to ambulate or transfer. The interventions were not individualized to the resident's needs due to Resident 9's confusion, dementia, and lack of safety awareness. The care plan interventions dated August 11, 2015, for fall prevention were not effective and useful to prevent the fall that resulted in a laceration to the forehead and nasal fracture. For example, there were no interventions to continuously monitor and supervise Resident 9 while sitting in the wheelchair. There were no interventions to ensure Resident 9 was properly positioned, for safety to prevent her from falling while sitting in the wheelchair, due to her difficulty maintaining a sitting balance, such as a safety device. Resident 9?s fall was unwitnessed while she was supposed to be in ?line of sight? and sitting at the nursing station for supervision. The Admission Fall Risk Review dated October 2, 2015, indicated Resident 9 had a balance problem for sitting/standing, and was at risk for falls. A review of the daily and every shift charting dated October 2, 2015, indicated Resident 9 was alert and confused upon readmission to the facility. A review of the device and physical restraint review note dated October 2, 2015, indicated Resident 9 had a history of fall, was confused, was unaware of safety needs, and was unable to make needs known most of the time secondary to dementia. A review of the event summary report regarding the October 4, 2015, fall incident, (dated October 6, 2015), indicated Resident 9 fell out of the wheelchair face forward to the floor on October 4, 2015, at 2:15 p.m. while sitting in the hallway. The resident sustained a laceration on the forehead 4 cm x 1.5 cm with minimal bleeding and a cut on the nose. The report indicated the fall was unwitnessed. A review of the Situation, Background, Assessment, Request (SBAR) post (after) fall progress note dated October 4, 2015, indicated Resident 9 was confused and unable to describe the incident. A review of the Comprehensive pain assessment dated October 4, 2015, after the fall incident indicated a pain level of 0 on a 0 to 10 pain scale (0 being no pain and 10 being the most severe pain). A review of the device and physical restraint review note dated October 4, 2015, after the fall, indicated the IDT's (interdisciplinary team - team of health professionals) recommendation was to apply an anti-tilt (to prevent from tilting) device on Resident 9's wheelchair. A review of the non-witnessed statement dated October 4, 2015, indicated Resident 9's assigned Certified Nursing Assistant 10 (CNA 10) was charting at nursing station 2 at 2 p.m., and heard a noise at 2:15 p.m. in the hallway. CNA 10 checked at the origin of the noise and saw Resident 9 on the floor and reported it to the charge nurse. The licensed nurse notified the physician who ordered to transfer Resident 9 to the GACH emergency room on October 4, 2015. A review of the Daily and Every Shift Reporting dated October 4, 2015, indicated Resident 9 was transferred to the GACH at 4:00 p.m., for an unspecified reason. A review of the physical exam from the GACH dated October 4, 2016, at 16:06 p.m. indicated Resident 9 had a horizontal mid forehead laceration approximately 3 centimeter in diameter and bruising and swelling to the bridge of the nose, no septal hematoma (a collection of blood within the part of the nose between two nostrils). A review of the GACH result of Resident 9?s computerized tomography scan dated October 4, 2015, and timed 4:45 p.m., indicated fractures of the nasal bones with minimal displacement. A review of the GACH discharge summary dated October 4, 2015, indicated that Resident 9 was sent to the emergency department for injuries sustained as the result of a mechanical fall. The final diagnoses on the summary included mechanical fall, head injury, nasal bone fracture, and forehead laceration with suture (stitches) repair. Resident 9 was readmitted to the skilled nursing facility on the same date, October 4, 2015. The physician was notified and new orders were obtained the same date to continue current orders (neurocheck per protocol) and Keflex (an antibiotic) 500 milligram one capsule oral three times a day for 7 days for laceration of forehead. A review of the neurological evaluation flow sheet initiated on October 4, 2015, at 2:15 p.m., indicated a recommended schedule of "Q1hr." (every one hour) X (times) 4, then Q 4hr. X 4 then Q Shift to make total of 72 hour evaluation period." There were no neurological assessments done on October 5, 2015, and October 6, 2015, during the 11 p.m. to 7 a.m. shift, to determine the presence of signs and symptoms of more serious underlying head injury, and as indicated in the facility's Fall Management policy. A review of the IDT notes dated October 7, 16, 23, and 30, 2015, did not indicate Resident 9 had suffered a nasal fracture. There were more than three attempts with administrative staff to identify the nursing staff that transferred Resident 9 to the GACH on October 4, 2015, for an interview, without success. The nursing staff assignment record provided by the facility on October 13, 2016, did not include the 3 p.m. to 11 p.m. shift of the staff working at Station 2 on October 4, 2015. On October 5, 2016, at 3:30 p.m., Resident 9 was observed in bed in her room and she was not interviewable to provide accounts of the fall incident. On October 7, 2016, at 12:04 p.m., during an interview, Licensed Vocational Nurse 3 (LVN 3) stated Resident 9 had some level of confusion and no safety awareness prior to the fall incident. According to LVN 3, Resident 9 would attempt to stand up unassisted from the wheelchair, but was unable because she had no strength. The staff would place Resident 9 near the nursing station because the staff could not leave her alone due to the resident's lack of safety awareness. On October 7, 2016, at 2:32 p.m., during an interview, the Director of Nursing (DON) stated Resident 9 was sitting in the wheelchair near the nursing station for "line of sight" (safety precautions). She stated the staff should have assessed fall precaution interventions while the resident was sitting in the wheelchair considering the fact that Resident 9 was participating in activities while sitting in the wheelchair, was using the wheelchair for locomotion, and was receiving restorative nursing assistance for ambulation. When asked regarding the resident's fractured nose, the DON stated that the facility should have known about the fractured nose because upon admission or re-admission of a resident to the facility, the facility received a discharge summary from the GACH to find out what was done in the GACH. She also stated that if Resident 9's discharge summary was not available at the time of re-admission after the fall incident, the medical records staff should have followed through and requested the GACH discharge summary. On October 13, 2016, at 2:39 p.m., during an interview, CNA 10 stated he was assigned to Resident 9 the day of the fall incident. CNA 10 stated Resident 9 was usually confused, would sometimes attempt to get out of bed unassisted, and would attempt to self-propel while sitting in the wheelchair. CNA 10 stated after lunch, he asked the resident if she wanted to go to bed or the toilet, and the resident stated no. CNA 10 left Resident 9 in the hallway and proceeded to make his rounds. The morning of the fall incident, Resident 9 was sitting near the nursing station and CNA 10 notified other staff to "keep an eye on her" because the resident sometimes tried to self-propel around. In the afternoon, prior to making his rounds, CNA 10 stated that he did not notify the staff because the resident was calm and not moving. CNA 10 stated he was in another resident's room when he heard staff saying that Resident 9 fell, and went to assist Resident 9 back to bed. She was bleeding from the nose, "looked sad," did not make any facial grimaces, and was quiet. On October 5, 2016, at 4:02 p.m., and on October 11, 2016, at 8:59 a.m., during interviews and review of Resident 9's medical record, the DON stated that no interventions were added in the current plan of care for risk for falls. She also stated that Resident 9's plan of care was not updated to include the IDT's recommendation for the new intervention for falls (anti-tilt device). There was no documentation or plan of care regarding the fracture of the nasal bones. During this review, the DON stated that she was not aware that the discharge instructions for the "fractured nose" were available in Resident 9's clinical record. The DON stated if the discharge instructions regarding a "broken nose" were in Resident 9's clinical record, most likely the licensed personnel from the facility and GACH talked about it. There was no documented evidence provided that services and treatment were being administered to the fractured nose. Also, there was no documented evidence Resident 9 was being monitored for bleeding from the nose, swelling, nasal stiffness, and complications related to a fracture of the nasal bones. A review of the facility's revised policy dated March 15, 2016, and titled "Fall Management" indicated the following: 1. Resident determined to be at risk for fall will receive appropriate interventions to reduce risk and minimize injury 2. To develop individualized plan of care 3. To update the care plan to reflect new interventions 4. Perform neurological assessment for all unwitnessed falls and witnessed falls with head injury. The facility failed to ensure Resident 9 received adequate supervision and assistance devices to prevent accidents by failing to: 1. Develop and implement a plan of care with effective and useful interventions to prevent a fall, based on individual needs for Resident 9, who had a history of falls and was assessed at risk for falls. 2. Continuously monitor and supervise Resident 9, who was at risk for falls due to difficulty maintaining a sitting balance, poor safety awareness, and attempted to stand unassisted, while sitting in a wheelchair. As a result, Resident 9 fell from her wheelchair, sustaining a laceration to the forehead and a nasal bone fracture. Resident 9 was transferred to the GACH and received suture repair to the laceration of the forehead. Resident 9 also had a potential to develop undetected injuries from head trauma, as a result of incomplete provision of neurochecks, in accordance with the facility?s Fall Management policy. The above violation presented a substantial probability that serious physical harm would result to Resident 9. |
| 920000077 |
ALAMEDA CARE CENTER |
920012812 |
A |
9-Jan-17 |
HSWW11 |
13226 |
F-223 CFR 483.13 (b) The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. F-309 CFR 483.25 Quality of Care Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. F323 483.25 (h) Accident Hazards/Supervision/Devices The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. On 5/18/16, at 8:20 a.m., an unannounced visit was made to the facility to investigate an entity reported incident regarding Resident 2?s sustaining a fall and a face injury during an altercation with Resident 1. Based on observation, interview, and record review, the facility failed to ensure each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being; failed to ensure each resident receives adequate supervision and assistance devices to prevent falls and injuries; and failed to ensure each resident had the right to be free from physical abuse, including: 1. Failure to protect Residents 2, 3, 4, and 5 from physical abuse inflicted by Resident 1 by lacking supervision of the residents to prevent altercations. 2. Failure to ensure Resident 2 was not physically injured by Resident 1 by lacking supervision to Resident 1, who was assessed as having aggressive behavior towards others, and by not monitoring the whereabouts of Resident 2, who was assessed as confused and able to walk independently to prevent altercations. 3. Failure to re-evaluate, develop, and implement an ongoing plan of care with specific interventions to address Resident 1?s assessed aggressive behavior towards others. 4. Failure to have a monitoring system in place to ensure Resident 1 did not attack any residents and for the protection of other residents. 5. Failure to implement the facility?s policy on Abuse & Mistreatment to establish a system to prevent residents to be subjected to abuse by anyone and to ensure comprehensive assessments and care planning for residents with needs and behaviors which might lead to conflict. As a result, on 5/6/16 Resident 2 was subjected to physical abuse by Resident 1, who pushed the resident twice causing her to fall to the floor, face down, sustaining a forehead laceration (torn or jagged wound) requiring transfer to a general acute care hospital (GACH) where sutures were applied to the lacerated forehead. Resident 2 also sustained and a dislocated left 5th finger which required immobilization with a splint. Resident 2, who was able to walk independently, became non-ambulatory and dependent on staff to move between surfaces after the fall on 5/6/16. In addition, on different occasions, Resident 1 pushed Residents 3, 4, and 5 causing them to fall with no apparent injuries. On 5/18/16, at 8:30 a.m., Resident 2 was observed sitting on a wheelchair in the hallway. Resident 2 had a 1.5 centimeter pink scar/laceration, bruising (light pink with faded blue) to her left upper side of the face and to her left lower eye. The resident had a splint on her left little (5th) finger. The Director of Nursing (DON) spoke to Resident 2 and she responded with mumbling and intermittent laughs, the resident had a blank stare and did not appear to understand what the DON was asking. A review of the clinical record indicated Resident 1 was admitted to the facility, on XXXXXXX, with diagnoses including epilepsy (seizures or convulsions associated with abnormal electrical activity in the brain), dementia (decline in mental ability severe enough to interfere with daily life such memory loss), and psychotic disorder (loss of contact with reality) with hallucinations (sensory experience of something that does not exist outside the mind). According to the Minimum Data Set (MDS - standardized assessment and care planning tool) dated 2/5/16, Resident 1 was usually understood and could usually understand others, was able to walk and move around the facility, had delusions (misconceptions or beliefs that are firmly held, contrary to reality), and was physically abusive towards others (hitting, kicking, pushing, scratching, grabbing, abusing other sexually). There was no documented plan of care addressing the resident?s physically abusive behavior to ensure other residents were protected from abuse. A care plan developed on 10/3/15, indicated Resident 1 had a problem with interacting with peers and the goal was to have no further episodes in the next 90 days. The care plan interventions included redirection, separating them if in close proximity, and advice resident to call for help. This care plan was discontinued as resolved; however, the behavioral problem continued. The plan of care was not revised or updated. The interventions to this care plan did not include a system to better monitor Resident 1. A review of the clinical record indicated Resident 2 was admitted to the facility, on XXXXXXX, with diagnoses including dementia and Alzheimer's disease (progressive mental deterioration). The MDS assessment dated 8/13/15 indicated Resident 2 was usually understood and had the ability to understand others. The MDS, dated 2/12/16, indicated Resident 2 was able to walk without assistance and moved around the facility. On 5/18/16, at 9 a.m., during an interview, the DON stated on 5/6/16, at around 3 p.m., Resident 2 was walking and wandering through the stations and hallways and ended up standing by Resident 1's doorway. The residents were conversing and Resident 1 told Resident 2, "Move step back," then Resident 1 pushed Resident 2 who fell to the floor face down. The resident had a cut with moderate bleeding to the left upper forehead and the facility called 911 to transfer Resident 2 to a GACH. The DON stated Resident 1 had a history of paranoia (delusions of persecution, unwarranted jealousy, or exaggerated self-importance) and schizophrenia (chronic and severe mental disorder that affects how a person thinks, feels, and behaves). On 5/18/16, at 10:43 a.m., the incident surveillance video dated 5/6/16, at 3:10 p.m., was observed. Resident 2 was walking around the station alone and ended up in Resident 1's doorway. After an exchange of words, Resident 1 pushed Resident 2 twice and Resident 2 fell to the floor. The surveillance video indicated there was no staff present when the incident occurred. On 5/18/16, at 11:46 a.m., during another interview, the DON stated it had been a problem having Resident 1 at the facility because, "This is not a psych [iatric] facility." The DON stated Resident 1 was paranoid and impulsive and she had tried to transfer the resident to another facility but no facility would take him. The DON added Resident 1 was hard to monitor and he was a risk to others because he thinks other residents want to harm him. On 5/18/16, at 2:28 p.m., during an interview and a review of Resident 1?s clinical record, the DON was unable to provide evidence of a current plan of care developed to address Resident 1?s physical aggression towards others with specific interventions. The DON stated there was no monitoring system in place for Resident 1 to protect other residents. The DON also stated Resident 1 had previously been involved in resident-to-resident physical and verbal altercations and in all instances, he had been the aggressor. A review of the monthly incident report logs, indicated on 10/3/15, 12/14/15, 3/23/16, and 5/6/16 Resident 1 was involved in physical altercations with four different residents, Residents 2, 3, 4, and 5. All four residents sustained falls as a result of Resident 1?s aggression. A review of the GACH Emergency Department (ED) record indicated the resident had blunt trauma, left periorbital (around the eye) contusion (injured tissue), and a facial laceration on the left side of the forehead measuring two centimeters in length which was repaired with sutures. Resident 2 returned to the facility the same day. At the facility, on 5/8/16, the physician ordered x-ray of the left little finger (5th digit) due to swelling/discoloration. The x-ray result on the same day indicated Resident 2 had subluxation (dislocation) of the middle joint of the 5th finger. On 5/10/16, the physician ordered to a splint to the left 5th finger. A review of the Physical Therapy Evaluation and Plan of Treatment dated 5/10/16 indicated Resident 2 fell on 5/6/16 and now had difficulty in walking. The neuromuscular assessment indicated Resident 2 had poor standing balance and impaired coordination. The functional mobility assessment indicated Resident 2 was totally dependent with walking and the distance walked was zero. Resident 2?s physical condition substantially declined after the fall. A review of the undated policy titled, "Care of Wandering Resident Policy and Procedure," indicated that its purpose was to protect the wandering resident from injury...Wanderers are to be checked on a regular basis...Monitoring the resident's location with visual checks at least once every two hours." A review of the undated Secured Unit Policy indicated the Secured Unit would consider placement for residents who wander and were not otherwise a danger to themselves or others. Resident would be screened prior to admission to Secured Unit for appropriateness of placement. Placement in the Secured Unit would be for the resident's safety and for closer observation by facility staff. Residents would be observed at specific frequencies. A review of the undated facility's policy titled, "Abuse & Mistreatment of Residents," indicated the purpose was to uphold a resident's right to be free from verbal, sexual, and physical and mental abuse. The definition of abuse was "the willful infliction of injury...with resulting physical harm or pain or mental anguish." The policy indicated the facility shall establish a system to prevent...abuse...Residents shall not be subjected to abuse by anyone, including...other residents." The facility shall also ensure comprehensive assessments and care planning for residents with needs and behaviors which might lead to conflict or neglect were initiated. The f facility failed to ensure each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being; failed to ensure each resident receives adequate supervision and assistance devices to prevent falls and injuries; and failed to ensure each resident had the right to be free from physical abuse, including: 1. Failure to protect Residents 2, 3, 4, and 5 from physical abuse inflicted by Resident 1 by lacking supervision of the residents to prevent altercations. 2. Failure to ensure Resident 2 was not physically injured by Resident 1 by lacking supervision to Resident 1, who was assessed as having aggressive behavior towards others, and by not monitoring the whereabouts of Resident 2, who was assessed as confused and able to walk independently to prevent altercations. 3. Failure to re-evaluate, develop, and implement an ongoing plan of care with specific interventions to address Resident 1?s assessed aggressive behavior towards others. 4. Failure to have a monitoring system in place to ensure Resident 1 did not attack any residents and for the protection of other residents. 5. Failure to implement the facility?s policy on Abuse & Mistreatment to establish a system to prevent residents to be subjected to abuse by anyone and to ensure comprehensive assessments and care planning for residents with needs and behaviors which might lead to conflict. As a result, on 5/6/16 Resident 2 was subjected to physical abuse by Resident 1, who pushed the resident twice causing her to fall to the floor, face down, sustaining a forehead laceration (torn or jagged wound) requiring transfer to a general acute care hospital (GACH) where sutures were applied to the lacerated forehead. Resident 2 also sustained and a dislocated left 5th finger which required immobilization with a splint. Resident 2, who was able to walk independently, became non-ambulatory and dependent on staff to move between surfaces after the fall on 5/6/16. In addition, on different occasions, Resident 1 pushed Residents 3, 4, and 5 causing them to fall with no apparent injuries. The above violation presented either (1) imminent danger that death or serious harm to the residents of the Skilled Nursing Facility would result therefrom, or (2) substantial probability that death or serious physical harm to the residents of the Skilled Nursing Facility would result therefrom. |
| 970000003 |
ALEXANDRIA CARE CENTER |
920012817 |
A |
23-Dec-16 |
24Z411 |
22685 |
F309 ?483.25 Quality of Care Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychological well-being, in accordance with the comprehensive assessment and plan of care. The facility failed to effectively manage pain for Resident 12, who suffered with severe, prolonged right foot and leg pain by failing to: 1. Notify Resident 12?s physician as requested by the resident two weeks earlier, to ensure the resident?s right foot and leg pain that was not controlled by the pain medication was evaluated and treated promptly. 2. Promptly reassess in accordance with standard nursing practice, Resident 12?s right foot and leg pain when the resident reported to the staff her right leg and foot felt numb, cold and had severe, constant pain, in order to determine if additional interventions were required to relieve the resident?s pain. 3. Promptly notify and consult with Resident 12?s physician or nurse practitioner when the resident?s right leg and foot pain was not relieved as manifested by groaning, moaning, crying, and screaming of pain for one and a half hours after she was administered a narcotic pain medication to obtain effective pain control interventions, and to determine if the resident required additional medical assessment and treatment. 4. Promptly administer additional pain medication as ordered by the physician, after Resident 12 reported to the licensed nurse, right leg and foot pain level rating increased after the administration of a narcotic pain medication, to ensure pain relief was attained. 5. Implement Resident 12?s care plan regarding pain as follows: a. Assess if the resident has pain to include the site, pain scale (0 to 10), type of pain. b. Reassess the resident 30 minutes to 1 hour after pain medication is given to determine if relief is noted, and to refer accordingly. c. Elevate resident?s legs as tolerated when sitting to promote comfort. 6. Assess upon readmission to the facility specific characteristics of pain such as the primary location, quality, character, onset, duration, aggravating or alleviating factors, effectiveness of the current pain management regimen, history of pain management, effects of the pain, and the resident?s goals for pain and acceptable or tolerable level of pain, in order to determine if the resident?s pain control needs changed or if the resident required additional pain control interventions. As a result, Resident 12 experienced unnecessary, prolonged, pain and suffering due to a delay in nursing and medical treatment for untreated right leg and foot pain. The resident was observed crying and screaming, and pleading for mercy, due to unbearable and constant pain. A review of Resident 12?s history and physical from the general acute care hospital (GACH) dated July 22, 2016, indicated Resident 12 had end-stage renal disease (severe kidney disease), received hemodialysis (a way to treat advanced kidney failure) three times a week, and was treated for steal syndrome (blood flow restriction to the hand). A review of the admission record indicated the resident was originally admitted to the skilled nursing facility (SNF) on January 5, 2016 and was readmitted on August 19, 2016, with diagnoses that included bacteremia (bacteria in the blood), end stage renal (kidney) disease, cardiomyopathy (diseases of the heart muscle), type II diabetes mellitus (high blood sugar), and atrial fibrillation (a quivering or irregular heartbeat (arrhythmia) that can lead to heart-related complications, and presence of automatic (implantable) cardiac (heart) defibrillator (apparatus used to control heart irregularities). A review of the Initial Nursing Assessment dated August 19, 2016, indicated Resident 12 was not experiencing pain or showing signs/symptoms of pain. A review of Resident 12?s physician?s order indicated the following: 1. Tramadol 50 mg. one tablet by mouth every eight hours as needed for moderate to severe pain dated August 19, 2016. 2. Tylenol No. 3 (acetaminophen-codeine) 300/30 milligrams (mg) two tablets by mouth every four hours as needed for moderate pain dated August 20, 2016. The physician?s order for pain medication did not specify the site or location of Resident 12?s pain. A review of the care plan dated August 21, 2016, indicated the resident exhibited or was at risk for alterations in comfort. The care plan goals indicated the resident is to achieve acceptable level of pain control, will not exhibit non-verbal indicators of pain and will experience no pain for 90 days. The interventions included to: 1. Evaluate pain characteristics: quality, severity, location, precipitating, relieving factors, utilize pain scale (measures a patient?s pain intensity or other features). 2. Medicate resident with hydrocodone-APAP, acetaminophen, and Tramadol as ordered for pain and monitor for effectiveness. 3. Report to the physician as indicated. 4. Monitor for non-verbal signs/symptoms of pain and medicate as ordered. 5. Assist the resident to a position of comfort utilizing pillows as appropriate positioning devices. 6. Monitor for non-verbal signs of pain: increase in agitation, grimace and resistance to care. 7. Reassess resident 30 minutes to 1 hour after pain medication is given if there?s relief noted. 8. Assess resident with complaint of pain to include site, scale (0 to 10), and refer accordingly. A review of Resident 12?s care plans dated August 21, 2016, did not specify the resident had pain in the right leg and right foot. A review of Resident 12?s history and physical examination from the skilled nursing facility (SNF) dated August 25, 2016, indicated the resident had the capacity to understand and make decisions. A review of the Minimum Data Set (MDS) assessment (an assessment and screening tool) dated August 26, 2016, indicated Resident 12 was usually understood, usually understands others, was able to recall after cueing and required extensive physical assistance for her care needs. The resident did not have presence of pain. The MDS indicated the resident had a pressure reducing device for bed, surgical wound care, and application of dressings to feet with or without topical medications, and required oxygen and dialysis. On October 4, 2016, from 9:50 a.m. to 10:25 a.m., during an observation and interview with Resident 12, in the presence of the Certified Nursing Assistant (CNA 1), the resident was sitting in the wheelchair in her room with both feet resting on the footrests not elevated. Both of her legs and feet were swollen. The resident had bandages/dressings applied to the right lower leg and right foot dated October 4, 2016. The resident stated her right leg and right foot were very painful. The resident stated her pain level was 10 out of 10, (a pain level rating scale of 0 being no pain and 10 being the worst possible pain, excruciating pain). During the observation and interview with CNA 1 and Resident 12, at 10:05 a.m., Licensed Vocational Nurse 2 (LVN 2), who had entered the room during the interview, stated the resident had a right foot blister and the resident?s right foot and leg were swollen. Resident 12 stated at times her right foot feels numb and cold. At this time during Resident 12?s description of pain, she was crying, moaning, groaning, yelling, and screaming in pain. Resident 12 stated, ?I can?t handle it, I can?t handle it, it hurts so bad! Oh Lord, have mercy, it throbs when I am in pain!? The resident stated her right leg and foot were very tender, felt warm, and were red. The resident stated she told the staff members every day for a period of two weeks, about the pain, and wanted to see the doctor or go to the hospital, but nothing was done. At 10:25 a.m., LVN 1 (the medication nurse) came into the resident?s room and administered Tylenol No. 3, two tablets, but did not ask the resident to rate her pain level before she gave the tablets, and left the room. On October 4, 2016, between 9:50 a.m. to 10:25 a.m., during an interview with CNA 1, he stated Resident 12 was always yelling and screaming. A review of Resident 12?s PRN (as necessary) Pain Medication Flow Sheet indicated on October 4, 2016 at 10:20 a.m., LVN 1 administered an unspecified number of tablets of Tylenol No. 3, to the resident, but indicated the resident had a pain rating level of eight, for pain of the bilateral lower extremities (BLE). The non-pharmacological treatment section was blank. According to the flowsheet, the pain rating scale level (0 to 10 out of 10) for cognitively intact residents were as follows: 0 (zero) was no pain, 1 to 2 was mild pain, 3 to 4 was moderate pain, 5 to 6 was moderate/severe pain, 7 to 8 was severe/horrible pain, and 9 to 10 was excruciating pain. On October 4, 2016, at 10:50 a.m., during an interview, LVN 1 was asked about the documentation on the PRN Pain Medication Flow Sheet, which indicated on October 4, 2016 at 10:20 a.m., Resident 12?s pain level was 8 out of 10. LVN 1 stated she documented the resident?s pain level rating as 8 out of 10, because the resident?s pain level usually was 8 out of 10. However, when asked why she did not assess the resident?s pain level prior to administering the Tylenol No. 3, she was unable to provide an explanation. On October 4, 2016 at 12 p.m., Resident 12, while in her room, was heard from Nursing Station 3, screaming and crying. Upon entering her room, the resident continued to scream and cry. When asked why she was screaming and crying, she stated her pain was still a level of 10 out of 10. The resident was still sitting in the wheelchair, in the same position with her feet on the footrests, not elevated. LVN 1, who was in the hallway outside the resident?s room, was asked if she reassessed the resident?s pain level after giving Tylenol No. 3, or if the resident had been given any additional pain medication. LVN 1 stated no, but she would give additional pain medication now. On October 4, 2016 at 12 p.m., a review of the PRN Pain Management Flow Sheet did not indicate Resident 12?s pain was reassessed thirty minutes to one hour after Tylenol No. 3 was administered, to determine if pain relief was noted, as the care plan indicated. There was no documented evidence in Resident 12?s Licensed Nurses? Notes, progress notes or PRN Pain Management Flow Sheet of October 4, 2016, to indicate the resident was administered additional pain medication until the surveyor intervened, and asked LVN 1 about the resident?s pain at 12 p.m. The resident remained in pain of level 10, for over an hour and a half after giving Tylenol Number 3; there was no indication LVN 1 notified or consulted with the physician or the nurse practitioner regarding management of the resident?s ongoing, unrelieved pain, until October 4, 2016, at 3 p.m. On October 4, 2016 at 4:12 p.m., in an interview and record review for Resident 12?s pain management, the Director of Nursing (DON) stated there was no care plan to address Resident 12?s right leg and foot pain because no assessment was completed. She stated after the surveyor questioned LVN 1 about Resident 12?s unrelieved pain, the nurse practitioner was contacted, who ordered a vascular (vessels, especially carrying blood) and pain management consult. A review of the PRN Pain Management Flow Sheet indicated LVN 1 administered Resident 12 Tramadol 50 milligrams (mg) for pain at 12 p.m., as the physician ordered; at 1 p.m. the resident went to dialysis. There was no indication a reassessment was conducted by the licensed nurse thirty minutes to one hour after the Tramadol was administered to determine if pain relief was noted. A review of Resident 12?s nursing progress notes dated October 4, 2016, at 10:28 p.m., indicated the physician ordered Norco (a medication used to relieve moderate to moderately severe pain), 5/325 milligrams (mg) one tablet by mouth every 6 hours if needed for moderate pain, and Norco 10/325 mg one tablet by mouth every six hours if needed for severe pain, in order to obtain effective pain control. There was no documentation Resident 12 was administered Norco 10/325 mg until October 6, 2016, at 7 a.m., even though the resident continued to have unrelieved pain. For example, on October 4, 2016, at 5 p.m., with a pain rating of 5 out of 10; October 5, 2016, at 7:45 a.m., a pain rating of 7 out of 10; October 5, 2016, at 9:20 a.m., a pain rating of 8 out of 10; and October 5, 2016, at 6 p.m., a pain rating was 7 out of 10. On October 4, 2016 at 12 p.m., Resident 12?s pain was unrelieved by the Tylenol No. 3, but there was no documented evidence in the progress notes or licensed nurses notes of October 4, 2016, to indicate a pain assessment was done in accordance with standards of nursing practice, in order to determine if additional pain control interventions were necessary to relieve the resident?s right leg and foot pain. There was no documented evidence in the October 4, 2016, progress notes or licensed nurses? notes to indicate the resident was assessed by an appropriate professional such as a physician or nurse practitioner in an attempt to determine if medical intervention was required to resolve the resident?s unrelieved pain. Comprehensive initial assessment of pain should include: Pain Characteristics such as primary location, quality, onset, duration, severity, alleviating factors, aggravating factors, effectiveness of the current pain management regimen, history of the pain management, effects of the pain and the resident?s goals for pain and acceptable or tolerable level of pain (American Journal of Nursing October 2016, Volume 116, No. 10). Resident 12 had a delay of over 32 hours in receiving her pain medication from October 4, 2016 at 10:28 p.m., when the physician ordered Norco to relieve the resident?s uncontrolled pain, until October 6, 2016 at 7 a.m., when the resident was administered Norco. A review of the Nursing Home to Hospital [General Acute Care Hospital (GACH)] Transfer Form dated October 5, 2016, indicated Resident 12 was transferred to the GACH for uncontrolled pain of the right lower leg, despite pain medication. The resident was administered Morphine Sulfate (a pain reliever used to treat moderate to severe pain) 4 mg/milliliter, at 2:12 p.m. for right lower leg pain and was prescribed Bactrim (an antibacterial- decreases bacteria) 800 mg ? 160 mg one tablet every 12 hours for cellulitis. The resident returned to the skilled nursing facility on the same day at 3:36 p.m., with instructions to make an appointment with the physician in two days. A review of Resident 12?s report of arterial ultrasound (a device used in medical imaging) of both lower extremities (legs/feet), dated October 6, 2016 at 7:53 p.m., for unspecified pain, indicated there was evidence of high grade stenosis (narrowing) or occlusion (blockage or closing of a blood vessel) of the right superficial femoral artery (the main artery of the thigh) with moderate to moderately severe arterial insufficiency distally (blockage or a major artery, resulting in less blood flow to a body part situated away from the obstruction). A review of Resident 12?s progress notes dated October 7, 2016, indicated at 11:45 a.m., the resident complained of 7 out of 10 pain rating in bilateral lower extremities and Norco was 10/325 mg was given. At 10:39 a.m., the physician ordered the resident to be transferred to the GACH for an arterial Doppler (noninvasive test that can be used to estimate your blood flow through blood vessels) of both lower extremities. A review of the emergency records from the GACH dated October 7, 2016, indicated Resident 12 appeared in distress due to uncomfortable pain. Edema was present to both lower extremities, with abnormal pulse findings, pedal (foot) pulses not palpable (not felt), posterior tibial (back of the lower leg) pulses not palpable and scattered healing ulcerations. A review of the GACH physician consultation report dated October 11, 2016, for ulceration in the right lower extremity, indicated Resident 12 was admitted to the hospital for calciphylaxis (a serious, uncommon disease in which calcium accumulates in small blood vessels causing painful skin ulcers, and may cause serious infections that can lead to death) ischemic lower extremity (lack of blood flow to the leg/foot) with ischemic ulcer. A review of Resident 12?s GACH angiogram (imaging equipment to guide the physician in carrying out a diagnostic or therapeutic procedure) report dated October 10, 2016, indicated a right lower extremity run-off (a study of blood flow); percutaneous transluminal angioplasty (a procedure that can open up a blocked blood vessels) of the right anterior tibial (lower leg) and tibiopeoneal arteries (arteries in the legs). The resident had gangrenous (dead tissue caused by a critically insufficient blood supply and can lead to amputation if not treated), changes in the top of the right foot, and foot pain. ?As shown by ultrasound, there was a significant improvement in velocity of flow in the posterior tibial (back of lower leg) and peroneal (relating to or situated in the outer side of the calf of the leg) arteries distally. A review of the GACH Discharge Summary dated October 14, 2016, indicated Resident 12 was discharged on October 14, 2016. The discharge diagnoses included peripheral vascular disease. The summary indicated the resident had been complaining of unbearable lower extremity pain for around a month. The physician performed angioplasty of the right lower extremity, successfully opening the circulation, improving her pain. A review of the facility?s Pain Management Policy revision date of March 15, 2016, indicated residents will be evaluated as part of the nursing assessment process for the presence of pain with a change in pain status. Residents receiving interventions for pain will be monitored for the effectiveness of providing pain relief. The care plan will be evaluated for effectiveness until satisfactory pain management is achieved. A review of the Guideline for Physician/Mid-Level Provider Notification urgency grid dated January 2, 2014, indicated to notify the Physician/Mid-Level Provider: 1. For general pain, new or severe, and any pain not responsive to prescribed medication requires urgent notification. 2. For general pain, new mild, or moderate requires routine notification. The facility?s policy and procedure titled ?Pain Management? dated March 15, 2016, indicated the resident will be evaluated as part of the nursing assessment process for the presence of pain upon admission/re-admission, quarterly, with change in condition or change in pain status, and as required by the state thereafter. The nurse will notify the physician/mid-level provider as appropriate and obtain treatment orders as indicated. At a minimum of daily, residents will be evaluated for the presence of pain by making an inquiry of the resident or by observing the signs of pain. If a resident has a change in pain status, complete a pain evaluation (electronic) or paper. Residents receiving interventions for pain will be monitored for the effectiveness and side effects in providing pain relief. Document effectiveness of PRN medications, ineffectiveness of routine or PRN medications including interventions, follow-up, and physician/mid-level provider notification, and non-pharmacological interventions and effectiveness. The care plan will be evaluated for effectiveness until satisfactory pain management is achieved. Contact the physician/mid-level provider to report findings and obtain revised treatment orders, if indicated. Review the non-pharmacological approaches for effectiveness. Revise the care plan as indicated. The facility failed to effectively manage pain for Resident 12, who suffered with severe, prolonged right foot and leg pain by failing to: 1. Notify Resident 12?s physician as requested by the resident two weeks earlier, to ensure the resident?s right foot and leg pain that was not controlled by the pain medication was evaluated and treated promptly. 2. Promptly reassess in accordance with standard nursing practice, Resident 12?s right foot and leg pain when the resident reported to the staff her right leg and foot felt numb, cold and had severe, constant pain, in order to determine if additional interventions were required to relieve the resident?s pain. 3. Promptly notify and consult with Resident 12?s physician or nurse practitioner when the resident?s right leg and foot pain was not relieved as manifested by groaning, moaning, crying, and screaming of pain for one and a half hours after she was administered a narcotic pain medication to obtain effective pain control interventions, and to determine if the resident required additional medical assessment and treatment. 4. Promptly administer additional pain medication as ordered by the physician, after Resident 12 reported to the licensed nurse, right leg and foot pain level rating increased after the administration of a narcotic pain medication, to ensure pain relief was attained. 5. Implement Resident 12?s care plan regarding pain as follows: a. Assess if the resident has pain to include the site, pain scale (0 to 10), type of pain. b. Reassess the resident 30 minutes to 1 hour after pain medication is given to determine if relief is noted, and to refer accordingly. c. Elevate resident?s legs as tolerated when sitting to promote comfort. 6. Assess upon readmission to the facility specific characteristics of pain such as the primary location, quality, character, onset, duration, aggravating or alleviating factors, effectiveness of the current pain management regimen, history of pain management, effects of the pain, and the resident?s goals for pain and acceptable or tolerable level of pain, in order to determine if the resident?s pain control needs changed or if the resident required additional pain control interventions. As a result, Resident 12 experienced unnecessary, prolonged, pain and suffering due to a delay in nursing and medical treatment for untreated right leg and foot pain. The resident was observed crying and screaming, and pleading for mercy, due to unbearable and constant pain. The above violations presented either an imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result to Resident 12. |
| 920000001 |
All Saints Healthcare |
920012874 |
A |
9-Jan-17 |
7JR111 |
12461 |
CFR 483.25 Quality of Care Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. CFR 483.25 (g) (2) Ng Treatment/Services ? Restore Eating Skills Based on the comprehensive assessment of a resident, the facility must ensure that -- (1) A resident who has been able to eat enough alone or with assistance is not fed by naso-gastric tube unless the resident's clinical condition demonstrates that use of a naso-gastric tube was unavoidable; and (2) A resident who is fed by a naso-gastric or gastrostomy tube receives the appropriate treatment and services to prevent aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers and to restore, if possible, normal eating skills. 483.25 (h) Accident Hazards/Supervision/Devices The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. On 9/16/16, at 8 a.m., an unannounced visit was made to the Skilled Nursing Facility (SNF) to investigate a complaint regarding Resident 1?s gastrostomy tube (GT ? a flexible tubing surgically inserted into the stomach through the abdominal wall to provide nutrition and medication) being pulled out (dislodged) during care resulting in blood loss. Based on interview and record review, the facility failed to provide its residents with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, by failing to ensure that a resident who is fed by a gastrostomy tube receives the appropriate treatment and services to prevent complication, and by failing to ensure each resident receives adequate supervision and assistance devices to prevent accidents, including: 1. Failure to ensure Resident 1, who required total care and two-person assistance with transfers, was transferred by two persons as per assessment as indicated in the plan of care and facility?s policy. 2. Failure to ensure the GT was safely handled during care to prevent dislodgement, pain, and bleeding complication. 3. Failure to ensure the plan of care developed for GT care included interventions for the nursing staff to safely handle the tubing when providing care to the resident including transferring and repositioning. 4. Failure to ensure the plan of care developed for the resident?s potential for accidents/injuries related to inability to balance self when turning to the sides, included individualized interventions addressing the specific techniques and number of support persons to prevent accidental dislodgement of the GT. 5. Failure to ensure implementation of the facility?s policy and procedure on Patient Lifting and Transferring Guidelines which indicated the resident will be evaluated for safety and an individualized care plan would be initiated to address how a resident will be moved. As a result, on September 13, 2016, Resident 1?s GT dislodged causing bleeding from the GT stoma (artificial opening on the abdomen leading to the stomach) site requiring transfer to a general acute care hospital (GACH) where the resident underwent sutures of the GT stoma site to stop the bleeding and blood transfusion with over six units of blood. A review of the admission record indicated Resident 1 was initially admitted to the facility on XXXXXXX, with diagnoses including dysphagia (difficulty in swallowing), GT feeding, comatose (prolonged unresponsiveness ? deep sleep), chronic kidney disease Stage 3 (CKD3 - progressive loss of kidney function), anemia (the blood lacks healthy red blood cells to transport oxygen throughout the body), and chronic respiratory failure. A care plan dated August 31, 2016, developed for the resident requiring maximum assistance with all activities of daily living (ADLs ? eating, repositioning, transferring, toileting, bathing, and personal hygiene), included in the approaches to provide the appropriate number of support persons to assist resident with ADLs and to turn and reposition the resident maintaining proper body alignment at all times. A care plan dated August 31, 2016, developed for Resident 1?s potential for falls and injury related to inability to balance self when turned to the sides had a goal for the resident to be free from falls and injury at all times. The approaches included turning, repositioning, and transferring in and out of bed using the right technique and number of support people. The plan of care did not specify the right techniques for the nursing staff to use and the number of support staff to assist during turning and repositioning to prevent injuries. A care plan dated August 31, 2016, developed for the resident?s alteration in nutrition due to presence of GT feeding, included in the approaches to check placement and patency of the GT per protocol. The plan of care did not include techniques for the nursing staff to safely handle the GT and the connecting tubing to prevent accidental dislodgement. On September 4, 2016, a laboratory test indicated Resident 1 had a low hemoglobin (HGB - a protein in red blood cells that carries oxygen throughout the body) level at 8.5 grams per deciliters gm/dl (normal range 11.0-18.0) and a low hematocrit (HCT - a protein in red blood cells that carries oxygen throughout the body) level at 26.5% (normal range 35.0 -53.7). The Minimum Data Set (MDS - standardized assessment and care planning tool) dated September 9, 2016, indicated Resident 1 was totally dependent on two-person physical assistance with all ADLs. Resident 1 weighed 209 pounds and had impaired functional range of motion (unable to move the joints) on both upper and lower extremities. According to a nursing note dated September 13, 2016, timed at 11:30 a.m., Licensed Vocational Nurse 1 (LVN 1) reported to Registered Nurse 1 (RN 1) Resident 1's GT was accidentally removed during repositioning. At 12:10 p.m., LVN 1 reported to RN 1 Resident 1's GT stoma site was bleeding and the dressing was totally soaked with blood. The nursing notes indicated direct pressure dressing and ice pack were applied to Resident 1's GT stoma site but the interventions were ineffective. Physician 1 was notified and ordered to transfer Resident 1 to nearest GACH emergency department (ED) due to the active bleeding on the GT stoma site. A review of GACH 1 inter-hospital transfer summary indicated Resident 1 arrived to the ED at 1:19 p.m., the GT stoma site was sutured to stop the bleeding. At 4:07 p.m., Resident 1's laboratory results indicated the HGB was 7.6 g/dl and the HCT was 24.3%. At 4:46 p.m., Resident 1 received a blood transfusion of one unit of packed red blood cells (PRBC). Resident 1 was admitted to GACH 1. On September 15, 2016, Resident 1 received two units of PRBCs and on XXXXXXX Resident 1 was transferred to GACH 2. On September 17, 2016, at GACH 2, Resident 1 received four more units of PRBCs. The resident remained in GACH 2 until XXXXXXX when Resident 1 was discharged to another SNF. A review of the nursing assignment for September 13, 2016, indicated CNA 1, CNA 2, and LVN 1 were assigned to Resident 1, RN 1 was the charge nurse and RN 2 was the RN Supervisor. October 25, 2016 at 4 p.m., during a concurrent interview with the Director of Nursing and the Director of Staff Development (DSD), they explained CNAs are assigned in pairs so they can safely care for the residents. The DSD stated almost all the adult residents, including Resident 1, required two- person assistance. The DSD stated CNA 2 should have asked another CNA or her charge nurse for assistance. On October 25, 2016, at 1:57 p.m., during an interview, LVN 1 stated when CNA 2 informed her of the GT dislodgement, she replaced it as per facility protocol and notified Physician 1 when she could not stop the bleeding from the stoma site. On October 25, 2016, at 2:18 p.m., during an interview, CNA 2 stated she was turning Resident 1 to change the incontinent brief. CNA 2 stated she thought she could turn Resident 1 by herself as CNA 1 was relieving another CNA and did not ask other CNAs or her charge nurse for assistance. CNA 2 stated the GT was tangled with Resident 1's hand and when she turned the resident, the G-tube was dislodged. A review of the facility's policy and procedure titled, "Patient Lifting and Transferring Guidelines," dated August 27, 2015, indicated the unit manager or charge nurse will evaluate residents for safety and determine how the resident will be moved on admission, and as needed thereafter. A care plan will be initiated and individualized to address how a resident will be moved. Each resident over 50 pounds would be moved using either two persons or a mechanical lift. On December 7, 2016, during an interview, the Director of Nursing (DON) stated the care plan should include nursing interventions to prevent complications such as proper placement of the tubing prior to moving the resident. A review of the staff in-service form titled, "G tubes," dated July 7, 2015, indicated the educational objectives included to be aware of resident tubing when turning, repositioning, and transferring residents and to be careful with resident tubing when working with the residents. Make sure the resident is not laying on any type of tubing, and give the tubing enough slack when turning, repositioning, and transferring. Communicate with your nurse if the GT is dislodged. The sign-in sheet indicated CNA 2 attended this in-service. A review of the in-service titled, "Lifting criteria and care plans for residents," dated September 27, 2015, indicated the educational objectives included a care plan would be initiated and individualized to address how a resident would be moved. The in-service indicated each resident over 50 pounds would be moved using either two persons or a mechanical lift. The sign-in sheet indicated CNA 2 attended this in-service. The facility failed to provide its residents with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, by failing to ensure that a resident who is fed by a gastrostomy tube receives the appropriate treatment and services to prevent complication, and by failing to ensure each resident receives adequate supervision and assistance devices to prevent accidents, including: 1. Failure to ensure Resident 1, who required total care and two-person assistance with transfers, was transferred by two persons as per assessment as indicated in the plan of care and facility?s policy. 2. Failure to ensure the GT was safely handled during care to prevent dislodgement, pain, and bleeding complication. 3. Failure to ensure the plan of care developed for GT care included interventions for the nursing staff to safely handle the tubing when providing care to the resident including transferring and repositioning. 4. Failure to ensure the plan of care developed for the resident?s potential for accidents/injuries related to inability to balance self when turning to the sides, included individualized interventions addressing the specific techniques and number of support persons to prevent accidental dislodgement of the GT. 5. Failure to ensure implementation of the facility?s policy and procedure on Patient Lifting and Transferring Guidelines which indicated the resident will be evaluated for safety and an individualized care plan would be initiated to address how a resident will be moved. As a result, on September 13, 2016, Resident 1?s GT dislodged causing bleeding from the GT stoma (artificial opening on the abdomen leading to the stomach) site requiring transfer to a general acute care hospital (GACH) where the resident underwent sutures of the GT stoma site to stop the bleeding and blood transfusion with over six units of blood. The above violations presented either an imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result and was a direct proximate cause of death of Resident 1. |
| 920000280 |
ANTELOPE VALLEY CARE CENTER |
920012883 |
A |
13-Feb-17 |
GGOY11 |
18439 |
CFR 483.25 F309
Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
The facility failed to ensure Resident 1, who wore an arm sling for immobilizing (prevent movement) the arm after shoulder surgery, was provided the necessary care and services to prevent skin breakdown and infection, that led to rehospitalization, by failing to:
1. Develop a plan of care with interventions to address care provisions to a resident using an immobilizer (arm sling).
2. Provide and ongoing skin assessment and monitoring in order to ensure an identified skin condition on admission was resolving or worsening.
3. Obtain and/or clarify the physician?s order for the care of a resident using a sling in order to prevent complications from the use of the device.
4. Prevent the progression of a skin infection for a resident at high risk for skin trauma due to the use of anticoagulant (a medication used to help prevent blood to clots) therapy.
The facility?s failure resulted in Resident 1?s development of a candidiasis (a yeast-like parasitic fungus) infection, and skin breakdown under the right armpit. She required hospitalization in a general acute care hospital (GACH) for 5 days, to treat the infection.
On October 21, 2016, an unannounced visit (CA00508093) was conducted as the result of an informal conference.
A review of Resident 1's general acute care hospital (GACH) operative report, dated August 27, 2015, indicated an immobilizer (sling) was placed after surgery.
A review of Resident 1's admission record indicated she was originally admitted to the skilled nursing facility (SNF) on XXXXXXX 2015 and readmitted on XXXXXXX 2015, with diagnoses that included, epilepsy (abnormal electrical activity in the brain), aftercare following joint replacement surgery, (open repair of traumatic (denoting physical injury), rotator cuff (tendons of the muscles of the shoulder) tear right shoulder on September 4, 2015), muscle weakness, hemiplegia (paralysis of one side of the body), following a cerebrovascular disease (a stroke) affecting the left side, long term (current) use of anticoagulants, and diabetes mellitus (abnormally high levels of the sugar glucose in the blood.)
A review of Resident 1's initial SNF admission assessment dated September 6, 2015, indicated a discoloration was noted on the right armpit area. A review of nursing admission notes dated September 6, 2015, did not indicate Resident 1 was admitted to the SNF with a sling.
A review of physician's progress notes on September 6, 2015, September 14, 2015, September 16, 2015, and September 17, 2015 indicated resident had a sling to right upper extremity and skin was warm and dry, no rash or erythema (a superficial reddening of the skin as a result of injury or irritation causing dilatation of the blood capillaries) present.
A review of the skin trauma risk assessment dated September 6, 2015, indicated Resident 1 was at ?high risk? due to poor nutrition, three or more predisposing diagnoses present, taking anticoagulants, (medication to prevent blood from clotting),analgesics (medication that relieves pain), having intermittent confusion and having a current skin problem. The current use of a device (sling) was not identified on the assessment.
A review of Resident 1?s restorative nursing assistance [RNA-restorative aide to help residents recover their physical emotional and mental health by providing rehabilitation care] range of motion (ROM) screening dated September 8, 2015, indicated how to appropriately perform ROM for non-weight bearing (no weight to be put on the arm) upper extremities. The screening did not indicate Resident 1 had a sling or how to perform ROM to a resident using a sling.
A review of the interdisciplinary team (a coordinated group of medical experts) review (ITR) notes, conducted on September 8, 2015, with FM 1, indicated Resident 1 had a right shoulder immobilizer (sling). The ITR did not address necessary care required to prevent the progression of a skin infection to a resident who was immobile and at a high risk for skin trauma due to the use of anticoagulant (a medication used to help prevent blood to clots) therapy.
A review of Resident 1's Minimum Data Set [MDS-comprehensive assessment] dated September 13, 2015, indicated her cognitive status was moderately impaired. The MDS indicated Resident 1 needed extensive assistance with a minimum of one person assist for bed mobility, dressing, and personal hygiene, and was totally dependent on one person physical assistance with bathing. The MDS indicated Resident 1 had an impairment of both upper extremities, and had a shoulder joint replacement.
Resident 1 had a care plan initiated on September 14, 2015, for limitations in joint mobility related to status post shoulder surgery, history of cerebrovascular accident (stroke) with left hemiplegia (left sided weakness). The intervention approaches included to monitor areas of potential breakdown for redness and notify the physician accordingly, and non-weight bearing to the right shoulder.
Another care plan initiated on September 14, 2015, indicated Resident 1 was at "High risk for skin discoloration/hematoma (a collection of blood outside of a blood vessel), skin tears/skin breakdown" due to use of anticoagulants, and use of device (type not indicated). Intervention approaches included to monitor skin condition at least once a day, notify the physician if skin redness discoloration impairments are noted, handle gently during care, and provide good skin care.
A review of Resident 1's care plan initiated on September 14, 2015, titled "Impaired skin integrity related to edema (swelling)" included an approach to monitor increasing in size and to report to the physician promptly. The care plan did not address the discoloration noted on the right armpit area identified during the initial SNF admission assessment of September 6, 2015.
A review of Resident 1's physician's order summary dated September 5, 2015, indicated Coumadin (an anticoagulant), five milligrams by mouth in the evening for atrial fibrillation (an irregular fast heart rate), was ordered, and was discontinued on September 14, 2015. A new order was obtained on September 14, 2015, for Coumadin two milligrams by mouth in the evening every Thursday for atrial fibrillation. The physician?s order summary did not indicate the nursing staff obtained or clarified the physician?s order for the care of a resident regarding the use of a sling in order to prevent complications.
A review of Resident 1's international normalized ratio [INR- a calculation used to monitor blood thinning medications] results dated September 14, 2015, was 2.3 (high), indicating the resident was more likely to experience skin changes. The reference range is between 0.8 and 1.2.
The National Institutes of Health/U.S. National Library of Medicine, MedlinePlus, regarding the use of Warfarin (Coumadin), indicates that a physician must be called immediately if a purplish or darkened color to skin, skin changes, ulcers, or an unusual problem in any area of the skin or body, or color or temperature change in any of the body is experienced by the patient (resident).
A review of Resident 1's physician's order summary dated September 16, 2015, indicated no range of motion to the right shoulder, non-weight bearing on right shoulder every day shift for non-weight bearing until October 18, 2015. The summary indicated RNA (restorative nursing assistant) for range of motion to the right elbow towards flexion and extension (bending and straightening the elbow) every day, 5 days a week for 90 days every day shift. There was no physician order to remove the resident?s sling as part of providing daily care needs to the resident or to assess and monitor the resident?s skin status in relation to the sling use. There was no documented evidence the physician was notified of the discoloration of the resident?s right armpit as indicated in the care plan.
A review of occupational and physical therapy plans of care, dated September 8, 2015, did not indicate Resident 1?s use of a sling/immobilizer. A review of occupational therapy discharge summary, dated September 16, 2015, indicated incorporation of assistive/adaptive equipment into safety skills education. Resident was discharged to RNA program. The type of device was not indicated in the discharge summary and to whom discharge instructions were given to.
A review of an ITR dated September 18, 2015, indicated rehabilitation services have been transferred to RNA program and RNAs have been educated and trained appropriately regarding ROM and exercises. The ITR did not specify how to care for Resident 1 for the use of the sling as part of providing daily care needs, or to assess and monitor the resident?s skin in relation to the sling.
A review of certified nursing assistant (CNA) daily flow sheets for September 7, 2015, to September 21, 2015, indicated Resident 1 was receiving partial and full bed baths and was dependent on full staff assistance. The daily flow sheets did not specify Resident 1?s sling was removed or the resident?s skin was observed when providing daily care needs, to determine the resident?s skin status.
There was no documented evidence in Resident 1's licensed nurses notes, certified nursing notes, rehabilitation notes, RNA notes or progress notes from September 6, 2015, when the resident was readmitted to the SNF, to XXXXXXX 2015, when the resident was discharged home, to indicate the status of the resident?s right armpit. There was no documented evidence of an ongoing assessment of Resident 1?s armpit area, to include the size and color of the area, or if any drainage was present, whether intervention was required or if the discoloration was resolving or worsening.
