| 020000026 |
Bay View Rehabilitation Hospital, LLC |
020009078 |
AA |
05-Mar-12 |
8JFW11 |
9084 |
483.25 PROVIDE CARE/SERVICES FOR HIGHEST WELL BEINGEach 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 provide services to ensure Resident 1's highest practical physical condition when the facility did not provide care when Resident 1 was bleeding which resulted in Resident 1 bleeding to death. Record review on 12/20/10 showed that the facility admitted Resident 1, a 74-year old, on 10/16/10. Resident 1 had diagnoses that included kidney disease. His kidneys did not adequately remove waste, salts and water from his body and Resident 1 was treated with artificial kidney treatments (hemodialysis) three times each week; on Monday, Wednesday, and Friday.Resident 1 had an arteriovenous fistula (AVF) in his upper left arm. The AVF had been created by a surgeon. In the upper arm, under the skin, a large artery had been connected to a large vein so that a large amount of blood flowed rapidly. The AVF was necessary to perform hemodialysis treatments.According to radiological studies of AVF fistulas and success for hemodialysis treatments, "successful fistulas," had an average blood flow rate in AVF of, "780," milliliters (ml) every minute." (Blood flowed at a rate of approximately 1.6 pints every minute.) [Reference: Radiology, October 2002, Hemodialysis Arteriovenous Fistula Maturity: US Evaluation, pages 59 - 63]Blood flow rates in mature devices typically may reach up to 2000 ml/min. but more typically they are 800-1200 ml/min. [Reference: "Clinical Dialysis" 4th edition; 2005 Nissenson, Fine]. "If an AVF bleeds, apply direct pressure until the bleeding stops. Rationale: Bleeding can be a life threatening emergency." Reference: "Textbook of Basic Nursing," 9th edition, 2008 Lippincott Williams & Wilkins. Resident 1's nursing care plan, titled, "Kidney Dialysis: Potential Problems," dated 10/18/10, instructed that the nurse was to monitor and check the AVF every shift. There were no interventions for bleeding included in the plan. Review of nurse's progress notes, dated 11/7/10 at 12:30 a.m., showed an entry that recorded RN A's assessment of Resident 1's condition; he was pale and weak. RN A gave Resident 1 a breathing treatment and recorded his blood pressure as 110/80, pulse=70, temperature=96.4 and respirations=24.The Medication Administration Record (MAR) records, for the date 11/7/10, showed the initials of RN A to indicate that RN A gave Resident 1 a breathing treatment of Acetylcysteine (mucolytic agent: loosens up thick mucus) at 1 a.m.Nurses notes, at 2:35 a.m. on 11/7/10, showed that RN A recorded that a Certified Nurse Aide (CNA 1) told her that there was blood on Resident 1's, "chest, (left AVF) shunt and abdomen." Resident 1, "was breathing," but RN A was unable to measure his blood pressure or an oxygen saturation level (amount of circulating oxygen in the blood). Facility staff made a, "911," telephone call to transfer Resident 1 to a hospital emergency department and RN A documented in the nurse's notes the administration of another breathing treatment to Resident 1. RN A did not record any information as to the cause of blood on Resident 1's body, nor was there any information recorded as to any attempt to stop bleeding.Review of the ambulance emergency response team report, dated 11/7/10, indicated the emergency response team arrived at the bedside of Resident 1 at 2:56 a.m. Paramedic A recorded that the response team found Resident 1 with, "blood on the bed and his bandages. "Paramedic A recorded that a CNA had told him that there was, "blood everywhere..." Resident 1 went by ambulance to the hospital emergency department (ED) and arrived at 3:12 a.m.A review of hospital ED records, dated 11/7/10, showed that on arrival Resident 1 was, "pulseless," and not breathing. "...the patient (Resident 1) was pronounced dead at 3:22 a.m."The death of Resident 1 was referred to the Alameda County Coroner. Coroner Autopsy Examination Findings, dated 11/10/10, included examination of Resident 1's AVF. "There is an (oval shaped opening) defect, measuring 3/4 inch in length...""The opening leads into the (vessel)...no other abnormalities are noted." There was a hole in Resident 1's AVF. During an interview on 12/28/10 at 11:00 a.m. Paramedic A stated a call was received from the facility on 11/7/10 concerning a resident, "who was vomiting blood." Paramedic A stated he found Resident 1 lying in bed, looking pale, skin cool to touch, sweating and with an abnormal breathing pattern.Paramedic A stated "...there was no blood in (Resident 1's) mouth which is not consistent with vomiting blood." Resident 1's left arm bandage was soaked in blood. On 12/28/10 at 11:a.m. during an interview, Emergency and Fire Response Captain H stated that (Resident 1) was all cleaned up but had a blood soaked bandage on his left arm where the shunt was. He noted that the bed sheets were clean but there were blood soaked sheets on the bathroom floor. A bandage on Resident 1's left arm was blood soaked. The nurses were, "vague," about what happened and the story kept changing about when the resident was last seen by facility staff.The Coroner stated in an interview on 12/20/10 at 8:08 a.m., that his preliminary report indicated that Resident 1 died on 11/7/10 from shock due to hemorrhaging (excessive bleeding).During an interview on 12/27/10 at 2:23 p.m., Police Officer 1 stated he did an investigation because Resident 1 was dead on arrival to the hospital. Review of Police Officer 1's investigative report of the interview with RN A dated 11/7/10, indicated that RN A stated that she failed to identify the source of Resident 1' s bleeding and had not lifted, changed, removed or touched any portion of the access shunt device dressing. Digital photographs taken by the Police Officer showed several blood soaked linens and a bloody bandage from Resident 1's left upper arm where the access device was located.In an interview on 12/20/10 at 2:19 p.m. RN A confirmed that she did not apply direct pressure to the bleeding AVF and that she did not check Resident 1's AVF during her work shift or contact the physician regarding the observed change in Resident 1's condition. She stated "I was exhausted. I made up the vital signs and did not give a breathing treatment as documented at 1 a.m. I didn't know where the blood was coming from." RN A was unable to identify the signs/symptoms of hemorrhaging and stated, "I don't know ...I am blank." During an interview on 12/23/10 at 3:54 p.m., CNA 1 said she took a break at 2:00 a.m. and returned at 2:30 a.m. to check on Resident 1 and found a lot of blood around the left side of his body. CNA 1 stated she noted Resident 1 was, "breathing big breaths," so she immediately called RN A. She said RN A came into the room, took one look at Resident 1 and left to call 911. During this time, CNA 1 said she observed RN A walking back and forth in front of Resident 1's room and returning to the nurses' station to check the chart or use the phone at least three times while she (CNA 1) cleaned Resident 1 of the blood. Facility staff did not assess Resident 1 for bleeding from the AVF and did not apply pressure to the bleeding AVF.During an interview on 12/20/10 at 1:53 p.m., the facility's Executive Director stated that the facility had a Policy and Procedure (P& P) titled "Bleeding Control" dated 4/28/09, which indicated that firm direct pressure was to be applied to the site of the injury and pressure was to be maintained until the bleeding stops.In an interview on 12/20/10 at 3:09 p.m., Resident 1's attending physician stated she would expect the staff to do a full assessment of Resident 1's pale and weak condition, notify the physician and apply a gloved hand or use a towel to control the bleeding.The nephrologist, (a physician specializing in kidney disorders) during an interview on 12/21/10 at 9:56 a.m., stated he would expect the staff to put pressure if there was bleeding at the AVF. In an interview on 4/4/11 at 3:00 p.m. the Staff Developer Coordinator (SDC) who was responsible for staff training, confirmed there was no training for care of a hemodialysis dependent resident during RN A's orientation. The SDC stated that she eventually gave staff a mandatory dialysis in-service, but RN A was always too busy to attend the meeting. The SDC was unable to provide any documentation which validated a staff in-service training of care of the dialysis dependent resident prior to 11/7/10. Therefore: The facility failed to assess the condition of Resident 1 to determine the cause of bleeding and did not apply pressure to the hemorrhaging AVF thus allowing Resident 1 to bleed to death.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 and was a direct proximate cause of the death of the patient. |
| 630011713 |
Baywood Court Health Center |
020010385 |
A |
17-Jan-14 |
5DUB11 |
11183 |
F333 483.25(m)(2) RESIDENTS FREE OF SIGNIFICANT MED ERRORS The facility must ensure that residents are free of any significant medication errors. This REQUIREMENT is not met as evidenced by: The facility violated the aforementioned regulation by failing to ensure one of one sampled residents (1) was free of a significant medication error. Four licensed nurses (RN 1, RN 2, LVN 4, LVN 3) continued to give Coumadin 5 mg (milligrams) every day for four days after Resident 1's PT/INR on 9/23/13 indicated she was at high risk for bleeding, resulting in Resident 1 experiencing black tarry stools and vomiting brownish liquid on 9/27/13. Resident 1 was bleeding and was admitted to the critical care unit at the local acute care hospital for blood transfusions. On 10/8/13, record review showed that Resident 1, an 80 year old female, was admitted to the facility on 9/20/13 with a history of Atrial Fibrillation (irregular heart rate which increases risk of clot development which can cause a stroke), severe CHF(congestive heart failure), hypertension, dementia and was recovering from a pacemaker placement (pacemaker is a small device that's placed in the chest or abdomen to control abnormal heart rhythms). Review of the admission physician orders dated 9/20/13 showed Coumadin (causes delays in the blood clotting mechanism) 5 milligrams (mg) to be given once a day. The order included a lab test for PT/INR on 9/23/13. A care plan titled "Potential for Bleeding" dated 9/21/12, due to Coumadin and Aspirin 81 mg.(milligrams) use for stroke prevention indicated the interventions included monitoring and notifying the Medical Doctor (MD) if the INR ranges were above 1.8 - 2.2 for the elderly with Atrial Fibrillation. The Prothrombin Time (PT) ranges were set at 1-1/2 to 2 times the control, Normal PT + 10-13 Sec. According to the Laboratory report, dated 9/23/13, completed at 12:03 p.m., Resident 1' PT was 40.2 seconds H (high). According to the aforementioned care plan interventions the range should have been between 15-26 seconds. The INR was 4.07 H. Again, the care planned range was 1.8 to 2.2. During an interview at the facility on 10-9-13 at 11:45 a.m. LVN 1 stated that she received the laboratory results on 9/23/13 and NP 1 was in the facility so she handed the results to her. LVN 1 stated in another telephone interview on 10/21/13 at 1:30 p.m. that she also filled out the "Therapeutic Anti-coagulation Medication Flow Sheet" and placed it in the Medication Administration Record (MAR). She said that she endorsed this information to RN 1 who was taking over the PM shift at 3 p.m. on 9/23/13. LVN 1 stated that she told RN 1 that there were lab reports that came in and needed to be followed up with NP 1. However, she did not remember if she told RN 1 that Resident 1 had an elevated PT/INR or what the exact numbers were. A review of the "Progress Note" dated 9/23/13 and signed by NP 1 revealed her plan for Resident 1 was to "...hold Coumadin" and recheck (the PT/INR). The handwritten order by NP 1 dated 9/23/13 reflected, "...hold PT/INR re (check) PT/INR Wed..." PT/INR (Prothrombin Time/International Normalized Ratio (PT/INR): Prothrombin time (PT) is a blood test that measures how long it takes blood to clot. The order did not reflect NP 1's intention to hold Coumadin as indicated in her progress note.RN 1 wrote a progress note dated 9/23/13 at 11 p.m. which revealed, "Seen by NP (1) with new orders and carried out." On 10/21/13 at 1:10 p.m., during a telephone interview, RN 1 stated that the evening shift on 9/23/13 was complicated. She stated that she was in charge and had to pass medications and answer calls for the patients. She had to watch the certified nursing assistants (CNAs) and they were all busy. She worked through the registry many times and was familiar with the facility. She stated, "I saw that order and I questioned it. I said "I'm going to call that NP. I missed it on my thoughts to call. It totally went out of my thoughts." She also stated that the day shift nurse did not endorse to her anything about the labs for Resident 1. She also denied seeing the "Therapeutic Anticoagulation Medication Flow Sheet" in the MAR. She denied knowing Resident 1 had an elevated PT/INR and she was not aware of a lab result in the record nor did she look at the lab section of Resident 1's chart while taking the order off that evening. Additionally she did not read NP 1's progress note which included the plan to hold the Coumadin. During a record review on 10/8/13 the MAR reflected that: RN 1 gave the Coumadin 5 mg. on 9/23/13 at 5 p.m.; LVN 4 gave the Coumadin 5 mg on 9/24/13 at 5 p.m.; RN 2 gave the Coumadin 5 mg on 9/25/13 at 5 p.m.; RN 1 gave the Coumadin 5 mg on 9/26/13 at 5 p.m.; and LVN 3 gave the Coumadin 5 mg on 9/27/13. A review of the Therapeutic Anticoagulation Medication Flow Sheet, PT/INR/Coumadin sheet revealed an entry made on 9/23/13 at 3:30 pm showed INR results 4.07, PT results 40.2 Current Coumadin Dose 5 mg every day, date/time MD notified 9/23/13 3/30 pm. The spaces labeled "Dose Change", "Next Date PT/INR" and "Nurse's Signature" was left blank.In a telephone interview on 10/22/13 at 7:30 a.m. LVN 2 stated that on the night shift beginning on 9/23/13 and ending on 9/24/13 she checked the order left by NP 1 for Resident 1. She saw that NP 1 wrote "hold PT/INR" and thought that was what NP 1 wanted and did not question the order. She saw the Therapeutic Anticoagulation Medication Flow Sheet in the MAR but wasn't sure about it. A review of the "IDT (interdisciplinary team) Risk Meeting" record, dated 9/26/13, revealed on the back of the sheet "PT/INR ...WNL (within normal limits), MD aware). In an interview with LVN 1 on 10/9/13 at 11:45 a.m. she stated that she wrote that note on the back of the IDT Risk Meeting. She stated that RN 2 who was the Director of Nurses at the time was dictating from the chart and LVN 1 was writing down the information. She did not know where the DON was getting the information that the PT/INR was within normal limits and that the MD was aware. A review of the medical record on 10/8/13 that there were no PT/INR results from the lab tests drawn on 9/25/13, and according to LVN 1 the PT/INR was not done on 9/25/13 as ordered. According to the nurses note dated 9/27/13 at 11:00 p.m. Resident 1 did not eat dinner and wanted to go back to bed at dinner time. She took all of her medications, including the Coumadin 5 mg. At 6 p.m. Resident 1 started to vomit 100 milliliters of brownish liquid and had a black bowel movement. At around 10:30 p.m. Resident 1 vomited again about 300 milliliters of brownish liquid with some undigested food particles and had another black stool. The nurse notified the MD and received an order for Zofran IM (intramuscularly) 4 mg. (medication that blocks the actions of chemicals in the body that can trigger nausea and vomiting) as needed every 8 hours for 3 days and occult blood times 3. The Zofran IM was given at 10:45 p.m. and the first stool sample was collected. While collecting the stool sample the nurse noted that there was blood in the stool. She notified the MD again at 11 p.m. The MD stated that she wanted to wait until the morning and see if her condition changes. LVN 3 notified the family and spoke with family member who wanted to send the resident out to the hospital "right now." Resident 1 was sent to the emergency room at 12:15 a.m. on 9/28/13. In a telephone interview on 10/8/13 at 12 noon, NP 2 stated that she was looking at her calendar and she saw her notes regarding the resident's nausea and blood in stool. She had ordered Zofran and occult blood to check if there was blood in the stool. She couldn't remember how the nurse described the resident's condition or color of emesis, stool or if there was emesis. Also she did not know anything about the resident such as what medications Resident 1 was on or what her diagnoses were. NP 2 stated she did not know that Resident 1 was on Coumadin or that she had elevated PT and INR results. The MD for Resident 1 was present in the room during the telephone interview with NP 2 on 10/8/13 and stated that if it had been him in the situation, he would have asked the nurse what medications the resident was on and what her diagnoses were. He would have asked for more information about the resident's condition before giving orders. In a telephone interview on 10/15/13 at 9:25 a.m. LVN 3 verified the nurses' notes dated 9/27/13 and stated that around 6 p.m. Resident 1 started vomiting brownish liquid and had a bowel movement which was black. She went to the MAR and noticed that the resident was on iron, which she knew could make the stool black. Then around 10:30 p.m. Resident 1 was vomiting brownish liquid with food particles and had another bowel movement which was black and paste like. She called NP 2 and told her the resident vomited twice and had black stools, and she asked NP 2 if she could do a test for blood in the stool. NP 2 ordered the Zofran IM and occult blood test for the stool. LVN 3 noticed when she got the stool sample that there was blood on the diaper so she called the NP 2 back and asked "Should we send her out?" NP 2 said to LVN 3, "there's nothing we can do right now, just monitor and wait until the morning and see if her condition changes." NP 2 then advised LVN 3 that she could call the family and see what the family wanted to do. LVN 3 stated that she knew the resident was on Coumadin, but there was no lab data available. She stated that she did not tell the NP that the resident was on Coumadin and, she did not ask what her diagnoses were or what mediations she was on. A review of the Emergency Room record at the acute care hospital dated 9/28/13 at 12:46 am. the doctor wrote "...pt. (patient) brought in from SNF (facility) for n/v (nausea/vomiting) and melena (black stool) started at 6 pm earlier this evening ...Pt. just has AICD (pacemaker) placed and is on Coumadin ...General - moaning, opens eyes to voice but unable to answer questions or follow commands, ill-appearing." She was admitted to ICU and receiving PRBCs (packed cells-blood transfusion) and FFP (fresh frozen plasma, the liquid portion of Human blood" that has been frozen and preserved after a blood donation.) as well as vitamin K (promotes clotting). The note reveals at 3:30 a.m. "...pt. looks better, color better; eyes open and saying 'help me'..." A critical Care Note written on 9/28/13 revealed, "...Interventions were performed emergently to prevent sudden or life threatening deterioration." The PT and INR results taken in the emergency room were 120.0 and 19.2 respectively. Her final diagnoses were gastrointestinal bleeding, anemia (decreased red blood cells), urinary tract infection and elevated INR.After hospitalization and treatment, Resident 1 was discharged to another SNF and returned to the ER on 10/14/13 for treatment of ventricular tachycardia, hypotension and anuria (lack of urine and expired on 10/16/13.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. |
| 630011713 |
Baywood Court Health Center |
020010855 |
B |
14-Jul-14 |
VGE011 |
5644 |
THIS CITATION IS AMENDED TO CORRECT THE INCIDENT/COMPLAINT NUMBER. ALL OTHER ITEMS OF THE CITATION REMAIN UNCHANGED AND EFFECTIVE. F323 - Accidents 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 provide adequate assistance to prevent a fall for Resident 1 when one staff attempted to assist Resident 1's transfer. Resident 1 needed the assistance of two persons, or a stand lift (mechanical lift) when transferring according to the plan of care. As a result, Resident 1 lost her balance while being transferred to a wheelchair and fractured her ankle, which required surgical repair. On 8/6/13, the facility reported to the Department of Public Health (Reference Intake #365105) that Resident 1 sustained a displaced right ankle fracture when she was assisted to the bathroom by her C.N.A. (certified nursing assistant). Resident 1's record was reviewed at the facility on 8/19/13. Resident 1 was a 71 year old female admitted to the facility on 8/21/12 with diagnoses including lymphedema ( a collection of fluid that causes swelling in the arms and legs), and chronic pain. The quarterly assessment dated 6/13/13, reflected that she required two plus persons to transfer her between surfaces. She was oriented to the year, month, and date. She had functional limitations in range of motion on both sides of her lower extremities.Review of Resident 1's care plans, dated 5/3/13, showed that the facility identified that Resident 1 needed two persons to assist with her transfers. On 5/3/13, the staff included in Resident 1's Fall Care Plan, that she was to be transferred with two persons assistance or use a stand lift at all times. According to the "24 Hour Resident Skilled Care Notes" dated 8/5/13, at 3:45 p.m., the charge nurse wrote, "Notified that pt. (patient) had, "Assisted fallen" in bathroom by C.N.A. On arrival, pt. sitting supine with back leaning on toilet bowl supported with pillows. Pt. verbally expressing pain in right foot radiating to right knee...N.P. (nurse practitioner) able to assess pt. and requested resident be transferred to E.R. (Emergency Room) at a local acute hospital." According to the notes, "Patient transferred from the bathroom floor to bed using a Hoyer lift (mechanical lift) with rightleg immobilized as much as possible. She was transferred to a local hospital by ambulance.Review of the acute hospital's "Discharge Summary & Transfer Instruction," dated 8/8/13, showed the result of Resident 1's right ankle X-ray on 8/5/13 as an oblique (slanted) fracture of the proximal(nearest) aspect of the right fibula (leg bone) and a severe trimalleolar (three ankle bones) fracture dislocation of the right ankle joint. The hospital discharge Summary, dated 8/8/13, included a report called, "Treatment Rendered & Hospital Course." It reflected that "Patient was admitted in the hospital for ankle fracture after a fall.....O.R.I.F. (Open Reduction Internal Fixation-surgical procedure used to treat a bad fracture) was performed." Review of C.N.A 1's employee file showed she was hired to work at the facility on 1/16/13. The review showed that on 5/13/13, C.N.A. 1 was given a verbal counseling for failing to ensure the alarm was on a resident whom the facility identified as high risk for falls, and that this incident contributed to a resident's fall. The record review showed that on 8/5/13, C.N.A. 1 was counseled for failure to follow instructions on a resident's safe transfer and handling, which caused the resident (1) to sustain right knee pain and a right ankle fracture. C.N.A. 1 was given a "Safe resident transfer and handling" in-service on 5/29/13. C.N.A. 1 was terminated from the facility after the incident with Resident 1 on 8/5/13.On 8/19/13 at 2:00 p.m., during an interview, Resident 1 described what happened in the bathroom on 8/5/13. "The girl (C.N.A. 1) tried to pick me up but she couldn't because I'm heavy. Usually there are two nurses to help me transfer. But this girl always transfers me herself. I was frightened. My ankle was bending over. It was painful. I'm still in pain. Thank God for pain pill. I broke my right ankle. They get me up with a Hoyer lift now. I feel safe." During a telephone interview on 8/20/13 at 9:30 p.m. C.N.A. 1 said, "It was 3:20 p.m. She (Resident 1) said she wanted to go to the bathroom. When she finished using the bathroom, she stood up with her hands on the bar. I was cleaning her while she was standing up holding the bar in the bathroom. Then she said, "My legs. I can't stand up." I tried to get the wheelchair and tried to put it back of her, but she was too low to the floor. I was calling help, but no one came for one to two minutes. The front desk nurse came and helped me. I always transfer her by myself. They didn't tell me she was a two person transfer. But everybody is so busy. No one has time to help you transfer the residents." The charge nurse was interviewed on 8/20/13 at 2:10 p.m. He stated, "Resident 1 requires two person assist with transferring, and the C.N.A (1) was informed during the shift report.Therefore, the facility failed to provide adequate assistance to prevent a fall in accordance with Resident 1's care plan for two persons or standing mechanical lift support for transfers and, as a result, Resident 1 fell and fractured her ankle. This has a direct or immediate relationship to patient's health, safety or security. |
| 020000026 |
Bay View Rehabilitation Hospital, LLC |
020011017 |
B |
26-Sep-14 |
DMY511 |
15209 |
F 284 483.20(l)(3) ANTICIPATE DISCHARGE: POST-DISCHARGE PLANWhen the facility anticipates discharge, a resident must have a discharge summary that included a post-discharge plan of care that was developed with the participation of the resident and his or her family, which will assist the resident to adjust to his or her new living environment. The facility violated the aforementioned regulation, by failing to provide discharge preparation with information concerning continuing care post-discharge for three (1, 2, 3) of three sampled residents. Residents 1, 2 and 3 were discharged to an unsafe situation and were turned away at the designated accepting facility due to their medical needs. Since the designated facility refused to readmit the residents, all 3 had to be sent to the hospital for treatment of possible dehydration and missed medications. As a result of the inappropriate transfer, Residents 1, 2 and 3 resided in the hospital for four nights.On 7/2/14 at 8:00 a.m., during a phone interview, the hospital social worker (SW 2) stated, "The three residents (1, 2, 3) arrived via ambulance from Agency 2 (an unlicensed transitional housing unit for homeless men and veterans) and we couldn't turn them away." The Social worker stated she contacted the facility where they resided prior to going to the transitional housing place. The Social Worker stated "The facility refused to take them back; they (Residents 1, 2, 3) were admitted to the observation unit (of the hospital) on 6/28/14. None needed medical care. They were weak and hadn't eaten. I called the facility again on the following Monday and left messages. No one called back. On 6/30/14, I spoke to the ADM (administrator) and assistant social worker and they refused to re-admit." 1. On 7/4/14, review of the medical record showed Resident 1 was admitted to the facility on 1/29/14 with diagnoses that included brain neoplasm (tumor), seizures, acute venous embolism (a clot obstructing a vein), HIV, and stroke with hemiplegia (paralysis on one side of the body). A physician's order, dated 4/12/14, showed that Resident 1 had capacity to make healthcare decisions. Review of the physician's orders showed a discharge order dated 6/27/14 for Resident 1 to be discharged to Agency 2 (a boarding house type facility). The Post Discharge Plan of Care, dated 6/27/14, showed date of admission and date of discharge, name and address of accepting agency; name and phone number of home health agency for PT (physical therapy); "follow up with primary physician, equipment needs: wheelchair." The accompanying form, titled "Release of Responsibility for Medications" showed a list of twelve medications with administration directions. The column "Time to be Taken" and "Amount of Medication Leaving" were blank. One of the medications listed was Depakote for seizure prevention. Patients who take Depakote must have blood levels drawn routinely to maintain a therapeutic level in the bloodstream. Resident 1 was sent to Agency 2 (boarding house type facility) but was never admitted and according to the ambulance staff's documentation, dated 6/27/14, "Responded code 2 (not emergency) as the third ambulance for a group of patients with unknown problems. The patient designated to me first was a 47 year old male (Resident 1) with a headache. On scene sitting in a wheelchair outside of (receiving facility)...Patient was kicked out of [Facility A] along with 2 other patients stating that their time for rehab is over....When patients arrived at the accepting facility (Agency 2) , they realized that none of the patients were ambulatory. Staff refused in taking them due to the fact that they are not equipped to handle patients of this nature. Paramedic supervisor notified of abandonment situation ...Taken to hospital." According to the hospital emergency department report, dated 6/27/14, "Patient (Resident 1) complained of headache for three days getting worse. Patient discharged from [Facility A] this morning to board and care facility with two other individuals. All three were deemed unacceptable for admission after arriving due to medical complaints and 911 was subsequently called with patients transferred here. (Facility A) has been called and they refuse to take the patient back into their facility." During interview on 7/1/14 at 10:35 a.m., the Director of Nurses (DON) stated, "The physician did not document lower level of care was needed. We got a telephone order only." When asked how the interdisciplinary team (IDT) planned discharges, DON stated, "We need to get together on planning discharges." DON confirmed that there were no IDT notes about discharge planning. During interview on 7/1/14 at 11:15 a.m., RN 1 was asked what medications were sent with the resident and what arrangements were made for laboratory tests. RN 1 stated, "We don't know what meds were sent. There's nothing written about where to go for lab work. He should have blood drawn for Depakote level (an anti- seizure medication)." During interview on 7/1/14 at 3:15 p.m., the Rehabilitation Director stated, "He (Resident 1) was wheelchair-bound. We loaned him a wheelchair when he was discharged. We should all be getting together about discharge planning." 2. According to the medical record at Facility A, Resident 2 was admitted to the facility on 5/29/14 and discharged on 6/27/14. His diagnoses included acute respiratory failure due to heart failure and severe hypoglycemia (low blood sugar) due to liver mass. There was a physician's order, dated 5/29/14, showing that Resident 2 had capacity to make healthcare decisions.A form titled "Certification and Recertification", dated 5/29/14, showed, "Speech therapy 5x/week for 12 weeks for cognitive and communication deficit. PT for difficulty walking 5x/week for 12 weeks. Due date- 7/1/14." Social Service Notes, dated 6/26/14, showed that a staff person from the accepting facility (Agency 2) visited the resident..."and was accepted into their facility. SSD met with resident who agreed to be transported the facility. 6/27/14- Resident was discharged with home health, PT (physical therapy), OT (occupational therapy), front wheel walker and commode. Orders were given to ... home health agency." 6/28/14- Was informed that resident is at the hospital." The "Post Discharge Plan of Care, dated 6/27/14, "showed a blank area under "Special Training/ Instructions." There was a list of twelve medications with blank spaces under the headings, "Time to be Taken," and Amount of Medication on Leaving." The headings, "Special Training/ Instructions," and "Accuchecks (finger stick blood sugar checks) and "Blood pressure 'How to take'" were blank. The medication list showed "Check FSBS (fingerstick blood glucose) every four hours around the clock; and Lisinopril (medication to lower blood pressure) 10 mg (milligrams) one tab orally daily hold is SBP less than 100." According to the ambulance staff's documentation, dated, 6/27/14, "Dispatched code three for 'dehydrated patient, possibly multiple patients.' Arrived on scene to find three patients sitting in front of address in no acute distress. Patient is currently complaining of shortness of breath. Patient was admitted to [Facility A] on 5/19/14 with diagnosis of congestive heart failure (CHF). Patient has been on home oxygen and prescribed Lasix (diuretic)... He cannot get up the stairs. Also, patient has no spare oxygen tanks. Patient states, "I'm supposed to be in an in-home care facility and states he wants to go back to [Facility A] or another facility that can take care of him properly."The hospital emergency department documentation, dated 6/27/14, showed, "Presenting problem: Shortness of breath due to CHF, primary lung disease,..anxiety. History: 73 year old male brought to ER by paramedics. Patient was transferred to accepting facility with two other patients, but found to be inappropriate for the facility. 911 was called and paramedics arrived on the scene. [Facility A] has been called and they refuse to take patients back. Primary impression: nursing home abandonment." During interview on 7/1/14 at 9:25 a.m., Social Worker 1 (SW 1) stated, "Resident 2 was here for respiratory failure...On 6/27/14 at 2:00 p.m., he was picked up by the accepting facility. At 7:00 p.m., I got a call that he was in the hospital. I called the accepting facility and asked why we were not called. I was told that he ran out of oxygen and they called 911. The other two went along in the ambulance. All three are still at the hospital." During interview on 7/1/14 at 9:35 a.m., Social Service Designee (SSD) stated, "I guess we should have taken them there to make sure they liked it. None of us have seen the facility." During further interview and concurrent record review on 7/1/14 at 2:00 p.m., the SSD was asked about the physician's order, dated 5/29/14, "treat hypoglycemia (low blood sugar) per treatment protocol." SSD stated, "You should ask nursing. We never had an IDT meeting to discuss his discharge." During interview on 7/14/14, at 11:20 a.m., SSD stated, "I expected they (receiving facility) would take care of the oxygen, showering, dressing. He (Resident 2) was on oxygen with a tank attached to his wheelchair. Their staff told me they could get oxygen across the street at a medical supply."During observation and interview on 7/14/14 at 1:00 p.m., Resident 2 was sitting in a wheelchair, dressed in street clothes, in his room. He had used the urinal and the front of his pants was wet. When asked about being discharged and being brought back to the facility, Resident 2 stated, "They didn't check the place out and tell them I needed care. When I got there, the owner sent me by ambulance and then I came back here. I need a care home." 3. According to the medical record, Resident 3 was admitted to the facility on 6/21/14 with diagnoses that included respiratory failure, pneumonia, and alcohol and opiate withdrawal.Social Services Notes, dated 6/23/14, showed "Resident stated he is homeless and would need a place to live on discharge. ...SS to assist with resources and placement. 6/26/14- Resident spoke with receiving agency staff and agreed to go there. 6/27/14- Spoke with receiving agency and they stated they can pick him up today." According to federal regulations, a "post-discharge plan of care" means the discharge planning process which includes: assessing continuing care needs and developing a plan designed to ensure the individual's needs will be met after discharge from the facility into the community. According to the facility's policy and procedure, titled "Discharge Summary and Plan," revised 12/12, "When a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/ her new environment." The list of items included in the discharge policy summary were "Sensory and physical impairments; nutritional status and requirements, special treatments or procedures; and mental and psychosocial status." The section titled "Content of Post Discharge Plan," showed, "The post-discharge plan will be developed by the Care Planning/ Interdisciplinary Team with the assistance of the resident...and will contain, as a minimum: a description of the resident's preference for care; a description of how the resident will access such services; a description of how care should be coordinated if continuing treatment involves multiple caregivers; the identity of specific resident needs after discharge and a description of how the resident should prepare for discharge. The representative (sponsor) should provide the facility with a minimum of 72 hours notice of a discharge to assure that an adequate discharge plan can be developed. The social service department will review the plan with the resident...twenty-four hours before the discharge is to take place." This facility policy defined documentation requirements as, "Documentation from the Care Planning Team concerning all transfers or discharges must include, as a minimum, and as they may apply: The reason for the transfer or discharge; that an appropriate notice was provided to the resident; that the resident...participated in a pre-discharge orientation program; the new location; the mode of transportation, a summary of the resident's overall medical, physical, and mental condition; and disposition of medications. The attending physician must document that the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility." During interview on 7/1/14 at 8:50 a.m., the facility administrator (ADM) stated, "These three residents no longer needed skilled care. Our social workers contacted the receiving facility and their staff came here and assessed the residents and accepted them. They were transferred there on 6/27/14. The following day, the hospital called and said 'We have your three residents here and need to send them back to you.' We refused and all three remain at the hospital."The medical record contained a copy of the Post Discharge Plan of Care, dated 6/27/14. It showed that Resident 3 was discharged, "Home" and to, "Transitional housing," The areas for post discharge plans/community agencies, equipment needs, special training/ instructions were blank. Medications were listed with medical abbreviations, not in common language. There was no notation of quantity given or instruction for re-fills.The "Controlled Drug Record" showed that an unknown number of Hydrocodone 10 mg (milligrams) (an opiate pain control drug) with Tylenol 325 mg was given to the resident with no written instructions. According to the ambulance staff's documentation, dated 6/27/14, "Dispatched code 3 as the second unit for multiple patients with unknown problems. Upon arrival, this patient complained of 6 out of 10 chest pain upon inspiration and palpitations. The patient states he was discharged from a SNF...and was supposed to be taken to a transitional housing facility that could facilitate his medical needs and rehabilitation. Upon arrival at the facility, was informed that they could not accommodate his needs and activated 911 due to concern over his health needs. Hospital emergency department (ED) records, dated, 6/27/14, showed, "Discharged from another hospital with diagnosis of pneumonia 2 weeks ago. Presents today, per emergency medical technicians, with complaint of SOB, pneumonia and chest pain. History: ...a 50 year old male who was brought to the ED by paramedics. Patient was transferred from [Facility A] to a board and care center with two other patients, but found to be inappropriate for the facility as he is on oxygen. 911 was called ...[Facility A] has been called and they refuse to take the patient back."During phone interview on 7/8/14 at 10:30 a.m., Staff A at Community Care Licensing stated that the accepting facility was not a board and care. "They are not licensed for care." Therefore the facility failed to: Ensure that Residents 1, 2 and 3 received proper discharge evaluations, instructions and were sent to an appropriate level of care. The facility also refused to readmit the residents to the facility. |
| 020000060 |
Baypoint Healthcare Center |
020011957 |
B |
13-Jan-16 |
MZ3811 |
4883 |
F 323 483.25 (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 a safe environment when the registered nurse in charge (RN 1) failed to assess a bariatric resident's need for more than one staff person when turning Resident 1. RN 1 also failed to instruct the certified nursing assistant (CNA 1) on proper turning and safety needs for a bariatric resident. These failures resulted in Resident 1 falling over the half side rail to the floor when CNA 1 asked Resident 1 to turn away from her and there was no one on the other side to support Resident 1 and prevent her from rolling off the bed. (Bariatrics is the branch of medicine that deals with the causes, prevention and treatment of obesity.) The facility also failed to ensure that RN 1 knew the protocol for calling 911 to assist Resident 1 back to bed and to take her to the hospital. This failure resulted in Resident 1 spending the entire night on a mattress on the floor without a physician's assessment which placed Resident 1 at risk for unrecognized injuries and delayed treatment. Resident 1 was sent to the hospital's emergency department the next morning for evaluation of increased back pain after the fall. Review of the medical record showed that Resident 1 was admitted to the facility on 10/19/15 with diagnoses that included chronic pain, diabetes, and high blood pressure. Resident 1 was middle aged, weighed over 400 pounds and was alert, oriented, and able to express her needs. A nursing note, dated Monday, 10/19/15 at 11:45 a.m., showed that Resident 1 had, "...No pain or discomfort. Skin assessment done. Kept resident comfortable. Call light within reach..." The facility document titled, "Change of Condition," showed, "At 1:30 a.m., before CNA [CNA 1] start to do diaper change, she was giving instructions, the patient turned so fast that she slid slowly from the bed down to the floor. She landed at the right side of the bed. Alert and oriented, aware of what happened, on assessment, no injury, no skin tear, no bumps noted at this time. Able to move all extremities..." A "Fall Risk Assessment" on the day of admission,10/19/15, showed "History of Falls in past 3 months- 3 or more," Chair bound, unable to stand, and a total risk score of 12." On the Fall Risk Evaluation Document there was the following instruction: "...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 and documented on the care plan." During phone interview on 10/29/15 at 2:30 p.m., RN 1 stated, "I'm the charge nurse on night shift. The other licensed nurse is an LVN (licensed vocational nurse). It was my first time taking care of someone who weighed over 300 pounds. The CNA [CNA 1] was going to change her brief. The CNA was alone. No one was on the other side of the bed, the side where she fell. She was on the floor when the CNA called me. Only the top quarter railing was up. We tried to put her back to bed but couldn't. ..I didn't call 911 because I was in doubt. I didn't do a skin check. I gave her pain and anxiety medication. I should have called the MD and the RP [responsible party] and made out an incident report. The verbal report I got didn't say she was at risk for falls. I didn't know her capability of moving and neither did the CNA. I didn't call the DON. [Director of Nursing] I was in doubt."During a phone interview on 11/2/15 at 2:15 p.m., CNA 1 stated, "She [Resident 1] called and wanted a change of brief. She turned by herself while we were talking. She fell through the railings and I couldn't stop her. I will take another staff with me in the future." A "late entry nursing note, dated 10/20/15, showed, "All night shift staff started to put her (Resident 1) back to bed. Tried Hoyer (mechanical) lift but sling did not fit patient and also not appropriate for her size. Several attempts done by staff using bed sheets but not able. This writer was in doubt to call fire department at this time for help. Instead, she was provided with another mattress placed next to her bed and slowly help her to this mattress and put several pillows for support. Was offered Ativan to relax her and Ultram for complaint of muscle strains due to being on the floor...." On 10/20/15 at 9:40 a.m., the physician wrote an order to transfer Resident 1 to the hospital via a bariatric basic life support (with equipment and technicians who know how to care for a bariatric resident) for evaluation of increased back pain after the fall.This violation had a direct or immediate relationship to the health, safety or security to Resident 1. |
| 020000060 |
Baypoint Healthcare Center |
020011961 |
B |
13-Jan-16 |
MZ3811 |
6372 |