A review of the Licensed Personnel Progress notes dated September 21, 2015, at 6:50 p.m., indicated Resident 1 was discharged home. A review of the licensed nurse discharge note dated September 21, 2015, did not indicate Resident 1?s shoulder staples, shoulder dressing, right axilla (armpit) discoloration, or that the resident had a right arm sling. There was no documented evidence that education was provided to Resident 1 or FM 1 regarding skin care, with the consideration of the presence of her arm sling.
A review of Resident 1's GACH emergency room (ER) assessment dated September 23, 2015, at 2:50 p.m., indicated the resident was evaluated and treated 44 hours after being discharged from the SNF. Resident 1 was diagnosed with a skin rash (moist skin breakdown) to the right armpit.
A review of GACH physician's consultation notes dated September 26, 2015, indicated Resident 1 was admitted to the GACH and was diagnosed with right axilla (armpit) candidiasis and tinea (ringworm). Resident 1 was treated with Nystatin Powder and Lamisil (antifungal medications), and was being administered Zyvox and Levaquin (antibiotics used to treat different types of bacterial infections).
A review of the GACH transfer records dated XXXXXXX 2015, indicated Resident 1 and FM 1 refused to return to the SNF and Resident 1 was discharged home with FM 1.
On October 21, 2016, during an interview at 12:00 p.m., the director of rehabilitation (DOR) stated residents who have an immobilizer and have an order for non-weight bearing to the extremity, the physician would order not to remove the immobilizer. The DOR stated the immobilizer would be removed during physical and occupational therapy treatment. The DOR stated a physician's order is required for the removal frequency of the immobilizer. When the DOR was asked regarding checking the resident?s skin when an immobilizer is removed, the DOR stated the skin assessment is under nursing care and the nurses are supposed to check for orders regarding removing the immobilizer.
On October 21, 2016 at 12:30 p.m., during an interview the licensed vocational nurse (LVN 1) stated usually there are orders on how to care for residents with an immobilizer.
A review of Resident 1?s physician order summary dated September 16, 2015, did not include an order with instructions on how to provide skin and hygiene care for the resident who had an arm immobilizer (sling).
On October 21, 2016, at 2:00 p.m., during an interview with the director of nursing (DON) while reviewing Resident 1?s medical record, she stated when a resident has a hard immobilizer/brace, the skin is to be checked every two hours. She stated the monitoring for skin discoloration should be addressed in the care plan and documented in the medication administration record (MAR) or the treatment administration record (TAR). The DON could not provide documentation on the September 2015 MAR or TAR, to indicate Resident 1?s right armpit condition was monitored and/or assessed during the resident?s SNF stay.
On October 21, 2016, at 2:50 p.m., during an interview and concurrent record review, licensed vocational nurse (LVN 2) stated Resident 1 had discoloration under her armpit at admission. LVN 2 could not provide documentation related to the skin discoloration to Resident 1?s right armpit on the admission note. LVN 2 stated no orders were indicated on the MAR to monitor the discoloration of the armpit.
On October 21, 2016, at 3:05 p.m., during an interview, LVN 3 stated she cared for Resident 1 during her admission. LVN 3 stated she fixed Resident 1's sling during repositioning, but did not look at the resident?s right armpit. LVN 3 stated she did not remove the resident?s sling to assess the resident?s skin.
On November 7, 2016 at 10:30 a.m., during an interview Physician 1 stated she does not recall receiving a call from the nursing staff regarding a skin issue or for clarification of the sling order for Resident 1.
On November 8, 2016, at 10:53 p.m., during an interview, LVN 4 stated he recalled the report was to not remove Resident 1?s sling at all. LVN 4 stated Resident 1 and FM 1 would get upset when staff would touch the arm. LVN 4 stated Resident 1 would scream when staff attempted to touch or look under the sling. LVN 4 stated he did not check the physician order regarding the sling. LVN 4 stated he should have looked at the orders related to the sling.
During a phone interview on November 17, 2016, at 9:30 a.m., Registered Nurse (RN) 1 stated she is no longer employed at the SNF. She stated she does not recall Resident 1. RN 1 stated while employed at the SNF, the role of the RN supervisor was to ensure the LVN completed assessments correctly.
A review of the facility's policy and procedure dated May 17, 2016, titled "Skin Assessment Clinical Guideline" indicated skin assessments are to be completed on admission and as needed. The following will be completed by:
1. Upon admission an assessment will be completed by a licensed nurse and documented. The assessment will include but is not limited to: trunk, observation of suspected deep tissue injuries, bruising, discoloration of skin, rashes, dry skin, surgical incisions and/or scars.
2. On a daily basis: CNAs will observe skin during a.m., and p.m. care, bathing, showers, during turning and incontinent care and will report skin concerns to the charge nurse immediately.
3. On as needed basis: Licensed nurses are to do skin assessment/reassessment of all residents identified as high risk for skin breakdown. The licensed nurse will document assessment, intervention and outcome.
4. If a problem with integrity is noted the nurse will document the problem, notify the physician and family, initiate treatment per physician orders and initiate a plan of care entry. The nurse needs to review and revise the care plan to respond to new problems or needs.
A review of the facility's "Use of rehab equipment and adaptive equipment" undated policy and procedure indicated will use rehab equipment(s) and/or adaptive equipment(s) in conjunction with their professional clinical skills, experience, judgements, ability and knowledge in compliance with applicable statutes, regulations, rules, and directives of regulatory bodies having jurisdiction over facility and all currently acceptable and approved methods and practices of the professional specialty of therapy in which the particular individual providing the service is involved.
A review of the facility's undated policy and procedure titled, "Admission Procedures," indicated the registered nurse (RN) should thoroughly review the admission orders, ensure accuracy, assess resident for significant medical compromise, take note of body check, skin edema, incisions, and dressings.
A review of the manufacturer?s Arm Sling instructions includes a warning issued to follow the facility's policy and procedure for frequency of patient (resident) monitoring. The manufacturer recommends that this product be removed a least every two hours to check for skin integrity, proper circulation and range of motion.
The facility failed to ensure Resident 1, who wore an arm sling for immobilizing the arm after shoulder surgery, was provided the necessary care and services to prevent skin breakdown and infection, that led to rehospitalization, by failing to:
1. Develop a plan of care with interventions to address care provisions to a resident using an immobilizer.
2. Provide and ongoing skin assessment and monitoring in order to ensure an identified skin condition on admission was resolving or worsening.
3. Obtain and/or clarify the physician?s order for the care of a resident using a sling in order to prevent complications from the use of the device.
4. Prevent the progression of a skin infection for a resident at a high risk for skin trauma due to the use of anticoagulant therapy.
The facility?s failure resulted in Resident 1 developing a candidiasis infection and skin breakdown under the right armpit. She required rehospitalization in a GACH for 5 days, to treat the infection.
The above violations, jointly, separately or in any combination presented a substantial probability that serious physical harm would result. |
| 920000001 |
All Saints Healthcare |
920013111 |
B |
10-Apr-17 |
8C4111 |
6988 |
F-226 CFR 483.13 ? Staff Treatment of Residents
The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property.
On 1/25/17, an unannounced visit was made to the facility to investigate a complaint regarding Resident 1 being subject of abuse from certified nursing assistant 1 (CNA 1).
Based on observation, interview, and record review, the facility failed to ensure written policies and procedures that prohibit abuse of residents were implemented including:
1. Failure to investigate an alleged abuse resulting in a discolored bruise on the left upper arm.
2. Failure to report within 24 hours, to the Department and Ombudsman office, an incident of alleged abuse inflicted by CNA 1 to Resident 1
As a result, Resident 1 was placed at risk for further abuse and increased fear and crying episodes when the alleged perpetrator, CNA 1, entered Resident 1?s room.
A review of the admission record indicated Resident 1 was admitted to the facility on XXXXXXX15, with diagnoses including chronic respiratory failure (condition in which not enough oxygen passes from your lungs into your blood) and intracerebral hemorrhage (bleeding in the brain).
The Minimum Data Set (MDS ? standardized assessment and care planning tool), dated 11/14/16, indicated Resident 1 was able to respond adequately to simple, direct communication; required extensive assistance during bed mobility and dressing; and was totally dependent for toilet use, personal hygiene, and bathing with one to two persons physical assistance.
A review of the care plan developed 1/20/17 for Resident 1?s skin discoloration on left upper arm, had a goal was for Resident 1 to have clear skin in 14 days. The care plan approaches included monitoring the affected area for increase in size, any changes, and to handle the resident gently at all times.
On 1/25/17, at 1:05 p.m., Resident 1 was observed in her room, sitting upright on the bed and was noted to have a yellowish-reddish skin discoloration on her left upper arm of approximately 6 centimeters. During a concurrent interview, Resident 1 stated a CNA who worked in the afternoon grabbed her on the left upper arm. Resident 1 was unable to recall the CNA's name, but stated she was able to identify the CNA.
On 1/25/17, at 1:50 p.m., during an interview, Family Member 1 (FM 1) stated she was at the facility on 1/22/17, at 1 p.m. to visit Resident 1 when she saw the discoloration on Resident 1's left upper arm and Resident 1 reported it was caused by a CNA. FM 1 stated she informed Registered Nurse 1 (RN 1) of the allegation of abuse and showed the bruise on Resident 1's left upper arm. At around 3:30 p.m. that day, FM 1 stated there were two CNAs inside Resident 1's room, a female CNA (CNA 1) and a male CNA (CNA 2) providing care to Resident 1?s roommate and Resident 1 identified the CNA 1 as the one who grabbed her on her left upper arm. FM 1 stated Resident 1 started to cry and was scared.
On 1/25/17, at 2 p.m., during an interview, RN 2 stated the discoloration on Resident 1's left upper arm was identified on 1/20/17, at 2:30 p.m. Resident 1 complained of mild pain on her left upper arm and Tylenol (a medication used to treat mild pain) was administered. RN 2 stated the physician was informed of the discoloration and ordered an x-ray, which was negative for fracture. After reviewing the clinical record, RN 2 was unable to find documentation of the size of the discoloration.
The facility policy and procedure titled, "Documentation of Bruises," dated 5/1/10, indicated the facility must properly assess and identify proper skin care and management of the affected area. The site and size must be noted and the wound care nurse must evaluate the progress and effectiveness of the therapy every week.
According to the facility?s policy and procedure titled, "Reporting of Alleged Abuse," dated 1/1/99, should any employee be informed of an allegation of abuse or directly witness abuse, the employee is charged with the responsibility of reporting the alleged incident immediately. The employee must immediately notify his/her supervisor of the allegations. A thorough investigation must be conducted in order to ascertain all the events that allegedly occurred. The investigation would be timely and would be given priority. Any authorities that need to be contacted (Police Department, Ombudsman, Department of Public Health) would be contacted within 24 hours.
On 1/25/17, at 2 p.m., during an interview, the Director of Nursing (DON) stated she did not suspect abuse and should have exerted more effort in finding out what happened to Resident 1 and not assume. The DON reviewed the clinical record and was unable to find any documentation of the alleged abuse and there was no plan of care developed for the alleged abuse.
On 1/26/17, at 1:30 p.m., during a telephone interview, RN 1 stated she informed the DON that FM 1 was very upset and reported an alleged physical abuse by a staff towards Resident 1. RN 1 stated on 1/22/17, the family approached her and stated they knew who abused Resident 1 and Resident 1 cried when CNA 1 entered her room. RN 1 further indicated she noticed Resident 1 covered herself with blanket upon seeing CNA 1. RN 1 stated she spoke to CNA 1 outside of Resident 1's room and asked what happened but CNA 1 denied the abuse allegation. RN 1 stated CNA 2 took over Resident 1's care the rest of the shift. RN 1 stated she did not document the alleged abuse on 1/22/17 because she assumed it was all taken care of.
On 1/26/17, at 2:30 p.m., during a follow up telephone interview, the DON confirmed she was informed by RN 1 on 1/22/17 regarding FM 1's concern and the allegation of abuse by CNA 1 towards Resident 1. The DON was unable to explain the reason she did not follow the facility's protocol during an allegation of abuse and did not report the abuse allegation to the proper authorities within 24 hours.
On 2/1/17, at 7:15 a.m., during an interview, CNA 1 denied abuse and stated when she worked on 1/20/17 (3 p.m. to 11 p.m. shift,) the skin discoloration was already present. CNA 1 stated she was not assigned to Resident 1 prior to 1/20/17.
The facility failed to ensure written policies and procedures that prohibit abuse of residents were implemented including:
1. Failure to investigate an alleged abuse resulting in a discolored bruise on the left upper arm.
2. Failure to report within 24 hours, to the Department and Ombudsman office, an incident of alleged abuse inflicted by CNA 1 to Resident 1
As a result, Resident 1 was placed at risk for further abuse and increased fear and crying episodes when the alleged perpetrator, CNA 1, entered Resident 1?s room.
The above violation had direct or immediate relationship to the health, safety, or security of Resident 1. |
| 920000002 |
ASTORIA NURSING AND REHAB CENTER |
920013340 |
B |
12-Jul-17 |
3QJ011 |
9447 |
F224
?483.12 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident?s symptoms.
483.12(b) The facility must develop and implement written policies and procedures that:
(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,
(b)(2) Establish policies and procedures to investigate any such allegations, and
(b)(3) Include training as required at paragraph ?483.95,
F241
?483.10 (a)(1) A facility must treat and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life recognizing each resident?s individuality. The facility must protect and promote the rights of the resident
F309
?483.24 Quality of life
Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident?s comprehensive assessment and plan of care.
On May 23, 2017, at 8:48 a.m. during recertification survey, Resident 1?s quality of care and quality of life status were investigated.
Based on observation, interview, and record review, the facility failed to ensure the resident has the right to be free from abuse; failed to ensure the resident is treated and care for in a manner and in an environment that promotes dignity and respect; and failed to ensure the resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident?s assessment and plan of care, including:
1. Failure to ensure Certified Nursing Assistant 1 (CNA 1) did not rough handled Resident 1 while dressing the resident.
2. Failure to ensure CNA 1 stopped providing care when Resident 1, yelling and crying in pain, told CNA 1 several times, to stop because she (Resident 1) had a broken arm and CNA 1 was hurting her.
3. Failure to ensure CNA 1 was informed Resident 1 had a fracture to the left clavicle (broken collar bone) and to implement the plan of care to promote Resident 1?s independence by allowing time to the resident to perform each task before offering assistance.
4. Failure to implement the facility?s policy on Staff Treatment of Residents and Resident Rights by CNA 1 mistreating and disrespecting Resident 1.
As a result, on May 23, 2017, Resident 1 experienced rough treatment, disrespect, was given care against her will, suffered unnecessary pain and mental anguish, and had the potential to result in complication from a re-injured left collar bone.
According to the admission record, Resident 1 was admitted to the facility on XXXXXXX 2017, with diagnoses including fracture of the left clavicle and history of fall.
A plan of care developed on admission for Resident 1's problem/concern of left clavicle fracture with history of fall, included in the interventions providing physical therapy (PT) and occupational therapy (OT) as ordered and encouraging as much independence as possible by allowing time to the resident to perform each task before offering assistance.
A review of Resident 1's History and Physical (H&P) examination by the physician, dated May 20, 2017, indicated the resident had a left distal (close to the shoulder) clavicle fracture and was admitted to the facility for rehabilitation trial due to fall and weakness.
A plan of care developed on May 22, 2017, for Resident 1's use of a left arm sling (a hanging bandage suspended from the neck to support an injured arm and prevent movement), included in the interventions providing therapy exercises, safety training, and cognitive (thinking) training.
According to the licensed nursing notes from May 20 to May 22, 2017, Resident 1 was awake, alert, and able to follow directions.
On May 23, 2017 at 8:48 a.m., Resident 1's room door was observed closed and Resident 1 could be heard from the hallway yelling and screaming from inside the room. Resident 1 was saying, "I have broken arm, stop, you are hurting me." From 8:48 a.m. to 8:51 a.m., Resident 1 was continuously yelling and screaming (pausing 10 to 15 seconds at times) repeating, "Stop, you are hurting me, my arm hurts."
At 8:51 a.m., upon entering the room, Resident 1 was observed lying in bed on her right side, her knees were bent and drawn up to her abdomen, and was crying while CNA 1 was standing at Resident 1?s bedside. When asked what was happening, Resident 1 stated CNA 1 rough handled her, and she told CNA 1 to stop because her arm was broken and it was hurting. CNA 1 upon interview stated there was, ?No issue? and she was just changing the resident?s clothes. When Resident 1 heard what CNA 1 had just said, Resident 1 indicated CNA 1 was lying and stated she (CNA 1), "Roughed her up."
On May 23, 2017 at 8:53 a.m., CNA 1 explained she touched Resident 1's left arm while attempting to put the resident's arm into the long sleeves of her blouse. CNA 1 stated she did not stop after the resident verbalized more than once her arm was hurting, when she was supposed to stop.
On May 23, 2017 at 12 p.m., during a follow up interview, CNA 1 stated she did not know Resident 1 had a clavicle fracture and when the resident complained of having broken bones and kept trying to push her away, she (CNA 1) assumed the resident was confused. CNA 1 stated she was assigned to the resident also the day before (May 22, 2017) and was not informed by the licensed nurses Resident 1 had a broken clavicle.
On May 23, 2017 at 2:29 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated she did not notify CNA 1 of Resident 1's fractured clavicle on May 22 and 23, 2017. LVN 1 stated she assumed CNA 1 knew about the resident's fractured clavicle, because the resident was wearing a sling on May 22, 2017. LVN 1 also stated she should have notified CNA 1 to be extra careful with Resident 1 while providing care, because the resident had a broken bone.
On May 23, 2017 at 2:43 p.m., during an interview, Occupational Therapist 1 (OT 1) stated a clavicle fracture could be painful during upper body dressing.
On May 24, 2017 at 7:43 a.m., during an interview, the Director of Staff Development (DSD) stated if Resident 1 was complaining of pain during care and was asking CNA 1 not to touch her, CNA 1 should have stopped and notify the charge nurse.
A review of the facility's policy and procedure dated December 2016, titled "Staff Treatment of Residents" indicated preventive practices are those that work to preclude, eliminate, or lessen the possibility of resident abuse through development and implementation of written policies and procedures that prohibit mistreatment, neglect, abuse, and misappropriation of resident property. Training includes initial employee orientation that includes employee written acknowledgement of the legal responsibilities and residents' rights.
A review of the facility's Resident Rights document indicated a resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The respect and dignity, section of the document indicated a resident has the right to be treated with respect and dignity including the right to reside and receive services in the facility with reasonable accommodation of their needs and preferences.
The facility failed to ensure the resident has the right to be free from abuse; failed to ensure the resident is treated and care for in a manner and in an environment that promotes dignity and respect; and failed to ensure the resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident?s assessment and plan of care, including:
1. Failure to ensure Certified Nursing Assistant 1 (CNA 1) did not rough handled Resident 1 while dressing the resident.
2. Failure to ensure CNA 1 stopped providing care when Resident 1, yelling and crying in pain, told CNA 1 several times, to stop because she (Resident 1) had a broken arm and CNA 1 was hurting her.
3. Failure to ensure CNA 1 was informed Resident 1 had a fracture to the left clavicle (broken collar bone) and to implement the plan of care to promote Resident 1?s independence by allowing time to the resident to perform each task before offering assistance.
4. Failure to implement the facility?s policy on Staff Treatment of Residents and Resident Rights by CNA 1 mistreating and disrespecting Resident 1.
As a result, on May 23, 2017, Resident 1 experienced rough treatment, disrespect, was given care against her will, suffered unnecessary pain and mental anguish, and had the potential to result in complication from a re-injured left collar bone.
The above violation had direct or immediate relationship to the health, safety, or security of Resident 1. |
| 930000793 |
ALHAMBRA HOSPITAL MEDICAL CENTER D/P SNF |
930011599 |
B |
30-Jul-15 |
X7O812 |
16159 |
CFR 483.25(c) Pressure Sore Based on the comprehensive Assessment of a resident, the facility must ensure that ? (1) A resident who enters the facility without pressure sores does not develop pressure sores unless the individual?s clinical condition demonstrates that they were unavoidable; and (2) A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Based on observation, interview, and record review, the facility failed to ensure: (1) Resident 1 with a pressure sore (ulcer) received appropriate treatment during wound care to prevent infection; (2) A pain management program was in place for Resident 1; (3) Resident 1 was handled in a gentle manner during dressing change. The above violations had the potential to result in increased pain and suffering, preventing ulcer from healing, and cause harm to Resident 1. Findings: 1. On April 16, 2015 at 8 a.m., during the recertification survey, Resident 1 was observed lying on a low air loss (LAL) mattress (special air-fluidized bed which relieves pressure on the skin and promotes wound healing). Resident 1 had a tracheostomy (a tube which is surgically inserted into the airway for purposes of providing oxygen to the airway passages), which was connected to a tracheal collar (a device which delivers continuous aerosol administration of water to the upper airways in order to hydrate airway secretions, and promote cough), and was receiving a tube feeding through a gastrostomy tube (GT- a tube which is surgically inserted through the abdomen into the stomach for purposes of nutrition and medication administration).The resident, whose eyes were open, appeared to have difficulty focusing, and exhibited constant jerking motions of her head.A review of Resident 1's clinical record indicated the resident was admitted to the facility on December 23, 2012, with diagnoses which included chronic respiratory failure, history of stroke, Stage IV coccygeal pressure ulcer -full tissue thickness loss with exposed muscle, tendon, or bone- slough or eschar (dead tissue) may be present- and dementia (brain condition that causes problems with thinking and memory). A review of the Minimum Data Set (MDS- standardized assessment tool), dated March 17, 2015, indicated Resident 1 was severely impaired in her ability to make decisions, was unable to walk, was incontinent of bowel and bladder, and was totally dependent on staff for all daily living needs. A review of the recapitulated monthly summary physician orders for April 2015, indicated an order, dated December 29, 2009 for acetaminophen (Tylenol) 650 milligrams (mg) via GT every four hours as necessary for fever/pain. There were no further orders for pain medication.A review of the computerized summary sheet provided by the facility pharmacy, indicated the dates Resident 1 had received acetaminophen since her admission to the facility, was June 3, 2012, March 15, 2013, and April 18, 2013.The physician's order, dated December 31, 2013, indicated to clean decub (pressure ulcer) wound with wound cleanser, pat dry, pack with Alginate wound dressing rope, cover with 4x4 dressing daily at 12 a.m. and PRN (whenever necessary). A review of the Interdisciplinary Team (IDT) monthly meeting notes from July, 2014-March, 2015, did not address pain level assessment, nor updates on the condition of the coccygeal pressure ulcer.An undated Resident 1's care plan, titled, "Skin Fragile", indicated one of the interventions was to be gentle when handling the patient. Resident 1's care plan, titled, "Alteration in Comfort Related to Pain at Back", dated March 17, 2015, included interventions to assess discomfort and relief post intervention, PRN (as needed) meds as ordered, check effectiveness of medications given, and provide comfort measures. On April 17, 2015 at 2 p.m., an observation was conducted of Resident 1's wound care for the sacrococcygeal pressure ulcer. LVN 1 failed to ask the resident if she was having any pain, prior to starting the wound care.LVN 1 and CNA 2 turned the resident onto her left side without informing the resident. After donning disposable gloves, LVN 1 removed the old dressing, then removed the Alginate packing. The wound appeared to be one inch in length, and one half inch wide, with moderate red-brown drainage, and with a suparating appearance (the formation or discharge of pus). There was also a small amount of yellow slough (dead tissue) noted in the wound bed, and the perimeter of the wound was reddened. Wearing the same pair of gloves, LVN 1 reached for a bottle of wound cleanser and sprayed the wound, without first informing the resident. At that time, the resident jerked her body. LVN 1 then removed his gloves, and without washing/sanitizing his hands, donned another pair of gloves, and cleaned the inside of the wound with gauze in a hurried manner. The resident jerked her body a second time. LVN 1 did not ask the resident if she was having any pain, and did not stop the treatment in order to assess for pain, but continued conducting the wound care.He removed his gloves, then donned a pair of sterile gloves without washing/sanitizing his hands, and failed to do so throughout the remainder of the wound treatment. LVN 1 packed the wound with the Alginate dressing, then covered the wound with gauze, securing the dressing with Micropore tape. The skin of the resident's left buttock had several large reddened wrinkles. LVN 1 placed a Medline Ultra Absorbent ES (extra strength) disposable absorbent pad under the resident, then placed a pillowcase which contained a bath towel, under the resident's perineal area for use as an incontinent brief. LVN 1 failed to inform the resident of his actions throughout the wound care, and conducted the care in a rough, hurried manner, which included wound care, as well as changing and repositioning the resident. An interview was conducted with LVN 1 immediately following the observation. When questioned why he did not use paper tape to secure the dressing, LVN 1 responded it sometimes left a residue on the skin. He then stated the resident was usually wet, which made it easier to remove the micropore tape. When questioned regarding the redness and wrinkling of the skin on the resident's left buttock, LVN 1 replied it could be from either the urine or the tape. When questioned regarding the potential for the resident experiencing pain, LVN 1 replied, "No- she came in with the Stage IV, so it isn't like she would be in a lot of pain." Regarding not informing the resident of his actions prior to rendering care, LVN 1 stated he had informed the resident prior to starting the wound treatment, but did not tell her step by step. When asked about using a bath towel and pillowcase as an incontinent brief, LVN 1 indicated the absorbent pad was very thin, so would not be effective by itself. When pointed out that he did not wash or sanitize his hands during the wound care, LVN 1 responded, "I touched the dirty [outer] dressing, but didn't touch the inside of the wound", then stated he should have cleaned his hands throughout the treatment. LVN 1 added that he had not noticed much improvement in the appearance of the resident's pressure ulcer over the past several months, and that maybe a different treatment plan would help. When the surveyor mentioned his handling of the resident, LVN 1 had a puzzled look. At 2:05 p.m. on April 17, 2015, during an interview, the unit director stated LVN 1 should not have handled the resident in that manner, and should have asked the CNA for assistance with the resident's care. She then stated, "Maybe he's a bit nervous- he should have gotten the CNA- that shouldn't have happened." Review of a coccygeal wound culture result, dated October 31, 2012 (two days after the resident's admission to the facility) and provided by the unit director, indicated the wound was positive for moderate Staphylococcus aureus, and moderate Streptococcus dysgalactiae.On April 20, 2015 at 9 a.m., during an interview, the unit director stated a pressure ulcer is cultured if ordered by the physician. When asked what signs/symptoms of a wound might indicate need for a culture, and if there was any tunneling of Resident 1's wound, the unit director responded a wound culture would be appropriate if the wound developed an odor, increased drainage, or change in color. She then stated she would check the weekly Skin Care Progress Notes for any mention of tunneling. According to the website, woundsource .com (http://www.woundsource .com/patientcondition/tunneling-wounds-or-sinus-tracts), the article titled, "Tunneling Wounds and Sinus Tracts", dated 2008-2105, indicated a tunneling wound or sinus tract is a narrow opening or passageway underneath the skin that can extend in any direction through soft tissue and results in dead space with potential for abscess formation. When mentioned the resident had been receiving the same wound care since December, 2013, the director stated the resident's wound had gotten smaller in size since her admission. She then stated wound treatment orders should have a stop date in order to allow for reassessment of the wound, and the physician should be notified. A review of Resident 1's Skin Care Weekly Progress Notes, dated January 4, 2015-March 20, 2015, indicated the sacrococcygeal pressure ulcer average measurements were three centimeters (cm) in length, two cm in width, and 1.0-1.3 cm depth. There was no documentation the wound was checked for the presence of tunneling.On April 20, 2015 at approximately 9:35 a.m., Resident 1 was observed receiving a bed bath by LVN 2 and certified nursing assistant (CNA) 1, and was noted to be incontinent of urine. After several minutes, LVN 2 was called away to take care of another matter, and CNA 2 arrived to assist with the bath. When the resident was turned onto her side, the coccygeal dressing was observed to be saturated with urine, and had a large amount of reddish-brown drainage. CNA 2 removed the outer gauze dressing at that time. 2. On April 20, 2015 at 12:50 p.m., an observation of Resident 1's wound care treatment was conducted with LVN 2. The following tunneling measurements were obtained: One cm at 12 o'clock position, 0.8 cm at 3 o'clock, 0.2 cm at six o'clock position, and 0.8 cm at nine o'clock position. LVN 2 stated she obtained tunneling measurements when she was assigned to the resident, and when the weekly skin report was due. LVN 2 failed to wash or sanitize her hands following removal of her gloves throughout the treatment, and also failed to inform the resident of her actions, prior to rendering care.At 4:35 p.m. on April 20, 2015, during another interview regarding Resident 1's pressure ulcer, the unit director stated, "Maybe she needs a Foley catheter (a rubber tubing inserted into the bladder in order to drain urine). We try not to put in Foley catheters unless it's justified- we're afraid of UTI's (urinary tract infection). I'll talk to her doctor about inserting one." When asked if the subacute unit utilized a wound consultant, the director stated there was a wound nurse for the general acute care hospital, but the wound nurse did not come to the subacute unit. When it was mentioned that the last wound culture was performed in 2012, and that the most recent wound treatment order was December, 2013, the director replied the subacute staff did a good job in pressure ulcer wound management, and that she and the staff had seen a great improvement in Resident 1's wound since she was first admitted to the unit.According to the Hartford Institute for Geriatric Nursing website, ConsultGeri.com (http://consultgerirn.org /topics/pressure_ ulcers/and_ skin_ tears/want_to_know_more), updated December 2012, "Nonadherent dressings should be used on frail skin...If tape must be used, be sure it is made of paper, and remove it gently. Also, tape can be applied to hydrocolloid a (wound cover that creates a waterproof, bacteria-proof and oxygen-proof barrier, and adhere to wet and dry wounds) strips placed strategically around the wound, rather than taping directly onto fragile surrounding skin." A review of the facility's policy, titled, "Pressure Ulcer Management Protocol", revised September 2013, indicated under the heading, "Special Mattress", to use minimal linen, such as an underpad only, when low air loss mattress is in use. The facility's policy, titled, "Pain Management: Nursing Practice", revised April, 2011, indicated the following: "All patients admitted to [the facility] will be assessed for pain on admission, and pain goal should be met. Pain assessment should be done every shift thereafter by a registered nurse if the patient does not complain of pain. A licensed vocational nurse under supervision of the RN collects data regarding pain..." The section which addressed pain assessment indicated if the patient is cognitively disabled, the observation must focus on emotion, movement, verbal cues, facial cues, and positioning, and assigned points based on criteria, such as face, legs, activity, crying, and consolability. The "Face" category indicated a level 2 pain was frequent to constant quivering chin, and clenched jaw. The "Activity" category indicated level 2 pain was "arched, rigid or jerking [movement]".3. On June 15, 2015, at 8:15 a.m., during a follow-up survey, Resident 1 was observed lying on a low air loss (LAL) mattress (special air-fluidized bed which relieves pressure on the skin and promotes wound healing). The resident had a tracheostomy (a tube which is surgically inserted into the airway for purposes of providing oxygen to the airway passages), which was connected to a tracheal collar (a device which delivers continuous aerosol administration of water to the upper airways in order to hydrate airway secretions, and promote cough), and was receiving a tube feeding through a gastrostomy tube (GT- a tube which is surgically inserted through the abdomen into the stomach for purposes of nutrition and medication administration). The resident was awake, and exhibited constant jerking motions of her head.On June 15, 2015, at 9:20 a.m., during an observation of Resident 1's pressure ulcer wound care treatment, RN 1 stated the resident had received Tylenol 650 milligrams (mg) at 8:45 a.m. (35 minutes prior). She then indicated the dressing was changed several times a day, due to the resident's urinary incontinence. The resident did not show any obvious signs of discomfort during the procedure. Review of Resident 1?s Monthly Interdisciplinary Team Conference (IDT) notes, dated May 15, 2015, failed to indicate the change in the wound care treatment order. There was no documentation regarding assesssment or treatment of pain. A review of Resident 1?s physician order dated May 22, 2015, indicated to administer Tylenol (acetaminophen) 650 mg via GT daily at 9:30 before decubitus (pressure ulcer) dressing change. A review of the Skin Care Weekly Progress Note document, indicated wound measurements of the pressure ulcer, obtained on June 14, 2015, were length:2.5 centimeters (cm), width: 2.0 cm, depth: 0.8cm., and wound tunneling, measuring 1.0cm., at the 4 o'clock position. A review of the May 31, 2015, and June 7, 2015 measurements also indicated tunneling, ranging from 0.2 to 0.6 cm, at the 3 o'clock and 6 o'clock positions. A review of a Charge Details Report document, provided by the facility pharmacy, indicated that following April 17, 2015, (recertification survey exit), Resident 1 received a dose of acetaminophen on April 20, 2015, and a dose on May 5, 2015.The next dose was not administered until May 22, 2015. Failure of the facility to ensure: (1) Resident 1 with a pressure sore (ulcer) received appropriate treatment during wound care; (2) A pain management program was in place; and (3) Resident 1 was handled in a gentle manner had a direct relationship to the health, safety, or security of patients. |
| 940000051 |
AVALON VILLA CARE CENTER |
940009634 |
B |
30-Nov-12 |
URF411 |
6133 |
? 72523. Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 3/15/12 at 12:45 p.m., an unannounced visit was made to the facility to investigate a complaint regarding Patient 1 having an ankle fracture and the cause of the fracture was not investigated. Based on observation, interview and record review, the facility failed to implement written patient care policies and procedures by failing to: 1. Investigate Patient 1?s right fractured ankle. 2. Report to the Department an injury of unknown source. On 2/3/12 at 10 a.m., Patient 1 was identified with swelling and pain on the right ankle and an x-ray ordered by the physician on the same day revealed a fracture of the right ankle. The patient was transferred to an acute hospital for evaluation and treatment. The origin of the fractured ankle was unknown and there was no investigation conducted to explain the injury or rule out abuse. The injury of unknown source was not reported to the Department. This resulted in a lack of plan of action to prevent further injuries.On 3/15/12, a review of the clinical record revealed of Patient 1?s was a 71 years old male admitted to the facility on 12/16/11, with diagnoses including hypertension, osteoarthritis (disease characterized by degeneration of cartilage and its underlying bone within a joint as well as bony overgrowth), psychosis (loss of contact with reality) and a history of alcohol abuse. The initial Minimum Data Set (MDS ? a standardized assessment and care plan tool), dated 12/28/11, indicated the patient had memory problems, delusions (misconceptions or beliefs that are firmly held, contrary to reality) hallucinations (perceptual experiences in the absence of real external sensory stimuli) and required extensive assistance with transfers, walking, dressing and personal hygiene. The patient used a wheelchair and a walker as mobility devices. The patient was also assessed as having history of fall prior to admission and two or more falls since admission with no injuries.The physician?s orders dated 1/13/12, indicated physical and occupational therapy was ordered daily five times a week for four weeks. According to the nursing notes and care plan, the patient sustained falls without significant injuries five times from 12/19/11 to 1/28/12. The Fall Risk Evaluation form dated 12/19/11, indicated a score of 16. According to the form, a score of 10 or higher indicates a high risk for potential falls. On 1/3/12, the patient?s score was 20.According to a nursing note dated 2/3/12, timed at 10 a.m., the physical therapist brought to the attention of the nurse, the patient had swelling to the right ankle and pain during range of motion (ROM). The physician was informed and ordered an x-ray to the right ankle. At 1 p.m. the physician visited the patient and obtained the x-ray result which revealed a fracture of the right ankle. The physician ordered to transfer the patient to the acute hospital for evaluation and treatment. The patient returned to the facility the same day with a splint (immobilizer) on the right ankle. Further record review revealed no documentation addressing the cause of the injury to the right ankle. According to the facility?s policy and procedure on Reporting/Investigating Resident Accidents/Incidents updated 1/2000, all accidents/incidents involving patients will be reported to the director of nursing and to the administrator. All accidents/incidents will be thoroughly investigated by management and the findings of such investigation will be recorded in the patient?s medical record. All injuries of an unknown source will be reported to appropriate agencies as outlined in the facility?s policy entitled, ?Reporting Abuse to State Agencies and Other Entities/Individuals.? On 3/15/12 at 2:00 p.m., the patient was observed lying in bed in his room, able to communicate in a foreign language. At 2:20 p.m., an interview with the use of a translator revealed the patient was confused and unable to provide information regarding the cause of the injury.On 3/15/12 at 3:35 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated she called the physician on 2/3/12, when she was informed by one of the physical therapy (PT) staff members the patient had swelling on the right ankle. LVN 1 was unaware how the patient sustained the injury. On 3/15/12 at 3 p.m., during an interview, the MDS Nurse was unable to provide evidence of an investigation as to the cause of the fracture or that the injury was reported to the Department (State Agency). On 3/15/12 at 4:15 p.m., during an interview, the director of nursing and the administrator in training (AIT) were unable to provide evidence the patient?s fracture was investigated to rule out abuse/mistreatment and to develop plan of actions to prevent further recurrence. The director of nursing also stated there was no report regarding the patient?s fracture made to the Department. The director of nursing and the AIT were unable to explain the reason the facility?s policy and procedure on investigating accident/incidents was not implemented. The facility failed to implement written patient care policies and procedures by failing to: 1. Investigate Patient 1?s right fractured ankle. 2. Report to the Department an injury of unknown source. On 2/3/12 at 10 a.m., Patient 1 was identified with swelling and pain on the right ankle and an x-ray ordered by the physician on the same day revealed a fracture of the right ankle. The patient was transferred to an acute hospital for evaluation and treatment. The origin of the fractured ankle was unknown and there was no investigation conducted to explain the injury or rule out abuse. The injury of unknown source was not reported to the Department. This resulted in a lack of plan of action to prevent further injuries. The above violation had direct or immediate relationship to the health, safety or security of Patient 1. |
| 940000049 |
Affinity Healthcare Center |
940012357 |
A |
28-Jun-16 |
UZ5O11 |
12863 |
F315 ?483.25(d) NO CATHETER, PREVENT UTI, RESTORE BLADDER Based on the resident's comprehensive assessment, the facility must ensure that a resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; and a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible. F309 ?483.25 Quality of Care Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The Department received a complaint on 1/5/16, alleging a resident (Resident 1) was sent to a general acute care hospital (GACH) in respiratory distress and was diagnosed with a severe urinary tract infection (UTI) having pus (typically white-yellow, yellow, or yellow-brown, formed at the site of inflammation [a part of the complex biological response of body tissues to harmful stimuli, such as pathogens [anything that can produce disease], damaged cells, or irritants, during an infection). The facility failed to provide each resident with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care and to ensure residents, who had indwelling urinary catheters, received appropriate treatment and services to prevent urinary tract infections, including but not limited to: 1. Failure to accurately assess urine characteristics and report findings to the physician. 2. Failure to follow its policy and procedure regarding indwelling urinary catheter (flexible plastic tubes used to drain urine from the bladder) care. 3. Failure to follow the resident?s plan of care. These deficient practices resulted in a delay in diagnosis and treatment for Residents 1 and 7. Resident 1 was transferred to a GACH in respiratory distress (difficulty breathing) and was diagnosed upon admission to the GACH with a urinary tract infection ([UTI], an infection involving any part of the urinary system, including urethra, bladder, ureters, and kidney) and sepsis (a serious medical condition caused by an overwhelming immune response to infection). Resident 7 did not receive an antibiotic treatment for the UTI until 21 days after a family member (FM1) reported an abnormal urine characteristic. Resident 7 had another U/A (urine analysis), after 15 days of the first U/A and C/S ([culture sensitivity] a culture test identifies bacteria or fungus that caused an infection, and a sensitivity test identifies the antibiotic that best treats the illness or infection), due to possibly being contaminated. The facility initially did not want to repeat the UA and C/S because they stated Resident 7 was asymptomatic, but once the UA and C/S was repeated it was identified positive for bacteria. This resulted in a delay of Resident 7's diagnosis and treatment. a. A review of Resident 7's Admission face sheet indicated Resident 7 was a 70 year-old female who was initially admitted to the facility on XXXXXXX, and re-admitted on XXXXXXX. Resident 7's diagnoses included chronic respiratory failure, UTI, and a Stage IV pressure ulcer (any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s) (Stage IV [full thickness tissue loss with exposed bone]). A review of Resident 7's Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 4/20/16, indicated Resident 7 was totally dependent on staff for all care and was not able to verbalize needs. A review of a nurse's note, dated 5/7/16, and timed at 6 p.m., indicated Resident 7's FM 1 "requested a U/A with a culture and sensitivity test (a culture test identifies bacteria or fungus that caused an infection and the sensitivity test identifies the antibiotic that best treat the illness or infection)." A nursing note, dated 5/11/16, and timed at 6 p.m., indicated Resident 7's preliminary U/A results had a large amount of blood, but indicated that Resident 7 was asymptomatic (no symptoms). A review of the Nurses Catheters Notes, dated from 4/1/16 to 4/30/16, and notes from 5/23/16 to 5/27/16, indicated Resident 7's urine was yellow, had no sediment, or no foul smelling urine. A review of Resident 7's care plan titled, "Possible UTI with chronic sedimentation," dated 5/16/16 indicated to "Monitor urine for sediment (particles that may be indicative of an infection), cloudiness, odor, blood tinge, and amount and report to MD for any of those symptoms." During an observation accompanied by a registered nurse (RN 1) on 5/25/16 at 3:28 p.m., Resident 7 was lying in bed and had an indwelling urinary catheter. The urine in the tubing and catheter bag had sediment and a strong, foul odor permeating the room. During a concurrent interview, RN 1 confirmed that there was sediment in Resident 7's urine tube and that there was a strong, foul urine smell permeating the resident?s room. RN 1 stated, "Sediment, fever, bad odor, and blood in the urine are all signs and symptoms of a urine infection." On 5/25/16 at 3:28 p.m., during an interview, while at the Resident 7's bedside, FM 1 stated that she had requested (per the nurses? note on 5/7/16) a urinalysis (U/A) test to check for infection, because there was a "strong urine odor and a lot of sediment with blood in the tubing" in Resident's 7's catheter. A review of Resident 7's laboratory results titled, ?Laboratory urinalysis, culture and sensitivity report," dated 5/13/16 indicated "multiple organisms isolated probable contaminant, repeat culture if indicated." During a concurrent interview, on 5/25/16 at 3:38 p.m., RN 1 and LVN 3 stated that the C/S was not repeated because "The resident was asymptomatic." In a later interview on the same day, LVN 3 stated that she called the physician assistant ([PA] a healthcare professional who provides healthcare within the medical model as part of a team with physicians), who then ordered to repeat the C/S. On 5/25/16 at 4:45 p.m., during a telephone interview, Resident 7?s PA stated Resident 7 was asymptomatic per nursing assessments. The PA stated Resident 7 was receiving cranberry supplements (used to prevent UTI) and he would wait for the C/S results. A review of Resident 7's U/A & C/S results, dated 5/27/16, twenty days after Resident 7's FM 1 requested the U/A and C/S, indicated it was positive for "Klebsiella pneumoniae," a type of gram-negative bacteria that can cause different types of healthcare-associated infections, including pneumonia, bloodstream infections, and wound or surgical site infection. The record also indicated a handwritten note by a nurse (unidentified nurse) on the U/A & C/S result, "No new orders, the resident (Resident 7) is asymptomatic." A review of Resident 7?s CBC (completed blood count), dated 5/31/16, the WBC (white blood cells [indicative of an infection if elevated]) results were "11.40 H? ([high] normal reference range 4.0-11.0). The CBC lab result also indicated a handwritten note by a nurse (unidentified nurse) on the result page, "on ATB (antibiotic) already." A review of Resident 7's physician orders, dated 5/28/16, indicated an order for Azactam (an antibiotic) 1 gram IV (intravenous [into the vein]) every 12 hours for seven days for UTI. The facility's inaccurate assessments and lack of systems in place resulted in Resident 7's delay in diagnosis and treatment of the UTI. b. On 5/25/16 at 2:35 p.m., during an interview, the director of nursing (DON) stated Resident 1 was admitted to the facility on XXXXXXX with an indwelling catheter and did not have a urine infection. The DON stated Resident 1 "was transferred to a GACH on 1/1/16 for difficulty in breathing." A closed review of Resident 1's Admission face sheet indicated Resident 1 was a 89 year-old female who was admitted to the facility on XXXXXXX. Resident 1's diagnoses included intestinal obstruction (blockage in the colon), dysphagia (difficulty swallowing) with a gastrostomy tube (a tube inserted into the stomach to deliver nutrition [G-tube]), and a Stage III pressure ulcer (an ulcer caused by unrelieved pressure that results in damage to the underlying tissue(s) (Stage III is a full thickness loss of dermis [a layer of skin between the epidermis and subcutaneous tissues; middle skin area]). A review of the Resident 1's Minimum Data Set (MDS) a resident assessment and care screening tool, dated 12/21/15, indicated Resident 1 required extensive assistance for daily activities and was not able to verbalize needs. A review of a licensed nurses' progress note, dated XXXXXXX, and timed at 7:48 p.m., upon admission to the facility, indicated Resident 1's indwelling catheter was draining clear yellow urine. A review of the nurses' Treatment Catheter Notes, dated from 12/14/15 to 12/31/15, indicated Resident 1's urine was clear and did not have any presence of urine sediment, mucus, blood, and/or urine foul odors. A review of Resident 1's care plan titled, "Foley catheter (name of an indwelling urinary catheter)," dated 12/14/15, indicated Resident 1 was at risk for urinary tract infection (UTI) and the staff 's interventions included to "Monitor urine for color and clarity (clearness)." A review of Resident 1's nurses? note, dated 1/1/16, indicated Resident 1 was in respiratory distress (difficulty in breathing) with an elevated heart rate. The facility called 911 and Resident 1 was transferred to the GACH. A review of Resident 1 's GACH records, dated 1/1/16, indicated Resident 1's diagnoses included an acute respiratory distress, sepsis (a serious medical condition caused by an overwhelming immune response to an infection), and UTI with urosepsis (an infection that can progress to septic shock [life threatening] it untreated) and hypotension (low blood pressure). Resident 1's white blood cell ([WBC] indicative of an infection) was up to 39,700 upon admission to GACH (normal reference range 3,800-10,800 WBC per microliter). Resident 1 was treated with an antibiotic Zosyn 3.375 grams via intravenous (IV [into the vein]), an antibiotic (used only to treat or prevent infections that are proven or strongly suspected to be caused by bacteria). A review of Resident 1's GACH nurse's note, dated 1/1/16, and timed 10:35 p.m., indicated Resident 1's urine specimen collected was cloudy. A review of Resident 1's GACH's laboratory report, dated 1/1/16, and timed at 11:50 p.m., indicated the following UA results; yellow cloudy urine and positive for 4+bacteria (large amount of bacteria, consistent with having a UTI). The C/S results dated 1/2/16, and timed at 7:10 a.m., indicated it was positive for Proteus Mirabillis (a rod-shaped bacterium found in putrid meat, abscesses, and fecal material responsible for complicated UTIs that sometimes causes bacteremia [bacteria in the blood]) of 100, 000 colonies per/cc According to the ?National Institute of Health,? the signs and symptoms of UTI included, but not limited to fever, urine that smells bad or looks cloudy or reddish in color, and pain during urination at According to an article titled, ?WBC Count," a high number of WBCs may be due to infections, most often those caused by bacteria. (). The facility's policy and procedure revised on October 2014 and titled, "Foley Catheter Care," indicated for the staff to report any signs and symptoms of infection, suspected obstruction and/or retention, significantly reduced output to the attending physician. The facility failed to provide each resident with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care and to ensure residents, who had indwelling urinary catheters, received appropriate treatment and services to prevent urinary tract infections, including but not limited to: 1. Failure to accurately assess urine characteristics and report findings to the physician. 2. Failure to follow its policy and procedure regarding indwelling urinary catheter (flexible plastic tubes used to drain urine from the bladder) care. 3. Failure to follow the resident?s plan of care. The above violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical or mental harm would result. |
| 940000049 |
Affinity Healthcare Center |
940012686 |
B |
25-Oct-16 |
O6K411 |
6437 |
CFR ? 483.12 (b) F205 Notice of Bed-Hold Policy and Readmission ? 483.12 (b) (1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or allows a resident to go on therapeutic leave, the nursing facility must provide written information to the resident and a family member or legal representative that specifies? (i) The duration of the bed-hold policy under the State plan, if any, during which the resident is permitted to return and resume residence in the nursing facility; and (ii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (b) (3) of this section, permitting a resident to return. ? 483.12 (b) (2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and a family member or legal representative written notice which specifies the duration of the bed-hold policy described in paragraph (b)(1) of this section. An unannounced visit was conducted on 10/28/15 at 7:30 a.m. for a complaint that was filed regarding violation of resident's rights. The facility failed to permit Resident 1 to return and resume residence in the facility during the duration of the bed hold policy which was seven days. Resident 1, who was transferred to the acute hospital for therapeutic leave on 10/9/15, was refused return to the facility on 10/15/15 and had to wait 11 days before being permitted to return to the facility. This deficient practice violated Resident 1's right to return and resume residence in the facility. A review of the Resident Admission Record indicated Resident 1 was admitted to the facility on XXXXXXX, with diagnoses that included respiratory failure, tracheostomy (an incision in the windpipe made to relieve a blockage to breathing) and dysphagia (difficulty or discomfort in swallowing). The record indicated Resident 1 was eligible for both Medicare and Medicaid (Medi-Cal in California) benefits. A review of the Minimum Data Set (MDS, a resident assessment and care-screening tool, dated 12/24/15, indicated Resident 1 was cognitively (mentally) impaired for daily decision-making. On 10/9/15 at 1:30 a.m., a physician's order indicated Resident 1 was to be transferred to the hospital for a Permacath (a flexible tube that is inserted into a vein) evaluation and was placed on seven day bed hold. On 10/9/15, at 2 a.m., the medical record indicated Resident 1's family member (FM1) was given the Bed Hold Informed Consent, dated 10/9/16 at 2 am. The form indicated the facility was to keep the bed vacant and available, so the resident could return to the facility within seven days. According to the Bed Hold Informed Consent, Resident 1's bed hold was until 10/15/15. A review of the hospital's physician progress notes, dated 10/15/15 at 4:07 p.m., indicated Resident 1 was no longer on isolation precautions. The hospital record, time stamped at 6:18 p.m., indicated the resident had no fevers, was stable, and would be discharged that day. The hospital's Case Management Progress Note, dated 10/15/15 (seventh day of therapeutic leave) at 5:16 p.m., indicated the case manager (CM 1) placed a call to the skilled nursing facility, regarding Resident 1's isolation status, and faxed the clearance to the facility. CM 1 was told that the director of nursing (DON) and administrator (ADM) were gone for the day, so Resident 1 could not be accepted back to the skilled nursing facility. The hospital's physician progress notes, dated 10/16/15 at 9:15 p.m., indicated Resident 1 lost his subacute bed (subacute care is a level of care needed by a patient who does not require hospital acute care, but who requires more intensive skilled nursing care than is provided to the majority of patients in a skilled nursing facility), because it was given away by the skilled nursing facility and the CM was looking for placement. During an interview, on 10/28/15 at 11:30 a.m., the DON stated Resident 1 was transferred to the hospital on XXXXXXX (Friday) for an infection. The DON stated the hospital called on 10/15/15, to transfer the resident back, which was after the bed hold. In an interview with the assistant administrator (AADM), on 10/28/15 at 12 p.m., he stated Resident 1 needed an isolation room. The AADM stated the facility did not refuse Resident 1; they just could not provide him with an isolation room. On 6/3/16 at 2:40 p.m., in an interview, the ADM stated she did not know why Resident 1 was not readmitted to the facility on XXXXXXX. On 6/20/16 at 12:20 p.m., in an interview, CM 1 from the hospital stated she called the skilled nursing facility on 10/15/15 at 4:30 p.m., to transfer Resident 1 back to the skilled nursing facility and let them know that Resident 1 was not on isolation precautions anymore. CM 1 stated the skilled nursing facility's admission coordinator told her the skilled nursing facility could not accept Resident 1 because the DON and the ADM were gone for the day. CM 1 stated she called the facility on 10/19/15, 10/22/15, 10/23/15, 10/24/15 and 10/25/15 and the facility told her there were no beds available. On 10/26/15, 11 days after the bed hold, Resident 1 was finally transferred back to the facility. A review of the skilled nursing facility's census for 10/15/15 showed there were no male subacute beds available and Resident 1?s bed was taken. On 10/20/15 there were 4 male subacute beds available, on 10/21/15 there was one male subacute bed available, on 10/24 and 10/25 there was one male subacute bed available. Resident 1 was readmitted to the facility on XXXXXXX, 11 days after the bed hold. A review of the facility?s Admission Agreement under Bed Holds and Readmission indicated, ?If Medical is paying for your care, then Medi-Cal will pay for up to seven days for us to hold the bed for you.? ?If we do not follow the notification procedure described above, we are required by law (Title 22 California Code of Regulations Sections 72520 ? and 73504 ? to offer you the next available appropriate bed in our Facility.? Therefore, the facility failed to permit Resident 1 to return and resume residence in the facility during the duration of the bed hold policy which was seven days. This violation had a direct relationship to the health, safety and security of Resident 1. |
| 940000051 |
AVALON VILLA CARE CENTER |
940012864 |
B |
6-Jan-17 |
L18H11 |
3484 |
483.13 (c) F224 ______________________________________________________________ Based on interview, and record review, the facility failed to ensure that one of one sampled resident (Resident 1) was free from financial abuse from a staff member. This deficient practice resulted in a facility staff cashing Resident 1's personal check without the resident's knowledge. Findings: On 12/31/14, a review of Resident 1's face sheet (admission record) indicated Resident 1 was admitted to the facility on XXXXXXX, with diagnoses that included bronchitis (an inflammation of the lining of the bronchial tubes, which carry air to and from the lungs), depression and diabetes (too much sugar in the blood). A review of a Minimum Data Set (MDS / a standardized assessment and care-screening tool) dated 12/28/14, indicated the resident was alert and oriented, had clear speech and able to express ideas and wants. During an interview, on 7/24/15 at 8 a.m., the Director of Nurses (DON) stated Resident 1 received a call from her bank stating there was a fraudulent check which was cashed from her account and that she needed to go to the bank to fill out a form. Resident 1 was taken to the bank on 12/11/14, and received a copy of the check. The check was made out to a certified nursing assistant (CNA) who worked for the facility. Resident 1 stated the signature on the check was not her signature. During a record review on 7/24/15 at 2 p.m., a copy of the check was with the records which indicated: Pay to the order of CNA 1 and dated 12/1/14 in the amount of $650.00. According to the facility's daily schedule, CNA 1 worked at the facility from 7 a.m. to 3 p.m. on December 2, 3,4,5,8,9,11, and 15th. In another interview, on 8/27/15 at 10:45 a.m., the DON stated if the residents are alert and oriented, we let them keep their own personal checks. However, the DON was unable to find a policy and procedure regarding residents keeping their own personal checks. A review of the local police's incident report on 8/25/15 at 3:00 p.m., regarding the misappropriation of property (Case #014-18953-2140-174), indicated CNA 1 stated Resident 1 gave CNA 1 the check as a Christmas present. The report further indicated, the resident did not know the name on the check and it was not the president?s signature on the check. Based on the facts and evidence, the local police department transported and booked CNA 1 at the police station on 12/15/14. Multiple attempts to contact Resident 1 at the board and care where she was transferred to on February 23, 2015 and Resident 1's personal cellphone went unanswered (on 8/27/15, at 11:30 a.m., 2:30 p.m., and on 8/28/15, at 10 a.m., 1:20 p.m.). According to the facility's policy and procedure titled, Adult/Elder Abuse Policy, with a revision date of 6/21/05, the resident has the right to be free from verbal, sexual, physical, mental and financial abuse, misappropriation of property, corporal punishment, isolation/ involuntary seclusion, abandonment, abduction, ?other treatment with resulting physical harm or pain or mental suffering" and deprivation by care custodian of goods or services that are necessary to avoid physical harm, and to attain/ maintain physical, mental, psycho-social well-being. Failure of the facility to ensure that Resident 1 was free from financial abuse by a facility staff member had a direct or immediate relationship to the health, safety or security of Resident 1. |
| 940000051 |
AVALON VILLA CARE CENTER |
940012986 |
A |
1-Mar-17 |
22EX11 |
16338 |
[F309] CFR ? 483.25 Quality of Care Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
[F328] CFR ? 483.25 (k) Special Needs
The facility must ensure that residents receive proper treatment and care for the following special services:
(6) Standard: Respiratory care
[F157] CFR ? 483.10 (b) (11) Notification of Changes
(i) A facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications); a need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or a decision to transfer or discharge the resident from the facility as specified in ?483.12(a).