Title 22 72527(a)(12) PATIENT RIGHTS Patients shall have the right: To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. The facility violated the aforementioned regulation by failing to honor Resident 1's right to considerate and respectful care when Resident 1 was left on a floor mattress all night after rolling out of bed. The facility did not provide services necessary for Resident 1's special needs as an individual with a bariatric condition. The facility lacked adequate staff, the proper lift equipment and did not call for guidance or emergency assistance. Resident 1 stated that she felt abandoned, depressed and angry as she lay on the floor all night. Review of the medical record showed that Resident 1 was admitted to the facility on 10/19/15 with diagnoses that included chronic pain, diabetes, and high blood pressure. Resident 1 was middle aged, weighed over 400 pounds and was alert, oriented, and able to express her needs. Review of the facility's policy and procedure, titled "Change in Resident's Condition," no revision date, showed, "Purpose: To clearly define guidelines for timely notification of a change in resident condition. Responsible Discipline: RN (registered nurse), LVN (licensed vocational nurse); Policy: It is the policy of this facility that all changes in resident condition will be communicated to the physician. 2. If unable to contact the attending physician TIMELY, notify Medical Director for follow-up to change in resident condition. The nurse in charge is responsible for notification of physician prior to end of assigned shift when a change in a resident's condition is noted." Review of a facility document titled, "Change of Condition," dated 10/20/15 showed, "At 1:30 a.m., before CNA [CNA 1] start to do diaper change, she was giving instructions, the patient turned so fast that she slid slowly from the bed down to the floor. She landed at the right side of the bed. Alert and oriented, aware of what happened, on assessment, no injury, no skin tear, no bumps noted at this time. Able to move all extremities..." A "late entry" nursing note, dated 10/20/15, showed, "All night shift staff started to put her [Resident 1] back to bed. Tried Hoyer [mechanical] lift but sling did not fit patient and also not appropriate for her size. Several attempts done by staff using bed sheets but not able. This writer was in doubt to call fire department at this time for help. Instead, she was provided with another mattress placed next to her bed and slowly help her to this mattress and put several pillows for support. Was offered Ativan to relax her and Ultram for complaint of muscle strains due to being on the floor...." During interview on 10/22/15 at 10:00 a.m., LVN 1 stated, "I went to see her on 10/20/15 because she was moaning. She denied pain but said she was feeling sorry for herself for her situation. She was on a mattress on the floor." During interview on 10/22/15 at 11:35 a.m., the Director of Nursing (DON) stated, "She [referring to the registered nurse in charge, RN 1] didn't know that it was okay to call 911. I told her she should have called me." During a phone interview on 10/29/15 at 2:30 p.m., RN 1 stated, "I'm the charge nurse on night shift. The other licensed nurse is an LVN. It was my first time taking care of someone who weighed over 300 pounds. The CNA (CNA 1) was going to change her brief. The CNA was alone. No one was on the other side of the bed, the side where she fell. She was on the floor when the CNA called me. Only the top quarter railing was up. We tried to put her back to bed but couldn't. ..I didn't call 911 because I was in doubt. I didn't do a skin check. I gave her pain and anxiety medication. I should have called the MD and the RP [responsible party] and made out an incident report. The verbal report I got didn't say she was at risk for falls. I didn't know her capability of moving and neither did the CNA. I didn't call the DON. I was in doubt."On 10/20/15 at 9:40 a.m., the physician wrote an order to transfer Resident 1 to the hospital via a bariatric basic life support (with equipment and technicians who know how to care for a bariatric resident) for evaluation of increased back pain after the fall. According to facility documentation, as stated above, Resident 1 was on the floor for over 8 hours. During interview and observation on 10/29/15 at 11:50 a.m., Resident 1 was lying in a bariatric bed (a bed designed and made to accommodate obese patients in a safe and comfortable manner) at facility 'B.' She was conversant with good eye contact. When asked about the fall at facility 'A,' she stated, "Only one CNA came in and she was small. She was on my back side and told me to turn away from her. We were counting to three. I kept going and she couldn't stop me. I went to the floor and landed on my buttocks. They tried to lift me but couldn't. I saw only women, no men. When I've fallen at home, I call 911 and the fire department comes and gets me up. I told them to call 911 three times and there was no leadership. They said they wanted to wait for management in the morning. They rolled me onto two mattresses on the floor and gave me the call button. I had no phone and no one offered me one. I couldn't reach anyone and was stuck on the floor. It became more depressing- the sense of abandonment. I felt anxious and have medication I take at home. I didn't sleep. They said the doctor would be in in the morning. I was checked on during the night. I had a fall at home and spent a day on the floor before my granddaughter came and found me. I have a terrible fear of falling and haven't left my home in a year. I believe the more injurious event was being on the floor all night because no one physically checked me, no visual inspection. I had to ask staff what was going on because no one told me. That's when I got angry. I know I was on the floor for twelve hours." Therefore the facility failed to observe Resident 1's right to be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. The violation of Resident 1's right produced a situation likely to cause significant humiliation, indignity, anxiety, or other emotional trauma. |
| 020000026 |
Bay View Rehabilitation Hospital, LLC |
020012676 |
B |
26-Oct-16 |
WHHQ11 |
7238 |
483.25(j) SUFFICIENT FLUID TO MAINTAIN HYDRATION The facility must provide each resident with sufficient fluid intake to maintain proper hydration and health. This REQUIREMENT is not met as evidenced by: The facility must provide each resident with sufficient fluid intake to maintain proper hydration and health. The facility violated the aforementioned regulation by failing to provide Resident 1 with enough fluids to avoid dehydration (a condition of decreased body water that results in weight loss, body chemical imbalance, and can lead to organ failure and death if not corrected). For Resident 1, this failure resulted in a five day hospitalization to treat hypernatremia (high sodium in the blood) and acute kidney injury (kidneys were unable to adequately filter waste products from the blood) due to dehydration. A review of the clinical record of Resident 1 indicated she was admitted to the facility on XXXXXXX, with the short term need for wound care of the right palm and rehabilitation. Resident 1 had a history of impaired vision and hearing, and a diagnosis of dementia (a condition of impaired memory and thinking skills).The Minimum Data Set (MDS, a resident assessment tool used to guide care), dated 3/25/15, reflected that Resident 1 required total to extensive assistance from at least one person for all activities of daily living (ADL). Review of the care plan, "Self Care Deficit: ADL's," dated 3/15/15, indicated Resident 1 required extensive assistance for eating, and staff should "offer fluids." A review of the care plan, "Dehydration Risk Assessment," dated 3/18/15, indicated Resident 1 was at high risk for dehydration. A review of the care plan, "Risk for Fluid Volume Deficit," dated 3/18/15, reflected, "assist with meals and fluid intake, encourage, offer and cue to drink more as tolerated ...Monitor meal and fluid intake." A review of the facility's, "Nutritional Assessment Screening...," dated 3/23/15, indicated Resident 1 had estimated fluid needs of 1.5 quarts to 1.7 quarts per day. The assessment also indicated Resident 1 had a history of stable weight for the last year, eating 50-75% of her meals at home, and receiving liquid supplement (increases caloric intake) when intake was low. A review of the physician's orders, dated 3/23/15, indicated Resident 1 was to receive 6.7 ounces of liquid supplement with each meal, and snacks twice a day. The "Risk for Fluid Volume Deficit" was updated on 3/23/15, to reflect the physician's orders for the liquid supplement and snacks. During a telephone interview, 4/18/16, the responsible party (RP) 1 for Resident 1, said Resident 1 went home on a four hour pass on 4/5/15, and was unable to eat or drink anything during the visit; Resident 1 just drooled and slept. RP 1 said she also noticed Resident 1's tongue seemed dry, and RP 1 voiced her concerns to the facility staff and the physician upon return to the facility. RP 1 said Resident 1 continued to lose weight over the next few days. RP 1 insisted Resident 1 go to the emergency room, on 4/11/15, when Resident 1 acted "like a zombie," and continued to lose weight. Follow-up review of the care plans showed no further updates or additional interventions dated after 3/23/15, when Resident 1 became less alert and continued to lose weight. A review of Resident 1's weights on the facility's, "Vital Sign Flow Sheet," reflected Resident 1 weighed 114.3 pounds when admitted on XXXXXXX; and 100 pounds on 4/10/15, representing a 14 pound weight loss over 24 days. A review of the Nurses' Notes, dated 4/7/15 at 1 p.m., indicated Resident 1 was "drooling, not eating loosing[sic] wt [weight]." A "Condition Change Form," dated 4/11/15 at 2 p.m., reflected "Resident [1] observed with poor appetite, decreased meal, fluids intake, lost weight, total 14 pounds since 3/18/15." The "Condition Change Form," dated 4/11/15 at 5:50 p.m., reflected "Refusing to eat or drink for some days now." At 8:40 p.m., Resident 1 was admitted to the hospital. A review of the facility's "Meal Intake Record," dated April 2015, indicated 32 meals were consumed during Resident 1's admission in April. Percentage intake of the 32 meals was as follows: 100%=5 meals; 75%=2 meals; 50 %=4 meals; 25%=6 meals; less than 25%=9 meals. A review of the "Medication Administration Record," for April 2015, indicated Resident 1's intake for all but one snack, and one liquid supplement was 50% or lower, from 4/7/15 to 4/11/15. During an interview, on 6/8/16 at 3:25 p.m., Licensed Vocational Nurse (LVN) 1 said certified nursing assistants recorded meal and fluid intake, which should then be reviewed by the resident's licensed nurse. LVN 1 said she noticed Resident 1 was not drinking and was losing weight, so she was not surprised when Resident 1 went to the emergency room. A review of the acute care hospital discharge summary, dated 4/16/15, indicated Resident 1 was admitted, on XXXXXXX, for drowsiness and weakness, altered mental state, acute kidney injury, and high blood sodium levels due to "profound dehydration," with no indication of any source of infection. The records also reflected the high blood sodium level required slow correction over three days, with discharge from the acute care hospital on 4/16/15. A review of routine laboratory blood testing for kidney health, collected at the facility, on 3/20/15 at 6:20 a.m., showed the following normal values: Sodium = 143 mEq/L (milliequivalents/Liter- how substances in the blood are measured), within the normal range of 136-145 mEq/L; Creatinine (a waste product in blood; an increased value indicates decreased kidney function) = 1.2 mg/dL (milligrams/deciliter), within the normal range of 0.6-1.3 mg/dL; Blood Urea Nitrogen (a blood waste product; an increased value indicates decreased kidney function) = 21 mg/dL, within the normal range of 7-25 mg/dL; There was one abnormal value: Glomerular filtration rate (a measurement of rate of kidney blood filtration; a decreased value indicates slower clearance of toxins) = 49.61 mL/min (milliliters/minute), below the normal range of 60-499 mL/min. A review of the emergency room blood tests obtained, on 4/11/15 at 5:15 p.m., indicated the following values: Sodium = 174 mEq/L, above the normal range of 133-145 mEq/L; Creatinine = 5.04 mg/dL, above the normal range of 0-1.11 mg/dL; Blood Urea Nitrogen = 91mg/ dL, above the normal range of 7-27 mg/dL; Glomerular Filtration Rate = 10, below the normal range of greater than 60 mL/min. A review of the Merck Manual, Professional Version, reflected "The major signs of hypernatremia result from central nervous system dysfunction due to brain cell shrinkage. Confusion, neuromuscular excitability, hyperreflexia, seizures, or coma may result." (Reviewed/revised April 2016 by James L. Lewis, III, MD.) [http://www.merckmanuals.com/professional/endocrine-and-metabolic-disorders/electrolyte-disorders/hypernatremia] Therefore the facility failed to reassess the hydration status of Resident 1 when she had signs and symptoms of dehydration and failed to revise the care plan causing Resident 1 to develop hypernatremia and acute renal failure. The above violation had a direct relationship to the health, safety or security of Resident 1. |
| 630011713 |
Baywood Court Health Center |
020012887 |
B |
19-Jan-17 |
F2ZE11 |
7975 |
F323 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 follow the aforementioned regulation by failing to serve hot beverages at a safe temperature, resulting in Resident 1 sustaining a second degree, burn (involves the first two layers of skin and may present as deep, reddening and blistering of the skin) after spilling hot tea unto her left thigh. Additionally, the facility failed to implement safety precautions after the accidental burn incident, potentially placing Resident 1 and other residents at risk for another accidental burn from hot water. On 4/29/16, review of Resident 1's admission records showed Resident 1 was admitted to the facility's skilled nursing center in XXXXXXX 2012. The diagnoses included peripheral venous insufficiency (failure of the veins to adequately circulate blood from the legs back to the heart and can cause ulcers and slow healing wounds), and arthritis (joint stiffness) of the carpometacarpal joint (thumb joint responsible for a wide range of motion and pinching and grasping). The Minimum Data Set (MDS, an assessment tool which guides care) showed that Resident 1 was cognitively intact and could eat independently with tray setup help. On 4/29/16 at 12:16 p.m., during an observation and interview, Resident 1 was observed sitting up in bed. When asked how she was, Resident 1 said: "I was a lot better before I burned my leg with boiling water." Resident 1 related that she received hot tea with her evening meal yesterday (4/28/16) and when she set the cup down it caught the edge of the tray, spilling hot tea onto her left thigh. A dressing encircling the left mid-thigh was observed with dark reddened skin areas visible above and below the dressing. On 4/29/16 at 12:20 p.m., observation showed Licensed Vocational Nurse (LVN) 1 removed the dressing. There was a large, dark reddened skin area, eight inches long, beginning mid-front left thigh and ending lower inner left thigh. The burned skin, spill tract was narrow, 0.5 inches wide at the bottom and two inches at the top, and gradually widened to four inches in the center. There was a three inch diameter, fluid-filled blister at mid inner, left thigh and excoriated (skin removed as in an abrasion--second degree burns) areas around the blister. On the left front and outer side of the thigh there was a five inch by one to two inch pinkish area (first degree burn). LVN 1 said when she dressed the burn yesterday there was no blister. LVN 1 thought the spill was due to the instability of the paper trays in use. Today lunch was being served on regular trays. LVN 1 said staff poured coffee and hot water into paper cups from aluminum carafes, immediately prior to delivering each tray to a resident. LVN 1 also said, "This is the first wing [to be served] so very hot." On 4/29/16 at 12:40 p.m., RN 1 said the residents received their food and beverages on paper plates and cups, in their rooms, because the facility had a gastro-intestinal outbreak. The facility protocol is to confine residents to their rooms for meals to prevent spread of the GI symptoms. During an observation, certified nursing assistant (CNA) 2 picked up the tray of food for Resident 1 from the tray carrier and Registered Nurse (RN) 1 filled a paper cup with hot water from a carafe. RN 1 placed the hot water cup into another cup and placed it on Resident 1's tray. The cup was a regular 8 ounce, hot beverage cup, narrower at the bottom than at the top. There was no cap placed on the cup. CNA 2 delivered the tray to Resident 1 by placing it on the overbed table in front of her. RN 1 said he didn't know the temperature of the water in the carafe. Upon request RN 1 checked the temperature of a test cup of water, poured from the carafe. The temperature was 130 degrees (ø) Fahrenheit (F). (The time for a third degree burn to occur when water temperature is 130 øF is between 15 seconds and 1 minute per Moritz and Herriques. Studies of thermal injuries as referenced in the American Burn Association Scald Injury Prevention Educator's Guide 2006.) On 4/29/16 at 1 p.m., during an interview, Registered Dietician (RD) 1 said: "We like to keep it [temperature of hot liquids] 160 øF - 180 øF." RD 1 said the kitchen was late serving the trays today and that's why the temperature of the hot liquids dropped below 140 øF. RD 1 said according to the policy hot beverages should be 170 øF - 190 øF in the kitchen. RD 1 further stated, "We want it to be 160 øF - 180 øF when served." Rd 1 said the policy is the same for all residents housed in the facility: skilled nursing, assisted living and independent residents. Further interview on 4/29/16 at 1:10 p.m., and concurrent record review of the "Meal Service" policy and procedure, dated 3/13, showed the following directions: under the heading of Policy: "Meals...will be served...at the appropriate temperatures." Under the heading of Procedure : "...The food temperatures will be served on trayline at the recommended temperatures as below and recorded on the daily therapeutic menu in the temperature column...Food item: Soup and hot beverage-170 øF - 190 øF*...(*Soups and hot beverages being served immediately may be cooler so as to avoid temperature injury to the resident.)" RD 1 said she thought the concern was that the temperature of the water was in the danger zone (below 140 øF can promote bacterial growth in foods). RD 1 said she would re-evaluate the recommended beverage temperatures after hearing of Resident 1 being burned. RD 1 said the temperatures of beverages should be one of the items dietary staff checked and recorded on a daily basis and also during the monthly test tray evaluation by the RD. On 4/29/16 at 1:26 p.m., during interviews and concurrent record review, Dietary Aide (DA) 1 presented a binder with the daily logs of temperatures of foods served. There were no temperatures of beverages recorded. DA 1 said the kitchen only checked the foods. DA 1 said beverages were checked prior to serving in the skilled nursing center. Mutual review, with RD 1, of the "Test Tray Evaluation" monthly log, showed a space for hot beverage temperatures with an "Acceptable Temp" at trayline of greater than or equal to 160 øF; and in the nursing unit of greater than or equal to 140 øF. There were no recorded hot beverage temperatures in 2016. RD 1 said after checking with dietary and skilled nursing center staff, no one in either the kitchen or skilled nursing center measured and recorded hot beverage temperatures. RD 1 agreed there was no way to determine the temperature of the hot water on 4/28/16, which caused the second degree burn to Resident 1. On 4/29/16, further record review of the Resident Progress Notes, dated 4/28/16 at 6:12 p.m., showed LVN 1 noted the burn to the left inner thigh, placed a petrolatum type dressing, and notified the physician and Resident 1's responsible party. Review of the Care Plan, dated 4/29/16 at 2:14 p.m., had approaches to monitor for pain and infection. The care plan included no safety measures to prevent future burns. On 4/29/16 at 2:10 p.m., during an interview, the Director of Nursing (DON) said usually staff would go over safety measures in the morning stand-up meeting. Due to the outbreak there was no meeting today. DON said due to the GI outbreak, residents were not eating at tables in the dining room which may have prevented the hot water spill. DON agreed there should have been some precautions taken for Resident 1 so as not to place her at risk for another burn. Therefore the facility failed to ensure the residents' environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents by failing to serve hot drinks at a safe temperature to prevent burns to residents. |
| 030001525 |
Barton Memorial Hospital D/P SNF |
030009530 |
B |
28-Sep-12 |
SIEH11 |
7720 |
Patient Care Policies And Procedures - 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 6/1/11 at 1:30 p.m., an unannounced visit was made to the facility to investigate an entity self-report #CA00203145 regarding care and services.The Department determined that the facility failed to: 1. Follow its policy and procedure for patient personal alarm monitoring when they failed to ensure that Patient 1's personal alarm was always on to alert facility staff whenever she tried to get up without assistance.On 9/24/09, Patient 1's alarm was not in the on position and she was able to get up from her recliner unobserved and fell to the floor, sustaining a hip fracture.On 6/1/11 at 1:30 p.m., Patient A's medical record was reviewed. Patient A was admitted to the facility on 3/18/06 with diagnoses that included Alzheimer's, depression and anxiety. On 8/27/09 a form titled, "Pre-Restraining Assessment For Physical Restraint" read that the Interdisciplinary Team's (IDT) recommendations were that Patient A needed no restraints. Less restrictive measures included a room visible from the nurses' station and a personal safety alarm (tab alarm). The personal safety alarm would alarm to alert the facility's staff if Patient A's movement was beyond a predetermined distance. In Patient A's case, it was used to alert staff if she tried to get out of her bed or out of her recliner without assistance from facility staff members.A quarterly fall risk assessment dated 8/27/09, showed a score of 16, which meant that Patient A was at a high risk for falls. An 8/27/09 IDT care plan titled, "At Risk for Injury", read that Patient A would not ask for assistance with walking and that she had impaired mobility. Some of the approaches were to keep the call light within reach, use of the tab alarm and line of sight room.An IDT care plan dated 8/27/09 indicated that Patient A's activities of daily living (ADL) were impaired for transfers and ambulation (walking). The approaches for these problems included that the call light should be placed close to Patient A's reach and that the facility would provide assistive devices (tab alarm) as necessary.An annual, "Minimum Data Set" (MDS-a standardized tool that assesses the functional capacity of patients of long term care facilities) completed with the last signature date of 8/28/09 indicated that during this time, Patient A needed limited assistance with movement between surfaces (to/from bed, chair, wheelchair and standing position). The information collected from the documentation on the MDS, triggered a Resident Assessment Protocol (RAP) for the section titled, "ADL Functional Rehabilitation Potential". This RAP indicated that although Patient A would walk to and from the bathroom, she refused to walk assisted by facility staff. A RAP for falls indicated that Patient A was at a high risk for falls, wears a tab alarm and is in a room visible from the nurse's station for increased supervision. Review of the nurses' notes for 9/9/09, indicated that Patient A was on "alert charting" which meant that a nurse's note would be done on every shift. This extra nursing assessment documentation was due to Patient 1 having a cough and increased confusion. On 9/23/09 (entry not timed), the notes indicated that Patient A was now off alert charting. On 9/24/09 at 1:15 p.m., the nursing notes read that Patient A had been found on the floor between her recliner and bed. The notes indicated that Patient A was sitting upright on the floor against a dresser. Follow-up documentation read that Patient A's family and physician had been notified. An x-ray ordered by the physician confirmed that Patient A had broken her hip and was transferred to the hospital for care on 9/24/09. On 9/25/09, the physician indicated that Patient 1 was on a cardiac monitor, had 2 intravenous fluid therapies in place, a foley catheter and her urine output was severely decreased. The physician discussed the risks and benefits of hip surgery and the family decided to follow through with the surgery even if it meant Patient 1 would require dialysis post operatively. The physician documented that Patient 1 was to be transferred to another general acute care hospital where she would be able to receive dialysis (if needed) and also have a nephrology and cardiology consultation prior to her surgery. Patient 1 was transferred on 9/25/09 and physician documentation read that she was not stable for surgery at this time. On 9/29/09, Patient 1 underwent an open reduction and internal fixation of her broken left femur (the large thigh bone).A review of the investigation submitted to the state agency (SA) on 9/25/09 by the Director of Nurses (DON) indicated that Patient A had been on alert charting, was at high risk for falls and she was in a room close to the nurse's station for line of sight. The investigation revealed that Patient A's fall was from her recliner, was unobserved and that Patient A's tab alarm had been turned off. This meant that no alarm sounded to alert the staff that Patient A was trying to get out of her recliner.On 6/1/11 at 2:20 p.m., the Director of Nurses (DON) was interviewed. The DON stated that Patient A was a high fall risk and they had moved her to a room that was visible from the nurse's station for supervision. The DON concurred that Patient A's personal alarm had been turned off prior to the fall; however, she was not able to pinpoint when it occurred or who had done it. The DON stated that the unit would be turned off during regular daily operations such as showering, toileting, etc., but that it should have been reinstated when the care was completed. The DON stated that they were very concerned about Patient A during that time because she was very weak and they had been assessing her more frequently because of her change in condition.On 6/1/11 at 2:45 p.m., an interview was conducted with the on-duty charge nurse (CN 1) who stated that Patient A did not like to get out of her bed or recliner very often. CN 1 stated that had the alarm been on, it would have notified staff that Patient A was attempting to get out of the recliner. On 6/2/11 at 12:35 p.m., the charge nurse (CN 2) who was on-duty the day of the fall was interviewed. CN 2 demonstrated in the room how Patient A was found on the floor after the fall. CN 2 showed that the recliner was stationed across from the bed and the dresser was located a little behind both of them. CN 2 described that Patient A was found on the floor, legs spread out in front of her and she was leaning against the dresser. CN 2 was asked if Patient A was trying to get to her bed or dresser and she stated, "I'm not sure, probably the bed." CN 2 was asked if the alarm would have alerted them that she was getting out of bed and she stated, "Yes" and that the staff responds very well to all alarms.A review of the facility policy and procedure (P&P) titled, "The Posey Personal Alarm II" (dated 8/02) indicated the procedure for verifying that the alarm is working properly. Under the area titled, "Response and Documentation", read that the staff were to, "respond to the alarm immediately", when activated to check on the Patient.The Department determined the facility failed to follow its policy and procedure for ensuring that Patient A's (who was at a great risk for falling without staff assistance) electronic fall monitoring system was in the, "on" position and working.This failure presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result therefrom. |
| 100000017 |
Bethany Home Society San Joaquin County |
030010063 |
A |
08-Aug-13 |
TVGD11 |
8281 |
F323 - Free Of Accident Hazards/supervision/devices - 42 CFR 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. This citation was written as a result of an unannounced visit on 9/22/11 to investigate complaint number CA00232318, a facility reported incident.The Department determined the facility failed to ensure Resident 1's sling was in good condition and securely attached to the mechanical lift prior to and during her transfer from the wheelchair to the bed resulting in her fall from the lift and a prolonged hospitalization and surgery.Resident 1 was a 73 year old admitted to the facility on 5/26/1999. She had diagnoses including osteopenia and osteoporosis. Resident 1 required the use of a mechanical lift for transfers. The lift was a manually operated lift that utilized a sling placed under the resident. The sling was then secured to the bars of the lift by four sling attachment clips. The resident was then lifted and transferred to another surface.On 6/14/10 Resident 1 was being transferred between the wheelchair and the bed by Certified Nurse Assistant (CNA) 1. A front clip on one corner of the sling used to transfer her became dislodged causing Resident 1 to fall to the floor. She landed in a face down position.Manufacturer guidelines, dated November 2005, for the use of the lift slings were reviewed. Number 2 under "During use" directs, "Always check that the sling attachment clips are fully in position before and during the commencement of the lifting cycle, and the tension as the resident's weight is gradually taken up." Licensed Personnel Weekly Progress Notes, dated 6/14/10 at 10:10 a.m., revealed Licensed Nurse (LN) 1 was "called into Residents room by CNA. During transfer out of bed Resident fell forward onto floor. Is alert answering questions appropriately. [Complained of] neck discomfort. Able to move all extremities. [Central Nervous System] good. Abrasion top [left] foot & lateral left ankle. Bruise top [left] foot. Stabilized her neck & log rolled onto her back. [Physician] notified. New order received & noted to transfer to [emergency room] for evaluation. RN nursing supervisor notified. Notified [family member] per resident's request." Paramedics transferred Resident 1 to the acute care hospital emergency department. She arrived at the hospital at 11:20 a.m. on 6/14/10. The Emergency Department Chart indicated she complained of neck pain, right knee pain, and left ankle pain. She denied having a headache. There was no change in her level of consciousness. She had bilateral upper extremity contractures with the ability to use her hands. It was determined Resident 1 sustained a fracture to her spine at the second cervical vertebra - C2 (neck area of the spine) and an odontoid process fracture. The odontoid process is a tooth like upward projection at the back of the C2 vertebra. The odontoid process serves as the pivot point for turning the head. Resident 1 also sustained upper rib fractures and a fracture of her right femur (long bone of the upper leg) which required surgical repair. A CT scan of the cervical spine was completed on 6/14/10 at 12:55 p.m. The impression of the scan indicated, "There is a fracture involving the body of C2 with mild retropulsion (pushing) into the spinal canal. There is no [spinal] cord compression."A History and Physical, dated 6/14/10, indicated Resident 1 was admitted to the Neurological (Neuro) Intensive Care Unit of the hospital. According to the History and Physical, Resident 1 "has become hypotensive (low blood pressure) and has had [oxygen saturations] decreased into the 70s (normal is 90 - 100). She has been placed on nonrebreather mask (oxygen delivery mask that prevents rebreathing of exhaled air) and she is getting fluid boluses and [IV medication] therapy to stabilize her."A Progress Record, dated 6/15/10 at 8:30 a.m., had notations from the neuro physician. He reviewed the C-spine (neck, site of C2 injury) films and noted, "Although [fracture] is unstable some, will not require surgery."A Progress Record, dated 6/16/10 at 6 a.m., indicated Resident 1 required two units of blood because of low hemoglobin (red blood cells).A chest x-ray was taken on 6/24/10 which revealed a mild pleural effusion (an abnormal, excessive collection of fluid in the sack surrounding the lungs) with some atelectasis (partial collapsed lung). She became short of breath and was placed back on oxygen. She was started on antibiotics for pneumonia. Surgery had been scheduled for 6/24/10 to repair her femur fracture, but was cancelled due to her unstable medical condition at that point in time. Resident 1 was finally able to have surgical repair of her right leg on 6/30/10, 16 days after the fracture occurred. She had been medically unstable for surgery during the 16 days.A Discharge Summary from the acute care hospital, dated 7/5/10, indicated Resident 1 had final diagnoses including a complex C2 fracture and a distal (lower end) right femoral fracture with open reduction and internal fixation (surgery where hardware is inserted to repair the bone). Resident 1 was discharged from the acute care hospital on 7/5/10. CNA 1 was interviewed on 6/15/10 by LN 2. In a written statement by LN 2, she indicated, "CNA 1 had the resident up in the total lift and was in the process of moving her to transfer her to the bed when she fell forward onto the floor. When [CNA 1] was asked how it happened, she stated she didn't know. When questioned further about details she stated that one of the front clips came off and the resident fell forward."In a second written statement by LN 2, dated 6/15/10, she indicated, "[CNA 1] verbalized to [LN 2] her knowledge of the correct way to attach total lift slings to the total lifts. However, she was visibly shaken and could not recall whether she heard them snap into place or not. [CNA 1] stated that the resident had been up in the sling for a while without any problems noted and then when she went to move the lift the resident fell forward out of it. She was not sure how it occurred but stated that one of the front clips had somehow detached and the resident fell forward." An Incident Description Form was completed by the representative from the lift company. The lift was inspected by the representative on 6/16/10. Under the section for Device Examination, he indicated the lift was in "good condition"; however, "The accessory sling that I saw and was told was in use at the time of the incident was in very poor condition, it was very worn and had stitching coming out."He also indicated, "The lifter seems to be functioning without any problem that I could see; however, the sling that was allegedly used at the time of the incident has a clip time stamp of 4/99. The sling appears to me to be very old and in an unsafe condition."An interview was conducted with the Director of Nursing (DON) on 6/15/10 at 11:59 a.m. She stated the sling "came undone...not too sure why." She stated the mechanical lift was operational. The sling used with Resident 1 "showed some wear" around the edges. It was immediately removed from use.An interview was conducted with the DON on 9/22/11 at 1:45 p.m. She stated prior to the accident all the slings were to be replaced. Resident 1 "preferred" the older sling and one was kept in the drawer at her bedside. She stated while CNA 1 was transferring Resident 1 from her bed, the strap "somehow came off and she fell." She stated Administrative staff "did not know the sling was still being used." The Department determined the facility failed to ensure Resident 1's sling was in good condition and securely attached to the mechanical lift prior to and during her transfer from the wheelchair to the bed resulting in her fall from the lift and a prolonged hospitalization and surgery.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. |
| 040001000 |
BETHESDA LUTHERAN COMMUNITIES-GATEWAY |
040009096 |
B |
08-Mar-12 |
C7LS11 |
6799 |
Title 17, Section 50510(a) (5) 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. Complainant reported incident: CA00282371 Citation Number: 040009096 The facility failed to ensure Client A was provided prompt and appropriate medical treatment when Client A's prescribed dental procedure (placement of a crown) was not addressed for one year. A review of Client A's clinical record revealed Client A was admitted to the facility on 2/12/91. Client A's diagnoses included diabetes (high blood sugar levels) which placed Client A at a high risk for gum disease. Client A was dependent on staff for most activities of daily living due to his complex health needs. Client A was dependent on staff for scheduling and attending medical appointments. The "Health/Medical Progress Notes" indicated Client A had dental disease and was not treated for one year resulting in the loss of six teeth and mouth and jaw pain. There was no documented evidence Client A was treated for one year. Client A's clinical record contained documentation Client A had lost 16 pounds in the past six months and nothing had been done with regards to the weight loss. The dental "PHYSICIAN'S PROGRESS NOTES" dated 9/15/10, indicated Client A's tooth number 18 (second to the last tooth on the lower left side of the mouth) required a crown. Client A's clinical record contained no documented evidence of any further dental follow up until 12/13/10. The dental "PHYSICIAN'S PROGRESS NOTES" dated 12/13/10, indicated Client A's tooth number 18 needed root canal therapy (the removal of an infected nerve in a tooth, then covered with a special root filling material). The dentist further wrote, "It is recommended pt (patient) put under sedation and do procedures." The "HEALTH/MEDICAL PROGRESS NOTES" dated 12/13/10, written by Direct Support Staff 2 (DSS 2), indicated Client A went to the dentist for a follow up visit. The dentist said if Client A's tooth was repaired with a filling, the tooth would decay. The dentist said the tooth needed a crown with a possible root canal and sedation would be required to complete the procedure. The dentist gave a referral to a surgical center where the procedure could be done while Client A was under general anesthesia. Client A's "Patient Clinical Notes" dated 9/8/11 (one year later) indicated Client A had an examination with a new dentist. The note indicated tooth number 26 and 27 (second and third teeth respectively, front right side of lower mouth) were "mobile" (exquisitely sensitive to touch). The note further indicated Client A had four other teeth in need of repairs and a surgery date was to be scheduled. The "HEALTH/MEDICAL PROGRESS NOTES" dated 9/8/11, written by Direct Support Staff (DSS 3), indicated "[Client A] was in a lot of pain." On 9/19/11 at 2:05 p.m., during an interview, the Program Manager (PM) stated there had been a delay in Client A's dental treatment. On 9/19/11 at 2:40 p.m., during an interview, Client A responded to questions on how he was feeling. Client held his right lower jaw and stated "teeth hurt." When asked if he had told anyone that his teeth hurt, Client A stated "yes" and stated "[PM]." On 9/28/11 at 11:40 a.m., during an interview, Client A's Case Manager (CM) stated during Client A's quarterly meeting on 9/1/11, Client A persistently put his hand to his mouth and stated his mouth hurt. The CM stated he asked why nothing had been done and was told by Direct Support Staff 1 (DSS 1) that Client A needed to have blood work, chest x-ray and an EKG (electrocardiogram - a test that checks electrical activity of the heart) be completed before a root canal could be done. The CM further stated it had been reported during the quarterly meeting that Client A had lost 13 pounds in the past six months and nothing had been done with regards to the weight loss. A review of Client A's "Vital Signs Flow Chart" dated 3/11 through 9/11, indicated Client A weight averaged 178.5 pounds in 3/11 and averaged 162.5 pounds in 9/11. This indicated a weight loss of 16 pounds in six months. On 9/28/11 at 2:40 p.m., during an interview, DSS 1 stated she was the staff responsible for arranging client appointments. DSS 1 stated Client A had oral surgery on 9/20/11 (one year later) and had six teeth pulled and two teeth repaired. DSS 2 acknowledged there had been a one year delay for Client A's dental treatment (9/15/10 through 9/20/11). Client A's "Post-Op (after surgery) Note" dated 9/20/11 indicated, "Post Op Dx (diagnosis) included caries of the permanent dentition (teeth) and periodontal disease (inflammation and infection that destroys the tissues that support the teeth)."The note further indicated five teeth had been extracted (tooth six, 18, 24, 25, and 27) and two teeth had cavities repaired. (The Post-Op Note omitted the extraction of tooth 26). On 9/29/11 at 10:30 a.m., during an interview, the Administrator stated his expectation was to have all clinicians' recommendations followed up as soon as possible. He acknowledged that did not happen with regards to the dentist's recommendations for Client A. The facility policy and procedure titled, "Supporting and Maintaining Best Possible Health" dated 5/27/10 indicated, " It is the policy of (Facility) to be proactive in maintaining and protecting the physical health of people receiving services . (Facility) staff will take action in a timely manner in response to identified changes in conditions." The facility failed to provide medical treatment for 12 months (9/15/10 through 9/20/11) for Client A's dental needs. Due to the medical treatment delay, Client A physically demonstrated oral pain when he held his mouth and verbally stated, "Teeth hurt." Client A's physical pain resulted in a weight loss of 16 pounds in six months and he was placed on a mechanical soft diet restriction. The outcome of Client A's medical treatment delay resulted in oral surgery with the extraction of six permanent teeth and two cavities repaired. Client A's enduring loss of six teeth resulted in the continued mechanical soft diet restriction with an ongoing increased risk of choking on solid foods. The above violations 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. |
| 040001000 |
BETHESDA LUTHERAN COMMUNITIES-GATEWAY |
040009768 |
B |
05-Mar-13 |
IT9S11 |
6578 |
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 following reflects the findings of the Department of Public Health during an investigation of Complaint # CA00302405. Representing the Department of Public Health: Jan Basart RN.The facility failed to ensure Client A was provided prompt and appropriate medical treatment when Client A's dental needs were not addressed between 11/06 and 10/11 (five years).A review of Client A's clinical record revealed Client A was admitted in 1998. Client A's diagnoses included Bruxism (grinding of the teeth causing damage to the teeth), moderate to advanced periodontal disease (gum disease caused by plaque - buildup of bacteria on the teeth) and halitosis (bad breath associated with periodontal disease). 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 scheduling and attending medical appointments.The dentist's "PROGRESS NOTES" dated 2/2/06 indicated Client A had heavy cervical (gum line) plaque and calculus (hardened plaque) with associated generalized gingivitis (inflammation of the gums), along with halitosis resulting in the loss of eight teeth and mouth pain. There was no documented evidence Client A had dental treatment between 11/06 and 10/11 (four years).The dentist's "PROGRESS NOTES" dated 10/13/11 indicated Client A teeth were "obscured by heavy deposits of plaque, calculus and debris; generalized moderate to advanced periodontal disease; generalized gingival hyperplasia (swollen and inflamed gums).The dentist wrote for staff to report gingival (gum) bleeding during oral hygiene procedures. The dentist wrote Client A would require dental treatment under general anesthesia.Client A's "Patient Clinical Notes" dated 1/9/12 indicated Client A had an examination with a new dentist. The note indicated Client A had severe halitosis with tooth number nine (top tooth on the left) had been broken off just above the gum line.Due to Client A's resistance in the dental chair the dentist wrote, "fillings...deep cleaning, and extractions would have to be performed in the OR [operation room] under general anesthesia to treat pt. [patient]."On 3/15/12 at 3:25 p.m., during an interview, Qualified Mental Retardation Professional (QMRP) stated there had been a delay in Client A's dental treatment. QMRP was unable to provide documented evidence annual dental examinations had occurred between 11/29/06 and 10/13/11.On 3/15/12 at 3:35 p.m., during an interview, Direct Support Staff 1 (DSS 1) stated he had known Client A for several years and Client A's breath had always been bad. DSS 1 stated Client A's gums would always bleed when his teeth were brushed. DSS 1 stated he did not report to anyone that Client A's gums bled when his teeth were brushed. DSS 1 stated Client A had pain when his teeth were brushed because Client A would push the staff and toothbrush away when the staff attempted to brush his teeth.DSS 1 stated prior to surgery Client A would put his fingers in his mouth and drool a lot, also indicating possible pain.Client A's "Individual Habilitation Plans" dated 11/11/09, 6/10/10, 12/21/10, and 11/10/11, indicated "[Client A] does drool when he...has some discomfort to his mouth." On 3/15/12 at 3:45 p.m., during an interview, the Licensed Nurse (LN) stated Client A had oral surgery under general anesthesia on 3/8/12. Client A had eight teeth extracted, four were abscessed, two were ground down and two were impacted wisdom teeth.On 5/10/12 at 5:40 p.m., during an interview, Client A's conservator stated she had not been told that Client A had no dental treatment between 11/29/06 and 10/13/11. Client A's conservator stated during every Individual Service Plan (ISP) meeting the facility would report Client A had no cavities.Client A's conservator stated when she spoke with the dentist and heard the condition of Client A's teeth and the need for extractions it made her sick and angry. Client A's conservator stated Client A's halitosis was extremely bad and the facility staff were constantly complaining how bad it was. Client A's conservator stated she suspected Client A had pain due to his increased drooling and it had been reported he was putting his fingers/fist in his mouth. On 5/16/12 at 10:35 a.m., during an interview, Client A's case manager (CM) stated Client A's halitosis did effect the client's quality of life due to no one wanted to get close to him because of the "horrific smell."CM stated he had not been told that Client A had no dental treatment between 11/29/06 and 10/13/11. CM stated at each of Client A's ISP meetings the facility reported Client A had no cavities.Client A's "Operative Report" dated 3/8/12, indicated "Rationale for Full Mouth Dental Rehabilitation in the operating room under general anesthesia: Patient is uncooperative in the dental chair, and has dentalalveolar (tooth and surrounding bone) discomfort." The report indicated further indicated Client A's gums were red, severely inflamed with profuse bleeding on probing.The facility policy and procedure titled, "Supporting and Maintaining Best Possible Health" dated 5/27/10 indicated, "It is the policy of [Facility] to be proactive in maintaining and protecting the physical health of people receiving services. [Facility] staff will take action in a timely manner in response to identified changes in conditions."The facility failed to provide medical treatment of Client A's dental needs between 11/06 and 10/11 (five years). Due to the medical treatment delay, Client A's quality of life was impaired due to the "horrific" oral smell caused by his halitosis, oral pain when staff attempted to brush his teeth as demonstrated by Client A's placing his fingers in his mouth, and increased drooling. The outcome of Client A's medical treatment delay resulted in oral surgery with the extraction of eight permanent teeth.The above violation had a direct or immediate relationship to the client's health, safety, or security, and therefore constitutes a Class "B" Citation. |
| 630006901 |
Bonavente Laureen Home |
040010723 |
B |
12-May-14 |
CJG511 |
3700 |
SECTIONS VIOLATED - W 150 ? 483.420(d)(1)(i)CLASS B CITATION---Staff Treatment of Clients ? Staff of the facility must not use physical, verbal, sexual, or psychological abuse or punishment. The facility failed to ensure three of six clients (Clients A, B and C) were not exposed to physical and psychological abuse when they were physically locked in their bedrooms and not able to exit freely. On 4/23/14 at 4:04 p.m., an anonymous complaint was received by the California Department of Public Health, indicating Client D had reported to Complainant that three clients (Clients A, B, and C) were locked in their rooms at night. The Complainant further indicated the Complainant reported this to the House Manager (HM). The Complainant indicated the HM told her not to tell anyone about it. On 4/24/14 at 4:20 a.m., an unannounced visit was made to the facility to investigate this incident of alleged client abuse. On 4/24/14 at 4:20 a.m., during a concurrent observation and interview with Direct Care Staff (DCS) 2, Client A had his own bedroom and Clients B and C shared a bedroom. DCS 2 stated Clients A, B, and C were ambulatory and were able to go to the bathroom independently at night. On 4/24/14, Clients A, B, and C?s Comprehensive Functional Assessments indicated the clients were ambulatory and were able to use the restroom independently. Clients A, B, and C were not interviewable.On 4/24/14 at 9:15 a.m., during a telephone interview, the Complainant stated Client D told the Complainant that DCS 1 took some string and tied it from Client A's doorknob to Clients B and C's doorknob, to prevent both bedroom doors from opening. The Complainant stated Client D informed the HM and DCS 1 about the string.The Complainant stated DCS 2 placed a towel between the door and the door jamb and closed the door tightly, so the door could not be opened. The Complainant further stated, Client A had been wetting the bed because the client could not open the physically manipulated door to go to the bathroom.On 4/24/14, a review of Clients A, B, and C's clinical records, provided no documented evidence of a Human Rights Committee review, an Interdisciplinary Committee review, or the clients' conservators? consents, clinically justifying these physical and psychological restraints on their bedroom doors.On 4/24/14 at 3:55 p.m. during an interview, Client D stated DCS 1 tied a string from Client A's doorknob to Client B and C's doorknob, to lock the clients in their rooms. Client D stated she informed the HM and DCS 3 about the string on the doorknobs. Client D further stated the clients were locked in their rooms on weekends and the clients "pee-d (urinated) on themselves." On 4/24/14 at 4:15 p.m., during an interview, DCS 3 confirmed Client D had informed her about the string on the doorknobs on multiple nights. DCS 3 further stated on the nights the doorknobs were tied, were nights when all clients were "uptight, especially [Client B], who walked back and forth screaming...but I can't remember the exact dates." DCS 3 stated Clients A, B and C used the bathroom independently.On 4/28/14 at 1:40 p.m., during a telephone interview, DCS 2 stated he used a towel between the door and door jam of the outside exit door to ensure Client B would not get out because Client B had a history of elopement. For the clients, these failures denied clients of free access to exit doors during an emergency/disaster situation, denied clients of their right to be free from physical and psychological abuse, and denied clients of having their basic needs (i.e. water, food, and toileting) met. These violations had a direct relationship to the health, safety, and security of the clients. |
| 040000645 |
BETHESDA LUTHERAN COMMUNITIES-MITCHELL |
040010948 |
B |
21-Aug-14 |
6KOE11 |
20833 |
42 CFR 483.420 (d) (l) Staff Treatment of Clients The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect or abuse of the client. The following reflects the findings of the California Department of Public Health during the investigation of:Entity Reported Incidents: CA00404438 and CA00406288. The facility failed to implement policies that prohibited the neglect, mistreatment, or abuse of Client A when Direct Support Professional (DSP) 1 threw underwear at Client A's face; refused to shower Client A; refused to assist Client A to change her clothes; refused to toilet Client A timely, causing Client A (who was otherwise continent) to soil herself; left Client A wet, cold, and shivering while she was seated in the shower; and when DSP 1 told Client A to stop singing, when Client A enjoyed singing. CA00404438 1. Client A's clinical record contained documentation that she was admitted to the facility in 12/2013 and had diagnoses which included cerebral palsy, depression, and post-traumatic stress disorder. Client A's Comprehensive Functional Assessment (CFA) dated 1/3/14, contained documentation Client A only dressed herself "with help." The CFA also contained documentation Client A, "Demonstrates the ability to report abuse, neglect, and poor treatment by others." Client A, "Greets and interacts with others according to boundaries implied in relationships" and "Expresses likes and dislikes appropriately." On 7/7/14 the Qualified Mental Retardation Professional (QMRP) sent a report to the California Department of Public Health (CDPH) that on 7/3/14 (no time included), Client A alleged DSP 1 threw underwear at Client A while assisting the client to change into swimming attire. The QMRP documented he "believes (Client A) does not like the staff person in question and got upset when questioned about her lack of cooperation; wanting to change clothes by herself. The QMRP could not substantiate (Client A's) allegation The QMRP has a baseline for false allegations in place and will develop a program for this behavior."On 7/23/14 at 10:10 a.m., during an interview, the QMRP stated when he and the Program Manager (PM) interviewed DSP 1 regarding this incident on 7/3/14; she denied throwing underwear at Client A. The QMRP stated when he interviewed DSP 2 (who also worked on that date), DSP 2 stated Client A was upset when DSP 2 entered Client A's bedroom.On 7/23/14 at 12:15 p.m., during an interview, Client A stated there was a staff member who treated her badly (demonstrated threw underwear in her face). Client A was not able to recall the date of this occurrence. She stated this incident made her "feel sad." Client A stated she did not like this staff member and stated when this staff member worked, the staff member would not talk to her, (would ignore her). Client A stated she told the QMRP and PM this happened, but Client A did not think they believed her because the staff had continued to do these things to her. Client A stated she was "glad" this staff no longer worked at the facility. Client A stated she did not want the staff member to work with her anymore. When asked for clarification if Client A was referring to DSP 1, Client A immediately said "yes" and nodded her head "yes." On 7/23/14 at 4:20 p.m., during a concurrent interview with the QMRP and PM, both staff stated they interviewed all staff who were present on 7/3/14 when this allegation occurred and "did not get a sense that staff (DSP 1) had done anything wrong." The QMRP and PM stated they both left the facility on 7/3/14 at 5 p.m. or so (without placing DSP 1 on administrative leave). After this allegation was made, DSP 1 continued to work with Client A on 7/3/14 until 10:07 p.m. She also worked on 7/6/14, 7/7/14 and 7/8/14 (four days) before she was placed on administrative leave on 7/9/14. The computerized narrative note, written by DSP 1 on 7/3/14 at 8:49 p.m., contained documentation, "(Client A) had behaviors of false accusation on staff prior to swim activity... (Client A) was crying while existing (sic) her bedroom on her way to kitchen for dinner. The PM was with her as she requested to talk to PM (program manager). Client A had a complaint and was brought to Q attention. The Q had investigate among all staff on duty regarfing (sic) (Client A) complaint and was unfound... She had a good evening after dinner time." The next computerized narrative note regarding Client A, written by DSP 3 on 7/4/14 at 6 a.m., contained documentation, "This morning when she (Client A) was laying in bed waiting for staff to shower her i (sic) could smell she had a very bad oder (sic)... so i asked her if she had a shower before she went to bed and she had told me no. She proceeded to tell me she wanted one but a p.m. staff who has been here for a long time told her she wasn't (sic) getting one last night. So (Client A) told me she was mad and upset about it." On 7/24/14 at 3:45 p.m., during an interview, DSP 2 stated on 7/3/14 she had been working with Client A. She stated as she began to wheel Client A to her bedroom to change for a swimming activity, DSP 1 came and volunteered to assist Client A to change her clothes. DSP 2 stated Client A did not vocalize any objection at that time. DSP 2 stated about 10 minutes later, she was coming down the hallway checking client bedrooms, when DSP 1 exited Client A's bedroom and asked DSP 2 to switch spots with her because of the way Client A was behaving, (being combative, did not want DSP 1 in her bedroom and did not want her help). DSP 2 stated when she entered Client A's bedroom, Client A was "crying and pretty hysterical." She stated she asked Client A about four times, what was wrong but Client A repeatedly replied, "nothing."On 7/24/14 at 5:10 p.m., DSP 1 stated during an interview, she did not recall any incidents while working with Client A. DSP 1 stated the QMRP gave her positive feedback that she was doing a "good job" with Client A. When specifically asked about the allegation of DSP 1 throwing Client A's underwear at her, DSP 1 denied throwing underwear at Client A, and stated Client A became real upset and did not want her to help. DSP 1 stated she was not working with Client A that day, but assisted Client A because another staff asked her to.On 7/30/14 at 4:20 p.m., during an interview, DSP 3 stated she woke (Client A) up when she began her shift (unable to recall the exact date), but stated there was an odor coming from the client. DSP 3 stated she asked Client A if she got a shower the night before. She stated Client A replied, she "asked for one but (DSP 1) told her she couldn't have one." DSP 3 stated Client A "rolled her eyes all mad and just said (DSP 1) refused." On 8/5/14 at 2:25 p.m., Client A demonstrated her location in her bedroom when the alleged incident of DSP 1 throwing underwear at her occurred. Client A stated DSP 1 was seated on Client A's bed, texting on her cell phone. She stated DSP 1 did not assist her to change clothes or pay any attention to Client A. Client A stated DSP 1 was laughing and texting on her cell phone. Client A stated she did not know what was so funny. During this interview and demonstration, Client A frowned, had tense muscles, and showed frustration about the incident. Client A stated DSP 1 ignored her except to tell Client A to "hurry up!" Client A said that she could remove her top but taking off her shorts was difficult (due to having spastic muscles [spasms that cause uncontrolled muscle movements] and her knees, hips, and ankle joints had contractures [occurs when normally stretchy (elastic) tissues are replaced by nonstretchy (inelastic) fiber-like tissue, makes it hard to stretch the area]). Client A stated it hurt to move her legs. Client A tried to demonstrate how much she could move her legs, (not two inches) and stated she could not remove or put on clothing items on her lower body in her wheelchair. Client A stated she began screaming at DSP 1 to leave her room (because of how she was being treated), but stated DSP 1 replied to her, "you don't boss me around" and continued to sit on Client A's bed on the phone. CA00406288 2. On 7/21/14 the QMRP notified CDPH of an allegation DSP 1 was being inattentive to Client A's needs which included not toileting her in a timely manner and ignoring the client's requests for help. The report contained documentation dated 7/17/14, "...several staff members report witnessing, the staff person in question (DSP 1) not being attentive to (Client A's) needs, which includes not toileting her in a timely manner and ignoring her requests for help. Staff report coming onto their shift and finding (Client A) in the bathroom waiting to be toileted while the staff person in question is on her phone or texting..." When Client A does ask for assistance, the staff person in question will often make her wait while she finishes texting or talking on the phone or ignore the request. The QMRP's report included a written statement from DSP 4 dated 7/17/14, which contained documentation that while coming on for her shift (no date of shift included), she saw "(Client A) waiting to be toileted while (DSP 1) was in the front room on her phone." The QMRP's report also included a document dated 7/11/14 written by DSP 3, when Client A asked DSP 1 for assistance with toileting, "she (DSP 1) will walk away from her (Client A) or sit at table and text on her cell or talk on her cell phone causing (Client A) to urinate on herself." On 7/23/14 at 12:15 p.m., Client A stated during an interview, there was a staff member who treated her badly. She stated that meant the staff member did things including, not helping her go to the bathroom and telling her to do it herself, while staff texted or called her friends on her phone. Client A was not able to recall the specific dates that this happened to her, but stated it made her feel "sad" when she had to be toileted, but was not assisted by staff timely and was allowed to urinate on herself. Client A stated at times, she was also left sitting on the toilet even though she yelled out to staff for help. Client A stated she was "ignored" by staff. Client A stated she told the QMRP and the PM that these things were happening, but did not think they believed her, because the staff continued to do these things to her. When asked for clarification if Client A was referring to DSP 1, Client A immediately said "yes" and nodded her head "yes." On 7/23/14 at 4:20 p.m., during a concurrent interview with the QMRP and the PM, the QMRP stated there had been previous clashes between Client A and DSP 1 which included incidents where DSP 1 was "slow to toilet" Client A. The PM stated when toileting Client A, staff were to pull the (bathroom) door closed, but were to stand right outside and return to assist the client when needed.Client A's CFA dated 1/3/14, contained documentation Client A only toileted "with help."On 7/24/14 when direct support professionals' narrative notes were reviewed from (12/23/13 - 7/22/14) to verify any toileting accidents, a note dated 7/8/14 at 8:29 p.m., written by DSP 2 contained documentation, "(Client A) keeps telling me that (DSP 1) is mean to her when other staff are not present. (Client A) keeps bringing up the alleged incident between her and (DSP 1) from 7/3/14." On 7/24/14 at 4:15 p.m., DSP 2 stated during an interview, there were times (unsure of specific dates) that DSP 1 would take clients (including Client A) to the restroom then return to the front area of the facility. DSP 2 stated after about 10 - 15 minutes, DSP 1 would state, "Oh I forgot (client name)." DSP 2 stated if a staff member inquired where a specific client was, DSP 1 would reply, "oh, I forgot all about her." DSP 2 stated, "We're generally supposed to stand by the door, in case they (the clients) try to get up and fall."7/24/14 at 5:35 p.m., DSP 1 stated during an interview, she had not refused to provide care to any client, had not ignored any client's request for assistance, and stated she always toileted Client A when she came home from day program because she was usually the first staff on at that time (around 2 p.m.) and Client A was always the first client to arrive home.On 7/30/14 at 3:55 p.m., DSP 3 stated during an interview, she recalled an incident (about a month prior) when she was preparing to clock out from work at 2:15 p.m., Client A had just returned from her day program. DSP 3 stated Client A wheeled herself to DSP 3 to ask for assistance with toileting, but she was in a hurry to clock out. DSP 3 stated DSP 1 was also there. DSP 3 stated she told Client A to ask DSP 1 to take her to the restroom; loud enough for DSP 1 to hear her directing Client A to come to her for toileting assistance. DSP 3 stated Client A said "hi" to DSP 1, but DSP 1 did not respond to Client A. Client A responded, "Hi, how come you not talk to me?" She stated Client A then asked, "Can you take me to the bathroom?" At that point, DSP 1 walked past Client A to the back of the facility and returned with clothes for the laundry. DSP 3 stated that she had to leave, but DSP 1 had not assisted Client A to the bathroom when she left the facility. 3. On 7/21/14 the QMRP notified CDPH of an allegation a staff member (DSP 1) was inattentive to a client's (Client A's) needs. The QMRP's investigative report dated 7/17/14 also included a separate document written by DSP 3, with concerns of DSP 1's treatment of Client A. DSP 3 documented (no date provided) she was entering a note in the computer system, when she "could hear a cry for help coming from the back where the bedrooms are." Being a newer staff member, she documented she "thought it might be a behavior so I stayed in the front of the house. Looking at the clock after about 10 minutes I felt I should go see if (DSP 1) needed help and to make sure everything was ok. When I went into the back shower I see (Client A) crying as she sat on her shower chair dripping wet, no water running on her to keep her warm< (sic) no towels to dry her and No staff helping her. This bothered me very much because this crying went on for aprox (sic) 10 min (minutes) before I went in with assumption staff was with her. So I grabbed some towels and proceeded to dry (Client A) off and apologize to her that she was left like that. DSP 1 comes in as im (sic) drying her off and starts to take towel from me as she tells me she will finish her. Bothered by the fact she left her alone like that for as long as she did and in the condition she did I grabbed another towel and replied to her that I will finish her as it seems she was busy else where (sic). DSP 1 yanked the towel from me again and I then told her she needed to finish her then and not leave her until she was completely done..." On 7/23/14 at 10:25 a.m., during an interview the QMRP stated DSP 1 was no longer employed at the facility.On 7/23/14 at 12:15 p.m., during an interview, Client A stated there was a staff member who treated her badly (which included leaving her wet and cold in the shower while she texted and talked to her friends on her phone). Client A was not able to state the date of this occurrence but stated it made her feel "sad" and stated that she was "cold." When Client A stated she was "cold", she also demonstrated shivering while left wet in the shower. Client A stated she did not like this staff member. Client A stated this staff would "ignore" her even though she yelled out to staff for help. She stated she told the QMRP this was happening, but did not think he believed her because staff continued to do these things to her. Client A stated she was "glad" this staff did not work with her anymore. Client A immediately said yes and nodded when asked if she was referring to DSP 1. On 7/24/14 at 5:10 p.m., DSP 1 stated during an interview, she did not recall any incidents while working with Client A. During the interview, (at 5:35 p.m.,) when specifically asked about leaving Client A in the shower wet, without immediately drying her off, DSP 1 asked, "That incident?" She further stated, "I already talked to (PM) about that incident. That was when (DSP 3) first started." DSP 1 never explained what occurred during this incident. On 7/30/14 at 3:40 p.m., during an interview, DSP 3 stated (she was unable to recall the date), DSP 1 took Client A to the back of the facility. DSP 3 stated she kept hearing someone say "help" but she ignored it because another staff (DSP 1) was already back there. DSP 3 stated approximately 10 minutes went by. She went back and saw Client A in the bathroom alone, "soaking wet, on a shower chair." DSP 3 stated "no water was running" (to keep the client warm), (Client A) "was shivering, crying, and there were no towels" available in the restroom. DSP 3 stated Client A's hair was wet also. DSP 3 stated when she began drying Client A off, DSP 1 came in and went to grab the towel from her. DSP 3 stated she told DSP 1 "that's ok, I got it" (meaning since she found Client A in that condition, she would take care of her). DSP 3 stated DSP 1 insisted, telling DSP 3 she would do it and grabbed the towel from DSP 3. DSP 3 stated that Client A had a (behavioral) plan in place for "false accusations." She stated Client A had not lied to her; however Client A was "not believed most of the time." 4. On 7/21/14 the QMRP notified CDPH of an allegation a staff member (DSP 1) told Client A to "shush" while the client was singing to music. The QMRP verified this incident occurred during the evening of 7/8/14. On 7/23/14 at 12:15 p.m., during an interview, Client A stated there was a staff member who treated her badly (which included telling her to "shh" while she was practicing singing). Client A was not able to recall the specific date this occurred but stated she went to church on Sundays and liked to practice singing. Client A stated when she was singing, a staff told her to "shh" and demonstrated to zip her mouth shut by crossing her fingers across her mouth. Client A stated this made her feel "sad" because she "really liked singing" when she went to church and liked to practice.On 7/24/14 at 3:45 p.m., during an interview, DSP 2 stated (unable to recall the date) at about 8 p.m., she was working in an adjacent room of the facility (not easily visible to other staff at the facility) and Client A was seated at the dining room table singing to music. DSP 2 stated she heard DSP 1 call Client A's name twice. DSP 2 stated each time DSP 1 called Client A's name, Client A would stop singing. DSP 2 stated, the last time DSP 1 called Client A's name, she told Client A to "be quiet and stop singing." DSP 2 stated Client A was not singing that loudly and stated at that time of the evening all of the other clients were already in bed. She stated Client A's singing was not bothering anybody. DSP 2 stated DSP 1 was seated on a sofa in the vicinity of where Client A was. DSP 2 stated when she approached the area; Client A told her she "didn't understand why she had to stop singing." At that time, DSP 1 left the area.The facility's policy titled, "Abuse/Neglect of Individual" last review date 2/26/14 contained documentation, "[Corporation Name] shall ensure that individuals supported by [Corporation] are not subjected to neglect, physical, verbal, sexual, or psychological abuse, or punishment..." The policy contained a definition of abuse which included, "...Verbal or demonstrative harm caused by oral or written language, or gestures with disparaging or derogatory implications. Psychological, mental or emotional harm caused by ... intimidation, humiliation, harassment..." The facility failed to implement policies that prohibited the neglect, mistreatment, or abuse of Client A when DSP 1 threw underwear at Client A's face; refused to shower Client A; refused to assist Client A to change her clothes; refused to toilet Client A timely, causing Client A (who was otherwise continent) to soil herself; left Client A wet, cold, and shivering while she was seated in the shower; and when DSP 1 told Client A to stop singing, (an activity Client A enjoyed). The facility also failed when Administrative staff (the QMRP) did not believe Client A's complaints that she was being mistreated, created an individual habilitative plan (IHP) objective for "false accusations," and allowed DSP 1 to continue to work with Client A on 7/3/14, 7/6/14, 7/7/14 and 7/8/14 (four days) before placing DSP 1 on administrative leave on 7/9/14. DSP 1's treatment of Client A caused the client to suffer humiliation, harassment, to feel "sad," and made her cry. The above violation either jointly, separately or in any combination had a direct or immediate relationship to the client's health, safety or security and therefore constitutes a Class 'B' Citation. |
| 040000647 |
BETHESDA LUTHERAN COMMUNITIES-ROGERS |
040011040 |
B |
01-Oct-14 |
H29J11 |
6526 |
42 CFR 483.420 (d)(1) Staff Treatment of Clients The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect or abuse of the client. The facility failed to implement policies that prohibited the neglect and mistreatment when a direct care staff (DCS) 1 was reported to have left two clients (Clients A and B) unsupervised in the facility van with windows and doors closed for an extended time and outdoor temperatures were at 100.0 degrees Fahrenheit.On 9/17/14 the facility reported to California Department of Public Health that on 9/11/14 Client A reported she and another client (Client B) were left unsupervised in the facility van on 9/6/14. Clinical record review indicated, Client A was moderately developmentally delayed; was verbal and was able to report abuse, neglect, and poor treatment by others. Client A's Individual Service Plan dated 3/19/14, indicated "[Client A] is a legally incompetent adult who does not fully understand...responsibilities or decisions regarding her welfare. Client A was verbal and interviewable. Clinical record review indicated, Client B was moderately developmentally and was not verbal and not interviewable. On 9/23/14 at 9:56 a.m., during an interview at the facility's regional office, the Program Manager (PM), stated on 9/11/14 when she checked the mileage on the facility van used during the outing, the PM noticed there was more mileage on the facility van than it took to travel to the show and back. The PM then asked Client A "What did they do after the show ended?" Client A stated they went to DCS 1's house and she and Client B were left inside the facility van. Client A stated when she began to "get hot" she sounded the horn in the van to signal the staff to hurry up.On 9/23/14 at 11:40 a.m., during a telephone interview, the Qualified Intellectual Disabilities Professional concurred that when Client A and Client B were left in the van unsupervised, it would constitute a case of neglect. On 9/23/14 at 11:43 a.m., during a telephone interview, the Area Director (AD) stated, "What the staff did was a complete failure to supervise the clients..." On 9/23/14 at 1:10 p.m., during a telephone interview, DCS 1 stated after the show she took Client A and Client B to a fast food restaurant and then took the clients back to the facility. DCS 1 declined to answer more questions. On 9/23/14 at 2:21 p.m., during a telephone interview, DCS 2 who was working at another agency owned facility, stated she and DCS 3 took four additional clients to the same show that DCS 1, and Client A and Client B went to. DCS 2 stated the show started at 2 p.m. and ended at 3:45 p.m., at which time they proceeded back to the facility. DCS 2 stated, all of the staff including DCS 1 agreed they would go back to their assigned facility for the 4 p.m. medication pass and then meet at the fast food restaurant. DCS 2 stated all staff had agreed to bring all the clients for lunch to the fast food restaurant. DCS 2 stated she and DCS 3 started making calls to DCS 1 around 4:15 p.m. Both DCS 2 and DCS 3 made multiple phone calls to DCS 1 with no answer. DCS 2 stated DCS 1 finally returned her call at 4:40 p.m. and stated she (DCS 1) was late due to traffic. DCS 2 stated she did not meet DCS 1, Client A and Client B at the fast food restaurant. DCS 2 stated DCS 1 along with the clients returned back to the facility approximately at 5:40 p.m. On 9/23/14 at 3:35 p.m., during an interview, Client A stated after the show DCS 1 drove the van to DCS 1's house. Client A stated she knew it was the DCS 1's house because DCS 1 told her they were going to drop by DCS 1's house to pick-up something. Client A stated she and Client B were left inside the van and DCS 1 went inside the house. Client A stated they waited for a long time in the van and it became hot. Client A stated she sweated, felt thirsty and wanted to go inside the house to get a drink. Client A stated she had not wanted to leave Client B inside the van alone. Client A stated if Client B had wanted to leave van, she could not because Client B would need to use the ramp of the van which was also closed [Client B was unable to step down from the van]. It became increasingly hot in the van. The Weather History for Fresno, CA at http://www.wunderground.com dated 9/6/16, indicated between 3:53 p.m. and 5:53 p.m. outdoor temperatures were 100.0 ? Fahrenheit (F).The facility's Investigation into allegation of "Neglect and Failure to supervise" dated 9/23/14 indicated, "Upon (sic) confronted with the fact that we [Management] have information that she [DCS 1] went to her residence, DCS 1 admitted she did go to her house and did not inform the PM. DCS 1 agreed it was wrong to leave the individuals unsupervised in the van for any reason." Client A's physician's order dated 9/14, included, Benztropine Mes (Cogentin) [medication used for the treatment of Parkinson type symptoms] 0.5 milligrams (mg) tablet PO (by mouth) every AM and 2 tabs, (1.0 mg) by mouth HS (hour of sleep) Parkinson (a degenerative disorder of the central nervous system). "Davis's Drug Guide For Nurses" Ninth Edition, page 110, indicated "Overheating may occur during hot weather. Patient should notify healthcare professional if unable to remain in an air-conditioned environment during hot weather." The Center for Disease Control and Prevention dated 9/23/14, indicated, "NEVER leave anyone in a closed, parked vehicle." The California Department of Public Health dated 5/27/14, titled "Hot Summer Weather Advisory" indicated, "... Health compromised individuals are more susceptible to extremes in temperature and possible dehydration." The facility's policy and procedure dated 7/11/14, titled, "ABUSE/NEGLECT OF INDIVIDUAL" indicated, "The [Facility] shall ensure that all persons served are not subjected to neglect...To protect the rights of all individuals, to treat each individual in a Christian manner, and to comply with the State and Federal Law." The facility failed to ensure Client A and Client B was free from neglect when Client A and Client B was left unattended in a closed vehicle, in extreme hot weather, which resulted in highly potential physical harm. The potential for Client A and Client B to experience heat related physical harm was extremely high due to this incident.The above violation had a direct relationship to the health and well-being of the clients. This violated Client A and Client B's rights and therefore constitutes a Class "B" Citation. |
| 040000647 |
BETHESDA LUTHERAN COMMUNITIES-ROGERS |
040011375 |
B |
09-Apr-15 |
2YS411 |
7885 |
Class 'B' Citation 42 CFR 483.20 (d)(1) Staff Treatment of Clients:The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect or abuse of the client.The following reflects the findings of the California Department of Public Health during the investigation of: Entity Reported Incident: CA00418666. The facility failed to implement their abuse policy and procedure for Client A when multiple male staff were scheduled to work unsupervised after a confirmed diagnosis of a sexual transmitted infection (STI) was known to management. The facility failed to implement a thorough investigation following the confirmed STI in accordance with the facility's policy.Client A was admitted to the facility on 7/15/13. Client A's Pap smear (a method of screening used to detect potentially pre-cancerous cells and STI's in the cervix; the cervix is the lower part of the female uterus or womb) dated 10/4/13, indicated the sample was negative for any infections. Client A's subsequent Pap smear dated 10/23/14, indicated "Trichomonas (STI) POSITIVE."The Center for Disease Control (CDC) Fact Sheet dated 8/3/12, indicated "Trichomonas is a common sexually transmitted disease (STD)... a parasite is passed from an infected person to an unaffected person during sex..." The "INDEPENDENT SKILLS ASSESSMENT" dated 10/11/14, indicated Client A only performs skills with help "...Engages in safe and socially acceptable forms of sexual expression...Demonstrated the ability to report abuse, neglect, and poor treatment by others...Expresses likes and dislikes appropriately...Discrimination between past, present and future...Displays good remote and recent memory...Discriminates between reality and imagination...Discriminates between good, bad, and confusing touch...Refrains from sexually provocative, exploitative and/or abusive behaviors."On 11/4/14 at 2:53 p.m., during an interview, Client A stated she did not have a boyfriend, but instead had a husband and he lived "Right here." When Client A was asked if he touched her in the perineum area (the part of the body between the vagina and anus in females) Client A stated "Yes, that's cuz [sic] he's my husband." When Client A was asked to be introduced to her husband, Client A had no response and looked away to the side.On 11/5/14 at 8:20 a.m., during a phone interview, Client A's physician assistant (PA) stated that Client A was sexually assaulted. The PA stated that Trichomonas occurs with full penetration (for example, when the penis or other sexual object is inserted into the vagina) and a person (the sexual partner) has had multiple partners.The facility schedule dated 10/26/14 to 11/8/14, indicated on 10/28/14, DSP 6 (male staff) worked unsupervised from "10-8AM" (from 10:00 p.m. to 8:00 a.m.) with Client A.On 11/5/14 at 12:10 p.m., during a phone interview, the Program Manager (PM) stated that on 10/28/14, during the gynecological (women doctor) visit, the registered nurse (RN) was informed of the STI diagnosis and the RN immediately contacted the Area Director (AD). The Program Manager (PM) stated that the AD had assigned DSP 6 (male staff) to work the night shift on 10/28/10. The PM stated that having DSP 6 work that night was not a wise idea.The facility schedule dated 10/26/14 to 11/8/14, indicated on 10/29/14, 10/30/14, 10/31/14, 11/1/14, 11/4/14, 11/5/14, 11/6/14, and 11/7/14, DSP 4, 5 or 8 (all male staff) were the only scheduled staff for the evening shift (from 1:00 p.m. to 10:00 p.m.). The timecards for DSP 4, 5, and 8 confirmed staff worked all or part of the shift alone with Client A on 10/29/14, 10/30/14, 10/31/14, and 11/6/14. (Schedule indicated appropriate corrective action had not been taken to protect Client A during these shifts). On 11/5/14 at 1:50 p.m., during a phone interview, the AD stated that on 10/28/14, DSP 6 worked the night shift and an investigation had not been finalized. The AD stated "It was not a male staff in the home (the perpetrator or sexual partner)" and the abuse policy had been followed.On 11/5/14 at 4:27 p.m., during an interview, DSP 5 (male staff) stated that a female staff had to work (be on every shift) at all times. On 11/6/14 at 2:27 p.m., during a concurrent interview and observation, upon entrance to the facility, DSP 5 (male staff) was the only staff present with three clients, including Client A. Client A sat on the couch in the living room. DSP 5 stated that he was the only staff scheduled. The facility schedule dated 10/26/14 to 11/8/14, indicated on 11/6/14, DSP 4 and 5 were scheduled to work together (both male staff).On 11/6/14 at 4:10 p.m., during an interview, the Qualified Intellectual Disabilities Professional (QIDP) stated that on 10/29/14, he interviewed the current staff at the facility. The QIDP stated that the night staff (DSP 10 and 11) were not interviewed because they were taken off the schedule due to another investigative incident.On 11/10/14 at 11:30 a.m., during an interview, DSP 6 stated that on 10/28/14, he worked on the night shift (alone and unsupervised). The facility's final investigative document, dated 10/30/14, indicated a list of interviewed staff: DSP 2, 3, 4, 5, 8 and 9. [no documented evidence of interviews included previous night shift DSP's, to include DSP's 10 and 11 (female staff) and DSP 6 (male staff)].On 11/10/14 at 2:40 p.m., during an interview, the QIDP stated that the former night staff (DSP 6) was not interviewed because DSP 6 was not on the current list of staff. The QIDP also stated that he did not know the period of suspected infection for Client A. On 11/12/14 at 10:05 a.m., during a phone interview, the AD stated that the previous full-time night DSP's (DSP's 10 and 11) and DSP 6, were not interviewed. The AD stated that he directed the sexual abuse investigation and the QIDP interviewed all regular and on-call DSP's. The AD also stated that for the week-end dates of 11/8/14 and 11/9/14, he reviewed the investigation interviews of "presently working staff" and became aware that DSP 6 had not been interviewed.The facility final investigative document dated 10/30/14, indicated "On 10/28, [Client A]... received a pap smear result that indicated positive for Trichomoniasis (sp), a Sexually Transmitted Disease (STI)." The document also indicated "... is yet to determine the source of infection....shall monitor [Client A] and the individuals supported..."The facility policy titled "ABUSE/NEGLECT OF INDIVIDUAL" dated 7/11/14, indicated "Abuse... A thorough investigation shall be initiated within 24 hours by a [Facility] Trained Investigator and completed within 72 hours." The facility policy titled "ABUSE/NEGLECT OF INDIVIDUAL" dated 7/11/14, indicated "In certain cases, it may be necessary to increase the staffing of the program site in order to ensure the safety of an individual during the investigation."The facility policy titled "ABUSE/NEGLECT OF INDIVIDUAL" dated 7/11/14, indicated "Abuse... 4. Sexual molestation, rape, sexual misconduct, sexual coercion, and sexual exploitation." The procedure indicated: "When an alleged incident is reported, the program staff and/or management staff will take action to assure that the victim is protected from future harm" and "In certain cases, it may be necessary to increase the staffing of the program site in order to ensure the safety of an individual during the investigation."The facility failed to implement their abuse policy and procedure for Client A when multiple male staff were scheduled to work unsupervised after a confirmed diagnosis of a sexual transmitted infection (STI) was known to management. The facility failed to implement a thorough investigation following the confirmed STI in accordance with the facility's policy.These violations had a substantial probability of sexual harm and therefore constitute a Class 'B' Citation. |
| 630002861 |
Bonavente ICF/DD-N Home |
040011460 |
B |
13-May-15 |
JS6611 |
10649 |