W&I Code ? 4502.ÿ
ÿ
(a) Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. An otherwise qualified person by reason of having a developmental disability shall not be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity that receives public funds.
ÿ
(b) It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following:
ÿ
(4) A right to prompt medical care and treatment.
[F224] CFR ?483.13? Staff Treatment of Residents
The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property.
"Neglect" means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. (42 CFR 488.301)
On 11/8/16 at 6:45 a.m., an unannounced visit was made to the facility to investigate a complaint regarding quality of care involving Resident 2.
Based on interview and record review, the facility failed to provide Resident 2 with the necessary care and services to attain or maintain the highest practicable physical, mental, psychosocial well-being, in accordance with comprehensive assessment and plan of care; to ensure that Resident 2 received proper treatment and care for respiratory problems; to immediately inform and consult with the resident?s physician when there was a change in the resident?s physical health status; and to develop and implement written policies and procedures that prohibited mistreatment, neglect, and abuse of residents, including but not limited to:
1. Failure to implement Resident 2's care plans to monitor the resident for nausea and vomiting, and signs and symptoms of chocking/aspiration (breathing foreign materials, usually food, liquids, vomit, or fluids from the mouth, into the lungs or airways) and to notify the physician of these conditions.
2. Failure to promptly check Resident 2 when Resident 2's roommate (Resident 4) called for help and reported that he heard Resident 2 choking.
3. Failure to call for help and/or report immediately and appropriately regarding Resident 2's significant change in condition.
4. Failure to conduct a comprehensive assessment on Resident 2 when the resident had rapid breathing.
5. Failure to identify Resident 2's emergency situation.
6. Failure to provide emergency (first aid) procedure to Resident 2.
7. Failure to notify Resident 2's physician (Physician 1) promptly at 5:30 a.m. when Resident 2 had a significant change in condition.
The Certified Nurse Assistant (CNA 1) heard Resident 2 making "unusual" breath sounds on 7/2/16 around 2 a.m. to 3 a.m. but CNA 1 left Resident 2 without checking on the resident and did not report. On 7/2/16 at 5:30 a.m., the Licensed Vocational Nurse (LVN 1) observed Resident 2 with rapid breathing with respirations of 29 breaths per minute (normal respiration rates for an adult person at rest range from 12 to 16 breaths per minute) and administered oxygen. LVN 1 did not conduct a comprehensive assessment on Resident 2 and did not immediately notify the Registered Nurse (RN 1) of the resident's significant change of condition. RN 1 observed Resident 2 on 7/2/16 at 6 a.m., pale and unresponsive, called 911 (emergency response team) and performed basic life support or cardiopulmonary resuscitation (CPR- an emergency procedure perform during cardiac and or respiratory arrest in which chest compression and artificial breathing are used to maintain blood circulation to the brain). Resident 2 had aspirated and the facility staff took a total of three to four hours to provide emergency procedures for Resident 2.
On 7/2/16 at 6:03 a.m., the emergency response team arrived at the facility and provided advanced cardiac life support (ACLS, refers to a set of clinical interventions for the urgent treatment of cardiac arrest, stroke and other life-threatening medical emergencies) to Resident 2. On 7/2/16 at 6:23 a.m., the emergency response team contacted the emergency room physician (Physician 2) regarding Resident 2's status and Physician 2 pronounced Resident 2 dead while at the facility. Physician 1, Resident 2's attending physician, was not notified about Resident 2's significant change of condition until 7 a.m. on 7/2/16.
A review of Resident 2's Admission Record indicated Resident 2 was admitted to the facility on XXXXXXXX15 and was readmitted to the facility on XXXXXXXX16. The Admission Record indicated Resident 2's diagnoses included muscle weakness, gastro-esophageal reflux disease (a long term condition where stomach contents leak backwards from the stomach into the esophagus - commonly known as the food pipe), unspecified convulsions (a sudden, violent, irregular movement of a limb or of the body, caused by involuntary contraction of muscles and associated especially with brain disorders), and developmental delay (mental or physical impairment due to a severe and chronic disability that begins before an individual reaches adulthood).
A review of Resident 2's Minimum Data Set (MDS - a resident assessment and care planning tool), dated 4/3/16, indicated Resident 2 was able to make himself understood sometimes and was able to understand others sometimes. The MDS indicated Resident 2 required limited assistance from staff with bed mobility (staff provided guided maneuvering of limbs or other non-weight bearing assistance) and was totally dependent on staff with transfers, eating, toilet use, and personal hygiene.
A review of Resident 2's Initial History and Physical (H&P), dated 5/3/16, indicated Resident 2 was gravely disabled with developmental delay. The H&P indicated Resident 2 did not have the capacity to understand and make decisions.
A review of Resident 2's Physician Orders for Life -Sustaining Treatment (POLST, a physician order form that informs care providers what kind of life sustaining treatment an individual resident and/or his responsible party does (or does not) want during a medical emergency), dated 9/22/15, indicated to attempt resuscitation/CPR and to provide full treatment including intubation (insertion of a tube through the mouth down into the trachea [windpipe] to serve as an open passage through the upper airway to permit air to pass freely to and from the lungs in order to ventilate the lungs) and defibrillation/cardioversion (administering a controlled electric shock in order to allow restoration of the normal heart rhythm) as indicated. The POLST indicated to transfer Resident 2 to the hospital if indicated.
A review of Resident 2's care plans indicated the staff would provide the following:
1) Gastroesophageal Reflux Disease Care Plan, dated 4/27/16, indicated the staff would monitor Resident 2 for abdominal pain, nausea and vomiting, heartburn, gas pain, diarrhea and position of comfort.
2) Nutritional Status Care Plan, dated 4/27/16, indicated the staff would monitor Resident 2 for signs and symptoms of choking/aspiration and to report to the physician.
On 11/8/16 at 12 p.m., during an interview, Resident 4 stated that Resident 2 was making choking sounds (on 7/2/16) and he used the call light but nobody came so he yelled for staff. Resident 4 stated that he told CNA 1 that Resident 2 was dying. Resident 4 stated CNA 1 looked at Resident 2 and left. Resident 4 stated CNA 1 did not do anything while Resident 2 was choking. Resident 4 stated that Resident 2 was trying to throw up but could not throw up then the whole body was shaking. Resident 4 stated that was the first time he saw Resident 2's body was shaking. Resident 4 stated that he saw a staff member checking Resident 2's vital signs (Resident 4 could not tell the time) but after that he did not see anyone come to check Resident 2's vital signs.
A review of Resident 2's record titled, "Licensed Nurse Documentation," by LVN 1, dated 7/2/16, indicated the following:
1) At 4 a.m., Resident 2 was awake with no shortness of breath.
2). At 5:30 a.m., Resident 2 was awake and had rapid breathing. Oxygen (O2) at 2 liters per minute (L/min) was started. Head of the bed was elevated. "Continued monitoring."
3) At 5:45 a.m., Resident 2 was breathing rapidly. Respirations 29 breaths per minute.
4) At 6 a.m., Resident 2 stopped breathing and unable to read pulse. 911 was called. Started CPR.
5) At 6:04 a.m., paramedics arrived.
6) At 6:23 a.m., Resident 2 was pronounced dead by Physician 2.
7) At 6:25 a.m., Physician 1 "was paged at this time". Awaiting response.
8) At 7 a.m., Physician 1 was notified.
A review of Resident 2's record titled, "Licensed Nurse Documentation," on 7/2/16, did not indicate that LVN 1 assessed Resident 2's breath sounds, quality of respirations, and responsiveness from 5:30 a.m. or reported Resident 2's rapid breathing to RN 1 and/or to Physician 1 at 5:30 a.m. and at 5:45 a.m.
On 1/6/17 at 9:36 a.m., during a telephone interview, when asked if CNA 1 reported to him about Resident 2's change of condition on 7/2/16, LVN 1 stated CNA 1 did not report anything regarding Resident 2. LVN 1 stated that on 7/2/16 at 5:30 a.m., Resident 2 was observed with rapid breathing and he administered oxygen at 2 liters per minute via nasal cannula according to the standard physician's order. LVN 1 stated he did not assess Resident 2's cause of rapid breathing or whether he needed to perform CPR. LVN 1 stated that he was not sure what time he reported to RN 1 regarding Resident 2's change of condition. LVN 1 stated he did not call and notify Resident 2's physician when he observed Resident 2 had a rapid breathing at 5:30 a.m. and 5:45 a.m. LVN 1 stated he was not sure if RN 1 called the physician.
On 1/10/17 at 6:45 a.m., during an interview, CNA 1 stated, "I cannot remember exactly the time, maybe between 2 a.m. to 3 a.m. (on 7/2/16) when I heard the resident (Resident 2) making unusual sounds while breathing." CNA 1 stated he did not look at Resident 2 making unusual sound on breathing because he did not know what that was and just called the licensed vocational nurse (LVN 1) to check on Resident 2 at that time. CNA 1 stated, "I don't remember what I did after that."
On 1/10/17 at 7:25 a.m., during an interview, RN 1 stated he could not remember the exact time but it was before 6 a.m. on 7/2/16, when LVN 1 reported to check on Resident 2. RN 1 stated LVN 1 told him that Resident 2 looked like he was not breathing. RN 1 stated he immediately went to check Resident 2 and observed Resident 2's color being pale and was not breathing. RN 1 stated he immediately performed CPR on Resident 2 and called 911 emergency services. RN 1 stated LVN 1 did not report to him that Resident 2 had rapid breathing at 5:30 a.m. RN 1 stated LVN 1 should have reported to him for any change on Resident 2's condition so he could assess and call the physician. RN 1 stated the physician should have been called immediately when Resident 2 was observed with rapid breathing.
On 1/10/17 at 3 p.m., during an interview and review of Resident 2's clinical record, the Director of Nurses (DON) stated she did not have any knowledge of the incident when Resident 2 had a change of condition. The DON stated the physician should have been notified immediately on 7/2/16 at 5:30 a.m. when LVN 1 observed Resident 2 having rapid breathing. The DON stated that Resident 2 should have been assessed for the cause of rapid breathing to render immediate care and intervention.
A review of the facility's policy and procedures titled, "Change in Resident's Condition or Status," dated 11/2015 indicated, ?Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status.?
1. ?The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: (d) A significant change in the resident's physical/emotional/mental condition.?
2. ?A ?significant change? of condition is a decline or improvement in the resident?s status that: (a) Will not normally resolve itself without intervention by staff or by implementing standard disease- related clinical interventions (is not ?self-limiting?).?
A review of the Prehospital Care Report Summary (by the Los Angeles County Fire Department), dated 7/2/16, indicated a call was received at 5:56 a.m., was on scene at 6:03 a.m. Resident 2 had no blood pressure, pulse rate was 30 beats per minute (normal pulse for healthy adults ranges from 60 to 100 beats per minute), no respirations. ACLS provided. CPR stopped at 6:23 a.m. Physician 2 pronounced Resident 2 dead at 6:23 a.m.
A review of Resident 2's death certificate, dated 10/10/16, indicated immediate cause of death was sepsis (life-threatening complication of an infection), pneumonia aspiration (lung infection from aspiration), developmental delay, and mental retardation.
Therefore, the facility failed to provide Resident 2 with the necessary care and services to attain or maintain the highest practicable physical, mental, psychosocial well-being, in accordance with comprehensive assessment and plan of care; to ensure that Resident 2 received proper treatment and care for respiratory problems; to immediately inform and consult with the resident?s physician when there was a change in the resident?s physical health status; and to develop and implement written policies and procedures that prohibited mistreatment, neglect, and abuse of residents, including but not limited to:
1. Failure to implement Resident 2's care plans to monitor the resident for nausea and vomiting, and signs and symptoms of chocking/aspiration and to notify the physician of these conditions.
2. Failure to promptly check Resident 2 when Resident 2's roommate (Resident 4) called for help and reported that he heard Resident 2 choking.
3. Failure to call for help and/or report immediately and appropriately regarding Resident 2's significant change in condition.
4. Failure to conduct a comprehensive assessment on Resident 2 when the resident had rapid breathing.
5. Failure to identify Resident 2's emergency situation.
6. Failure to provide emergency (first aid) procedure to Resident 2.
7. Failure to notify Resident 2's physician (Physician 1) promptly at 5:30 a.m. when Resident 2 had a significant change in condition.
The violation of these regulations, jointly, separately or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 940000051 |
AVALON VILLA CARE CENTER |
940013001 |
B |
24-Feb-17 |
22EX11 |
5591 |
CFR 483.25 (h) F323 Accidents
The facility must ensure that ?
(1) The resident environment remains as free from hazards as is possible; and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
On 11/18/16 at 6:30 a.m., an unannounced visit was made to the facility to investigate a complaint regarding quality of care for Resident 2.
Based on interview and record review, the facility failed to provide additional mattress next to the low bed of Resident 2, who had a behavior of crawling and/or rolling his body from the bed to the floor, as ordered by the physician and as indicated on the care plan.
On 6/30/16, Resident 2 was found on the floor on a floor mat with his head beneath the bed frame of his low bed. Resident 2 sustained a cut to the left outer orbit (outer corner of eye) with swelling and redness.
A review of Resident 2's Admission Record indicated Resident 2 was originally admitted to the facility on XXXXXXX15 and was readmitted to the facility on XXXXXXX16, with diagnoses that included muscle weakness, unspecified convulsions (a sudden, violent, irregular movement of a limb or of the body, caused by involuntary contraction of muscles and associated especially with brain disorders), schizoaffective disorder (a mental disorder characterized by abnormal thought processes and deregulated emotions), and developmental delay (a diverse group of chronic conditions that are due to mental or physical).
A review of Resident 2's Minimum Data Set (MDS, a resident assessment and care screening tool), dated 4/3/16, indicated Resident 2 was able to make himself understood sometimes and was able to understand others sometimes. The MDS indicated Resident 2 required limited assistance (staff provided guided maneuvering of limbs or other non-weight bearing assistance) from staff with bed mobility and was totally dependent on staff with transfers, eating, toilet use, and personal hygiene.
A review of Resident 2's Fall Risk Evaluation, dated 4/28/16, indicated Resident 2 was identified as high risk for fall.
A review of Resident 2's Order Summary Report, dated 4/28/16, indicated, "May have additional mattress next to bed due to having tendency to roll body out of bed."
A review of Resident 2's care plan for fall, dated 4/27/16, indicated that the staff would provide the following interventions:
a. Apply less restrictive devices, a bed alarm to prevent fall, and monitor the effect.
b. Provide visual checks of the resident during nursing rounds, nursing care, medicine pass, meal pass and activities.
c. Keep the bed on low position, provide additional mattress next to the bed due to Resident 2 rolling body out of bed.
A review of Resident 2's Initial History and Physical (H&P), dated 5/3/16, indicated Resident 2 was gravely disabled with developmental delay. The H&P indicated Resident 2 did not have the capacity to understand and make decisions.
A review of Resident 2's Medication Administration Record for June 2016 for frequency of Resident 2 crawling/rolling body from the mattress to the floor from 6/10/16 to 6/30/16 indicated the following:
a. Day shift (7 am-3 pm), Resident 2 rolled down the mattress a total of 19 times.
b. Evening shift (3 pm-11 pm), a total of 20 times.
c. Night shift (11 pm- 7 am), a total of one.
A review of Resident 2's Situation, Background, Assessment/Analysis, Request (SBAR, a technique that provides a framework for communication between members of the health care team), dated 6/30/16 at 10:18 p.m., indicated Resident 2 was found on the floor with a left orbit (around the eye) skin cut (no measurement). Resident 2 rolled out of bed onto the floor mat next to bed and landed with the head underneath the bed while the rest of his body was on the floor mat.
A review of Resident 2's record titled, ?Incident Report,? dated 6/30/16, indicated Resident 2?s head was underneath the small space between the bed and the floor because the bed was on a low position.
A review of Resident 2's Physician and Telephone Order, dated 6/30/16 at 10:18 p.m., indicated to obtain an x-ray to the resident's left orbit (eye) due to complaint of pain and swelling. Conduct 72 hour neurological checks. Cleanse the resident's left outer eye skin cut with normal saline (mixture of salt and water), pat dry, apply bacitracin (antibiotic ointment), and cover with dry dressing daily for 14 days.
On 1/10/17 at 6:45 a.m., during an interview, CNA 1 stated that Resident 2 was using a floor mat due to the resident's behavior of rolling out of the bed.
On 1/10/17 at 10:45 a.m., during an interview, LVN 2 stated Resident 2 should have another mattress next to the bed due to rolling out of bed.
On 1/19/17 at 5:15 p.m., during an observation and interview, the maintenance supervisor stated that he was never asked to place an additional mattress next to Resident 2's bed and he had never seen a mattress on the floor.
Therefore, the facility failed to provide additional mattress next to the low bed of Resident 2, who had a behavior of crawling and/or rolling his body from the bed to the floor, as ordered by the physician and as indicated on the care plan.
On 6/30/16, Resident 2 was found on the floor on a floor mat with his head beneath the bed frame of his low bed. Resident 2 sustained a cut to the left outer orbit with swelling and redness.
The above violations either jointly, separately, or in any combination had a direct or immediate relationship to Resident 2?s health, safety, or security. |
| 940000051 |
AVALON VILLA CARE CENTER |
940013002 |
A |
24-Feb-17 |
22EX11 |
5844 |
CFR ? 483.25 F309 Quality of Care Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
CFR 483.13 ? Staff Treatment of Residents
The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property.
On 11/18/16 at 6:30 a.m., an unannounced visit was made to the facility to investigate a complaint regarding Resident 1, who was found with a black eye and ?hand prints on her shoulder from someone handling her aggressively?.
Based on observation, interview, and record review, the facility failed to handle Resident 1 gently and carefully during care in accordance with the plan of care and facility policy to prevent mistreatment and injury.
A certified nursing assistant (CNA 5) turned Resident 1 fast during provision of care. This caused Resident 1 to hit the side rail of the bed.
This deficient practice resulted in Resident 1 sustaining a right eye swelling and discoloration and a broken bone to the right shoulder. Resident 1 was transferred to the acute hospital on XXXXXXXX16.
On 1/5/17 at 3:20 p.m., during an observation, Resident 1 was sitting on the wheelchair in the hallway and was not able to answer questions due to confusion.
A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility on XXXXXXXX12, and was readmitted on XXXXXXXX16, with diagnoses that included osteoporosis (fragile bones), blindness to one eye, and osteoarthritis (joint disease that results from breakdown of joint cartilage and underlying bone usually with joint pain and stiffness).
A review of Resident 1's care plan for osteoporosis, dated 12/29/15, indicated the staff would handle Resident 1 gently and carefully during care.
A review of Resident 1's Minimum Data Set (MDS - a resident assessment and care planning tool), dated 6/27/16, indicated Resident 1 was severely impaired in cognitive skills for daily decision making, required extensive assistance (weight bearing support and at times requires full staff performance) from staff with transfer, dressing, toilet use, personal hygiene and was independent with bed mobility and eating. The MDS indicated Resident 1 was frequently incontinent of urine.
A review of the facility's investigation report, dated 7/15/16, indicated that on 7/14/16 at approximately 11:30 p.m., Resident 1 was observed with discoloration on the right eye orbital (around the eye) and was slightly swollen and discoloration on the right arm. The report indicated that on 7/14/16 at 9:30 p.m., CNA 5 changed Resident 1?s diaper and gown and turned Resident 1 towards the window, and accidentally hit Resident 1's eye and arm on the side rail of the bed. The investigation report indicated that CNA 5 unintentionally turned Resident 1 fast while doing care and did not notice that Resident 1 was bumped (hit) on the rails.
A review of Resident 1's Physician and Telephone Order, dated 7/15/16 at 8:53 a.m., indicated to obtain an x-ray for the resident's face and right arm related to discoloration on the right eye and upper right arm.
A review of Resident 1's Diagnostic Laboratories, dated 7/21/16, indicated there was a tiny hairline stress fracture (a crack or break in the bone caused by repeated physical force or motion) involving the proximal (upper part nearer to the center of the body) humerus (the bone of the upper arm located between the shoulder and elbow) with medial (middle) shaft (long narrow part of the bone) humeral (of or relating to the humerus) subluxation (a partial dislocation). The conclusion indicated recent proximal right humerus fracture as described.
A review of Resident 1's record titled, ?Licensed Progress Notes?, dated 7/21/16 indicated Resident 1 was transferred to the acute hospital on XXXXXXXX 16 at 7:15 p.m.
On 1/10/17 at 1:05 p.m., during an interview, the Assistant Director of Nurses (ADON) stated that Resident 1 should have been handled gently while giving care and the staff members know it. When questioned about the care CNA 5 provided to Resident 1, The ADON stated, "The CNA was big and her strength outweighs Resident 1's small body." The ADON stated that Resident 1's body was fragile due to her age, her osteoporosis and taking medication that could cause easy skin discoloration.
On 1/18/17 at 4:35 p.m., during a telephone interview, CNA 4 stated that Resident 1 was capable of slowly moving his own body while lying in bed during care.
On 1/18/17 at 5:08 p.m., during an interview, CNA 5 stated she could not remember what happened to Resident 1 on 7/14/16.
A review of the facility?s policy and procedure titled, ?Abuse Prevention Program,? revised August 2009 indicated the facility residents have the right to be free from abuse, neglect, or mistreatment, misappropriation of resident property, corporal punishment and involuntary seclusion.
Therefore, the facility failed to handle Resident 1 gently and carefully during care to prevent mistreatment and injury in accordance with the plan to care and the facility?s policy..
CNA 5 turned Resident 1 fast during provision of care. This caused Resident 1 to hit the side rail of the bed resulting in Resident 1 sustaining a right eye swelling and discoloration and a broken bone to the right shoulder. Resident 1 was transferred to the acute hospital on XXXXXXXX16.
The above violations either jointly, separately, or in combination presented either an imminent danger that death or serious physical harm would result or a substantial probability that death or serious physical harm would result to Resident 1. |
| 940000051 |
AVALON VILLA CARE CENTER |
940013003 |
A |
24-Feb-17 |
22EX11 |
13286 |
CFR 483.25 F309 Quality of Care
Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
CFR 483.25 (h) F323 Accidents
The facility must ensure that ?
(1) The resident environment remains as free from hazards as is possible; and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
On 11/18/16 at 6:30 a.m., an unannounced visit was made to the facility to investigate an allegation regarding quality of care for Resident 3.
Based on observation, interview, and record review, the facility failed to care plan the cause of falls, ensure effectiveness of interventions, and identify the specific type and frequency of supervision needed for Resident 3.
The facility failed to provide the following care and services:
1. Resident 3 had a fall on 5/17/16 at 5:30 p.m. The interdisciplinary team (IDT, a group consisting of the head of the different departments who work together to discuss a resident's care) identified Ativan (a medication that causes sedation) was a "concern" but did not address this concern in the Resident 3's care plan.
2. Ensure the wheelchair alarm was properly placed and functional for Resident 3, who was known to the facility staff to have a behavior of getting out of bed/wheelchair without staff assistance. On 6/3/16 at 7:10 p.m., Resident 3 was able to stand up from the wheelchair unassisted without activating the alarm, attempted to walk and fell.
This deficient practice resulted in Resident 3 sustaining a left femoral (thigh bone) neck fracture (The hip is a ball-and-socket joint made up of the head of the thigh bone or femur that acts as the ball and fits into the rounded socket of the hip bone. The neck of the femur is the region just below the ball of the hip joint) with impaction (the adjacent [next to] fragmented ends of the fractured bone were wedged together). Resident 3 was transferred to the general acute care hospital (GACH) on XXXXXXX16.
3. Revise the care plan to indicate the type and frequency of supervision needed for Resident 3, after the fall on 6/3/16 resulting in left femoral neck fracture.
4. Conduct an IDT care conference when Resident 3 had another fall on 6/26/16 at 9:15 p.m., to identify the cause of the fall, evaluate interventions and to determine the type and frequency of supervision needed for Resident 3 and revise the care plan.
Resident 3 sustained bilateral (both) hip fractures, the right hip fracture being new on 6/26/16. Resident 3 was transferred to the GACH on XXXXXXX16. This was Resident 3?s second admission to the hospital within a month.
A review of Resident 3's Admission Record indicated Resident 3 was admitted to the facility on XXXXXXX16 and was readmitted on XXXXXXX16, with diagnoses that included Alzheimer's disease (memory loss and difficulty with thinking, problem-solving or language) and history of falling.
A review of Resident 3's Minimum Data Set (MDS - a resident assessment and care planning tool), dated 4/20/16, indicated that Resident 3 rarely/never made himself understood and rarely/never had the ability to understand others. The MDS indicated Resident 3 required limited assistance (staff provided guided maneuvering of limbs) with one person physical assist with bed mobility, transfer, walking in the room and corridor and was totally dependent on the staff with dressing, eating, toilet use and personal hygiene. The MDS indicated Resident 3's balance was not steady and was only able to move from a seated to standing position with staff assistance.
A review of Resident 3's History and Physical (H&P), dated 4/10/16 and 9/20/16, indicated Resident 3 did not have the capacity to understand and make decisions.
A review of Resident 3's Fall Risk Evaluation, dated 4/10/16, indicated Resident 3 was identified as high risk for falls.
A review of Resident 3's Situation, Background, Assessment/Analysis, Request (SBAR, a technique that provides a framework for communication between members of the health care team) Change of Condition Documentation indicated the following:
a. On 4/11/16 at 1:30 p.m., Resident 3 was found sitting down on the floor by the Director of Staff Development's (DSD) office. Resident 3 got out of bed without staff assistance.
A review of Resident 3's Care Plan for Falls, initiated on 4/11/16, indicated the staff would conduct visual checks of Resident 3's whereabouts during nursing rounds, nursing care, medication pass, meal pass and activities.
b. On 5/17/16 at 5:30 p.m., the Certified Nursing Assistant (CNA [not identified]) went to Resident 3's room when she heard the (bed) alarm. Resident 3 fell towards the bedside table and hit his forehead causing a laceration (skin cut). No measurements were documented in the record.
A review of Resident 3's record titled, IDT Conference Record -Falls, dated 5/18/16, indicated Resident 3 received Ativan (a medication used to treat anxiety and that causes sedation) 1 milligram (mg) at 4 p.m. on 5/17/16, and it was a "concern" in regard to the fall.
A review of Resident 3's Care Plan for Fall, dated 4/11/16, and updated on 5/18/16, indicated a risk factor for the fall on 5/18/16 was due to the use of PRN (whenever necessary) antianxiety drug. There was no change in the interventions to address the type of supervision that should be provided to Resident 3 after administration of Ativan medication.
On 1/19/17 at 3:19 p.m., during an interview and review of Resident 3's record, Licensed Vocational Nurse (LVN) 2 stated there was no care plan for the concern about the use of Ativan medication and its relationship to falls and stated she did not know why there was none.
c. On 6/3/16 at 7:10 p.m., Resident 3 stood up next to his wheelchair, lost his balance, and fell to the floor while attempting to walk independently. Resident 3 was assessed (staff not identified) with limited range of motion (refers to the extent of movement of a joint) and complained of pain to the left hip area.
A review of Resident 3's IDT meeting notes, dated 6/6/16, indicated the cause of the fall was due to the alarm in the wheelchair that did not sound.
A review of Resident 3's Care Plan for Fall, revised on 6/3/16, indicated to ensure that the alarm was placed on the adjustable side of the belt in order for the alarm to sound. The care plan was not revised to indicate the type and frequency of supervision needed for Resident 3.
On 1/10/17 at 3:35 p.m., during an interview, the Licensed Vocational Nurse (LVN) 2 stated that the seatbelt to Resident3?s wheelchair was not placed correctly and they had to adjust it.
On 1/10/17 at 4:30 p.m., during an interview and record review, the Director of Nursing (DON) stated that Resident 3's care plan for fall was not revised and updated to address the type and frequency of supervision for Resident 3. The DON stated Resident 3's care plan for fall should have been revised.
A review of Resident 3's record titled, "Diagnostic Laboratories," dated 6/3/16, indicated that Resident 3 sustained a fracture to the left femoral neck with impaction.
A review of Resident 3's SBAR, dated 6/3/16 at 10 p.m., indicated the primary physician was notified of the x- ray result and gave an order to transfer Resident 3 to the GACH.
A review of Resident 3?s record titled, ?Licensed Progress Notes,? dated 6/3/16, indicated Resident 3 was transferred to the GACH on 6/3/16 at 10:45 p.m.
A review of the GACH orthopedic (a branch of medicine that deals with the correction of muscles and bones) surgical consultation, dated 6/4/16, indicated a recommendation for hemiarthroplasty (surgical procedure in which the hip joint is replaced by a prosthetic implant) of the left hip; "however, there was a high possibility of postoperative dislocation." A review of the cardiology (a branch of medicine that deals with diseases and abnormalities of the heart) follow up, dated 6/9/16, indicated, "It is probably an old healing fracture. No surgical intervention needed."
d. A review of Resident 3's record titled, "Licensed Nurse Documentation," dated 6/26/16 at 9:15 p.m., indicated Resident 3 was found sitting on the floor by his bed, alert but confused.
On 1/10/17 at 3:35 p.m., a review of Resident 3's clinical record with LVN 2 in regard to Resident 3's fall on 6/26/16 indicated there was no IDT care conference conducted to identify the cause of the fall. The care plan was not revised to address the cause of the fall and did not indicate the type and frequency of supervision needed for Resident 3. During a concurrent interview, LVN 2 stated there should have been an IDT care conference conducted and a revision of the care plan to address Resident 3's fall on 6/26/16.
A review of Resident 3's record titled, "Diagnostic Laboratories," dated 6/27/16, indicated Resident 3 sustained bilateral hip fractures. The right hip fracture appeared new.
A review of Resident 3's record titled, "Licensed Nurse Documentation," dated 6/28/16 at 5 p.m., indicated Resident 3's primary physician was notified of x- ray result and the physician gave an order to transfer Resident 3 to the GACH.
A review of Resident 3?s record titled, ?Licensed Progress Notes,? dated 6/28/16, indicated Resident 3 was transferred to the GACH on XXXXXXX16 at 9 p.m.
On 1/13/17 at 11:06 a.m., during an interview, the DON stated the purpose of the bed and wheelchair alarms for residents that were identified as high risk for fall were to remind residents to call for assistance. The DON stated Resident 3 needed one staff to sit with the resident (one to one) close monitoring due to restlessness.
On 1/18/17 at 12:15 p.m., Resident 3 was observed in the wheelchair with a small white device at the back of the wheelchair and was connected to the seat belt. A sitter (a staff that provides one to one [1:1] supervision) was observed with Resident 3.
On 1/18/17 at 12:15 p.m., during an interview, the sitter stated that Resident 3 was using a seat belt when seated on the wheelchair because Resident 3 kept on standing up without assistance and would fall. When asked to check Resident 3's seatbelt for proper function, the sitter removed the seatbelt but the alarm did not make a sound. The sitter stated that the alarm was supposed to make a sound when Resident 3 stands up. The sitter and the DSD assisted Resident 3 to stand up but the alarm did not sound.
On 1/18/17 at 12:20 p.m., during an interview, the DSD stated the alarm should be working.
On 1/20/17 at 10 a.m., during an interview, the DON stated that Resident 3's care plan should have been revised and the IDT was responsible for implementing the care plan.
A review of the facility's policy and procedure titled, "Care Plans - Comprehensive," revised date 9/2010 indicated that an individualized, comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The care planning /interdisciplinary team is responsible for the review and updating of care plans, a. when there has been a significant change in the resident's condition, b. when desired outcome is not met, c. when the resident has been readmitted to the facility from a hospital stay.
Therefore, the facility failed to care plan cause of Resident 3?s falls, ensure effectiveness of interventions, and identify the specific type and frequency of supervision consistent to meet Resident 3?s needs.
The facility failed to provide the following care and services:
1. Resident 3 had a fall on 5/17/16 at 5:30 p.m. The IDT identified Ativan was a "concern" but did not address this concern in the Resident 3's care plan.
2. Ensure the wheelchair alarm was properly placed and functional for Resident 3, who was known to the facility staff to have a behavior of getting out of bed/wheelchair without staff assistance. On 6/3/16 at 7:10 p.m., Resident 3 was able to stand up from the wheelchair unassisted without activating the alarm, attempted to walk and fell. Resident 3 sustained a fracture to the left femoral neck with impaction and was transferred to the GACH on 6/3/16.
3. Revise the care plan to indicate the type and frequency of supervision needed for Resident 3, after the fall on 6/3/16 resulting in a broken left hip.
4. Conduct an IDT care conference when Resident 3 had another fall on 6/26/16 at 9:15 p.m., to identify the cause of the fall, evaluate interventions and to determine the type and frequency of supervision needed for Resident 3 and revise the care plan.
Resident 3 sustained bilateral hip fractures, the right hip fracture being new on 6/26/16. Resident 3 was transferred to the GACH on XXXXXXX16. This was the second admission of Resident 3 to the hospital within a month.
The above violations either jointly, separately, or in combination presented either an imminent danger that death or serious physical harm would result or a substantial probability that death or serious physical harm would result to Resident 3. |
| 940000049 |
Affinity Healthcare Center |
940013017 |
B |
6-Mar-17 |
LPQO11 |
5564 |
Freedom from Abuse/Neglect & Exploitation:
?483.12 Free from abuse/involuntary seclusion
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident?s symptoms.
Comprehensive Person Centered Care Planning:
?483.20(k) The facility must develop a comprehensive care plan for each residents that includes measurable objectives and timetables to meet a resident?s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the following:
(i) The services that are to be furnished to attain or maintain the resident?s highest practicable physical, mental, and psychosocial well-being as required under ?483.25; and
(ii) Any services that would otherwise be required under ?483.25 but are not provided due to the resident?s exercise of right under ?483.10, including the right to refuse treatment under ?483.10(b)(4).
On 2/6/17 at 8:33 a.m. an unannounced visit was conducted to the facility to investigate an entity reported incident regarding employee-to-resident physical abuse.
Based on observation, interview and record review, the facility failed to ensure that Resident 1 who had episodes of striking out and agitation was free from physical abuse by failing to:
1. Develop plan of care that has specific measures on how the facility staff will care for a resident with episodes of striking out behavior.
2. Ensure that a licensed vocational nurse (LVN 1) did not hold the resident?s hands and kick her right knee, witnessed by a certified nursing assistant (CNA 1).
On 2/6/17, 8:47 a.m., during an interview with the staff development (DSD), she stated that the director of nursing (DON) conducted the investigation regarding the abuse incident between the LVN 1 and Resident 1 that was witnessed by CNA 1.
A review of Resident 1's Face Sheet (Admission Record) indicated that the resident was initially admitted to the facility on XXXXXXX 17, with diagnoses that included dementia (gradual decrease in the ability to think and remember daily functioning), and general muscle weakness.
A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/5/17, indicated that Resident 1 was severely impaired in cognitive skills for daily decision-making, and required one person physical assist (staff provide guided maneuvering of limbs or other non-weight-bearing assistance) from the staff in eating, and walking in corridor.
Resident 1?s care plan dated 12/20/16 for potential for alteration in mood, behavior and physical ability impacting other aspects of health related to mood alteration, raising voice, striking out and episodes of agitation, included interventions to facilitate social engagement and to review social situations and acceptable response. The plan of care did not address specific measures on how the facility staff will care for the resident in the event the resident started to strike out or became agitated during care to prevent potential physical injury/abuse.
On 2/6/17, at 10:09 a.m., during a telephone interview with registered nurse supervisor (RNS 1), RNS 1 stated that CNA 1 reported to him that she had witnessed LVN 1 kicked Resident 1 on her leg. RNS 1 stated he reported the incident immediately to the DON, and LVN 1 was escorted out of the facility that same day.
On 2/6/17, at 10:30 a.m., during an interview with Resident 1, Resident 1 stated that she did not remember being kicked or hit by anyone. Resident 1 had a short and long-term memory problem.
On 2/6/17, at 10:50 a.m., during a telephone interview, LVN 1 stated on 1/19/17, she held Resident 1's wrists and lifted her leg up to block the resident?s kick. LVN 1 further stated "The resident is crazy; she hit me in my chest three days ago."
On 2/6/17, at 11:16 a.m., during an interview, the director of nurses (DON) stated that Resident 1 had an updated behavior care plan for striking out. The DON stated that LVN 1 did not report that she was previously hit by Resident 1.
On 2/6/17, at 11:49 a.m., during a telephone interview, CNA 1 stated that on 1/19/17 around 4:30 p.m., she was inside Resident 1's room, and she witnessed LVN 1 hold Resident 1?s hands and kick the resident on the right knee. CNA 1 stated that Resident 1 left the room yelling "She kicked me in my leg; she kicked me in my leg."
A review of the facility's 8/16, policy and procedures titled, "Prevention of Resident Abuse and Mistreatment," indicated that resident shall not be subject to abuse by anyone, including, but not limited to, facility staff; other residents, consultants or volunteers, staff of other agencies serving the individual, family members or legal guardians, friends, or other individuals.
The facility failed to ensure that Resident 1 who had episodes of striking out and agitation was free from physical abuse by failing to:
1. Develop plan of care that had specific measures on how the facility staff will care for a resident with episodes of striking out behavior.
2. Ensure that LVN 1 did not hold the resident?s hands and kick her right knee, witnessed by a CNA 1.
The above violation had a direct or immediate relationship to the health, safety, and security of Resident 1. |
| 940000007 |
ATLANTIC MEMORIAL HEALTHCARE CENTER |
940013130 |
B |
28-Apr-17 |
08F611 |
1899 |
1418.21. (a) A skilled nursing facility that has been certified for purposes of Medicare or Medicaid shall post the overall facility rating information determined by the Federal Centers for Medicare and Medicaid Services (CMS) in accordance with the following requirements:
(1) The information shall be posted in at least the following locations in the facility:
A) An area accessible and visible to members of the public
B) An area accessible for employee breaks
C) An area used by residents for communal functions, such as dining, resident council meetings,or activities
The facility failed to post its overall Star System rating as follows:
1. Accessible and visible in the employee break area
2. In the resident's communal areas
On 3/14/17 at 8:30 a.m., an observation of the Center for Medicare/Medicaid services (CMS) Rating Star System was posted at the facility's back side entrance door, close to Station 2, and one on the bulletin board near Station 1. During further observations of the facility, the resident's dining/activity room and the employee's lounge did not have the CMS star posting posted.
On 3/16/17 at 1:55 p.m., during an interview and concurrent observation, the administrator stated there were only two star postings currently posted in the facility.
During an interview, on 3/17/17 at 8 a.m., the administrator stated the resident's dining room was newly painted and the posting was taken down.
A review of an All Facilities Letter (AFL 10-49), dated 12/27/10, with an effective date of 1/1/2011, indicated the five star information shall be posted at three designated sites in the facility, one in an area accessible and visible to members of the public, one in an area for employee breaks, and a third in an area used for residents for communal functions, such as dining, resident council meetings, and/or activities. |
| 940000007 |
ATLANTIC MEMORIAL HEALTHCARE CENTER |
940013131 |
B |
28-Apr-17 |
08F611 |
6094 |
HSC 79839 (a) A call system shall be maintained in operating order in all nursing units. Call systems shall be maintained to provide visible and audible signal communication between nursing personnel and patients. The minimum requirements shall be:
(1) A call station or stations providing readily accessible patient controls to each patient bed.
(2) A visible signal in the corridor above or adjacent to the door of each patient room.
(3) An audible signal and light, on a continuous or intermittent basis indicating the room from which the call originates shall be located at the nurses' stations. Alternate systems must be approved in writing by the Department.
The facility failed to:
1. Ensure all residents call lights were audible upon activation.
2. Ensure all call lights were functioning.
This deficient practice resulted in call lights not being heard and answered, thus residents' needs not being met with a potential for adverse consequences.
On 3/14/17 at 9:52 a.m., during the facility's initial tour, the call lights in room 31, beds A, B, and C, were tested in the presence of a licensed vocational nurse (LVN 8). LVN 8 pressed the call lights for each bed and it was observed that the light did not illuminate and was not audible in the hallway above the doorway of Room 31.
During a concurrent interview with LVN 8, verified and stated the call lights were not working and that the call light should have been operable. LVN 8 stated he would call maintenance to repair the call light.
During a quality of life group meeting, conducted on 3/15/17 at 10 a.m., three of the 16 alert residents complained that the call lights were not being answered in a timely manner. The residents stated call lights took up to 45 minutes to one hour to be answered, especially during the evening shift. The residents also stated they pressed their call lights for needs such as; to use the bedside commode, pain medications, and/or assistance to get up out of bed. One of the three residents stated she felt embarrassed, because once, she had an accident of soiling herself from waiting so long for her call light to be answered.
A review of the Resident's Council Meeting minutes from 10/2016 through 2/2017, five consecutive months, indicated the residents who attended the council meetings complained about call lights not being answered timely. As documented on the Resident Council Meeting form, the facility provided in-services regarding the importance of answering call lights timely.
On 3/16/17 at 1:20 p.m., during an inspection of a medication room in Station 1, with a registered nurse (RN 2), an opened panel box was observed behind the door of the medication room that continued to alarm. During a concurrent interview, RN 2 stated the maintenance staff has been working on the call lights to have sound.
On 3/17/17 at 9:16 a.m., during an interview, a randomly selected resident (RSR 20) stated, "The call lights are not audible, the facility is short staffed on the night shift and they don't answer the call lights timely especially on the night shift."
A review of RSR 20's annual Minimum Data Set (MDS), a resident assessment and care screening tool, dated 1/15/17, indicated RSR 20 had a Brief Interview for Mental Status (BIMS) score of 15 (8 to 15 = interviewable) and had no memory problems, was able to make needs known and understand others. According to the MDS, RSR 20 was assessed as requiring limited assistance with bed mobility, transferring, locomotion on and off the unit, requiring supervision with eating and limited assistance with personal hygiene.
On 3/17/17 at 10:45 a.m., a licensed vocational nurse (LVN 11) was observed standing in front of a residents' room (Room 11) doorway passing medications. The medication cart was directly under the doorway. The call light indicator above LVN 11's head was visibly activated, but LVN 11 was not aware, because the call light was not fully audible. The call light was barely audible at Station 1 and not audible in front of Room 11. A registered nurse (RN 2) at Station 1 saw the call light was activated after approximately two minutes and went and informed LVN 11 that the call light had been activated. LVN 11, who was standing in the room's doorway, told RN 2 she did not hear the call light.
A review of the Centers for Medicare and Medicaid Services (CMS) form, 672 titled, "Resident Census and Conditions of Residents, completed by the director of nurses (DON) indicated the facility's residents conditions included:
One bedbound resident; 64 residents in the chair most or all the time; 44 residents frequently incontinent (inability to control) of urine; 40 residents frequently incontinent of bowel requiring a check and change every two hours (as per the facility's policy); six hospice (end of life) residents; six residents requiring respiratory treatment, and 13 residents with ostomies (an artificial opening in an organ of the body, created during an operation such as a colostomy, ileostomy, or gastrostomy; a stoma).
A review of the facility's call light repair invoice, dated 3/20/17, indicated the call system had no buzzer for routine and emergency call. It was not completely repaired until 3/20/17.
A review of the facility's admission packet given to newly admitted residents included a package titled, "California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities," revised on 5/2011, regarding written policies, rights of patients and facility's obligations. Page 11 indicated a call system shall be maintained in operating order in all nursing units and provide visible and audible signal communication between the nursing personnel and patients.
The facility failed to:
1. Ensure all residents call lights were audible upon activation.
2. Ensure all call lights were functioning.
This violation had a direct or immediate relationship to the health, safety or security of the patients. |
| 940000007 |
ATLANTIC MEMORIAL HEALTHCARE CENTER |
940013132 |
A |
28-Apr-17 |
08F611 |
10068 |
F328 ?483.25(k) Special Needs The facility must ensure that residents receive proper treatment and care for the following special services, tracheostomy care.
The intent of this provision is that the resident receives the necessary care and treatment including medical and nursing care and services when they need specialized services.
F 309
?483.25 Provide Care /Services for highest well being
Each resident must receive and the facility provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
The facility failed to provide Resident 8 with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, and to ensure that Resident 8 received proper care and treatment for services including tracheostomy care, by failing to:
1. Ensure the physician?s orders were followed in the care of a resident with a tracheostomy.
2. Ensure the necessary equipment was available and accessible at the resident?s bedside in case of an emergency situation, especially after Resident 8 complained of difficulty in breathing.
3. Implement the facility?s policy, dated 5/2007, and titled, ?Tracheostomy Replacement of Dislodge Tube.?
These deficient practices resulted in Resident 8 complaining of difficulty in breathing, not having his inner cannula changed per physician?s orders, having excessive brown secretions draining from the tracheostomy ([trach] an incision to open the windpipe to assist with breathing) site, and had the potential for adverse consequences that included the tracheostomy dislodgement and/or inability to breathe, and/or death.
On 3/14/17, at approximately 9 a.m., during the facility's initial tour accompanied by a licensed vocational nurse (LVN 4), Resident 8 was observed in the room with a tracheostomy. A suction machine was observed at the bedside with clear water inside the suction canister.
At approximately 11:30 a.m., on 3/14/17, Resident 8 was seen in the hallway asking the director of staff development (DSD), for two inner cannulas.
On 3/14/17 at 12:40 p.m., Resident 8 was found in his room having difficulty breathing, coughing, gasping for air, having pale skin color, difficulty in speaking due to increased secretions from the tracheostomy site, with audible garbled sounds (distorted speech). Resident 8 was observed with a paper towel draped under the tracheostomy site to catch the mucus dripping from the tracheostomy. There was no tracheostomy equipment at Resident 8's bedside, such as extra inner cannulas (the inner cannula fits inside the outer cannula of the tracheostomy), oxygen (O2), sterile gloves, trach kit and/or an obturator (allows changing of the entire tracheostomy tube and guides reinsertion of the new tube). During a concurrent interview, Resident 8, while crying, stated his inner cannula had not been changed since his admission on 3/12/17; even though, he had been asking staff for the inner cannulas, so he at least could change it himself. Resident 8 stated he was having difficulty breathing and stated, "I get frustrated, because I had this thing (pointing toward his trach) for over 40 years and they don't help me. They have not changed my cannula since I got here two days ago."
On 3/14/17 at 12:42 p.m., a licensed vocational nurse (LVN 7), who was the charge nurse for the station Resident 8 resided (Station 1), was interviewed about the type of equipment that should be available at the resident's bedside. LVN 7 replied, "There should be a suction machine, a trach care kit, and oxygen at the resident's bedside.?
On 3/14/17 at 12:43 p.m., during an interview, LVN 4 was asked what should be at a tracheostomy resident's bedside, LVN 4 replied, "Inner cannulas, trach care kits, including gauze and a suction machine should be at the bedside." However, a concurrent observation of Resident 8's bedside, with LVN 4, indicated there was a box of non-sterile gloves, one suction tip, and a suction machine. There were no other emergency trach supplies at Resident 8's bedside, as verified by LVN 4.
A review of the facility's policy, titled "Tracheostomy Replacement of Dislodge Tube," dated 5/2007, indicated dislodgement of a tracheostomy tube can be a medical emergency and prompt action is necessary. According to the policy, the necessary equipment to perform this procedure included extra trach sets, sterile gloves, sterile curved hemostat (Kelly Clamp [curved forceps used for clamping or grasping]), and a trach care kit. None of which were present at Resident 8's bedside or in the facility on 3/14/17, as verified by LVN 4.
On 3/14/17 at 12:55 p.m., during an interview, the director of nurses (DON) was interviewed about Resident 8's tracheostomy care and supplies. The DON stated, "We keep trach emergency kits in the central supply room with extra inner cannulas in the treatment cart."
On 3/14/17 at 1:23 p.m., during a concurrent observation and interview, with the central supply staff (CS), regarding the availability of obturators and tracheostomy kits in the facility, the CS stated, "The facility had borrowed four days of trach supplies (which included extra inner cannulas and trach kits) from a sister facility." There were no trach kits with obturators and/or inner cannulas in the central supply room. During the concurrent observation of the treatment cart there were only a few inner cannulas present, but no trach kits or an obturator.
A review of Resident 8's Admission Face Sheet indicated Resident 8 was a 63 year-old male, who was admitted to the facility on XXXXXXXX17. Resident 8?s diagnoses included difficulty in walking with falls, laryngeal (voice box [the larynx] which is located at the top of the windpipe [trachea]) cancer, and a tracheostomy.
A review of Resident 8's nursing initial assessment, titled "Licensed Nurse Initial Admission Record," dated 3/12/17, indicated Resident 8 was alert and oriented to time, place, person, and purpose. The initial assessment indicated Resident 8 was able to understand, but his ability to make concrete requests was limited. The nursing assessment indicated Resident 8 had a tracheostomy intact.
A review of Resident 8's care plan, titled "Tracheostomy care related to impaired breathing mechanics due to diagnosis of laryngeal cancer," dated 3/13/17, with the focus being impaired breathing mechanics due to the diagnosis of laryngeal cancer with a tracheostomy was vague, did not provide information about what supplies should be at the bedside. Resident 8's care plan goal was to not have abnormal drainage around the trach site. The staff's interventions included to monitor the resident's level of consciousness, restlessness, and provide tracheal suctioning, provide tracheostomy care and inner cannula changes.
A review of Resident 8's physician's orders, dated 3/13/17, indicated tracheostomy care and inner cannula change with a Portex (a flexible inner trach tubing) should be provided with a tube size of 9.0 every day, and as needed, for dislodgement (to remove or force out of a particular place) and/or clogged. The physician's order also indicated the tracheostomy care was to be provided every shift.
A review of Resident 8's treatment administration record, dated 3/12/17, indicated tracheostomy care should be provided every shift. There were no initials to indicate the trach care had been done on 3/13/17 for the 3-11 p.m. and the 11-7 a.m., shift.
A review of the facility's policy and procedure titled, "Tracheostomy, Care and Cleaning of," dated 5/2007 indicated tracheostomy care would be done at a minimum of once a day or as ordered by the physician. The policy indicated the required equipment for this procedure consists of a plastic bag for disposing of old dressing, tracheostomy care kit, suction machine, sterile water or saline, hydrogen peroxide, sterile suction catheter, sterile gloves, two sterile empty bowls or containers, if not in the care kit, and sterile pipe cleaners or trach brush, if not included in care kit.
On 3/14/17 at 2:56 p.m., during an interview, the facility's medical director was interviewed regarding the need for emergency supplies at Resident 8's bedside. The medical director stated there should be an emergency kit at Resident 8's bedside that included inner cannulas and an obturator.
On 3/15/17 at 7:45 a.m., during an observation, Resident 8 was having breakfast in the patio supervised by a staff member. During a concurrent interview, Resident 8 while observed tearful, stated he was thankful that the facility?s staff obtained the necessary trach supplies. Resident 8 stated that after the supplies were obtained, the facility's staff did provide the trach care he had been waiting for. He stated, "I am feeling better, I can breathe better now, I am very thankful for the nurse to helping me."
The facility failed to provide Resident 8 with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, and to ensure that Resident 8 received proper care and treatment for services including tracheostomy care, by failing to:
1. Ensure the physician?s orders were followed in the care of a resident
with a tracheostomy.
2. Ensure the necessary equipment was available and accessible at the resident?s bedside in case of an emergency situation, especially after Resident 8 complained of difficulty in breathing.
3. Implement the facility?s policy, dated 5/2007, and titled, ?Tracheostomy Replacement of Dislodge Tube.?
The above violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical or mental harm would result. |
| 940000007 |
ATLANTIC MEMORIAL HEALTHCARE CENTER |
940013133 |
A |
28-Apr-17 |
08F611 |
12835 |
F279 ?483.20(d) Use A facility must use the results of the assessment to develop, review and revise the resident?s comprehensive plan of care.