483.420 (d)(1) The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect or abuse of the client. The facility failed to implement written nursing policies to prohibit neglect of one sampled client, (Client A), when she acquired a pressure ulcer (formed when pressure on skin reduces blood flow and can cause tissue death and ulcers) to the coccyx and had no physician's orders for wound care, had additional unidentified pressure areas to her feet, and unidentified kidney infection (pyelonephritis) which required her to be hospitalized. Client A was admitted to the facility in 4/05 with diagnoses which included Diabetes Mellitus II (high blood sugar), and paraplegia (impaired function of the lower extremities). She was dependent on staff for all activities of daily living (ADLs), required the use of a wheelchair, and had limited bed mobility. On 3/18/15 at 1:55 p.m., during the investigation of Complaint CA00435510, Client A was observed lying in her bed. Client A was asked if she had a sore (pressure ulcer), she replied that she did. When asked how long she had the sore, Client A stated it had been about a month or so. She stated because of the sore, she had to lay in bed all day and was not able to attend day program. On 3/18/15 at 2:10 p.m., the Registered Nurse/Administrator (RN/Admin) stated during an interview, Client A's wound began as a "skin tear" at the coccyx crevice (tailbone area) on 2/19/15. The RN/Admin stated Client A went to the day program on 2/23/15 and the wound became infected. When the Nurse's Notes regarding Client A's care were requested, the RN/Admin stated Licensed Vocational Nurse (LVN) 1 was "still writing them." The most current documented Nurse's Notes in Client A's clinical record were dated 12/25/14, (approximately three months prior).Client A's Medication Administration Records (MARs) 2/15 and 3/15 were checked to verify if any physician ordered wound care treatments were being provided for Client A. There was no documentation of physician orders for wound care to be performed for Client A's pressure ulcer to the coccyx. On 3/18/15 at 3:22 p.m., the RN/Admin stated on 3/4/15 Client A was seen by her physician who ordered Bactrim DS (antibiotic) to be given three times a day and Rifampin (antibiotic) to be given twice a day, to treat the infected wound (coccyx pressure ulcer, but no wound care was ordered). On 3/18/15 at 3:45 p.m., Client A's pressure ulcer to the coccyx was observed with the RN/Admin. It appeared to be approximately 1 inch x 3/4 inch x an unknown depth. It had a strong odor with yellow/tan slough tissues (dead tissues in the process of separating) in the center of the wound. Staff had placed a 2x2 gauze pad in the center of the wound which had serosanguinous (contained both blood and serum liquids) on it. This gauze had fallen out of the wound and was lying in the client's protective undergarment. During this observation, the RN/Admin stated the wound site had "infection" and stated it was red without any slough tissue when she last saw it on 3/4/15 (two weeks prior). When asked if the wound was being measured, the RN/Admin stated it was not. When asked to provide the physician's orders for wound treatment, the RN/Admin showed an order initiated on 5/6/14 for, "Normal Saline (NS): Wash scrapes, scratches, skin tears and abrasions BID (twice a day) / PRN (as needed)." When told this order only covered topical minor skin injuries and not pressure ulcer treatment, the RN/Admin stated she would contact the physician to see if Client A could be evaluated in the ER (emergency room).On 3/19/15 at 2:45 p.m., the RN/Admin stated Client A had been admitted to the acute hospital for pressure ulcer treatment and treatment of a urinary tract infection (UTI). Client A remained hospitalized from 3/19/15 - 3/26/15.The acute hospital "Wound Care" notes dated 3/19/15 at 4:35 p.m., contained documentation, "Pt (patient) admitted with an unstageable (slough covering wound bed does not allow accurate depth verification) coccyx uler [sic] measuring 3 (centimeters - cm) x 2.2 x 1.3 with 80% slough. Wound will be a stage III or IV (damage to tissues below the skin / damage to the muscle and bone) as the slough is debrided (medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue)..." The acute hospital "Wound Care" notes dated 3/20/15 contained documentation, "Pt admitted with injuries to right foot... there are wounds over pressure areas... The right heel with a 4 x 4 reddened area, with a 1 x 1 lateral and a 2 x 1.5 medial area of SDTI (suspected deep tissue injury - a pressure-related injury to subcutaneous tissues under intact skin). Pt also with 1.5 x 1.5 area to the achilles area (just above the heel) as well as dorsal arch (top of the right foot) that may be from a strap or heel protector. There is an unstageable site over the bony prominence on the right dorsal foot That measures 1 x 1 with .5 x .5 center with black tissue... Pt does have a .8 x .3 x .2 wound to the medial aspect of the great toe which we sill [sic] dress daily with silvasorb gel (antimicrobial gel that helps moisten dry wounds and allow for optimal wound healing)." The acute hospital "Care Coordination" form contained a "Case Management Progress Note" dated 3/20/15 at 5:35 p.m., contained documentation, "Met with [RN/Admin]... Pt sleeps in a Hospital bed with an air mattress overlay, although that particular device may be inadequate for her condition... Pt needs a pressure relieving mattress per ET (Enterostomal Therapy RN - nurse who specializes in wound care). This will need investigation..." The acute hospital "History and Physical" notes dated 3/19/15 contained documentation, "...Workup was significant for pyelonephritis (kidney infection). The patient has a sacral (coccyx area) decubitus (pressure ulcer), for which she has been placed on Bactrim-DS 1 tablet t.i.d. (three times daily) for the past 7 days. Despite this, she comes with significant pyelonephritis..."The acute hospital "Significant Events" notes dated 3/19/15 at 3:36 p.m., contained documentation "Critical Results - Provider Notification" ... "... Critical Result Severe Sepsis Risk Notification" Documentation included "... 3/19/15 at 1311 (1:11 p.m.) Pulse Rate = 105 bpm (heart rate 105 beats per min - normal adult rate 60 - 100 bpm) ... WBC (white blood cell) Count 15.8 mm3 (millimeters cubed) (normal range 4.5 - 11.0 - high reading indicates infection) ... " The acute hospital "Discharge Summary" dated 3/26/15 contained documentation, "... patient ... with sacral decubitus, hospitalized with pyelonephritis with symptoms of nausea and decreased appetite with back pain."On 3/30/15 at 9:55 a.m., LVN 1 stated she was still attempting to obtain an appointment for Client A at a wound clinic (for care of the pressure ulcers). Upon review of the referral /order form, it contained a request for home health care, not a referral to a wound clinic. On 4/6/15 at 12:10 p.m., Client A was laying on her left side upon entrance to her bedroom. She was observed to have five wound areas visible on her right foot and three areas on her left foot, in addition to the coccyx wound. The wound to the top of Client A's right foot was covered with a bandaid. Client A was observed on the same hospital bed with the air mattress overlay that she had prior to her hospitalization. On 4/6/15 at 12:30 p.m., the House Manager (HM) stated Client A was still on the same hospital bed and the same air mattress overlay. He also observed the skin wounds to Client A's feet. The HM reviewed the client's (every two hour) turning schedule and saw it indicated she had been turned from her left side to her right side at 12 noon. The HM stated according to this schedule, Client A should have been currently on her right side. The HM accompanied surveyor to client's room, where Client A stated during an interview, she had been on her left side for about an hour or so.On 4/6/15 at 12:55 p.m., the RN/Admin removed the bandaid from the top of Client A's right foot and observed the wound was now open. She stated no one told her it had become an open wound. The RN/Admin was also asked to provide current measurements of Client A's wounds. On 4/6/15 from 12:55 p.m. - 1:45, the RN/Admin was observed to measure the wounds on Client A's right and left feet. She documented (8) wound/areas of concern to Client A's right foot: top 1 x .8 cm; lower leg/upper foot area with redness 3 x .5 cm; lateral foot 5 x 1.5 cm with bruising; medial foot 3.5 x 2.5 cm bruising covered with tegaderm; heel 1.5 x .2 cm redness; another heel area 1.5 x .8 cm brown/red; another heel area 2 x 1.5 redness; and posterior ankle area 1 x 1.5 cm bruise. Client A's left foot was documented to have (4) wound/areas of concern: medial area 2 x 1.5 cm redness; lateral foot .8 x .5 cm redness; 5th toe .8 x .5 cm redness; and 4th toe .2 x .2 cm redness.On 4/6/15 at 1:45 p.m., the RN/Admin stated during an interview she was not aware of the open area on top of Client A's right foot and stated she needed to be able to rely on the LVNs for client assessments. The RN/Admin stated she was not aware that the hospital bed with air mattress overlay was not sufficient as a pressure relieving device. She stated Client A was not scheduled to be seen by the wound clinic until 4/8/15 and did not have a follow up appointment scheduled with the physician until 4/15/15. The facility's policy and procedure for "Registered Nursing Services" last revision date 8/3/13, indicated the purpose was, "To provide guidelines of the Registered Nurses Services provided in accordance with the needs of each individual client as well as the job functional duties and requirements to ensure that appropriate nursing and educational training is being implemented and documented... and all assessments and observations on an on-going basis..." 42 CFR (Code of Federal Regulations) 483.420 (d)(1) defines neglect as the "failure to provide goods or services necessary to avoid physical or psychological harm." The facility failed to implement written nursing policies to prohibit neglect of one sampled client, (Client A), when she acquired a pressure ulcer to the coccyx and had no physician's orders for wound care, had additional unidentified pressure areas to her feet, and unidentified kidney infection (pyelonephritis) which required her to be hospitalized. The above violation had a direct or immediate relationship to the client's health, safety, or security, and therefore constitutes a Class 'B' Citation. |
| 040000531 |
BETHESDA LUTHERAN COMMUNITIES - FLORADORA |
040011669 |
B |
18-Aug-15 |
T1YC11 |
5974 |
Title 17 50510 (a) (8) 50510 Each person with a developmental disability, as defined by this subchapter, is entitled to the same rights, protections, and responsibilities as all other persons under the laws and Constitution of the State of California, and under the laws and 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 (8) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse or neglect. Medication shall not be used as punishment, for convenience of staff, as a substitute for program, or in quantities that interfere with the treatment program. The facility failed to ensure Client A was free from harm when on 6/27/15 Direct Care Staff (DCS 4) left Client A alone in the house two times between the hours of 10:30 p.m. and 1:20 a.m. The first time DCS 4 moved his car from the front of the house to the back of the house and the second time he stepped outside to answer a personal phone call. At 1:20 a.m. DCS 4 realized Client A had eloped into the neighborhood. As a result, Client A sustained a fracture to her right ankle with loss of mobility requiring a surgical procedure to repair (Open Reduction Internal Fixation) and required pain medication, physical therapy and occupational therapy to regain mobility and independence. Client A's "Individual Habilitation Plan" dated 5/26/15, contained documentation she was admitted to the facility in July 2005 with seizure disorder, compulsive disorder, and hypothyroidism. Client A is not verbal, able to ambulate, transfer and toilet herself independently.A facility clinical record titled "Health Care Evaluation Nurse Note" dated 7/1/15, indicated [Client A] "received back today from acute hospital after she eloped from the facility and was found in the yard of a house in the neighborhood with a swollen right leg. She went through ORIF (Open Reduction Internal Fixation) to repair a right ankle fracture... Half leg cast on the right leg wrapped with ace bandage. She will be on Lovenox 40 milligrams (mg) (blood thinner medication to prevent clotting)..." Client A's physician order dated 6/27/15, indicated: acetaminophen (Tylenol)-HYDROcodone (Codeine) 325 mg (milligram)-10 mg oral tablet 1. Instructions to take one tablet by mouth twice a day as needed x 10 days pain. Medication was given at home on 7/3, 7/4 and 7/5. On 7/2/15 at 9:15 a.m. during an interview, the Qualified Intellectual Disabilities Professional (QIDP) stated [Client A] walked very well before the incident. QIDP stated, when [Client A] was found sitting in a chair in the neighboring yard, she was frightened and she was unable to bear weight to stand as her right ankle was swollen. QIDP stated it looked as if [Client A] had walked up the stairs leading to a small entry room into the neighboring house. QIDP stated a second door from the entry room leading into the house was locked, so it appeared [Client A] came back down the stairs and fell dropping the papers she had been carrying at the bottom of the stairs.On 7/2/15 at 11:00 a.m., during a concurrent observation and interview, Client A was lying in bed with her eyes closed her right leg elevated on a pillow. A hard cast was in place wrapped with an ace bandage from below the right knee to the top edge of her toes.DCS 1 stated Client A would usually be in and out of bed walking around the house and using the bathroom. DCS 1 stated Client A now requires help and she forgets and attempts to get up alone at times. She requires frequent reminders to wait for help. The facility's administrative report untitled dated 6/27/15, indicated on June 27th 2015 the Qualified Intellectual Disabilities Professional (QIDP) had received a telephone call at approximately 2:30 a.m., from the Area Director (AD) notifying her (QIDP) the late night shift staff (10:00 p.m-7:00 a.m.) DCS 4 reported he could not find Client A during rounds at 1:20 a.m. The local police as well as staff at the facility arrived to search. After a lengthy search Client A was found down the street in a neighboring backyard. She was sitting in a chair and unable to stand. Her right foot was swollen and turned outward. There was facility labeled documents scattered about the yard at the bottom of a staircase leading into the neighboring house. Acute Hospital Clinical record titled "Final Report" History and Physical dated 6/27/15, indicated [Client A] was brought in by ambulance due to an acute ankle fracture. [Client A] apparently wandered off from her home in the middle of the night and was found in a neighboring home sitting in a chair in acute pain. She was unable to ambulate (walk). Her right ankle was swollen with the foot protruding outwards. An x-ray of the right ankle was performed revealing an acute fracture of the medial malleous and distal fibula just above the level of the ankle. [Client A] was admitted for repair of the ankle fracture. Facility document titled "ABUSE/NEGLECT OF INDIVIDUAL" dated 7/11/14 indicated "[Facility] shall ensure that individuals supported by [facility] are not subjected to neglect...and to inform employees of their responsibilities as mandated reporters...B. 'Neglect' means the following...Failure to provide supervision...appropriate care...to an individual..." The facility failed to ensure Client A was free from harm when Direct Care Staff (DCS 4) left Client A alone in the house and Client A eloped into the neighborhood. As a result, Client A sustained a fracture to her right ankle with loss of mobility requiring a surgical procedure to repair and required pain medication and physical therapy to regain mobility and independence. The above violation had a direct or immediate relationship to the client's health, safety, or security, and therefore constitutes a Class 'B' Citation. |
| 630005941 |
Bonavente Fremont Home |
040011991 |
A |
26-Jan-16 |
BWYV11 |
10046 |
Class A Citation - Title 17 Article 2. 50510 (a) (8)Rights of Persons with Developmental Disabilities Each person with a developmental disability, as defined by this sub-chapter, is entitled to the same rights, protections, and responsibilities as all other persons 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. (8)A right to be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect.The facility failed to ensure Client A's right to be free from neglect. On 11/10/15 at 8:15 a.m., Client A was found unresponsive in his bed. The two Direct Care Staff (DCS) present at the facility did not provide immediate resuscitative measures and instead, waited for Emergency Medical Services (EMS) to arrive and perform Cardiopulmonary Resuscitation (CPR - an emergency procedure performed in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing). Client A was transferred to the General Acute Care Hospital's (GACH) Intensive Care Unit (ICU) where he was intubated (tube inserted through the mouth down into the trachea so oxygen can be supplied into the lungs) with ventilator (a machine designed to mechanically move breathable air into and out of the lungs) support until he expired the next day on 11/11/15.On 11/13/15, an onsite visit was conducted to investigate CA00465043. Client A's "Client Record Face Sheet" indicated he was admitted to the facility on 8/1/15, with diagnoses of mild mental disability, End Stage Renal Disease (ESRD, a permanent kidney failure) and Coronary Artery Disease (CAD, a blockage of one or more arteries that supply blood to the heart). The facility document titled "Incident Report" dated 11/10/15, indicated Client A was found unresponsive and not breathing. The same document indicated, "9-1-1 was called. Paramedics performed CPR."On 11/13/15 at 2:15 p.m., during an interview, Direct Care Staff 1 (DCS 1) stated that on 11/10/15 from 6:00 a.m. to 7:38 a.m., Client A "slept" through morning care and breakfast. When asked if this was the norm for Client A, DCS 1 stated she didn't know because it was her third day working at the facility. DCS 1 stated that DCS 2 went to Client A's bedroom at 7:38 a.m. and asked Client A if he was ready to get up and he stated "yes." DCS 1 stated at 8:00 a.m., after a few of the clients were picked up by the bus for Day Program, she and DCS 2 went back inside the house. DCS 1 stated, "I was getting gloves and she [DCS 2] sat and wrote on the clients' program books... Around 8:15 a.m., DCS 2 was with Client A in his room... I heard her call out, "He [Client A] is not responding!" DCS 1 stated she ran to Client A's room, shook the client's leg, and when he did not respond, she took out her personal cell phone and called 9-1-1. (Thirty-seven minutes had passed from the time Client A stated he wanted to get up at 7:38 a.m. to the time Client A was found unresponsive at 8:15 a.m.) During the same interview, DCS 1 was asked to describe what took place while she was on the phone with 9-1-1. DCS 1 stated, "[DCS 2] was panicking, pacing, and crying hysterically. Client A looked very pale, almost grey-white and he wasn't moving." When asked to describe what resuscitative measures were attempted or done to revive Client A, DCS 1 stated, "I didn't check his pulse or breathing. I did not do CPR... I did not know how... [DCS 2] didn't do anything..." DCS 1 stated the Fire Department arrived first and did CPR on Client A until the paramedics arrived and took over.On 11/13/15 at 3:05 p.m., during an interview, Licensed Nurse 1 (LN 1) stated Client A's health was stable. She stated Client A had a "Full Code" status (Full Code status means that all possible measures are taken to revive a person and sustain life). When asked what the facility's standard of practice was when a client was found unresponsive or not breathing, LN 1 stated, "Staff should first check for pulse and breathing. If there is no pulse and no breathing, staff must call 9-1-1 first and start compressions (application of pressure on the chest to circulate the blood of a person whose heart is no longer beating effectively enough to sustain life.) right away. [DCS 1 and DCS 2] did not attempt to resuscitate Client A at all... they did not do CPR."On 11/17/15 at 8:15 a.m., during a telephone interview, the Qualified Intellectual Disability Professional/Licensee (QIDP/L) stated DCS 1 and DCS 2 did not perform CPR on Client A as required by the facility's policy and standards of practice.On 11/17/15 at 9:29 a.m., during a telephone interview, DCS 2 stated, "On 11/10/15 at 8:15 a.m., I went to Client A's room to ask if he was ready to get up. He did not respond so I came closer and saw his face was white... pale. I called out to [DCS 1] and told her [Client A] was not responding then ran back to the room..." When asked to describe what she did to revive Client A while DCS 1 was on the phone with 9-1-1, DCS 2 stated, "I did not do anything... I did not do CPR. I just waited for 9-1-1 to arrive..."On 11/17/15 at 1:00 p.m., Client A's acute hospital's clinical record was reviewed with the hospital's Registered Nurse 1 (RN 1). The following documents described Client A's course of hospitalization as follows:The documents titled, "Emergency Medical Services (EMS) Response Information and First Responder Prehospital Care Report" dated 11/10/15, indicated the following: 8:15 a.m.: Found down approximately 8:15 a.m., pulseless and apneic [no breathing] 8:22 a.m.: Call received (from facility) 8:23 a.m.: EMS enroute to facility 8:24 a.m.: Fire Department initiated CPR with AED (automated external defibrillator, a portable electronic device that is able to automatically diagnose life-threatening abnormal or irregular heartbeats, and is able to treat them through the application of electrical therapy which stops the irregular heartbeats and allows the heart to reestablish an effective rhythm).8:30 a.m.: EMS on Scene 8:31 a.m.: Patient Contact - Normal Sinus rhythm for 30 seconds then asystole [no heartbeat] 8:43 a.m.: Depart [from the facility] 8:57 a.m.: Arrival [at hospital]The document titled, "Code Blue Documentation" dated 11/10/15, indicated CPR was continued in the Emergency Department (ED) at 8:59 a.m. At 9:02 a.m., Client A was intubated and subsequently admitted to the Intensive Care Unit (ICU) for ventilator support and other critical life-sustaining measures and treatment. The document titled, "Final Report" dated 11/10/15, indicated "...Found down at 8:15 with a previous unknown down time. EMS was notified and CPR was not started until the arrival of EMS... Status post cardiac arrest with prolonged downtime...delay in resuscitative efforts... in ICU... intubated with ventilator support..." The document titled, ""Expiration Note" dated 11/11/15, indicated Client A expired on 11/11/15 at 2:51 p.m., from status post cardiac arrest, severe anoxic encephalopathy [a condition where the brain is deprived of oxygen and there is global loss of brain function], cardiogenic shock [condition in which the heart suddenly can't pump enough blood to meet the body's needs], and acute system failure [organs/body no longer performs the function it was intended to]. The American Heart Association (AHA) published article titled "CPR Facts and Stats and Cardiac Arrest versus Heart Attack" dated 1/13, indicated "Cardiac Arrest occurs when the heart stops beating unexpectedly... the heart cannot pump blood to the brain, lungs and other organs... Cardiac arrest can be reversible in some victims if it is treated within a few minutes... Death occurs within minutes if the victim does not receive treatment. If you see an unresponsive adult who is not breathing or not breathing normally, call 9-1-1 and push hard and fast on the center of the chest... Immediate CPR can double, or even triple, a victim's chance of survival."The facility documents titled "Employee Handbook, Basic Life Support" and dated 1/21/14, indicated "...All staff are required to maintain current CPR/First Aid Certification... All staff will respond promptly and appropriately to protect and care for all residents who are involved in an accident or incident... In case of serious injury, immediately initiate the medical emergency procedure...CPR is a combination of rescue breathing and chest compressions delivered to victims thought to be in cardiac arrest. When cardiac arrest occurs, the heart stops pumping blood. CPR can support a small amount of blood flow to the heart and brain to 'buy time' until normal heart function is restored... The victim in cardiac arrest needs CPR..." The facility document titled "Abuse or Neglect of Clients" dated 1/21/14, defined Neglect as "the delay or withholding of services, to include supervision that may cause or is likely to cause physical or psychological harm. Examples include failure to provide first aid or emergency medical services..." The facility neglected Client A when DCS 1 and DCS 2 withheld CPR and waited for EMS to arrive at the facility to provide CPR to Client A. From 8:15 a.m. to 8:24 a.m. (9 minutes), Client A did not receive any resuscitative measures from either DCS. As a result, Client A was transferred to the hospital where he was intubated and placed on ventilator support. Within 27 hours, Client A expired from status post cardiac arrest with prolonged downtime and delayed resuscitative efforts, severe anoxic encephalopathy, cardiogenic shock, and acute system failure. 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 and thus constitute a Class A Citation. |
| 040000644 |
Bethesda Lutheran Communities-Helm |
040011992 |
AA |
26-Jan-16 |
4ZRM11 |
13501 |
Class 'AA' Citation - Staff Treatment of Clients 483.420 (d)(1) The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect or abuse of the client. The facility failed to implement written policies and procedures that prohibited neglect of the client when: 1. Direct Support Professional (DSP) 1 failed to safely transport Client A to and from his routine doctor's appointment. 2. DSP 1 failed to stop at a railroad crossing gate, proceeded directly into the path of an oncoming Amtrak train, and caused the death of Client A in the process.Entity Reported Incident (ERI): CA00446191 Client A's Individual Support Plan (ISP - provides a basic description of the client's likes, dislikes, skills abilities and plan to maintain or improve his level of functioning), indicated he was a 47 year old male. Client A was admitted to the facility on 3/9/09. He was non-verbal, but could respond well to simple directives and prompts. Client A required staff assistance with activities of daily living (ADLs). Client A's Independent Skills Assessment dated 10/9/14 indicated he attended necessary medical appointments only with staff assistance.The County Coroner Certificate & Verdict dated 11/5/15, indicated Client A body systems as follows: "...INTERNAL EXAMINATION: ...All organs are normally situated... Neck fractures are present (See Evidence of Injury) ... lungs are otherwise pink in color... pulmonary veins and arteries are normal... heart shows no injuries... liver has normal appearance... spleen is completely normal... stomach... is normal... small intestine is normal... kidneys show no significant... changes ... pelvic bones are intact... the floor of the skull is intact... cut surfaces of the brain show no significant findings..." On 6/11/15 at 9:30 a.m., a visit to the facility's corporate office was made to investigate the Entity Reported Incident (ERI) CA00446191 involving Client A's death. The ERI indicated DSP 1 was transporting Client A on 6/10/15 at approximately 9 a.m., when the van was hit by an Amtrak train. It indicated that both DSP 1 and Client A were killed (in this accident).On 6/11/15 from 9:30 am to 10:20 a.m., during a concurrent interview and administrative document review, the Human Resources Director (HRD) stated the accident happened on (6/10/15) the morning of Client A's routine doctor's visit to a neurology (nervous system and diseases that affect it) examination whose office was located an hour away. He stated DPS 1 was the driver who was killed along with Client A (the passenger) when the facility's van collided with the Amtrak train.DSP 1's facility "Time Card" for 6/10/15 (date of accident) was reviewed. It indicated DSP 1 punched in at 8:55 a.m.On 6/11/15 at 11:10 a.m., during a group interview (with the Qualified Intellectual Disabilities Professional - QIDP and the House Manager - HM) at the facility, the QIDP stated Client A had a scheduled routine doctor's appointment at 10:30 a.m. on the date of accident (6/10/15). She stated the doctor's office was located in a nearby city (which would require approximately an hour of driving). The HM stated DSP 1 was assigned to transport Client A on that day and they left the facility at approximately 9 a.m. When HM was asked whether the intersection of the railroad crossing was en route to the doctor's office where Client A had an appointment, she said yes. When asked whether Client A was transported in a wheelchair she said no. The HM stated Client A was ambulatory with staff assistance utilizing a gait belt.DSP 1's personnel record was reviewed. It did not contain any driver training records for 2014 or 2015. When asked how the company ensured DSP 1 provided safe transportation for past two years (since his date of hire on 7/16/13) the HRD stated the facility's procedure was to provide the training /refresher in-service about safe driving annually. The HRD stated the annual training for this year (2015) was tentatively scheduled for July, (after the date of the accident 6/10/15); but he was not able to provide documented evidence that the annual training was provided to DSP 1 in 2014.The facility's policy and procedure titled "Motor Vehicle Standards and Records" was faxed to California Department of Public Health (CDPH) by the HRD. It indicated "Purpose: to provide safe transportation for people served, promote a safe driving culture and reduce the potential for injury and vehicle damage...Procedure: All positions which include regular driving responsibilities shall include this information in the job description: I. the job description should indicate: A. the position includes ongoing responsibilities for transporting people served (these people shall be considered "regular drivers" who transport people served) or...II. Individuals who infrequently drive a [facility] vehicle, e.g., to attend a conference, shall be considered "occasional drivers." The facility's job description titled "Direct Support Professional (DSP)" dated 3/28/15 and signed by DSP 1 was reviewed. It indicated, "...Training: a. All drivers are required to attend an in-service on general driving techniques at least once in a 12-month period. This generally consists of viewing a driving safety video. B. "Regular drivers who transport people served" are required to attend the training... and successfully complete behind the wheel training before driving on [facility] business." The facility's policy and procedure titled "ABUSE, NEGLECT, MISAPPROPRIATION AND MISTREATMENT, OF PERSON SERVED" last review date 3/8/13 indicated, "[Facility corporate name] shall ensure that all persons served are not subjected to neglect..." 42 CFR (Code of Federal Regulations) 483.420(d)(1) indicates "Neglect means failure to provide goods or services necessary to avoid physical or psychological harm." On 12/21/15, the "Traffic Collision Report" by the State of California Department of California Highway Patrol was reviewed. The report indicated the date of collision was 6/10/15 at 10:12 a.m. DSP 1 was the driver and Client A was the passenger who were both pronounced dead at the scene by the County Coroner at 10:18 a.m. It also indicated Client A's seat position was unknown and based on the County Coroner's Office's Toxicology Report, DSP 1 tested negative for alcohol. The report contained the list of four witnesses.The sketch diagram on the "Traffic Collision Report" confirmed the location of the accident. The physical evidence diagram confirmed the locations of the bodies of DSP 1 and Client A along with the location of the facility's vehicle. The section titled "Physical Evidence Analysis" indicated "19. Displaced railroad grade crossing gate: Item 19 was a displaced railroad grade crossing gate from the west entrance of the Conejo Avenue railroad grade crossing... Based on this item's location and orientation, this item was determined to have been in the down position when it was struck by the front of Vehicle 1 (Ford) - [the facility's van] as it entered the closed Conejo Avenue railroad grade crossing." The section titled "Scene/Roadway Description" indicated "The railroad grade crossing was controlled by a railroad grade crossing gate, railroad grade crossing signal lights; and railroad crossing signs. On the south dirt shoulder, 499 feet west of the railroad grade crossing, there were flashing amber lights, two railroad grade crossing warning signs and a "prepare to stop when flashing" yellow warning sign. It was determined the railroad grade crossing gate and signal system were working as designed at the time of the collision." The section titled "Parties" indicated "Vehicle #1 (V-1, Ford)... was completely burned... The driver's seat belt appeared to be in working order due to the fact the latch plate was attached to the buckle. Due to V-1 being completely burned, I was unable to check the other seatbelts. No mechanical defects or prior collision damage was noted or claimed..." The section titled "Statements:" indicated "... Party #2 (P-2) [Amtrak Service Engineer] had been sounding the horn throughout the area and at prior crossings as required. P-2 observed V-1 traveling eastbound on Conejo Avenue approaching the crossing at an unknown speed seconds prior to reaching the Conejo Avenue crossing. V-1 continued eastbound through the lowered crossing arms onto the tracks and P-2 realized V-1 was not stopping. P-2 tried to "dump the speed" (quickly slow the train) however; Amtrak Train 702 collided with V-1. P-2 related V-1 overturned and burst into flames. P-2 continued applying Amtrak Train 702's brakes and brought the train to a stop as soon as he could."The section titled "Witness #1" (W-1) indicated "...W-1 related he was driving eastbound on Conejo avenue approximately 50 feet behind V-1 and he estimated V-1 slowing to 25 to 35 MPH (miles per hour). W-1 related V-1 passed the warning flashing amber lights for the train and he then observed the taillights of V-1 illuminating. W-1 related V-1 hit the crossing arms and then the train hit the van causing it to overturn and burst into flames." The section titled "Summary" indicated "... P-1 [DSP 1] was driving ...V-1, (Ford) eastbound in the eastbound lane on Conejo Avenue approaching the railroad grade crossing west of Topeka Avenue at an estimated speed of 70-75 MPH. Passenger # 1 [Client A] was a passenger in V-1, but his seating position was unknown due to V-1 being fully engulfed as a result of this collision. P-1 [DSP 1] continued eastbound near the flashing amber lights for the train and slowed down to 25 MPH toward the closed railroad grade crossing gate and crossing signal lights. Vehicle 2 (Amtrak Train 702) was traveling southbound on the mainline track west of Topeka Avenue approaching Conejo Avenue at approximately 73 MPH to the northeast of V-1.The section titled "Summary" also indicated, "For an unknown reason, P-1 [DSP 1] failed to stop for the closed railroad grade crossing gate and crossing signal lights. P-1 [DSP 1] collided with the closed railroad crossing gate, continued eastbound and drove V-1 directly into the path of Amtrak Train 702. Due to Amtrak 702's size and speed, P-2 [Amtrak Train Driver] could not have stopped Amtrak Train 702 prior to the right front Passenger Car of Amtrak Train 702 colliding with the left side of V-1. The impact caused V-1 to burst into flames. V-1 was propelled in a southwesterly direction. P-1 [DSP 1] and PS-1 [Client A] were ejected from V-1. P-1 [DSP 1] landed in the grape vineyard southwest of the Conejo Avenue railroad grade crossing. PS-1 [Client A] landed on the dirt area southwest of the Conejo Avenue railroad grade crossing."The "Summary" further indicated, "After the collision, V-1 came to rest facing in a southeasterly direction in the dirt area southeast of the Conejo Avenue railroad grade crossing west of Topeka Avenue completely engulfed in flames. Amtrak Train 702 came to rest on its wheels on the mainline tracks facing in a southerly direction with the Locomotive approximately 2,873 feet south of the south pavement edge of Conejo Avenue. P-1 [DSP 1] came to rest lying in the grape vineyard southwest of Conejo Avenue railroad grade crossing. P-1 [DSP 1] succumbed to his injuries at the scene. PS-1 [Client A] came to rest lying on the dirt area between V-1 and the grape vineyard. PS-1 [Client A] succumbed to his injuries at the scene.The section titled "Cause" indicated, "...P-1 [DSP 1] caused this collision by driving V-1 in violation of section 22451(b) VC, which states: "No driver or pedestrian shall proceed through, around or under any railroad or rail transit crossing gate while the gate is closed." The County Coroner Certificate & Verdict dated 11/5/15, indicated in the section titled "EVIDENCE OF INJURY" Client A suffered the following injuries as a result of the collision: "... fracture... of the third cervical vertebra... fracture... of the fifth cervical vertebra (spine fractures which can result in paralysis or death)... brain has subarachnoid hemorrhage (bleeding in the brain caused by head injury - which can result in death)... Multiple bilateral posterior rib fractures are present at their junction with the thoracic spine (multiple broken ribs where they connect with the spine)..."The section titled, "CAUSE OF DEATH" indicated, "A. Head and chest injuries and B. Train-van collision."The section titled, "COMMENT" indicated, "The subject was a passenger riding in the van struck by a train at a railroad crossing. He was ejected from the vehicle during the collision. The vehicle caught on fire. The subject sustained injuries to the head and chest which were the cause of death." The facility failed to implement written policies and procedures that prohibited neglect of the client when: During the transport of Client A, DSP 1 neglected to obey the posted sign to stop the vehicle when the railroad grade crossing signal lights were flashing; neglected to stop in front of the rail road grade crossing gate; proceeded directly into the path of an oncoming Amtrak train; which lead to fatal injuries of an individual who otherwise did not have major health concerns.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 the patient and therefore constitutes a Class "AA" Citation. |
| 040000644 |
Bethesda Lutheran Communities-Helm |
040012130 |
B |
22-Mar-16 |
908D11 |
8886 |
Class B Citation - 483.460 (c) NURSING SERVICES The facility must provide clients with nursing services in accordance with their needs. The facility failed to provide Client B with nursing services in accordance with his needs when the Registered Nurses (RNs) did not review or monitor Client 5's daily use of five laxatives (substances that loosen stools and increase bowel movements).On 2/10/16, Entity Reported Incidents (ERI) CA00475863 and CA00472261 were investigated. Client B's Medication Administration Record (MAR) dated 2/16, indicated he had diagnoses which included quadriplegia (paralysis of all four limbs or of the entire body below the neck) and constipation. The MAR indicated Client B had been receiving the following routine laxatives since 1/21/15:1) Bisacodyl (a stimulant laxative which causes muscles in the colon to contract and allows stools to pass) 10 milligrams [mg], p.o. (by mouth) at bedtime. 2) Senna (herbal-based laxative which irritatates the lining of the colon/intestines causing a laxative effect) 8.6 mg, p.o. at bedtime.3) Milk of Magnesia (MOM) (a laxative with anti-acid) 60 milliliters (ml) p.o. at bedtime.4) Colace (softens stools and allows it to pass easier) 200 mg p.o. twice a day [BID]. 5) Reguloid (also known as Metamucil, a bulk-forming laxative which absorbs liquid in the intestines and makes a bulky, softer stool which is easier to pass) 2 tablespoons [tbsp] in 8 ounces of water three times a day [TID]. Client B's physician orders dated 2/16, included orders for 6 ounces of cranberry juice and 4 ounces of prune juice daily for constipation.On 2/9/16 at 4:45 p.m., during concurrent observation and interview, Client B drank 8 ounces of Reguloid. At 5:30 p.m., Direct Care Staff (DCS) 5 stated Client B had many laxative medications and was either constipated or had large amount of loose stools.On 2/10/16 at 9:36 a.m., during concurrent day program (DP) observations and interviews, Client B was wheeled to his classroom from the bathroom. He appeared pale and restless. At 9:38 a.m., Day Program Staff (DPS) 2 stated, Client B had loose stools everyday when he was at day program. At 9:50 a.m., the Case Manager (CM) stated Client B would be sent home (to the facility) because he had a large amount of watery "diarrhea," which leaked to his mid-back area and down to his legs. On 2/10/16 at 10:25 a.m., the Area Director (AD) arrived at the day program. She stated Client B would be assessed by Registered Nurse (RN) 1 and would be sent to the hospital if necessary. At 12:42 p.m., the AD stated Client B was taken to the hospital accompanied by DCS 5. On 2/10/16 at 12:45 p.m., a concurrent clinical record review and interview was conducted with the Qualified Intellectual Disabilities Professional (QIDP). Client B's "BM Record" (bowel movement record) dated 1/1/16 to 2/10/16, indicated that 10 of 31 days, Client B had medium, large, or extra-large stools 2-3 times per day. Five of these 10 days, Client B's stools were loose. This log was not inclusive of any bowel movements Client B had while at the day program. The QIDP stated Client B was in the hospital from 1/11/16 to 1/12/16, due to a urinary tract infection (UTI), fever, lethargy (slow movement, drowsiness), weakness, constipation, and (fecal) impaction (accumulation of a large mass of hard stools which are stuck in the rectum).The hospital document titled "History and Physical" indicated on 1/11/16, Client B presented to the ED with fever, abdominal pain, distended abdomen, and decreased bowel sounds. A computed tomography (CT - an x-ray that takes detailed images of internal organs) of Client B's abdomen indicated; "Marked fecal impaction with developing stercoral colitis (inflammation of the walls of the colon/intestines due to fecal impaction, which could lead to perforation (piercing), peritonitis (inflammation of the abdomen's lining, often accompanied by pain, vomiting, constipation, or diarrhea, and death." Client B was treated with intravenous (IV) fluids and disimpacted (manual removal of stool) and sent back to the facility on 1/12/16, with an order for polyethylene glycol (Golytely) [solution used for cleansing the bowels].On 2/10/16 at 4:45 p.m., a concurrent clinical record review and interview was conducted with RN 1. Client B's "Healthcare Evaluation and Nurse Notes" dated 2/10/16 at 11:45 a.m. written by RN 1 indicated, "... Weakness with diarrhea... had diarrhea at day program today... alert but weak, LOC (level of consciousness) decreases intermittently, mucous membranes are dry, poor skin turgor, sunken eyes... hyperactive bowel sounds... weak movement of arms... sent to (hospital) by ambulance due to decreased LOC and dehydration..." During the same interview, when asked if she had reviewed Client B's bowel management program (specifically, his multiple laxative use), RN 1 stated, "... I did not know he had multiple laxatives..." The document titled "Drug Regimen Review Protocol" dated bi-monthly from 2/16/15 to 1/4/16, was then reviewed with RN 1. This document indicated, "All irregularities in Med [Medication] administration are addressed." When asked how she completed this protocol if she did not know how many laxatives Client B used, RN 1 did not reply.The RN Quarterly Notes dated 6/29/15, 9/7/15, and 12/10/15, did not identify or address Client B's use of multiple laxatives.On 2/11/16 at 7:45 a.m., during an interview, the QIDP stated on 2/10/16 she received a voicemail from RN 1 informing her that the hospital physician diagnosed Client B with "laxative overuse."On 2/11/16 at 4:38 p.m., DCS 5 (accompanied Client B to the hospital) submitted a statement dated 2/10/16, "(Client B) was seen by (name of hospital physician)... because he was having diarrhea... he [MD] said it could be because he's on five different constipation medications..." The hospital documents titled "Emergency Department Notes" and "History and Physical" dated 2/11/16, indicated Client B presented to the ED with altered mental status, diarrhea due to multiple laxative use, and fatigue. The information from http://www.merckmanuals.com/home/digestive-disorders/symptoms dated 2016 indicated, "Constipation may be acute or chronic... People should not expect all symptoms to be relieved by a daily bowel movement, and measures to aid bowel habits, such as laxatives and enemas, should not be overused... The complications of constipation include... fecal impaction... Fecal impaction, in which stool in the rectum and last part of the large intestine hardens and completely blocks the passage of other stool, sometimes develops in people with constipation. Fecal impaction leads to cramps, rectal pain, and strong but futile efforts to defecate. Sometimes, watery mucus or liquid stool oozes around the blockage, which gives the false impression of diarrhea (paradoxic diarrhea)... Overusing these treatments can actually inhibit the bowel's normal contractions and worsen constipation..." The information from online.lexi.com dated 2016, indicated "... Chronic use or overdosage of [laxative] is habit forming and may produce persistent diarrhea, hypokalemia (lack of potassium [a chemical that is critical to the proper functioning of heart muscles]), loss of essential nutritional factors, and dehydration. Laxative dependence, chronic constipation, and loss of normal bowel function could occur during long-term use. .. May require immediate medical intervention with appropriate fluid and electrolyte replacement. Electrolyte [chemical] disturbances may produce vomiting and muscle weakness..."The administrative document titled "JOB DESCRIPTION - Registered Nurse (RN)" dated 3/12/14, indicated the RN's Essential Job Functions as follows: 1) Identifies health care needs for the person based on the data collected through the nursing process, 2) Develops a plan with goals and interventions specific to the needs of the person, 3) Implements the plan to promote, maintain, or restore wellness, prevent illness; and 4) Evaluates response of the person to the interventions and supports provided. The facility failed to provide Client B with Nursing Services in accordance with his needs when:* Client B had impaction then diarrhea as a result of the unmonitored use of multiple (five) laxatives.* At the day program (DP), Client B had a large amount of watery stools which leaked to his mid-back area and down to his legs, and appeared pale and weak. He was assessed by RN 1 and found to have dry mucous membranes, poor skin turgor, decreased LOC, and weak arm movements.* Client B was subsequently sent to the (hospital) by ambulance, where he was examined in the ED and diagnosed with diarrhea due to the use of multiple (five) laxatives and fatigue. This violation had a direct or immediate relationship to the client's health, safety, or security, and therefore constitute a Class 'B' Citation. |
| 030000852 |
Brandel Manor |
040012263 |
B |
18-May-16 |
3RPJ11 |
5795 |
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 when Resident 1 was not provided one on one supervision (one staff to observe Resident 1 at all times) as indicated in Resident 1's Care Plan. Facility staff left Resident 1 alone and unsupervised at the nurse's station. As a result of the failure to supervise, Resident 1 fell and suffered an acute (sudden onset) subdural hematoma (bleeding into part of the brain) which required hospitalization.On 3/14/16 at 8 a.m., an unannounced visit was made to the facility to investigate Entity Reported Incident CA00479473 regarding a resident fall.Review of Resident 1's clinical record titled, "Face Sheet" indicated Resident 1 was admitted to the Skilled Nursing Facility on 1/29/16 with diagnoses that included hemiplegia (inability to move one side of the body), muscle weakness, and dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). Resident 1's "Physician's Telephone Orders" dated 3/5/16 indicated Resident 1 was transferred to the emergency room (ER) on 3/5/16 for evaluation due to a fall.On 03/14/16 at 9:07 a.m., during an interview, Certified Nursing Assistant (CNA 1) stated she was on duty on 03/05/16 when Resident 1 fell while sitting at the nurse's station. CNA 1 stated she was down the hall when she heard an alarm. CNA 1 stated she ran up to the main nurses' station and found Resident 1 lying on the floor, on her left side. CNA 1 stated there was not any staff members present at the nurses' station when Resident 1 fell.On 3/14/16 at 9:31 a.m., during an interview, CNA 2 stated CNAs and licensed nurses were supposed to watch Resident 1 at all times. CNA 2 stated it was the responsibility of the nurse who sat at the nurses' station to keep a watch on Resident 1 (supervise).On 03/14/16 at 9:55 a.m., during an interview with the Director of Nurses (DON), the DON stated Resident 1 had fallen three times while in the facility. The DON stated on 03/05/16, there were initially two staff members at the nurse's station when Resident 1 sat in the wheelchair at the station. The DON stated one of the staff members left and the second staff member turned her back for "a couple of seconds."On 03/14/16 at 10:41 a.m., during an interview, Registered Nurse (RN) 2 stated Resident 1 had a fall on 03/05/16 at 11:50 a.m. at the front nurse's station. RN 2 stated she was called to assess Resident 1 after the resident fell. RN 2 stated "nobody was at the nurse's station to monitor the resident [Resident 1]."The facility's Physical Therapy Note dated 03/14/16, indicated Resident 1 was a high risk for falls.Resident 1's Care Plan dated 03/01/16, indicated, "Safety reinforced with routine care...d/t (due to) poor safety awareness and impulsivity." Resident 1's Care Plan dated 3/12/16 under S/P (Status post) fall indicated Resident 1 was a high risk for falls and included a plan to provide "1:1 supervision q (every) shift..." Review of the "Emergency Department Report" from the acute care hospital, dated 3/5/16 indicated Resident 1 was taken to the hospital on this date. Resident 1 had a Computerized Tomography (CT) scan (CT scanning is an X-ray test in which a computer generates cross-section views of a patient's anatomy. It can identify normal and abnormal structures, and it can be used to guide procedures) to the head. The document indicated under "diagnostic impression" Resident 1 had severe dementia and sustained an acute bilateral (both sides) intracranial hemorrhage (bleeding inside the skull) with chronic bilateral subdural hematomas. The report indicated "...history of severe dementia, intracranial hemorrhage from a previous fall with craniotomy [opening into the skull surgically] and burr hole [hole drilled into the skull to relieve pressure] placed in January of this year. The patient with multiple falls over the past 3 weeks...her [Resident 1's] son is at the bedside and reports patient fell out of a wheelchair today, and this is her 3rd fall in the past 3 weeks..." Review of the "Facility Investigative Report," undated, indicated, "On [3/5/16] resident [Resident 1] was up in wheelchair at nursing station, due to trying to climb out of bed without assistance. The nursing station is utilized for high risk resident that are trying to climb out of bed and/or wheelchair without assistance, accompanied by poor safety awareness and overestimation of their own abilities...Resident experienced an unwitnessed fall at the nursing station while trying get up from wheelchair. Resident was found on ground lying on her left side. Due to discoloration noted on left side of residents face and her history of subdural hematomas, patient was sent EMC [emergency medical care] for evaluation and/or treatment..." The "Emergency Department Report" dated 3/5/16, indicated Resident 1 was seen at one acute hospital ER, and then transported to a second hospital for neurology (study of the brain) consultation due to intracranial hemorrhage. "Http://www.medicinenet.com/hematoma/article.htm" defines a subdural hematoma as one in which the hematoma puts increased pressure on the brain, neurological abnormalities including slurred speech, impaired gait, and dizziness may result and progress to coma and even death. Therefore the facility's failure to supervise Resident 1, as indicated in her plan of care, resulted in a fall with significant medical harm.This violation had a direct relationship to Resident 1's health and safety and thus constitutes a Class B Citation. |
| 040000531 |
BETHESDA LUTHERAN COMMUNITIES - FLORADORA |
040012612 |
B |
4-Oct-16 |
V1TE11 |
9658 |
Bethesda Lutheran Communities - Floradora Class B Citation - 483.460 (c) NURSING SERVICES The facility must provide clients with nursing services in accordance with their needs. The facility failed to provide Client A with nursing services in accordance with her needs. Client A had significant, unplanned, and progressive weight loss of 16.7 pounds (11.4%) from 3/12/16 to 6/15/16; and the facility failed to report, monitor, and develop and implement health care interventions to reverse Client A's progressive weight loss. Client A had enlarged abdomen and occasional abdominal pain and a physician's recommendation for pelvic ultrasound was not followed. On 6/15/16, Entity Reported Incident (ERI) CA00491996 was investigated. 1. On 6/15/16 at 8:25 a.m., Client A was observed pacing in the living room. Client A's eyes were sunken with dark circles underneath; her face was pale in color, her lips were chapped, and her collar bone (the bone that connects the arm to the breast bone) and shoulder blades appeared to be markedly protruded. Her abdomen appeared distended. When greeted, Client A did not respond and Direct Care Staff (DCS) 1 stated Client A was non-verbal and therefore could not be interviewed. On 6/15/16 at 9:43 a.m., during an interview, DCS 1 stated Client A started losing weight towards the end of 4/16. DCS 1 stated, Client A had been eating 100% of her meals but continued to lose weight. She stated, each time she weighed and reported Client A's weight loss to the facility nurse (RN 1), she was instructed not to document the actual weight; but to document (a weight) that closely matched the last month's weight. Client A's Nutritional Progress Notes dated 12/9/15 indicated her Ideal Body Weight Range (IBWR) was 130 - 160 pounds. Her Vital Signs and Weight log from 8/15/15 to 6/11/16 (most current weights available) indicated her average body weight was 144.5 pounds. Client A's Vital Signs and Weights log dated 3/12/16 to 6/11/16 listed Client A's weights as follows: 3/12/16: 146.1 pounds 4/8/16: 145 pounds (-1.1 pound) 5/14/16: 141.9 pounds (-3.1 pounds) 6/11/16: 133.8 pounds (-8.1 pounds) From 3/12/16 to 6/11/16 (3 months), Client A lost a total of 12.3 pounds (8.4%) of her body weight. This total included the progressive weight loss of 6.8 pounds (4.83%) in 7 days from 6/4/16 to 6/11/16. On 6/15/16 at 11:49 a.m., during an interview, the Area Director (AD) stated Client A was picked up from her day program and brought home so RN 2 could assess her. The AD stated Client A was weighed after toiletting and before she had lunch. She stated, Client A weighed in at 129.4, another 4.4 pounds weight loss in 4 days, from 6/11/16 to 6/15/16. She stated, Client A lost a total of 16.7 pounds (11.4%) from 3/12/16 to 6/15/16. On 6/15/16 at 5:40 p.m., during an interview, RN 1 was asked to describe the facility's standard of practice for monitoring, documenting, reporting, and addressing weight (gain or loss) variances. RN 1 stated: a. Clients were weighed weekly on Saturdays. b. DCS would notify the House Manager (HM), RN, and Area Director when any client gained or lost 2 pounds per week. c. The RN would notify the physician, family/conservator and the Regional Center's Case Managers. d. A care plan would be developed, staff would be trained, and the care plan would be implemented. On 6/15/16 at 5:40 p.m., during the same interview, when asked if she was aware of Client A's weight loss of 6.8 pounds or 4.83% in 7 days (from 6/4/16 to 6/11/16), RN 1 stated she was onsite at the facility on 6/12/16 only to review the Medication Administration Record (MAR). She stated she did not have time to observe or assess Client A or any of the other clients. She stated she did not have time to review Client A's Vital Signs and Weights log as required by the facility's established practices and procedures. When asked if the recent significant weight losses noted on 6/4 & 6/11/16 were reported to Client A's Primary Care Physician (PCP), family/conservator and the Regional Center's Case Manager, RN 1 stated, "No, they have not been reported." When asked if she had developed a written plan of care for Client A's unplanned and progressive weight loss, RN 1 stated she did not. When asked to describe how Licensed Nurses/RNs monitored each client's weight, RN 1 stated she reviewed and initialed the Vital Signs and Weights record weekly, but did not realize Client A was losing "that much" weight. She stated she did not review Client A's most recent weight loss, did not review the monthly and quarterly weights, and did not identify any weight gain or loss variance that had occurred within those timeframes. On 6/16/16 at 7:00 a.m., during a telephone interview, the AD stated RN 1 did not monitor, reassess, or act upon Client A's change of condition (weight loss); and did not develop, teach, or implement a plan of care to address Client A's significant, progressive, and unplanned weight loss. The undated facility document titled "Procedure for Monitoring Body Weight" indicated, "...Body weight is a basic measure of health...Changes in body weight can tell us about the person's fluid status, nutritional status, or kidney and heart function...Sudden increases or decreases may alert us to disease or illness such as diabetes or cancer...Unexpected weight changes of 5% of total body weight should be reported to the health care provider...In certain individuals, a weight change of 2-3 pounds in a week, or 5 pounds in one month, need to be reported promptly as it may indicate problems with their fluid status, heart or kidneys." The administrative document titled "JOB DESCRIPTION - Registered Nurse" dated 5/31/15, indicated "...develops and maintains standards of practice... Oversees medical care including medication administration, pharmacy services, and overall plan of care... identifies health care needs and develops a plan with goals and interventions specific to the needs of the client... implements the plan to promote, maintain or restore wellness, evaluates the client's response to interventions, responsible for instructing unlicensed personnel in health-related subjects... Provides nursing care in compliance with recognized nursing standards and State and Federal Regulations..." On 6/22/16 at 2:58 p.m., during an interview, the Regional Nurse Consultant (RNC) stated RN 1 did not implement the facility's written policy and procedure for monitoring weights. 2. On 6/15/16 at 10:34 a.m., during an interview, DCS 1 stated, on several occasions, Client A appeared to have stomach pain. When asked to describe how Client A (who was non-verbal) displayed her (stomach) pain or discomfort, DCS 1 stated, "She would be standing with her legs crossed and leaned on to the wall or furniture..." When asked if Client A still had her menses (blood, secretions, and tissue comes out from the uterus in a non-pregnant woman), DCS 1 stated, Client A still had her menses, but they had been irregular for the past 3 years. She stated she was not sure if Client A's stomach pain was related to her irregular menses or to her constipation. She stated, on 2/23/16 Client A was sent to the Emergency Department (ED) where she was diagnosed with "Abdominal Pain." Client A's physician's order dated 6/16, indicated an order for yearly PAP smear (A screening test for Cervical cancer) and gynecological examination. The Physician's Progress Notes dated 12/16/15, indicated Client A refused PAP smear and or pelvic examinations. Client A's Medical Appointment Form dated 12/30/15, indicated Client A again refused to have a pelvic examination done. The physician's report dated 12/30/15 indicated; "... Here for PAP... Pt (patient) not willing to undress... This was fourth visit at which patient not willing to cooperate... Need for alternate method of pelvic exam...Refer for pelvic ultrasound (A pelvic ultrasound is a quick and non-invasive diagnostic exam that produces images that are used to assess organs and structures within the female pelvic organs)." From 12/30/15 to 6/15/16 (6 months), there was no documentation of any arrangement or referral made by the facility RNs for Client A to have pelvic ultrasound. On 6/15/16 at 5:53 p.m., during an interview, when asked what follow-up had been made to obtain a referral for pelvic ultrasound for Client A, RN 1 stated, "... She (Client A) does not need an ultrasound... she is not sexually active." The facility failed to provide Client A with Nursing Services in accordance with her needs when: 1. On 6/15/16, Client A's eyes were sunken with dark circles underneath; her face was pale in color, her lips were chapped, and her collar bone (the bone that connects the arm to the breast bone) and shoulder blades appeared to be markedly protruded. From 3/12/16 to 6/15/16 (3 months), Client A lost a total of 16.7 pounds (11.4%) of her body weight. The facility failed to monitor, develop, and implement a plan of care to address Client A's unplanned, significant, and progressive weight loss; which placed her at risk for undetected disease process or complications to her health and well-being. 2. Client A had enlarged abdomen and displayed occasional abdominal pain by crossing her legs and leaning on to the walls or furniture. The facility failed to follow a physician's order to refer her for pelvic ultrasound. As a result, Client A continued to experience abdominal pain which placed her at risk for undetected disease process or complications to her health and well-being. The above violations had direct or immediate relationship to Client A's health, safety, or security, and therefore constitutes a Class B Citation. |
| 040000644 |
Bethesda Lutheran Communities - Helm |
040012849 |
A |
28-Dec-16 |
4SEB11 |
16289 |
76875 (a) Health Support Services - Nursing Services The facility shall provide registered nursing services in accordance with the needs of the clients. 76875 (b) Health Support Services - Nursing Services 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 facility failed to provide Client A with nursing services in accordance with his needs when Client A had a significant change of condition (COC) manifested by rapid heart rate, a large amount of watery stools, and lethargy on 6/26/16; the facility failed to accurately assess Client A's symptoms, failed to monitor his vital signs, failed to promptly report Client A's worsening symptoms to the physician and Responsible Party/Conservator (RP/C), and failed to transfer Client A to the hospital until thirteen hours after the onset of a change of condition. Client A was evaluated in the Emergency Department (ED) on 6/27/16 at 9:34 a.m., with abnormal vital signs and then admitted to the Intensive Care Unit (ICU) on the same day at 8:37 p.m., for management and treatment of Acute Hypoxic Respiratory Failure (insufficient oxygen for the body tissues to function), Septic Shock (medical condition that occurs when sepsis, which is organ injury or damage in response to infection, leads to low blood pressure), Pancolitis (inflamed bowels), and Fecal Impaction (large lump of dry, hard stool that stays stuck in the rectum). Client A expired on 7/18/16 at 8:38 p.m. from Respiratory Failure and Pneumonia complicated by Fecal Impaction and Acute Renal Failure. On 6/29/16 at 3:30 p.m., an onsite visit was conducted at the facility to investigate Entity Reported Incident (ERI) CA00493640. At this time, a concurrent interview and clinical record review indicated Client A was a 42 year old male with diagnoses which included Seizure Disorder (uncontrolled and involuntary muscle contractions due to sudden disruption of the brain's normal electrical activity), constipation (a condition of the bowels in which the feces are dry and hardened and evacuation is difficult and infrequent), and Quadriplegia (paralysis of the entire body below the neck). On 6/30/16 at 1:31 p.m., during a telephone interview, Direct Care Staff (DCS) 1 stated on 6/26/16 at 7:45 p.m., Client A had extra-large brown watery stools which seeped/leaked out of his briefs and spread to his thighs, mid-back, and below his shoulders. DCS 1 stated, "[Client A] "moaned" as if he was hurting somewhere..." DCS 1 stated Client A again had extra-large watery stools at 7:55 p.m. and 8:10 p.m. DCS 1 stated after he put Client A back to bed, he checked the client's pulse which was 120 beats per minute. The website for the Mayo Clinic (www.mayoclinic.org/normal-heartbeat) indicated, "... A normal adult heart rate ranges from 60 to 100 beats per minute. A heart rate below 60 or above 100 beats per minute may indicate an underlying health problem and should be discussed with a doctor, especially if accompanied by dizziness or shortness of breath." DCS 1 stated Client A's pulse was "usually" in the 80's. DCS 1 stated he called Registered Nurse (RN) 1 at 8:30 p.m. and reported Client A's symptoms (moaned as if he was hurting, weakness, extra-large watery stools, and elevated pulse). When asked what instructions did RN 1 give to alleviate Client A's symptoms, DCS 1 stated RN 1 instructed him to recheck Client A's pulse. When asked if he had given Client A water or fluids after the client had three extra-large watery stools, DCS 1 stated he had not. When asked what was Client A's pulse on the re-check, DCS 1 stated he did not re-check the client's pulse as instructed by the RN. DCS 1 stated RN 1 arrived at the facility at 8:44 p.m. and assessed Client A. DCS 1 stated he had hoped RN 1 would send Client A to the hospital due to Client A's change of condition (COC). DCS 1 stated RN 1 instead instructed him to continue to monitor Client A for a declining status which would indicate a further COC. When asked if he had documented Client A's condition and vital signs, DCS 1 stated he had not. On 6/30/16 at 2:03 p.m., during a telephone interview, DCS 2 stated on 6/26/16 at 10:30 p.m., she arrived at the facility and was informed about Client A's watery stools from DCS 1. DCS 2 stated RN 1 was at the facility at this time and directed her to check Client A's vital signs every four hours while the client was awake, and to call her [RN 1] if Client A continued to have loose or watery stools. DCS 2 stated on 6/27/16 at 1:00 a.m., Client A had "very large" brown, watery stools, was weak and slow to respond. When DCS 2 was asked if she gave water or any other type of fluid to prevent Client A from becoming dehydrated, DCS 2 stated she gave Client A four ounces of water (equal to 8 tablespoons). When asked if she called RN 1 to report Client A's loose stool and slow responsiveness observed at 1 a.m., DCS 2 stated she did not call RN 1 until five hours later on 6/27/16 at 6:30 a.m. DCS 2 also stated she did not check Client A's vital signs as instructed by RN 1. DCS 2 did not offer a reason why she had not followed RN 1's directions to recheck Client A's vital signs When asked if she had documented Client A's known symptoms of a COC (watery stools, weakness, and slow response), DCS 2 stated she had not. On 6/30/16 at 2:45 p.m., during a telephone interview, DCS 3 stated on the morning of 6/27/16, Client A had two large watery brown stools which leaked out of his briefs. DCS 3 stated she had taken Client A's vital signs, which indicated a heart rate of 108 beats per minute. DCS 3 stated Client A appeared weak and would not respond when he was touched or when his name was called. DCS 3 stated she had called and informed RN 1 of Client A's condition at this time. DCS 3 stated, "I begged her (RN 1) to send Client A to the hospital... she then instructed us to call 9-1-1." On 6/30/16 at 2:45 p.m., during the same interview, DCS 3 stated on 6/27/16 (could not recall the exact time), the emergency medical personnel arrived at the facility and checked Client A's vital signs. DCS 3 stated the emergency medical personnel informed her Client A's heart rate was high at 150 beats per minute. DCS 3 stated RN 1 called again and when told the emergency medical personnel were at the facility, RN 1 instructed her to send the emergency medical personnel away because Client A's RP/C "did not want (Client A) to go to the ED [Emergency Department] to be seen for "flu-like symptoms." DCS 3 stated the emergency medical personnel then spoke with RN 1 on the phone and recommended Client A be sent to the hospital now because Client A was less responsive than before and his heart rate was high at 150 beats per minute. DCS 3 stated, "... The emergency medical personnel left the facility without taking Client A to the hospital." On 6/30/16 at 3:21 p.m., during a telephone interview, the RP/C stated Client A was cheerful, happy, and had no signs and symptoms of illness when she visited him at the facility on 6/23/16. Client A's RP/C stated on 6/27/16 at 7:00 a.m., RN 1 called her for the first time and informed her Client A had diarrhea and "flu-like symptoms" since 6/26/16 after dinner. The RP/C stated RN 1 had told her she had called the physician and reported Client A had "flu-like" symptoms. The RP/C stated, "... I asked her if he had fever, cough, sneezing, or headache, symptoms he had when he had the flu, and (RN 1) only told me about the loose stools... she did not mention (Client A) had fast heart rate..." The RP/C stated, "... She (RN 1) told me 9-1-1 was called and asked me if they should be canceled... I told her that if it was the "flu" as she had thought, then maybe we should just wait and see..." The RP/C stated, "She (RN 1) was the nurse, she had the responsibility to make critical assessments and decisions... she assured me (Client A's) symptoms were 'flu-like'." On 7/1/16 at 1:00 p.m., during a telephone interview, RN 1 stated, on 6/26/16 at 7:50 p.m., DCS 1 reported Client A had an extra-large loose bowel movement and was weak. RN 1 stated she went to the facility and assessed Client A. She stated Client A's pulse was 100 beats per minute but he "appeared to be just fine." She stated Client A was placed on "Stop and Watch," (the facility's monitoring system when clients had change of condition) and instructed DCS 1 and DCS 2 to monitor the client for any further loose stools, and to notify her and/or call 9-1-1 for non-responsiveness or a lethargic state. RN 1 stated she had not received a report of further loose stools from the night shift (DCS 2) until 6/27/16 after 6:00 a.m. (by DCS 2). RN 1 stated, "... I called Client A's physician for the first time a little after 7:00 a.m., and reported Client A had "flu-like" symptoms," had diarrhea, and was "slightly" lethargic. RN 1 stated, the physician ordered to continue to monitor Client A and "push" fluids. RN 1 stated after she spoke to the physician, she called Client A's RP/C for the first time and informed the RP/C of Client A's "flu-like" symptoms (loose stools, weakness and lethargy). RN 1 stated the RP/C requested to "wait" for improvement." Client A's "Health Care Evaluation/Nurse" Note dated 6/27/16 (document date was 10:00 a.m.) and written by RN 1 indicated; "... Staff called to report client is weak and lethargic with 3 loose stools last night and 1 watery this am at approx. (approximately) 0620 [6:20 a.m.]... Call to Dr. to report 4 loose stool (sic) since last night...with slightly lethargic state... V/S (vital signs)... 108 [pulse]... fluids taken well this am per night shift...Call received from Dr. at approximately 0700 with instruction to monitored (sic) and if no further change of condition, continue current care, if no lethargic state or change of condition by 12 pm we will continue to monitor and increase fluids... If there is any change of condition by 12 pm call 911... (Name of RP/C) informed of above... staff states continues to have loose stools and is very weak... Call placed to 911 per RN instructions... RN placed another call to [RP/C] and informed of 911 call and staff concerns, her request is to wait for any further change of condition or improvements... call to house to inform staff to cancel 911 per [RP/C] request... 0720 (7:20 1.m.) Paramedic at home stated v/s BP [blood pressure] 90/58, P [pulse] 120, recommends client to be transported to prevent seizure activity... Call to RP/C to inform of recommendation by paramedic, she states she wishes to wait for improvement and monitor... RN arrived at home at approx. 0830 (8:30 a.m.) assessed [Client A] and found R [respiration] 40, P [pulse] 160, lethargic, pale, eyes sunken, watery stool... 911 called and transported to ER (Emergency Room)..." On 7/1/16 at 5:00 p.m., during a telephone interview, the physician stated on 6/27/16 (could not recall the time); RN 1 reported Client A had diarrhea and "flu-like" symptoms since 6/26/16. The physician stated RN 1 reported Client A could have gotten the flu from other clients at another facility. Client A's physician stated, "... I was not informed that [Client A] had become weak and had rapid heart rate..." The physician stated Client A should have been sent to the hospital on 6/26/16, instead of waiting to do so the next day (6/27/16). The "Emergency Department Provider Notes," dated 6/27/16 indicated, Client A arrived at the ED at 9:34 a.m., with a heart rate of 151 beats per minute, respirations (breathing) of 48 breaths per minute, and a blood pressure of 85/60 [low]. The ED "Clinical Impression" dated 6/27/16; indicated Client A had Sepsis (bacterial infection in the bloodstream or body tissues), acute diarrhea, severe Dehydration (excessive loss of body water), and Tachycardia (rapid heart rate). The acute care hospital document titled, "Critical Care Consult Notes" dated 6/27/16 at 8:37 p.m., indicated Client A was admitted to the Intensive Care Unit (ICU) with "Acute Hypoxic Respiratory Failure" (insufficient oxygen for the body tissues to function), Septic Shock (medical condition that occurs when sepsis [organs are injured or damaged in response to infection], leads to low blood pressure), Pancolitis (inflamed bowels), and Fecal Impaction. The same report indicated Client A's prognosis (forecast) was "Guarded" and "Critically ill." The "Death Note" dated 7/18/16 at 8:38 p.m., indicated, "... (Client A) became asystolic (no heartbeat), no heart tones, and no respirations." The "Certificate of Death" dated 8/2/16 indicated, "... Immediate cause of death: Respiratory Failure; Sequential Cause of Death: Pneumonia; and, Significant conditions contributing to death: Fecal Impaction and Acute Renal Failure." The facility document titled, "Supporting and Maintaining Best Possible Health," dated, 4/10/15 indicated, "... When notified of any change in condition, the Registered Nurse or Program Manager will determine if immediate attention is needed, or if consultation with the physician should be attempted first... Communicate and notify all involved parties with any change in the person's health according to guidelines... Do not hesitate!" The facility document titled, "Change in Condition" dated 3/1/14 indicated, "...Change in Condition: Any adverse change in physical health related to illness... Direct Support Professionals may observe subtle changes that are early warning signs of a change in condition... It is important to observe and report any changes promptly for further evaluation and monitoring or treatment...The 'Stop and Watch' is used for identification and communication of changes observed... Prompt and adequate treatment will be provided in a timely manner... Responsible parties will be notified of any changes resulting from illness... Observe, record and report any condition change to the attending physician, guardians and families so proper treatment will be implemented...For medical emergencies, call EMS (911)... For serious medical issue that requires prompt medical attention, assist and transport the individual to the Emergency Room." The administrative document titled, "JOB DESCRIPTION - Registered Nurse" dated 5/31/15, indicated "...develops and maintains standards of practice... Oversees medical care including medication administration, pharmacy services, and overall plan of care... identifies health care needs and develops a plan with goals and interventions specific to the needs of the client... implements the plan to promote, maintain or restore wellness, evaluates the client's response to interventions, responsible for instructing unlicensed personnel in health-related subjects... Provides nursing care in compliance with recognized nursing standards and State and Federal Regulations..." The facility failed to provide Client A with Nursing Services in accordance with his needs when Client A had a significant change of condition (COC) manifested by rapid heart rate, large amount of watery stools [feces], and lethargy (state of tiredness, weakness, or fatigue); and the facility failed to: 1. Accurately assess Client A's symptoms. 2. Monitor his vital signs. 3. Promptly report Client A's worsening symptoms to the physician and Responsible Party/Conservator (RP/C). 4. Follow Emergency Medical Personnel recommendation to transfer Client A to the hospital due to abnormal (elevated heart rate and less-responsiveness). These failures resulted to delayed medical evaluation necessary to treat and sustain Client A. Client A was seen in the Emergency Department (ED) on 6/27/16 at 9:34 a.m., 13 hours after the onset of a significant change of condition (diarrhea, elevated heart rate, and lethargy). Client A's condition worsened whereupon, he was admitted to the ICU on 6/27/16 at 8:37 p.m., for management and treatment of Acute Hypoxic Respiratory Failure, Septic Shock, Pancolitis, and Fecal Impaction. Client A expired on 7/18/16 at 8:38 p.m. from Respiratory Failure and Pneumonia complicated by Fecal Impaction and Acute Renal Failure. The above violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious harm would result and therefore constitute a Class 'A' Citation. |
| 040000015 |
BETHEL LUTHERAN HOME, INC. |
040013080 |
AA |
24-Mar-17 |
H54511 |
22114 |
F 309 483.24 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.
F 279
483.20(d) Use. Resident Assessments
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.
483.2(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?(2) and 483.10?(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?(6).
On 5/31/16 an unannounced visit was made to the Skilled Nursing Facility (SNF) to investigate Entity Reported Incident CA 00488228 regarding a resident fall with injury.
The facility failed to ensure Resident 12 received the necessary care and services to maintain the highest physical and mental well-being in accordance with the plan of care, when Resident 12's care plan for fall prevention was not implemented. Resident 12 walked in her room unassisted and unsupervised, without the benefit of a tab alarm (an audible alarm attached to resident clothing in an effort to alert caregivers when the resident is getting up out of bed or chair).The tab alarm is a preventive measure to be used in accordance with Resident 12's safety measures documented in the plan of care. The facility failed to revise the care plan in response to Resident 12's identified behaviors which placed Resident 12 at risk for falls.
As a result of these failures Resident 12 fell on XXXXXXXX 16 and sustained a head injury that required transportation by ambulance to the acute care hospital for treatment. The head injury Resident 12 suffered included bleeding into the brain, facial bone fractures and a scalp laceration requiring sutures. Because of the serious nature of the head injury, the family of Resident 12 chose to not admit to the hospital for possible corrective surgery and instead Resident 12 was sent back to the SNF for palliative (treatment directed at relieving symptoms and providing comfort rather than seeking a cure) care. On 5/17/16 Resident 12 fell again. Resident 12 expired seven days after the first fall due to injuries related to the fall.
Review of Resident 12's clinical record titled, "Admission Record" (document containing personal information) indicated Resident 12 was admitted to the facility on 1/27/16 with diagnoses including self-care deficit, urinary frequency (frequent urination), dementia (loss of mental ability to recall memories and perform functions of daily living), tremors (unintentional involuntary movements) and generalized weakness.
Review of Resident 12's clinical record titled, "Physician Orders" dated 5/1/16, indicated, "Hx [history] of falls prior to admit [before admission to the SNF]."
Review of Resident 12's clinical record titled, MDS 3.0 (Minimum Data Set) (a comprehensive resident assessment tool used to guide development of the resident's care plan) assessment, dated 5/9/16, indicated Resident 12 had a BIMS (Brief Interview of Mental Status) score of 10 of a possible 15 points. The score indicated Resident 12 had moderate memory impairment. The MDS 3.0 assessment indicated Resident 12 required supervision with bed mobility, transfers, eating and limited assistance (guided maneuvering of limbs) to walk in the room and corridor, dressing, toileting, personal hygiene and bathing. The MDS 3.0 assessment indicated Resident 12 had a history of falls prior to admission to the SNF.
Review of Resident 12's clinical record titled, "Fall Risk Assessment" dated 5/9/16, indicated Resident 12 had a high risk for falls.
Review of Resident 12's care plan titled, "Falls" dated 1/27/16, indicated, "Concerns and Problems: Falls, At risk for falls, At risk for injury R/T [related to] fall . Resident Goals: No fall, No significant injury secondary to fall. Approach Plan: 1. Up in W/C [wheelchair] with assist?2. Keep bed in low position 3. Encourage Resident to use call light for assistance if able (answer promptly)?11. Keep call light within?reach of Res [Resident]. Tab alarm in place (Body Alarm)." Resident 12's "Fall" care plan dated, revised 5/10/16, indicated, "Concerns and Problems: Poor safety awareness, non-compliant with ambulation, resident ambulating without staff assistance." The care plan revised 5/10/16 did not indicate any new interventions for fall prevention and "Concerns and Problems" did not include Resident 12's known history of removing her tab alarm as indicated during interviews with facility staff.
On 5/31/16 at 9:50 a.m., during an interview and concurrent clinical record review, Licensed Nurse (LN) 1 stated she was the nurse assigned to Resident 12 on 5/16/16, the night Resident 12 fell. LN 1 stated Resident 12 had poor balance and did not use any assistive devices to help with balance. LN 1 reviewed Resident 12's "Fall" care plan and stated the care plan dated 5/10/16, indicated Resident 12 had poor safety awareness and a risk for fall. LN 1 stated no new interventions to reduce the risk for fall were identified on Resident 12's care plan dated 5/10/16. LN 1 stated Resident 12's "Fall" care plan indicated Resident 12 should have had a tab alarm in place as an intervention to prevent falls. LN 1 stated Resident 12 did not have a tab alarm on 5/16/16, the night she fell. LN 1 stated, "Honestly I feel so bad because I know it was something that we could have prevented, I didn't know she needed a tab alarm." LN 1 stated, "I was sitting at the nurse's station when I heard a loud smack. It sounded like something cracked. My co-worker?also heard the noise that [Resident 12] made when she fell." LN 1 stated they responded to Resident 12's room finding Resident 12 on the floor in a "pool of blood and "breathing funny." LN 1 stated Resident 12 had a history of getting up from her bed and her recliner without assistance.
Review of Resident 1's clinical record titled, "Nurses Notes" dated 5/16/16 at 1:47 a.m., indicated, "Heard a loud noise from a room across the hall?went to [Resident 12's] room found [Resident 12] on the floor with face tilted to right side and ?blood under her face ?[Resident 12] was unconscious for less than 2 minutes?"
Review of Resident 12's clinical record from the acute care hospital, dated 5/16/16, titled, "CT [computed tomography - a specialized radiologic image that provides a more detailed information than an X-Ray] Head without Contrast [dye]" indicated, "There are scattered hyper dense [extremely dense] collections within the right parietal and both frontal lobes [parts of the brain] compatible with subarachnoid hemorrhages [SAH] [bleeding into the layers of the membrane that covers the brain]. There is slight deformity of the inferolateral [below and to one side] left bony orbital [eye socket] wall compatible with fracture. There may be a small fracture of the right lateral [pertaining to the right side] maxillary [upper jaw] sinus wall. There is left periorbital edema [swelling around the eyes]. There is left lateral periorbital [around the orbit of the eye] scalp laceration."
On 5/31/16 at 11:05 a.m., during an interview, Certified Nursing Assistant (CNA) 1 stated he recalled providing care to Resident 12 prior to her fall during her stay at the SNF. CNA 1 stated Resident 12 was a "little confused" and "wobbly on her feet." CNA 1 stated Resident 12 was known to remove her tab alarm. CNA 1 stated he did not know if a different approach to assist Resident 12 with wearing the tab alarm had been attempted. CNA 1 stated Resident 12 was supposed to have a tab alarm on all of the time in order to alert staff when she was getting up unassisted. CNA 1 stated Resident 12 would get up frequently without calling for help and staff would find her going through her clothes inside her closet. CNA 1 stated, "[Resident 12] was very forgetful and did not always call us for help. The problem is that without a tab alarm we would not always know when and if she was getting up without assistance."
On 5/31/16 at 11:15 a.m., during an interview, CNA 2 stated he was familiar with Resident 12. CNA 2 stated Resident 12 knew who she was but was often confused about where she was and what was happening. CNA 2 stated Resident 12 was at risk for falls and would frequently walk in her room without assistance from staff. CNA 2 stated, "We would assist her back to the couch and would remind her that it was important for her to call us for help but she never did. She always attempted to be independent." CNA 2 stated he did not know if Resident 12 had a tab alarm available to use but he knew Resident 12 was supposed to have a tab alarm in place.
On 5/31/16 at 11:35 a.m., during a telephone interview, the Director of Nursing (DON) stated nursing staff checked on Resident 12 "as often as possible." The DON stated Resident 12 was not compliant in asking for assistance and staff on duty was told to listen for noises from Resident 12's room which would alert them Resident 12 was up and needed assistance. The DON stated Resident 12 had a history of removing her tab alarm but that problem had not been addressed in Resident 12's care plan. The DON stated Resident 12's care plan needed a different approach to prevent a fall when Resident 12 frequently removed the tab alarm. The DON stated Resident 12's care plan should have reflected an intervention to manage Resident 12's history of noncompliance in asking for help when she needed to get up. The DON stated the IDT (interdisciplinary team) (a group composed of a doctor, a nurse, social service person, activity director and dietician) did not review Resident 12's falls in the facility to determine the root cause of the fall on 5/16/16.
Review of Resident 12's "Interdisciplinary Care Plan Conference Notes," dated 5/10/16 indicated, "?Resident removes and hides alarms?"
Review of Resident 12's nursing care plan, dated 5/10/16 indicated, "Tab alarm in place (Body Alarm." There was no documented evidence of an intervention in place to prevent Resident 12 from removing the tab alarm on this date.
Review of Resident 12's nursing care plan for falls, dated 5/17/16 indicated "tab alarm in place on sock at foot of bed due to res taking it off."
On 5/31/16 at 12:10 p.m., during a telephone interview, CNA 3 stated Resident 12 did not have a tab alarm on 5/16/16, the night Resident 12 fell. CNA 3 stated, "I know at one time yes [she had an alarm], but I am not sure if she was supposed to have one. That [not knowing if Resident 12 needed a tab alarm] was the confusion we had." CNA 3 stated the nurses and the DON notified the CNA whenever a resident required use of a tab alarm. CNA 3 stated Resident 12 would frequently get up and walk into the restroom without assistance. CNA 3 stated Resident 12 was at risk for falling.
On 6/1/16 at 12:40 p.m., during a telephone interview, CNA 4 stated she approached and woke Resident 12 on 5/16/16 at 1:06 a.m., to ask if she needed to use the restroom. CNA 4 stated Resident 12 did not always use her call light to call for assistance. CNA 4 stated Resident 12 did not have a tab alarm the night of the fall. CNA 4 stated Resident 12 had a history of removing her tab alarm. CNA 4 stated she did not know if Resident 12 needed a tab alarm when in bed. CNA 4 stated, "When she first came to the facility [SNF], she had one [tab alarm] but later we just didn't see one."
On 6/7/16 at 8:45 a.m., during an interview and concurrent clinical record review, the DON stated Resident 12 was sent to the hospital following the fall on XXXXXXXX 16 and returned the same day at 3:08 p.m. The DON stated upon return to the SNF on 5/16/16 Resident 12 was started on a "30 minute monitor" (observation of Resident 12's condition every 30 minutes by a CNA). The DON stated on 5/17/16 at 7:25 a.m., Resident 12 was left alone and sustained another fall. The DON was unable to produce documentation of the intervals in which "30 minute monitoring" had been completed.
Review of Resident 12's care plan dated 5/16/16 under problem indicated, "Fall c (with) injury." Under intervention the care plan indicated, "30 min and prn [as needed] chk [check] through the noc [night] shift."
On 6/7/16 at 9:08 a.m., during an interview, LN 2 stated on 5/17/16 at 7 a.m., she saw Resident 12 in a low bed with a tab alarm in place and a blue mat on the floor. LN 2 stated Resident 12 was restless throughout the night on 5/16/16 and early morning hours of 5/17/16. LN 2 stated Resident 12 had required Ativan (medication used to treat anxiety) to help reduce her agitation. LN 2 stated on 5/17/16 at 7:25 a.m., Resident 12 had a second fall after her return from the acute hospital and was found lying on the floor next to her closet. LN 2 stated she did not know when the last "30 minute monitor" was done by CNA 5. LN 2 stated there was no documentation in place to evidence a "30 minute monitoring" had occurred. LN 2 stated Resident 12 sustained multiple skin tears on her arms following the fall on 5/17/16.
Review of Resident 12's "Nurses Notes" dated 5/17/16 at 3:30 a.m., indicated, "Heard the alarm [tab alarm] go off. When staff went in room found resident [Resident 12] sitting at the edge [of the bed]. Very agitated, would not calm down?Resident was trying to pick out the sutures [stitches above left eye]. At 0400 [ 4a.m.] this nurse tried to give resident Ativan SL [sublingual, method of administering medication by placing it under the tongue] but resident threw out of her mouth twice. Finally this writer gave her Ativan."
Review of Resident 12's clinical record titled, "Nurses Notes" dated 5/17/16 at 7:25 a.m., indicated, "Writer was called to [Resident 12] room. [Resident 12] was lying on the floor on her back, head against closet door. [Resident 12] was assessed, above right eyebrow a 3 centimeter (cm)(unit of measurement) laceration [cut], Right chin hematoma [collection of blood under the skin] with a small laceration, right top shoulder 3 cm abrasion with bruising around it, right outer hand a 3 cm skin tear, left outer hand 4 cm skin tear?[Physician] notified of fall ?new order to move [Resident 12] to room [closer to the nursing station] to be observed more closely?[Resident 12] tab alarm was on and had been pulled off by [Resident 12]?"
On 6/7/16 at 9:45 a.m., during an interview and concurrent clinical record review, the DON stated Resident 12 did not have a tab alarm in place the night of the first fall on 5/16/16. The DON stated she did not know the location of Resident 12's tab alarm the night of her fall. The DON stated the LN's and CNA's were responsible to ensure the tab alarms were being applied on the residents. The DON stated all the residents in the facility had a "Resident Status Sheet" in which was documented whether Resident 12 required use of a tab alarm. The facility produced Resident 12's "Resident Status Sheet," an undated document that indicated Resident 12 required a tab alarm to be in place. The DON stated the second fall occurred on 5/17/16 at 7:25 a.m., after Resident 12 removed her tab alarm.
On 6/23/16 at 9:40 a.m., during a telephone interview, LN 2 stated she completed an assessment on 5/9/16 (seven days prior to the initial fall) which evaluated Resident 12's cognitive and functional abilities. The assessment indicated Resident 12 required supervision by staff for bed mobility and transfers in and out of bed. LN 2 stated Resident 12 required limited assistance for dressing and walking. LN 2 stated she completed an assessment of Resident 12 following her return from the acute care hospital for the head injury on XXXXXXXX16. LN 2 stated Resident 12 returned to the SNF with unclear speech and had declined in her functional abilities. LN 2 stated Resident 12 no longer would take food or fluids by mouth. LN 2 stated Resident 12 would no longer participate in activities of daily living and required total staff assistance for bed mobility, transfers, toileting, hygiene, grooming, dressing and eating after the fall on 5/16/16.
On 1/12/17 at 2:43 p.m., during a telephone interview, the DON stated Resident 12 sustained a fall on 5/16/16 which required an acute hospital evaluation. The DON stated Resident 12 was diagnosed with a Subarachnoid Hemorrhage (SAH) during her hospitalization, and her family chose to have Resident 12 return to the facility under comfort care only (care directed at providing comfort rather than aggressive measures directed at obtaining a cure) following her fall and diagnosis of SAH. The DON stated Resident 12 had a second fall on 5/17/16 and was not sent for a hospital evaluation. The DON stated Resident 12's physician made the decision not to transfer the resident to the hospital at that time, after the fall on 5/17/16, based on the "Physician Orders for Life- Sustaining Treatment" (POLST ) form which documented to transfer Resident 12 to the hospital only if her comfort needs could not be met in the facility.
On 1/12/17 at 3:30 p.m., during a telephone interview, Resident 12's physician (MD) 1 stated, "?After the SAH [diagnosis] [Resident 12] was no longer able to respond like before. Her family spoke with [acute care physician] and they opted not to treat the SAH ?" MD 1 stated the hemorrhage caused from the SAH would induce agitation and pain from the head injury. MD 1 stated Resident 12's decline and death were related to the SAH sustained from the fall.
Review of Resident 12's SNF clinical record titled, "Discharge Summary" undated, indicated, "Course in Facility: Resident was admitted from [Acute Care Hospital] following treatment for abdominal pain at the request of her family ?During her stay in the facility (prior to 5/16/16) Resident was alert and forgetful. Her ADL status had improved to limited assist. Resident was eating meals in the main dining room and had gained weight?Events That Led to Discharge: On 5/16/16 at 1:47 a.m., Resident sustained a fall in her room in which Resident appeared to be returning to her bed from the bathroom. Resident was noted to have a [loss of consciousness] and trauma to her head?While at [acute hospital] Resident was noted to have a Subdural Hemorrhage [bleeding below the membrane that covers the brain]?On 5/23/16 Resident expired." The document was signed by the DON and MD 1.