?483.20
(k) Comprehensive Care Plans
(1) The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following ?
(i)The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under ?483.25.
F 309
?483.25 Provide Care / Services for highest well being
Each Resident must receive and the facility provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
The facility failed to provide Resident 3 with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being by ensuring Resident 3 received proper care and treatment which included performing a thorough initial assessment upon admission by failing to:
1. Perform a thorough initial assessment on Resident 3 upon admission to the facility on XXXXXXX 15.
2. Assess and identify Resident 3?s placement of a deep brain stimulator, since 12/2015 ([DBS] a surgically implanted, battery-operated device similar to a heart pacemaker and approximately the size of a stopwatch) used to treat Parkinson's disease (a long-term movement disorder; The brain cells that control movement start to die and cause changes in how the person moves, feels, and acts).
3. Develop a comprehensive plan of care to assess Resident 3 continuously for side effects and/or adverse consequences of the DBS, as indicated by the physician in 2015 (15 months prior).
These deficient practices resulted in the physician's initial order, after the implantation of the DBS, not being followed to monitored the side effects of the DBS, which had a potential for severe adverse consequences, such as seizures (changes in the brain?s electrical activity), headache, confusions, infection and coma (a state of unconsciousness) for Resident 3.
On 3/14/17 at 9:10 a.m., during the facility's initial tour, accompanied by a licensed vocational nurse (LVN 4), Resident 3's hospital gown on the right shoulder was exposing a square item embedded under the skin of his right/mid chest, measuring approximately 3 inches by 2 inches in size. LVN 4 was asked what the item was and she stated she did not know.
Resident 3's Admission Face sheet indicated Resident 3 was a 73 year-old male, who was admitted to the facility on XXXXXXX 15, and most recently readmitted on XXXXXXX 16. Resident 3's diagnoses included hypertension (high blood pressure), diabetes mellitus (elevated sugar in the blood), history of pressure ulcers of the buttock (sores as a result of pressure), anemia (condition that develops when your blood lacks enough healthy red blood cells [RBCs] or hemoglobin [Hgb]), hyperlipidemia (abnormally elevated levels of any or all lipids [fats] and/or lipoprotein in the blood), colostomy (a surgical procedure of an opening (stoma) to the healthy end of the large intestine or colon through for an alternative channel for feces (stool) to leave the body) and dementia (gradual decrease in the ability to think and remember).
A review of Resident 3's readmission assessment, dated 1/7/16, and timed at 8:08 p.m., under additional documentation, indicated, "Right chest." There was no other information about what the writer was referring to on Resident 3's right chest.
A review of Resident 3?s history and physical (H/P) from a general acute care hospital (GACH), dated 12/30/15, had orders for monitoring the side effects of Resident 3's DBS such as seizures, infection, headache, confusion, temporary pain and swelling at the implantation site every shift.
A review of Resident 3?s H/P, dated 1/7/16, upon readmission to the facility, indicated the physician documented Resident 3 was a 72 year-old male with Parkinson?s disease status-post DBS battery replacement. There was no further documentation about Resident 3?s DBS.
A review of Resident 3's current Admission Face Sheet, dated 1/7/16, at the time of the resident?s readmission, did not indicate any documentation related to the placement of the DBS in 2015.
A review of Resident 3?s typed H/P, dated 1/3/17, that was not in the resident?s current record, but was provided by the facility?s medical record staff, indicated under assessment and plan (A/P) that the resident had severe Parkinson?s disease complicated by requiring a DBS. The H/P indicated Resident 3?s DBS battery was changed in 12/2015 and the resident required routine follow-up with the neurologist (a medical doctor who has trained in the diagnosis and treatment of the nervous system disorders) for continued care and monitoring. The H/P note indicated Resident 3 should be monitored for seizures, headache, confusion, and pain at the site.
A review of Resident 3's Minimum Data Set (MDS), an assessment and care screening tool, dated 3/1/17, indicated Resident 3 had some ability to understand, but difficulty to be understood by others [sic]. Resident 3 had a brief interview for mental status (BIMS), score of 6 (0-7 = non-interviewable) [sic]. According to the MDS, Resident 3 was not ambulatory and was totally dependent on staff for most care and required a one-person physical assist with all activities of daily living.
A review of Resident 3?s care plans did not have a plan of care to address the resident?s DBS and the need to monitor the site for adverse consequences.
On 3/14/17 at 9:40 a.m., after being interviewed about the item under Resident 3's chest wall, LVN 5 and the assistant director of nursing (ADON) were observed at Resident 3's bedside asking Resident 3 if his right chest hurts. LVN 5 stated she will call the physician to get more information related to Resident 3's DBS and develop a plan of care for the DBS to monitor for side effects.
On 3/14/17 at 10:15 a.m., during an interview, LVN 5 stated that she was unaware of Resident 3's right chest protrusion until now.
At 10:16 a.m., on 3/14/17, during an interview, LVN 4 indicated that she did not know about Resident 3's DBS.
On 3/14/17, at 11:50 a.m., LVN 5, was observed searching the computer for DBS information. LVN 5 stated that she found out after searching Resident 3's closed old record, dated 12/2015, which indicated Resident 3 had a protruding box in the right chest area, which was a deep brain stimulation (DBS) therapy machine. LVN 5 stated she called the physician and the physician indicated Resident 3 should have been monitored for seizure activity and blood pressure problems. During a concurrent review of Resident 3's records, LVN 5 verified there was no assessment (other than the documentation ?right chest?) or a plan of care for Resident 3's DBS.
A review of Resident 3's nurse's progress note, dated 3/14/17, a licensed vocational nurse (LVN 5) indicated that the physician was contacted regarding Resident 3's DBS on his right upper chest for his Parkinson's disease. LVN 5 documented the physician was informed of the DBS.
A review of Resident 3?s electronic note (EMR), dated 3/14/17, and timed at 11:57 a.m., indicated the physician was notified regarding the resident's DBS. The EMR note indicated the physician was informed that the DBS was implanted in 12/2015, and had orders to monitor for side effects, such as seizure, infection, headache, confusion, and stroke (brain attack/interruption of the brain's blood supply), hardware complications, such as eroded lead wire, and pain and swelling at the implantation site.
In an interview, on 3/14/17 at 12:25 p.m., the director of nursing (DON) indicated the nurses should have known what the protruding area on the resident's right mid-chest area was upon the initial assessment and should have followed-up. The DON stated there should have been a care plan initiated for the DBS care on how to monitor for side effects.
On 3/14/17 at 2:56 p.m., during an interview regarding the DBS, the medical director stated that the staff should have obtained information about Resident 3's DBS, because the DBS should be monitored for side effects.
On 3/15/17 at 11:36 a.m., during an interview, the facility's corporate clinical director (CCD) indicated that they made a mistake regarding Resident 3's DBS and they understood the seriousness. The CCD stated, "We should have in-serviced the staff, and made sure everyone was aware of the side effects and developed a care plan. The physician came yesterday and examined the resident (Resident 3) and we made a follow up appointment with the neurologist (a medical doctor who specializes in treating diseases of the nervous system) for the resident to have it (the DBS) checked."
On 3/15/17, at 1:25 p.m., LVN 1 was interviewed regarding Resident 3's DBS. She stated that she was the one who performed Resident 3's initial assessment upon readmission, on XXXXXXX17 and only documented ?right chest.? LVN 1 was interviewed what was meant by "right chest" and LVN 1 stated, "I did not know what the box under the resident's skin was and I asked another nurse, who did not know either." LVN 1 stated she never followed-up. LVN 1 indicated that she should have follow-up regarding Resident 3's DBS.
At 2:15 p.m., on 3/15/17, during Resident 3?s colostomy care observation with two treatment nurses, LVN 1 and 2, Resident 3 stated while grabbing the DBS, "Who told you about my box? Since you told them (the facility?s staff), they have been in here looking at it, and touching it and asking me does it hurt."
A review of a general acute care hospital (GACH) encounter record, dated 7/6/16, indicated Resident 3's DBS was implanted in 2015 in the right upper chest area. A physician's note, dated 7/21/16, written on the encounter GACH's form indicated Resident 3' Parkinson's condition was severe with moderate improvement after the DBS battery change.
A review of an online article titled, "Parkinson's disease: Guide to Deep Brain Stimulation Therapy" by the National Parkinson Foundation, provided by LVN 5, indicated that the DBS involved the surgical placement of a thin wire, with four electrical contacts at its tip placed into a very specific and carefully selected brain region. The wire is called the DBS leads that are placed in the brain. According to the article, magnetic and electrical current in the environment can cause the DBS system to malfunction and can be dangerous, which included magnetic resonance imaging (MRI) scanning. The online article indicated people with a DBS should remove any unnecessary magnets in their home, stand away from the microwave when in use, and avoid walking through metal detection devices if possible, not to allow any electrical or magnetic device to be placed near their DBS.
A review of the facility's revised policy, dated 10/2010, titled, "Accuracy of Assessment," indicated, a resident should receive an accurate assessment that reflected the resident's status; by a staff who was qualified to assess relevant care areas and was knowledgeable about the resident's status, needs, strengths, and areas of decline.
The facility failed to provide Resident 3 with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being by ensuring Resident 3 received proper care and treatment, which included performing a thorough initial assessment upon admission by failing to:
1. Perform a thorough initial assessment on Resident 3 upon admission to the facility on 11/11/15.
2. Assess and identify Resident 3?s placement of a deep brain stimulator, since 12/2015 ([DBS] a surgically implanted, battery-operated device similar to a heart pacemaker and approximately the size of a stopwatch) used to treat Parkinson's disease (a long-term movement disorder; the brain cells that control movement start to die and cause changes in how the person moves, feels, and acts).
3. Develop a comprehensive plan of care to assess Resident 3 continuously for side effects and/or adverse consequences of the DBS, as indicated by the physician in 2015 (15 months prior).
The above violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical or mental harm would result. |
| 940000007 |
ATLANTIC MEMORIAL HEALTHCARE CENTER |
940013427 |
A |
15-Aug-17 |
XSRW11 |
11472 |
F 328 ?483.25 (k) Special Needs
The facility must ensure that residents receive proper treatment and care for the following special services:
Injections;
Parenteral and enteral fluids;
Colostomy, ureterostomy, or ileostomy care;
Tracheostomy care;
Tracheal suctioning;
Respiratory care;
Foot care; and
Prostheses.
F279 ?483.20(d)
A facility must use the results of the assessment to develop, review and revise the resident's comprehensive plan of care.
?483.20(k) Comprehensive Care Plan
The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.
The care plan must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under ?483.25; and any services that would otherwise be required under ?483.25 but are not provided due to the resident's exercise of rights under ?483.10, including the right to refuse treatment under ?483.10(b)(4).
On 5/29/15, at 9:40 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding quality of care.
Based on interview and record review, the facility failed to develop a plan of care and provide respiratory care to Resident 1 by failing to consistently assess breath sounds and suction respiratory secretions every shift from 12/28/14, to 1/1/15, as ordered by the physician and in accordance with facility policy and procedures.
As a result of this deficient practice, Resident 1 was admitted in the emergency department (ED) with acute (sudden) respiratory failure (failure of the lungs to provide adequate oxygen to the body) due to thick semi-solid gelatinous secretions that blocked the airway and required emergency intubation (placement of a tube into the windpipe to maintain an open airway), intensive care (care to manage a life threatening condition) monitoring and hospitalization for 12 days. Resident 1 was subsequently discharged to a subacute facility (a level of care needed by a resident who does not require hospital care, but who requires more intensive skilled nursing care than is provided to the majority of residents in a skilled nursing facility).
A review of Resident 1's record titled, "Admission Record," indicated Resident 1 was admitted to the facility on XXXXXXX14, with diagnoses that included cerebral artery occlusion with infarct (an area of dead tissue in the brain resulting from lack of blood supply).
A review of Resident 1's record titled, "Order Summary Report," dated 12/28/14, at 9:56 p.m., indicated to suction Resident 1 as needed for increased secretions and assess lungs for signs and symptoms of aspiration (breathing foreign materials usually food, liquids, and vomit [stomach contents] into the lungs or airways) every shift.
A review of Resident 1's record titled, "History and Physical," dated 12/29/14, indicated Resident 1 had a large cerebrovascular accident (CVA, the sudden death of brain cells due to lack of oxygen supply) with right hemiplegia (unable to move the right side of the body) and dysphagia (difficulty swallowing).
A review of Resident 1's record titled, "Physician's Progress Notes," dated 12/30/14, indicated Resident 1 had severe diminished breath sounds at the bases of the lungs and completed seven-day antibiotic therapy for treatment of aspiration pneumonia (infection of the lungs due to aspiration).
A review of Resident 1's record titled, "Care Plan," dated 12/30/14, indicated Resident 1 required tube feeding related to swallowing problems and to prevent aspiration. The interventions included for the facility staff to monitor and report to the physician abnormal lung sounds. There was no plan of care developed to address Resident 1's respiratory care for respiratory assessments and needed suctioning.
A review of Resident 1's record titled, "Nursing Progress Notes," dated 12/31/14, at 11:02 p.m., indicated Resident 1's breath sounds had rales (breath sounds that indicate presence of fluids or secretions in the lungs); the physician was informed and ordered to increase the frequency of the breathing treatment medication.
A review of Resident 1's record titled, "Order Summary Report," dated 12/31/14, at 11:14 p.m., indicated a telephone order to increase Ipratropium-Albuterol solution 0.5-2.5 milligrams/ 3 milliliters, inhale orally every six hours as needed for shortness of breath.
A review of Resident 1's record titled, "Minimum Data Set (MDS, a resident assessment and care screening tool), dated 1/1/15, indicated Resident 1 was unable to speak, rarely or never able to express ideas, sometimes able to understand others and had severe cognitive (mental abilities) impairment (rarely or never made decisions). The MDS indicated Resident 1 required extensive assistance (resident involved in activity and staff provided weight-bearing support) with one person assistance with activities of daily living. The MDS indicated Resident 1 had limitation in range of motion (the distance and direction a joint can move to its full potential) on all extremities.
A review of Resident 1's Nursing Progress Notes, dated 1/1/15, indicated the following:
1. At 10:15 a.m., Resident 1 had shortness of breath (SOB) and Resident 1's family member (FAM 1) was informed and agreed to provide Resident 1 with oxygen and perform cardiopulmonary resuscitation (CPR, an emergency procedure performed to preserve the brain function and to restore blood circulation and breathing), but no intubation.
2. At 10:45 a.m., Resident 1's physician was informed.
3. At 10:55 a.m., Resident 1 was awake, alert to name with shortness of breath, oxygen saturation (a measurement of oxygen level in the blood, normal blood oxygen level is 90-100 percent [%]) of 82 %. Oxygen was administered using a non-rebreathing mask (mask that provides oxygen at a high rate and high level) at 10 liters per minute (LPM) and the oxygen saturation increased to 98%. FAM 1 was informed of Resident 1's progress and agreed to transfer Resident 1 to the hospital by 9-1-1 (an emergency phone number).
A review of Resident 1's Nursing Progress Notes, dated from 12/28/14, through 1/1/15, indicated that there was no evidence that Resident 1 was consistently assessed for breath sounds, reassessed for effectiveness of breathing treatments, suctioned for increased secretions, and assessed for character of secretions, amount, color, and thickness.
A review of Resident 1's record titled, "Medication Administration Record (MAR)," from 12/28/14 to 1/1/15,indicated that there were no nurses' initials to indicate suctioning, every shift, was provided to Resident 1.
A review of Resident 1's hospital record titled, "ED Notes," dated 1/1/15, at 10:46 a.m., indicated Resident 1 was brought to the ED by the paramedics with shortness of breath and agonal respiration (gasping for breath) with respiratory desaturation (low oxygen level in the blood) of 70% (normal range 90-100%) and was intubated for respiratory distress/failure and was transferred to the intensive care unit.
A review of Respiratory Therapist 1's (RT 1) documentation on the ED Notes, dated 1/1/15, at 1:11 p.m., indicated that during Resident 1's intubation, there was a large amount of thick , gelatinous material (secretions) obstructing Resident 1's airway.
A review of Resident 1's hospital record titled, "Discharge Summary," dated 1/12/15, indicated Resident 1 was discharged to the subacute facility with diagnoses that included acute respiratory failure secondary to aspiration with very thick semi-solid nasal (nose) oropharyngeal (mouth and throat) secretions with recent stroke and severe dysphagia and was extubated (removed from respirator [machine designed to assist or replace normal breathing]).
A review of Resident 1's Nursing Progress Notes, MAR, and care plans for 12/28/14 to 1/1/15, conducted with Registered Nurse 1 (RN 1) on 5/29/15, at 11:50 a.m., RN 1 stated she could not find documentation regarding color and amount of Resident 1's secretions and the quality of breath sounds. RN 1 stated the nursing staff should have assessed Resident 1's breath sounds and suctioned secretions as needed according to the physician's order. RN1 stated she could not find a plan of care for respiratory care to address suctioning and assessing breath sounds.
During an interview on 4/11/16, at 10:15 a.m., FAM1 stated she visited Resident 1 every day and she did not see the facility staff suction Resident 1 during her visits and she noticed the container for the suction machine (a machine used to remove respiratory secretions) was always empty.
During an interview on 6/15/17, at 2:30 p.m., the Director of Nursing (DON) stated the nursing staff should have assessed Resident 1 for respiratory problems such as; listening to the breath sounds, suctioning Resident 1 when necessary, and documenting the amount, color, and thickness of the secretions. The DON stated Resident 1 should have been assessed if secretions were in the upper (from the nose down to the folds of the vocal cord) or lower respiratory tract (from the vocal cord down to the lungs) needing deep suctioning (the use of a smaller suction catheter to reach down into the resident's airway). The DON stated Resident 1's vital signs (heart rate, body temperature, respiration rate, and blood pressure [the strength of the blood pushing against the sides of the blood vessels]), including the blood oxygenation level should have been assessed.
A review of the facility's policy and procedures, dated 5/2007, titled, "Care of Resident with respiratory secretions," indicated it is the policy of the facility to clear the airway of obstructing secretions and prevent aspiration. The facility will evaluate and assess the resident for signs and symptoms of impaired respiratory function, assess breath sounds, significant decrease in oximetry results (a device placed in the finger and detects how much oxygen is in the blood), to call MD (medical doctor) and discuss respiratory changes, and provide suctioning as needed.
A review of the facility's policy and procedures titled, "Care Planning," dated 5/2007 indicated it is the policy of the facility that the Interdisciplinary Team (IDT, a group consisting of the head of the different departments who work together to discuss a resident's care) develop a comprehensive plan of care for each resident.
Therefore, the facility failed to develop a plan of care and provide respiratory care to Resident 1 by failing to consistently assess breath sounds and suction respiratory secretions every shift from 12/28/14 to 1/1/15, as ordered by the physician and in accordance with facility policy and procedures.
As a result of this deficient practice, Resident 1 was admitted in the emergency department with acute respiratory failure due to thick semi-solid gelatinous secretions that blocked the airway and required emergency intubation, intensive care monitoring and hospitalization for 12 days. Resident 1 was subsequently discharged to a subacute facility.
The above violations either jointly, separately, or in combination presented either an imminent danger that death or serious physical harm would result to Resident 1. |
| 950000045 |
ARCADIA HEALTH CARE CENTER |
950009303 |
A |
04-Jun-12 |
PEKW11 |
9958 |
F323 483.25 (h) The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. On August 18, 2011, an unannounced visit was made to the facility to investigate an entity reported incident regarding patient safety and falls.Based on observation, interview, and medical record review, the facility failed to ensure that Patient 1?s environment remains as free of accident hazards as is possible by ensuring that the mechanical lift sling was maintained as recommended by the manufacturer so as to prevent accidents during transfers by failing to:1. Complete a monthly maintenance check of the mechanical lift which includes straps, and slings as recommended by the manufacturer to ensure that the mechanical lift slings or straps were not damaged or worn.2. Replace the mechanical lift slings after one year according to manufacturer?s recommendation to ensure that the slings were safe to use for transferring patients.As a result, Patient 1 fell to the floor when the sling from a mechanical lift broke and Patient 1 sustained a major laceration injury that required an evaluation and treatment at an acute care hospital. Patient 1 required a laceration repair with the placement of 4 subcutaneous (underneath the skin) sutures and 17 simple sutures.Findings: A review of the medical record revealed that Patient 1 was a 96 year old female who was previously admitted to the skilled nursing facility (SNF) on December 2, 2003, with diagnoses that included; hypertension (high blood pressure), congestive heart failure (a condition when the heart is unable to maintain adequate circulation of blood), and dementia (is a loss of brain function). Patient 1 was readmitted on August 15, 2011, with diagnoses that included laceration of right elbow.The Minimum Data Set (MDS), a standardized assessment and care planning tool dated April 19, 2011, indicated that Patient 1, had short and long term memory impairment, poor decision making skills, requiring supervision, totally dependent for all activities of daily living (ADLs) such as bed mobility, transfer, and had impairment of both lower extremities, and used a wheelchair. The Quarterly Assessment dated July19, 2011, indicated the resident did not have a significant change or clinical change.A review of a revised care plan dated January 3, 2010, titled ?Self-care deficit total dependence for transfers?, indicated that the nursing staff was to ensure patient?s safety when providing care.On August 18, 2011, at 9:45 a.m., at the skilled nursing facility, Patient 1 was observed to be non-verbal. A white dressing/bandage was also observed on the patient?s right arm.The review of the licensed nurses? progress notes dated August 3, 2011, at 9:40 a.m., revealed that the charge nurse, Employee 3, was paged to go into the patient?s room. The note further indicated that the patient was observed lying on the right lateral side and with the right side of her face on the floor.The licensed nurses? progress notes indicated that first aid was rendered by Employee 4 at the patient?s bedside while Employee 5 assessed and completed a body check on the patient. According to the notes, Employee 5 noted a bump on the forehead and laceration on the right upper arm of Patient 1. The emergency 911 was called at 9:45 a.m., the patient verbalized pain on her right leg and right upper arm at 9:50 a. m., the paramedics arrived at the facility at 10:05 a.m., and the patient was transported to an acute hospital emergency room, via 911 for further evaluation.Employee 1 was quoted as stating the following in the licensed nurse report dated August 3, 2011, ?I was transferring the patient after shower from Hoyer (mechanical) lift to geri-chair, then the sling broke, I just saw her went forward?A review of the acute hospital emergency room report dated August 3, 2011, at 10:25 a.m., indicated that Patient 1?s diagnoses included status post fall with a large laceration to the right arm. The emergency room (ER) procedure note dated August 3, 2011 at 4:01 p.m. indicated that Patient 1 had an 11 centimeter (cm) full-thickness laceration on the lateral aspect of the right elbow that extended into the anterior cubital area only involving the subcutaneous layer and the fat layer. Furthermore, the procedure included the placement of 4 subcutaneous sutures and 17 simple sutures to evert (to turn outward) the wound edges because of the length being 11 cm. While at the ER, Patient 1 had a computerized tomography (or CT scan- combines a series of X-ray views taken from many different angles to produce cross-sectional images of the bones and soft tissues inside the body) of the brain that revealed that there was no evidence of acute traumatic injury. The x-ray of the right tibia and fibula (the bones of the lower leg) was also performed and showed no acute injury. However, the chest x-ray revealed there was a small pleural effusion. The urinalysis test (a test used to detect and assess a wide range of disorders, including urinary tract infection, kidney disease and diabetes.) was also performed and revealed a urinary tract infection. The resident was subsequently admitted to the acute care facility for further observation, the treatment of the urinary tract infection and pneumonia. A review of the acute care discharge summary dated August 29, 2011, revealed the daily wound treatment, antibiotic medications, intravenous fluids and pain medications as needed (prn). On August 15, 2011, Patient 1 was discharged to the skilled nursing facility.On August 18, 2011, at 9:50 a.m., during an interview with Employee 1 she stated that on August 3, 2011, at 9:30 a.m., while she was transferring Patient 1 from the shower chair to the geri-chair using the mechanical lift, the sling (a component of the mechanical lift) broke and the patient fell onto the floor. Employee 1 stated she called Employee 3 to assist her with the patient. Employee 1 also stated that she did not notice if the mechanical lift sling was ripped or damaged before she used it.On August 18, 2011, at 10 a.m., during an interview with the administrator he stated that Employee 6, was responsible for maintaining and inspecting all the devices being used in the SNF and it included the mechanical lift. The administrator further stated that the facility did not have documentation to indicate that the mechanical lift was maintained and inspected prior to Patient 1?s fall/injury and that the monitoring of the mechanical lift only started after Patient 1 fell. During an interview on October 18, 2011 at 9:30 a. m., Employee 6, Maintenance Supervisor, stated that he cleans and checks the batteries only of the mechanical lift. A review of the manufacturer?s mechanical lift maintenance and service checklist indicated that the components and operating points should be inspected at intervals not greater than one month. There was no evidence that Employee 6 inspected the mechanical lift components (slings) and operating points as the manufacturer recommended.On August 18, 2011, at 10 a.m., further interview with the administrator revealed that he did not remember how old the mechanical lift slings were. Employee 2 stated that the mechanical lift sling that was used for transferring Patient 1 on August 3, 2011, broke where the strap was attached to the sling. Employee 2 further stated that ? The stitching of one of the sling loops that attaches to the hook of the mechanical lift came apart, that caused Patient 1 to fall off of the sling.?1. On March 15, 2012, a review of the purchase order obtained for the mechanical lift slings indicated the facility purchased four mechanical lift slings on September 22, 2006. There were no additional slings purchased until August 5, 2011, indicating that the facility did not replace the mechanical lift slings until after Patient 1 fell from the mechanical lift sling on August 3, 2011 which was contrary to the manufacturer?s recommendation of replacing the mechanical lift slings after one year, to ensure that the slings were safe for use for the transfer of patients.A review of the manufacturer?s maintenance checklist for the Mechanical lift indicated that the basic checks be made periodically throughout the life of the device as follows:* Basic checks are periodically made by maintenance staff to ensure on-going safety. * Components and operating points must be scheduled for inspection at intervals not greater than one month. * Check the whole sling including loops, and stitching for damage. If there is any, discard and order a new one. * ?If excessively worn, replace immediately. * It is recommended that slings be replaced after one year.The facility failed to ensure that a mechanical lift sling was maintained as recommended by the manufacturer to prevent accidents during transfers by failing to:1. Complete a monthly maintenance check of the mechanical lift which includes straps, and slings as recommended by the manufacturer to ensure that the mechanical lift sling or straps were not damaged or worn.2. Replace the mechanical lift slings after one year according to manufacturer?s recommendation to ensure that the slings were safe to use for transferring patients.The facility?s failure to maintain the mechanical lift sling as recommended by the manufacturer resulted in Patient 1 falling to the floor when the sling broke causing a large laceration injury, that required an evaluation and treatment at an acute care hospital. Patient 1 required a laceration repair with the placement of 4 subcutaneous (underneath the skin) sutures and 17 simple sutures.The above violation presented a substantial probability that serious physical harm would result to Patient 1 and it did. |
| 950000103 |
ALLIANCE NURSING AND REHABILITATION CENTER |
950012248 |
B |
09-May-16 |
CK3111 |
10111 |
F314-Treatment/Services to Prevent/Heal Pressure Ulcers.Based on the comprehensive assessment of a resident, the facility must ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Based on observation, interview and record review, the facility failed to ensure the efficacy of a pressure relieving device of a resident who had a high risk of pressure sore development for Resident A by failing to: 1. Follow the inflation guideline for the use of a ROHO Prodigy mattress overlay (provides individualized pressure to reduce pressure on areas that are at high risk for pressure ulcers development),2. Follow the ROHO manual linen recommendations to use at a maximum:a. one flat or contoured sheet arranged loosely over the mattress overlay.b. a draw sheet for moving and transferring c. one incontinent pad or a Water-resistant Reusable Overlay Cover3. Provide education and training to direct care staff in the proper application of the ROHO Prodigy mattress overlay.4. Identify an open skin area for Resident A, who had a history of pressure sores (an area of damaged skin caused by staying in one position for too long).As a result of these deficient practices, Resident A developed a recurrent stage two (superficial open sore in the upper layer of skin) pressure sore to the medial left upper buttocks/sacral area (the area at the bottom of the spine) and experienced a delay in treatment and services to promote healing.A review of Resident A's clinical record indicated the resident was 77 years old who was originally admitted to the facility on August 3, 2012 and readmitted on August 13, 2013, with diagnoses that included presence of pressure ulcer stage 4 (full thickness skin loss with extensive destruction, dead tissue, or damage to muscle, bone, or supporting structures) of the sacral that healed on December 12, 2012, dementia (decreased intellectual functioning that interferes with normal life functions), and diabetes. Resident A was assessed as moderately at risk to develop a new pressure sore at admission and was reassessed on August 3, 2013 as having a high risk to develop a new pressure sore. According to the MDS (Minimum Data Set, a standardized assessment and care planning tool) dated August 14, 2013, Resident A was rarely or never able to understand and be understood by others, required total assistance in repositioning while in bed and in performing activities of daily living (ADLs). The MDS indicated the resident was at risk for developing pressure sores and did not have one or more unhealed pressure ulcers at Stage One (non blanchable erythema/redness of skin surface that persists when pressure is applied of intact skin, the heralding lesion of skin ulceration) or higher. The assessment indicated the use of a pressure reducing device (works by distributing local pressure over a wider body surface area) while in bed. A review of the skin breakdown care plan dated August 6, 2013, interventions included to monitor the skin and report promptly any changes of the resident's skin.A review of the Nursing History/Admission/Assessment Sheet dated August 13, 2013, indicated the resident had a left buttock boil (a collection of pus that forms in the skin) on the posterior (back) part of the body; all other areas of the posterior side of the body were intact. The treatment administration record for September 2013 indicated the left buttock boil was healed on September 7, 2013.A review of the physician orders dated September 2013 noted an order dated August 3, 2013 indicating the resident may have a low air loss mattress for decubitus management.On September 14, 2013 at 8:20 a.m., during a skin assessment conducted in the presence of treatment nurse 1 and the registered nurse (RN) supervisor, Resident A was lying on a ROHO mattress overlay with fitted sheets. Treatment nurse 1 and RN supervisor removed the positioning pillows that were placed between the resident and the ROHO mattress overlay. The resident was side lying and when the pillows were removed it revealed sanguineous fluid (blood) on the sheet. The medial (middle of the body) left upper buttock/sacral was observed to have a wound that was open and red. Surrounding the area of the medial left upper buttock/sacral wound was a scarred healed area. When asked if Resident A had any recent breakdown to the area the treatment nurse stated no, just the healed tissue from the prior stage 4 pressure ulcer to the sacral area. Treatment nurse 1 described the open wound as a Stage 2 (partial thickness skin loss involving epidermis, dermis, or both- the ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater) that measured 0.6 centimeters (cm) in length by 0.4 cm in width. On September 14, 2013 at 8:55 a.m., after reviewing the clinical record, treatment nurse 1 acknowledged there was no documented evidence the physician was notified the resident developed a Stage 2 pressure ulcer. The physician was called and ordered to cleanse the left upper buttock Stage 2 pressure ulcer, with normal saline and to apply a Duoderm patch (a patch that provides a healing environment for wounds) every other day for 14 days and then to reevaluate the wound.On September 14, 2013 at 9:30 a.m., during an interview, the (director of nurses) DON stated the use of a ROHO mattress overlay was implemented in the facility a few months ago. The maintenance staff inflates the overlay and places it in the resident's room. She further stated that there was no in-service to the staff on the proper use of the ROHO mattress overlay. The overlay mattress is evenly inflated and is not deflated once the resident is placed on the mattress as indicated by the manufacturer?s information booklet. During the course of the interview, the DON went to Resident A's room and the treatment nurse was starting the treatment for the Stage 2 pressure ulcer. The pressure ulcer was observed by the DON to be in the area where the resident had a history of a Stage 4 pressure ulcer. In addition, The DON acknowledged the facility staff was not aware of the manufacturer guidelines of how much air is needed to inflate the overlay correctly. Treatment nurse 2, on September 14, 2013 at 9:45 a.m., stated the ROHO mattress overlays are ordered from central supply when the resident has an order for a low air loss mattress. The maintenance staff then fills the overlay with air and places the overlay in the resident's room with a certified nursing assistant. She further mentioned that as a treatment nurse she checks that the mattress is filled when she is providing the treatment to the resident. However, she does not inflate or deflate the overlay.During an interview with the maintenance staff, on September 14, 2013 at 9:55 a.m., he stated there are three sections to the ROHO mattress overlay that need to be filled with air. After he fills the overlay he places it in the resident's room with the licensed nurse and checks for no punctures and makes sure the overlay is not too hard or too soft once the resident is on the overlay. The maintenance staff was not aware of any measurements per manufacturer of how the overlay needs to be inflated after the resident is on the overlay. During an observation on September 14, 2013 at 10:15 a.m., in the presence of the RN supervisor, Resident A was on the ROHO mattress overlay and the overlay was covered with two sheets, one draw sheet and there was a pillow used to position the resident side lying between the resident and the overlay. According to the ROHO Non-Powered Mattress Overlay Operation Manual dated 2008-2012, indicated the adjustment instructions for the Prodigy overlay. Step 5, of the instructions indicated to reapply bed linens (maximum one sheet, one draw sheet, or one incontinent pad). Step 6, for proper immersion of each section; slide your hands between the mattress overlay and the end-user under the lowest bony prominence. Release air from section until area of high risk is within the suggested Inflation Guidelines.The Inflation Guidelines for the Prodigy are 1 inch (in) to 1.5 in for the distance from base. In addition, the instructions indicated not to allow end-user to lie on an under-inflated or over-inflated mattress overlay and to check the overlay at least once a day for proper adjustment. The mattress overlay is most effective when the Inflation Guidelines are followed and there is air between all parts of the end-user and the base. Under-inflation and over-inflation reduce or eliminate the mattress overlay's therapeutic benefit, which may increase risk of the skin and other soft tissue.The operational manual indicated that too many linens between the mattress overlay and the end-user will compromise performance, prevent the end-user from sinking in, and reduce pressure distribution. It is recommended that a maximum of:One flat or contoured sheet was to be arranged loosely over the mattress overlay.If needed, a draw sheet for moving and transferring can be used.If needed, one incontinent pad can be used. Water-resistant ReusableOverlay Covers and Overlay For special positioning it is recommended that if the end-user has special positioning needs while lying on his/her side or back, a pillow can be placed beneath the mattress overlay. Consult with your clinician and / or healthcare provider for proper pillow positioning. http://www.spinlife.com/files/ROHO%20Mattress%20Overlay%20Manual1.pdf There was no evidence that the facility staff followed the inflation and linen guidelines for the use of the pressure relieving mattress, and failed to identify the emergence of a stage 2 pressure sore. The above violation has a direct relationship to the health safety of the resident. |
| 950000012 |
ARBOR GLEN CARE CENTER |
950012756 |
B |
16-Nov-16 |
RRDF11 |
4650 |
? 483.13(c)(2) F 225 The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). ? 483.13(c) (3) the facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. On 7/7/2016 at 1:00 p.m., an unannounced visit was made to the facility to investigate a complaint regarding resident neglect and an injury of unknown origin. The facility failed to: 1. Investigate an injury of unknown source to Resident 1. 2. Send a written notification of Resident 1?s injury of unknown source to the State survey and certification agency within 24 hours. A review of the Admission Record indicated Resident 1 was admitted to the facility on 6/24/2016 with diagnoses that included, but not limited to, muscle weakness, heart failure (weak heart resulting in unable to pump blood), hypothyroidism (thyroid gland does not produce enough hormones causing weakness). A review of an undated document titled "History and Physical Examination" indicated Resident 1 had the capacity to understand and make decisions. A review of a document titled "Initial Admission Record" dated 6/24/2016 indicated Resident 1 was alert, oriented to time, place and person; able to follow simple commands; edema (swelling) was present on the right arm and there was no limitation in range of motion of the right hand. During an interview on 7/7/2016 at 1:30 pm, Resident 1 stated he did not know how he fractured his right hand. Resident 1 stated he noticed it was painful when he was getting showered by certified nurse assistant (CNA) 1 on 6/30/2016. Resident 1 stated CNA 1 was scrubbing his hand and back too rough during shower. Resident 1 stated his right hand did not hurt prior to his admission to the facility. During an interview with CNA 1 on 7/8/2016 at 7:45 am, CNA 1 stated that Resident 1 told him on 6/30/2016 during shower that he was being too rough while scrubbing Resident 1's back. CNA 1 said he did not scrub Resident 1's hands. CNA 1 stated he scrubbed Resident 1's back more gently after Resident 1 told him that he was too rough. A review of a document titled "Progress Notes" dated 7/5/2016 indicated a late entry charting for 7/1/2016; "Resident noted with some swelling on right wrist.? The physician was notified and a new order was obtained for an x-ray to right wrist. A review of a document titled "Imaging Report" dated 7/1/2016 indicated a nondisplaced acute fracture fifth metacarpal (broken little finger), osteopenia (loss of bone tissue), and degenerative change. During an interview with licensed vocational nurse (LVN) 1 on 7/7/2016 at 3:30 pm, LVN 1 stated she was informed by the Social Services Director (SSD) about Resident 1's right hand and she reported it to the physician. LVN 1 stated that she did not investigate the cause of the swelling nor did she report Resident 1's injury to the supervisor. During an interview with the SSD on 7/8/2016 at 9:30 am, the SSD stated she saw a bluish discoloration on Resident 1's wrist and reported it to LVN 1 on 7/1/2016. The SSD also stated she was informed by Resident 1 about CNA 1 being too rough during shower. The SSD further stated she interviewed CNA 1 about the shower incident. During an interview on 7/7/2016 at 4:00 pm, the administrator stated that the incident involving Resident 1 was only reported to him on 7/5/2016. The administrator stated Resident 1 was not aware how the fracture happened and that an injury of unknown origin should have been reported to him and to the State within 24 hours. A review of the facility's policy and procedure titled "Incident Accident Reporting" dated 5/2007 indicated: It is the policy of this facility that: 5. The administrator will coordinate an investigation of the event, as needed, within twenty four (24) hours of the event. Any incident or accident that requires reporting will be completed according to the state's standard. Therefore, the facility failed to: 1. Investigate an injury of unknown source to Resident 1. 2. Send a written notification of Resident 1?s injury of unknown source to the State survey and certification agency within 24 hours. These violations had a direct relationship to the health, safety, or security of Resident 1. |
| 950000045 |
ARCADIA HEALTH CARE CENTER |
950012761 |
B |
17-Nov-16 |
49QC11 |
5196 |
? 483.13(c)(2) The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). ? 483.13(c)(3) The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. On 9/2/2016 at 1:00 p.m., an unannounced visit was made to the facility to investigate a complaint regarding an injury of unknown origin. The facility failed to: 1. Thoroughly investigate an injury of unknown source to Resident 1. 2. Send a written notification of Resident 1?s injury of unknown source to the State survey and certification agency within 24 hours. A review of Resident 1?s face sheet indicated Resident 1 was admitted to facility on 5/12/2016 with diagnoses that included, but not limited to, dysphagia (difficulty swallowing), Dementia (brain disease that cause a long term decrease in the ability to think and remember affecting a person's daily functioning), gastroesophageal reflux disease (acid reflux). A review of Resident 1?s ?History and Physical Examination? dated 5/15/2016 indicated Resident 1 did not have the capacity to understand and make decisions. Resident 1?s Minimum Data Set ((MDS), a comprehensive assessment tool), dated 6/10/2016 indicated that Resident 1 rarely/never understood self and others had severely impaired cognitive skills for decision making, required extensive assistance with bed mobility, transfer, dressing, toilet use and bathing. During the tour on 9/2/2016 at 1:30 pm with Social Service staff, Resident 1 was observed with purplish discoloration on the lateral corner of the right eye extending to the right cheek area. A review of Resident 1?s "Interdisciplinary Progress Notes" dated 8/27/2016 indicated that Certified Nursing Assistant (CNA) 1 noticed a discoloration on Resident 1's right eye and swollen periorbital (surrounding the eye) area at around 4:30 pm. A review of Resident 1?s "Physician's Progress Notes" dated 8/29/2016 indicated, "Resident 1 developed bruise around right eye 2 days ago (8/27/2016), not sure of the cause - per nursing, no reported falls." During an interview on 10/3/2016 at 11:40 am, Certified Nursing Assistant (CNA) 1 stated he noticed the bruise and swelling on Resident 1's right eye around 4:30 pm on 8/27/2016. CNA 1 also stated he immediately reported it to Licensed Vocational Nurse (LVN) 1. CNA 1 stated he was not aware of any incident of fall or trauma to Resident 1. During an interview on 10/3/2016 at 11:20 am, LVN 1 stated that he was informed by CNA 1 regarding Resident 1's bruise and swelling on the right eye. LVN 1 also stated he applied an ice pack over the swelling, called and informed the attending physician and responsible party about Resident 1's condition. LVN 1 further stated that he did not know how Resident 1 sustained the injury and that he tried to ask Resident 1 but could not speak nor understand Resident 1's language. During an interview on 9/2/2016 at 2:00 pm, the Social Service staff stated nobody from the facility could speak and understand Resident 1's dialect. Social Service staff also stated that there was no communication board present at bedside. During an interview on 9/8/2016 at 1:00 pm, the Director of Nursing (DON) stated that she was informed by LVN 1 about Resident 1's injury on the right eye area. The DON stated that Resident 1's condition was reported to the administrator. The DON also stated that the cause of Resident 1's injury to the right eye area was unknown. The DON further stated that she was not aware if this incident was supposed to be reported to State survey and certification agency and that she will check for the facility policy. During an interview on 9/8/2016 at 1:30 pm, the administrator stated that he was informed of Resident 1's incident on 8/27/2016 but he did not report the incident to State survey and certification agency. The administrator further stated that he should have reported the incident because the injury was of unknown source since there was nobody, including Resident 1, who could tell how the injury happened. A review of the facility policy and procedure titled "Unexplained Injury-Investigation" dated 9/2009 indicated that an investigation of all unexplained (including bruises and abrasions) is conducted by nursing personnel to ensure that resident safety was not jeopardized, written notification of all injuries is sent to the State health department (survey and certification agency) within 24 hours. Therefore, the facility failed to: 1. Thoroughly investigate an injury of unknown source to Resident 1. 2. Send a written notification of Resident 1?s injury of unknown source to the State survey and certification agency within 24 hours. These violations had a direct relationship to the health, safety, or security of Resident 1. |
| 950000012 |
ARBOR GLEN CARE CENTER |
950012777 |
B |
23-Nov-16 |
OY1P11 |
8948 |
483.25(c) Pressure Sores Based on the comprehensive Assessment of a resident, the facility must ensure that? (1) A resident who enters the facility without pressure sores does not develop pressure sores unless the individual?s clinical condition demonstrates that they were unavoidable; and (2) A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. On 6/30/2016 at 1:00 p.m., an unannounced visit was made to the facility to investigate a complaint regarding quality of care/treatment. The facility failed to provide treatment and services to prevent the development of pressure sores (localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination with shear and/or friction) for Resident 2, who was at risk for developing pressure sore, by failing to: 1. Reposition Resident 2 at least every 2 hours. 2. Identify, assess, and provide treatment to Resident 2's pressure sore on the left buttocks. Resident 2 developed a new pressure sore measuring: 2 cm (centimeters) in length by 3 cm in width by x 0.2 cm in depth, on the left buttock covered with 80% eschar (dark colored dead tissue). The pressure sore was unstageable (Stage of the pressure sore reflects the depth of sore and the damage to the body tissues.) due to the presence of the eschar, which prevented determining the depth of the pressure sore. A review of Resident 2's Admission Record indicated he was admitted to facility on 3/14/2016, and readmitted to the facility on 6/3/2016, with diagnoses that included, but not limited to, muscle weakness, heart failure (heart is unable to pump enough blood to the system), and anemia (lowered ability of blood to carry oxygen). A review of a document titled "History and Physical Examination" dated 6/6/2016 indicated Resident 2 had the capacity to understand and make decisions, was diagnosed with paraplegia (impaired motor function of lower extremities), right hemiplegia (impaired motor function of the right side of body), Stage IV decubitus (full thickness tissue loss with exposed bone, tendon, or muscle) on coccyx (tailbone) S/P (status post) debridement (removal of dead, damaged or infected tissue), on wound vac (vacuum dressing for wound to promote healing). A review of the Minimum Data Set ((MDS), a comprehensive assessment tool), dated 6/10/2016 indicated Resident 2 was cognitively intact, required extensive assistance with one person assist for bed mobility, toilet use and personal hygiene, had an indwelling catheter (tube used to drain urine) and was frequently incontinent of bowel. The MDS indicated Resident 2 had one Stage IV pressure sore measuring: 7 cm in length by 13 cm in width by 0.2 cm in depth, with granulation tissue (healing tissue). No other pressure sores were documented for Resident 2. A document titled "Initial Admission Record" dated 6/3/2016 indicated Resident 2 had skin problems on admission and also indicated the resident refused to have a body check done and requested to have the body check done in the morning. Resident 2's clinical record did not indicate that a documentation of body check was done the following day on 6/4/2016. Resident 2's "Braden Scale for Predicting Pressure Sore Risk" dated 6/4/2016 indicated Resident 2 had a score of 14 which categorized Resident 2 as having a moderate pressure sore risk. Resident 2 was assessed as being bedfast (confined to bed), with very limited ability to change and control body position, unable to make frequent or significant changes (in body position) independently, had a problem with friction and shear (would drag body over sheets and surfaces potentially damaging the skin surface), required moderate to maximum assistance in moving, and complete lifting of the resident's body without sliding against the bed sheets was impossible. The care plan for pressure sores dated 6/4/2016 interventions included: To assess, record, monitor wound healing, and daily body checks. During a treatment observation and concurrent interview with Treatment Nurse (TN) 2 on 6/30/2016 at 2:00 pm, TN 2 changed the dressing of Resident 2's sacro-coccyx (tailbone area) pressure sore. Resident 2 was observed to also have a pressure sore on the left buttock. TN 2 stated that the pressure sore on Resident 2's left buttocks was new and there was no treatment order for it. TN 2 stated she will report it to the primary physician to get an order. TN 2 stated that the left buttock pressure sore on Resident 2 looked like it had been there for a while because the black covering looked like eschar and eschar does not develop overnight. TN 2 measured the left buttock pressure sore as 2 cm in length by 3 cm in width by 0.2 cm in depth. The left buttock pressure sore bed was covered with 80% eschar and the remaining 20% was pink in color. On 6/30/2016 at 3:30 pm, a concurrent interview and record review of Resident 2's Nurses' Progress Notes was done with TN 1. No documentation was found that body checks were done on 6/4/2016, 6/12/2016, 6/24/2016, 6/25/2016, 6/28/2016 and 6/29/2016. A review of the facility's "Pressure Sore Management Record" dated 6/14/2016, 6/21/2016 and 6/27/2016 did not indicate a documentation that an assessment was done on Resident 2's left buttock pressure sore. TN 1 stated that she measured the sacro-coccyx pressure sore on 6/27/2016, but did not check the left buttocks for any skin breakdown. During an interview with Charge Nurse 1 on 6/30/2016 at 4:00 pm, she stated the charge nurses performed weekly summary charting which included documentation of skin assessments and that body checks had been done on the residents. A review of Resident 2's "Nursing Summary-Weekly" with Charge Nurse 1 indicated the following: 1. 6/11/2016: No skin problems were noted, provide good skin care. 2. 6/18/2016: Sacro-coccyx pressure sore with treatment. 3. 6/25/2016: Resident 2 was free of any open areas. On 7/1/16 at 10:30 am, the above Resident 2's "Nursing summary-Weekly" was discussed with the Director of Nurses (DON). The DON stated the above documentation did not reflect the resident's actual condition. The DON stated nobody from the facility had identified the pressure sore on Resident 2's left buttock. During an interview with Certified Nursing Assistant (CNA) 1 on 7/1/2016 at 8:20 am, CNA 1 stated he showered Resident 2 on 6/28/2016 but did not check the resident's buttocks. CNA 1 stated he did not see Resident 2's buttocks on 6/29/2016 because it was covered with a diaper and he refused to be changed on 6/29/2016. On 7/1/2016 at 8:00 am and at 10:00 am, Resident 2 was observed lying on his back in bed. Resident 2 was interviewed on 7/1/2016 at 10:05 am. Resident 2 stated that nobody had offered to reposition him this morning. Resident 2 further stated that he never refused repositioning. During an interview with CNA 2 on 7/1/2016 at 10:20 am, CNA 2 stated she did not offer to reposition Resident 2 because Resident 2 always refused. A review of a document titled "ADL" (Activities of Daily Living) dated 6/30/2016 indicated an entry of "Y" (Yes) for turning and repositioning at 6:22 am, 11:56 am, 10:58 pm. Review of the same document dated 7/1/2016 indicated an entry of "Y" (Yes) for turning and repositioning at 6:34 am and 12:35 pm. When discussed with the DON on 7/1/16 at 10:30 am, she stated the CNA's only document once a shift. When asked to show the frequency of repositioning Resident 2, the DON was not able to show evidence Resident 2 was repositioned at least every two hours. There was no documentation that Resident 2 refused turning and repositioning on 6/29/2016 and 7/1/2016 on the ADL sheet. A review of document titled "Skin inspection, Shower Day" dated 9/2007 indicated "It is the policy of this facility to identify any pertinent skin issues with residents during routine inspections of residents at shower/bath times." A review of document titled "Skin Breakdown" dated 10/2007 indicated: It is the policy of this facility to complete an initial assessment upon admission. Procedures included: 1. The skin integrity will be monitored on an ongoing basis and any reddened areas noted will be reported to the licensed nurse. 2. If the resident is bedfast, then the resident should be repositioned at least every 2 hours, as appropriate. The facility failed to provide treatment and services to prevent the development of pressure sores Resident 2 who was at risk for developing pressure sore, by failing to: 1. Reposition Resident 2 at least every 2 hours. 2. Identify, assess, and provide treatment to Resident 2's pressure sore on the left buttocks. These violations had a direct relationship to the health, safety, or security of Resident 2. |
| 950000101 |
ALHAMBRA HEALTHCARE & WELLNESS CENTRE, LP |
950013006 |
B |
24-Feb-17 |
ESPO11 |
5153 |
?483.13(b) Abuse
The facility must ensure that ?
The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.
On 12/28/16 at 1 p.m., an unannounced visit was conducted at the facility to investigate an entity reported incident (ERI) regarding Resident 1 reporting that she was hit on her upper lip by certified nursing assistant (CNA) 1.
Based on interview and record review, the facility failed to ensure Resident 1 was not physically abused by CNA 1.
A review of Resident 1's medical record indicated the resident was admitted to the facility on XXXXXXX15 with diagnoses of Alzheimer?s disease (progressive disease that destroys memory and other important mental functions) and dementia (loss of brain function).
A review of a Minimum Data Set (MDS, a resident assessment and care screening tool), dated 10/27/16, indicated Resident 1 had clear speech and was usually understood. According to Section G, functional status, Resident 1 needed extensive assistance (staff provide weight bearing support) for transferring and bathing. According to Section E, Behaviors, Resident 1 did not have any physical, verbal or other behavioral symptoms directed towards others.
A review of Resident 1's Interdisciplinary Team Conferences (IDT) from 2/5/16 to 10/20/16, there was no documentation which indicated Resident 1 being combative, resisting care or displaying assaultive behaviors.
A review of Resident 1's weekly summary from 10/31/16 to 12/11/16 there was no documentation which indicated Resident 1 being combative, resisting care or displaying assaultive behaviors.
A review of Resident 1's care plans there was no documentation which indicated Resident 1 being combative, resisting care or displaying assaultive behaviors.
A review of Resident 1's, Incident and Accident Report Form, dated 12/9/16 at 9:45 a.m., indicated Resident 1 had a swollen upper lip 2 x 3 centimeters (cm) and a left upper arm skin tear 1 x 1 x 0.1 cm. The report indicated Resident 1 stating a girl hit her inside the room. On 12/9/16 at 12 p.m. a police officer arrived to the facility. On 12/9/16 at 1:45 p.m. Resident 1 was able to identify CNA 1 as the girl that hit her. CNA 1 was asked to leave the facility.
A record review of Resident 1's physician's orders dated 12/9/16 at 10:50 a.m., indicated to cleanse skin tear to left upper arm with normal saline (salt water), pat dry, apply triple antibiotic ointment, and cover with dry dressing every day for 14 days. Monitor upper lip for any skin breakdown, swelling, bleeding and complain of pain.
During an interview, on 12/28/16 at 10 a.m., with Resident 1 and the social service designee acting as interpreter, Resident 1 stated she remembered being hit by a fist by two women and one was wearing a dress.
During an interview, on 12/28/16 at 10:20 a.m., with the administrator (ADM) she stated Resident 1 first reported the alleged abuse to the activity assistant (AA) on 12/9/16 at 9:45 a.m. The ADM stated Resident 1 was unable to tell them who hit her, but stated it happened in the shower. CNA 1 was assigned to her that day and gave Resident 1 a shower that morning. The ADM stated CNA 1 denied hitting Resident 1. CNA 1 did mention Resident 1 was very combative that morning during the shower. The ADM stated on the afternoon of 12/9/16 there was visible swelling of Resident 1's upper lip. Resident 1 also had a bruise and skin tear on her left upper arm that was not present the previous day (12/8/16). The ADM stated due to the Resident 1's statement and the visible injuries, Resident 1's family did not feel it was safe for their family member to be around CNA 1. The ADM stated they terminated CNA 1 effective 12/12/16.
During an interview, on 12/29/16 at 9:52 a.m., with family member (FM 1) she stated she visited Resident 1 on 12/9/16 at 11:15 am. FM 1 stated "I saw my mom and her lip was swollen. I asked her what happed to her lip and she said someone hit her. I asked who and she couldn't tell me. I knew it was my mom's shower day because she takes showers on Tuesday and Fridays. I asked who her nurse was that day and they told me CNA 1. I asked to speak to CNA 1. I asked her what happened to my mom's lip and she said she didn't know. She did say my mom was not cooperative in the shower that morning. I asked the other CNA that feed her breakfast if her lip was swollen at breakfast and she said no. I think it happened in the shower or when they were transferring my mom. LVN 1 stripped her in front of me to check her body and there was a bruise on her left arm with blood. You could tell it was a fresh because there was blood too."