Resident 12's "Certificate of Death (CD)" dated 6/3/16, indicated Resident 12's date of death was XXXXXXXX16 at 11:52 a.m. Resident 12's CD indicated, "Cause of Death? Immediate Cause (Final disease or condition resulting in death) A. Pulmonary Arrest [breathing stopped]." Below line A the CD indicated, "Sequentially list conditions, if any, leading to the cause listed on line A. Enter the underlying cause (Disease or injury that initiated the events resulting in death) last." The CD sequentially listed the conditions leading to the cause listed on line A as "B. Aspiration Pneumonia [inflammation of the lungs due to inhaling food or fluid into the lungs]. C. Subdural Hemorrhage. D. Fall at nursing home." "Fall at nursing home" was listed last on the sequential list. This indicated the fall was the injury that initiated the cascade of events leading to the cause of death listed on line A.
The facility policy and procedure titled, "Resident Fall guidelines" dated 1/5/15, indicated, "To provide guidelines to licensed nurses for proper care of a resident when a fall occurs?Procedures?Residents who are found to be at risk for falling will have a care plan initiated immediately and interventions for fall prevention initiated?"
Facility policy and procedure titled, "Appropriate Development, Revising and Updating of Resident Care Plans" dated 1/5/15, indicated, "To provide guidelines to employees for appropriate development, revising and updating of comprehensive resident care plans. Policy ?3.) The resident will have a comprehensive resident care plan developed, revised, reviewed and or updated with each change in status, including but not limited to falls?at the time of the change in status by a licensed nurse. 4) The resident will have a comprehensive resident care plan developed revised, reviewed and or updated each week during the completion of their weekly progress note by a licensed nurse?A) for an existing care plan: the licensed nurse will review and evaluate current interventions for their appropriateness?"
Therefore, the facility failed to provide necessary care and services when Resident 12's care plan to prevent falls was not implemented and the care plan was not revised in response to Resident 12's identified behaviors which placed her at increased risk for falls Staff failed to ensure Resident 12 had a tab alarm in place as indicated necessary in the care plan to prevent falls. Resident 12 got up without a tab alarm in place to alert staff she was up unassisted and fell sustaining a head injury that initiated the events resulting in Resident 12's death.
This violation was a direct proximate cause of Resident 12's death and therefore constitutes a class "AA" citation. |
| 040000646 |
Bethesda Lutheran Communites - Richert |
040013234 |
B |
31-May-17 |
4XM511 |
11139 |
Bethesda Lutheran Communities - Richert
CLASS B CITATION - Patient Care
76875 (a) - Nursing Services
The facility must provide clients with nursing services in accordance with their needs.
The facility failed to provide Client A with nursing services in accordance with her needs when Client A developed a Stage 1 pressure ulcer (observable pressure-related alteration of intact skin characterized by redness, warmth, and pain) on her left hip. Client A's skin breakdown progressed to a Stage lll (a full tissue thickness loss with visible fat) pressure ulcer as a result of delayed treatment and the lack of a pressure relieving-device and other preventive measures. The facility failed to conduct a timely nursing assessment; failed to promptly notify Client A's PCP of the client's skin breakdown, failed to develop and implement appropriate care plan interventions necessary to treat, manage, and prevent further breakdown of her skin integrity; and, failed to follow up and promptly send Client A to the wound clinic as ordered by her primary care physician (PCP). Client A was transported to the hospital's Wound Clinic where she underwent surgical debridement (removing non-living tissue from pressure ulcers) of devitalized (weakened) and necrotic (dead) tissues on her left hip pressure ulcer. Client A was transferred to a skilled nursing facility (SNF) where she resided for 6 months for treatment and management of a Stage III pressure ulcer.
On 9/7/16 at 9:25 a.m., an onsite investigation was conducted to investigate Entity Reported Incident (ERI) CA00499533.
Client A's Face Sheet (a document containing the client's personal information) indicated Client A was a 62 year old female with diagnoses which included gross deformity of the hip joint, arthritis (inflamed and painful joints) of the left hip, and impaired mobility.
The "Braden Scale - for Predicting Pressure Sore Risk" (BSPPSR) [an assessment tool for predicting the risks for acquiring pressure ulcers] dated 4/16/16, indicated Client A was at risk for developing pressure ulcers due to factors such as limited ability to feel pain, skin moisture, incontinence (lack of voluntary control over bowel and urine) and limited mobility.
The interdisciplinary "Plan of Care" (POC)" dated 5/30/16, indicated Client A was at high risk for developing skin problems due to incontinence and refusal to turn [in bed]. The POC indicated a goal to provide Client A with preventive and early treatment of a pressure ulcer and other skin problems. The actions included notification of all skin problems to Client A's physician; and the use of a pressure relief or reduction device.
On 9/7/16 at 9:40 a.m., a concurrent interview and record review was conducted with Registered Nurse (RN) 1. RN 1 stated, on 8/5/16 at 8 p.m., she was informed Client A was found with a "dent" on the left side of her thigh. When asked to provide documentation of a nursing assessment of Client A's skin condition, RN 1 stated she had not assessed Client A's skin integrity until 8/10/16, five days after she was first informed of the client's skin breakdown on her left hip area.
Client A's "Health Care Evaluation/Nurse Note" documented by RN 1, dated 8/10/16 (5 days after the "dent" was found), indicated, "... Here to assess patient. Staff reported a spot on left hip... has a dark red spot left side of hip, circular in shape and indent about 1 cm [centimeter]. Measures about 5 cm by 5 cm...surrounding skin is red, hot and firm... no open skin, no drainage, tender to touch... voices "ouch" when area is touched... alert and verbal... Stop and Watch (a system for monitoring clients experiencing a change of condition [COC]) started... staff to report any changes to RN..." There was no other documentation provided to indicate Client A's skin was assessed by RN 1 or by any other facility RN; and no documentation to indicate Client A's PCP was notified of her skin breakdown from 8/5/16 to 8/10/16.
Client A's PCP's "Encounter Report" dated 8/11/16, indicated "...Brought in by caregiver... Skin: 1.0 x (by) 1.5 cm indurated (hardened) ulcer with dry scab and surrounding erythema (redness) noted over left buttocks. Diagnosis: Pressure ulcer of left buttocks, stage 1...Care Plans: Wound clinic referral sent for pressure ulcer of left buttocks... Apply duoderm (a moisture-retentive wound dressing used for partial and full-thickness wounds) ... daily to left buttock pressure ulcer..."
Client A's "Health Care Evaluation/Nurse Note" dated 8/11/16, documented by RN 1 indicated, "... Patient returned from doctor's appointment...referred to wound clinic..."
Client A's "Health Care Evaluation/Nurse Note" dated 8/15/16, documented by RN 1 indicated, "... On assessment ...noticed duoderm has light yellow discharge on it. About dime size amount... top skin layer is black, and has approximately eraser size white skin proximal to light black skin. Surrounding skin is red, hot and firm. Minimal light yellow discharge while cleaning. Wound is circular, approximately measures 2 1/4 inches by 2 1/2 inches. Spoke to wound clinic. Appointment rescheduled for tomorrow (8/16/16) at 8 a.m...."
The Wound Clinic's "Progress Note Details" for Client A dated 8/16/16 indicated, "... Acute sudden onset (in reference to a disease, rapidly progressive, and in need of urgent care) Stage 3 Pressure Injury, Pressure Ulcer... measurements are 2.5 cm (centimeters) length x (by) 2.2 cm width x 0.8 cm depth, with an area of 5.5 square cm... irregular wound margin... no epithelialization (growth of new tissue)... with eschar (dark scab or dead skin )... with slough (dead tissues)... no granulation (pink-red moist tissue that fills an open wound)... the periwound (skin surrounding the wound) skin exhibited induration (hardened skin) ... erythema (redness)... Active Problem: Pressure Ulcer of Left Hip, Stage 3... Procedure: A skin/subcutaneous tissue level excisional/surgical debridement (removal of dead tissue from the wound to facilitate or improve healing) with a total area debrided of 5.5 square cm was performed... Subcutaneous (under the skin) was removed along with devitalized tissue, necrotic/eschar and slough..."
Client A's "Health Care Evaluation/Nurse Note" dated 8/16/16, documented by RN 1 indicated, "... Patient returned from wound clinic visit... dressing to be removed daily and clean with saline, apply Santyl (a substance used to clean wounds to clear the way for healthy tissue), received order... "Air mattress" (an inflatable mattress or pad used to relieve pressure from body parts) and higher level of care placement. The subsequent Nurse Note dated 8/17/16 indicated Client A was then admitted to the hospital. She was transferred to a Skilled Nursing Facility on XXXXXXX16 for 24-hour skilled wound care.
On 9/7/16 at 9:43 a.m., during a concurrent interview and record review, the RN 1 stated she had been very busy and was not able to do the nursing assessment on Client A's left hip "wound" until 5 days later on 8/10/16. RN 1 stated Client A's left hip wound condition changed significantly on 8/15/16, when she noted there was a light yellow discharge and the surrounding skin was red, hot and firm to touch. When asked if Client A's PCP was made aware of the changes in the client's skin integrity, RN 1 stated she had not. RN 1 stated she only made an appointment for 8/11/17 for the evaluation of Client A's skin condition.
On 9/12/16 at 9:55 a.m., during a telephone interview, RN 1 was asked why the PCP referral to the wound clinic dated 8/11/16 was not acted upon until 8/16/16; RN 1 stated she did not know there was a referral for Client A to the wound clinic.
On 9/12/16 at 10:20 a.m., during a telephone interview, Direct Care Staff (DCS) 2 stated she accompanied Client A for her PCP appointment on 8/11/16 and the client was given a referral to the wound clinic. DCS 2 stated, "RN 1 knew Client A had a referral to the wound clinic because I told her and handed her the referral form."
On 2/10/17 during a telephone interview, when asked what preventive care plan interventions were developed and implemented to ensure Client A did not develop or acquire pressure ulcers or any other type of skin breakdown, the Area Director (AD) stated she couldn't find a care plan specific to preventing Client A from acquiring pressure ulcers. When asked if an air mattress was provided for Client A upon discovery of her left hip pressure ulcer on 8/5/16, the AD stated she did not know. When asked to speak with RN 1, the AD stated RN 1 was no longer employed at the facility. The AD stated Client A was at the SNF from 8/18/16 to 2/6/17 (6 months.)
The facility's policy and procedure titled, "Change in Condition" dated 4/1/15 indicated, "...Prompt and adequate care and treatment will be provided in a timely manner... To observe, record and report any condition change to the attending physician..."
The administrative document titled, "JOB DESCRIPTION - Registered Nurse" dated 3/12/14 indicated, "... Implements the plan to promote, maintain, or restore wellness, prevent illness...assumes responsibility for continued competence, professional development and accountability... Provides nursing care according to the physician's orders, in compliance with the recognized nursing standards and State and Federal regulations..."
The information published by the Agency for Healthcare Research and Quality (www.ahrq.gov) dated 3/09 indicated, "...Pressure sores develop when persisting pressure on a bony site obstructs healthy capillary flow, leading to tissue necrosis. Pressure ulcers can develop within 2 to 6 hours. The pressure ulcer can range from a very mild pink coloration of the skin, which disappears in a few hours after pressure is relieved on the area, to a very deep wound extending to and sometimes through internal organs and into bone... All pressure sores have a course of injury similar to a burn wound. This can be a mild redness of the skin and/or blistering such as a first degree burn to a deep open wound with a lot of blackened tissue in it such as a third or fourth degree burn. This black tissue is called eschar. A decubitus ulcer can develop in as little as eight hours in an immobile, debilitated person..."
The facility failed to provide Client A with nursing services in accordance with her needs. The facility's failure to promptly assess Client A's skin, failure to develop and implement care plan interventions necessary to treat, manage, and prevent further breakdown of her skin integrity; failure to promptly notify Client A's PCP of the client's skin breakdown, and the failure to follow up and promptly send Client A to the wound clinic as ordered by her PCP resulted in delayed treatment, progression of the left hip pressure ulcer to Stage III, surgical wound debridement, hospitalization, and a prolonged stay at a Skilled Nursing Facility.
The above violations presented imminent danger that serious harm would result or a substantial probability that serious harm would result and therefore constitute a Class "B" Citation. |
| 050000139 |
BAYSIDE CARE CENTER |
050008833 |
A |
01-Feb-12 |
DCQM11 |
4507 |
F323 483.25 (h)(h) Accidents - The facility must ensure that the resident environment remains free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.The facility failed to identify resident risk hazards, develop and implement safety precautions, including adequate supervision, to prevent an accident. On September 7, 2011 (at approximately 7:50 a.m.), Resident 7 attempted to light a cigarette while receiving oxygen (via a nasal cannula). This resulted in the ignition of the oxygen and a fire. The resident sustained noted burns and life threatening injuries, which required admission to an acute hospital.Resident 7 was admitted to the facility from an acute hospital on XXXXXXX 2011, with diagnoses including diabetes mellitus, anxiety state, depression, chronic bronchitis and chronic obstructive pulmonary disease. The hospital history and physical (dated August 19, 2011) stated in part that the resident was "most notable for chronic medication noncompliance and possible ongoing smoking." The admission physician's orders included an order for the resident to receive continuous oxygen via nasal cannula.A review of the resident's admission comprehensive nursing assessment dated August 31, 2011, identified the resident was able to understand others, and make herself understood. The resident received continuous oxygen for shortness of breath, had moderate cognitive impairment, used a wheelchair or a walker for mobility, and required extensive staff assistance in most ADL (activities of daily living) areas except with eating. The assessment also indicated when the resident was asked about current tobacco use, Resident 7's response was "yes" (answer is for last seven days and indicates that the resident used tobacco in some form during that time frame). Per the assessment the resident was the sole source of information collected for the assessment data.Interview on October 18, 2011 at 10:30 a.m. with CNA 1, the staff person who observed the incident and who was the first responder, revealed that he had seen Resident 7 on the facility patio when he observed a flash (the igniting of the oxygen). The resident was attempting to put out flames that were around the oxygen's nasal cannula. He stated that the flames concentrated around the resident's nose, so he broke the melted oxygen cannula to get it away from the resident's face. Resident 7 had attempted to light a cigarette while receiving oxygen (via the nasal cannula).According to interdisciplinary progress notes the resident had sustained a burn (blister) on her upper lip and a dark smoke area was observed around her mouth. The physician was notified, treatment orders received and the resident was assessed for pain and respiratory distress. The resident experienced increased lethargy, wheezing and shortness of breath and at 4:30 p.m. an order was received to transfer the resident to the acute hospital for further evaluation and treatment.A review of Resident 7's plans of care revealed no plan(s) were developed or implemented addressing the resident need for and continuous use of oxygen, and the increased fire safety risk, prior to the accident. There was no indication the resident's recent history of smoking, tobacco use, and non compliance was identified as a possible risk and accident hazard, and patient education provided. An interview with the DON (Director of Nursing) on October 18, 2011, verified that there was no plan of care for use of oxygen developed for Resident 7 prior to the accident. A review of the acute hospital records dated September 7, 2011 at 5:06 p.m., revealed the emergency department's admission diagnoses included chronic obstructive pulmonary disease, second degree burn to face, neck and head." The physical examination revealed "some singed nose hairs and soot is noticeable in her sputum." The resident's condition continued to deteriorate and the resident expired the same day (September 7, 2011) at 9:10 p.m.The facility failed to identify resident risk hazards and implement interventions to ensure adequate supervision was provided to prevent an accident. This resulted in the ignition of the oxygen and a fire. The resident sustained noted burns and life threatening injuries, which required admission to an acute hospital.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.. |
| 050000044 |
BELLA VISTA TRANSITIONAL CARE CENTER |
050009334 |
A |
24-Jul-12 |
RTSV11 |
6701 |
Title 22. 72311 (a)(1)(A) (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. Title 22. 72311 (a)(3)(B) (a) Nursing service shall include, but not be limited to the following: (3) Notifying the attending physician promptly of: (A) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient.The facility did not comply with the above regulation by failing to assess Patient A and promptly notify the patient's physician when a family member reported that Patient A was experiencing pain in her back and abdomen, expressed concern the patient might have a urinary tract infection (UTI), and requested that a urinalysis be performed. Two days later, Patient A experienced chills and hypoxia, was transferred to the hospital, diagnosed with sepsis and a urinary tract infection, and admitted to the Intensive Care Unit.Patient A was 85 years old and was admitted to the facility on 1/7/05 with diagnoses including severe dementia, hypertension, atrial fibrillation and depression. The comprehensive assessment dated 3/26/09, noted that Patient A's cognition and her ability to communicate were impaired, and that she was incontinent and required extensive assistance with activities of daily living, including dressing, bathing , toileting and personal hygiene.On 5/4/09 and 5/5/09, a family member went to visit Patient A and found the patient moaning in her sleep. The family member reported that Patient A complained of pain in her back when she awoke on 5/4/09, and was grabbing at her right side and complained of pain in her abdomen on 5/5/09. On both days, Patient A's family member notified Licensed Nurse 1 (LN1), expressed concern the patient might have a urinary tract infection (UTI), and requested that a urinalysis be performed.On 5/4/09, LN1 gave the patient some Tylenol for pain, and told the family member she did not think Patient A had a UTI because her urine did not have a strong odor and was not discolored. LN1 did not assess the patient for a possible change of condition, and did not notify the physician of Patient A's status or the family member's concern.On 5/5/09 LN1 sent a fax to Patient A's physician and requested an order for Vicodin (a narcotic pain medication). The fax noted that Patient A was complaining of back pain, and that her family had been in and was aware. However, the fax did not include an assessment of the patient, did not inform the physician that Patient A had also complained of pain the day before, that the pain was in her abdomen as well as her back, and that the patient's family was concerned she might have a UTI and requested a urinalysis.Patient A's record was reviewed and no nursing notes or assessments of the patient were documented on 5/4/09, 5/5/09 or 5/6/09. On 5/7/09 at 8:40 am, however, the Registered Nurse (RN) Supervisor documented that she was summoned to Patient A's room, that Patient A was in bed, the head of her bed was elevated, and that Patient A was pale and sallow, her nail beds were dusky, and she was shaking and not able to talk. The RN also noted that Patient A's physician was in, assessed the patient, and gave a verbal order to transfer the patient to the hospital for evaluation.Patient A was transported to the hospital by ambulance and evaluated by the emergency room physician at 9:13 am for an altered level of consciousness. The physician noted that Patient A was in significant distress with upon arrival, with a temperature of 105.4 and a rapid respiratory rate. Following arrival, Patient A became hypotensive, with systolic blood pressures ranging from 70 to the low 90's, a right subclavian central line was placed, and Patient A was treated aggressively with intravenous fluids, antibiotics, and medication to maintain her blood pressure. Laboratory and diagnostic studies including a urinalysis, blood cultures, a complete blood count, a comprehensive metabolic panel, a chest x-ray and an electrocardiogram were also performed. Patient A was diagnosed with sepsis and a urinary tract infection, and was admitted to the Intensive Care Unit for further evaluation and management.LN1 was interviewed on 6/6/09 and indicated Patient A's family member visited the patient on 5/4/09 and 5/5/09, asked her to come and look at the patient and said that Patient A was moaning in her sleep and appeared to be in pain. On 5/4/09 the family member said that Patient A had back pain, and on 5/5/09, that she had pain in her abdomen. LN1 indicated the family member asked her if she thought Patient A had a UTI, and she told her that she did not think so, because the patient's urine did not have a strong odor.LN1 stated that she gave Patient A a dose of Tylenol of 5/4/09, sent a fax to the physician on 5/5/09 requesting an order for Vicodin, and gave the patient a dose of Vicodin when the order was received. LN1 acknowledged that she did not assess Patient A for a possible change of condition on 5/4/09 or 5/5/09, or notify the physician that her family had requested a urinalysis. The facility administrator was interviewed on 6/15/09 and stated Patient A's family member contacted the facility on 5/7/09, spoke with the Director of Nursing (DON) and expressed concern about the care that was provided to the patient by LN1. The administrator indicated that the DON investigated the complaint, concluded Patient A had a change in condition when she had an increase in pain requiring a change in medication, and LN1 should have initiated charting for a change of condition, completed an assessment including vital signs, and updated the physician on the patient's condition and the family member's concern that a urinalysis should be done.The facility violated the above regulation by failing to assess Patient A and promptly notify the patient's physician when a family member reported that Patient A was complaining of pain in her back and her abdomen, was concerned that the patient had a UTI, and requested a urinalysis. Two days later, Patient A was transferred to the hospital, diagnosed with sepsis and a urinary tract infection, and admitted to the Intensive Care Unit. The violation presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 050000549 |
BUENA VISTA CARE CENTER |
050011086 |
A |
09-Jan-15 |
295N11 |
2184 |
" CFR 483.25 (h) Accidents - The facility must ensure that- (2) Each resident receives adequate supervision and assistance devices to prevent accidents.The facility failed to provide an environment free from accidents when a certified nursing assistant (CNA1) repositioned Resident A by self instead of utilizing additional staff. Resident A sustained injuries which resulted in hospital visits which included amputation of Resident A's left thumb. Resident A was a 91 year old male admitted to the facility with diagnoses including Parkinson's disease (progressive disorder of the nervous system that affects movement) and dementia (loss of brain function that affects memory, thinking, communication, language, reasoning, and judgment). On July 8, 2014, a comprehensive assessment indicated Resident A had severe memory problems, required extensive assist with two person assistance for moving about in bed, transferring from bed, bathing, and toilet use. The facility's care plans indicated Resident A required repositioning every two hours and was an extensive/maximum assistance for bed mobility.On September 7, 2014, during the night shift, CNA 1 cared for Resident A including repositioning Resident A in bed and brief changes. CNA 1 confirmed repositioning and brief changes of Resident A without the use of other facility staff. Resident A sustained a perineal (groin) laceration, bruising to left eye, left ear, left temple area, swollen area to right cheek, laceration and fracture to left thumb. A licensed nurse (LN 1) indicated the injuries to Resident A could not have been self-inflicted.Facility supervisory staff verified CNA 1 had a history of not being patient with residents, had received verbal counseling's to slow down his approach to facility residents and being impatient with the residents.The facility's failure to provide supervision to CNA 1 to create a safe environment for Resident A resulted in Resident A sustaining injuries which resulted in the amputation of Resident A's left thumb. 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. |
| 050000044 |
BELLA VISTA TRANSITIONAL CARE CENTER |
050011205 |
A |
14-Oct-15 |
WJ8S11 |
3194 |
CRF 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 assistance for Resident A, who was left unattended while on the toilet and fell. As a result, Resident A sustained a right lower leg fracture. Resident A was a 92 year old female admitted to the facility with diagnoses including muscle weakness, gait instability and history of falls.The comprehensive assessment dated 8/12/14, revealed Resident A has moderately impaired decision making skills and needed extensive assistance with transfers and toileting. The fall risk evaluation dated 6/6/14 and 8/10/14 identified Resident A was a high risk for falls. The care plan initiated on 7/7/13 for fall prevention, included intervention for staff to stay near Resident A while in the bathroom due to poor safety awareness and requests for bathroom to be closed when toileting for privacy reason. Review of nurses' notes dated 6/12/14 at 12:31 p.m., revealed Resident A fell while in the bathroom by herself. Interdisciplinary team (IDT) investigation of the fall incident, dated 6/12/14, revealed Resident A was taken to the bathroom by a certified nursing assistant (CNA), put a tab alarm (an alarming monitoring device) on, reminded resident to call for assistance, then left resident to attend to another resident. However, Resident A disabled the tab alarm, transferred herself and fell. IDT recommended to ensure staff compliance of not leaving resident unattended while inside the bathroom. Review of nurses' notes dated 10/16/14 at 5:42 p.m., revealed, Resident A fell again while inside the bathroom. Resident A was found sitting on the wet floor, tab alarm in place but not sounding, and complained of pain on the right leg. IDT review of the fall incident dated 10/17/14, revealed CNA 1 assisted Resident A to the bathroom, applied tab alarm, and closed the bathroom door. CNA 1 was called to assist another resident and left Resident A alone inside the bathroom.During an interview on 10/29/14 at 4 p.m. with CNA 1 confirmed, on 10/16/14 before dinner, CNA 1 assisted Resident A to the bathroom and was called to assist a coworker. He left Resident A inside the bathroom and asked the licensed nurse (LN 1), the medication nurse, to watch Resident A.Interview with the licensed nurse (LN 1) on 10/29/14 at 4:30 p.m., revealed, she was passing medications during Resident A's fall incident on 10/16/14. LN 1 confirmed, she was outside Resident A's room door, not on the bathroom door, preparing medications. LN 1 stated, she heard a "thud", then "help" coming from the bathroom door. Resident A was sitting on the floor, legs out to the side with arms forward supporting her. Resident A asked CNA 1, "Where were you?" Review of Resident A's right lower leg x-ray result dated 10/17/14, revealed, "nondisplaced (bone crack but maintains in proper alignment) fracture of the distal fibula (lower leg bone). This presented imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 060001137 |
BETHESDA LUTHERAN COMMUNITIES - LAS BOLSAS |
060009500 |
A |
18-Sep-12 |
LIF011 |
22132 |
California Welfare and Institutions Code Section 4502(d) 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. The facility must ensure that Client A was provided prompt medical care and treatment. On 5/17/12, the Department received a complaint that Client A had been on Lamictal (an anticonvulsant medication) to control seizures prior to going to a GACH (General Acute Care Hospital) for surgery. Following his stay at the GACH, the client was discharged without an order to continue the Lamictal. According to the complainant, this was not caught by the facility RN (RN 1). The complainant also reported that on 4/14/12, Client A had an unwitnessed fall and personality changes, becoming resistive to care; and on the night of 4/14/12, the client had multiple seizures and became cyanotic and aspirated (the entry of secretions or foreign material into the trachea and lungs). The complainant further stated that 911 was not called until 4/15/12 and Client A was transferred to a GACH's emergency department (ED) where he was intubated (the placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway).On 5/17/12, an unannounced visit was made to the facility to investigate the above allegations. Based on interviews and record review, the facility failed to provide prompt medical care and treatment to Client A by failing to: 1. Ensure Client A's safety when a registered nurse (RN 1) was not directly informed of Client A having multiple seizures (10 documented seizures) over a six hour period.2. Ensure Client A received prompt medical treatment after he began to have multiple seizures. The facility did not call 911 until the client had 10 documented seizures, seven of which occurred over an hour and 15 minute period causing the client to become cyanotic (a bluish discoloration of the skin and mucous membranes resulting from inadequate oxygenation of the blood). The ED physician documented the client was in respiratory distress with audible wheezing and a lowered oxygen saturation of 88% on room air (the fraction of the hemoglobin molecules in a blood sample that are saturated with oxygen at a given partial pressure of oxygen. Normal saturation is 95%-100%). Upon arrival to the ED, laboratory testing revealed the client had severe hypoxemia (an abnormally low concentration of oxygen in the blood) that required mechanical intubation and transfer to the intensive care unit (ICU). The QMRP (Qualified Mental Retardation Professional), interviewed on 5/17/12 at 1550 hours, confirmed that prior to the above incident, Client A had been in the GACH from 3/18/12 to 4/9/12 for gastrointestinal (GI) surgery. The QMRP stated that prior to going into the hospital the client had been on three different anticonvulsant medications, one of which was Lamictal. According to the QMRP, the Lamictal was stopped sometime during the client's stay in the hospital and was not restarted when the client was discharged.The QMRP stated that on 4/15/12, she spoke twice with the NOC (night shift) DCS (direct care staff) on the telephone. The QMRP stated the NOC DCS called her at home at approximately 0615 hours, to inquire about AM shift staffing, but did not say at that time anything about Client A having seizures. The QMRP went on to say she called the facility back at approximately 0715 hours to speak with the NOC DCS and again, the staff did not inform her of the client's seizure activity. It was later, not until approximately 0730 hours, an AM staff called the QMRP to inform her Client A had a few seizures lasting a few seconds each. The QMRP said she called RN 1 to inform her of the client's seizure activity at approximately 0745 hours on 4/15/12, and left a message. She also stated she sent a text message to RN 1. Although she was uncertain of the time, the QMRP recalled RN 1 called her back and she passed on the information. The QMRP called the facility back, she thought this was approximately 0815 hours, to check on Client A and was told 911 had been called. The QMRP made another follow up call to the facility at approximately 0845 hours and was told Client A was taken to the hospital. The staff reported to her they called and left a message to RN 1; however, RN 1 had not responded to their call.Client A's clinical record was reviewed on 5/17/12. The following was identified: 1. DCS documented in the interdisciplinary notes that during the evening on 4/14/12, Client A had been resistant to getting up off the toilet; changing his diaper; wearing his retainer; and taking his medications. The DCS also documented that while the client was in his bedroom putting on his pajamas he apparently had a fall as he was found on the floor of his room with a scratch on his back and buttock. Staff documented they notified the QMRP and left a message for RN 1.2. DCS documented in a note dated 4/15/12 AM, that Client A had three seizures lasting two seconds each, at 0220 hours, 0415 hours and 0600 hours.3. DCS documented in the next entry dated 4/15/12, the client had a series of seizures between 0700 to 0845 hours as follows: a 30 second seizure at 0729 hours, a 45 second seizure at 0730 hours, a 33 second seizure at 0734 hours, a 20 second seizure at 0740 hours, an 18 second seizure at 0810 hours, a 28 second seizure at 0825 hours, and a 48 second seizure at 0845 hours. The DCS documented the QMRP and RN 1 were called and messages were left. It was also documented that staff called 911 at 0845 hours when the client started turning blue during a seizure.4. The nursing care plan dated April 2009, included the following interventions: - During and following a seizure staff were to note the time, duration, body parts involved, changes in respiratory functions and changes in consciousness and report to the PM (program manager) RN and MD. - Staff were to call 911 if a seizure lasted more than five minutes or the client stopped breathing.5. Review of the physician's orders for March 2012, showed prior to going to the GACH on 3/18/12, Client A was taking phenytoin sodium (generic for Dilantin, an anticonvulsant) 200 mg in the morning and 130 mg at bedtime, zonisamide (generic for Zonegran, an anticonvulsant) 200 mg twice a day, and lamotrigine (generic for Lamictal, an anticonvulsant) 400 mg twice a day. 6. An undated Physician Discharge Instruction form, for the GACH admission of 3/18/12, listed the following anticonvulsant medications: - Dilantin 100 mg every 8 hours; - Zonegran 100 mg twice per day. This discharge instruction showed the Dilantin was decreased by 30 mg to 100 mg three times a day, the Zonegran was decreased by 200 mg to 100 mg twice a day, and there was no order for the Lamictal.7. RN 1 sent a faxed message to the client's neurologist on 4/10/12 at 0601 hours, to inform the neurologist of the changes to Client A's medications that occurred during his stay in the GACH.The changes that RN 1 noted were as follows: - Dilantin was changed from 200 mg in the morning and 130 mg at bedtime (total of 330 mg per day) to 100 mg three times per day (total of 300 mg per day). - Lamictal 800 mg per day was discontinued. - Zonegran "unchanged" from 100 mg twice a day. RN 1 documented in the message to the neurologist that the current dose of Zonegran was unchanged; however, comparison between the facility's March 2012 physician's orders and the orders at discharge from the GACH on 4/9/12 showed the Zonegran had actually been reduced from 200 mg twice a day (total of 400 mg per day) to 100 mg twice a day (total of 200 mg per day).8. The "Monthly Nursing Summary" for the month of April 2012, read in part: - On 4/9/12, it was documented that the client was discharged from the GACH that afternoon and had several medication changes. - On 4/11/12, it was documented that the neurologist was called and wanted to schedule an appointment to address medication changes. It was also documented that "Staff notified." - On 4/16/12, it was documented that review of the staff notes from the past two days showed Client A had a total of 10 seizures as follows: - The first seizure occurred at 0220 hours, followed by a second at 0415 hours and another at 0600 hours. These three seizures were documented to have lasted two seconds each. - Beginning at 0729 hours, Client A's seizures became more frequent and longer in duration as follows: 0729 hours - 30 seconds; 0730 hours - 45 seconds; 0734 hours - 33 seconds; 0740 hours - 20 seconds; 0810 hours 18 seconds; 0825 - 28 seconds; and at 0845 hours - 48 seconds.9. Review of the seizure record, Client A's last seizure, prior to 4/15/12, occurred on 4/7/11 more than one year ago.A request of Client A's medical record from the GACH was made. Review of the record showed upon arriving in the ED, Client A had severe hypoxemia (an abnormally low concentration of oxygen in the blood) and required intubation. The ED physician documented that review of the chest x-ray indicated the client had aspiration pneumonia (inflammation of the lungs and airways to the lungs [bronchial tubes] from breathing in foreign material). It was also documented that the endotracheal tube was suctioned and returned thick tenacious (thick) secretions.RN 1 was interviewed on 5/21/12. She stated that at the time of Client A's discharge from the hospital on 4/9/12, she was told that he had not been on Lamictal while in the hospital. However, upon reviewing the hospital records she recalled references to the client being on Lamictal in different reports. She recalled it was in approximately three of the hospital reports. The RN went on to say she documented all of the client's changes in medication from the time he was in the hospital and faxed the information to the neurologist. She added the neurologist's office staff made contact with her on 4/11/12, and requested an appointment be made for Client A to come into the office so his medications could be straightened out. According to the RN she does not make the appointments and one of the DCS was asked to make the appointment; however, she could not recall which staff she asked. The RN went on to say she did not get any phone messages until 0900 hours on 4/15/12. She stated that on 4/15/12, she received a text message at 0843 hours, reporting the client had multiple seizures. She added the client had already been taken to the ED by the paramedics at that time. She then called the neurologist to inform him of what had occurred.On 5/21/12, the QMRP and RN 1 were asked what date the appointment with the neurologist had been made for. After checking the schedule, the QMRP stated she did not see an appointment with the neurologist for Client A. She went on to say the house manager usually made the appointments for the clients and there was currently no house manager for the facility.DCS 1, who worked the NOC shift, was interviewed by telephone on 5/21/12 at 1600 hours and on 5/29/12 at 1115 hours. She stated she saw Client A have two seizures on 4/15/12, one at 0200 hours and the second at 0400 hours. She said when the AM shift DCS relieved her at approximately 0600 hours, she told the staff to watch Client A closely because he was having seizures. DCS 1 said she had called and spoke with the QMRP twice that morning. She recalled the phone calls were at approximately 0600 hours and 0615 hours. She stated she did not tell the QMRP about Client A having seizures during either phone conversations because Client A was all right at that time. DCS 1 went on to say that when the AM staff arrived at the facility she went to make breakfast for the clients and pass medications. She said an AM staff called out at about 0700 hours, that Client A was having another seizure and she told them to call 911. DCS 1 further stated that she left the facility at 0753 hours and told the two AM staff to call 911 if the client had any more seizures. When asked why she did not call 911 herself, she replied it was because the other staff had the phone.DCS 2 was interviewed by telephone on 5/21/12 at 1630 hours. She stated she had worked the AM shift on 4/15/12 and recalled arriving at the facility at about 0700 hours. DCS 2 said initially she was helping other clients to get up and after giving another client a shower she was asked to watch Client A because the client was having seizures. She stated she never heard another staff in the facility say to call 911. She went on to say she was the person who called 911 and she called because the client was having more seizures and his lips and nails were turning blue. She added she did hear DCS 1 making a call to the nurse; however, she does not know what was said. She thought this was sometime after 0700 hours. DCS 2 added she also called the QMRP and RN 1 at approximately 0800 and left a message. She did not try to contact a different RN within the organization when RN 1 did not return her call. DCS 2 stated she was not informed of any changes to the client's seizures medications. DCS 2 added she had recently started working at the facility and was not given any information regarding Client A's medical conditions.DCS 3 was interviewed by telephone on 5/25/12 at 1330 hours. She stated she got to work at about 0600 hours on 4/15/12; and DCS 1 had stated Client A was having seizures and asked DCS 3 to watch him closely. DCS 3 said she saw the client have two seizures. Both seizures lasted approximately 30 seconds and occurred close to 0700 hours. She recalled that in-between the seizures Client A did not talk and his eyes were closed, his breathing seemed slightly different, however, she said after the second seizure, DCS 2 was monitoring the client. DCS 3 stated she inquired from the other staff if they had called RN 1 and she was told by DCS 1 that the RN was called at 0600 hours and DCS 2 said she called the nurse but did not get an answer. DCS 3 stated she did not witness the client turning blue during a seizure, that it was DCS 1 who remarked the client was turning blue and DCS 2 called 911.In a follow up interview with RN 1 on 5/25/12 at 1400 hours, she stated it is the expectation of the facility that when staff are contacting the RN and there is no response from the RN in 15 minutes, then they need to call another RN. She added staff are instructed on this practice at basic medication training. Review of the facility's P&P titled, Change in Condition (with a last review date of 9/26/2010 and in place during the time of the incident), showed the following: a. The purpose of the P&P read in part: "Staff will be able to identify a change of condition, injury or accident, provide prompt and adequate treatment and provide notification to all responsible parties."b. The definition of a change in condition was "Any adverse change in physical or mental health related to illness, injury or accident." c. The P&P listed examples of the changes in condition that included: - Difficult to arouse. - Seizure that is either a first time event for person, longer or more severe than is normal for person. Any generalized seizure more than 5 minutes in length, or partial seizure or cluster of seizures lasting more than 30 minutes. d. "Obtaining prompt and adequate care and treatment" is defined as consultation with a healthcare provider is sought in a timely manner in relationship to the severity of the adverse effect on the person's health. The procedures under "Obtaining prompt and adequate care and treatment" read in part: - Life threatening situation - Call EMS (911) Examples of life threatening conditions are: ...prolonged seizure activity. Review of the facility's protocol on "Calling 911" and dated 1/2011, read in part: "In any of the following emergencies, Staff are instructed to call 911 FIRST" ; "Notify the PM, RN, and QMRP after the person is safe." ; "Seizures: Any seizure lasting 3 minutes or more or with injuries."Review of the paramedic's report titled "Prehospital Care Report" showed they arrived at the facility at 0853 hours, and Client A's oxygen saturation was 80% (the fraction of the hemoglobin molecules in a blood sample that are saturated with oxygen at a given partial pressure of oxygen. Normal saturation is 95%-100%) on room air when they first arrived to the facility. The client was started on 10 liters of oxygen and his oxygen saturation increased to 89%. The paramedic's report also indicated that per the caregivers, Client A had approximately 7 to 10 seizures that morning. Review of the facility's communication log showed the following: RN 1 wrote a note dated 4/9/12, alerting staff that Client A's "medications have changed a lot. Please be extra careful when giving them." The Staff were also made aware of the client's change in diet order and bowel care regime. There was no information to inform the staff that the changes in medications included a reduction in all of his seizure medications nor were there any additional directions for staff to follow as a result of the reduction in anticonvulsant medication; such as notifying the RN immediately of any seizure activity. On 4/15/12, an AM shift DCS documented in the communication log, "NOC staff tried to give AM medications to ____ but he was not able to take it. He was in bed, staff give him two pills? but others not, as per NOC staff."In a follow up interview with the NOC DCS (DCS 1) on 5/29/12 at 1115 hours, she stated she had given Client A his medications on the morning on 4/15/12 at approximately 0700 hours. She said she recalled there was a total of three pills for the client, he took two of the pills and refused to take the third, throwing the pill away. She was unable to say which medication the client had refused to take or if it was an anticonvulsant medication. DCS 1 confirmed she spoke with the QMRP twice on the morning of 4/15/12. She said the first time was shortly after 0600 hours and the second was at approximately 0615 hours. DCS 1 stated she did not tell the QMRP about Client A having seizures during either one of her telephone conversations with the QMRP. DCS 1 stated she had worked for the company for several years and at this particular facility for the past year. She stated she had never seen Client A have a seizure before 4/15/12. Looking again at the client's discharge orders from the GACH, the client was on Protamine 5 mg three times a day, Dilantin 100 mg three times per day, Effexor 75 mg twice a day and Zonegran 100 mg twice a day. Depending on administration times it was possible four medications were due to be given at the AM medication pass. The facility was asked for a copy of the medication administration record (MAR) to see what times these medications were scheduled to be given and to determine which medication the client did not take at the 0700 hour medication pass on 4/15/12 as described by DCS 1. After looking through the client's clinical record, the QMRP stated the MAR sheets for April 2012 were missing. The facility was unable to provide the Department with a copy and therefore was unable to verify if all the medications due at that time on 4/15/12, had been prepared, which medications the client was given and which medication the client had refused to take.The neurologist's office was contacted for an interview on 6/4/12. According to the RNP (registered nurse practitioner) at the neurologist's office, they did receive a faxed message from the facility regarding changes that had been made to Client A's medications while he was in the hospital; and after showing the faxed message to the neurologist, the front desk personnel was asked to call and schedule an appointment for the client to come into the office. The RNP stated the receptionist documented she called the facility RN who in turn stated she would call and have someone from the facility call and make an appointment. The RNP went on to say there was no further call from facility staff and no appointment had been made.Even though RN 1 identified that Client A had changes to his anticonvulsant medications that included the reduction of doses for at least one medication (a total of two medication had reduced doses) and the elimination of the third seizure medication (Lamictal) after his return from the GACH on 4/9/12, RN 1 failed to ensure the DCS were made aware of the medication reduction, alerted to be on watch for the possible onset of seizures or to contact an RN if seizure activity did occur; and RN 1 failed to ensure a follow up appointment as requested by the neurologist was made in a timely manner. Also, RN 1 stated she did not receive her phone messages until after 911 had been notified. All three DCS stated they called RN 1 to report Client A's seizures but their calls to the RN were not returned and/or they did not attempt to contact another RN within the organization. As of 0729 hours on 4/15/12, Client A began a cluster of seizures but staff did not take steps to obtain emergency medical aid until one hour and 15 minutes later at 0845 hours. In addition, it is not clear whether Client A received all of his anticonvulsant medication as ordered on the morning of 4/15/12.The above events resulted to Client A being transported to the GACH via paramedics where Client A was intubated and was admitted to the ICU for further treatment. The failure of the facility to ensure that Client A received prompt medical care 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. |