According to the facility's policy and procedure titled, "Abuse Prevention Program," dated 11/2016 indicated the facility is to ensure the health, safety, and comfort of residents by preventing abuse and mistreatment.
The facility failed to ensure Resident 1 was not physically abused by CNA 1.
The above violation had a direct or immediate relationship to the health, safety, or security of Resident 1. |
| 950000039 |
ATHERTON BAPTIST HOME-SAM B. WEST |
950013297 |
B |
16-Jun-17 |
THR311 |
5393 |
F225 ? Abuse
? 483.13(c)(2) The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency).
An unannounced annual recertification survey of the facility was conducted from 5/18/2017 to 5/21/2017.
Based on observation, interview and record review, the facility failed to immediately report (within 24 hours) Resident 11?s injury of unknown source to the State survey and certification agency.
Findings:
A review of Resident 11's profile face sheet indicated Resident 11 was admitted to the facility on XXXXXXX 2014 with diagnoses that included cerebral infarction (brain injury resulting from decreased blood supply and oxygen), hypertension (chronic elevated blood pressure), Alzheimer's disease (brain disorder that is characterized by long term and gradual decrease in the ability to think and remember) and hyperlipidemia (elevated fats in the blood).
A review of Resident 11's Minimum Data Set (MDS), a comprehensive assessment and care-planning tool dated 4/13/17 indicated Resident 11 had a brief interview for mental status (BIMS- screens for cognitive impairment) score of 3 (a score of 0-7 indicates severely impaired cognition), required extensive assistance with 2 person assist for transfer and toilet use, had no impairment in range of motion for bilateral upper extremity (shoulder, elbow, wrist, hand).
A review of Resident 11"s "Licensed Nurses Progress Notes" dated 5/12/17 indicated Resident 11 complained of left shoulder pain, was noted with indentation on left anterior shoulder which was tender (painful) to touch, unable to move left upper extremity, attending physician was notified and ordered a Stat (immediate) x-ray (photo image to check for abnormalities of bone and soft tissue) of left shoulder.
A review of Resident 11's "X-Ray of left shoulder" dated 5/12/17 indicated Resident 11 had an anterior/inferior left shoulder dislocation.
A review of Resident 11's "Physician Telephone Order Sheet" dated 5/12/17 indicated to transfer Resident 11 to General Acute Care Hospital (GACH) for evaluation of left shoulder dislocation.
A review of Resident 11's GACH notes titled, "Emergency Documentation" dated 5/12/17 indicated Resident 11 was transferred to GACH due to left shoulder pain, underwent procedural sedation (a technique of administering substance that induces sedation that allows the patient to tolerate unpleasant procedures) and reduction (a procedure to restore dislocation to correct alignment) of left shoulder dislocation.
During an interview with Licensed Vocational Nurse (LVN) 3 on 5/19/17 at 7:00 p.m., LVN 3 stated that Resident 11 did not have any fall incident and the left shoulder dislocation is an injury. She also stated that Resident 11 is confused and could not tell how the shoulder got dislocated, and nobody from the facility knew how Resident 11's left shoulder got dislocated. LVN 3 stated that this should have been reported to the state.
During an interview with the Director of Nursing (DON) on 5/19/17 at 7:19 p.m., DON stated that she did a thorough investigation of Resident 11' left shoulder dislocation incident. DON also stated that the left shoulder dislocation is an injury. DON also stated that nobody knew how Resident 11's shoulder was dislocated. DON also stated that Resident 11 had osteoporosis and stiff shoulders and that the left shoulder dislocation could have been because of those. DON also stated that she did not report the injury of unknown source to state licensing and certification agency. DON further stated that she will report Resident 11's injury of unknown source to the State now.
During an interview with the administrator on 5/20/17 at 10:00 a.m., administrator stated that she did not file a report about Resident 11"s injury of unknown source because she was focused on the result of the x-ray showing no fracture.
A Review of an undated facility policy and procedure titled, "Abuse Investigations" indicated all reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management.
A review of an undated facility policy and procedure titled, "Reporting Abuse to Facility Management" indicated that when an alleged or suspected case of mistreatment, neglect, injuries of unknown source, or abuse is reported, the facility administrator, or his/her designee, will notify the following persons or agencies of such incident within twenty-four (24) hours as deemed appropriate based on initial investigation:
a. The State licensing/certification agency responsible for surveying/licensing the facility;
b. The local/State Ombudsman;
c. The Resident's Representative of Record;
d. Adult Protective Services;
e. Law Enforcement Officials;
f. The Resident's Attending Physician;
g. The Facility Medical Director.
Therefore, the facility failed to immediately report (within 24 hours) Resident 1?s injury of unknown source to the State survey and certification agency.
This violation had a direct relationship to Resident 11?s health, safety, or security. |
| 960001900 |
ABLANO HOME |
960010223 |
B |
18-Oct-13 |
DWYX11 |
6853 |
4502 (h) Welfare and Institutions Code Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following: (h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect. On May 23, 2013, an unannounced visit was made to the facility to conduct an annual survey. A reported incident which involved quality of care was investigated.Based on observation, interview, and record review, the facility's staff failed to ensure Client 3 was free from harm by failing to: 1. Safely secure the client in a shower chair during bathing. 2. Develop a plan for Client 3 based on physical therapy evaluation. 3. Document training for staff regarding how to safely care for Client 3. Client 3 was admitted to the facility on July 26, 1999, with diagnoses that included profound intellectual disability (cognitive ability that is markedly below average level less than one fifth of chronological age-incapable of self-care), down syndrome (a set of mental and physical symptoms that result from having an extra copy of chromosome 21), seizure disorder (a brain disorder involving repeated, spontaneous convulsions) and severe osteoporosis (a condition of fragile bones with increased risk of fractures). Client 3 was wheelchair dependent, nonverbal, and dependent on staff for all activities of daily living. A review of an incident report dated May 10, 2013, indicated Staff reported hearing a crepitus (crackling, crinkly, or grating sound under the skin or in the joints) of the lower leg during hygiene care. The report further indicated while dressing Client 3 she seemed very uncomfortable. The Registered Nurse (RN) instructed staff to take Client 3 to the emergency room for further evaluation. Client 3 was admitted for further tests and possible pneumonia. During a telephone interview with the RN, on May 24, 2013, at 6:07 p.m., she stated Staff A was transporting Client 3 from a shower chair to a wheelchair and heard a sound from the knee. The RN further stated Client 3 was transported to the hospital on May 10, 2013, and diagnosed with a left leg fracture. Client 3?s History and Physical, dated May 10, 2013, from the hospital was reviewed. The report indicated, according to the caregiver, the client slipped in the bathroom. The diagnosis was a tibial (the largest long bone of the lower leg) fracture. Client 3?s medical consultation from the hospital, dated May 11, 2013, indicated Client 3 was brought to the emergency room on May 10, 2013, after she reportedly fell out of a shower chair while being bathed. The report further indicated a plan to obtain a proper fitting immobilizer for the left lower extremity. During a review of Client 3?s Radiological Report (x-ray) of the left knee from an acute care hospital which was dated May 10, 2013, indicated Client 3 had an Intra-Articular left proximal tibia fracture (a fracture of the larger bone in the lower leg which occurs through the articular surface into the joint). During an interview, and a signed declaration from Staff A on May 30, 2013, at 6:47 a.m., Staff A stated Client 3 was seated in the shower chair in the bathroom. While bathing Client 3, Staff A stated he leaned the client forward to lather her back, in doing so, Client 3 fell forward out of the shower chair and her left lower leg hit the floor. Staff A further stated there was no safety belt on the shower chair. The clinical record for Client 3 was reviewed on May 28, 2013, the Physical Therapy Evaluation dated July 14, 2012, indicated Client 3?s gross motor status was poor to fair head and trunk control, was dependent for transfers, supports minimal weight on lower extremities with poor balance, and staff to complete 2 person transfer. The report also indicated under recommendations, staff to continue dependent transfers since client is no longer able to stand. During an interview with the RN, on May 28, 2013, at 9:28 a.m., she stated there was no plan in place related to the safety for Client 3. She further stated there was no nursing care plan or a plan to prevent falls or injury for Client 3. During an interview with the RN, on May 28, 2013, at 9:59 a.m., she stated there was no documented in-service or training for staff on client safety. On May 30, 2013, at 6:33 a.m., Client 3?s record was reviewed further, there was no evidence of any plans in place or documented staff training that would enable staff to safely care for Client 3. During an observation on May 30, 2013, at 7:01 a.m., Staff A brought out the shower chair he used for Client 3 on May 10, 2013. The shower chair did not have any type of safety belt in place. The back of the shower chair where the back would rest did not have any support, it was open and a full view of the clients back could be seen. During this time, Staff A stated he removed the blue cloth like material that would cover the metal handle on the back of the shower chair. During a telephone interview with the RN, on May 31, 2013, at 2:04 pm, she stated, ?That particular shower chair doesn?t have any type of safety belt or straps.? During a telephone interview with Staff A, on October 15, 2013, at 8:29 a.m., he stated, the Qualified Intellectual Disabilities Professional/Administrator (QIDP/ADM) would observe him while showering Client 3 but was never told he was doing it incorrectly. Staff A stated, ?leaning Client 3 forward was the only way I could wash her back.? Staff A further stated, Client 3 was totally dependent and he was not aware Client 3 had limited control of her upper body. When Staff A was asked if the QIDP informed him of Client 3?s poor to fair trunk control, he stated ?no.? The facility policy and procedure titled "Health and Safety", undated, indicated, staff members should be constantly aware of conditions which pose a threat to safety and well-being of the consumers.The facility staff failed to ensure Client 3 was free from harm by failing to: 1. Safely secure the client in a shower chair during bathing 2. Develop a plan for Client 3 based on physical therapy evaluation. 3. Document training for staff regarding how to safely care for Client 3.The above violation had a direct and immediate relationship to the health, safety, and security of the client. |
| 960001724 |
Angels Garden Home |
960010266 |
B |
18-Nov-13 |
R7CO11 |
4593 |
HEALTH AND SAFETY CODE 1265.5. (a) (1) Prior to the initial licensure or renewal of a license of any person or persons to operate or manage an intermediate care facility/developmentally disabled habilitative, an intermediate care facility/developmentally disabled-nursing, an intermediate care facility/developmentally disabled-continuous nursing, or an intermediate care facility/developmentally disabled, other than an intermediate care facility/developmentally disabled operated by the state, that secures criminal record clearances for its employees through a method other than as specified in this section or upon the hiring of direct care staff by any of these facilities, the department shall secure from the Department of Justice criminal offender record information to determine whether the applicant, facility administrator or manager, any direct care staff, or any other adult living in the same location, has ever been convicted of a crime other than a minor traffic violation.(f) Upon the employment of any person specified in subdivision (a), and prior to any contact with clients or residents, the facility shall ensure that electronic fingerprint images are submitted to the Department of Justice for the purpose of obtaining a criminal record check.On September 11, 2013, an unannounced visit was made to the facility to conduct a fundamental survey. Based on observation, interview and record review, the facility's administration failed to obtain criminal clearance from the department for direct care staff (Staff A) prior to contact with three sampled clients (Client 2, 4, and 5) and three non-sampled clients (Client 1, 3, and 6). This breech in client safety had the potential to result in client abuse. During survey observations on September 11-13, 2013, Staff A provided direct care services to all the clients residing in the facility.A review of the client roster on September 11, 2013, indicated Clients 1, 4, 5 and 6 were admitted to the facility with diagnoses that included severe intellectual disability. Clients 2 and 3 were admitted to the facility with diagnoses that included moderate intellectual disability. During a review of the employee files on September 11, 2013, at 11:15 a.m., Staff A, who was hired on January 9, 2013, did not have a fingerprint clearance letter from the department in her employee file. There was no documentation found in the new employee files pertaining to abuse prevention and client rights upon hiring. During a telephone interview with the department representative, on September 11, 2013, at 11:25 a.m., she stated there was no transmittal application on file for Staff A for a criminal record clearance.During an interview with the qualified intellectual disabilities professional (QIDP), on September 12, 2013, at 12:45 p.m., he stated he had not submitted Staff A's information to the department prior to September 11, 2013.On September 11, 2013, a review of Staff D?s written reply regarding the facility?s system to protect clients from abuse stated:"All staff are being in-serviced about what is abuse, the difference kinds of abuse, so everybody knows about it. All staff knows they are mandated reporters and should report to the ombudsman (citizen advocate) right away if there is abuse. New staff's finger prints are transmitted to the department of justice prior to starting work and Live Scan forms are transmitted to the department upon date of hire.?During an interview, with the QIDP, on September 12, 2013, at 3:25 p.m., the QIDP stated the facility did not have a written policy regarding screening or fingerprinting new staff. During an interview with the QIDP on September 17, 2013, at 12:30 p.m., regarding Staff A?s Live Scan, he stated, "We always make sure they do the Live Scan. The Live Scan was not sent to the state because the staff did not have an ITIN (individual tax identification number) until May 2013, and without the ITIN, I could not send it to the department.?The facility's undated policy and procedure titled "Personnel Policies," provided by the QIDP, did not address employee screening for a criminal record. The facility's administration failed to obtain criminal clearance from the department for direct care staff (Staff A) prior to contact with three sampled clients (Client 2, 4, and 5) and three non-sampled clients (Client 1, 3, and 6). This breech in client safety had the potential to result in client abuse. The above violation had a direct relationship to the health, safety, or security of all clients in the facility. |
| 960001724 |
Angels Garden Home |
960012642 |
A |
1-Dec-16 |
3UHT11 |
7734 |
Title 22: 76918 Clients Rights (a) Each client shall have those rights as specified in sections 4502 through 4505 of the Welfare and Institution Code. 4502(h) Welfare and Institutions Code Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which received public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to the following: (h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect. On August 26, 2016 at 8:10 a.m., an unannounced visit was made to the facility to investigate an entity reported incident. The facility's administrative staff failed to protect Client 1 from harm. Client 1 was placed in a broken shower chair and the shower chair collapsed. According to direct care staff (DCS 1), she stated two days prior to the incident (8/11/16), she informed the licensee that the shower chair was broken and needed to be replaced. DCS 1, knowing the shower chair was broken, used the broken shower chair to assist Client 1 with a shower and as a result Client 1 sustained a left rotator cuff injury (injury of a capsule with fused tendons that supports the arm at the shoulder joint). A review of Client 1's clinical record indicated the client was admitted to the facility on 6/5/16 with diagnoses of moderate intellectual disability (noticeable developmental delays) and cerebral palsy (a condition marked by impaired muscle coordination and/or other disabilities, typically caused by damage to the brain before or at birth). During an observation, on 8/26/16, at 8:35 am, Client 1 was sitting on her electrical/power wheelchair wearing a sling (a flexible strap or belt used in the form of a loop to support or raise a weight) on her left hand. During an interview with Client 1, on 8/26/2016, at 8:40 am, she stated on 8/11/16, at 7:00 am, while she was sitting on the shower chair, the shower chair collapsed. Client 1 stated the shower chair broke and her ?bottom" sank into the rim of the chair toward the floor with her feet up in the air. Client 1 stated Direct Care Staff 1 (DCS 1) grabbed her left hand to prevent the client's bottom from falling further down onto the floor, however in so doing she injured the client?s left shoulder. Client 1 stated, the next day, Tuesday, 8/12/16; she went to the hospital's Emergency Room (ER) for an evaluation due to left shoulder pain. Client 1 stated the doctor told her she had a torn ligament (A ligament is the tissue that connects two bones to form a joint) and a swollen shoulder. Client 1 stated she was taking pain medication (Norco) two times a day but the pain was not well controlled. Client 1 stated on Monday, 8/15/16 she went to the ER for a second time, due to continuing shoulder pain and the physician prescribed another pain medication. Client 1 stated all this could have been prevented if the facility's owner replaced the broken shower chair. Client 1 stated on Sunday, 8/7/16, 4 days prior to the incident, while she was sitting on the shower chair, she heard a cracking sound. Client 1 stated DCS 1 was with her and heard the cracking sound. Client 1 stated she and DCS 1 told the facility's owner about the broken shower chair and requested a new shower chair. Client 1 stated the facility's owner did not replace the broken shower chair. Client 1 stated there were two clients in the facility using the shower chair, herself and another male client (Client 2). Client 1 stated when Client 2 was using the broken shower chair, it was alright, but when she used it, it collapsed because she was heavier than Client 2. During a telephone interview with DCS 1, on 8/26/16, at 3:00 pm, she stated after she transferred Client 1 from the client's bed to the shower chair, the client yelled out for help. DCS 1 stated when she turned around she saw the shower chair collapse and the client's bottom was sinking down toward the floor. DCS 1 stated she tried to grab Client 1's left arm to prevent the client from falling further down onto the floor, but the client was too heavy. DCS 1 stated her hands were also hurt as the result of trying to help Client 1. DCS 1 stated two days prior to the incident, she asked the facility's owner to buy a new shower chair for Client 1 because there was a crack on the shower chair. DCS 1 stated the facility's owner had not replaced the shower chair and it collapsed when Client 1 was sitting on it. A review of the first ER evaluation, dated 8/12/16, indicated Client 1 was diagnosed with left shoulder's muscle strain (tearing of ligaments) and possible damage to the rotator cup. Client 1 received pain medication, Norco (hydrocarbon-acetaminophen 5/325 milligram-mg), two tablets and a nonsteroidal anti-inflammatory drug (NSAID) injection, ketorolac (Toradol) 60 milligram. The physician prescribed Norco, one to two tablets every six hours for pain and instructed the client to return to the emergency department for worsening symptoms or any other concern. Client 1 returned to ER again on Monday, 8/15/16, due to her left shoulder pain was not well control with the Norco. A review of the second ER's evaluation, dated 8/15/16, indicated that Client 1 had left arm pain, rotator cuff injury with status post fall. The physician prescribed an opioid pain medication Percocet (oxycodone and acetaminophen, 5/235 mg) one tablet every four hours for pain. The physician also referred the client to an orthopedic physician (a branch of medicine dealing with the correction of deformities of bones or muscles). During an interview with the facility's owner, on 8/26/16, at 3:20 pm, she stated DCS 1 told her to buy a new shower chair due to the old shower chair was making cracking sounds when Client 1 sat on the shower chair. The facility's owner further stated she did not have time to buy the new shower chair. The facility?s owner stated "I should tell my staff not to put the clients on a cracked shower chair.? A review of the facility's undated policy and procedure titled "Administrative Policy Manual," stipulated medical equipment and supplies in each facility shall be of the quality and in the quantity necessary for care of clients as ordered or indicated. These shall be provided and properly maintained at all time. The policy also indicated the clients should receive assistive devices, equipment, supplies and instructions for use as required by the clients. The facility's administrative staff failed to protect Client 1 from harm. Client 1 was placed in a broken shower chair and the shower chair collapsed. According to direct care staff (DCS 1), she stated two days prior to the incident, she informed the licensee that the shower chair was broken and needed to be replaced. AS a result, Client 1 sustained a left rotator cuff injury (injury of a capsule with fused tendons that supports the arm at the shoulder joint), DCS 1 knowing the shower chair was broken, used the broken shower chair to assist Client 1 with a shower. The above violations either jointly, separately, or in any combination presented either an imminent danger that death or serious physical harm would result or a substantial probability that death or serious physical harm would result. |
| 960001724 |
Angels Garden Home |
960012860 |
B |
5-Jan-17 |
DZGB11 |
2300 |
Health & Safety Code 1265.5 (f) Upon the employment of a person specified in subdivision (a), and prior to any contact with clients or residents, the facility shall ensure that electronic fingerprint images are submitted to the Department of Justice for the purpose of obtaining a criminal record check. On April 5, 2016 at 5:30 a.m., an unannounced visit was made to the facility to conduct an annual recertification survey. The facility failed to ensure fingerprinting clearance for one staff working in the facility. This failure had the potential of not ensuring the safety and well-being of 6 clients residing in the facility. During an interview with the interim owner, on April 5, 2016 at 1:30 p.m., she stated Staff E worked in the facility for one month and resigned. During a review of the ?Client Roster Information? dated April 5, 2016, indicated 2 clients with diagnoses of moderate intellectual disability (developmentally functions below chronological age and can learn elementary health and safety habits), and 4 clients with diagnoses of severe intellectual disability (considerable delay in development and require daily supervision and support). On April 6, 2016 at 4:40 p.m., a call was made to the Interactive Voice Response Unit for Criminal Clearance. The automated response system disclosed Staff E had no record on file. During a review of Staff E?s employee file on April 5, 2016, no documented evidence of criminal clearance through the Department of Justice (DOJ) could be found. The employee file indicated a hire date of February 11, 2016. There was a DOJ clearance addressed to a different facility dated February 13, 2009. The facility policy and procedure titled ?Prevention of Abuse, Neglect and Mistreatment? undated, indicated for the prevention of abuse, neglect and mistreatment of clients, the administration would screen individuals prior to employment to prohibit employment of individuals with convictions. This screening included the following: screen prior employment work history of all direct care staff and have individuals cleared through the department?s fingerprint data base. The failure of not ensure fingerprinting clearance for one staff had a direct relationship to the health, safety, and security of clients. |
| 960001724 |
Angels Garden Home |
960012862 |
B |
5-Jan-17 |
DZGB11 |
2231 |
Health & Safety Code 1265.5 (f) Upon the employment of a person specified in subdivision (a), and prior to any contact with clients or residents, the facility shall ensure that electronic fingerprint images are submitted to the Department of Justice for the purpose of obtaining a criminal record check. On April 5, 2016 at 5:30 a.m., an unannounced visit was made to the facility to conduct an annual recertification survey. The facility failed to ensure fingerprinting clearance for one staff working in the facility. This failure had the potential of not ensuring the safety and well-being of 6 clients residing in the facility. During a review of the ?Client Roster Information? dated April 5, 2016, indicated 2 clients with diagnoses of moderate intellectual disability (developmentally functions below chronological age and can learn elementary health and safety habits), and 4 clients with diagnoses of severe intellectual disability (considerable delay in development and require daily supervision and support). During a review of Staff C?s employee file on April 5, 2016, no documented evidence of criminal clearance through the Department of Justice (DOJ) could be found. The employee file indicated a hire date of January 4, 2016. On April 6, 2016 at 4:40 p.m., a call was made to the Interactive Voice Response Unit for Criminal Clearance. The automated response system disclosed Staff C had no record on file. During an interview with the interim owner, on April 7, 2016 at 7:20 p.m., she stated the facility?s administration did not have fingerprint clearance for Staff C. The facility policy and procedure titled ?Prevention of Abuse, Neglect and Mistreatment? undated, indicated for the prevention of abuse, neglect and mistreatment of clients, the administration would screen individuals prior to employment to prohibit employment of individuals with convictions. This screening included the following: screen prior employment work history of all direct care staff and have individuals cleared through the department?s fingerprint data base. The failure of not ensure fingerprinting clearance for one staff had a direct relationship to the health, safety, and security of clients. |
| 960001724 |
Angels Garden Home |
960012863 |
B |
5-Jan-17 |
DZGB11 |
2298 |
Health & Safety Code 1265.5 (f) Upon the employment of a person specified in subdivision (a), and prior to any contact with clients or residents, the facility shall ensure that electronic fingerprint images are submitted to the Department of Justice for the purpose of obtaining a criminal record check. On April 5, 2016 at 5:30 a.m., an unannounced visit was made to the facility to conduct an annual recertification survey. The facility failed to ensure fingerprinting clearance for one staff working in the facility. This failure had the potential of not ensuring the safety and well-being of 6 clients residing in the facility. During an interview with the interim owner, on April 5, 2016 at 1:30 p.m., she stated Staff J worked in the facility for one month and resigned. During a review of the ?Client Roster Information? dated April 5, 2016, indicated 2 clients with diagnoses of moderate intellectual disability (developmentally functions below chronological age and can learn elementary health and safety habits), and 4 clients with diagnoses of severe intellectual disability (considerable delay in development and require daily supervision and support). On April 6, 2016 at 4:56 p.m., a call was made to the Interactive Voice Response Unit for Criminal Clearance. The automated response system disclosed Staff J had no record on file. During a review of Staff J?s employee file on April 7, 2016, no documented evidence of criminal clearance through the Department of Justice (DOJ) could be found. The employee file indicated a hire date of February 11, 2016. There was a DOJ clearance addressed to a different facility dated February 13, 2009. The facility policy and procedure titled ?Prevention of Abuse, Neglect and Mistreatment? undated, indicated for the prevention of abuse, neglect and mistreatment of clients, the administration would screen individuals prior to employment to prohibit employment of individuals with convictions. This screening included the following: screen prior employment work history of all direct care staff and have individuals cleared through the department?s fingerprint data base. The failure of not ensure fingerprinting clearance for one staff had a direct relationship to the health, safety, and security of clients. |
| 630014956 |
Amalfi in the Desert |
980013387 |
B |
27-Jul-17 |
QZ7X11 |
8629 |
T22 DIV5 CH3 ART5 ? Patient Care Policies and Procedures
(a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved.
On May 16, 2017, 10 a.m., an unannounced visit was made to the facility to investigate an allegation regarding Patient Rights.
Based on record review and interview, the facility failed to ensure patient care policies and procedures shall be shall be implemented to ensure patient related goals and facility objectives are achieved by not implementing its policy on Behavior Management including:
1. Failure to ensure the Interdisciplinary Team (IDT) evaluated and investigated causes/triggers of Patient 1?s behavior manifestations which included anxiety (nervousness), aggressiveness, yelling, cursing, agitation, and wandering (going to different places usually without having a particular purpose or direction) out of the facility.
2. Failure to ensure the IDT initiated a Behavior Management Program to address Patient 1?s behavioral symptoms to implement appropriate interventions.
3. Failure to ensure the IDT completed the Behavior Evaluation and Review form since Patient 1 was admitted with orders for psychotropic medications (exert an effect on the chemical makeup of the brain and nervous system).
4. Failure to ensure nursing staff used the Behavior Monitoring Flow Sheet to document Patient 1?s exhibited behaviors and determine effectiveness of interventions and promptly notify the physician of increased deterioration of Patient 1?s mental status.
As a result, Patient 1?s unmanaged behaviors progressively increased and when, on XXXXXXX 2017, he refused to be transferred to a general acute care hospital (GACH) for a psychiatric evaluation, he was allowed to sign a leave Against Medical Advise (AMA) form and to leave the facility. Patient 1?s whereabouts were unknown, was reported missing to the police, and three days later on May 12, 2017, he was found at another city.
A review of the admission record indicated Patient 1 was admitted to the facility from a GACH on XXXXXXX 2017 with diagnoses including cerebrovascular accident (CVA - stroke), encephalopathy (brain disease), intravenous (IV) drug abuse, and persistent cognitive impairment (mental process of knowing, including awareness, perception, reasoning, and judgment).
According to the History and Physical (H&P) Examination from the GACH dated January 20, 2017, the psychiatrist evaluated Patient 1 as gravely disabled due to severe cognitive impairment from multiple infarcts and would require 24 hour supervision upon discharge from the GACH. The H&P indicated Patient 1 did not have the mental capacity to understand and make his own healthcare decisions due to cognitive deficits.
The Admission Orders and Plan of Care form dated May 2, 2017 indicated Patient 1 was incapable of understanding his total health status. A physician?s order on admission indicated Quetiapine (psychotropic for mental illness) 100 milligram (mg) by mouth twice a day.
The Admission Nursing Evaluation form dated May 2, 2017 indicated Patient 1 was alert and oriented towards people, confused at times, had wandering behavior, and was independent in walking and transferring.
The Social History and Psychosocial Assessment form dated May 2, 2017 indicated Patient 1 was tearful, sad, hallucinating, and had wandering/elopement behavior. The social service area of concern was for Patient 1 to leave the facility.
A review of the Daily Skilled Nurses Note documented by Licensed Vocational Nurse 1 (LVN 1) indicated Patient 1 had following behavioral symptoms:
- On May 4, 2017 at 4 a.m., Patient 1 stated he wanted to go home with all clothes packed. At 9 a.m., the patient became increasingly fidgety and anxious and Ativan (psychotropic medication ? affect the mind) was given at 9:13 a.m. At 2 p.m., Patient 1 attempted to leave, became aggressive, was yelling, and was cursing.
- On May 5, 2017, at 3:30 p.m. and 7 p.m., Patient 1 was looking for people who were not there.
- On May 7, 2017, at 5:50 p.m., Patient 1 grabbed attempted to kiss her, and became very aggressive after LVN 1 told him to stop. At 6:06 p.m., the patient attempted to leave and became angry yelling and cursing at LVN 1. Between 7 p.m. to 9 p.m., the patient was agitated, wandered out of the facility and staff brought him back to the facility.
- On May 8, 2017 at 1:40 p.m. Patient 1 was asking for persons who were no longer alive and saying they would visit him soon.
On May 9, 2017 at 10:08 a.m., the Daily Skilled Nursing Note indicated Patient 1 walked out on the front door to the street. The patient was agitated, walking fast, giving the staff inappropriate hand gestures. The physician was notified and the physician ordered a psychiatric evaluation. At 2 p.m., the patient wandered out of the facility again saying he was going to visit his mother (who was not alive). The patient became combative and attacked a staff member. At 2:09 p.m., a telephone order was received by the physician to transfer the patient to emergency room for psychiatric evaluation. At 2:22 p.m., when the ambulance arrived to pick up Patient 1 he refused to be transported. At 2:35 p.m., the form for leaving AMA was explained to Patient 1 who signed the AMA form and was allowed to leave the facility.
The Social Service Note dated May 10, 2017 and May 11, 2017 indicated the social service contacted hospitals and filed a Missing Person report. The Social Service Note dated May 12, 2017 indicated a family member reported Patient 1 was found in a another city.
According to the facility?s undated policy and procedure on Behavior Management, patients exhibiting problematic behavior symptoms would be evaluated and appropriate interventions would be implemented. Patients are evaluated for behaviors when exhibited and at other times as indicated. If the patient is admitted with an order for psychotropic medication and behavior symptoms identified, the IDT completes the Behavior Evaluation and Review Form. If the patient exhibits behavior symptoms, the IDT would investigate the specific behavior, its causes/triggers and symptoms and initiates a Behavior Management Program and use the Behavior Monitoring Flow Sheet to document behaviors.
Further review of Patient 1?s clinical record disclosed no documented evidence the IDT had evaluated or investigated Patient 1?s behavioral problems (anxiety, aggression, yelling, cursing, agitation, socially inappropriate, and wandering). There was no documented evidence of a Behavioral Management Program or a completed Behavior Monitoring Flow Sheet, as indicated in the facility?s policy.
On May 16, 2017, at 11:40 a.m., during an interview, Certified Nursing Assistant 1 (CNA 1) stated Patient 1 was aggressive, agitated, and wanted to go out saying he was going to work or to his mom?s house.
On May 16, 2017, at 11:55 a.m., during an interview, Social Service 1 stated the patient?s family member told her the patient was to be at the locked facility.
The facility failed to ensure patient care policies and procedures shall be shall be implemented to ensure patient related goals and facility objectives are achieved by not implementing its policy on Behavior Management including:
1. Failure to ensure the IDT evaluated and investigated causes/triggers of Patient 1?s behavior manifestations which included anxiety, aggressiveness, yelling, cursing, agitation, and wandering out of the facility.
2. Failure to ensure the IDT initiated a Behavior Management Program to address Patient 1?s behavioral symptoms to implement appropriate interventions.
3. Failure to ensure the IDT completed the Behavior Evaluation and Review form since Patient 1 was admitted with orders for psychotropic medications.
4. Failure to ensure nursing staff used the Behavior Monitoring Flow Sheet to document Patient 1?s exhibited behaviors and determine effectiveness of interventions and promptly notify the physician of increased deterioration of Patient 1?s mental status.
As a result, Patient 1?s unmanaged behaviors progressively increased and when, on May 9, 2017, he refused to be transferred to a GACH for a psychiatric evaluation, he was allowed to sign a leave AMA form and to leave the facility. Patient 1?s whereabouts were unknown, was reported missing to the police, and three days later on May 12, 2017, he was found at another city.
The above violation had direct or immediate relationship to the health and safety of Patient 1. |
| 010001005 |
Aldersly Skilled Nursing Facility |
110013127 |
B |
14-Dec-17 |
PS4J11 |
11047 |
F 323 Free of Accidents/Hazards/Supervision/Devices CFR(s): 483.25(h)
The facility failed to provide adequate supervision for Resident 1, identified as high risk for wandering, when Resident 1 left the facility without staff awareness in her wheelchair, and a neighbor discovered her at the bottom of a hill, behind the facility, with bruises on her face.
Findings:
Resident 1, admitted on 06/25/12, with diagnoses including difficulty walking, mental disorder, chronic obstructive pulmonary disease (COPD) (rigid lungs that require great effort to exhale), Asthma (narrowed, inflamed airways causing shortness of breath), Dementia w/behavioral disturbances (memory impairment), diabetes type II (low insulin levels and inability to stabilize blood sugar levels), hypertension (high blood pressure). Resident 1 also wore hearing aids and corrective lenses.
During a concurrent observation and interview on 04/28/15, at 9:40 a.m., a Wander guard box (a device that detects an electronic sensor, attached to a resident or wheelchair and sounds an alarm to alert staff that a resident was attempting to exit the facility) was located on the left rim of the exit door next to the nursing station. When asked if the door alarm had ever deactivated, Staff A stated there was a bypass function the staff could select to turn off the alarm if necessary.
During an interview on 04/28/15, at 10 a.m., Administrative Staff B stated, any resident wearing a Wanderguard bracelet, and electronically detected by the Wanderguard system, the alarm would sound, and the door would lock automatically.
During a concurrent observation and interview on 04/28/15, at 10:10 a.m., Resident 1 sat in her wheelchair at a table in the activity room. When asked to identify the device on Resident 1's right wrist, Staff B replied, a Wanderguard bracelet. Resident 1 colored a page in the coloring book, she did not look up and responded, "No" when interview was attempted.
During an observation on 4/28/15, at 10:35 a.m., the exit door led to a patio and to an unlocked gate approximately four and one-half feet high. This gate led to a sidewalk which was approximately ten yards and then led to a second unlocked gate of the same height. The second gate led to a street that immediately sloped downhill to the right, adjacent to the facility and approximately 300 yard's distance from the next intersecting street.
During an interview on 4/28/15, at 10:40 a.m., Administrative Staff E stated Resident 1 needed supervision and staff usually went with her if it was not during an activity. She also stated Resident 1 usually wheeled to the exit door, near the nursing station, and the alarm alerted staff to assist her to the patio when they had the manpower.
During an interview on 04/28/15, at 11:05 a.m., Unlicensed Staff I stated Resident 1 was always moving in her wheelchair, and she sounded the alarm at the exit door by the nursing station ten times a day.
During an interview on 05/06/15, at 2 p.m., Unlicensed Staff M stated the exit door to the patio was open many times during the day because family members picked up residents through the door that led to the patio.
During an interview on 05/06/15, at 4:10 p.m., when asked what she remembered about the evening of 03/09/14, Licensed Staff H stated she thought she had two nursing assistants that night, and she last noticed Resident 1 in the television room at approximately 5 p.m. She also stated no alarms sounded, but the paramedics showed up at approximately 7:30 p.m., and said they discovered Resident 1 in the street, near the facility, and they took her to the Emergency Room of a local hospital.
During an interview on 05/15/15, at 9 a.m., when asked what he remembered about the night of 03/09/14, Unlicensed Staff L stated he cared for other residents that night and was shocked when the police arrived and informed him they had found Resident 1. He stated he did not hear Resident 1's Wanderguard alarm sound. He also stated that sometimes the door to the patio was open, and he noticed a male resident went onto the patio that night with family. Unlicensed Staff L stated staff passed through the unlocked gate to deliver residents to family members' cars parked at the top of the hill.
During an interview on 05/21/15, at 11:40 a.m., Unlicensed Staff N stated the fire department received a call on 03/09/14, from neighbors near the facility who had found a woman down on the corner of two streets. The fire department found a confused elderly woman (Resident 1) at the bottom of a hill where two streets meet near the facility. Resident 1 had bleeding injuries consistent with a moderate speed crash in a wheelchair. The fire department gained access to the facility through the two unlocked gates and exit door and delivered Resident 1's wheelchair. Unlicensed Staff N also stated, "When the nurse at the nursing station learned an ambulance took Resident 1 to a local hospital, the nurse stated Resident 1 was in her room."
During a review of the San Rafael Fire Department document, on 5/21/15, at 12 p.m., the document titled, Narrative: "Page 3, CAD Incident Number: F14005873," indicated on "03/09/2014 at 19:43:59 (7:43 p.m.), 75 YOF (year old female) crashed off curb in her wheelchair . . . lift assist."
During an interview on 05/26/15, at 2:59 p.m., when asked how many staff members were present at the nursing station during the p.m. shift on 03/09/14, Administrative Staff D stated the nursing station always had one person in that area, but, "they must have gone away."
During an interview on 06/01/15, at 8:30 a.m., when asked for documentation that showed staff monitored Resident 1's behavior, i.e., wandering, Administrative Staff A stated the facility was not able to produce documentation for Wanderguard checks, per shift, by the nursing staff prior to 03/10/14.
During an interview on 08/18/15, at 3:05 p.m., when asked how Resident 1 eloped from the facility, Administrative Staff B stated she interviewed all the staff members and thought a staff member allowed Resident 1 to go onto the patio through the exit door which was open by the nursing station. Administrative Staff B also stated Resident 1 was able to manipulate the gate and open it, and she must have wheeled herself down the street and toppled over. She also stated Resident 1's documented behavior monitoring did not start until approximately July 2015.
During a review of the facility electronic medical record, dated 03/14, titled, "Resident 1's Wander Guard monitor sheet," had no initials from 03/01/14 to 03/09/14. The first initial signed by nursing staff was 03/10/15.
During a record review and concurrent interview, on 08/19/15, at 3:05 p.m., Administrative Staff B stated the MDS 3.0 (Minimum Data Set, document that assessed resident behavior on admission) dated 06-25-12, Section E, Behavior, Item E0900, identified wandering presence and frequency for Resident 1 occurred within the last one to three days.
During a review of Resident 1's care plan dated 5/2013 and revised 09/09/14, and concurrent interview, on 08/19/15 at 3:05 p.m. and 3:15 p.m., the care plan indicated, "Developed for Concerns/Problems: Elopement risk due to trying to leave facility unaccompanied and unaware of her safety. Approach Plan: > Monitor resident location with visual checks at least every 1-2 hours; > Wander Guard monitoring device to notify staff and remind resident not to exit facility without escort." When asked if the care plan approach included detailed monitoring, Administrative Staff B stated that a timeframe and visual checks was a detail. She also stated Resident 1 did not have documented behavior monitoring, by staff, in place prior to the elopement on 03/09/14.
During a concurrent review of the facility electronic record and interview on 08/19/15, at 3:15 p.m., document titled, "Physician's Order Entry, 06/05/2014, Wander guard Check 3 times Daily," showed no staffing initials recorded for March 1 through March 9, 2014. A note at the bottom of the form read, "To be checked by Charge Nurse each shift." Administrative Staff B stated the staff initials indicated the Wanderguard functioned electronically.
During a review of Resident 1's clinical record, the Telephone Encounter Info document, Encounter Date 3/10/14 1:22 a.m., indicated, "Patient had a bump on her head and local hospital emergency room is doing routine blood work and CT scan (x-rays and computerized images of bones, blood vessels, and soft tissue within the head). A second local hospital admission record from the Emergency Department titled, Emergency Department Visit - dated 03/10/2014, 2:29 a.m., indicated, "Pt. eloped from SNF (skilled nursing facility) in a wheelchair and apparently fell out of the wheelchair under unclear circumstances."
During a review of Resident 1's clinical records, the Inter-facility Transfer for an Acute Care Facility form, dated 3/10/14, indicated Resident 1's diagnosis: Right facial trauma. The Pre-Hospital Field Transfer Form (FTF), dated 03/09/14, indicated Chief Complaint, fall from wheelchair and Noted: Wrist Pain, Small laceration to face and hand. The Emergency Department (ED) Report, dated 03/09/14, indicated Resident 1 was brought in by paramedics. "Patient apparently wandered off with her wheelchair and had a ground-level fall.....She complained of having a headache. The patient has swelling over the right cheek and right eyelid with a small abrasion noted over the right cheek. Skin: Bruises and abrasion over the right side of her face."
During a review of the facility street map on 09/29/15, indicated paramedics found Resident 1 on a street which intersected another street.
The facility policy titled, "Behavior, Mood and Cognition: Wandering, Unsafe Resident," revised 09/2014, read, "The facility will strive to prevent unsafe wandering . . . for residents who are at risk for elopement. The Policy Interpretation and Implementation, Highlights, Assessment of Residents at Risk of Elopement, item 1. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). Care Plan, item 3. Interventions to try to maintain safety, such as a detailed monitoring plan will be included."
Therefore, the facility failed to provide adequate for Resident 1, identified as high risk for wandering, when Resident 1 left the facility without staff awareness in her wheelchair, and a neighbor discovered her at the bottom of a sloped street, behind the facility, with bruises on her face. Resident 1 had a history of elopement, and the facility failed to ensure she received care and supervision in a manner designed to meet her individual needs. These failures resulted in Resident 1's right facial contusion, abrasions and right periorbital swelling.
The above regulatory violation had a direct or immediate relationship to the health, safety, or security of patients. |
| 100000030 |
Alderson Convalescent Hospital |
030013604 |
B |
9-Nov-17 |
PNUX11 |
6276 |
California Health & Safety Code 1418.91
(a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours.
(b) A failure to comply with the requirements of this section shall be a class "B" violation.
An unannounced visit was made to the facility on 8/10/17 to initiate investigation of an entity reported incident #CA00546223.
The Department determined the facility failed to report an allegation of abuse within 24 hours as required, when the Certified Nursing Assistant 1 (CNA 1), who witnessed the alleged abuse, did not report it to the department.
Resident 1 was admitted to the facility in late 2006 with multiple diagnoses that included schizoaffective disorder (a mood disorder).
Review of the clinical record for Resident 1 included:
A Minimum Data Set (MDS - an assessment tool), dated 5/5/17, indicated Resident 1 had a BIMS (a brief interview of mental status) score of 8 out of 15, indicating moderate short-term and long-term memory problems.
A Plan of Care dated 7/15/16 for Alteration in Mood/Behavior indicated not to rush or show impatience with Resident 1 and approach in calm manner.
A Short term Care Plan dated 7/28/17, indicated Resident 1 had a potential for mood distress due to alleged abuse by staff.
A Progress Note dated 7/28/17 at 1:10 p.m., indicated RN 2 did a skin assessment with a scratch noted to right upper arm. Progress Notes indicated no pain, bleeding or other skin issues.
A review of the facility's documents included:
An abuse report dated 7/28/17 stated CNA 1 saw CNA 2 pushing Resident 1 into bed and raising his voice.
A handwritten letter dated 7/28/17, written by CNA 1 stated CNA 2 "...Used bad words and push [sic] into bed".
A follow up report dated 8/3/17, written by the SSD (Social Service Director) stated the alleged incident happened on 7/24/17 in the evening. CNA 1 met with the DON (Director of Nurses) and SSD on 7/28/17. CNA 1 stated CNA 2 was "In abuse [sic]" of Resident 1. When asked what she meant by "Abuse", CNA 1 said CNA 2 was raising his voice, speaking to her in his native tongue, and then "pushed Resident 1 into bed". CNA 1 also stated it bothered her the next couple of days so she felt she had to report it.
In a review of the facility's staffing records, CNA 2 continued to work two days after the alleged abuse occurred (7/26/17 and 7/27/17).
In an interview on 8/10/17 at 1:35 p.m., LN (Licensed Nurse) 1 stated Resident 1 was usually "Pretty alert, knows names and faces but forgets dates." LN 1 also stated Resident 1 was sleepy due to recent medication for restlessness, so was unable to hold a conversation.
In an interview on 8/10/17 at 2:50 p.m., The DON stated CNA 1 was hesitant to report the issue due to "being related" to CNA 2. The DON stated she could not "unsubstantiate" the abuse complaint so they terminated CNA 2 on 8/1/17.
In an interview on 8/10/17 at 3:05 p.m., CNA 1 stated it was an afternoon shift and CNA 2 was working with her at around 8:30 p.m. when they usually put residents to bed. CNA 2 was talking to Resident 1 about going to bed. He stated, "If you don't want to go to bed, I will push you." Resident 1 tried to scratch CNA 2. CNA 2 got mad and started to talk to Resident 1 in his own language (non-English). CNA 1 indicated she spoke the same language as CNA 2. CNA 2 stated, "She never wants to go to bed," so he lifted her from the wheelchair and threw her in the bed. CNA 2 raised his voice as if he was mad at Resident 1 and made a comment that he was "the man". CNA 1 was afraid to say anything at first because she had a family relationship to CNA 2 but she felt "bad" so she told her charge nurse on her next day back at work, 7/27/17.
In an interview on 8/10/17 at 3:50 p.m., LN 2 stated CNA 1 notified her of the incident on 7/27/17 in the evening. LN 2 came in the following morning and reported it to the DON. LN 2 stated she was aware of the abuse reporting timelines and knew she should have reported when she was aware of the abuse. LN 2 assessed Resident 1 on the evening shift of 7/27/17 after she learned of the incident. LN 2 asked if Resident 1 was "ok" but did not note assessment on progress note. LN 2 was not aware of the short -term care plan that stated to monitor Resident 1 for 72 hours. LN 2 also stated she had heard of other residents commenting about CNA 2 being "rough," and CNA 2's assignment would be changed so he would not have those residents.
In an interview on 8/10/17 at 4:40 p.m., DON acknowledged that the report of abuse was not made with 24 hours as required.
In a phone interview on 8/22/17 at 2:20 p.m., The DON verified they had suspended CNA 2 on 7/28/17, but CAN 2 continued to work two more days after incident (7/26/17 and 7/27/17) before they were aware of the alleged allegation of abuse.
In a phone interview on 8/22/17 at 2:25 p.m., The SSD stated he was the Director of the Abuse Committee. He confirmed his expectations of abuse reporting would be "all staff will follow policy and procedure of abuse reporting and report immediately to supervisor" and verified his expectations were "residents will be free from abuse from all staff and other residents". The SSD also confirmed that the allegation of abuse was reported late per facility policy.
A facility policy titled "ABUSE, PREVENTION OF," dated 12/2012, indicated the following:
1. Abuse, neglect, mistreatment...will not be tolerated at this facility."
2. All mandated reporters are required by law to report incidents of known or suspected abuse.
3. First responder or first staff member informed will be responsible for informing immediate supervisor and initiating incident report.
4. Administrator or designee shall report all incidents of alleged abuse or suspected abuse to DHS within 24 hours.
Therefore, the Department determined the facility failed to report an allegation of abuse within 24 hours as required, when the Certified Nursing Assistant 1 (CNA 1), who witnessed the alleged abuse, did not report it to the department.
This violation had a direct or immediate relationship to the health, safety, or security of the residents. |
| 940000007 |
ATLANTIC MEMORIAL HEALTHCARE CENTER |
940013530 |
B |
5-Oct-17 |
MIW311 |
20509 |
F157 ? 42 CFR ?483.10(g)(14) Notification of Changes
(i) A facility must immediately inform the resident; consult with the resident?s physician; and notify, consistent with his or her authority, the resident representative(s) when there is?
(A)An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B)A significant change in the resident?s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C)A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D)A decision to transfer or discharge the resident from the facility as specified in ?483.15(c)(1)(ii).
F309 ? 42 CFR ?483.24 Quality of life
Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident?s comprehensive assessment and plan of care.
483.25 Quality of care
Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents? choices, including but not limited to the following:
(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences.
(l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences.
Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident?s comprehensive assessment, plan of care, and professional standards of practice to Resident 1 by failing to:
1. Notify the physician of Resident 1?s low blood pressure (a change of condition) prior to the administration of the anti-hypertensive and narcotic medications.
2. Ensure the licensed vocational nurse (LVN 1) called the physician and clarified if the anti-hypertensive and narcotic medications could still be given to Resident 1, who was exhibiting a low blood pressure (either the systolic blood pressure, the upper number of the blood pressure, or the diastolic blood pressure, the bottom number of the blood pressure, was low).
3. Inform and involve the registered nurse to assess Resident 1 when the resident was consistently having a low blood pressure.
4. Ensure Resident 1, who had a low blood pressure, was not given the anti-hypertensive and narcotic medications that further lowered the blood pressure.
Resident 1, who was hypotensive (a blood pressure that is lower than 90/60 millimeter per mercury or mmHg), had a blood pressure of 82/49 mm/Hg (normal range for blood pressure is more than 120/80 mmHg and less than 140/90 mmHg) and then 106/48 mm/Hg (the diastolic blood pressure or DBP was low) 50 minutes later, and the licensed vocational nurse (LVN 1) continued to administer Amlodipine Besylate (a medication that lowers blood pressure) and Benazepril-Hydrochlorothiazide (a combination drug of medication that lowers blood pressure and a diuretic [water pill]) to Resident 1. LVN 1 also administered to Resident 1 four doses of narcotic pain medications, two tablets of 5-325 mg of Norco in the morning and in the afternoon, when the resident's blood pressure was already low. LVN 1 did not inform and involve the registered nurse to assess Resident 1 further and did not notify the physician regarding the resident's change of condition prior to the administration of these medications.
This deficient practice resulted in Resident 1?s transfer to an acute care hospital via 911-Paramedics for hypotension (low blood pressure) and receiving intravenous fluids of normal saline (a sterile salt solution) to increase her blood pressure.
A review of Resident 1's Admission Record indicated the resident was admitted to the facility on 5/25/17, and readmitted to the facility on 5/31/17, with diagnoses that included hypertension (abnormally high blood pressure), dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury marked by memory disorders and impaired reasoning), and atrial fibrillation (irregular heart beat that can lead to blood clot).
A review of Resident 1's care plan, initiated on 5/26/17, indicated Resident 1 had hypertension. The interventions included checking the resident's vital signs as ordered and notifying the physician of any abnormal readings.
A review of Resident 1's Initial History and Physical, signed by the physician on 5/27/17, indicated the resident did not have the capacity to understand and make decisions.
A review of Resident 1's Minimum Data Set (MDS, a care screening tool), dated 5/29/17, indicated that Resident 1's cognition (the ability to think and reason) was moderately impaired. The MDS indicated Resident 1 required extensive assistance (resident involved in activity; staff provide weight bearing support) with all activities of daily living.
A review of Resident 1's physician order, dated 5/25/17, indicated to give the resident the following medications:
a. Amlodipine Besylate Tablet 5 milligrams (mg), one tablet by mouth one time a day for hypertension.
b. Benazepril-Hydrochlorothiazide 20-12.5 mg, one tablet by mouth one time a day for hypertension.
The physician order included holding these two medications (Amlodipine Besylate and Benazepril-Hydrochlorothiazide) if the systolic blood pressure (SBP, the top number of the blood pressure) was less than 100 millimeters of mercury (mmHg).
c. Norco tablet 5-325 mg, one tablet my mouth every four hours as needed for moderate pain (pain level of 4 to 6 over 10), and two tablets by mouth every four hours as needed for severe pain (pain level 7 to 10 over 10) not to exceed a maximum of 3,000 milligrams (acetaminophen) for 24 hours.
A review of Resident 1?s consumption of Norco indicated the resident received one tablet of Norco for moderate pain of six out of 10 pain level on 5/27/17 at 6:36 p.m., for right hip pain and two tablets for severe pain on 5/27/17 at 10:19 p.m. for right hip pain. Resident 1 received one tablet of Norco for moderate pain on 5/28/17 at 9:38 p.m. for right leg pain.
A review of Resident 1?s Weights and Vitals Summary from 5/25/17 to 5/28/17 indicated the resident?s blood pressure measurements were between 113/58 mmHg to 133/66 mmHg.
A review of Resident 1's Physical Therapy (PT) Treatment Encounter Note, dated 5/29/17, and timed at 9:19 a.m., indicated that the physical therapy assistant (PTA) performed one hour of physical therapy to Resident 1. Resident 1 was seen by PTA in bed due to "Lower BP (blood pressure." Resident 1's BP at rest was documented at 82/49 mmHg and heart rate at rest was 82 beats per minute or bpm (the normal range for heart rate is 60 to 100 bpm).
A review of Resident 1's Medication Administration Record (MAR) and the Medication Administration Audit Report, dated 5/29/17, indicated Resident 1 received the following medications from LVN 1:
a. At 9: 54 a.m., two tablets of Norco (a narcotic pain medication) 5-325 mg for severe pain of seven out of 10 pain level. There was no documentation for the resident?s location of pain.
b. At 10:10 a.m., Amlodipine Besylate 5 mg tablet for blood pressure of 106/48 mmHg.
c. At 10:12 a.m., Benazepril-Hydrochlorothiazide 20-12.5 mg tablet for blood pressure of 106/48 mmHg.
d. At 2:29 p.m.., two tablets of Norco (a narcotic pain medication) 5-325 mg for severe pain of seven out of 10 pain level. There was no documentation for the resident?s location of pain.
A review of Resident 1's Progress Notes, dated 5/29/17 at 2:05 p.m., indicated the following documentation from LVN 1:
a. At 10 a.m., Resident 1 was observed to have a low BP of 85/38 mm/Hg. The resident did not exhibit signs of dizziness. Resident 1 was repositioned to Trendelenburg position (the body is laid flat on the back (supine position) with the feet higher than the head by 15-30 degrees) and resident's blood pressure was monitored hourly.
b. At 11 a.m., Resident 1's blood pressure readings were 81/38 mmHg
c. At 12 p.m., Resident 1's blood pressure readings were 88/45 mmHg. There was no documented evidence that the resident?s blood pressure was obtained at 1 p.m.
d. At 2 p.m., Resident 1's blood pressure readings were 96/52 mmHg. The attending physician was notified and new orders (not specified) were carried out. The responsible party was made aware. There was no documented evidence of the resident?s blood pressure measurement until 7 p.m, when it was69/40 mm/Hg.