| 060001718 |
Brookdale Yorba Linda |
060009663 |
B |
10-Dec-12 |
KLOI11 |
2734 |
Three licensed nursing staff willfully falsified a Medication Administration Record (MAR) for Patient 1. Patient 1 has a diagnosis of congestive heart failure. The licensed nurses were to monitor and record a pulse oximetry (a non-invasive method of monitoring the saturation of oxygen in the blood) every shift to assess the adequacy of the oxygen in the patient's blood. On 9/19/12, a copy of the MAR was obtained. There were no documented pulse oximetry results from 9/1/12 through 9/19/12. On 9/20/12, a copy of the same MAR was obtained and showed the pulse oximetry results were documented for all three shifts throughout the month. Two Licensed Vocational Nurses (LVN) 1 and 2 and the Director of Nursing (DON) stated they filled in the documentation. This results in an inaccurate monitoring of Patient 1's medical condition. Health record review for Patient 1 was initiated on 9/19/12. Review of the Physician's Orders dated 8/29/12, showed an order to monitor Patient 1's pulse oximetry every shift. Review of Patient 1's MAR dated September, 2012, was initiated on 9/19/12. On 9/19/12, the MAR showed no documentation to show the results of the pulse oximetry tests. On 9/20/12, the same MAR was reviewed and showed the pulse oximetry results for all three shifts from 9/1/12 through 9/20/12, were documented. An interview with the DON was initiated on 9/20/12 at 0745 hours. The DON was asked to explain why the documentation on the MAR for the pulse oximetry was missing on 9/19/12, and filled in on 9/20/12. The DON stated she did not know what happened.An interview with LVN 1 was initiated on 9/20/12 at 1055 hours. LVN 1 was asked about the documentation. The LVN stated he had not documented the pulse oximetry results on the MAR originally, but yesterday, he was asked by the DON to fill in the results of the pulse oximetry. He stated he worked 9/3/12 through 9/6/12, during the day shift, and filled in the results of the test as best as he could remember. A telephone interview with LVN 2 was initiated on 10/11/12 at 1410 hours. LVN 2 stated the DON asked her to fill in the pulse oximetry results. She stated she filled out some of the results and a co-worker filled in some of the results. An interview with the DON was initiated on 10/11/12 at 1630 hours. The DON stated, during the survey, she was asked about the pulse oximetry test. LVN 1 was working and asked her if he should fill in the results. She told him to go ahead. The DON stated, not all the nurses were available to fill in the results of the tests, so she filled the results in for them. The facility's licensed nursing staff willfully falsifying a MAR had a direct or immediate relationship to the health, safety, or security of the patient. |
| 060001137 |
BETHESDA LUTHERAN COMMUNITIES - LAS BOLSAS |
060009693 |
B |
01-Feb-13 |
PDX511 |
4548 |
Welfare and Institutions Code, Section 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 above statute was NOT MET as evidenced by: Based on interview and document review, the facility failed to ensure the client's money was not used for unauthorized purchases for four of four clients (Client 1, Client 2, Client 3 and Client 4).Findings: On 11/21/12, the Department received an entity reported incident (ERI) that several unauthorized purchases were made using the clients' trust account. On 11/27/12, an unannounced visit was conducted to investigate the above ERI. The facility is licensed and certified to house six clients. At the time of the visit, the facility had a census of four clients (Clients 1, 2, 3, and 4) who had different levels of mental retardation and needed assistance from staff or their responsible family member to manage their finances.On 11/27/12 at 1625 hours, the Program Manager stated when she was reviewing the bank statement for the clients trust account she noticed some purchases made with a check card. The Program Manager stated the check card was issued by the bank for the clients' trust account when the account was opened. The Program Manager further stated the check card was automatically sent to the facility but the House Manager was instructed to turn in the check card so it could be destroyed.The Program Manager was asked who was the person using the card and how did they get it. The Program Manager stated the person was a former employee (Staff 1) that was put on leave in February 2012 and then terminated in March 2012. Staff 1 was a House Manager for the home. The Program Manager stated a check card was probably sent and Staff 1 did not turn in the check card for destruction. When asked if the purchases made with the check card were from the clients' trust account, the Program Manager stated, yes.Review of the bank's Transaction History form, dated 10/1/2012 to 10/31//12, and the bank's Account Activity form, dated 10/24/12 to 11/23/12, showed the following purchases were made: - On 10/9/12, a check card purchase at Tustin Toyota for $936.12. - On 10/25/12, a check card purchase at H&M for $59.10. - On 10/29/12, a check card purchase at Macy's for $13.99. - On 10/29/12, a check card purchase at Trader Joe's for $21.37. - On 10/31/12, a check card purchase at Ralph's for $5.95. - On 11/2/12, a check card purchase at Corner Bakery for $1.89. - On 11/2/12, a check card purchase at Denny's for $22.97. - On 11/5/12, a check card purchase at Holiday Inn Express for $89.67. - On 11/6/12, a check card purchase at Zara USA for $54.27. The total of the check card purchases was $1,203.35.When asked if there had been any purchases since 11/6/12, the Program Manager stated the bank was called and the check card was cancelled as well as Staff 1's name was removed from being able to sign checks for purchases. On 12/10/12 at 1135 hours, a telephone interview was conducted with the facility's Business Director. When asked who was responsible for making sure the check card was turned in to be destroyed, the Business Director stated it was the Assistant Director. However, the Assistant Director was terminated at the same time Staff 1 was terminated. The Business Director also stated she should have called the bank and had Staff 1's name removed from the list "but it fell through the cracks.' The facility failed to prevent unauthorized purchases made from the clients' trust account by not ensuring the check card was retrieved and/or deactivated when Staff 1 was terminated. Also, the facility failed to ensure Staff 1's name was removed from the list of authorized personnel from being able to sign checks for purchases. The failure of the facility to prevent unauthorized purchases using the clients' money had a direct relationship to the safety or security of the clients. |
| 060001079 |
BEL AIR |
060009909 |
B |
16-May-13 |
7C5M11 |
5995 |
Welfare and Institutions Code, 4502(d) 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 d development 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.Based on clinical record and interview, the facility failed to ensure Client 1's primary care physician (PCP) was notified immediately when Client 1 presented with a swollen left index finger. As a result, Client 1's left index finger remained swollen and the physician was not notified until seven days later. Client 1's finger was x-rayed and showed a fractured left index finger. Findings: On 3/4/13, the Department received an entity reported incident (ERI) regarding Client 1's fractured left index finger. On 3/8/13 at 1540 hours, the facility was visited to investigate the above ERI.At 1550 hours, LVN 1 was interviewed. When asked when he was made aware of Client 1's swollen left index finger, LVN 1 stated on 2/8/13 at 2000 hours, with the assistance of a DCS, LVN 1 conducted a body check while changing Client 1's diaper. That was when he noticed the very swollen left index finger. The LVN stated Client 1 showed no signs of pain. The LVN continued Client 1's father, who was a pediatrician, visited the next day and was told about the swollen index finger. The LVN stated Client 1's father looked at the swollen finger and told LVN 1 to monitor Client 1's finger.When asked when he notified the RN regarding Client 1's swollen left index finger, LVN 1 stated he told the RN on 2/11/13, when the RN came to the facility. The LVN stated the RN looked at the swollen left index finger and they continued to monitor the swelling of Client 1's index finger but the swelling did not subside. The LVN stated the client was not seen by his PCP until 2/15/13, seven days later. The PCP ordered an x-ray of the left index finger.When asked when Client 1 was taken to get an x-ray, the LVN stated the authorization for Client 1 to have an x-ray was not approved until 2/21/13 and Client 1 got an x-ray the same day. The LVN stated on 2/27/13 the x-ray results showed Client 1 had a fractured left index finger. At 1600 hours, the House Manager was asked if Client 1 could move his arms. The House Manager stated Client 1 could barely move his arms. The clinical record for Client 1 was reviewed. Client 1 was admitted to the facility on 7/27/05 with diagnoses including moderate mental retardation. Client 1 was also nonverbal and was dependent on the staff for all his needs. Documentation showed Client 1 was seen by his PCP on 2/15/13 and wrote an order for x-ray of the left index finger. An x-ray of the left index finger was completed on 2/21/13. The x-ray result, received by the PCP on 2/27/13, showed a fractured left index finger. The PCP ordered an orthopedic consultation and Client 1 was seen by an orthopedic doctor on 2/27/13. The orthopedic doctor ordered application of a left hand splint every day and to be released every 2 hours for circulation. On 3/14/13 at 0920 hours, the RN was interviewed by telephone. When asked about the facility's policy for change of condition and when to report injuries to the doctor, the RN stated they do not really have a policy but the staff knows if there is a change of condition to notify her. The RN was informed Client 1 had a very swollen left index finger that was noticed on the 2/8/13 and the RN was not informed until three days later when she went to the facility. The RN stated she did not know why LVN 1 did not notify her.The RN was asked what happened the day she went to the facility on 2/11/13. The RN stated she only goes to the facility once a week. She stated the LVN asked her to look at Client 1's swollen finger. The RN stated she checked Client 1 and told LVN 1 that Client 1 may need to see the physician. The RN stated LVN 1 told her that Client 1's father had seen the swollen finger and told LVN 1 to monitor it because it may have been caused by Client 1 clenching his hand in a fist tightly.The surveyor informed the RN that Client 1's father was not the client's PCP whom should have been notified. The RN was asked who was responsible for notifying the physician. The RN stated the LVN is the one responsible to call because the RN was not in the facility every day.On 3/14/13 at 1030 hours, the QMRP was interviewed by telephone. When asked if the facility had a policy and procedure for change of condition, the QMRP stated the facility may have a policy and procedure for change and the RN was trying to find it. The QMRP was asked when or what things should be reported to the physician regarding a change of condition. The QMRP stated they would call the PCP if there was something that warranted the client to be seen by the physician, and gave an example of an emergency like a very high fever. The QMRP was informed of LVN 1 notifying Client 1's father instead of the PCP when they identified Client 1's left index finger was swollen. The QMRP stated Client 1's father only confirmed what the LVN had observed. When asked who the LVN or the staff should report to if there was a medical situation that required a RN, since the RN only works nine (9) hours per week, the QMRP stated the RN is available 24 hours a day, seven days a week.Failure of the staff to notify the PCP timely resulted to a delay in providing the proper care and treatment to Client 1's fractured left index finger.The violation of this regulation had a direct or immediate relationship to the health, safety, or security of clients. |
| 060000078 |
BETHESDA LUTHERAN COMMUNITIES - MITHRA |
060011195 |
B |
29-Dec-14 |
5CY711 |
11936 |
CLASS B CITATION - Clients not subjected to abuse Welfare and Institutions Code, Section 4502 (h). 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: (h) - A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect. Client 6 was a 54 year old female with diagnoses including moderate intellectual disability (person with an IQ score of 40-55) and psychosis (a loss of contact with reality that usually includes false beliefs about what is taking place or who one is [delusions] or seeing or hearing things that are not there [hallucinations]). Client 1 was a 57 year old female with diagnoses including mild intellectual disability (person with an IQ score of 55-70) and autistic savant (individual with autism who has extraordinary skills not exhibited by most persons, the most common forms involve mathematical calculations, memory feats, artistic abilities, and musical abilities). On 11/12/13, review of the facility's Incident Report was conducted. The following was identified: - Review of the Incident Report dated 5/12/14 at 0615 hours, showed Client 6 hit the direct care staff (DCS A) on his back.- Review of the Incident Report dated 5/27/14 at 0620 hours, showed Client 6 hit DCS A on the right arm and hit Client 1.- Further documentation showed Client 6 had hit Client 1 "several times before" when Client 6 saw Client 1 doing her crossword puzzle while sitting on the sofa. In addition, the documentation showed Client 6's behavior affected Client 5 and Client 5 did not want to go to the day program. On 11/12/14 at 0850 hours, DCS A was interviewed. DCS A stated Client 6 yelled and screamed in the morning and wanted to stay in her bedroom. DCS A stated yesterday (11/11/14) was a holiday and five clients stayed home including Client 6. DCS A stated Client 6 did not have one to one (1:1) direct supervision on 11/11/14. DCS A stated that yesterday at approximately 0830 hours, when Client 1 was sitting in the chair and doing her crossword puzzle, Client 6 grabbed Client 1's leg and hit it repeatedly. The DCS stated Client 6 had hit Client 1 several times in the past and the hitting had always occurred in the morning. The DCS stated the QIDP was aware of Client 6 hitting Client 1; however, DCS A had not notified the Program Manager (PM) or Qualified Intellectual Disability Professional (QIDP) of the incident on 11/11/14 nor had he completed an incident report. The DCS also stated Client 6 had these behaviors for about six months. DCS A stated he thought of it as client to client abuse, but the abuser was not aware after the incident.On 11/12/14 at 0905 hours, an interview was conducted with the QIDP. The QIDP stated it was hard to handle Client 6's behaviors in the home and the Regional Center of Orange County (RCOC) had funded the 1:1 direct supervision for Client 6 for about the last six months. The QIDP stated Client 1 and DCS G were the targets of Client 6's behaviors. The QIDP stated Client 6's 1:1 staffing was provided from 0600 hours through 0800 hours and from 1400 hours through 2000 hours on weekdays; and eight hours per day on weekends. The QIDP was informed there was no staff working 1:1 with Client 6 this morning. The QIDP stated it was difficult to find an extra DCS to provide the 1:1 direct supervision in the morning. The QIDP verified the required ratio was one staff to three clients; however, the QIDP stated when Client 6 was having behaviors, one DCS should work with Client 6 and the other DCS should take care of the other five clients.On 11/12/14 at 0920 hours, the QIDP stated she spoke with the PM and verified it was hard to find staff to provide the 1:1 supervision for Client 6 during the morning shifts on weekdays.Review of the staffing schedule from 11/2/14 through 11/15/14, showed 1:1 direct supervision for Client 6 was scheduled Monday through Friday from 1500 hours through 2100 hours and Sundays from 0800 hours through 1600 hours. There was no 1:1 direct supervision scheduled on Saturdays, on 11/11/14, or during the morning on weekdays.On 11/12/14 at 0950 hours, an interview was conducted with the PM. The PM stated the RCOC provided funding for six hours of 1:1 direct supervision for Client 6 per day to be used when it was needed most. The PM stated sometimes Client 6's behaviors were in the morning and sometimes they were in the evening. The PM stated the facility had a staff meeting on 10/22/14, and the plan was to provide two hours of 1:1 direct supervision in the morning and four hours in the afternoon because Client 6 was having increased behaviors in the morning. When asked why the 10/22/14 plan had not been implemented, the PM stated he was going to hire someone for the morning shift.In a later interview, the PM stated they were not staffing Client 6 with 1:1 direct supervision in the mornings, on Saturdays, and yesterday (11/11/14) because they did not have enough staff. Review of the Psychologist's report dated 7/1/14, showed the following: - Client 6 had increased behaviors at the home.- According to staff, there was a peer (Client 1) in the home that Client 6 did not like and became quite agitated when she was even in the same room with Client 1.- The staff indicated the home had to coordinate two different meal times so that Client 6 and Client 1 sat separately.- There was another peer (Client 5) in the home that had increased her hand biting due to tension and fighting between Client 6 and Client 1.- There was a specific staff that Client 6 did not like. Client 6 had attempted to hit the staff on a regular basis.- The home had identified the following behaviors in the home including self-injurious behavior, physical aggression, emotional outbursts with cursing, and protest behavior. Review of the QIDP monthly summaries, Incident Reports, and semi-annual Individual Service Plan (ISP), the following were the documentation of behaviors manifested by Client 6 towards Client 1 and unidentified client(s): In January 2014: - One episode of verbal aggression towards unidentified person(s). In February 2014: - Three episodes of verbal aggression towards unidentified person(s). In March 2014: - One episode of verbal aggression towards unidentified person(s). In April 2014: - None. In May 2014: - One episode of hitting Client 1.In June 2014: - One episode of hitting Client 1. - Three episodes of verbal aggression towards staff and peer(s). In July 2014: - Five episodes of verbal aggression towards unidentified person(s). In August 2014: - One episode of hitting peer. - One episode of verbal aggression towards unidentified person. In September 2014: - One episode of attempting to hit peer. - Two episodes of verbal aggression towards peer. - One episode of verbal aggression towards Client 1 at dinner. - One episode of verbal aggression to unidentified person. - One episode of hitting Client 1 in the leg. In October 2014: - One episode of physical aggression towards Client 1. - One episode of hitting Client 1 in the arm. In November 2014: - Two episodes of hitting Client 1. - One episode of verbal aggression towards Client 1.Review of the facility's policy and procedures (P&P) titled Abuse/Neglect of Individual dated 7/11/14, showed in part, the following: - Abuse means intentional or willful infliction of physical injury; verbal or demonstrative harm caused by oral or written language, or gestures with disparaging or derogatory implications; and psychological, mental or emotional harm caused by unreasonable confinement, intimidation, humiliation, harassment, threats of punishment, or deprivation. - Prohibited practices include: hitting, pinching, the infliction of physical pain, screaming, swearing, name calling, belittling or other verbal activity that may cause damage to an individual's self respect or dignity. - Person(s) observing or suspecting the occurrence of abuse shall be responsible for reporting it to their supervisor immediately. The Area Director and Regional Director will be notified immediately.- Two incident reports will be filled out in CASPer for each incident, one incident report will be identified as a challenging behavior for the initiating individual, in the incident report for the victim the incident will be identified as peer to peer abuse. - A thorough investigation shall be completed by the PM within 24 hours. - Within 24 hours, the Area Director/PM will follow the Incident Reporting Procedure and file a report to RCOC, CDPH, Community Care Licensing and Adult Protective Services using the reporting tool. This includes any physical aggression between two or more individuals even if there was no injury.On 11/12/14 at 1610 hours, an interview was conducted with Client 1. Client 1 stated Client 6 was hitting her a lot yesterday and pulled her hand. Client 1 stated it hurt when Client 6 hit her, but she did not have any bruises. When Client 1 was asked if Client 6 had hit her on other occasions, she stated Client 6 had hit her on six occasions. Client 1 stated Client 6 hit her on her right arm sometime in October 2014, and DCS E, F, and H witnessed it. Client 1 stated Client 6 hit her on her right leg in September 2014, but no staff witnessed it. The client stated the PM knew Client 6 hits her. Client 1 stated Client 6 had gone to her room and hit her all the time. The client stated she never had any marks on her body from Client 6 hitting her. Client 1 stated she was scared and afraid of Client 6. Client 1 also stated she would "gets out of here" when Client 6 started yelling.On 11/12/14 between 1555 to 1646 hours, the surveyors observed Client 6 displaying aggressive and abusive verbal and physical behaviors when Client 1 was within her sight and in the same area. For example: - At 1625 hours, while being assisted by DCS B to walk from the bathroom to her bedroom, Client 6 was observed pointing and flipping her index finger several times in a threatening manner at Client 1 who was passing by in the hallway at the same time. Client 6 was also overheard to scream loud derogatory remarks at Client 1, i.e. "She is dirty, she smells; She's a dirty, dirty, dirty child; and That's an idiotic child of her!" Client 1's bedroom was located opposite to the bedroom of Client 6. - At 1645 hours, Client 6 was observed in the dining area at the end of the table. Client 6 was in her wheelchair doing table top activities. DCS B was with the client and was standing by the client's right side. A pitcher of iced water was left on the table in front of Client 6's activity supplies. At 1646 hours, Client 1 went to help herself pour iced water from the pitcher that was on the table. Client 6 immediately stood up and hit Client 1 on her right lower arm and made physical contact. DCS B failed to prevent Client 6 from hitting Client 1 since she did not stand in between the two clients. It was apparent this physical intervention was necessary since Client 6 was manifesting aggressive behaviors just 20 minutes earlier towards Client 1.The facility failed to ensure Client 1 and other clients in the facility were not subjected to physical and verbal abuse from Client 6. As a result, Client 1 and unidentified client(s) were subjected to repeated hitting and verbal abuse from Client 6.This failure had a direct and immediate relationship to the health, safety, and security of the client. |
| 060000078 |
BETHESDA LUTHERAN COMMUNITIES - MITHRA |
060011886 |
B |
09-Dec-15 |
S8NR11 |
7026 |
CFR 483.460(c), W331 W331 dual enforcement to Class B citation from survey 11/9/15 W331: The facility must provide clients with nursing services in accordance with their needs. The facility's policy and procedure (P&P) titled Change in Condition dated 4/1/15, read in part: Direct Support Professionals are able to recognize and report signs and symptoms that indicate a change of condition. Managers and Nursing Professionals are able to report and obtain prompt healthcare treatment when needed for a change in health status of individuals supported.The facility's P&P titled Supporting and Maintaining Best Possible Health dated 4/10/15, read in part: "[facility] staff will monitor the health status and physical condition of persons served and takes action in a timely manner in response to identified changes in conditions."Review of the facility's document titled Vital Signs and Weight Record dated 2015, indicated to notify the RN as soon as possible if the client had a weight change of five pounds or more. Review of the Job Description for the Registered Nurse (RN) dated 5/31/13, showed the RN should oversee the medical care of the clients including medication administration, pharmacy services, medical appointments, medical records, and overall plan of care.Clinical record review was initiated for Client 1 on 10/30/15 at 1200 hours. Client 1 was admitted to the facility on 4/21/15, with diagnoses including mild intellectual disability (an individual with an IQ of 50 to 69), Down's syndrome, mild vision, hearing loss, epilepsy, anxiety, and Alzheimer's disease.Review of the 2015 Vital Signs and Weight Record showed the following monthly weight record for Client 1: - 4/22/15 = 118.6 pounds - 5/3/15 = 117 pounds - 6/6/15 = 116 pounds - 7/4/15 = 99 pounds (17 pound weight loss in one month) - 8/1/15 = 91 pounds (8 pound weight loss in one month) - 9/6/15 = 90 pounds - 10/4/15 = 88 pounds On 10/30/15 at 1330 hours, the RN Consultant (RNC) was interviewed. When asked about the 17 pound weight loss in July 2015, the RNC stated she was not aware of the weight change documented on 7/4/15 until "closer to August." The RNC stated she visited the facility weekly to check the Medication Administration Records (MARs) and do visual checks. The RNC stated she did not realize Client 1's weight loss was so dramatic.When asked what the facility's protocol for weight loss was, the RNC stated the Direct Care Staff (DCS) should notify the RNC for a weight change of five pounds. When asked for any documentation to show the DCS had notified the RNC when Client 1 had the 17 pound weight loss, the RNC was unable to provide any documentation. Also, there was no documentation to show the RNC had notified the physician (MD) or the Registered Dietitian (RD) of the client's 17 pound weight loss in July 2015.On 11/2/15, the DCS documentation from the computer system was provided for review. Review of the DCS notes from 6/1/15 through 7/31/15, showed the DCS' description of the client's food intake was inconsistent. For example: the client ate 50% once on 6/9/15, she did not eat well once for dinner on 7/13/15, and ate dinner okay on 7/18/15, and all other documentation was from 75% to 100% including "ate well", "ate very well", and "ate all."The documentation regarding bowel movements showed on 6/14/15, Client 1 had one "[messy] bowel movement (BM)"; on 6/23/15, the client had one episode of diarrhea; and on 7/1/15, the client had a BM in her incontinence briefs.Review of the Change in Condition Tracking Form dated 6/24/15, showed the client was monitored for diarrhea. The form showed the diarrhea was resolved by 6/25/15. Review of the RD's quarterly progress note dated 7/10/15, showed the client's weight of 99 pounds in July 2015 was an "inconsistent weight...please re-weigh for accuracy." The RD requested to provide high protein milk at breakfast and dinner, health shakes daily, and to weigh weekly to monitor weight changes. The RD also requested to be notified of weight changes greater than five pounds, changes in bowel movements, and changes in intake and dietary preferences.Review of the July 2015 MAR showed the weekly weights were added, but the high protein milk at breakfast and dinner, and daily health shakes were not initiated.Further review of the clinical record showed Client 1 had the following physician visits: - 6/9/15, visit with the Physician Assistant (PA 1) for an eye irritation; - 6/19/15, visit with PA 2 for an eye follow-up; - 6/19/15, visit with MD 1 for a 60 day follow-up; - 6/23/15, visit with MD 2 for viral gastroenteritis. The MD recommended to increase fluids, monitor progress, and recheck in 2-3 days if not better; - 6/30/15, visit with MD 3 for resolving diarrhea, scalp lesion, hearing loss; - 8/20/15, visit with PA 3 for weight loss (8 pounds in 3 months), knee pain, and evaluation of nutrition. PA 3 ordered daily health shake, to monitor weight, and to recheck in 2 months; - 8/21/15, visit with MD 3 for 60 day follow-up. MD 3 documented the client denied vomiting/diarrhea; - 9/11/15, visit with PA 3 for weight loss (four pounds in one month), eye evaluation, mammogram, colonoscopy, laboratory requests.On 11/2/15, documentation from the facility's "Communication Binder" was provided for review. Review of the documents showed these were daily notes written as a form of communication amongst staff regarding all the clients in the facility. The following was identified: - On 6/23/15, the doctor asked to monitor Client 1 for loose stool for three days, and no incidents were noted by 6/30/15.- On 8/14/15, the RNC documented, "Please put [Client 1's name] on weekly weights. She has been losing a lot of weight."- On 8/20/15, the RNC faxed a request to the pharmacy for high protein milk recommended by the RD on 7/10/15 for Client 1.- On 8/21/15, the RNC added ensure daily (which the RD recommended on 7/10/15) for Client 1. - On 8/21/15, the RNC noted Client 1 had loose stools, wrote to hold the Citrucel (a bulk-forming laxative), and encourage fluids.On 11/2/15 at 1045 hours, the Qualified Intellectual Disabilities Professional (QIDP) stated the documentations made in the "Communication Binder" were not kept in the client's clinical record. Review of the Nurses Note dated 8/20/15, showed Client 1 was seen by MD 2 or MD 3 (not specified) "for weight loss over a period of 3 months, of 8 [pounds]."Review of the Physician's Orders dated 10/1/15 through 10/31/15, showed the high protein milk at breakfast and dinner was dated 8/20/15, and the daily health shake was not ordered until 9/2/15.On 11/2/15 at 1205 hours, an interview with the RNC confirmed the weight loss for three months (from 5/20 to 8/20/15) was 26 pounds, not eight pounds. The RNC further confirmed there were no physician visits between 6/30 and 8/20/15, and the client's weight loss was not addressed until 8/20/15.The failure of the facility to assess Client 1's weight loss had a direct relationship to the health, safety, or security of the client. |
| 080001515 |
BROOKDALE CARMEL VALLEY |
080010839 |
B |
01-Jul-14 |
VRQX11 |
7649 |
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 facility failed to accurately assess and manage dysesthesia pain (abnormal sensation of pain when being touched-also known as neuropathic {nerve} pain) for 1 of 11 sampled residents (28). As a result, Resident 28 suffered episodes of uncontrolled, excruciating pain during his 7 day stay.Resident 28 was admitted to the facility on 5/15/14, with diagnoses that included status post spinal cord injury and MS (Multiple Sclerosis-a disease which deteriorates the central nervous system) per facility Admission Record. Dysethesia pain is a common symptom of patients with MS. Per Initial History and Physical, documented by MD 1, on 5/15/14, Resident 28 had history of a compression fracture of the lumbosacral (lower back) spine (spinal cord) injury.On 5/20/14 at 3:00 P.M., during an observation and concurrent interview Resident 28 was lying on his bed in a darkened room.Moaning could be heard from the hallway. Resident 28 stated, "I don't feel comfortable here....I need a bullet to my head....I can't stand the pain....pain all over."On 5/21/14 at 9:50 A.M., an observation was made when Family Member (FM) 1 approached Licensed Nurse (LN) 3, who was at her medication cart. FM 1 asked LN 3, "Are you sure you are giving him his medications?What are you not giving him? My father is in so much excruciating pain he can't be touched. He thinks he is not getting his medications. What ever worked at the [Acute Care Hospital], we need. Are you giving that to him?"According to progress notes, printed on 5/22/14, Resident 28 last received a PRN (as needed) pain medication; Tylenol 650 mg. on 5/19/14 at 4:24 P.M. During an observation on 5/21/14 at 10:30 A.M., Resident 28 position was changed by two (Certified Nurse Aide) CNAs. He was crying out with the movement. "Please....Easy!.....Legs, Please!.....Watch my face....Don't touch me!....Easy! Easy!"His face was grimacing, and his arms had spastic movements while he was being turned.On 5/21/14, Resident 28's clinical record was reviewed. Per the Admission History and Physical documented by (Medical Doctor) MD 1 on 5/15/14, MD 1 listed the current medications as, "Tylenol (pain medication) 650 mg PRN (as needed), alprazolam (medication for anxiety), baclofen (medication for spasms) 20 mg in the AM, and 30 mg in the P.M., gabapentin (medication for nerve pain) 200 mg TID (three times a day), and tramadol (pain medication) PRN pain."However, MD 1's written order's dated 5/15/14, did not include gabapentin, tramadol or alprazolam. This was a contradiction to the medications listed in the Admission History and Physical. Tylenol was the only medication ordered to address his pain.Per the Initial Nursing Assessment done on 5/15/14 at 7:18 P.M., LN 1 documented Resident 28 had no pain, and on a scale of 1-10, "2" was an acceptable level of pain. On the same assessment, Resident 28 was, "Alert, oriented to person, place, and time and was verbally appropriate." A pain assessment dated 5/16/14 by LN 2, was reviewed. Resident 28's pain intensity was a "6" and he indicated pain by non-verbal sounds such as crying, whining, gasping, moaning or groaning and by vocal complaints of pain. The frequency of pain or possible pain was not filled out on the assessment. There was no care plan present to address pain, only spasms.On 5/21/14 at 11:52, during an interview with LN 3, she stated Resident 28's, "...pain was not all the time, only when he moved." LN 3 stated she did not report the pain to the physician. On 5/21/14 at 2:30 P.M., during an interview with the Director of Nurses, she stated, "We don't have a pain care plan." On 5/21/14 at 3:15 P.M., during an interview with CNA 1, she stated that Resident 28 was, "Always in pain....I always tell the nurse about that, since first day." We always tell them that he is in pain..."we don't ask how much pain." CNA 1 acknowledged that Resident 28's pain increased when moved and it takes 2-3 CNAs to help him turn. On 5/21/14 at 3:30 P.M., during an interview with CNA 3, regarding Resident 28's pain, CNA 3 stated, "Yes, especially when turning him, even when you touch him. They know and report to us that he has had pain meds."On 5/21/14 at 3:41 P.M., during an interview with LN 4, she acknowledged that report was given to her by CNA 3 regarding pain on the 5/15 and 5/16. "He is just too much care. This is my 4th day with him. Yesterday I asked him if he was in pain, he said "Yes", but I have not reported to the physician." LN 4 further acknowledged, I didn't report it because before, when I would ask him, he said he was not in pain. During an interview on 5/21/14 at 6:20 P.M., with MD 1 regarding Resident 28, the physician stated, "He is too highly complex for us....he needs to be in Long Term Acute Care (a facility that admits patients needing a higher level of care then provided at a skilled nursing facility), I was aware the day he came in, that he was too complex." I was not notified (re: pain), I have been out of town since Friday....He is on gabapentin (for treatment of neuropathic pain)...it is right here in my phone." MD 1's original admission orders did not have gabapentin ordered.On 5/22/14 at 12:30 A.M., during an interview the Consultant Pharmacist 1 stated, discontinuing the gabapentin would, "....make him more alert and more sensitive to things around him....He would be more cognitively clear and be more perceptive to pain." On 5/27/14 at 9 A.M., FM 1 stated, "There was no plan for his pain, when doctor met with us on the first day." A few days later, he was still not getting his regular medications from the facility that he was getting from the VA." She further stated staff on numerous occasions did not communicate back with her why Resident 28 was not getting his pain medication which were given at the [Acute Care Hospital].On 5/27/14 at 11:30 A.M., during an interview the Director of Programs (Therapies), stated Resident 28 "...had pain when moved. I don't see any documents that we reported it."On 5/27/14, during a review of Resident 28's Physical Therapy Daily Treatment Note, pain was documented to be a 10/10 bilaterally to his lower extremities with a passive stretch (someone stretching his arms or legs for him.)The facility policy and procedure dated 7/15/13 titled Pain Management, reads " 1. Facility staff will identify individuals who have pain or who are at risk for having pain...c...whenever there is a significant change in condition and at any time when an onset of new pain or worsening of existing pain is suspected...b. Licensed staff will evaluated nonverbal individuals for nonspecific signs and symptoms that could reflect pain; for example, grimacing while being reposition or having wound dressing changed.5. Licensed nurse will notify the attending physician if non-drug interventions are not effective.If the ordered pain medication is not effective, licensed nurse will also notify with attending physician. 6. Licensed staff and interdisciplinary team (including physician) will help identify causes of pain by examining the resident directly, reviewing the resident's history, and having a sufficiently detailed discussion with the resident and staff. 9. With input from the resident and /or advocate, the physician and staff will establish goals of pain treatment." The cumulative effect has a direct relationship to the health, safety, and security of patients. |
| 080000007 |
Boulder Creek Post Acute |
080011251 |
A |
05-Feb-15 |
EX0X11 |
14177 |