A review of Resident 1's Speech Therapy (ST) Encounter Note, dated 5/29/17, indicated Resident 1 was seen by the speech therapist during lunch at the bedside with a family member present (Family 1). The ST Treatment Encounter Note indicated the resident was observed with mild SOB (shortness of breath) and fatigue during the meal.
A review of a Physician's Telephone Order, dated 5/29/17, and timed at 2:56 p.m. to 2:57 p.m., indicated a clarification of the BP medications (Amlodipine Besylate and Benazepril-Hydrochlorothiazide) parameters that were confirmed by LVN 1 for Resident 1. The new hold parameters for both BP medications were changed from holding the BP medications for systolic blood pressure (SBP) of 100 mm/Hg to 110 mm/Hg.
A review of Resident 1's Progress Notes, dated 5/29/17, and written at 8 p.m., indicated that registered nurse (RN 2) was monitoring Resident 1's low BP and that at 7 p.m., Resident 1's BP was at 69/40 mm/Hg and pulse at 57 beats per minute. The attending physician ordered to transfer Resident 1 to the emergency department if symptomatic and if the systolic blood pressure was below 80 mm/Hg. A 911 call was made and paramedics arrived at the facility at 7:20 p.m. and left with Resident 1 at 7:30 p.m. Family 1 was at the bedside during this time.
A review of the acute hospital's History and Physical Exam, dated 5/30/17, indicated Resident 1 was brought to the emergency department (ED) on 5/29/17. Resident 1 presented to the ED with a blood pressure of 69/30 mm/Hg. Resident 1 denied any fever, chills, nausea, vomiting, abdominal pain, chest pain, shortness of breath, dizziness, and syncope (fainting). Resident 1 was "noticed to have had episode of hypotension at the facility of 60/30 mm/hg and then sent to the ED." The Impression and Plan indicated diagnoses of "hypotension likely secondary to medications versus urinary tract infection, right hip fracture status post arthroplasty (the surgical reconstruction or replacement of a joint) - hold most pain medications and will continue with less round the clock pain medications ..., hypovolemic hyponatremia (low sodium levels in the body) with normal osm (osmolality - a test that measures the concentration of all chemical particles found in the fluid part of blood) - patient on BP medication combo with hydrochlorothiazide, will discontinue." Resident 1 received normal saline at 75 milliliter per hour (ml/hr).
A review of Resident 1?s acute hospital's Inpatient Summary, dated 5/31/17, indicated Resident 1's discharge diagnosis was "Hypotension due to drugs."
During a telephone interview, on 6/8/17 at 10 a.m., Family 1 (Fam 1) stated that on 5/28/17, Fam 1 observed Resident 1 sleeping "way too much." Fam 1 stated it was not Resident 1's usual behavior. Fam 1 stated the next day, on 5/29/17, Fam 1 observed Resident 1 still sleeping a lot more. Fam 1 stated she stayed at Resident 1's bedside the whole day of 5/29/17.
During the interview, Fam 1 stated that Resident 1 had physical therapy in bed (on 5/29/17) because Resident 1 was too tired and Fam 1 observed Resident 1 falling asleep during the physical therapy. Fam 1 stated one of the licensed nurses (unable to recall name) checked Resident 1's blood pressure at around 10:30 a.m. and it was 85/48 mm/Hg. Fam 1 stated that late in the afternoon, Fam 1 asked a licensed nurse (unable to recall name) to check on Resident 1's blood pressure again because Resident 1 was still sleeping way too much. Fam 1 stated Resident 1's blood pressure was 60/40 mm/Hg. Fam 1 stated the facility called 911 Paramedics and Resident 1 was transferred to the acute hospital. Fam 1 stated the diagnosis in the acute hospital was Resident 1 had a low blood pressure "due to drugs."
During an interview, on 6/8/17, at 5:10 p.m., LVN 2 was asked for his nursing opinion of what a reasonable and prudent nurse (a nurse that uses good judgement in providing nursing care according to accepted standards and that other nurses with similar education and experience in similar circumstances would provide) would do if a resident was being monitored for abnormally low blood pressures, would he still give narcotics or other blood pressure lowering medications. LVN 2 stated he would not give the medications. LVN 2 stated he would attempt other non-pharmacological interventions first and then, ask assistance from the registered nurse to reassess the resident to find out whether the medications can be given or not.
During an interview, on 6/8/17, at 5:15 p.m., RN 1 was asked for her expert opinion as a licensed nurse that if a resident was being monitored for abnormally low blood pressures, would she still give narcotics or other blood pressure lowering medications. RN 1 stated she will check the blood pressure of the resident first "manually for accuracy" and if it was still abnormally low, she will notify the physician. RN 1 stated she will review the trend of the resident's blood pressure readings and compare the trend from the resident's "baseline" to have enough information to decide whether to give the medications or not. RN 1 stated she will inform the resident's physician first and ask if the medications are still "okay" to be given or not. When asked about some of the side effects of Norco, RN 1 stated it can cause drowsiness and falls, and can lower the blood pressure.
During a telephone interview, on 6/9/17, at 1:45 p.m., the physical therapy assistant (PTA) stated that he performed physical therapy with Resident 1 at the bedside on 5/29/17, at around 8:30 a.m., because the resident's blood pressure was low at 82/49 mm/Hg. PTA stated that he informed the "charge nurse" (LVN 1) that morning about Resident 1's low blood pressure. PTA stated he checked Resident 1's blood pressure again after physical therapy (before 9:19 a.m.) and the systolic blood pressure was still between 80's to 90's.
During a telephone interview, on 7/7/17, at 10:45 a.m., LVN 1 stated it is a facility practice to administer the medications to a resident and document administration in the electronic record immediately after administration. LVN 1 stated that PTA informed him about Resident 1's low blood pressure in the morning. LVN 1 stated he took the blood pressure of Resident 1 in the morning, around 10 a.m. (unable to recall exact time), while FAM 1 was at the bedside and it was 85/38 mmHg. LVN 1 stated he positioned Resident 1 in Trendelenburg position and monitored the blood pressure of Resident 1 hourly as documented in the progress notes (11 a.m. and 12 noon) and then notified the physician.
During the interview, LVN 1 stated he administered Resident 1's routine blood pressure medications in the morning of 5/29/17. LVN 1 stated he checked Resident 1's blood pressure before giving the Amlodipine Besylate and Benazepril-Hydrochlorothiazide medications in the morning and the resident's blood pressure was 106/48 mm/Hg. LVN 1 stated he administered the medications because he followed the physician order to "hold for SBP less than 100." LVN 1 stated he did not involve the registered nurse of the facility to clarify if Resident 1 needed further assessments prior to receiving the routine blood pressure medications in the morning.
During the interview, LVN 1 stated he administered narcotic pain medication to Resident 1 on 5/29/17, at 9:54 a.m. because Resident 1 stated she was in severe pain. LVN 1 stated he was unable to recall if he rechecked the blood pressure prior to giving the anti-hypertensive medications and the Norco. He stated, "I could not remember which was first." LVN 1 stated he again administered Norco to Resident 1 around 2 p.m. for severe pain because the resident asked for her pain medication. LVN 1 stated he was aware that Norco can bring a resident's blood pressure down but Resident 1 was alert and crying in severe pain." LVN 1 stated "I will still give it," because the resident was asymptomatic (did not exhibit signs and symptoms) with her low blood pressure. LVN 1 stated he did not call the physician to clarify if Resident 1 was stable enough to receive the narcotic pain medications.
During a telephone interview, on 7/10/17, at 9:35 a.m., the director of nurses (DON) stated the facility does not have a policy and procedure for administration of blood pressure medications.
According to https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=b52e2905-f906-4c46-bb24-2c7754c5d75b, updated 12/15/08, Amlodipine Besylate causes a reduction in blood pressure ...After oral administration the peak plasma concentrations (the highest level of drug that can be obtained in the blood) will be between 6 and 12 hours.
According to https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=e7222f81-3e6b-dfe1-379a-83ca350f91a9, updated 6/6/17, indicated:
"Pharmacokinetics and Metabolism:
Following oral administration of Benazepril HCL and Hydrochlorothiazide peak plasma concentrations are reached within 0.5 to 1.0 hours."
"Hypotension
Benazepril HCL and Hydrochlorothiazide should be used cautiously in patients receiving concomitant therapy with other antihypertensives. The thiazide component of Benazepril HCL and Hydrochlorothiazide may potentiate the action of other hypertensive drugs. If hypotension occurs, the patient should be placed in a supine position, and if necessary, treated with intravenous infusion of physiological saline."
According to https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=aaef2d01-126d-4aab-9b2a-eee31a769150, updated 8/1/14, indicated:
"Overdosage:
Signs and Symptoms
Serious overdose with Hydrocodone (Norco) is characterized by respiratory depression (a decrease in respiratory rate) extreme somnolence ..., skeletal muscle flaccidity, cold and clammy skin, and sometimes bradycardia and hypotension ... Hypotension is usually hypovolemic and should respond to fluids.
The facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident?s comprehensive assessment, plan of care, and professional standards of practice to Resident 1 by failing to:
1. Notify the physician of Resident 1?s low blood pressure (a change of condition) prior to the administration of the anti-hypertensive and narcotic medications.
2. Ensure the licensed vocational nurse (LVN 1) called the physician and clarified if the anti-hypertensive and narcotic medications could still be given to Resident 1, who was exhibiting a low blood pressure (either the systolic blood pressure, the upper number of the blood pressure, or the diastolic blood pressure, the bottom number of the blood pressure, was low).
3. Inform and involve the registered nurse to assess Resident 1 when the resident was consistently having a low blood pressure.
4. Ensure Resident 1, who had a low blood pressure, was not given the anti-hypertensive and narcotic medications that further lowered the blood pressure.
The above violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 250000010 |
ALTA VISTA HEALTHCARE & WELLNESS CENTRE |
250013441 |
B |
1-Sep-17 |
BVFO11 |
8660 |
483.25(h) Free of Accident Hazards/Supervision/Devices
The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.
On May 17, 2016, at 9:40 a.m., an unannounced visit was made to the facility to investigate an entity reported incident regarding Patient 1?s accident with injuries, that occurred on May 2, 2016, while the patient was being transported to her dialysis clinic in the facility?s transportation bus.
It was determined that the facility failed to ensure one sampled patient (Patient 1) remained free from avoidable accidents and injuries when a staff member (Maintenance Supervisor- MS) did not ensure the patient?s wheelchair straps in the transportation bus were in good condition, and did not come loose and unfastened from the patient?s wheelchair. This failure caused Patient 1 to abruptly roll forward and then backward at a traffic stop, resulting in the patient hitting her head on the back wall of the bus. Patient 1 sustained a bump/hematoma to the back of the head, pain to her head and upper back, and was transferred to the hospital emergency room (ER) for further evaluation and treatment.
Review of Patient 1's medical record indicated she was admitted to the facility on April 28, 2016, and had diagnoses that included status post above the knee amputation (AKA), end stage renal disease (ESRD - inability of the kidneys to remove waste from the blood and make urine), weakness, and legally blind in the left eye. Patient 1 received dialysis treatment three times a week at a dialysis clinic away from the facility.
A written investigative summary and time line of the events, dated May 2, 2016, was provided by the facility?s Assistant Administrator (AA) and indicated the following:
"...8:56 am while driving to the Dialysis (clinic), (Patient 1's name) strap became loose and slipped through the tightening clasp causing the (wheel) chair to move forward and to subsequently tilt back when accelerating.
8:57 am (name of bus driver) pulled the bus over to the side of the road and repositioned, re-strapped, and double checked all fittings and buckles.
8:57 am (name of bus driver) asked if she (Patient 1) was ok, she stated "my back hurts a little but I'm ok."
The written investigative summary of events further indicated Patient 1 complained of back pain, wanted to go to the emergency room (ER), and was afraid of being transported again in the facility?s bus.
On May 17, 2016, at 9:55 a.m., the facility bus driver, who was also the Maintenance Supervisor (MS), was interviewed and asked about the incident involving Patient 1 while inside the facility bus being transported to the dialysis clinic on May 2, 2016. The MS stated, "Straps came off loose," referring to the front anchor straps from the floor that went around the bottom frame of the patient?s wheelchair when the bus came to a stop at a red light. The MS stated the bus then accelerated forward at the green light. The MS stated Patient 1 was still seated in the wheelchair when the wheelchair was tilted backward toward the back wall of the bus. The MS further stated the straps that came off were old, defective, thrown away after the accident, and new anchor straps had been ordered. The MS could not confirm if the defective straps were the reason they came off, or if the MS did not properly secure them.
When the MS was asked about his job responsibilities at the facility, the MS stated he was hired two months ago and his main job responsibility was Maintenance and Housekeeping Supervisor. The MS stated he was to make sure life and safety equipment used by patients in the facility were in good working condition. The MS further stated he was given additional work responsibility to take over as a bus driver, transporting patients to their scheduled appointments (such as at dialysis clinics) when the main bus driver was not available.
The MS was asked if he was given orientation or training regarding patient safety when transporting patients in the bus, prior to assuming the responsibility as facility bus driver. The MS stated, "No training, no orientation."
On May 17, 2016, at 11:35 a.m., an interview with the Administrator and the Assistant Administrator (AA) was conducted. The Administrator and AA were asked if, prior to the accident involving Patient 1, the facility bus drivers including the MS had been provided with safety training and orientation for transporting patients on the bus. The Administrator acknowledged the designated facility bus drivers including the MS, did not receive safety training and/or orientation on safe transport of patients until after the accident occurred with Patient 1. The Administrator could not confirm if the wheelchair straps came off because they were defective, or because the MS did not properly secure them.
The Administrator was asked if the facility had a safety policy and procedure for transporting patients in the facility bus, the Administrator was not able to provide the requested policy. The Administrator instead provided a written, undated document titled, "Van (Bus) Driver/Transporter Job Description." The job description indicated the driver's principal responsibilities included:
"...Provides transportation of residents (patients) to and from physician appointments in a timely manner... Maintains a high level of safety following safety policies and procedures while in Center and transporting residents. Maintains van (bus) in good working condition..."
On June 20, 2016, at 9:25 a.m., Patient 1 was observed at her dialysis clinic prior to the start of her dialysis treatment. Patient 1 was seated in a wheelchair and had an AKA of the left leg. Patient 1 was awake, alert, and able to communicate verbally.
In a concurrent interview with Patient 1, on June 20, 2016, at 9:25 a.m., she was asked about her health condition, and the accident she had inside the facility's transport bus on May 2, 2016. Patient 1 stated she was sitting in her wheelchair which was anchored at the back end of the bus. Patient 1 stated she was so scared when the straps at the bottom of her wheelchair came off, and as the bus accelerated forward she was abruptly pushed backward toward the wall of the bus. The patient explained that the backward force tipped her wheelchair backward in a tilted position, with her legs thrown upward and her head in a downward direction as the wheelchair traveled backward toward the back wall of the bus. Patient 1 stated, "The driver (the facility's Maintenance Supervisor) didn't even notice I fell backward. I have to keep yelling at him to stop the van (bus)." Patient 1 stated she hit the back of her head and upper back on the back wall of the bus, and sustained a small bump on the back of her head. Patient 1 stated she had pain on her head and upper back area after the accident.
On June 20, 2016, at 9:35 a.m., the dialysis Registered Nurse (RN 1) was interviewed regarding Patient 1's health condition before, during, and after her dialysis treatment on May 2, 2016. RN 1 stated Patient 1 was alert, oriented, and complained of upper back pain. The resident?s dialysis physician was notified of the incident with orders to send Patient 1 to the ER for further evaluation and treatment. RN 1 stated Patient 1 requested she wanted to complete her dialysis treatment at the clinic prior to being transferred to the ER.
Patient 1's dialysis treatment record dated May 2, 2016, indicated, "...complained of back pain... 5/10 (moderate pain on pain scale on 1/10), ...symptomatic hypotension (abnormally low blood pressure): lightheadedness, cramping. ...Sent to ER (acute hospital's name) for evaluation and possible CT (CAT Scan/x-ray) of the head. Seen by (physician's name)."
A review of the ER physician?s notes dated May 2, 2016, at 2:16 p.m., indicated Patient 1 complained of "headache, dizziness", and moderate pain on the "head and neck." The diagnostic considerations the patient was assessed for were closed head injury, fracture (broken bone) and hematoma (bruise). Patient 1 further received laboratory tests including a CT of the head and spine, and was admitted to the hospital as in-patient for further observation and treatment. The CT results indicated, "No apparent fracture (of the head and spine) or dislocation..."
The violation of this regulation had a direct relationship to the health, safety, and optimal physical, mental, and psychosocial well-being of Patient 1. |
| 070000096 |
Amberwood Gardens |
070013594 |
B |
15-Nov-17 |
2B8S11 |
5305 |
F323-483.25(d)(1)(2)(n)(1)-(3) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES
(d) Accidents.
The facility must ensure that -
(1) The resident environment remains as free from accident hazards as is possible; and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
(n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements.
(1) Assess the resident for risk of entrapment from bed rails prior to installation.
(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.
(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight.
The facility failed to follow their fall policy and accident/incident policy for Resident 1 when the resident slid out of the wheelchair in a van on 10/9/17. This failure had the potential to compromise Resident 1's health and safety.
Resident 1 was admitted to the facility on 7/7/16 with diagnoses including right below the knee amputation and end stage renal disease (impaired kidney function). The Minimum Data Set (MDS, an assessment tool) dated 10/28/17 indicated Resident 1 was cognitively intact. She required assistance with transfers, mobility, and had functional limitation in her upper and lower extremities.
During a record review with the assistant director of nursing (ADON) on 10/27/17, the following were noted:
On 10/9/17, the daily nurses' notes indicated two certified nursing assistants (CNA A and CNA B) needed to assist the van driver (VD) inside the van because Resident 1 slid out of the wheelchair on the way to the facility.
On 10/11/17, the daily nurses' note indicated during morning care CNA A informed the nurse of the scratch on Resident 1's left knee.
On 10/13/17, the daily nurses' notes indicated Resident 1 complained of pain on the left below the knee area. The licensed vocational nurse (LVN) and the physician noted a bump with slight swelling, dry scab, and bluish greenish skin discoloration on the left below the knee area. An X-ray of the left leg was ordered and revealed proximal tibia fracture (broken shinbone lower portion of the knee) and soft tissue swelling.
During an observation and interview on 10/24/17 at 12:00 p.m., Resident 1 stated she was seated in her wheelchair inside the van and while the van was "running", she slid down on the floor. The VD "stopped the car" and picked her up from the floor. Resident 1 stated she was positioned in the van's passenger seat not in her wheelchair. Resident 1 showed a dry scab below her left knee measuring approximately 0.5 cm x 0.5 cm. Resident 1 stated she did not know why she had a scab on her left knee.
During a telephone interview on 10/27/17 at 12:22 p.m., CNA A stated on 10/9/17 he was told to assist the VD to reposition Resident 1 tin her wheelchair because the resident slid out of the wheelchair.
During an interview on 10/27/17 at 1:00 p.m., (using a translator) the VD stated on 10/9/17, while driving back to the facility, he turned to an intersection of a street (approximately 0.2 mile away from the facility) and heard Resident 1 screaming. The VD stated he looked at the rear view mirror and saw Resident 1's hands up in the air. He stated he pulled over and stopped the car. The VD stated he lifted the resident who had slid out of her chair and transferred her to the van's passenger seat.
During an interview and record review on 10/27/17 at 3:17 p.m., licensed vocational nurse C (LVN C) stated on 10/9/17, Resident 1 arrived in the facility and CNA B informed her Resident 1 slid out of her wheelchair in the van. LVN C stated she assessed Resident 1 who did not complain of any pain or discomfort. LVN C acknowledged there was no completed documentation of a full body assessment or neurological assessment. LVN C stated she did not investigate the incident but reported the incident to her supervisor. LVN C acknowledged there was no evidence this incident was followed up on 10/10/17 and 10/11/17.
During a concurrent telephone interview with the supervisor, she stated she was not able to remember if she investigated the incident.
During a telephone interview on 10/30/17 at 3:45 p.m., the administrator acknowledged the accident/incident was not investigated and reported on time to the California Department of Public Health.
Review of the facility's 2015 policy on "Falls- Clinical Protocol" indicated the nurse should assess and document the neurological status, musculoskeletal function, observing changes in range of motion, weight bearing and more.
The facility's undated policy on "Accidents and Incidents" indicated all accidents or incidents involving residents, employee, and visitors should be investigated. The nurse supervisor and/or the department director shall complete a report of incident/accident form and submit the original to the director of nursing within 24 hours of the incident or accident.
The above violation had a direct relationship to the health, safety, or security of residents. |
| 920000280 |
ANTELOPE VALLEY CARE CENTER |
920013596 |
A |
3-Nov-17 |
WM2W11 |
13985 |
?483.10(g)(14) Notification of Changes
(i) A facility must immediately inform the resident; consult with the resident?s physician; and notify, consistent with his or her authority, the resident representative(s) when there is?
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment);
483.24 Quality of life
Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident?s comprehensive assessment and plan of care.
483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents? choices, including but not limited to the following:
(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences.
On September 19, 2017, during the Annual Recertification survey, Resident 1?s clinical record was reviewed.
Based on observation, interview, and record review, the facility failed to ensure its residents receive treatment and care in accordance with the person-centered plan of care consistent with professional standards of practice and failed to ensure effective pain management, including:
1. Failure to implement the facility?s policy and procedures on Bowel Care ? Constipation by not assessing Resident 1?s risk for constipation based on the medications taken, including narcotics. Resident 1 was receiving Norco, a narcotic pain medication.
2. Failure to implement Resident 1?s plan of care for potential alteration in bowel elimination, related to immobility and use of ferrous sulfate (a medication to increase iron levels in the blood with constipation as side effect), by not monitoring bowel movements amount and consistency and medications causing constipation.
3. Failure to implement Resident 1?s plan of care for alteration in comfort by not notifying the physician of pain not relieved by prescribed medication Norco (narcotic medication used to treat moderate to severe pain), as evidence by frequent administration of the medication.
4. Failure to implement the facility?s Pain - Clinical Protocol policy and procedure plan of care for risk of alteration in comfort, by not identifying onset, quality, and manner of expressing pain, to determine possible pain causal factors.
As a result, on September 20, 2017, Resident 1 developed severe abdominal pain, requiring transfer to a General Acute Care Hospital (GACH) where a computerized tomography (CT) scan (combines a series of X-ray images taken from different angles and uses computer processing to create cross-sectional images of body parts) showed dry stool in the large bowel.
On September 19, 2017, at 8:45 a.m., during the initial tour of the facility, accompanied by Licensed Vocational Nurse 1 (LVN 1)/Unit Manager, Resident 1 was observed moaning in pain all over her body. LVN 2, the medication nurse, stated she gave Resident 1 pain medication 15 minutes prior for pain severity of 7/10 (rating pain scale from zero to 10, zero indicating no pain, and 10 indicating the worst possible pain).
On September 20, 2017, at 9:25 a.m. Resident 1 was observed in bed moaning in pain on the lower abdomen. Resident 1 was unable to give a numerical rating of the pain but indicated, "It hurts a lot."
During a follow up interview with Resident 1 on September 20, 2017 at 11:25 a.m., when asked if her pain had lessened since she received pain medication, she stated, "My pain didn't go nowhere." LVN 2, present at the time of the interview with Resident 1, asked Resident 1 if she remembered telling her the pain had lessened. Resident 1 stated, "I did not tell you that." Resident 1 stated her pain, at that moment, was at least 5/10.
A review of the Admission Record, indicated Resident 1 was admitted to the facility on June 27, 2017 with diagnoses that included stroke, chronic pain syndrome, hemiplegia (inability to move one side of the body) following a stroke.
A review of the Physician's Orders dated June 27, 2017 included:
- Norco two tablets every six hours as needed for moderate to severe pain.
- Milk of Magnesia 30 cubic centimeters (cc) daily as needed for constipation.
- Dulcolax (loosens stools) suppository 10 milligrams (mg) daily as needed for constipation, if no results eight hours after Milk of Magnesia (laxative to treat constipation) is given.
Another Physician?s Order date July 3, 2017, indicated Ferrous sulfate 325 milligrams (mg) three times a day for anemia (a medication to increase iron levels in the blood with constipation as side effect).
A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care planning tool), dated July 4, 2017, indicated Resident 1 was moderately impaired in making daily decisions, was unable to make needs known, required two-person total assistance for bed mobility and transfers, was dependent on a gastrostomy tube (GT - a soft tube surgically inserted into the stomach through the abdominal wall to administer medications and nutrition) for feeding, and was always incontinent of bowel and bladder functions.
A review of Resident 1?s care plan for potential for alteration in bowel elimination, related to immobility and use of ferrous sulfate dated July 5, 2017, indicated in the goals that resident would have a bowel movement regularly in the next three months. The interventions included monitoring bowel movements amount and consistency and medications causing constipation.
A care plan dated July 5, 2017, developed for Resident 1's alteration in comfort, included in the interventions identifying frequency, location, quality, onset, and manner of expressing pain, and administer Norco every six hours as needed for moderate to severe pain. Notify MD (medical doctor) of increasing pain or if pain is not relieve by prescribed medications/treatment. The plan of care did not address the frequent use of Norco and its constipating side effects.
A review of the Narcotic and Hypnotic Record and the Medication Administration Record (MAR), indicated Resident 1 received Norco 54 times during the month of July 2017, 56 times during the month of August 2017, and 34 times from September 1 to 21, 2017. There was no documented evidence Resident 1?s physician was notified of Resident 1 frequent use of Norco.
During the month of September 2017, Dulcolax was administered twice, on September 3, and 4, 2017.
On September 20, 2017 at 9:35 a.m., during an interview, LVN 2 stated Resident 1 was given pain medication approximately an hour and a half ago. LVN 2 stated most of the time Resident 1 is asleep and when staff move her she starts "whining." LVN 1 stated the Unit Manager (LVN 1) will try to obtain a referral to a pain management physician.
A review of Resident 1?s Bowel Elimination Record for the month of September 1 to 20, 2017, indicated the resident had routine bowel movements.
A review of the Bowel and Bladder Elimination Record for the month of September 2017, indicated Resident 1 had a soft semi-formed, medium size bowel movement on September 20, 2017 at 1:34 a.m. There was no documentation to indicate Resident 1's abdominal pain was relieved as a result of the bowel movement.
A review of the Nursing Progress Notes dated September 20, 2017 at 12:34 p.m., by Registered Nurse 1 (RN 1) indicated Resident 1 was crying and when asked where the pain was the resident touched all over the lower abdomen. A rectal exam was done and the resident was identified with full, hard bowel inside.
A review of Resident 1's MAR for September 2017, indicated Resident 1 received Milk of Magnesia as needed for bowel management on September 20, 2017, at 1:20 p.m., after the resident's abdominal pain was brought to the attention of LVN 2.
On September 20, 2017 at 2:30 p.m., during an interview, the Pain Management Nurse Practitioner (PM - NP), stated Resident 1's pain medication would be changed and Resident 1 would be placed on a bowel management program. PM - NP stated in addition to the new medications, a KUB [kidney, ureter (urine passage), and bladder] X-ray was ordered to assess for constipation and possible fecal impaction [a mass of dry, hard stool that will not pass out of the body).
On September 20, 2017 at 3 p.m., during a review of Resident 1?s clinical record with LVN 2, she stated Resident 1 had pain this week since Monday, September 18, 2017. LVN 2 stated Resident 1 was, "Whining on Monday." LVN 2 was unable to state the location of the pain on the other days Resident 1 was having pain. The location of the pain was not documented. LVN 2 was unable to provide documentation that on September 19, 2017, at 8:45 a.m., Resident 1 was monitored for relief of pain, cause of pain, and effectiveness of interventions.
A review of the Interdisciplinary Team (IDT- a group of different healthcare disciplines and the resident or resident?s representative) Notes dated September 20, 2017 at 3:48 p.m. indicated the following: "Abdomen distended with resident guarding abdomen. RN able to pull 210 milliliters of GT residual (residual is the amount of feeding formula not absorbed. Large residual indicates lack of digestion of the formula.) The physician was notified and ordered referral for pain management consult and a KUB to evaluate bowel patterns. There was no documented evidence the IDT addressed the used of Norco and its constipating side effect.
On September 20, 2017 at 4:35 p.m. during an interview, LVN 2 stated the KUB had not been ordered yet, as she was busy, but was going to enter the order.
On September 20, 2017 at 6:20 p.m., Resident 1 was sent to a GACH via paramedics, for evaluation of severe abdominal pain.
A review of the clinical record from the GACH Emergency Room dated September 20, 2017 timed at 6:23 p.m., indicated Resident 1 was brought due to abdominal pain and unable to have bowel movement for 24 hours. Resident 1's pain level was of 10/10.
A review of the CT scan of the abdomen and pelvis (lower part of the trunk of the human body between the abdomen and the thighs), dated September 20, 2017, timed at 11:23 p.m., indicated Resident 1 had increased formed stool throughout the colon (large bowel) suggestive of constipation with no evidence of bowel obstruction. The CT indicated the stool in the descending colon, sigmoid colon and rectum is markedly hyperdense (dry stool).
A review of the facility's policy and procedure titled, "Pain - Clinical Protocol," Revised June 2013, indicated staff and physician will identify the nature (characteristics such as location, intensity, frequency, pattern, etc.) and severity of pain and the physician will help identify causes of pain; for example, by examining the resident directly, reviewing the resident's history, and via discussion with the resident and staff.
A review of the facility's undated policy and procedure titled, "Bowel Care - Constipation indicated the facility will assess any resident that is clinically at risk for constipation based on medication administration. Such medications that will be reviewed are narcotics that are known to cause constipation. The following procedures will be initiated for any residents with no substantial bowel movement within three days. Any resident on a narcotic, unless contraindicated, will be given Colace as ordered. Constipation Risk Assessment will be completed on all residents upon admission, any requiring narcotics, and residents that trigger as high risk. The policy indicates that a resident at risk for constipation will be placed on routine laxatives per physician's orders.
The facility failed to ensure its residents receive treatment and care in accordance with the person-centered plan of care consistent with professional standards of practice and failed to ensure effective pain management, including:
1. Failure to implement the facility?s policy and procedures on Bowel Care ? Constipation by not assessing Resident 1?s risk for constipation based on the medications taken, including narcotics. Resident 1 was receiving Norco, a narcotic pain medication.
2. Failure to implement Resident 1?s plan of care for potential alteration in bowel elimination, related to immobility and use of ferrous sulfate, by not monitoring bowel movements amount and consistency and medications causing constipation.
3. Failure to implement Resident 1?s plan of care for alteration in comfort by not notifying the physician of pain not relieved by prescribed medication Norco (narcotic medication used to treat moderate to severe pain), as evidence by frequent administration of the medication.
4. Failure to implement the facility?s Pain - Clinical Protocol policy and procedure plan of care for risk of alteration in comfort, by not identifying onset, quality, and manner of expressing pain, to determine possible pain causal factors.
As a result, on September 20, 2017, Resident 1 developed severe abdominal pain, requiring transfer to a GACH where a CT scan showed dry stool in the large bowel.
The above violation presented either an imminent danger that death or serious harm would result or substantial probability that death or serious harm would result to Resident 1. |
| 630003462 |
ATLANTA HOUSE |
060013669 |
B |
7-Dec-17 |
NIUM11 |
6361 |
W331 - 483.460(c) The facility must provide clients with nursing services in accordance with their needs.
On 10/12/17, an Entity Reported Incident (ERI) was received by the California Department of Public Health, Licensing and Certification (CDPH, L&C) Program regarding Client 1 sustaining a fracture to the right foot.
On 10/20/17 at 0745 hours, an unannounced visit was made to the facility to investigate the ERI.
Clinical record review for Client 1 was conducted on 10/20/17. Client 1 was a 65 year old with diagnoses including moderate intellectual disability (an individual with an intelligence quotient of 36 to 49). Client 1 was mobile with the use of a four wheel walker and manual wheelchair and was dependent on facility staff for his health care needs. Client 1 was verbal, but his awareness was "varied."
On 10/20/17 at 0820 hours, an interview was conducted with the House Leader. The House Leader stated Client 1 complained of pain in his right foot on 9/23/17. The House Leader further stated she elevated Client 1's foot, applied ice, and notified the Registered Nurse (RN) by phone. The House Leader was asked if the RN had completed an assessment of Client 1's right foot. The House Leader verified the RN did not conduct an assessment of Client 1's right foot. The House Leader stated the facility's RN was out of the country at that time and the owner, who was an RN, was covering for the facility's RN. The House Leader was asked if the owner came to the facility to complete a nursing assessment on Client 1's right foot. The House Leader verified the owner did not conduct an assessment of Client 1's right foot. The House Leader was asked if there was a nursing care plan developed addressing Client 1's right foot fracture. The House Leader stated there was none.
During a later interview with the House Leader on 10/20/17 at 0908 hours, the House Leader stated when she informed the RN on 9/23/17, regarding Client 1's complaints of pain to the right foot, the RN instructed the House Leader to take Client 1 to see his physician if his right foot pain was not relieved in two to three days. The House Leader was asked if she called the physician on 9/23/17, to inform him of Client 1's complaints of right foot pain. The House Leader stated she did not because the physician's office was closed on Saturday (9/23/17). The House Leader stated she waited until the physician's office opened on Monday (9/25/17) to inform the physician of Client 1's complaints of right foot pain.
Review of the physician's progress note dated 9/25/17, showed Client 1 was seen by his physician on 9/25/17, two days after Client 1's complaint of pain to the right foot and the physician ordered an x-ray of the client's right foot.
Review of the right foot x-ray results dated 9/26/17 (three days after Client 1's complaint of pain), showed Client 1 had a fracture involving the fifth distal metatarsal (the long bone on the outside of the foot that connects to the little toe).
Review of the orthopedic physician's progress note dated 10/4/17 (eight days after Client 1 was diagnosed with a fracture), showed Client 1 was seen and provided a foot fracture boot (an orthopedic device prescribed for the treatment and stabilization of severe sprains, fractures, and tendon and ligament tears in the ankle or foot) to wear. In addition, the orthopedic physician ordered a follow-up visit on 11/1/17.
Review of the facility's policy and procedure (P&P) titled Nursing Services (undated) showed in part, the attending physician shall be notified immediately of any sudden and/or marked adverse change in signs, symptoms, or behavior exhibited by a client. The RN consultant shall visit the facility for health services and client health assessment as needed, but no less than one hour per week per client.
Review of the facility's P&P titled Conditions Requiring Notification of Physician (undated) showed in part, the physician shall be notified of any change in the client's condition including unknown pain or discomfort. The RN or designee will contact the physician immediately if symptoms are serious.
Review of the facility's P&P titled Emergency Medical Procedure (undated) showed in part, emergency medical services will be available at all times. If the attending physician or the attending physician taking his calls cannot be reached, take the client to the emergency room of the local hospital.
Review of the nurse's notes showed the most recent documentation was dated 7/12/17. There was no documented evidence Client 1 was assessed by the RN when he complained of pain to his right foot on 9/23/17. There was no documented evidence the RN attempted to notify the physician regarding Client 1's complaint of pain to the right foot as per the facility's P&P. In addition, there was no documented evidence Client 1 was taken to the emergency room of the local hospital if the attending physician could not be reached as per the facility's P&P.
Further review of the clinical record showed there was no documentation from the RN during Client 1's visits to his primary physician and orthopedic physician including their recommendations and there was no nursing care plan developed to address the care of Client 1's right foot fracture.
On 10/20/17 at 0855 hours, the Qualified Intellectual Disabilities Professional (QIDP) was informed of the concerns with the RN not completing an assessment for Client 1 on 9/23/17, not receiving immediate medical treatment, and not receiving timely follow up by the RN for the client's right foot fracture. The QIDP verified the above findings. The QIDP further stated the RN had seen Client 1 since she returned to the country on 10/7/17. However, the RN did not document anything.
The facility failed to ensure the appropriate nursing care was provided for one of one sampled client (Client 1). Client 1 was not assessed by the RN when he complained of foot pain on 9/23/17. Client 1 had a right foot fracture that was not followed up by the RN. These caused a delay in treatment and had the potential for the client to experience health consequences that could have been prevented with nursing oversight.
This failure had a direct and immediate relationship to the health, safety, and security of the client. |
| 940000049 |
Affinity Healthcare Center |
940013664 |
A |
1-Dec-17 |
IS8011 |
30987 |
F157 ? 42 CFR ?483.10(g)(14) Notification of Changes
(i) A facility must immediately inform the resident; consult with the resident?s physician; and notify, consistent with his or her authority, the resident representative(s) when there is?
(A)An accident involving the resident, which results in injury and has the potential for requiring physician intervention;
(B)A significant change in the resident?s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C)A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D)A decision to transfer or discharge the resident from the facility as specified in ?483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in ?483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is?
(A)A change in room or roommate assignment as specified in ?483.10(e)(6);
or
(B)A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s).
F279 ? 42 CFR ?483.20(d) Use
A facility must maintain all resident assessments completed within the previous 15 months in the resident?s active record and use the results of the assessments to develop, review and revise the resident?s comprehensive care plan.
?483.21(b) Comprehensive Care Plans
(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at ?483.10(c)(2) and ?483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following?
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under ?483.24, ?483.25 or ?483.40; and
(ii) Any services that would otherwise be required under ?483.24, ?483.25 or ?483.40 but are not provided due to the resident's exercise of rights under ?483.10, including the right to refuse treatment under ?483.10(c)(6).
(iv)In consultation with the resident and the resident?s representative (s)? (A) The resident?s goals for admission and desired outcomes.
F309 ? 42 CFR ? 483.24 Quality of life
Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident?s comprehensive assessment and plan of care.
42 CFR ? 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents? choices, including but not limited to the following:
F323 ? 42 CFR ?483.25(d) Accidents.
The facility must ensure that ?
(1) The resident environment remains as free from accident hazards as is possible; and
(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
H&SC ?1418.6
No long-term health care facility shall accept or retain any patient for whom it cannot provide adequate care.
Title 22 72543(a)
(a) Records shall be permanent, either typewritten or legibly written in ink, be capable of being photocopied and shall be kept on all patients admitted or accepted for care. All health records of discharged patients shall be completed and filed within 30 days after discharge date and such records shall be kept for a minimum of 7 years, except for minors whose records shall be kept at least until 1 year after the minor has reached the age of 18 years, but in no case less than 7 years. All exposed X-ray film shall be retained for seven years. All required records, either originals or accurate reproductions thereof, shall be maintained in such form as to be legible and readily available upon the request of the attending licensed healthcare practitioner acting within the scope of his or her professional licensure, the facility staff or any authorized officer, agent, or employee of either, or any other person authorized by law to make such request.
Resident 1 was an 88-year old man with diagnoses of Alzheimer?s dementia (loss of brain function that affects memory, thinking, language, judgment, and behavior) and a high risk for falls.ÿAbout 24 hours after his admission to the facility, Resident 1 fell near his wheelchair as he was wandering unsupervised in a hallway on 11/28/16 at 5:10 p.m.ÿThe physician ordered the licensed nurses to conduct neurological checks on Resident 1 for 72 hours.ÿ The form titled ?72 Hour Neuro Checks,? that the licensed nurses were supposed to complete and document the specific frequency of the neurological checks, was missing from Resident 1?s medical record. There was no other evidence in the medical record that the licensed nurses conducted neurological checks. Resident 1?s nursing progress notes on 11/29/16 indicated the resident was sleepy all day, refused breakfast and lunch, and had an elevated temperature. Documentation of Resident 1?s complete vital signs (blood pressure, pulse rate, respiration, and temperature) and physician notification of the resident?s change of condition occurred on 11/29/16 at 2:30 p.m.ÿOn 11/29/16 at 6 p.m., Resident 1 was transferred to a general acute care hospital (GACH) via 9-1-1 emergency services. Resident 1 was diagnosed with new hemorrhage (bleeding) at the back of the brain and placed under hospice care (end-of-life palliative care focused on providing comfort and relief from pain and symptoms of illness) because no meaningful recovery was expected. Resident 1 passed away at home under hospice care 20 days after discharge from the acute hospital.
Based on interview and record review, the facility failed to provide necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, and to ensure that its residents receive treatment and care in accordance with the facility?s policy and procedures, the comprehensive assessment, and plan of care to meet the needs of the residents, including but not limited to:
1. Failure to assess Resident 1 for need for one-on-one supervision.
2. Failure to provide Resident 1 with one-on-one supervision.
3. Failure to develop a plan of care to implement interventions to prevent falls.
4. Failure to perform and keep a record of the neurological checks for 72 hours as ordered by Resident 1?s physician, consisting of assessment of Resident 1?s blood pressure, temperature, pulse rate, respirations, level of consciousness, size and reaction of the right and left pupil, and the right and left hand grip.
5. Failure to promptly identify the changes in Resident 1?s neurological status.
6. Failure to notify Resident 1?s attending physician of the changes in the resident?s neurological status.
These deficient practices resulted in delayed intervention and Resident 1?s emergency transfer to a general acute care hospital due to a serious brain injury, 25 hours after the fall.
A review of Resident 1's Face Sheet (admission record) indicated Resident 1 was admitted to the facility on 11/27/16 with diagnoses that included generalized anxiety disorder and transient cerebral (brain) ischemic attack (also known as transient ischemic attack or TIA, loss of blood flow to the brain and resembles a stroke, producing similar symptoms, and causing no permanent damage).
A review of the Resident 1's undated Resident Admission Form (an admission assessment form) indicated the facility admitted the resident on 11/27/16 at 4:30 p.m. The assessment form indicated the resident was alert and oriented to person and that the resident wanders.
A review of Resident 1's History and Physical Examination (HPE), signed by Resident 1's attending physician on 11/28/16, indicated Resident 1's diagnoses included a recent TIA with symptoms resolved and the resident was started on aspirin (an antiplatelet, a medication that eliminate or reduce the risk of blood clots), brief psychotic disorder (a period of incoherence and disorganized behavior whose duration is generally shorter), and Alzheimer's dementia (a loss of mental ability severe enough to interfere with normal activities of daily living). The HPE indicated that Resident 1 did not have the capacity to understand and make decisions.
A review of Resident 1's Physical Restraint Review, dated 11/27/16, indicated that Resident 1 had poor safety awareness, poor sitting balance, gait dysfunction (abnormal manner of walking), and aggressive behavior. The Physical Restraint Review indicated that Resident 1 would have a tab alarm (a sensor device applied to the bed or chair that creates an alarming sound when the resident gets up while in bed or chair).
A review of a facility's document titled, "Resident 1's Fall Risk Evaluation," dated 11/27/16, indicated the resident had a total fall risk assessment score of 15, which indicated that Resident 1 was a high risk for potential falls. The Fall Risk Evaluation form indicated a "prevention protocol" should be initiated immediately and documented in the care plan.
A review of Resident 1's Physician Orders, dated 11/27/16 and timed at 4:30 p.m., indicated to administer to the resident enteric coated (tablet film coatings designed to be resistant to stomach acid) aspirin 81 milligrams (mg) orally, and quetiapine (an antipsychotic medication for mental illness) 12.5 mg twice a day orally for psychosis manifested by recurrent outbursts of anger and 12.5 mg every 6 hours as needed for psychosis manifested by aggressive behavior towards staff. The physician ordered the tab alarm to be placed and monitored in the resident's wheelchair and bed.
A review of a facility document titled "Interdisciplinary Team Conference Record," dated 11/27/16, indicated an IDT meeting was conducted for Resident 1's "Complex medical condition at risk for decline, fall, and unavoidable change in condition." The IDT record indicated that Resident 1 was placed on a one-on-one "sitter" (one staff supervises one resident at all times) and had physical restraints while in the acute hospital; the resident had a diagnosis of Sundowner's Syndrome (a symptom of a mental illness wherein confusion and agitation gets worse in the late afternoon and evening); and was hard of hearing with an implanted in his left ear. The IDT record indicated that appropriate care plans were developed to assist with Resident 1's needs, safety, and level of care, including placement of tab alarm while in the wheelchair.
A review of a sampled blank facility form titled, "72 Hour Neuro Checks," which the facility used to record a resident's neurological checks, indicated that the licensed nurses were to conduct a neurological assessment every 15 minutes for four times, followed by every one hour for two times, every two hours for four times, every four hours for four times, and every eight hours for six times. The neurological signs to be checked were the resident's blood pressure, temperature, pulse rate, respirations, level of consciousness, size and reaction of the right and left pupil, and the right and left hand grip. The form required the initial of the licensed nurse conducting the neurological checks.
A review of Resident 1's Licensed Nurses Progress Notes, dated 11/28/16 and timed at 2:40 p.m., indicated Resident 1 needed to be monitored at all times due to being a high risk for fall.
A review of Resident 1's Licensed Progress Notes, dated 11/28/16 and timed at 3 p.m., indicated that Resident 1 was seen sitting in the wheelchair with a certified nursing assistant or CNA (whom the facility was unable to identify) and a family member (Fam 1). At 5:05 p.m., "Resident wheel himself to the laundry room door." At 5:10 p.m., according to the laundry personnel (LS), Resident 1 asked him if he could let him in. LS turned around and walked two steps (away from the resident); the resident then stood up from his wheelchair and then slowly fell back. Resident 1's wheelchair moved back, then the resident fell on the floor, hit his head, but "it's not hard." A licensed vocational nurse (LVN 1) went to check the resident, there was no injury noted, no bump on his head, and no redness. The resident denied any pain or discomfort.
A review of a facility document titled "COC (change of condition)/Interact Assessment Form (SBAR)" (Situation; Background; Assessment; Request plan), dated 11/28/16 and timed at 5:10 p.m., indicated that Resident 1 had a witnessed fall without injury. The resident's blood pressure (BP) was 128/78 millimeters of mercury or mm/hg (the normal range is 120/80 mm/hg), pulse rate was 69 beats per minute (normal range is 60 to 100 beats per minute), respiratory rate (RR) was 19 breaths per minute (normal range is 12 to 20 breaths per minute), and a temperature of 98.2 degrees Fahrenheit (normal range of 97.8 to 99.0 degrees Fahrenheit). The COC form indicated the plan for the resident was to monitor his vital signs and "observe." The COC form did not indicate what the facility staff needed to "observe" from Resident 1. The COC form did not contain a documentation of the licensed nurse's assessment of Resident 1's level of consciousness, size and reaction of his right and left pupil, and the right and left hand grip to establish a baseline of the resident's neurological condition.
The Licensed Progress Notes, 11/28/16 at 5:05 p.m., indicated that Resident 1's physician was notified and the physician ordered to conduct on the resident a neurological check for 72 hours and inform physician of "changes." The progress note did not indicate what type of changes needed to be reported to the physician.
A review of Resident 1's care plan titled, "Actual Fall," dated 11/28/16, indicated the resident had a fall on 11/28/16, in front of the facility's laundry room. The interventions included conducting neurological checks, monitoring for delayed pain or injury, decrease in function, and report to the physician.
A review of Resident 1's Licensed Progress Notes, dated 11/29/16 and timed at 8:30 a.m., indicated that a certified nursing assistant (CNA [could not be identified by the facility]) observed Resident 1 "drowsy" during breakfast and having a temperature of 99.5 degrees Fahrenheit (a fever is considered a body temperature above the normal 98.6 degrees Fahrenheit). The progress note indicated Resident 1 stated he did not sleep all night. LVN 2 documented in the progress notes evaluating Resident 1's abdomen and bowel sounds, respiration, and oxygen saturation (the amount of oxygen bound to hemoglobin in the blood) in room air but there was no rationale (reasoning) documented for his interventions.
Although Resident 1?s physician ordered a 72-hour schedule of neurological checks for Resident 1, there was no documented evidence that the licensed nurse assessed Resident 1's neurological function when Resident 1 was observed drowsy at 8:30 a.m. on 11/29/16, and had a slight increase in temperature of 99.5 degrees Fahrenheit from the baseline temperature of 98.2 degrees, or informed the physician of "changes" in Resident 1?s neurological status.
There was no documented evidence in Resident 1?s medical records of the resident?s health status and that the licensed nurse monitored Resident 1's neurological status and communicated to the physician the changes in Resident 1?s health status between the hours of 8:30 a.m. to 2 p.m. on 11/29/16.
A review of Resident 1's Licensed Nurses Progress Notes, dated 11/29/16 and timed at 2 p.m., indicated LVN 2 documented that Resident 1 had a temperature of 100.5 degrees Fahrenheit and he refused water and Tylenol "by not responding." At 2:30 p.m., LVN 2 documented that Resident 1 refused to eat breakfast and lunch; he notified Resident 1's attending physician and responsible party that the resident had been asleep all day and had been difficult to arouse; and that his "temperature was rising (100.5 degrees Fahrenheit)." Resident 1 was responding to painful stimuli only. Resident 1 had an elevated blood pressure of 150/80 mm/hg, body temperature of 100.2 degrees Fahrenheit, pulse rate of 109 beats per minute, and shallow respirations of 23 breaths per minute. The attending physician was notified and he ordered laboratory blood tests. At 2:35 p.m., Resident 1 received two tablets of crushed 325 milligrams (mg) of Tylenol for fever.
There was no documented evidence in the medical records of Resident 1?s health status and that the licensed nurses monitored Resident 1's neurological status and communicated to the physician any changes in Resident 1?s health status between the hours of 2:35 p.m. to 5:30 p.m. on 11/29/16.
A review of Resident 1's Physician Telephone Orders, dated 11/29/16 and timed at 5:30 p.m., indicated to send the resident to the emergency room for evaluation of change in level of consciousness.
A review of Resident 1's Licensed Nurses Progress Notes, dated 11/29/16 and timed at 6 p.m., indicated LVN 2 documented the facility sent Resident 1 to the emergency room for a change in his level of consciousness (a measurement of a person's arousability and responsiveness to stimuli from the environment). The vital signs during the time of transfer were 167/97 mm/hg (BP), 102.1 degrees Fahrenheit (body temperature), and 106 beats per minute (pulse rate).
A review of a facility's document titled, "Interview/Investigation Record," (no date) showed a handwritten documentation that indicated a licensed nurse notified Resident 1's responsible party (Fam 1) that the resident would be transferred to the acute hospital via 9-1-1 for evaluation of altered level of consciousness. The investigation record indicated that Fam 1 was present when the paramedics arrived at the facility and Fam 1 informed the paramedics that Resident 1 hit his head due to a recent fall.
A review of Resident 1's GACH records titled, "Emergency/Urgent Care," dated 11/29/16, indicated Resident 1 was seen at the emergency room at 6:08 p.m., with vital signs that included 160/90 mm/hg (BP), 106 beats per minute (heart rate), and 18 breaths per minute (respiratory rate). There was no temperature recorded. Resident 1's Computed Tomography ([CT] special x-ray tests that produce cross sectional images of the body) result taken from the acute hospital, on 11/29/16 and timed at 9:35 p.m., indicated that compared to Resident 1's previous CT examination taken and recorded on 11/23/16, there was a new area of hemorrhage in Resident 1's right occipital lobe. The hemorrhage measured 2.9 centimeters (cm) in width and 2.9 cm in length, and 1.9 cm in height.
A review of Resident 1's Discharge Summary from the GACH, dated 12/4/16, indicated that the neurologist recommended no surgical intervention. The summary indicated, "Resident 1 offered no meaningful recovery and was accepted to hospice." Resident 1 was discharged to home on hospice care on 12/4/16.
A review of Resident 1's hospice records, titled "Discharge Transfer Summary Report," dated 12/24/16 indicated that Resident 1 was admitted to hospice care with a diagnosis of debilitating (life limiting condition) CVA (cerebrovascular accident stroke).
A review of Resident 1's Certificate of Death, dated 12/24/16, indicated that the resident's immediate cause of death was end stage cerebrovascular accident. The resident died at his home.
During an interview on 8/4/17 at 9 a.m., the medical record supervisor (MRS 1) stated that Resident 1's "72 Hour Neuro Checks" sheets from 11/28/16 to 11/29/16 were missing from the resident's medical records, including the resident's Medication Administration Records (MAR) from 11/27/16 to 11/29/16.
During an interview on 8/4/17 at 1:25 p.m., LVN 1 stated he started conducting the neurological check on Resident 1 after his fall on 11/28/16 and he followed the frequency specified on the facility's form titled, ?72 Hour Neuro Checks.?
During a telephone interview on 8/4/17 at 2:35 p.m., Fam 1 stated that on 11/27/16, before Resident 1?s admission to the facility, she toured the facility with the admission coordinator (AC 1). Fam 1 stated she communicated to AC 1 about Resident 1's fall risk and need for one-on-one direct staff supervision. Fam 1 stated that on 11/28/16, around 5 p.m., she was getting ready to leave the facility and wanted to tell the staff not to leave Resident 1 alone in the wheelchair because he would fall. Fam 1 stated she left Resident 1 with a certified nursing assistant (unable to recall name) before she went to the nursing station.
During the telephone interview, Fam 1 stated she watched the video footage of the facility camera on 1/12/17, at around 12 p.m. with the Administrator and the video footage showed "How the people (facility staff) were just passing by him (Resident 1)."
A review of the facility document titled, "Marketing Communication Log," dated 11/27/16, indicated that Resident 1's ETA (estimated time of arrival to the facility) was at 4 p.m. on 11/27/16. The behavior, restraint, and comment portion of the Marketing Communication Log was blank. There was no documented evidence that the admissions coordinator (AC 1), prior to Resident 1's admission to the facility, had communicated to the licensed staff, Resident 1's behavior and need for one-on-one staff supervision as indicated in the acute hospital record.
During an interview on 8/4/17 at 9:50 a.m., AC 1 stated he could not remember talking to Fam 1 about Resident 1's fall risk and need for one-on-one direct staff supervision. AC 1 stated it was the previous director of nursing (DON 1) that reviewed the Resident 1?s medical records from the acute care hospital prior to the resident?s admission in the facility. AC 1 stated that it is the facility?s standard practice to know the fall risk of a resident prior to admission because they could not accept a resident that required a "sitter."
During an interview on 8/4/17 at 10:30 a.m., a registered nurse (RN) 2 stated that she could not
find documented evidence in Resident 1's medical records that a care plan for high risk for falls and the use of a tab alarm in bed and wheelchair was developed prior to Resident 1's fall incident on 11/28/16, at 5:10 p.m. RN 2 stated that the prevention protocol indicated in the Fall Risk Evaluation form included application of a tab alarm device, use of floor mats at bedside, and frequent monitoring. RN 2 stated she did not know if the facility had a documented "preventive protocol" for falls. There was no documented evidence that the facility developed a care plan to address Resident 1's high risk for falls upon admission to the facility and before the actual fall on 11/28/16.
During an interview on 8/4/17 at 1:25 p.m., LVN 1 stated that on 11/27/16, Fam 1 communicated to LVN 1 that Resident 1 needed a sitter (one on one staff supervision) because the resident had a sitter in the acute care hospital due to Resident 1 would try to get up, would not ask for assistance, and fall. LVN 1 stated he notified DON 1 of what Fam 1 had told him. LVN 1 stated DON 1 stated they would try to look for a sitter. LVN 1 stated he did not know what happened after he notified DON 1. There was no documented evidence that the facility had conducted an assessment of Resident 1's need for one-on-one staff supervision (sitter).
During a telephone interview, on 8/10/17, at 4:48 p.m., RN 1 stated that he remembered seeing Resident 1 that day (on 11/28/16) wheeling his wheelchair in the facility's hallway. RN 1 stated that prior to the resident?s fall, a facility staff (unable to recall whom) placed Resident 1 (on 11/28/16) in front of the nursing station to be monitored by facility staff. RN 1 was asked if he knew that Resident 1 was at high risk for falls. RN 1 stated, "Everybody here was at risk for falls. But Resident 1 was able to propel his own wheelchair."
A review of the facility's security video recording, on 8/9/17 at 10:45 a.m., in the presence of the facility's administrator, DON 2, Fam 1, AC 1, and medical records supervisor (MRS 1) showed a CNA (unidentified) wheeled Resident 1 in front of the nursing station. The CNA left the resident alone on 11/28/16 at 5:04 p.m. Fam 1 was observed facing the Nursing Station with her back facing Resident 1. Resident 1 was wearing socks and a pair of long pajamas with the hem extending to the middle part of the resident's foot. The video recording showed Resident 1 was independently propelling his wheelchair after being left alone in front of the nursing station. At 5:10 p.m., Resident 1 propelled his wheelchair in front of the laundry room, which was 34 feet from the nursing station; the resident stood up from the unlocked wheelchair and fell backwards. The facility's security video camera recording showed a jolt to Resident 1's head when his right shoulder landed on the floor, which prevented the head from hitting the floor.
During an interview on 8/9/17 at 11:50 a.m., LVN 1 stated that on 11/28/16, he left the facility at 11:30 p.m. and Resident 1 was still up in the wheelchair in front of the Nursing Station. LVN 1 stated Resident 1 was very restless that night. LVN 1 stated when he came back to the facility the next day, on 11/29/16 at 3 p.m., Resident 1 was lying in bed and very sleepy. During a concurrent review of Resident 1's medical records, LVN 1 stated that he checked the resident's blood pressure (BP) and the BP was high and the resident had a fever. LVN 1 stated he did not receive information from the previous licensed nurses regarding the result of Resident 1's neurological check for the first 24 hours. LVN 1 stated he did not pay attention whether the "72 Hour Neuro Checks" sheets were completed. LVN 1 stated that Resident 1's status was semi-arousable when the resident left the facility (transferred to the hospital) on 11/29/16. LVN 1 stated "he would just moan if I try to arouse the resident or to painful stimuli."
During an interview on 8/9/17 at 1 p.m., the administrator (ADM 2) stated that Resident 1's Medication Administration Records (MAR) and neurological checks sheets could not be found. ADM 2 stated that the records for the neurological checks was usually included with the MAR. ADM 2 stated that the medical records supervisor (MRS 1) already searched everywhere and could not find the records.
A review of an undated facility policy and procedure titled "Admissions," indicated "The admission coordinator would conduct preadmission interviews as appropriate with the representative of the facility from which the patient is being transferred, usually by telephone." The policy indicated that the director of nursing services or administrator would review the admission inquiries to ensure that the facility admits only those residents for whom it can provide adequate care.
A review of the facility policy and procedure titled "Fall Risk Assessment Identification and Reduction," dated 10/2014, indicated that the "Resident at risk for falls shall have a care plan that identifies the risk factors for that individual resident and appropriate interventions based on the individual risk factors. The facility nursing staff and/or the IDT shall update the residents' plan of care accordingly to reduce the risk of further occurrences of a fatal or related incident."
A review of an undated facility policy and procedure titled "Procedure: Evaluating Neurological Signs," indicated that the licensed staff should ascertain the resident's level of consciousness (LOC) according to the five levels such as:
Alert- Resident is able to initiate appropriate conversation.
Drowsy - Resident seemed oriented, but lethargic or "restless."
Stupor- Resident is less responsive and in a sleeplike state.
Semi-comatose - Resident responds only to painful stimuli.
Coma - Resident lacks any consciousness and cannot be aroused.
The "Procedure: Evaluating Neurological Signs," indicated that for evaluating neurological signs, the earliest warning changes were found in the degree of responsiveness.
A review of the undated facility policy and procedure titled "Change of Condition" indicated "All changes of condition in a resident shall be handled promptly." The policy indicated that upon notice of a change in condition for any reason, nursing staff members should call the physician promptly.
The facility failed to provide necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, and to ensure that its residents receive treatment and care in accordance with the facility?s policy and procedures, the comprehensive assessment, and plan of care to meet the needs of the residents, including but not limited to:
1. Failure to assess Resident 1 for need for one-on-one supervision.
2. Failure to provide Resident 1 with one-on-one supervision.
3. Failure to develop a plan of care to implement interventions to prevent falls.
4. Failure to perform and keep a record of the neurological checks for 72 hours as ordered by Resident 1?s physician, consisting of assessment of Resident 1?s blood pressure, temperature, pulse rate, respirations, level of consciousness, size and reaction of the right and left pupil, and the right and left hand grip.
5. Failure to promptly identify the changes in Resident 1?s neurological status.
6. Failure to notify Resident 1?s attending physician of the changes in the resident?s neurological status.
These deficient practices resulted in delayed intervention and Resident 1?s emergency transfer to a general acute care hospital due to a serious brain injury, 25 hours after the fall.
The above violations, jointly, separately, or in any combination, presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 940000051 |
AVALON VILLA CARE CENTER |
940013004 |
A |
1-Dec-17 |
3WCT11 |
12270 |
F325 ? 483.25 (g) Assisted nutrition and hydration
Based on a resident?s comprehensive assessment, the facility must ensure that a resident-
(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and possible electrolyte balance, unless the resident?s clinical condition demonstrates that this is not possible or resident?s preferences indicate otherwise
(2) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.
F361?483.35(a) Staffing
The facility must employ a qualified dietitian either full-time, part-time, or on a consultant basis.
?483.35(a)(2) A qualified dietitian is one who is qualified based upon either registration by the Commission on Dietetic Registration of the American Dietetic Association, or on the basis of education, training, or experience in identification of dietary needs, planning, and implementation of dietary programs.
Based on observation, interview, and record review the facility failed to ensure Resident 1, who lost more than 15 percent (%) of his total body weight within four months, weight and nutritional status were maintained by failing to:
1. Provide the necessary assessment and care for Resident 1?s nutritional needs to ensure they were maintained within the acceptable parameters.
2. Ensure the registered dietician (RD) accurately assessed and provided Resident 1 with foods of preference to encourage food intake.
3. Ensure that the RD was knowledgeable and implemented an adequate dietary program.
Resident 1 had an unplanned weight loss of 30 pounds from 4/2017 to 9/2017, had unplanned weight loss, and malnutrition (condition that results from eating a diet in which nutrients are either not enough or are too much such that the diet causes health problems).
A review of Resident 1's Admission Face Sheet indicated the resident was a 62 year-old male who was originally admitted to the facility on 4/5/17, and readmitted on 8/27/17. Resident 1's diagnoses included an opened wound to the scrotum (the skin sack that holds the testicles) and testes (male testicles), UTI, and gastric ulcer (an open sore in the stomach).
A review of Resident 1's care plan titled, "Nutritional Status manifested by leaving 25% or more of uneaten food on the plate for at most meals," dated 4/6/17. The staff's interventions included to offer a substitute when food was refused, monitor weight, report significant weight loss/gain to the physician, honor food preferences, and monitor food intake and record.
A review of Resident 1's History and Physical Examination (H/P), dated 4/7/17, indicated the resident had the capacity to understand and make decisions.
A review of Resident 1's monthly weights indicated the following:
April 2017 (on admission) - 153 pounds (lbs.)
May 2017- 148 lbs. (15 pounds weight loss).
June 2017- 147 lbs.
July 2017- 144 lbs.
August 2017- 136 lbs.
September 2017- 130 lbs. (total of 23 pounds weight loss in 6 months).
A review of the "Nutritional Screening and Data Collection" form, dated on 4/11/17, completed by the RD, indicated Resident 1 received a regular no added salt (NAS) diet, ate independently with a good appetite and had a skin condition. According to the RD's assessment, Resident 1 required 83-105 grams (gm) of protein and 2100-2450 calories (cal) per day. Resident 1's ideal body weight (IBW) was documented as 182-202-222 lbs.
A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 4/12/17, indicated Resident 1's cognition was moderately impaired and was independent with meal intake, with a weight of 153 pounds.
A review of the Licensed Nurses' documentations, dated 5/11/17 to 5/14/17, and 5/21/17, indicated Resident 1 was being monitored for a five pound weight loss and meal consumption of 30 %.
A review of Resident 1's "Nutritional Screening and Data Collection" forms completed by the RD indicated the following:
On 5/16/17, who had a five pound weight loss, possibly due to an infection and the plan included to provide a fortified (increase the nutritive value of (food), especially with vitamins) NAS diet and do weekly weights for four weeks.
a. On 5/30/17, weighed 147 lbs., with a three pound weight loss, 'possibly due to an infection.' The plan was the resident to receive a four ounce (oz.) high performance nutrition (HPN) supplement.
b. On 6/13/17, weighed 144 lbs., had three more pounds weight loss, possibly due to UTI, continue with current supplement.
c. On 6/27/17, weighed 143 lbs., had another pound weight loss, continue with current supplement.
d. On 7/7/17, weighed 144 lbs., had a one pound weight gain, continue with weekly weights.
e. On 7/18/17, weighed 138 lbs., had a six pound weight loss, continue with current supplement and Boost VHC ([Very high calorie] complete nutritional drink) twice daily, remain at nutritional risk, low body weight and low body mass index.
A review of the Nursing Assistant Daily Flow sheets, dated 6/1/17 to 9/1/17, Resident 1's meal substitution for breakfast and lunch indicate "not applicable."
A review of Resident 1's physician orders, dated 6/27/17, indicated to weigh the resident weekly on the day shift, every Monday for four weeks.
A review of Resident 1's MDS, dated 7/12/17, indicated the resident's weight was 144 pounds and was not on a regimen for weight loss.
A review of Resident 1's weight variance, dated 7/18/17, indicated the resident did not have skin issues and a supplement for boost VHC twice daily was recommended.
A review of Resident 1's weight variance dated 8/1/17, indicated the resident's meal intake was 35 %.
A review of the Nursing Assistant Daily Flow sheet indicated Resident 1's breakfast and lunch meal consumption was less than 50% on the following days: 8/1/17 to 8/4/17, 8/8/17 to 8/13/17, 8/19/17 and 8/20/17.
A review of a nurses' progress note, dated 8/1/17 and timed at 1:56 p.m., indicated the physician was notified of Resident 1 not eating well.
A review of Resident 1's albumin (most common protein found in the blood; used by the body for growth and tissue repair; a good marker for malnutrition in the physically impaired elderly) laboratory results, dated 8/2/17, indicated it was low at of 2.8 grams/deciliter (gm/dL) (normal reference range [NRR] is 3.4 g/dL to 5.4 g/dL).
A review of Resident 1's weight variance, dated 8/8/17, indicated the resident's meal intake was 40 %.
A review of the physician's orders, dated 8/15/17, indicated an order to administer Remeron (an antidepressant used to treat major depressive disorder) 7.5 milligrams (mg) to Resident 1 by mouth at bedtime for poor appetite.
A review of the Nurses' note, dated 8/15/17, and timed at 12:30 p.m., indicated the physician was aware of Resident 1's poor appetite, with a plan for the staff to monitor the resident's poor appetite by percentage of each meal, if less than 75 % with meals for poor appetite.
A review of the RD's progress note, dated 8/16/17, and timed at 8:53 a.m., indicated the physician was made aware and agreed with the RD's recommendations for Prostate (liquid protein) 30 milliliters (mL) to be given to Resident 1 and the RD would continue to monitor the resident.
On 9/8/17 at 12:13 p.m., during an interview, the RD stated there were no residents in the facility that had significant weight loss or were at risk for weight loss. The RD stated when residents are at risk for weight loss, a dietary assessment was completed and the resident was enrolled in weight variance for four weeks. The RD stated weight variance committee meets, which was similar to that of an interdisciplinary team (IDT) meeting (develop plan of care that meets the patient needs and goals). The RD stated if the resident continued to lose weight then
additional interventions would be implemented. The RD stated she reviews residents' monthly weights to determine if there are any significant weight loss. When the RD was asked for a log/list of residents currently at risk for weight loss, the RD stated that she did not have a log or a list, but stated the progress notes were a form of tracking the resident's monthly weights.
On 9/8/17 at 1:30 p.m., during a concurrent interview and record review with the RD, the facility's Weight Summary Report, dated for the week ending on 8/11/17, the RD was asked again how many residents in the facility had a significant weight loss. The RD stated that she did not know, "Maybe a few and I visit three different facilities." The RD was observed calculating weights on a "cheat sheet" and stated, "There are only two residents in the facility with a significant weight loss for the month of July (2017), but I am not sure."
At 2 p.m., on 9/8/17, during a concurrent observation and interview, Resident 1 was fully clothed, lying in bed awake, alert, and oriented to person, place and time. Resident 1 stated he was able to feed himself and the facility's food taste was satisfactory, but stated fried chicken was his favorite dish.
During an interview on 9/8/17 at 2:30 p.m., Certified Nursing Assistant 1 (CNA 1) stated Resident 1 had been assigned to her for the past five months. CNA1 stated on some days, depending upon what was served, Resident 1 would consume 20 to 30 % of his meals. CNA1 stated when chicken or fish was served Resident 1 would consume 100 percent of his meals.
On 9/8/17 at 4 p.m., during an interview, the RD was asked if Resident 1 had any food preferences, the RD stated Resident 1 ate everything and did not have any food preferences nor a food substitution card. The RD stated she was informed by the nursing staff that Resident 1 would not eat based on his mood.
During an interview on 9/8/17 at 4:10 p.m., the RD was asked if Resident 1 was provided with adequate fortification, such as increased calories and protein to maintain weight, RD was unable to provide a reason for the resident's weight loss.
A review of the facility's undated policy titled, "Weight" indicated when weight gain or loss of five pounds or more, the resident must be re-weighed in the presence of the Licensed Nurse to supervise. The residents must be re-weighed by the Licensed Nurse and the CNA together if the clinical data prompts the Consultant to consider a formula change that results in less than 1200 calories a
day. The re-weigh must be done before the Consultant Dietician finalizes the recommendation.
A facility's policy titled, "Nutrition (Impaired) Unplanned Weight Loss," dated 9/2012, indicated the Dietician will estimate calorie, nutrient and fluid needs and with the Physician; will identify whether the resident's current intake was adequate to meet his or her nutritional needs. The staff will also evaluate the care plan to determine if the interventions are being implemented and whether they are effective in attaining the established nutritional and weight goals.
The facility failed to ensure that Resident 1 as provided the, who lost more than 15 percent (%) of his total body weight within four months by failing to:
1. Ensure and provide the necessary assessment and care of the resident nutritional needs were maintained with the acceptable parameters.
2. Failed to accurately assess the resident?s needs and food preferences to encourage food intake.
Based on observation, interview, and record review the facility failed to ensure Resident 1, who lost more than 15 percent (%) of his total body weight within four months, weight and nutritional status were maintained by failing to:
1. Provide the necessary assessment and care for Resident 1?s nutritional needs to ensure they were maintained within the acceptable parameters.
2. Ensure the registered dietician (RD) accurately assessed and provided Resident 1 with foods of preference to encourage food intake.
3. Ensure that the RD was knowledgeable and implemented an adequate dietary program.
The above violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical or mental harm would result. |
| 940000051 |
AVALON VILLA CARE CENTER |
940013478 |
B |
22-Sep-17 |
C7CI11 |
7379 |
42 CFR ? 483.24 Quality of life
Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident?s comprehensive assessment and plan of care.
? 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents? choices, including but not limited to the following:
?483.25(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences.
?483.25(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences.
Based on interview and record review, the facility failed to ensure safety of a resident in an area frequented and commonly used by residents by failing to:
1. Ensure the certified nursing assistants, CNA 2 and 3, did not have a physical altercation in the residents? dining area that caused a fall and injury to Resident 3.
Resident 3's wheelchair tipped over to the right when a certified nursing assistant (CNA 3) fell on the resident's right arm that was resting on top of the wheelchair's tire during a physical altercation with CNA 2.
This deficient practice resulted in Resident 3 experiencing swelling and severe pain on his right arm and right foot, and soreness on his right shoulder and had the potential to result in a right arm fracture. The resident received three doses of narcotic pain medication (Norco) to relieve his pain for two days and had an order for a warm soak on his right arm every shift for 5 days.
During an interview, on 7/3/17 at 1:40 p.m., Resident 3 stated while he was in the "Little Lunch Room" on 5/13/17 at 11 a.m., he heard CNA 2 and 3 having a verbal altercation. Resident 3 stated he was wheeling his wheelchair towards the "Little Lunch Room" when both CNAs started fighting. Resident 3 stated he was behind CNA 3 when CNA 2 hit CNA 3. Resident 3 stated CNA 3 fell on his (Resident 3's) right arm that was resting on the wheelchair's tire and then the wheelchair tipped over to the right. Resident 3 stated CNA 3's body and the wheelchair's tire were pressed against his right arm when the wheelchair tipped over to the right.
During the interview, Resident 3 stated he had an x-ray (an image of the structure inside the body) done to his right arm and he received medications for his pain. Resident 3 stated his right arm was swollen a few hours after the fall and that currently, he felt like the strength and range of motion (the full movement of a joint) of his right arm was not the same anymore. Resident 3 stated the two CNAs should have acted more professionally while at work because there were other residents present that could have been affected or could get hurt.
During an interview, on 7/3/17, at 9:55 a.m., the licensed vocational nurse (LVN 1) stated that according to the Licensed Nurse Documentation, dated 5/13/17 (no time indicated), Resident 3 was given a pain medication (Norco) after complaining of a pain level of 6 out of 10 (severe pain is between pain level 6 to 9 out of 10 and 10 out of 10 being the excruciating pain) and swelling to his right arm.
On 7/3/17, at 3:30 p.m., during an interview and concurrent review of Resident 3's Joint Mobility Screening, dated 5/17/17, the physical therapist (PT 1) stated that on 5/17/17, which was four days after the incident, he assessed Resident 3's range of motion to both upper and lower extremities. PT 1 stated Resident 3 had full range of motion to the right arm and right foot.
A review of Resident 3's Face Sheet (Admission Record) indicated that Resident 3 was a 55 year-old male, who was admitted to the facility on 10/27/15 and was re-admitted on 11/10/16 with diagnoses that included anemia (deficiency of red blood cells in the blood), diabetes mellitus (a condition that occurs when the body cannot use glucose [a type of sugar] normally), and major depressive disorder (a mental disorder characterized by low mood).
A review of Resident 3's Minimum Data Set (MDS, a resident assessment and care screening tool), dated 5/17/17, indicated that Resident 3's cognition (refers to mental ability) was intact and the resident had no communication impairments. The MDS indicated Resident 3 used the wheelchair for mobility.
A review of Resident 3's Licensed Nurse Documentation, dated 5/13/17 and timed at 11 a.m., indicated that CNA 3 reported to the charge nurse how CNA 3 fell on top of Resident 3 during a "Fight with another CNA." Resident 3 reported to the charge nurse how he was tipped or pushed down while on the wheelchair by CNA 3 while fighting with CNA 2.
A review of Resident 3's Telephone Order Summary, dated 5/13/17 and timed at 10:41 p.m., indicated an order to apply a warm soak on Resident 3's right arm every shift for 5 days.
A review of Resident 3's Pain Assessment Flowsheet for May 2017 indicated that Resident 3 received one tablet of Norco (pain medication) 5-325 milligrams (mg) on 5/13/17 timed at 10:45 a.m. for his right foot pain with a pain level of 6 out of 10 (severe pain is between 6 to 9 out of 10, and 10 being the excruciating pain) and another dose of Norco for his right elbow pain timed at 3 p.m., with a pain level of 8 out of 10. Resident 3 received another dose of Norco tablet 5-325 mg the next day (5/14/17) timed at 10 a.m., for his right elbow pain with pain level of 7 out of 10.
A review of Resident 3's Social Services Notes, dated 5/15/17, 5/16/17, and 5/17/17, indicated that Resident 3's right shoulder was still feeling sore because of the fall.
A review of CNA 2 and CNA 3's employee records and a document titled Employee Separation Report, dated 5/22/17, indicated that CNA 2 and 3 were terminated on 5/22/17 due to their verbal and physical altercation while on duty with each other in the residents' dining area causing a resident to fall on the floor.
A review of the facility's "Employee Handbook," revised on 8/5/09, indicated under "Employees Conduct and Work Rules" that the facility expects employees to follow rules of conduct that will protect interests and safety of all employees and the organization. These rules of conduct included discourteous treatment, inappropriate behavior toward residents, misconduct on or off duty, and acts of physical violence, which occur on facility property.
The facility failed to ensure safety of a resident in an area frequented and commonly used by residents by failing to:
1. Ensure the certified nursing assistants, CNA 2 and 3, did not have a physical altercation in the residents? dining area that caused a fall and injury to Resident 3.
The above violation had a direct or immediate relationship to the health, safety, or security to Resident 3. |
| 940000051 |
AVALON VILLA CARE CENTER |
940013564 |
A |
27-Oct-17 |
XKTW11 |
15478 |
42 CFR ? 483.24(a)(3)
(a) Based on the comprehensive assessment of a resident and consistent with the resident?s needs and choices, the facility must provide the necessary care and services to ensure that a resident?s abilities in activities of daily living do not diminish unless circumstances of the individual?s clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that:
(3)Personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident?s advance directives.
42 CFR ? 483.24 Quality of life
Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident?s comprehensive assessment and plan of care.
42 CFR ? 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents? choices, including but not limited to the following:
Based on interview and record review, the facility failed to provide necessary care and services to its residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being, to ensure that its residents receive treatment and care in accordance with professional standards of practice, facility policy and procedures, and the comprehensive assessment and plan of care to meet the needs of the residents, and to ensure that facility personnel provide basic life support to residents requiring such emergency care prior to the arrival of emergency medical personnel, including but not limited to:
1. Failure to promptly identify Resident 1's emergency, when he was found unresponsive and with no pulse (the rhythmic expansion and contraction of the arteries as blood is pumped through them by the heart) on 4/30/17.
2. Failure to implement immediate basic life support (BLS), including cardiopulmonary resuscitation (CPR, an emergency procedure performed during the absence of heart beat and breathing in which chest compression and artificial breathing are used to maintain blood circulation to the brain) when Resident 1 was observed unresponsive and with no pulse.
3. Failure to ensure the licensed nursing staff checked the carotid pulse (found at the side of the neck) when performing a pulse check on an unresponsive resident, Resident 1.
A certified nursing assistant (CNA 1) found Resident 1 unresponsive and pulseless on 4/30/17 at 8:40 a.m. CNA 1, LVN 1, and RN 1 did not start CPR immediately, but instead left Resident 1's room to call the 9-1-1 emergency services and to get the crash cart (a set of shelves on wheels containing emergency medication and equipment). Before leaving Resident 1?s room, RN 1 checked for the resident?s radial pulse (found in the wrist area). RN 1 returned to the resident?s room and started CPR on Resident 1 at 8:50 a.m., 10 minutes after CNA 1 found the resident unresponsive and pulseless at 8:40 a.m.
These deficient practices caused delayed provision of appropriate medical interventions for Resident 1, a delay that resulted in Resident 1's death. The emergency services (9-1-1) pronounced Resident 1 dead in the facility on 4/30/17 at 9:08 a.m.
A review of Resident 1's record titled, "Admission Record," indicated Resident 1 was a 63 year-old male, who was admitted to the facility on 7/22/10, and was readmitted on 4/10/17. The Admission Record indicated Resident 1's diagnoses included nausea (sensation of unease and discomfort in the upper stomach), vomiting, paraplegia (paralysis [the loss of the ability to move] of the lower part of the body, including the legs), and dysphagia (difficulty in swallowing).
A review of Resident 1's record titled, "Physician Orders for Life -Sustaining Treatment (POLST, a physician order form that informs care providers what kind of life sustaining treatment an individual resident and/or his responsible party does (or does not) want during a medical emergency)," dated 5/27/16, indicated to attempt resuscitation/CPR and to provide full treatment including intubation (insertion of a tube through the mouth down into the windpipe for air to pass freely to and from the lungs) and defibrillation/cardioversion (administering a controlled electric shock in order to allow restoration of the normal rhythm of the heart) as indicated. The POLST indicated to transfer Resident 1 to the hospital if indicated.
A review of Resident 1?s care plan titled ?Tube feedings,? initiated on 12/28/16 and re-evaluated on April 2017, indicated the resident had dysphagia (difficulty swallowing) and a gastrostomy tube (a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications). One of the interventions was to provide the feeding as ordered.
A review of Resident 1's record titled, "Minimum Data Set (MDS, a resident assessment and care screening tool), dated 3/30/17, indicated Resident 1 was severely impaired in cognitive skills (the ability to think and reason) for daily decision making and was totally dependent on staff with activities of daily living.
A review of Resident 1's record titled, "Initial History and Physical," dated 4/12/17, indicated Resident 1 did not have the capacity to understand and make decisions.
A review of the facility?s policy and procedure titled, ?Emergency Procedure ? Cardiopulmonary Resuscitation,? revised on March 2015, indicated ?The facility?s procedure for administering CPR shall incorporate the steps covered in the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care of facility BLS (basic life support) training material.?
According to the 2010 American Heart Association, BLS for Healthcare Providers, high-quality CPR improves a victim?s changes of survival. The critical characteristics of high-quality CPR include:
a. Start compressions within 10 seconds of recognition of cardiac arrest.
b. Push hard, push fast: Compress at a rate of at least 100 per minute with a depth of at least 2 inches (5 centimeters) for adults.
c. Allow complete chest recoil after each compression.
d. Minimize interruptions in compressions (try to limit interruptions to less than 10 seconds).
e. Give effective breaths that make the chest rise.
f. Avoid excessive ventilation.
The 2010 American Heart Association, BLS for Healthcare Providers indicated that although basic life support is taught as a sequence of distinct steps to enhance skills retention and clarify priorities, several actions should be accomplished simultaneously (for example, begin CPR and activate emergency response system) when multiple rescuers are present. Step 1 of the BLS steps indicated the first rescuer who arrives at the side of the victim must quickly be sure that the scene is safe. The rescuer should then check the victim for a response. Check to see if the victim is breathing, if a victim is not breathing or not breathing normally (gasping), the rescuer much activate the emergency response. Step 2 of the BLS steps indicated if the rescuer is alone and find an unresponsive victim not breathing, shout for help. Step 3 of the BLS steps indicated to perform a pulse check in the adult, palpate a carotid pulse. If the rescuer does not definitely feel a pulse within 10 seconds, start chest compressions.
During an interview on 5/6/17 at 9:49 a.m., CNA 1 stated that on 4/30/17 at 7:10 a.m., Resident 1 looked "pale," and was "cold to the touch," and CNA 1 stated she informed LVN 1. CNA 1 stated that on 4/30/17 at 8:40 a.m., Resident 1 vomited "a lot of brown fluid" from his mouth, and that Resident 1 became unresponsive and had no pulse. CNA 1 stated she did not perform CPR; she left the room to look for LVN 1. CNA 1 stated LVN 1 went inside Resident 1's room; LVN 1 did not start CPR. CNA 1 stated LVN 1 left Resident 1's room to call for help.
During an interview on 5/6/17 at 10:45 a.m., LVN 1 stated he was assigned to care for Resident 1 on 4/30/17. LVN 1 stated that on 4/30/17 at 7:30 a.m., CNA 1 informed him that Resident 1 vomited and he (LVN 1) went to check Resident 1. LVN 1 stated he observed Resident 1 "drooling" and Resident 1's stomach was "bloated." LVN 1 stated he did not conduct a comprehensive assessment and inform Physician 1 and the registered nurse. LVN 1 stated he assumed that "drooling" and a distended abdomen were not considered changes of condition.
During an interview on 5/6/17 at 11:30 a.m., LVN 1 stated that CNA 1 informed him on 4/30/17, a little after 8:30 a.m., that Resident 1 "did not look good." LVN 1 stated he went inside Resident 1's room and observed Resident 1 "pale" and he could not feel the resident?s pulse. LVN 1 stated he did not start CPR immediately; he stepped out of Resident 1's room to call 9-1-1 and he went to get the facility's crash cart (wheeled container carrying equipment for use in emergency resuscitations). LVN 1 stated he should have initiated CPR and that CNA 1 should have called for help.
During a telephone interview on 9/5/17 at 9:40 a.m., RN 1 stated that LVN 1 went to the nursing station (middle nursing station) to inform her that Resident 1 was unresponsive and that she (RN 1) then went to Resident 1's room and checked Resident 1's radial pulse (found at the wrist area). RN 1 stated that she did not feel a radial pulse and that she (RN 1) did not start CPR immediately and that instead, she (RN 1) left the room to get Resident 1's medical records to check if Resident 1 was full code (to perform CPR) or DNR (do not resuscitate, no CPR) and to get the crash cart. RN 1 stated that she should have checked the carotid pulse (neck area) instead of the radial pulse and that she (RN 1) should have started CPR immediately.
A review of Resident 1's record titled, "Licensed Nurse Documentation," indicated that on 4/30/17, at 8:50 a.m., Registered Nurse 1 (RN 1) was called to look at Resident 1 being unresponsive. CPR was started.
During an interview on 6/29/17 at 1:52 p.m., the Assistant Administrator (ASSADM) stated he arrived at the facility on 4/30/17 between 8:30 a.m. and 9 a.m. and once he entered the facility's building, he saw the commotion in Resident 1's room. The Assistant Administrator stated he observed RN 1 giving CPR to Resident 1 and then he assisted RN 1 with chest compressions (an effort to pump the blood in the heart to the rest of the body). The assistant administrator stated he stepped out of the room after the paramedics/fire fighters arrived in the resident?s room.
A review of Resident 1's record titled, "SBAR (Situation ? Background ? Assessment - Recommendation, a framework for communication between members of the health care team) Change of Condition Documentation," dated 4/30/17, at 8:50 a.m., indicated LVN 1 wrote that Resident 1 was lethargic (abnormal drowsiness) and unresponsive, and he was unable to obtain the resident?s vital signs (heart rate, body temperature, respiration rate, and blood pressure [a measurement of the strength of the blood pushing against the sides of the blood vessels]). The SBAR indicated LVN 1 informed the supervisor (RN 1) regarding the resident?s condition and a code blue (an emergency code) was called. CPR was initiated on Resident 1. At 8:55 a.m., 9-1-1 emergency services arrived at the facility. At 9:08 a.m., the 9-1-1 emergency services personnel pronounced Resident 1 dead.
A review of a document titled, "Prehospital Care Report Summary (by the 9-1-1 emergency services)," dated 4/30/17, indicated a call was received from the facility at 8:45 a.m., the paramedics/fire fighters were on scene at 8:55 a.m., and patient contact was at 8:56 a.m. The Prehospital Care Report Summary indicated Resident 1 was found in asystole (there was no electrical activity from the heart, showing flat line in the heart monitor); had no blood pressure, no pulse rate (heart beat), no respirations; and that Resident 1 had no change in asystole at 9:08 a.m. The paramedics/fire fighters left the scene (the facility) at 9:10 a.m.
During a telephone interview on 9/13/17 at 4:42 p.m., the fire fighter (the 9-1-1 emergency services personnel) stated that he took over the CPR on Resident 1 immediately upon arrival at the facility and that he did not remember anything else.
During a telephone interview on 7/7/17 at 8 a.m., the Medical Director (Physician 2) stated that if a resident was full code (as indicated in the POLST) and found unresponsive and with no pulse, the nurses should start CPR and call 9-1-1.
A review of Resident 1's death certificate indicated the resident died on 4/30/17 and the immediate cause of death was cardiopulmonary arrest (the heart and lungs suddenly stopped functioning).
During an interview on 6/29/17 at 10:55 a.m., the Director of Staff Development (DSD) stated the facility did not have any records indicating the licensed nurses received skills validations or any documents indicating the licensed nurses were monitored to ensure that they were competent with their job description and responsibilities. The DSD stated she was not sure if the facility's licensed nurses were competent to perform nursing duties.
The facility failed to provide necessary care and services to its residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being, to ensure that its residents receive treatment and care in accordance with professional standards of practice, facility policy and procedures, and the comprehensive assessment and plan of care to meet the needs of the residents, and to ensure that facility personnel provide basic life support to residents requiring such emergency care prior to the arrival of emergency medical personnel, including but not limited to:
1. Failure to promptly identify Resident 1's emergency, when he was found unresponsive and with no pulse (the rhythmic expansion and contraction of the arteries as blood is pumped through them by the heart) on 4/30/17.
2. Failure to implement immediate basic life support (BLS), including cardiopulmonary resuscitation (CPR, an emergency procedure performed during the absence of heart beat and breathing in which chest compression and artificial breathing are used to maintain blood circulation to the brain) when Resident 1 was observed unresponsive and with no pulse.
3. Failure to ensure the licensed nursing staff checked the carotid pulse (found at the side of the neck) when performing a pulse check on an unresponsive resident, Resident 1.
These deficient practices caused delayed provision of appropriate medical interventions for Resident 1, a delay that resulted in Resident 1's death on 4/30/17.
The above violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 940000051 |
AVALON VILLA CARE CENTER |
940013562 |
A |
27-Oct-17 |
XKTW11 |
23218 |
42 CFR ?483.10(g)(14) Notification of Changes
(i) A facility must immediately inform the resident; consult with the resident?s physician; and notify, consistent with his or her authority, the resident representative(s) when there is?
(A)An accident involving the resident, which results in injury and has the potential for requiring physician intervention;
(B)A significant change in the resident?s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C)A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D)A decision to transfer or discharge the resident from the facility as specified in ?483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in ?483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is?
(A)A change in room or roommate assignment as specified in ?483.10(e)(6);
or
(B)A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s).
42 CFR ?483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must?
(i) Meet professional standards of quality.
(ii) Be provided by qualified persons in accordance with each resident?s written plan of care.
(iii) Be culturally-competent and trauma-informed.
42 CFR ? 483.24 Quality of life
Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident?s comprehensive assessment and plan of care.
42 CFR ? 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents? choices, including but not limited to the following:
42 CFR ? 483.25(g)(5) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids.) Based on a resident?s comprehensive assessment, the facility must ensure that a resident?
(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complication of enteral feeding including but not limited to aspiration, pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharangeal ulcers.
42 CFR ?483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in ?483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.
(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.
(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-
1) Provides consultation on all aspects of the provision of pharmacy services in the facility.
42 CFR ?483.70(i) Medical records.
(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are?
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized
(5) The medical record must contain?
(i) Sufficient information to identify the resident;
(ii) A record of the resident?s assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician?s, nurse?s, and other licensed professional?s progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under
?483.50.
Title 22 ?72313 Nursing Services ? Administration of Medications and Treatments
(a) Medications and treatment shall be administered as follows:
(1) No medications or treatment shall be administered except on the order of a person lawfully authorized to give such order.
Resident 1 was a 63-year-old man with dysphagia (difficulty swallowing) who was fed through a gastrostomy tube (a tube placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications). He was severely impaired in cognitive skills (the ability to think and reason) for daily decision making and was totally dependent on staff with activities of daily living.
Based on interview and record review, the facility failed to provide necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, and to ensure that its residents receive treatment and care in accordance with professional standards of practice, facility?s policy and procedures, and the comprehensive assessment and plan of care to meet the needs of the residents, including but not limited to:
1. Failure to conduct a comprehensive assessment when Resident 1 had a change of condition.
2. Failure to notify and consult Resident 1?s attending physician (Physician 1) about the resident?s vomiting and distended abdomen (a change of condition).
3. Failure to obtain a physician order to administer an enema (the insertion of a tube into the rectum to infuse a liquid mixture and encourage a bowel movement) to relieve Resident 1?s fecal impaction (a mass of dry, hard stool that will not pass out of the colon or rectum).
4. Failure to communicate with Licensed Vocational Nurse 3 (LVN 3) of the incoming shift that Resident 1 was vomiting, had a distended abdomen, and the reason for turning off his enteral feeding machine (a medical device that pumps nutrition liquid formula to the stomach through a tube).
5. Failure to document in Resident 1?s medical record the date, time, and reason that LVN 1 stopped the resident?s tube feeding and that LVN 2 conducted a digital (finger) rectal exam to check for fecal impaction and administered an enema.
Resident 1 exhibited a change of condition by vomiting and having a distended abdomen starting on 4/29/17 at 7 a.m. up to 4/30/17 at 8:40 a.m. A licensed vocational nurse (LVN 1) stopped the tube feeding and LVN 2 checked for fecal impaction by digital exam as nursing interventions, and LVN 2 administered an enema without a physician order. The night shift (11 p.m. to 7 a.m.) licensed charge nurse, LVN 3, restarted Resident 1?s tube feeding at the beginning of her shift because she did not receive a report that Resident 1 had a change of condition but stopped the tube feeding again on 4/30/17 at 4 a.m. when the resident vomited. LVN 1, 2, and 3 and a registered nurse (RN 1) did not conduct a comprehensive assessment when the resident was vomiting and having a distended abdomen, and notify the resident's physician of the resident's change of condition. There was no documentation in Resident 1?s medical record that his tube feeding was stopped. The Medication Administration Record (MAR) indicated the licensed nurses for all three shifts on 4/29/17 and 4/30/17 administered Resident 1 his tube feeding.
These deficient practices caused delayed provision of appropriate medical interventions for Resident 1 for 25 hours that resulted in Resident 1's death. The emergency services (9-1-1) pronounced Resident 1 dead in the facility on 4/30/17 at 9:08 a.m.
A review of Resident 1's record titled, "Admission Record," indicated Resident 1 was a 63 year-old male, who was admitted to the facility on 7/22/10, and was readmitted on 4/10/17. The Admission Record indicated Resident 1's diagnoses included nausea (unpleasant sensation in the stomach), vomiting, paraplegia (paralysis [the loss of the ability to move] of the lower part of the body, including the legs), and dysphagia (difficulty in swallowing).
A review of Resident 1's record titled, "Physician Orders for Life -Sustaining Treatment (POLST, a physician order form that informs care providers what kind of life sustaining treatment an individual resident and/or his responsible party does (or does not) want during a medical emergency)," dated 5/27/16, indicated to attempt resuscitation/CPR and to provide full treatment including intubation (insertion of a tube through the mouth down into the windpipe for air to pass freely to and from the lungs) and defibrillation/cardioversion (administering a controlled electric shock in order to allow restoration of the normal rhythm of the heart) as indicated. The POLST indicated to transfer Resident 1 to the hospital if indicated.
A review of Resident 1?s care plan titled ?Tube feedings,? initiated on 12/28/16 and re-evaluated on April 2017, indicated the resident had dysphagia (difficulty swallowing) and a gastrostomy feeding tube. One of the interventions was to provide the feeding as ordered.
A review of Resident 1's record titled, "Minimum Data Set (MDS, a resident assessment and care screening tool), dated 3/30/17, indicated Resident 1 was severely impaired in cognitive skills (the ability to think and reason) for daily decision making and was totally dependent on staff with activities of daily living.
A review of Resident 1's record titled, "Initial History and Physical," dated 4/12/17, indicated Resident 1 did not have the capacity to understand and make decisions.
A review of Resident 1's record titled, "Order Summary Report," indicated a physician's order on 4/15/17, for Resident 1 to receive enteral feedings (feedings given directly into the stomach through a tube) of Diabetic Source (a nutritional formula) at the speed of 75 milliliters (ml) per hour, starting feeding at noon and stop at 8 a.m. or until dose is complete.
A review of Resident 1?s MAR indicated the initials of the licensed nurses for all three shifts: day shift (7 a.m. to 3 p.m.), evening shift (3 p.m. to 11 p.m.), night shift (11 p.m. to 7 a.m.) on 4/29/17 and 4/30/17 indicating Resident 1 received his tube feeding. There was no documentation in Resident 1?s medical record that the resident did not receive his tube feeding from 4/29/17 at noon up to 4/29/17 at 11 p.m. and from 4/30/17 starting at 4 a.m.
A review of CNA 3's signed "Declaration," dated 6/29/17, at 1:47 p.m., indicated that on 4/29/17, she told a licensed vocational nurse (LVN 1) that Resident 1 was vomiting and that Resident 1 looked a little yellow. CNA 3 wrote in the Declaration that LVN 1 turned Resident 1's feeding machine off because Resident 1 was vomiting and he did not look like himself. CNA 3 wrote that LVN 2 gave Resident 1 an enema.
During an interview on 5/6/17 at 10:36 a.m., CNA 3 stated that on 4/29/17 at 7:15 a.m., she observed LVN 2 administering an enema to Resident 1. CNA 3 stated Resident 1 vomited three times during her shift (7 a.m. to 3 p.m.) on 4/29/17. CNA 3 stated she notified LVN 1 on 4/29/17 that Resident 1 "did not look good and was pale."
During an interview on 5/6/17 at 10:45 a.m., LVN 1 stated he was assigned to care for Resident 1 on 4/29/17, during the day shift (7 a.m. to 3 p.m.). LVN 1 stated that LVN 2 informed him that she (LVN 2) administered an enema to Resident 1 because Resident 1's abdomen was distended and had fecal impaction. LVN 1 stated he did not consider vomiting and having a distended abdomen a change of condition. LVN 1 stated he did not conduct a comprehensive assessment on Resident 1 and that he did not inform Physician 1.
During an interview on 5/6/17 at 11:07 a.m., LVN 2 stated that on 4/29/17 at 7 a.m., she observed Resident 1 vomiting and had a distended abdomen. LVN 2 stated she checked Resident 1 for fecal impaction using her finger, and then she administered a saline enema. LVN 2 stated she informed LVN 1 but she did not inform Physician 1. LVN 2 stated she should have called Physician 1.
A review of LVN 2?s ?Declaration,? dated 6/29/17, indicated LVN 2 checked Resident 1 for fecal impaction and then gave him an enema. LVN 2 wrote that two hours after the enema, Resident 1 had a bowel movement. There was no documentation in Resident 1?s medical record that the resident had a digital exam and received an enema.
During an interview on 5/6/17 at 11:44 a.m., the Assistant Director of Nursing (ADON) stated the licensed nurses were supposed to auscultate (listen to sounds) Resident 1's abdomen using a stethoscope (a medical instrument used for listening to sounds inside the body) when they first noticed that Resident 1's abdomen was distended.
During a telephone interview on 5/8/17 at 2:19 p.m., Director of Nursing 1 (DON 1) stated licensed nurses were supposed to conduct a comprehensive assessment when a resident exhibited a change of condition. DON 1 stated that vomiting and a distended abdomen were considered changes of condition for Resident 1 even though Resident 1 had a diagnosis of vomiting. DON 1 stated the licensed nurses were supposed to notify Physician 1 regarding Resident 1?s change of condition.
During a telephone interview on 5/26/17 at 1:39 p.m., LVN 3, the night shift (11 p.m. to 7 a.m.) licensed nurse, stated that on 4/29/17 at 11:30 p.m., she observed Resident 1's feeding machine turned off so she turned the feeding machine back on. LVN 3 stated that the she did not receive a report from the outgoing evening shift (3 p.m. to 11 p.m.) licensed nurse that Resident 1 was vomiting, and she did not ask why the resident's feeding machine was turned off so she assumed that she had to turn the machine back on. LVN 3 stated she turned off the feeding machine at 4 a.m. (on 4/30/17) because Resident 1 vomited. LVN 3 stated she did not conduct a comprehensive assessment on Resident 1 and she did not notify Physician 1.
During a telephone interview on 5/26/17 at 2:35 p.m., CNA 4 stated that during his shift (11 p.m. to 7 a.m.) on 4/29/17, he observed Resident 1 with a "hard stomach," and that it was unusual for Resident 1's stomach to be hard. CNA 4 stated he notified, during his shift, the night shift's registered nurse supervisor (RN 1).
During a telephone interview on 5/26/17 at 2:46 p.m., RN 1 stated that on 4/29/17 (RN 1 did not mention the time), CNA 4 notified her that Resident 1 vomited. RN 1 stated she went inside Resident 1's room and observed Resident 1 with a distended abdomen. RN 1 stated she observed Resident 1 vomiting. RN 1 stated she did not conduct a comprehensive assessment on Resident 1 and she did not inform Physician 1 of Resident 1's medical condition because she believed that it was okay to wait and call the physician in the morning. RN 1 stated she was supposed to inform Physician 1 because the resident exhibited a change of condition.
During an interview on 5/6/17 at 9:49 a.m., CNA 1 stated that on 4/30/17 at 7:10 a.m., Resident 1 looked "pale," and was "cold to the touch," CNA 1 stated she informed LVN 1. CNA 1 stated that on 4/30/17 at 8:40 a.m., Resident 1 vomited "a lot of brown fluid" from his mouth and that Resident 1 became unresponsive and the resident had no pulse. CNA 1 stated she did not perform CPR; she left the room to look for LVN 1. CNA 1 stated LVN 1 went inside Resident 1's room; LVN 1 did not start CPR. CNA 1 stated LVN 1 left Resident 1's room to call for help.
During an interview on 5/6/17 at 10:45 a.m., LVN 1 stated he was assigned to care for Resident 1 on 4/30/17. LVN 1 stated that on 4/30/17 at 7:30 a.m., CNA 1 informed him that Resident 1 vomited and he (LVN 1) went to check Resident 1. LVN 1 stated he observed Resident 1 "drooling" and Resident 1's stomach was "bloated." LVN 1 stated he did not conduct a comprehensive assessment and inform Physician 1 or the registered nurse (RN 1). LVN 1 stated he assumed that "drooling" and a distended abdomen were not considered changes of condition.
During an interview on 5/6/17 at 11:30 a.m., LVN 1 stated that CNA 1 informed him on 4/30/17, a little after 8:30 a.m., that Resident 1 "did not look good." LVN 1 stated he went inside Resident 1's room and observed Resident 1 "pale" and he could not feel the resident?s pulse.
During a telephone interview on 9/5/17 at 9:40 a.m., RN 1 stated that LVN 1 went to the nursing station (middle nursing station) to inform her that Resident 1 was unresponsive (on 4/30/17).
A review of Resident 1's record titled, "Licensed Nurse Documentation," indicated that on 4/30/17, at 8:50 a.m., Registered Nurse 1 (RN 1) was called to look at Resident 1 being unresponsive. CPR was started.
A review of Resident 1's record titled, "SBAR (Situation ? Background ? Assessment - Recommendation, a framework for communication between members of the health care team) Change of Condition Documentation," dated 4/30/17 at 8:50 a.m., indicated LVN 1 wrote that Resident 1 was lethargic (abnormal drowsiness) and unresponsive, and he was unable to obtain the resident?s vital signs (heart rate, body temperature, respiration rate, and blood pressure [a measurement of the strength of the blood pushing against the sides of the blood vessels]). The SBAR indicated LVN 1 informed the supervisor (RN 1) regarding the resident?s condition and a code blue (an emergency code) was called. CPR was initiated on Resident 1. At 8:55 a.m., 9-1-1 emergency services arrived at the facility. At 9:08 a.m., the 9-1-1 emergency services personnel pronounced Resident 1 dead.
A review of Resident 1's death certificate indicated the resident died on 4/30/17 and the immediate cause of death was cardiopulmonary arrest (the heart and lungs suddenly stopped functioning).
During an interview on 6/29/17 at 10:55 a.m., the Director of Staff Development (DSD) stated the facility did not have any records indicating the licensed nurses received skills validations or any documents indicating the licensed nurses were monitored to ensure that they were competent with their job description and responsibilities. The DSD stated she was not sure if the facility's licensed nurses were competent to perform nursing duties.
During a telephone interview on 7/7/17 at 8 a.m., the Medical Director (Physician 2) stated that the nurses could check Resident 1 for presence of fecal impaction and if the nurse noticed fecal impaction, the nurse was supposed to inform the physician and let the physician determine what to do next. Physician 2 stated that nurses needed a physician order to administer an enema.
A review of the undated facility's policy and procedure titled, "Change in Resident's Condition or Status," indicated, "Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the SBAR Communication Form."
A review of the undated facility?s policy and procedure titled, ?Enteral Tube Feeding via Continuous Pump,? indicated report complications (e.g. gastric distention, respiratory distress) promptly to the supervisor and attending physician.
A review of the facility?s policy and procedure, titled, ?Medication and Treatment Orders,? revised on April 2014, indicated medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state.
A review of the job description of a licensed vocation nurse (LVN) indicated the LVN was responsible for accurate observations, evaluations, and reporting of resident?s symptoms, reaction, and progress to the Charge Nurse, Director of Nursing, and other participating in care and treatment of the resident.
A review of the job description of a registered nurse (RN) indicated duties an RN that included assessing and evaluating total patient care needs; communicating resident?s status with physician; providing leadership and guidance for members of the nursing team and keeping them informed of changes in the plans of care for residents through good communication skills, verbal, and written; providing comprehensive assessments on existing and new residents; and supervising and evaluating the performance of nursing team members, and counsels to promote improvement.
The facility failed to provide necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, and to ensure that its residents receive treatment and care in accordance with professional standards of practice, facility?s policy and procedures, and the comprehensive assessment and plan of care to meet the needs of the residents, including but not limited to:
1. Failure to conduct a comprehensive assessment when Resident 1 had a change of condition.
2. Failure to notify and consult Resident 1?s attending physician (Physician 1) about the resident?s vomiting and distended abdomen (a change of condition).
3. Failure to obtain a physician order to administer an enema (the insertion of a tube into the rectum to infuse a liquid mixture and encourage a bowel movement) to relieve Resident 1?s fecal impaction (a mass of dry, hard stool that will not pass out of the colon or rectum).
4. Failure to communicate with Licensed Vocational Nurse 3 (LVN 3) of the incoming shift that Resident 1 was vomiting, had a distended abdomen, and the reason for turning off his enteral feeding machine (a medical device that pumps nutrition liquid formula to the stomach through a tube).
5. Failure to document in Resident 1?s medical record the date, time, and reason that LVN 1 stopped the resident?s tube feeding and that LVN 2 conducted a digital (finger) rectal exam to check for fecal impaction and administered an enema.
These deficient practices caused delayed provision of appropriate medical interventions for Resident 1 for 25 hours that resulted in Resident 1's death. The emergency services (9-1-1) pronounced Resident 1 dead in the facility on 4/30/17 at 9:08 a.m.
The above violations, jointly, separately or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 970000003 |
ALEXANDRIA CARE CENTER |
920013638 |
B |
21-Nov-17 |
6IC011 |
7159 |
?483.12(b) The facility must develop and implement written policies and procedures that:
?483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property
?483.12(b) The facility must develop and implement written policies and procedures that:
(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,
(2) Establish policies and procedures to investigate any such allegations, and
(3) Include training as required at paragraph ?483.95.
On October 3, 2017, during recertification survey, Resident 49?s family member grievance concern was investigated.
Based on observation, interview, and record review, the facility failed to implement written policies and procedures to ensure Resident 49 was free from abuse and neglect, including:
1. Failure to implement the facility?s policy and procedure on Abuse Prevention Manual ? Investigation, Corrective Actions and Administrative Action, by not conducting thorough investigations of allegations of abuse made by Resident 49?s family member.
2. Failure to implement the facility?s policy and procedure on Abuse Prevention Manual ? Protection, by not removing Certified Nursing Assistant 2 (CNA 2), from the care of Resident 47, during the abuse investigation.
3. Failure to implement the facility?s policy and procedure on Abuse Prevention Manual ? Reporting, by not reporting to the Department (State Agency) the abuse allegation involving Resident 49.
4. Failure to ensure CNA 2 had an employee?s file available with evidence of credentials, competency, abuse training, and criminal background clearance.
As a result, Resident 49 was subjected to mistreatment and neglect.
On October 4, 2017 at 8:20 a.m., during an interview, Family Member 1 stated nursing staff was rude to Resident 49. FM 1 stated during one of her visits in September 2017, Resident 49 was crying saying she did not want to reside in the facility because the nursing staff was mean to her. FM 1 stated Resident 49 told her that a day prior to her visit, Resident 49 requested assistance to go to the bathroom for bowel movement and CNA 2 told the resident to pass the bowel movement in her incontinence brief. After Resident 49 had done so, CNA 2 called Resident 49, "Nasty lady," while cleaning her.
According to the Admission Record, Resident 49 was originally admitted on June 29, 2015 and re-admitted on August 24, 2017, with diagnoses including muscle weakness, difficulty in walking, and urinary tract infection (UTI- an infection in any part of the urinary system, the kidneys, bladder or urethra).
A review of the Minimum Data Set (MDS, an assessment and care screening tool), dated August 31, 2017, indicated RSR 49 required extensive assistance with one-person physical assist with transfer, dressing, toilet use, and personal hygiene.
A review of the Grievance Form indicated FM 1 filed a grievance on September 8, 2017 regarding Resident 49 not liking CNA 2 because of resident to CNA incompatibility. The corrective action indicated CNA 2 would no longer be assigned to Resident 49.
On October 5, 2017 at 7:20 a.m., during an interview, Social Services Designee 3 (SSD 3) stated when she received the grievance from FM 1 on September 8, 2017, she felt it was an allegation of abuse. SSD 3 stated she interviewed CNA 2 regarding the allegation, but did not interview other residents assigned to CNA 2, to inquire about her behavior, attitude, and/or work ethics.
On October 5, 2017 at 9:20 a.m., during an interview, the Administrator stated she would re-open the investigation. The ADM also stated if FM 1 had reported that CNA 2 called Resident 49 a, "Nasty lady," then the abuse allegation should have been reported to the Department.
On October 4, 2017 at 11 a.m., during a review of employees' file with the DSD and concurrent interview, DSD stated she was unable to provide CNA 2's employee file at the time and was trying to locate it.
A review of the facility's revised policy and procedure dated July 1, 2005, titled, "Abuse Prevention Manual," indicated each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion. The Center will take proactive measures to prevent the occurrence of abuse to any resident. Screening: All CNAs will be properly screened for criminal background. Protection: If a resident incident is reported, discovered or suspected, where the health, welfare of safety of the resident(s) is involved, the Center will take steps to provide a safe environment for the resident(s) as indicated by the situation: if the suspected perpetrator is an employee, then immediately remove the employed from the care of vicinity of the resident. Suspend the employee during the investigation. Investigation: The investigation shall include interviews of employees, resident(s), family, visitors who may have knowledge of the alleged incident. Reporting: Any known or suspected abuse will be reported by completing an Incident and Injury Report. The Administrator shall report all alleged or suspected violations to the Quality Assurance and Assessment (QAA) Committee will analyze the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences. The Administrator of designee will verify that mandated in-services are presented on a timely basis. If incident involves a facility staff member, verify that the employee involved attended that appropriate in-service.
A review of the facility's revised policy and procedure dated February 13, 2017 and titled, "Grievance/Concern," indicated when the formal grievance/concern is logged, the Center Executive Director (CED) and appropriate department manager will be notified. Immediate action will be taken to prevent further potential violations of any resident right while the alleged violation is being investigated.
The facility failed to implement written policies and procedures to ensure Resident 49 was free from abuse and neglect, including:
1. Failure to implement the facility?s policy and procedure on Abuse Prevention Manual ? Investigation, Corrective Actions and Administrative Action, by not conducting thorough investigations of allegations of abuse made by Resident 49?s family member.
2. Failure to implement the facility?s policy and procedure on Abuse Prevention Manual ? Protection, by not removing CNA 2 from the care of Resident 47, during the abuse investigation.
3. Failure to implement the facility?s policy and procedure on Abuse Prevention Manual ? Reporting, by not reporting to the Department (State Agency) the abuse allegation involving Resident 49.
4. Failure to ensure CNA 2 had an employee?s file available with evidence of credentials, competency, abuse training, and criminal background clearance.
As a result, Resident 49 was subjected to mistreatment and neglect.
The above violation had a direct or immediate relationship to the health, safety, and security of Resident 49. |
| 970000003 |
ALEXANDRIA CARE CENTER |
920013639 |
B |
21-Nov-17 |
6IC011 |
8335 |
?483.12(b) The facility must develop and implement written policies and procedures that:
?483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property
?483.12(b) The facility must develop and implement written policies and procedures that:
(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,
(2) Establish policies and procedures to investigate any such allegations, and
(3) Include training as required at paragraph ?483.95.
On October 3, 2017, during recertification survey, the grievance of Resident 47?s Family Member (FM 2) was investigated.
Based on observation, interview, and record review, the facility failed to implement written policies and procedures to ensure Resident 47 was free from abuse and neglect, including:
1. Failure to implement the facility?s policy and procedure on Abuse Prevention Manual ? Investigation, Corrective Actions and Administrative Action, by not conducting a thorough investigation of the allegations of Resident 47?s mistreatment and neglect voiced by FM 2.
2. Failure to implement the facility?s policy and procedure on Abuse Prevention Manual ? Protection, by not removing from the care of residents the alleged certified nursing assistant, who had an allegation of neglecting the incontinent care needs of Resident 47, pending thorough investigation.
3. Failure to implement the facility?s policy and procedure on Abuse Prevention Manual ? Reporting, by not reporting to the Department (State Agency) an allegation of staff neglect involving Resident 47.
4. Failure to ensure LVN 3?s employee?s file had a current license and evidence of training education on elder abuse prevention.
As a result, Resident 47 was subjected to mistreatment and neglect.
According to the Admission Record, Resident 47 was originally admitted on May 16, 2016, and re-admitted on July 5, 2017, with diagnoses including uterus cancer and high blood pressure.
A review of a Grievance form indicated Resident 47's family member (FM 2) filed a grievance on September 14, 2017. FM 2 reported that on September 4, 2017, LVN 4 had poor bedside manners when she requested Resident 47's blood pressure to be taken and to give Resident 47 pain medication. LVN 4 told FM 2, "I will get to that room when I get to that area, or go away, or I will get there when I get there." FM 2 also reported she approached LVN 3 to request Resident 47's blood pressure to be taken. LVN 3 responded, "No, I am busy. Go to the charge nurse." LVN 3 was short tempered and did not listen to FM 2's concerns. The assigned CNA (name not indicated) did not offer to provide incontinence care to Resident 47 during the 7 a.m. to 3 p.m. shift. LVN 10 did not assess Resident 47's pain to determine which pain medication to administer. The recommended corrective action was to add frequent check to the CNA's plan of care and the three employees involved in the grievance would no longer return to work at the facility.
On October 5, 2017 at 7:20 a.m., during an interview, the Director of Nursing (DON) stated the grievance received on September 14, 2017 indicated neglect from LVN 3 and LVN 4. The DON stated she did not interview other residents assigned to LVN 3, 4, and 10 to inquire about their treatment to them; the DON did not provide in-service education regarding Elder Abuse Prevention to the nursing staff after the grievance was filed; the DON did not conduct a thorough investigation in regards to the alleged neglect; and the abuse allegations were not reported to the Department.
On October 11, 2017 at 12:53 p.m., during an interview, FM 2 stated the nurses have neglected Resident 47 by ignoring her medical condition and complaints of pain. FM 2 stated on September 4, 2017, Resident 47 was agitated because of pain. FM 2 told LVN 4 to provide pain medication to Resident 47, but LVN 4 did not show up for two hours (from 4 p.m. to 6 p.m.). When FM 2 approached another nursing staff (LVN 3) requesting pain medication, LVN 3 responded he was busy and got mad. FM 2 stated the CNAs working during the night shift would, "Disappear" and did not attend to Resident 47's needs. FM 2 stated during her visits, she witnessed nursing staff calling resident?s derogatory (disrespectful) names, such as, ?Pig" or ignoring the residents' calls for assistance.
On October 4, 2017 at 11 a.m., a review of LVN 3's employee file was reviewed in the presence of the DSD. LVN 3?s license had expired on January 30, 2013. The DSD stated LVN 3 licensed was checked, but was not placed in the employee?s file. The employee file did not contain evidence of abuse prevention training and the DSD was unable to provide documentation on training education on elder abuse prevention training within the past year.
A review of the facility's revised policy and procedure dated July 1, 2005, titled, "Abuse Prevention Manual," indicated each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion. The Center will take proactive measures to prevent the occurrence of abuse to any resident. Training: All employees will receive orientation and ongoing training on abuse prevention and reporting. Protection: If the suspected perpetrator is an employee, then immediately remove the employee from the care or vicinity of the resident. Suspend the employee during the investigation. Investigation: The investigation shall include interviews of employees, resident(s), family, visitors who may have knowledge of the alleged incident. The investigation and report shall include, at a minimum name of witnesses and their statement of the incident, when applicable, information from any other individuals involved, recommendations for corrective action if applicable, outcome of investigation, and follow-up resolution of further action if necessary. Reporting: The Administrator shall report all alleged or suspected violations to the appropriate state agencies immediately or within 24 hours (California H&S Code 1418.19a). Administrator or designee shall investigate all suspected or alleged abuse and report incident to the local ombudsman or the local law enforcement agency by telephone immediately or as soon as practically possible, and by written report (SOC 341) sent within two working days. Administrative Action: The Administrator of designee will verify that mandated in-services are presented on a timely basis. If incident involves a facility staff member, verify that the employee involved attended that appropriate in-service.
A review of the facility's revised policy and procedure dated February 13, 2017 and titled, "Grievance/Concern," indicated when the formal grievance/concern is logged, the Center Executive Director (CED) and appropriate department manager will be notified. Immediate action will be taken to prevent further potential violations of any resident right while the alleged violation is being investigated.
The facility failed to implement written policies and procedures to ensure Resident 47 was free from abuse and neglect, including:
1. Failure to implement the facility?s policy and procedure on Abuse Prevention Manual ? Investigation, Corrective Actions and Administrative Action, by not conducting a thorough investigation of the allegations of Resident 47?s mistreatment and neglect voiced by FM 2.
2. Failure to implement the facility?s policy and procedure on Abuse Prevention Manual ? Protection, by not removing from the care of residents the alleged certified nursing assistant, who had an allegation of neglecting the incontinent care needs of Resident 47, pending thorough investigation.
3. Failure to implement the facility?s policy and procedure on Abuse Prevention Manual ? Reporting, by not reporting to the Department (State Agency) an allegation of staff neglect involving Resident 47.
4. Failure to ensure LVN 3?s employee?s file had a current license and evidence of training education on elder abuse prevention.
As a result, Resident 47 was subjected to mistreatment and neglect.
The above violation had a direct or immediate relationship to the health, safety, and security of Resident 47. |
| 970000003 |
ALEXANDRIA CARE CENTER |
920013634 |
B |
21-Nov-17 |
6IC011 |
13688 |
?483.60 (i) Food safety requirements.
The facility must ?
?483.60(i) (2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
?483.90(i)(4) Maintain an effective pest control program so that the facility is free of pests and rodents.
On October 3, 2017 at 8:10 a.m., during recertification survey, an inspection of the facility?s kitchen was conducted and the pest control program was investigated.
Based on observation, interviews and record review, the facility failed to ensure residents? food were stored, prepared, and distributed in accordance with professional standards for food safety by maintaining an effective pest control program to prevent the infestation of roaches in the kitchen, including;
1. Failure to suppress cockroach population by maintaining a pest control service in the kitchen.
2. Failure to follow the recommendations made by the pest control technician on the control of the cockroaches including patching holes and cracks that allowed entry of cockroaches into the kitchen.
3. Failure to maintain floor drains, a source of water for the cockroaches.
4. Failure to maintain the kitchen in a sanitary condition.
As a result, on October 3, 2017, 168 residents residing in the facility were placed at risk of serious complications from food borne illness (food poisoning). Symptoms of food borne illness include diarrhea, vomiting, headaches, fever, and confusion, loss of appetite, abdominal cramping and pain. When those conditions persist the residents can lead to dehydration and may require hospitalization and in some cases death.
During the tour of the kitchen on October 3, 2017 at 8:10 a.m., the floor of the dry storage room was soiled with food debris and sticky material. There were open bags of tortillas, muffins and a partially opened bag of chocolate pudding mix was observed on the shelves in the dry storage room. Two live cockroaches were also observed crawling across the floor during the concurrent observation in the dry storage room. Two Dietary Service Supervisors (DSS and DSS 2) were present during the observation. The floor of the dry storage room was dirty with a buildup of dark colored dirt and grime. There was a thick buildup of dark colored oily substance around the stove and cooking area.
On October 3, 2017 at 8:15 a.m., the DSS stated in a concurrent interview and observation of the kitchen, the Pest Control Company Technician (PCT) had come to perform services the week before, and the night before the observations of October 3, 2017 at 8:10 a.m.
There was a sewage back-up of two floor drains in the kitchen. On October 3, 2017 at 12:29 p.m., a big drain under the dish washing machine, measuring about 12 inches by 8 inches, was observed with an accumulation of black colored, malodorous liquid in the drain. An examination of the drain contents showed black colored sediments.
At 12:48 p.m. on October 3, 2017, water with a strong, rotten odor was observed flowing freely out of one of the kitchen floor drains, leaving a puddle surrounding the drain. The floor in the area of the kitchen drain remained wet, and the sewage (waste water conveyed in sewers) was tracked throughout the kitchen. There were wet shoe prints throughout the kitchen.
On October 3, 2017 at 1:55 p.m. in an interview, the Assistant Supervisor (AS), stated whenever the hand washing sink and dish washing machine are used at the same time, the kitchen drains back up. Dietary Aide 2, who was one of the many food service staff present, stated the water flowing out of the floor drain, when hand washing is being done, happened in the past two to four months and happened also the day before October 2, 2017. Diet Aide 3 stated the kitchen drain back up happened, "Last night and today."
On October 3, 2017 at 3:30 p.m., while hand washing, in kitchen hand washing sink, located at the entrance to the kitchen, water was observed flowing out of the floor drain onto the kitchen floor. The Maintenance Supervisor (MS) who was present, stated the drain pipes were old, but did, "Snake the pipe every three to four months and jet (hydro) every six months" to keep the drain lines flowing (open). The MS stated the food service staff informed him of the kitchen sewer drain line back up, once a month.
A review of a receipt by a plumbing company dated 3/02/2017 showed the kitchen "floor drains were backed up." The plumbing company had to "snake all floor drains and perform hydrojet on all lines." The plumbing services rendered on March 2, 2017, provided a two - month warranty. In addition, there was a recommendation to, "Repipe (remove and replace with new pipes) drain lines." There was no documented evidence provided to the survey team, by the facility to indicate recommendations to,"Repipe drain lines," or other services were performed to resolve the ongoing floor drain sewage back up.
On October 3, 2017 starting at 4:05 p.m. there were four additional live cockroaches observed crawling underneath the food preparation kitchen sink. Inspection of the kitchen, revealed holes in the walls behind the dish washing machine, a hole approximately 3 inch by 3 inch behind the door in the dry storage room, numerous floor tile cracks, tiles and coving separated from the walls in several areas throughout the kitchen. One dead cockroach was observed on the ladder in the dry storage room. There was a large gaping hole on the wall adjacent to the elevator door that was about 30 inches long and 2 inches wide. A live cockroach was observed crawling on the coving next to the elevator.
At 4:15 p.m. on October 3, 2017, the plumber from the same company who had performed services on March 2, 2017, was observed in the kitchen. In a concurrent interview the MS stated the work on the floor drains had been completed and the floor drains were flowing well. A review of the receipt provided, confirmed observations that had been made by the survey team. The plumbing company found, "Two drains were backing up on the same branch line ... Found there was a usual build up in pipe." The receipt also indicated "last time we performed jet 3/2/17." The MS stated in the concurrent interview and observation at 4:16 p.m., the drains had not been re-piped and the facility had plans to do so in the near future. The facility had a bid out for the repairs.
In an interview conducted on October 3, 2017 at 4:30 p.m., food and nutrition staff 1 (FNS 1), stated the presence of cockroaches in the kitchen have been observed for several months and had been reported to the previous food service supervisor.
A review of the binder containing receipts of pest control services performed from June 12, 2017 through October 1, 2017, showed the kitchen had not been included in the areas treated prior to September 20, 2017. The pest control report titled, "Customer Service Report" indicated from June 12, 2017, the pest control services were only performed for the exterior of the facility building, only for large fly, rodents and cockroaches in the dumpster/ garbage area and basement interior. This service report indicated there was a 1/4 inch gap or greater at the exit door in the basement area next to the laundry. The report recommended replacing the door sweep to reduce the number of pests entering the area. The kitchen is located in the basement.
The pest control report dated 7/9/2017 indicated under the subheading "structural concerns that could cause pest problems, the kitchen interior floor tiles or baseboards loose missing." The report noted "please repair to eliminate potential pest harborage/breeding site." The report dated "9/20/2017," indicated "cockroaches noted during service, activity noted in cook line area." The report indicated the presence of a hole/gap behind the dish washing machine.
On October 4, 2017 at 11:05 a.m., after the kitchen had been serviced by the pest control company (on October 3, 2017), the kitchen was inspected for the presence of cockroaches. There was one live cockroach observed in the dry storage room. A wet tile which was lifted with ease off the floor, in the dry storage room, revealed the presence of about six dead cockroaches underneath the tile. The location of the wet tile was on the floor next to the wall that separated the dry storage room from the kitchen, across from the dish washing area. The presence of moisture on the floor in the dry storage room, indicated an amount of water leaked from the dishwashing area of the kitchen, sufficient enough to move into the dry storage area underneath the wall.
On October 4, 2017 at 11:55 a.m., in the Dining Room, meal service was set up, served and distributed, in one corner of the Main Dining Room. On observation, the area lacked hand washing facilities. When two employees were asked where they wash their hands, they stated they washed their hands in the kitchen (in the basement). The staff after asked about handwashing went to wash their hands down the hallway at the nurse's station before meal service. The food from the emergency menu had been prepared (heated) at the sister facility. The food was transported to the facility in an employee's car, of an unknown sanitary condition.
On October 4, 2017 starting at 6:52 p.m., one live cockroach was observed in the kitchen food preparation area underneath the sink, on the back wall, around a mesh and plaster covering. Another cockroach was observed behind the freezer crawling into one of the floor drains. Another live cockroach was observed on the wall adjacent to the food preparation sink. The cockroach was crawling around one of the pipes. A live baby cockroach was also found a few minutes later, underneath the sink near the mesh and plaster area, in the same vicinity as was observed with the first cockroach at 6:52 p.m.
On October 5, 2017 at 8:25 a.m., there were also approximately twenty dead cockroaches in the water on the floor, underneath the dish washing machine, in the kitchen.
No other cockroaches were observed during subsequent checks to the kitchen on October 5, 2017 at 3:30 p.m. all the wall and floor cracks had been repaired and sealed. No food preparation was taking place in the kitchen; all floor tiles in the dry storage room were removed with plans to replace them. The whole kitchen was deep cleaned including walls. All food items in the dry storage room had been discarded.
On October 6, 2017 at 8:30 a.m., two small live cockroaches were observed in the dry storage room. Deep cleaning of the kitchen equipment and kitchen hood were observed. The facility's kitchen remained closed until October 7, 2017.
Cockroaches are nocturnal insects. They prefer to live and feed in the dark, a cockroach seen during the day is a possible sign of infestation. Cockroaches tend to prefer dark, moist places to hide and breed and can be found behind refrigerators, sinks and stoves, as well as under floor drains and inside of motors and major appliances. The bodies of dead cockroaches can also be found throughout the house. (www.orkin.com)
According to the booklet titled "Effective Management of Cockroach Infestations" by the County of Los Angeles Vector Management Program, "The German cockroach is the most common of the cockroach species". This species reproduces more rapidly than the other common pest cockroaches. German cockroaches are believed to be capable of transmitting disease causing organisms such as Staphylococcus spp., Streptococcus spp., hepatitis virus, and coliform bacteria. They also have been implicated in the spread of typhoid and dysentery. They prefer food preparation areas, kitchens, and bathrooms because they favor warm, humid areas that are close to food and water. In severe infestations they may spread to other parts of the structure. Generally, for every cockroach seen in the daytime there are many more concealed in dark, protected locations.
The facility's blocked kitchen sewage drains and wet floor provided the moisture that was needed to keep cockroaches thriving. The dirty kitchen environment including cracks in the walls and floors provided both food and safe places to harbor and the warm kitchen conditions was the final condition necessary to encourage the cockroaches to thrive. The German cockroach was the kind of cockroach found in the facility's kitchen and food storage area.
The facility failed to ensure residents? food were stored, prepared, and distributed in accordance with professional standards for food safety by maintaining an effective pest control program to prevent the infestation of roaches in the kitchen, including;
1. Failure to suppress cockroach population by maintaining a pest control service in the kitchen.
2. Failure to follow the recommendations made by the pest control technician on the control of the cockroaches including patching holes and cracks that allowed entry of cockroaches into the kitchen.
3. Failure to maintain floor drains, a source of water for the cockroaches.
4. Failure to maintain the kitchen in a sanitary condition.
As a result, on October 3, 2017, 168 residents residing in the facility were placed at risk of serious complications from food borne illness (food poisoning). Symptoms of food borne illness include diarrhea, vomiting, headaches, fever, and confusion, loss of appetite, abdominal cramping and pain. When those conditions persist the residents can lead to dehydration and may require hospitalization and in some cases death.
The above violation had direct or immediate relationship to the health, safety, or security of 168 residents. |
| 970000003 |
ALEXANDRIA CARE CENTER |
920013641 |
B |
21-Nov-17 |
6IC011 |
6326 |
?483.12(b) The facility must develop and implement written policies and procedures that:
?483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property
?483.12(b) The facility must develop and implement written policies and procedures that:
(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,
(2) Establish policies and procedures to investigate any such allegations, and
(3) Include training as required at paragraph ?483.95,
On October 3, 2017, during recertification survey, Resident 31?s allegation of abuse from staff was investigated.
Based on observation, interview, and record review, the facility failed to implement written policies and procedures to ensure residents were free from abuse and neglect, including:
1. Failure to implement the facility?s policy and procedure on Abuse Prevention Manual ? Screening, by not verifying credentials of Licensed Vocational Nurse 1 (LVN 1), who was supplied by a temporary staffing agency.
2. Failure to implement the facility?s administrative policy and procedure on Temporary Agency Background Checks, by not having evidence of LVN 1?s background clearance.
As a result, Resident 31 was subjected to mistreatment and mental abuse from LVN 1.
On October 3, 2017 at 9:29 a.m., during an observation, Resident 31 was sitting at the edge of the bed, awake, alert, and oriented to person, place, and time. Upon interview, in the presence of Registered Nurse 2 (RN 2), Resident 31 stated the nursing staff was rude, and had a nasty attitude. Resident 31 stated LVN 1, a former employee, was rude to him. Resident 31 also stated that when he pressed the call light to request assistance, the nursing staff would stroll by his room and not answer the call light to attend to his needs.
According to the Admission Record, Resident 31 was admitted on November 16, 2015, with diagnoses including muscle weakness, difficulty in walking, and congestive heart failure (a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues).
A review of the Minimum Data Set (MDS, an assessment and care-screening tool), dated August 22, 2017, indicated Resident 31 had no memory problems, was able to make decisions, required extensive assistance with one-person physical assist with dressing and toilet use. The MDS indicated Resident 31 was feeling down, depressed or hopeless (two to six days in the past 14 days), had trouble falling or staying asleep (two to six days in the past 14 days), and feeling tired or having little energy (two to six days in the past 14 days).
On October 4, 2017 at 11 a.m., during a review of employees' file with the Director Staff Development and concurrent interview, she was unable to provide LVN 1's employee file and explained LVN 1 was hired through a registry and they were trying to contact the registry to request LVN 1's file.
On October 5, 2017 at 10:55 a.m., during an interview, the Administrator, who was also the abuse prevention coordinator, stated LVN 1's employee file was not available and that it will be available on October 6, 2017 from the registry. The Administrator stated she was unable to provide documented evidence the facility had verified the nursing staff provided by the contracted registry had verified previous employment history, criminal background, and licenses.
A review of the facility's revised policy and procedure dated July 1, 2005, titled, "Abuse Prevention Manual," indicated each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family member(s) or legal guardian, friend(s), or other individuals. The Center will take proactive measures to prevent the occurrence of abuse to any resident.
The policy indicated that the purpose is to ensure the resident's rights are protected by providing a method for the prevention, reporting and investigation of any type of alleged resident abuse. Screening: All potential employees will have reference verification with current and/or past employment. All CNAs will be properly screened for criminal background and approved by the Department of Health Services, through use of their CNA Abuse Registry and Certification Program. Any CNA who has been previously employed out of the state of California will also be subject criminal background screens through state registry. Licenses will be verified for all employees who hold licenses.
A review of the facility's revised policy and procedure dated June 1, 2014 and titled, "HR206 Temporary Agency Background Checks: Criminal and Driving," indicated Genesis Healthcare will only use temporary staffing agencies that complete criminal background checks on their staff. Background checks must include: verification of credentials, licenses, certificates, or other documents required for the position, criminal background check, driving record check, substance abuse screening, abuse registry check, Health and Human Services Office of Inspector General and General Services Administration check, and employee health screening. Before a Genesis Healthcare location is permitted to use an external temporary staffing agency, the agency must provide confirmation that they are in compliance with this policy pursuant to the terms of their contract.
The facility failed to implement written policies and procedures to ensure residents were free from abuse and neglect, including:
1. Failure to implement the facility?s policy and procedure on Abuse Prevention Manual ? Screening, by not verifying credentials of LVN 1 from a temporary staffing agency.
2. Failure to implement the facility?s administrative policy and procedure on Temporary Agency Background Checks, by not having evidence of LVN 1?s background clearance.
As a result, Resident 31 was subjected to mistreatment and mental abuse from LVN 1.
The above violation had a direct or immediate relationship to the health, safety, and security of Resident 31. |
| 970000003 |
ALEXANDRIA CARE CENTER |
920013640 |
B |
21-Nov-17 |
6IC011 |
8202 |
?483.12(b) The facility must develop and implement written policies and procedures that:
?483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property
?483.12(b) The facility must develop and implement written policies and procedures that:
(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,
(2) Establish policies and procedures to investigate any such allegations, and
(3) Include training as required at paragraph ?483.95.
On October 3, 2017, during recertification survey, Residents 32 and 45?s allegations of neglect were investigated.
Based on observation, interview, and record review, the facility failed to implement written policies and procedures to ensure Residents 32 and 45 were free from abuse and neglect, including:
1. Failure to implement the facility?s policy and procedure on Abuse Prevention Manual ? Investigation, Corrective Actions and Administrative Action, by not conducting thorough investigation regarding Residents 32 and 45?s alleged mistreatment and neglect; by not interviewing other residents assigned to Certified Nursing Assistant 9 (CNA 9) regarding treatment received by CNA 9; and by not developing corrective actions.
2. Failure to implement the facility?s policy and procedure on Abuse Prevention Manual ? Training, by not providing in-service training on Abuse Prevention to all CNAs including CNA 9.
3. Failure to implement the facility?s policy on Grievance/Concern, by not taking immediate actions to prevent further potential violations of any resident?s right while alleged violation were investigated and by not developing and implementing corrective actions.
As a result, Residents 32 and 45 were subjected to mistreatment and neglect.
a. On October 4, 2017 at 7:50 a.m., during an observation, Resident 32 was lying in bed, awake, alert, and oriented to person, place, and time. At the time of the observation, during an interview, Resident 32 stated the nursing staff had been rude to him in the past.
According to the Admission Record, Resident 32 was admitted on August 8, 2017, with diagnoses including muscle weakness and difficulty in walking.
A review of the Minimum Data Set (MDS, an assessment and care screening tool), dated August 15, 2017, indicated Resident 32 had no memory problem and was able to make decisions. Resident 32 required extensive assistance with one-person physical assist with transfer, dressing, toilet use, and personal hygiene.
A review of a Grievance Form indicated the Resident 32 filed a grievance on September 7, 2017. Resident 32 reported that on September 5, 2017, he pressed the call light at 6:30 p.m. to have his incontinence brief changed and CNA 9 did not answer the call light until 8:30 p.m. The corrective action was to provide an in-service regarding answering call lights in a timely manner to all CNAs and charge nurses.
On October 4, 2017 at 12:15 p.m., during an interview, Social Service Designee (SSD 1) stated the administrative staff did not interview other residents assigned to CNA 9 to inquire about CNA 9?s provision of care and treatment.
On September 12, 2017, the facility was unable to provide documented evidence an in-service was provided to all CNAs, including CNA 9.
b. According to the Admission Record, Resident 45 was originally admitted on March 28, 2007 and re-admitted on September 6, 2014, with diagnoses including muscle weakness, pain, and contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints).
A review of the MDS dated July 5, 2017, indicated Resident 45 required total assistance from staff with dressing and personal hygiene.
On October 4, 2017 at 9:05 a.m., during an observation, Resident 45 was sitting in her wheelchair, awake, alert and oriented to person. The pad call light was located behind the resident's wheelchair (not within the resident?s reach). There was a note posted on the wall by Resident 45's bed indicating to place the call light on the chest, not on the nightstand.
On October 12, 2017 at 11:30 a.m., during an interview, Resident 45's responsible party (RP 1) stated CNAs had been, "Mean and nasty" to the resident. RP 1 stated that about three weeks ago, a CNA threw Resident 45's call light under the bed after Resident 45 pressed the call light to request assistance during night shift (11 p.m. to 7 a.m.). RP 1 stated she placed the sign on the wall because she noticed the nurses were placing the call light on the night stand because, "They did not want to be bothered."
On October 12, 2017 at 11:50 a.m., during an interview in the presence of RP 1, Resident 45 stated the CNAs were sometimes mean and rough-handled her during incontinence care. Resident 45 stated the way the CNAs talked to her was mean.
A review of the facility's revised policy and procedure dated July 1, 2005, titled, "Abuse Prevention Manual," indicated each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion. The Center will take proactive measures to prevent the occurrence of abuse to any resident. Training: All employees will receive orientation and ongoing training on abuse prevention and reporting. Investigation: The assigned staff will be informed of the nature of the incident and continue the investigation process. The investigation shall include interviews of employees, resident(s), family, visitors who may have knowledge of the alleged incident. Factual information only will be documented, not assumptions or speculations. The investigation and report shall include recommendations for corrective action if applicable, outcome of investigation, and follow-up resolution of further action if necessary. Administrative Action: The Administrator of designee shall initiate an investigation immediately, which may include interviews of the involved resident(s), and other parties (employees, visitors, and other residents, volunteers, family members, etc.) who have knowledge of the alleged incident.
A review of the facility's revised policy and procedure dated February 13, 2017 and titled, "Grievance/Concern," indicated when the formal grievance/concern is logged, the Center Executive Director (CED) and appropriate department manager will be notified. Immediate action will be taken to prevent further potential violations of any resident right while the alleged violation is being investigated. The department manager will contact the person filling the grievance to acknowledge receipt, investigate the grievance, take corrective actions as needed, engage the support of the Ombudsman, if warranted, and notify the person filing the grievance of resolution within 72 hours by providing a copy of Grievance/Concern Form to the resident/resident representative.
The facility failed to implement written policies and procedures to ensure Residents 32 and 45 were free from abuse and neglect, including:
1. Failure to implement the facility?s policy and procedure on Abuse Prevention Manual ? Investigation, Corrective Actions and Administrative Action, by not conducting thorough investigation regarding Residents 32 and 45?s alleged mistreatment and neglect; by not interviewing other residents assigned to CNA 9 regarding treatment received by CNA 9; and by not developing corrective actions.
2. Failure to implement the facility?s policy and procedure on Abuse Prevention Manual ? Training, by not providing in-service training on Abuse Prevention to all CNAs including CNA 9.
3. Failure to implement the facility?s policy on Grievance/Concern, by not taking immediate actions to prevent further potential violations of any resident?s right while alleged violation were investigated and by not developing and implementing corrective actions.
As a result, Residents 32 and 45 were subjected to mistreatment and neglect.
The above violation had a direct or immediate relationship to the health, safety, and security of Residents 32 and 45. |
| 970000003 |
ALEXANDRIA CARE CENTER |
920013629 |
A |
21-Nov-17 |
6IC011 |
13887 |
483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents? choices.
?483.25(b) Skin Integrity
?483.25 (b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that?
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual?s clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
On October 3, 2017 at 8:06 a.m., during recertification survey, Resident 10?s clinical record was reviewed.
Based on observation, interview, and record review, the facility failed to ensure its residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan to prevent the development of pressure sores (localized injury to the skin and underlying tissue usually over a bony prominence as a result of pressure or pressure in combination with shear and/or friction) and to promote healing, including:
1. Failure to provide Resident 10 with a low air loss mattress (LAL mattress - a pressure relieving mattress which provides alternating pressure to aid in the management of pressures sores) as ordered by the physician on June 26, 2017.
2. Failure to provide a pressure relieving mattress to Resident 10 to prevent the development of pressure sores, promote healing and prevent re-occurrences of pressure sores.
3. Failure to notify the Registered Dietitian (RD) of Resident 10's pressure sores to obtain nutritional evaluation and recommendations to promote wound healing.
4. Failure to ensure Certified Nursing Assistant 11 (CNA 11) notified a licensed nurse of a newly open sore to Resident 10's right hip.
As a result, Resident 10 developed a left hip deep tissue injury (DTI - pressure-related injury to subcutaneous (under the skin) tissues under intact skin. Initially with appearance of a deep bruise); a DTI to the sacro-coccyx (tailbone) area; a left hip Stage 3 (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed) pressure sore which deteriorated into an unstageable (depth of the pressure sore cannot be determined) pressure sore; and a right lateral (outer) hip Stage 2 pressure sore.
On October 3, 2017, at 8:06 a.m., Resident 10 was observed in bed, sleeping over a LAL mattress. On closer observation at 8:15 a.m., in the presence of RN 5, the LAL mattress power box indicated the mattress had a power fail. RN 5 called Treatment Nurse 1 to attend to the mattress power failure.
A review of the Admission Record indicated Resident 10 was initially admitted to the facility on March 3, 2017 with the most recent re-admission dated September 16, 2017, with diagnoses including muscle weakness, diabetes (high blood sugar), dysphagia (difficulty swallowing), gastrostomy tube (GT - tube surgically placed directly into the stomach through the abdominal wall for long-term nutrition and medication administration), and dementia (decline in mental ability severe enough to interfere with daily life).
A review of the Admission Skin Assessment form upon initial admission, March 3, 2017, indicated Resident 10 had discoloration to both forearms with no other skin problems. Resident 10 weighed 136.8 pounds and was 61 inches tall. Resident 10 did not have pressure sores when initially admitted to the facility.
A review of the Minimum Data Set (MDS - standardized assessment and care planning tool) dated June 16, 2017 indicated Resident 10?s cognition (memory and thinking skills) was severely impaired and required extensive assistance from staff for bed mobility and transfers. Resident 10 was assessed at risk for skin breakdown and had no pressure sores.
A review of the MDS dated September 30, 2017 indicated Resident 10 weighed 112 pounds and had multiple pressure sores, including one Stage 2, two Stage 3, one unstageable pressure sore, and four DTIs.
A review of the Care Plan dated March 3, 2017, developed for Resident 10?s risk for skin breakdown, included in the interventions evaluating skin risk factors, monitoring skin for signs/symptoms of skin breakdown (no frequency indicated), and completing the Norton/Braden Assessment per policy. The interventions did not include the use of pressure relieving devices, nutritional evaluation and monitoring, repositioning schedule program, etc.
A review of the Nursing Progress Notes dated June 7, 2017 indicated Resident 10 required transfer to a General Acute Care Hospital (GACH). Resident 10 returned back to the facility on June 14, 2017 with no pressure sores.
A review of a Change in Condition Evaluation dated June 26, 2017, indicated Resident 10 was identified with a left lateral (outer) hip DTI measuring six centimeters (cm) in length by 5.5 cm in width.
A review of a Physician's Order dated June 26, 2017, timed at 6:43 a.m., indicated to provide Resident 10 with a LAL mattress for wound management.
A review of the Nursing Progress Notes dated June 26, 2017 timed at 10:19 p.m. by Licensed Vocational Nurse (LVN 12) indicated Resident 10 did not have a LAL mattress.
A review of a Change in Condition Evaluation dated June 27, 2017, indicated Resident 10 developed a DTI injury to the sacro-coccyx area, the size was not indicated.
A review of the Nursing Progress Notes dated June 28, 2017 timed at 12:13 a.m. by LVN 12 indicated Resident 10 did not have a LAL mattress.
A review of the Nursing Progress Notes dated July 2, 2017 indicated Resident 10 was transferred to a GACH.
Resident 10 returned to the facility on July 7, 2017. The Admission Skin Assessment form dated July 8, 2017 indicated Resident 10 had pressure sores as follows:
1. Right heel DTI,
2. Left heel DTI,
3. Left hip Stage 2
4. Sacro-coccyx Stage 2
A review of the physician?s orders, nursing notes, and plan of care indicated no documentation a LAL mattress or another pressure relieving mattress was ordered or requested to the physician for Resident 10, to promote healing of pressure sores after re-admission on July 7, 2017.
A review of the Nursing Progress Notes dated July 9, 2017 indicated Resident 10 was transferred to a GACH.
Resident 10 returned to the facility on July 20, 2017. The Nursing Progress Note dated July 21, 2017 indicated Resident 10 had pressure sores as follows:
1. Right lateral (outer) heel DTI
2. Left trochanter (bony prominence of the hip bone - site 1) Stage 3
3. Left trochanter (site 2) Stage 2
4. Sacro-coccyx Stage 4 (full thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone).
A review of the physician's orders, nursing notes, and care plan for July and August 2017 indicated no order for the use of a LAL or another pressure relieving mattress for Resident 10.
A review of a Change in Condition Evaluation dated September 5, 2017 indicated Resident 10?s left hip (site 1) Stage 3 pressure sore developed into an unstageable pressure sore [80% black eschar (dead tissues) and 10% slough (dead subcutaneous tissue)].
A review of Resident 10's September 2017 TAR indicated monitoring for proper functioning and set up of a LAL mattress for wound management began on September 6, 2017. Resident 10's September 2017 TAR indicated that monitoring for both heel protectors also began on September 6, 2017.
A review of the Nursing Progress Notes dated September 9, 2017 indicated Resident 10 was transferred to a GACH.
Resident 10 returned to the facility on September 16, 2017. According to the Nursing Progress Note dated September 16, 2017, by Treatment Nurse 2, indicated Resident 10 the pressure sores as follows:
1. Right lateral heel Stage 3
2. Right middle foot DTI
3. Left greater trochanter unstageable pressure injury,
4. Left inferior (lower) greater trochanter open blister
5. Left inner knee Stage 3
6. Sacro-coccyx Stage 2
A review of the Nursing Progress Note dated September 18, 2017 by Treatment Nurse 1 indicated Resident 10 developed three additional pressure sores:
1. Right lateral malleolus (outer ankle) DTI
2. Right lateral foot DTI
3. Left lateral knee DTI.
Resident 10 had a total of nine pressure sores.
A review of Resident 10's Physician's Order dated September 18, 2017 indicated to provide Resident 10 with a LAL mattress and to monitor functioning of the LAL mattress. Resident 10, who was bed bound (remained in bed), was not provided with a pressure relieving mattress until September 18, 2017, after developing a total of nine pressure sores since initial admission to the facility.
On October 10, 2017 at 10:45 a.m., Treatment Nurse 1 was observed performing treatment to Resident 10's pressure sores with the assistance of Certified Nursing Assistant 11 (CNA 11). Resident 10 had wound dressings to the right foot, left outer knee, and left inner knee. After removing the disposable incontinent pad, Treatment Nurse 1 and CNA 11 turned Resident 10 towards the right side in preparation for cleaning a Stage 2 pressure sore to the sacro-coccyx area. There were two additional dressings to Resident 10's left hip and buttock, which appeared soiled. After cleansing and dressing the sacro-coccyx pressure sore, Treatment Nurse 1 and CNA 11 turned Resident 10 towards the left side in preparation for cleansing a pressure sore to the right buttock. Once Resident 10 was turned towards the left side, Resident 10 was observed to have an open area to the right hip. Treatment Nurse 1 stated the open area to the right hip was a new Stage 2 (outer layer of the skin and part of the underlying layer of skin is damaged or lost) pressure sore, which was not present the day prior. CNA 11 stated she noticed the open sore in the morning when providing care to Resident 10 but did not report it to Treatment Nurse 1 or the RN.
A review of the facility's policy and procedure revised on November 28, 2016, titled, "NSG236 Skin Integrity Management," indicated the purpose of the policy was to provide safe and effective care to prevent the occurrence of pressure ulcers, management treatment, and promote healing of all wounds. The policy indicated to notify the dietitian as indicated but did not specify when the dietitian should be notified.
On October 10, 2017, at 3:35 p.m., during an interview, RD 1 stated licensed nurses are to notify the RD when a resident developed a pressure sore in order to determine if the existing nutritional support was appropriate and to recalculate the estimated needs for calories, proteins, and fluids. RD 1 reviewed Resident 10's clinical record and found RD evaluations of Resident 10 dated June 21 and July 27, 2017. RD 1?s documentation did not address Resident 10?s pressure sores.
On October 11, 2017 at 6:30 p.m., during an interview, LVN 12 reviewed the Nursing Progress Notes and confirmed Resident 10 was not on a LAL mattress from June 26 to June 28, 2017.
On October 12, 2017 at 9:37 a.m., during an interview, Treatment Nurse 1 stated that the Maintenance Supervisor (MS) was verbally notified when a resident needed a LAL mattress. Treatment Nurse 1 stated that all LAL mattresses were distributed to other residents on June 26, 2017. MS contacted a rental company to obtain a LAL mattress for Resident 10.
During an interview on October 12, 2017 at 11:36 a.m., the Director of Staff development (DSD) confirmed there was no documentation in the physician's orders and Nursing Progress Notes indicating Resident 10 was on a LAL mattress after re-admission on July 20, 2017 through August 2017.
The facility used the Pressure Injury/Ulcer Prevention Guideline revised on 2005 as a resource. The guideline indicated to evaluate for presence of specific risk factors and develop plan of care to address the following risk factors: Impaired/decreased mobility or function, bed mobility problem, and cognitive impairment. The Pressure Injury/Ulcers Prevention Guidelines indicate observation of the skin would be performed daily.
The facility failed to ensure its residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan to prevent the development of pressure sores and to promote healing, including:
1. Failure to provide Resident 10 with a LAL mattress as ordered by the physician on June 26, 2017.
2. Failure to provide a pressure relieving mattress to Resident 10 to prevent the development of pressure sores, promote healing and prevent re-occurrences of pressure sores.
3. Failure to notify the RD of Resident 10's pressure sores to obtain nutritional evaluation and recommendations to promote wound healing.
4. Failure to ensure CNA 11 notified a licensed nurse of a new open sore to Resident 10's right hip.
As a result, Resident 10 developed a left hip deep tissue; a DTI to the sacro-coccyx area; a left hip Stage 3 pressure sore which deteriorated into unstageable pressure sore; and a right lateral (outer) hip Stage 2 pressure sore.
The above violation presented either an imminent danger that death or serious harm would result or substantial probability that death or serious harm would result to Resident 10. |
| 970000003 |
ALEXANDRIA CARE CENTER |
920013642 |
B |
21-Nov-17 |
6IC011 |
4606 |
?483.12(b) The facility must develop and implement written policies and procedures that:
?483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property
?483.12(b) The facility must develop and implement written policies and procedures that:
(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,
(2) Establish policies and procedures to investigate any such allegations, and
(3) Include training as required at paragraph ?483.95.
On October 3, 2017, during recertification survey, the grievance of Residents 37, 38 and 39?s Family Members were investigated.
Based on observation, interview, and record review, the facility failed to implement written policies and procedures to ensure Residents 37, 38 and 39 were free from abuse and neglect, including:
1. Failure to implement the facility?s policy and procedure on Abuse Prevention Manual ? Investigation, Corrective Actions and Administrative Action, by not conducting a thorough investigation of the allegations of Residents 37, 38 and 39?s mistreatment and neglect voiced by FM 5, FM 6 and FM 7.
2. Failure to implement the facility?s policy on Grievance/Concern, by not taking immediate actions to prevent further potential violations of any resident?s right while alleged violation were investigated and by not developing and implementing corrective actions.
As a result, Residents 37, 38 and 39 were subjected to mistreatment and neglect.
a. According to the Admission Record, Resident 37 was admitted on July 6, 2017, with diagnoses that included muscle weakness and difficulty in walking.
A review of the grievance received on July 23, 2017 indicated Resident 37's family member (FM 5) reported that on July 22, 2017 at around 4:00 p.m. to 4:30 p.m., Resident 37 had diarrhea (watery stool), pressed the call light and a nursing staff just turned off the light without even checking what Resident 37 wanted. The grievance form did not indicate administrative staff interviewed other residents or staff in regards to the alleged incident.
b. According to the Admission Record, Resident 38 was originally admitted on July 7, 2009 and re-admitted on June 16, 2017, with diagnoses including muscle weakness, contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).
A review of the grievance received on July 19, 2017 indicated Resident 38's family member (FM 6) reported concerns the night shift (11 p.m. to 7 a.m.) did not turn and reposition Resident 38 and resulted on Resident 38 developing wounds on her backside. The grievance form did not contain an investigation.
c. According to the Admission Record, Resident 39 was originally admitted on June 11, 2017 and re-admitted on August 28, 2017, with diagnoses including muscle weakness and cellulitis (a bacterial skin infection) of the abdominal wall.
A review of the grievance received on July 19, 2017 indicated Resident 39's family member (FM 7) reported the Certified Nursing Assistant working between the 11 p.m. to 7 a.m. shift, did not check on Resident 39 because she visited Resident 39 at 7 a.m., and Resident 39 was soiled with bowel movement all the way up to Resident 39's back. The grievance form did not contain an investigation.
On October 10, 2017 between 4 p.m. to 4:37 p.m., during an interview while reviewing the Grievance forms, the Administrator stated the grievance require investigation.
The facility failed to implement written policies and procedures to ensure Residents 37, 38 and 39 were free from abuse and neglect, including:
1. Failure to implement the facility?s policy and procedure on Abuse Prevention Manual ? Investigation, Corrective Actions and Administrative Action, by not conducting a thorough investigation of the allegations of Resident 37, 38 and 39?s mistreatment and neglect voiced by FM 5, FM 6 and FM 7.
2. Failure to implement the facility?s policy on Grievance/Concern, by not taking immediate actions to prevent further potential violations of any resident?s right while alleged violation were investigated and by not developing and implementing corrective actions.
As a result, Residents 37, 38 and 39 were subjected to mistreatment and neglect.
The above violation had a direct or immediate relationship to the health, safety, and security of Residents 37, 38 and 39. |
| 970000003 |
ALEXANDRIA CARE CENTER |
920013630 |
A |
21-Nov-17 |
6IC011 |
10440 |
?483.25(c) Mobility.
(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident?s clinical condition demonstrates that a reduction in range of motion is unavoidable; and
On October 10, 2017 at 12:24 p.m., during recertification survey, Resident 10?s decline in range of motion (ROM ? movement of joints) was investigated.
Based on observation, interview, and record review, the facility failed to provide services to ensure a resident with limited mobility, admitted to the facility without limitation in range of motion, did not experience reduction in range of motion, including:
1. Failure to provide Resident 10 with passive range of motion (PROM ? amount of motion at a given joint when moved by another person) exercises by Restorative Nursing Assistant (RNA) to both arms from March 24 to September 22, 2017.
2. Failure to follow the facility?s guidebook on Restorative Nursing Care Delivery Process by the therapists not ensuring adequate training of the RNAs.
3. Failure to implement the facility?s policy on Restorative Nursing by not developing a restorative care plan with specific measurable goals and interventions.
4. Failure to implement the facility?s Restorative Nursing Care Delivery Process by not having a therapist periodically monitor the effectiveness of Resident 10?s RNA program and make adjustments as needed.
As a result, seven months after initial admission to the facility, on October 11, 2017, Resident 10 was assessed as having a contracture (shortening of muscle tissues and tendons in a joint, causing limitation in the extent of movement of a joint) to the left hand with pain to movement.
On October 10, 2017 at 12:24 p.m., Resident 10 was observed to receive RNA treatment by RNA 2. RNA 2 started the session by cleaning the inside of Resident 10's left hand using hand sanitizing wipes. RNA 2 threaded the wipes through Resident 10's left thumb and fingers without opening the hand. Resident 10's left thumb was bent into the left palm. RNA 2 stated Resident 10 did not have any device to maintain the hand open. When RNA 2 attempted to open Resident 10's left hand, Resident 10 groaned and resisted. RNA 2 stated Resident 10 had pain to the left hand and required a, "Warm up." RNA 2 then proceeded to slightly extend Resident 10's left fingers and bend the left wrist. RNA 2 then performed PROM to the left elbow; however, Resident 10 refused PROM to the left shoulder. RNA 2 then proceeded to perform PROM to the right arm. At the end of the session, RNA 2 returned to Resident 10's left hand to perform PROM. RNA 2 extended the middle and tip joints of the left fingers. Resident 10's left fingers did not extend fully due to limited motion at the large knuckle joint.
A review of the Admission Record indicated Resident 10 was initially admitted to the facility on March 3, 2017 and re admitted on September 16, 2017 with diagnoses including muscle weakness, diabetes (high blood sugar), dysphagia (difficulty swallowing), gastrostomy tube (GT ? tube surgically placed directly into the stomach through the abdominal wall for long term feeding), and dementia (general term for loss of memory and other mental abilities severe enough to interfere with daily life) without behavioral disturbance.
A review of the Minimum Data Sets (MDS a standardized assessment and care planning tool) dated June 16, 2017 and September 30, 2017 indicated Resident 10 was severely impaired in cognition (thinking and memory skills) for daily decision making, required extensive assistance with one person physical assist with transfers, personal hygiene, and dressing, and had no impairment to the arms.
A review of the Occupational Therapy Initial Evaluation dated March 6, 2017 indicated Resident 10's right and left arms ROM were within functional limits.
A review of the Occupational Therapy Treatment Encounter Notes from March 8, 2017 to March 24, 2017 indicated Resident 10 received treatment for ROM exercises to improve strength, increase joint mobility, and decrease the risk of contractures (chronic loss of joint motion).
A review of the Occupational Therapy Discharge Summary dated March 24, 2017 indicated Occupational Therapist 1 (OT 1) recommended RNA program for passive range of motion (PROM) to both arms in order to maintain joint mobility and reduce risk of joint contracture.
A review of the Physician's Order dated September 22, 2017 indicated RNA to perform to Resident 10 PROM to both arms and both legs, five times per week for 90 days as tolerated. A care plan addressing Resident 10's need for PROM to both arms and legs by RNA was not developed until October 5, 2017.
A review of the facility's guidebook revised August 2016 titled, "Restorative Nursing Care Delivery Process," included the procedure when transitioning a resident from skilled rehabilitation to restorative nursing care. The procedure indicated that therapists would educate restorative nursing assistants in two to three visits at a minimum, to ensure adequate training, return demonstration, and problem solving prior to discharge from skilled therapy.
During an interview on October 10, 2017 at 2:52 p.m., the Director of Rehabilitation (DOR) stated the rehabilitation therapists do not provide training to RNAs. The DOR stated the therapists do not work with the RNAs on an individual basis for each resident because active range of motion (AROM) and PROM were basic skill sets for RNAs. The DOR was unsure who determined the competency of the RNAs.
During an interview on October 11, 2017 at 8:49 a.m., RNA 2 stated Resident 10 developed tightness to the left hand for the past three months. RNA 2 stated the Director of Staff Development (DSD who was the RNA supervisor) was informed of Resident 10's left hand in the monthly RNA meeting. RNA 2 stated RNA 3 usually worked with Resident 10.
During an interview on October 11, 2017 at 9:16 a.m. via telephone, OT 1 confirmed Resident 10's Occupational Therapy Initial Evaluation dated March 6, 2017 indicated the ROM to both arms were within functional limits (WNL). OT 1 described WNL, the ability to use the arms for daily tasks. OT 1 stated the Occupational Therapy Encounter Notes did not indicate Resident 10 had any contractures on either arm. OT 1's Occupational Therapy Discharge Summary dated March 24, 2017 recommended RNA program for PROM to both arms in order to maintain joint mobility and to reduce the risk of joint contractures. OT 1 was unable to recall training the RNAs on PROM exercises for Resident 10 and stated the therapists did not train RNAs individually for each resident.
On October 11, 2017 at 10 a.m., during an interview, RNA 3 denied receiving training from OT 1 on the exercises for Resident 10. RNA 3 stated Resident 10 tolerated PROM well except for the pain on the left thumb which according to RNA 3, was relayed to the DSD.
During an interview with DSD and DOR on October 11, 2017 at 10:20 a.m., the DSD stated Resident 10's RNA order dated April 18, 2017 was for PROM to both legs, five times per week as tolerated for 90 days. The DSD stated Resident 10 did not receive RNA services for both arms as recommended on the Occupational Therapy Discharge Summary on March 24, 2017. The DOR stated Resident 10 did not have contractures to both arms when discharged from Occupational Therapy based on OT 1's discharge summary and treatment documentation. The DOR and the DSD both confirmed Resident 10 did not have orders for RNA for both arms until September 22, 2017. The DSD denied receiving verbal report during the monthly RNA meetings that Resident 10 was experiencing decline in ROM.
During an observation on October 11, 2017 at 10:52 a.m. at Resident 10's bedside, the DOR performed an assessment of both arms. Resident 10 was observed with the left thumb bent toward the palm. The DOR described the left thumb as having a flexion contracture, which was not functional for daily tasks. The DOR also stated Resident 10 had contractures to the left fingers due to the inability to fully extend each finger when providing PROM.
A review of the facility's policy and procedure revised on March 15, 2016 titled, "NSG232 Restorative Nursing," indicated practice standards included developing restorative nursing programs appropriate to the patient's identified needs. The policy indicated the facility should develop specific measurable goals and document goals and interventions on the patient's restorative care plan and implement the restorative nursing program according to the specifics on the care plan.
A review of the facility's Restorative Nursing Care Delivery Process document dated October 1, 2010 indicated the Restorative Nursing Assistant will continue until a resident's condition has changed warranting a new evaluation of the restorative nursing program. The process indicates for programs designed by rehabilitation, the therapist will periodically observed the effectiveness of the program and adjust as needed.
The facility failed to provide services to ensure a resident with limited mobility, admitted to the facility without limitation in range of motion, did not experience reduction in range of motion, including:
1. Failure to provide Resident 10 with passive range of motion (PROM) exercises by RNA to both arms from March 24 to September 22, 2017.
2. Failure to follow the facility?s guidebook on Restorative Nursing Care Delivery Process by the therapists not ensuring adequate training of the RNAs.
3. Failure to implement the facility?s policy on Restorative Nursing by not developing a restorative care plan with specific measurable goals and interventions.
4. Failure to implement the facility?s Restorative Nursing Care Delivery Process by not having a therapist periodically monitor the effectiveness of Resident 10?s RNA program and make adjustments as needed.
As a result, seven months after initial admission to the facility, on October 11, 2017, Resident 10 was assessed as having a contracture to the left hand with pain to movement.
The above violation presented either an imminent danger that death or serious harm would result or substantial probability that death or serious harm would result to Resident 10. |