The facility failed to ensure 1 of 3 sampled residents (3) received adequate treatment of his mid-back pressure sore until the wound progressed to a Stage IV (a full thickness tissue loss with exposed bone, tendon, or muscle) with extensive cellulitis (a bacterial infection of the skin with inflammation and swelling) to the surrounding tissues. The facility also failed to notify the physician, MD 1, until the back wound was a Stage III, and for the entire length of his stay, there was no documented evidence a physician or wound care consultant observed the pressure sores. As a result, Resident 3 was transferred to an acute care facility for an overwhelming infection and treatment of his Stage IV pressure sores. Resident 3 died after 3 days in the hospital. Resident 3 was admitted to the facility on 8/15/13, with diagnoses which included chronic kidney disease and peripheral neuropathy (nerve damage which causes weakness and numbness in the hands and feet) in relation to his diabetes, according to the Record of Admission. The admission Minimum Data Set (MDS - an assessment tool), dated 8/20/13, indicated Resident 3 was alert, oriented, and had no problems with memory or cognition, but required maximum assistance for the activities of daily living (ADLs) of transfer, dressing, and personal hygiene. The full admission nursing assessment was done by Licensed Nurse (LN 1) on 8/15/13 at 3:30 P.M. LN 1 documented 3 areas of redness or raw, irritated skin, on the resident's mid-back. Area #1 was documented as 1.2 cm (centimeters) x 1.2 cm (all measurements recorded in width (W) and length (L) in centimeters, where 2.5 cm = 1 inch). Area #2 measured 1 cm x 1 cm. Area # 3 recorded as 1.5 cm x 1.5 cm. All the areas were described as "open with a small amount of yellow slough." (Slough is yellow, green, or gray dead/nonviable tissue - caused by no blood flow.) On 8/15/13, during Resident 3's admission process, LN 1 initiated a care plan, "risk for developing pressure ulcers...and other types of skin breakdown in r/t (relation to): immobility, arterial insufficiency (any condition that slows or stops the flow of blood through the arteries) of both feet, and anemia. The Goal: "to minimize the risk of skin breakdown, bruising, or pressure sores daily..." The Approach/Action column included, but was not limited to: "assess skin integrity during care; pressure relieving devices prn (as needed); weekly body checks; and notify MD for any changes (i.e., deterioration in existing wounds and/or lack of effectiveness in a specified treatment). During an interview with LN 1 on 12/18/13 at 3:50 P.M., she stated that upon her initial assessment, Resident 3's back wounds, "were not pressure sores." LN 1 also clarified that any further documentation and treatment of the resident's mid-back wounds was done by the treatment nurse, LN 2. When asked why she documented the moist, open-areas as wounds and not pressure sores, LN 1 stated, "I felt the wounds, and they appeared not deep." Resident 3's Treatment Sheets, which included a weekly assessment and evaluation of the resident's pressure sores, were reviewed. According to the Wound/Skin Healing Record, initiated on 8/15/13, LN 2 documented the resident's mid-back lesion (#1) as unstageable, with no odor and no drainage. LN 2 also documented the resident's other mid-back lesions, #2 and #3, gradually improved and shrunk in size. On 9/1/13, LN 2 documented that both these pressure sores had resolved. The Wound/Skin Healing Record for the resident's mid-back lesion (#1) was further reviewed for assessment and documentation of wound deterioration. From 8/15/13 to 8/19/13, LN 2 documented the wound had developed into a Stage III, with a small amount of purulent (containing pus) discharge. A Stage III pressure ulcer is a full thickness tissue loss, which may include undermining (tissue destruction underneath intact skin and along wound borders); slough may be present, but does not obscure the depth of tissue loss. On 8/26/13, LN 2 described the ulcer as a Stage II, with a scant amount of serous (clear) drainage, with maceration (where surrounding skin retains too much moisture, turns white, and softens) to the wound edges. On 9/4/13, LN 2 described the surrounding skin as bright red "with extensive, surrounding maceration of 3 x 4 cms." By 9/10/13, according to LN 2, Resident 3's pressure ulcer had increased by 5 times over the previous week, to 1.7 cm x 1.5 cm. For the first time, LN 2 documented the pressure ulcer had "deteriorated," and the resident experienced pain of his wound, rated at 2-4/10. (Using the numeric pain scale 1-10: 0 = no pain; 2-4 = mild-to-moderate pain; 8-10 = severe pain; and 10 = the worst pain possible). LN 2 also checked the pressure ulcer had a moderate amount of serosanguinous (pink-tinged) drainage with maceration. According to the form, LN 2 did not notify the attending physician, MD 1, of the deterioration of the wound, nor the pain experienced by the resident. During further review of Resident 3's Wound/Skin Healing Record, LN 2 documented a significant change in the pressure sore on 9/16/13. According to LN 2, the wound now measured 6 cm x 5 cm, and the resident's level of pain had increased to 5/10 (moderate pain). LN 2 still described the pressure sore as Stage III, with the depth marked as "UTD" (unable to determine), even though the drainage was now "large and purulent, with 50 % slough." LN 2 documented the wound had again deteriorated, and that the physician was notified on 9/16/13. In the Comment section, LN 2 wrote, "3.0 cm dark-red maceration;" however, the Plan Of Care portion of the form was left blank, or not updated. On 9/22/13, according to LN 2, the resident's wound again increased in size, to 11 cm x 7 cm, with an UTD depth. LN 2 classified the wound as unstageable. At this point, the wound had a large amount of purulent drainage, and 100% slough. LN 2 continued to document Resident 3 experienced pain of his wound, and deterioration of the wound in response to treatment. The wound assessment by LN 2, on 9/30/13, indicated the pressure sore was a Stage IV, with dimensions of 18.2 cm x 7.5 cm x 2.5 cm. (A Stage IV is a full thickness tissue loss with exposed bone, tendon, or muscle, and often includes undermining and tunneling). The wound also had a foul-odor, and a copious (huge) amount of purulent drainage. LN 2 failed to include a pain assessment, but marked that the physician (MD 1) was notified.The nurses' progress notes were reviewed for additional documentation of Resident 3's status prior to transfer to the ED. From 9/26/13 through 9/30/13, there were no progress notes entered on the resident until the day of transfer. The Resident Transfer Record, dated 9/30/13, included the reason for transfer; "Further treatment and evaluation of open area on mid-back." On 1/15/14 at 2:30 P.M., LN 2 was interviewed regarding his documentation, in chronological order, of Resident 3's pressure sores on the Wound/Skin Healing Record. The interview focused on the resident's #1 mid-back wound, since, according to LN 2, the #2 and #3 lesions were considered "resolved." LN 2 was asked about his 8/19/13 assessment, in which he documented a purulent discharge, an increase in slough (necrotic or dead tissue), and, for the first time, pain from the pressure sore itself. When asked why the physician was not notified regarding these changes, LN 2 stated, "I felt the wound was improved due to a decrease in size." LN 2's wound assessments, dated 8/26/13 and 9/4/13, were jointly reviewed. LN 2 was asked about his documentation of the skin surrounding the wound, which was checked as "normal" on 8/26/13, but described as "bright red with maceration" on 9/4/13. When asked why, on 9/4/13, he marked the wound "improved," LN 2 stated, "Because the wound decreased in size." When asked to define maceration, LN 2 stated, "Sort of moist." During the same interview, on 1/15/14 at 2:40 P.M., LN 2 was asked about the significant change in the resident's wound, according to his 9/10/13 assessment. LN 2 was asked why MD 1 was not notified when the wound was 5 times larger than the previous week, and the wound had "deteriorated" in response to treatment. LN 2 stated, since the pressure sore had "a clean wound bed" (a sign of wound healing) and was "still superficial," he didn't feel it was necessary to notify the physician. LN 2's assessment of Resident 3's pressure sore, dated 9/16/13, was jointly reviewed. LN 2 acknowledged the wound had increased nearly 4 times in size from his assessment on 9/10/13, and now had large amounts of purulent drainage. LN 2 stated he notified MD 1, who ordered Santyl ointment (a protein-based debriding agent) daily to the wound. When asked why no wound culture was obtained, LN 2 stated, "Because the doctor didn't order it." LN 2's wound assessments, dated 9/22/13 and 9/30/13, were jointly reviewed. LN 2 stated, because the wound was covered with slough on 9/22/13, he documented the pressure sore as "unstageable" and the depth as unable to determine. LN 2 verified he did not notify the physician, even though the wound had deteriorated in response to the Santyl ointment. LN 2 verified that, on 9/30/13, when the pressure sore reached a Stage IV, and again increased in size, MD 1 was notified. Subsequently, Resident 3 was transferred to the ED "for wound evaluation." On 1/15/14 at 3:15 P.M., during the same interview, LN 2 was asked about his documentation of "wound deterioration," on 9/10/13, 9/16/13, and 9/22/13. When asked if a wound care physician, or a certified wound care nurse was ever contacted regarding Resident 3's pressure sores, LN 2 stated he wasn't sure. When asked if a Wound-Vac (a vacuum source which removes drainage and infection to prepare the wound for healing)would have been appropriate for this resident, LN 2 stated, "No, not in this case." When asked if the resident's wound, at any time, should have been debrided, LN 2 stated that he "never considered it." (Debridement is the removal of dead tissue with a sharp instrument). When asked if he was wound care certified, LN 2 stated, "No," but he was "taking classes towards certification." On 1/15/14 at 3:30 P.M., LN 2 stated he didn't think MD 1 ever observed Resident 3's mid-back pressure sores. On 1/15/14 at 3:40 P.M., the Director of Nursing (DON) was interviewed regarding the deterioration of Resident 3's pressure sore. The DON stated Resident 3 was non-compliant, because he resisted being turned and repositioned. The DON was informed of the significant increase in size and depth of the resident's back wound in the ED vs the facility's documentation. The DON stated she felt this happened because the "three pressure sores merged into one." MD 1 failed to respond to phone calls and requests to schedule an interview regarding Resident 3. The facility's policy & procedure, Wound Care Suggestions & Documentation, dated 5/2013, was reviewed. The policy included, but was not limited to: "Documentation: Wounds will be staged in accordance with the NPUAP (National Pressure Ulcer Advisory Panel) guidelines as follows: Unstageable (UTD) Full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar. Until the slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore, stage, cannot be determined. Infection/Cultures: Changes in drainage that is foul-smelling or purulent should be promptly called to the MD and cultures ordered as indicated." The History and Physical (H&P) from the Emergency Department physician (MD 2), dated 9/30/13 at 8:36 P.M., was reviewed. MD 2's Impression: "Multiple Stage IV decubitus ulcers, on the thoracic spine, and needed wound care... At this point, he is admitted for wound care." MD 2 ordered a wound care consult, and placed Resident 3 on IV (administered directly into the vein) antibiotics. At the time of the wound care consult, dated 10/1/13 at 8:27 P.M., MD 3 recorded the thoracic, mid-back pressure sore measured 20 cm x 15 cm x 4 cm. MD 3 described the ulcer as "full thickness all the way down to the level of the bone...with purulent exudate (drainage) throughout, which was pouring out." On 1/22/14 at 8:45 A.M., during a telephone interview, the wound care nurse (WCN 1) from the acute care facility clarified she reviewed the ED documentation, and the photos of Resident 3's Stage IV back wound. WCN 1 remarked that the spinal wound was very large and deep, and she was "surprised something further wasn't done at the nursing home."The wound assessment and documentation from LN 2 was reviewed with WCN 1. WCN 1 commented, "When a wound is unstageable, it is either a Stage III or a Stage IV - a full thickness loss." When asked to explain maceration, WCN 1 stated, "Maceration on the wound edges means infection." WCN 1 was informed of the documentation of the first time the wound had deteriorated, on 9/10/13. WCN 1 stated, "At this point, the facility should have called in a wound care consultant." On 1/28/14 at 1:15 P.M., during a telephone interview, MD 3 stated, "I didn't feel a thorough work-up was done" (in reference to the facility). MD 3 further stated Resident 3 needed to have a wound care specialist consult on his treatment. MD 3 also stated a Wound-Vac would have helped earlier, but not at this late stage. When asked if he felt the pressure sores contributed to this death, MD 3 stated, "This was definitely a factor in the resident's death. By the time I saw him, I recommended Hospice (end of life care)." The violation of this regulation presented either imminent danger that death or serious harm would result, or a substantial probability that death or serious physical harm would result.F 314 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 resident'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. |
| 080001515 |
BROOKDALE CARMEL VALLEY |
080012326 |
B |
16-Jun-16 |
DMPX11 |
5071 |
F-201 Transfer and Discharge Requirements-B Citation The facility failed to re-admit 1 sampled resident (1) to the facility after a brief hospitalization. As a result, Resident 1 was repeatedly denied his wish to return to the facility upon discharge from the hospital, which caused distress for Resident 1 and his family. Findings: On 5/12/16, 5/16/16, and 5/18/16, Resident 1's clinical record was reviewed. Resident 1, 65 years old, was admitted to the facility onXXXXXXX, from an acute care hospital for treatment of injuries sustained in a motor vehicle accident. Diagnoses included multiple fractures, nasogastric nourishment (feeding liquid through a tube through the nose into the stomach), and pain management, per the Admission Record. On 5/2/16, Resident 1 was repositioned in bed by staff, and sustained a bump on the head. Due to Resident 1's history of head injury from the motor vehicle accident, and being on blood thinning medications (medications that prevent blood clots), the physician ordered for Resident 1 to be transferred to an acute care hospital for evaluation. On 5/3/16, according to a communication document provided by the facility, the acute care hospital requested to send Resident 1 back to the facility. According to the communication document, on 5/4/16 the facility responded: " No, unable to accept patient. Care Needs Exceed Current Capacity." "Response Status: Placed Elsewhere." On 5/18/16 at 1:50 P.M., the Director of Nursing (DON) was interviewed. She stated she received the information for the request to initially admit Resident 1 from the hospital on 4/21/16. She stated she approved the admission based on him having, "good rehab potential," and his wife was going to stay with him. On 5/17/16 at 3:30 P.M., Licensed Nurse 1 (LN 1) was interviewed. She stated Resident 1, "had a lot of things going on." LN 1 said she did not feel uncomfortable with the care he required. On 5/17/16 at 3:45 P.M., during an interview, LN 2 stated Resident 1 needed frequent repositioning. She also stated, "the family was always there." On 5/17/16, at 3:40 P.M., Certified Nursing Assistant 1 (CNA 1) was interviewed. She stated Resident 1 was a heavy care resident, but the family was there and helped quite a bit. On 5/18/16, at 7:40 A.M., LN 3 stated Resident 1 required extensive assist with bed mobility, and needed pain medication, but felt it was manageable. "Resident 1's family was always there, even at night. Nice resident, nice family." On 5/18/16 at 10:30 A.M., the DON was interviewed. She stated after Resident 1 was sent to the hospital, she expected him to return to the facility. She also stated Resident 1, and his family wanted him to return to the facility. On 5/12/16 at 11:45 A.M., the Admissions Coordinator (AC) was interviewed. She stated she received the requests for admissions and re-admissions which were then approved by nursing before the facility accepted the resident. The AC said the facility received a request from the acute care hospital to re-admit Resident 1. She stated per the DON, even though there was a bed available, Resident 1 was not to be re-admitted due to the high level of care needed. The AC stated that the family was upset that the facility would not re-admit Resident 1. On 5/18/16 at 10:30 A.M., the DON stated Resident 1's family came in for his belongings a few days after he was transferred to the hospital and told her the family wanted him to return to the facility. The DON stated she told them Resident 1 needed a higher level of care. The DON stated Resident 1's wife was upset because he wanted to return to the facility. The DON stated Resident 1's son called her after Resident 1 was transferred to another facility. Resident 1's son asked again about Resident 1 returning to the facility. She said the son "got mad" because she told him Resident 1 could not return to the facility. According to the clinical records, Resident 1 was at the facility from 4/24/16 until 5/2/16, a total of 8 days. Services received from the facility included physical therapy, nasogastric nutrition, and pain management, per the Nursing Home Summary. There was no evidence in the clinical record to indicate Resident 1 required a higher level of care than the staff provided during the 8 days he was at the facility. The facility was also not able to provide evidence that Resident 1's condition deteriorated to a level requiring care beyond that which the facility could provide. According to the California Standard Admission Agreement for Skilled Nursing Facilities, dated 05/11, used by the facility: "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...If you are away from our Facility for more than seven days...we will readmit you to the first available bed...if you need the care provided by our Facility and wish to be readmitted." The above violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma. |
| 090000065 |
Balboa Nursing & Rehabilitation Center |
090009486 |
B |
11-Sep-12 |
CQT811 |
4499 |
72311 (a) Nursing service shall include, but not 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. The facility failed to develop an individual care plan related to a self-care deficit requiring assistance with activities of daily living for Patient 1. Two (2) certified nursing assistants (CNA's) transferred Patient 1 from the bed to a shower chair with the use of a hoyer sling lift (mechanical lift) that led to a fall causing a right shoulder fracture for Patient 1. There was no care plan to address how transfers were to be performed by the nursing staff for Patient 1 who required total assistance with transfer.Patient 1 was admitted to the facility on 7/18/11 with diagnoses that included quadriplegia (weakness of four limbs) and rehabilitation procedures per the Admission Information Sheet. The minimum data set (MDS) assessment dated 6/05/12 indicated that Patient 1 was able to complete the cognitive patterns interview. Patient 1's functional status assessment per the same MDS indicated total dependence with transfer requiring two or more person physical assistance. The clinical record also indicated that Patient 1 was five (5) feet and four (4) inches tall and weighed 143 pounds. A joint observation and an interview were conducted on 6/29/12 at 2:40 P.M. with Patient 1. Patient 1 was observed in bed. The right shoulder was immobilized with a sling. Patient 1 stated, "They used a sling quite a few times before and I did not fall. The sling suddenly fell. I cannot see. I'm blind. I felt half of my leg was on the chair and the other half was on the floor. I don't know if I slid. I just remember that the hoyer lift and sling suddenly dropped and I fell. My right shoulder hurts. It's on a sling."A review of Patient 1's medical record was conducted on 6/29/12 at 3:15 P.M. The x-ray report dated 6/18/11 indicated, "There is a recent fracture of the proximal humerus (upper arm) with no displacement of the right shoulder."An interview was conducted on 6/29/12 at 3:00 P.M. with certified nurse assistant (CNA) 1. CNA 1 stated, "The hospice CNA asked for help to transfer Patient 1 to a shower chair. Patient 1 indicated to use the same sling that was used before and Patient 1 liked that sling. I maneuver the hoyer lift. I lifted it like within my height, about five feet flat. Patient 1 slid and fell between the bed and the chair. The hospice CNA was assisting. It happened so fast. She slid and fell to the floor." An interview was conducted on 7/12/12 at 11:00 A.M. with the hospice CNA. The hospice CNA stated, "I took the hoyer sling lift from the third floor. The same sling was used per Patient 1's choice. I maneuvered the patient during the transfer and the facility CNA maneuvered the hoyer lift. The sling was too small for her. The sling should have been bigger but, the patient asked for the same sling that was used before. It happened so fast. She fell in between the chair and the bed. Her legs landed on the feet of the hoyer lift. The sling was attached to the hooks. The sling never detached from the hooks even after she fell."An interview was conducted on 8/31/12 at 1:10 P.M. with the manufacturer's technical support staff. The technical support staff stated, "We always recommend the size of the sling to match the size of the patient. It's the best practice to ensure safety."A joint interview and a review of the care plan for Patient 1 were conducted on 9/5/12 at 9:20 A.M. with the director of nurses (DON). The DON acknowledged and stated that there was no care plan to address how transfers were going to be performed by the nursing staff for Patient 1 who required total assistance.The facility failed to develop a care plan related to the problem of self-care deficit requiring assistance with activities of daily living for Patient 1. There was no care plan to address how transfers were to be performed by the nursing staff for Patient 1, who required total assistance with transfer from the bed to a shower chair. This had a direct cause for the fall that resulted into Patient 1's right shoulder fracture. A violation of this regulation had a direct or immediate relationship to the health, safety, and or security of this patient. |
| 010001140 |
Brookdale Fountaingrove |
110008291 |
B |
29-Feb-12 |
EUJX11 |
11381 |
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 facility failed to protect Resident 1 from neglect and abuse and treat her with dignity and respect when facility staff: 1) failed to prevent and follow physician orders for pressure ulcer care and 2) failed to respond to requests for pain medication and shook a finger at her while admonishing her and, 3) caused unnecessarily intense pain during wound care. A review of clinical records, on 10/22/10 at 1:10 p.m., indicated Resident 1 was a 71 year old woman admitted to the facility with diagnoses that included congestive heart failure, diabetes, and generalized chronic pain due to arthritis. Physician Orders, dated September, 2010, indicated Resident 1 had the capacity to make decisions regarding medical care. 1) A narrative report from the facility Ombudsman was received by CDPH, and reviewed, on 10/21/10. The narrative documented an interview conducted by the facility Ombudsman with Resident 1, on 10/20/10.The narrative indicated Resident 1 sat in a wheelchair for 12 hours a day for 2 days, when first admitted to the facility, because she thought that was what the nurses wanted. Resident 1 indicated it was then she developed a pressure ulcer. Interdisciplinary Team, (IDT), Progress Notes, dated 9/13/10, indicated Resident 1 developed an open blister on the left buttock. IDT Wound Committee notes, dated 9/17/10, indicated Resident 1 had developed a second pressure ulcer, on the right buttock. In addition to obtaining treatment orders for the new pressure ulcer, IDT recommended assessment by Physical Therapy for a pressure reducing surface for Resident 1's wheelchair.Subsequent IDT Progress notes documented the progression of the blisters to a Stage 3 pressure ulcers on both buttocks.(Pressure ulcer, a skin lesion caused by unrelieved pressure. Stage 3 involves full thickness skin loss with damage to subcutaneous tissue.)Review, of IDT Progress notes, dated 9/25/10, indicated Resident 1's open areas were worse, with excessive purulent drainage. During an interview, on 10/22/10, Resident 1 stated, in the past, she sat in a wheelchair for 12 hours at a time for two days in a row, prior to the development of the pressure ulcer(s). Resident 1 stated she did not have a wheelchair pad until after the pressure ulcers developed. Review, of Physician orders, dated 10/4/10, indicated treatment orders for care of the pressure ulcers, "...Cleanse the left buttock with wound cleanser..., cover with dry dressing. Change q (every) shift, TID (three times a day), and PRN (as needed) until slough removed". Orders for the right buttock pressure ulcer were similar except the dressing was to be changed twice a day: "Cleanse R(right) buttock with wound cleanser,.... Cover with dry dressing. (Change) BID (twice a day) until slough removed."Review of a letter written by Resident 1 to facility administration, dated 10/7/10, and provided for review, on 6/3/11, indicated Resident 1 had requested Licensed Staff A, change the pressure ulcer dressing(s), because the dressing was leaking and smelled bad. Resident 1 wrote that Licensed Staff A had stated that the dressings were only to be changed a.m. and p.m. When Resident 1 corrected him, Licensed Staff A stated he didn't have time to change the dressing(s), repeated that he only saw a.m. and p.m., (in the orders), and asked who had told her that? IDT Progress Notes, (Nurses Notes), dated 10/8/10, not timed, indicated Resident 1 had, "Foul smelling drainage...moderate amount of drainage that saturates the dressings", from the pressure ulcer on the left buttock.During an interview, on 10/22/10 at 2:45 p.m., Administrative Staff D stated Resident 1 had complained about the care she received from Licensed Staff A. Administrative Staff D stated when she counseled Licensed Staff A about Resident 1's complaints, Licensed Staff A stated Resident 1 wanted the pressure ulcer dressings changed one or two hours after the start of the night shift. 2) Review, of the Ombudsman's narrative of an interview with Resident 1 on 10/20/10, indicated that approximately two weeks previously, Resident 1 had requested pain medication from Licensed Staff A. When no pain medication came, Resident 1 sent a nurse's aide to Licensed Staff A to request the pain medication again. An hour passed without pain medication and Resident 1 again sent the nurse's aide to request it from Licensed Staff A. Licensed Staff A entered the room and told Resident 1, "Don't you ever, ever send her out more than once to get a pain pill. You aren't my priority...". Resident 1 had stated to the Ombudsman that she had felt very intimidated and afraid. The Ombudsman's narrative also indicated that an unidentified nurse's aide told Resident 1 that Licensed Nurse A told the aide, "Not to bother him with any requests from...(Resident 1)." During an interview, on 10/22/10 at 12:30 p.m., Resident 1 described the incident from earlier in her stay in which she sent unidentified staff person to Licensed Staff A to request her past due pain medication. Resident 1 waited an hour and the pain medication did not come. Resident 1 asked the unidentified staff to request the pain medication again, and it still did not come. After Resident 1 requested the pain medication a third time, Licensed Staff A came into the room and shook his finger at her while he stated, never send the aide for medication three times. Resident 1 stated she felt threatened. Resident 1 stated that a second staff member, Licensed Staff F, had told some of the nurse's aides not to come to her with Resident 1's needs. During a confidential interview, on 11/10/10, a facility staff member stated Licensed Staff F stated facility staff didn't need to remind her about medications because she had a "good memory". The staff member stated she felt bad for the residents because they had pain that wasn't treated. The staff member stated it felt like staff didn't have the right to ask for something (for the residents). During an interview, on 6/3/11 at 7 a.m., Licensed Staff A stated Resident 1 was admitted with medication orders that allowed Resident 1 to receive pain medications every two hours as needed. Licensed Staff A stated the facility staff had tried to get Resident 1's pain controlled so she wasn't, "Getting so much (pain medication)". 3) The Ombudsman's narrative of an interview with Resident 1 on 10/20/10, indicated that Resident 1 had stated that sometime between 10/4/11 and 10/14/11, during a dressing change, Licensed Staff A "scraped the wound", which was extremely painful. Licensed Staff A told Resident 1, "Every time I change it, it's going to hurt just like that and you just have to grin and bear it". When asked how she felt about the interaction, Resident 1 told the Ombudsman she felt scared and intimidated. During an interview, on 10/22/10 at 12:30 p.m., Resident 1 stated, sometime earlier in October, Licensed Staff A changed the dressing on the pressure ulcer and it had hurt "terribly". Resident 1 described the pain as "worse than a 10", (based on a numeric pain rating scale: 0=no pain, 10= severe pain, National Institutes of Health Pain Consortium, 2003), and stated dressing changes had never hurt like that. Resident 1 believed Licensed Staff A, "Didn't have the tools he needed". Resident 1 stated she was afraid that Licensed Staff A had made the wound worse. Resident 1 stated Licensed Staff A told her that every time he changed the dressing, "It would hurt like that".Review of the Vital Sign Flow Sheet for Resident 1, dated 8/15/10-10/15/10, indicated Resident 1's pain scale was documented at various times through the day. Resident 1's pain had never exceeded 8. Resident 1 stated she told Licensed Staff B about the incident the following day. Licensed Staff B urged Resident 1 to contact the facility administration. When Resident 1 spoke with Administrative Staff D, Administrative Staff D told Resident 1 that she had counseled Licensed Staff A that Resident 1 was sensitive. Resident 1, stated Administrative Staff D made her, "Feel like it was my fault". During an interview, on 11/10/10 at 9:20 a.m., Licensed Staff B stated Resident 1 told her what had happened, sometime in early October. Licensed Staff B stated Resident 1's wound had been covered with slough, (a layer of dead tissue), at the time. Licensed Staff B stated she did not think Licensed Staff A had made the wound worse, however, by using cotton swabs, he had loosened the edges of the wound and then she could see under the slough, that the wound was much deeper than previously thought. Licensed Staff B stated she reported the incident to Administrative Staff Dbecause Resident 1 was upset with Licensed Staff A and Resident 1 deserved to be treated well. During an interview, on 10/22/10 at 2:45 p.m., Administrative Staff D stated that Licensed Staff B had reported Resident 1's complaint sometime between 10/13/10 and 10/15/10. Administrative Staff D stated she had spoken to Licensed Staff A on 10/21/10. Administrative Staff D stated she had counseled Licensed Staff A that Resident 1 was sensitive. Review, on 11/10/10 at 6:55 a.m., of Physician Orders, dated 10/14/10, indicated, "Other than dressing changes, no one should attempt any kind of debridement of wound other than (Licensed Staff B)." Debridement is the removal of dead tissue from a wound, it can be accomplished in several ways, including chemically and surgically. Dead tissue must be removed before new tissue can grow. During an interview, on 6/3/11 at 7 a.m., about the dressing change in October, 2010, Licensed Staff A stated Resident 1's wound had appeared to have packing in it and packing had not been ordered. Licensed Nurse A stated he used cotton applicators to check if what he saw was indeed packing, which it was not. Licensed Staff A denied loosening the edges of the wound. Licensed Staff A stated the physician had indicated that Licensed Staff B only, was to do the wound care. Licensed Staff A stated he was, "Trying not to be DON (Director of Nursing) here", and to "Allow (Licensed Staff B) to be the wound care nurse". Review, on 10/22/10 at 3:30 p.m., of the facility policy titled, "Resident Protection and Abuse Prevention & Resident Intimacy", dated June 2008, page 4, indicated neglect was defined as "... a failure to provide services necessary to avoid ...deterioration of a resident's physical or mental condition". Page 3 of the same policy indicated the definition of physical abuse included "...non-accidental use of physical force that results in bodily injury, pain...."The facility failed to protect Resident 1 from neglect and abuse and to treat her with dignity and respect when facility staff: 1) failed to prevent and follow physician orders for pressure ulcer care and 2) failed to respond to requests for pain medication and shook a finger at her while admonishing her and, 3) caused unnecessarily intense pain during wound care. These failures resulted in Resident 1 feeling threatened, to not receive pressure ulcer care with the potential for poor wound healing, and resulted in Resident 1suffering unnecessary pain. These failures had a direct or immediate relationship to the health, safety and security of the resident. |
| 010001140 |
Brookdale Fountaingrove |
110008884 |
B |
29-Feb-12 |
EUJX11 |
4206 |
Health & Safety Code 1418.91(a)(b) (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 to the Department, an allegation that a facility staff member caused unnecessarily intense pain for Resident 1 during wound care, with the potential that the resident be subjected to further intense and unnecessary pain. A review, of clinical records was conducted on 10/22/10 at 1:10 p.m. and indicated Resident 1 was a 71 year old woman admitted to the facility with diagnoses that included congestive heart failure, and diabetes. Physician Orders, dated September, 2010, indicated Resident 1 had the capacity to make decisions regarding medical care. Interdisciplinary Progress, (IDT) notes, dated 9/13/10, indicated Resident 1 developed an open blister on the left buttock. Subsequent IDT Progress notes documented the progression of the blister to a Stage 3 pressure ulcer. During an interview, on 10/22/10 at 12:30 p.m., Resident 1 stated, sometime earlier in October, Licensed Staff A changed the dressing on the pressure ulcer and it had hurt "terribly". Resident 1 described the pain as "worse than a 10", (based on a numeric pain rating scale: 0=no pain, 10= severe pain, National Institutes of Health Pain Consortium, 2003), and stated dressing changes had never hurt like that. Resident 1 believed Licensed Staff A, "Didn't have the tools he needed". Resident 1 stated Licensed Staff A told her that every time he changed the dressing, "It would hurt like that".Resident 1 stated she told Licensed Staff B about the incident the following day. Licensed Staff B urged Resident 1 to contact the facility administration, which Resident 1 did by letter on 10/7/10. During an interview, on 11/10/10 at 9:20 a.m., Licensed Staff B stated Resident 1 told her what had happened, sometime in early October. Licensed Staff B stated Resident 1's wound had been covered with slough, (a layer of dead tissue), at the time. Licensed Staff B stated she did not think Licensed Staff A had made the wound worse, however, by using cotton swabs, he had loosened the edges of the wound and then she could see under the slough, that the wound was much deeper than previously thought. Licensed Staff B stated she reported the incident to Administrative Staff Dbecause Resident 1 was upset with Licensed Staff A and Resident 1 deserved to be treated well. During an interview, on 10/22/10 at 2:45 p.m., Administrative Staff D stated Licensed Staff B had reported Resident 1's complaint sometime between 10/13/10 and 10/15/10. Administrative Staff D stated she had spoken to Licensed Staff A, regarding the allegation of causing Resident 1 pain on 10/21/10, when he returned from vacation.During an interview, on 5/25/11 at 10:30 a.m., Administrator F stated the facility did an investigation of Resident 1's complaint about her care, and felt it was a "customer service issue". During an interview, on 6/3/11 at 7 a.m., about the dressing change in October, 2010, Licensed Staff A stated Resident 1's wound had appeared to have packing in it and packing had not been ordered. Licensed Nurse A stated he used cotton applicators to check if what he saw was indeed packing, which it was not.Review, on 10/22/10 at 3:30 p.m., of the facility policy titled, "Resident Protection and Abuse Prevention & Resident Intimacy", dated June 2008, page 3, indicated the definition of physical abuse included "...non-accidental use of physical force that results bodily injury, pain....". Page 4 stated" Upon receiving notice of an abuse allegation...notifies the appropriate State agencies of the alleged abuse immediately or as soon as possible with 24 hours: b) State Licensing Agency, i.e., Department of Health, Division of Licensure...". The facility failed to report to the Department an allegation that a facility staff member caused unnecessarily intense pain for Resident 1 during wound care, with the potential that the resident be subjected to further intense and unnecessary pain. |
| 010001140 |
Brookdale Fountaingrove |
110009120 |
B |
01-Jun-12 |
STR811 |
9826 |
72311(a)(2) 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. The facility failed to ensure one Resident's (Resident 2) care plan was followed when interventions to prevent a resident from falling were not followed, resulting in Resident 2 falling again and injuring his hip.On 1/30/12, review of a letter dated 1/25/12, faxed to the department from the facility indicated a resident (Resident 2), who was admitted on 11/11/11, to the facility, had a fracture of the left hip. The letter indicated that Resident 2 had a diagnosis of dementia and was admitted for aftercare of a healing osteoporatic fracture of the right acetabulum (right hip area). On 1/24/12 during a follow-up appointment and X-ray for the right acetabular fracture, a fracture was found on the left hip. On 2/8/12 at 2:05 p.m., during an interview, the Administrator stated that on 12/24/11, Resident 2 was in a wheel chair in the TV room and fell. The Administrator stated that Resident 2 had an alarm on, which went off after the fall. The Administrator stated that Resident 2's wife, usually sat with Resident 2, and also stated that Resident 2 was confused at times and fell after dinner. During an interview on 2/8/12 at 2:25 p.m., the DON stated that Resident 2 had a fall at the facility, previous to the fall on 12/24/11. The DON stated that the fall happened on 11/17/11. On 2/8/12 at 2:30 p.m., review of the physician visit notes signed on 11/14/11 indicated that Resident 2 was admitted to the facility on 11/11/11, and was there for aftercare of a healing fracture. Resident 2 had dementia and Parkinson disease and fell at another facility on 10/20/11, breaking his acetabulum (hip bone), was hospitalized, transferred to another facility for rehabilitation and then transferred to the present facility for long term custodial care. The patient was cooperative but a safety risk. Review of the MDS admission assessment dated 11/24/11 indicated that Resident 2 was severely impaired for decision making, used a wheel chair and was not steady when moving from a seated position to standing position. The MDS indicated that Resident 2 had a fall history. Review of the care area assessment notes for falls dated 11/24/11 indicated that Resident 2 was at risk for falls because of a history of falls and cognitive deficits affecting safety awareness.Review of the admission short term care plan dated 11/13/11 indicated that Resident 2 was a safety risk for falls and injury, and interventions listed were: staff were to ensure call systems were in place with reminders to residents to use them, frequent checks for safety, tab alarm, PT (Physical Therapy) and OT (Occupational Therapy). Review of the IDT (Interdisciplinary Team) notes dated 11/21/11 indicated a fall on 11/17/11, in which the resident stood up from a wheelchair and fell to his knees in the TV room. Recommended interventions indicated to keep the resident around the nursing station when the wife was not there to monitor for safety and frequent monitoring of the resident.Review of the care plan titled "Fall Incident Care Plan" dated 11/18/11 and revised 12/24/11, indicated that the tab alarm was in place and to check placement every shift, fall mat by the bed. After the 12/24/11 fall, CNAs were to check resident safety two times a shift while providing care and LVNs to check safety at least two times a shift including medication pass times. There was no mention in the care plan about IDT's recommendation to keep the resident around the nurses' station when the wife was not there for safety. On 2/8/12 at 2:45 p.m., Licensed Staff G stated that she had taken care of Resident 2 when he fell on 12/24/11 and he was in the T.V. room. She stated that a CNA came and got her and she found him on the floor, lying on his left side. His finger had a deep cut and his left wrist had a skin tear. Licensed Staff G stated that she heard that he fell there before. On 2/8/12 at 3:30 p.m., CNA K stated that she found Resident 2 on 12/24/11 in the evening on the floor in the TV room. His tab alarm went off and she heard it. The CNA K stated that Resident 2 was laying on his left side and his wife was not with him and she called for the other CNAs to help. On 2/8/12 at 3:55 p.m., Licensed Nurse H stated, that on 11/17/11, Resident 2 fell in the TV room after lunch, and she was at her medication cart, when someone called to say that they needed help in the TV room. Resident 2 was on the floor on his left side. There was a cut on the bridge of his nose from his glasses. Licensed Nurse H stated that his tab alarm went off and it was ringing, but it didn't stop him from getting up. Licensed Nurse H stated that they kept Resident 2 at the nurses' station as much as possible as he will get people's attention easier and it is easier to see if he gets up.On 2/8/12 at 4:30 p.m., during an observation and interview, Resident 2 was sitting in his wheelchair in his room, with Family Member M standing by him. Family Member M stated that he had fallen twice, while at the facility, and the last fall was on 12/24/11. Family Member M raised Resident 2's left ring finger to show a white scar on the underneath side of the finger. The Family Member M stated that the cut was deep. Resident 2's right arm was positioned on a pillow and appeared bent or contracted upward. Family Member M stated that when they left on 12/24/11, that they told staff not to leave Resident 2 alone. Family Member M stated on the second fall, he fell to the left and no one saw him fall. An X-ray showed a left femur fracture. Family Member M stated that the physician said the fracture looked recent, but was not new, and that it was healing. Family Member M also stated that around 11/16/11, Resident 2 was in the TV room and stood up and fell, hit his foot rest and another resident's chair, cut his nose as his glasses pushed in at his nose. Family Member M stated that the first fall, Resident 2 fell to the right and no one saw him fall and the second fall, he fell to the left and cut his finger and that was probably when he broke his femur. Family Member M stated that they told the facility staff to watch him and he was in the TV room. On 2/15/12 at 8:55 a.m., during a telephone interview, Resident 2's Physician stated that the fracture on the left was new with a callus formation or was healing. On the previous X-ray, from 11/3/11, there was no evidence of a fracture on the left side. The X-ray on 1/24/12 indicated on the right side, that there was an old healing fracture of the pelvis and on the left side, there was a new fracture with callus formation that was about a week to a month old. On 2/15/12 at 2:15 p.m., CNA J stated that he remembered a fall, where Resident 2 fell during the day, CNA J stated that he was on lunch break and the resident was put in the TV room. Resident 2 was trying to get up out of the wheelchair when he fell. CNA J stated that the CNAs were on the floor (Unit) trying to get residents up and usually no one is assigned to watch residents in the TV room. CNA J stated that usually if a resident is a fall risk, staff keep the resident by the front desk to keep an eye on them. On 2/15/12 at 2:35 p.m., CNA I stated that, on the day shift, Resident 2 fell in the TV room and thought that it happened before Christmas. CNA I stated that she heard a tab alarm go off, so she went into the TV room and saw Resident 2 on the floor with the nurse and other residents in there. CNA I stated that there are usually no staff assigned to watch residents in the TV room, but when we pass by, we look in there. On 2/15/12 at 3:30 p.m., the DON stated that when Resident 2 first fell, they made changes to the care plan such as continued physical therapy and placement of the tab alarm. It was the family's wish that there be more supervision and keep Resident 2 at the nurses' station, after the fall on 12/24/11, they increase the frequency of monitoring the resident, nurses and CNAs check at least 2 times a shift. The DON stated that no one is usually assigned to the TV room and the wife had left the facility. The staff have to go out of the TV room and answer the call lights. The DON stated that care plans were individual for each resident. Review of the IDT notes dated 11/21/11, with the DON indicated that the patient should be kept at an area of the nurses' station when Residents family was not there. The DON agreed that after the first fall in the TV room, the resident was not kept at the nurses' station and a 2nd fall occurred again in the TV room, where staff were not assigned to watch residents. The revised care plan dated 11/18/11 to 11/24/11, did not include the intervention to keep Resident 1 at the nurses' station, when wife was not present, even though this was an action plan that IDT (Interdisciplinary Team) had discussed. Review of the fall management guidelines, undated, on 2/15/12 indicated that staff should provide comprehensive care planning to meet specific residents needs and that the Interdisciplinary Team (IDT) will develop a comprehensive plan of care to reduce the risk of falls or injuries for each resident Nurses must update their care plan at the time of the fall, as new risk factors are identified. New interventions initiated may include but are not limited to Locating the resident closer to the nursing station and increased observation of the resident.The facility's failure to assure a fall prevention care plan was implemented for fall safety, had a direct relationship to the health, safety, or security of a patient, who fell twice on different dates, in the same unsupervised area resulting in a fractured hip. |
| 010001140 |
Brookdale Fountaingrove |
110009121 |
B |
01-Jun-12 |
None |
10916 |
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 ensure one Resident's (Resident 1) care plan was updated and new measures put in place, when staff noticed behaviors of the resident, which indicated preventive fall measures were not effective to prevent a potential fall. As a result, Resident 1 had a fall which resulted in fractured bones of the neck and hospitalization.On 1/13/12, the department received a faxed letter from the facility which indicated on 1/11/12, at roughly 10:30 p.m., a long term resident had an unwitnessed fall in her room. The resident went to the emergency room and was diagnosed with a cervical neck fracture, hospitalized and returned to the facility with a neck brace. On 1/18/12, review of another faxed letter received on 1/18/12, from the facility Executive Director, indicated that on 1/11/12 at 10:40 p.m., a sound was heard from Resident 1's room and a CNA (Certified Nursing Assistant) went to check. The resident was found on the floor. The letter indicated that when asked why Resident 1 tried to get out of bed, Resident 1 stated "'My Mother was in the Closet"'During an observation on 1/18/12 at 2:20 p.m., there was an elderly women sleeping, with a white plastic neck brace, in a bed that was low to the floor. On the top of her pillow was a white pull tab alarm box (device used to alert staff when the resident got out of bed) with a string that attached to her gown. During an interview at that time, Family Member L stated that Resident 1 wore the collar (neck brace) and had the ability to manipulate things such as her neck brace. Family Member L stated that Resident 1 had an alarm that Resident 1 was aware of, and wondered why staff were not alerted by the alarm when she fell on 1/11/12.On 1/18/12 at 3:10 p.m., review of the hospital physician History and Physical dated 1/12/12, indicated that Resident 1 was a frail elderly lady, with severe dementia, living at the facility, was found between the closet and the bed and complained of neck pain. The record indicated that it was unclear when the fall occurred or whether there was a loss of consciousness. The record indicated that Resident 1 had a contusion above the left eye and on the forehead and temporal region. The record also indicated that Resident 1 also had contusions of the left shoulder and knees and an abrasion on the left hand which required Seri strips. Resident 1 had complained of pain in their posterior cervical (neck) spine. The report indicated that the cervical spine CT indicated that there was a minimally displaced type two odontoid process (neck bone) fracture considered unstable with a comminuted fracture through the lateral mass of C2 (neck bone) involving the vertebral artery of foramen (blood vessel in a passageway in the neck bone) with bone fragments protruding into the foramen. During an interview on 1/18/12 at 3:15 p.m., CNA A stated that he worked from 2 p.m., until 10 p.m., the day that Resident 1 fell. CNA A stated that he put Resident 1 to bed about 8:45 p.m. to 9 p.m., because Resident 1 requested to go to bed. CNA A stated that he put on her tab alarm and made sure her call light was there. CNA A stated that he made his last rounds about 9:45 p.m., and Resident 1 was sleeping. CNA A stated that in the past one co-worker saw her standing in the bathroom and that Resident 1 did not like the alarms, and was able to take the alarm off about 80 % of the time and also stated that the nurses knew about it. During an interview on 1/18/12 at 3:45 p.m., Licensed Nurse B stated that she was called to the room by another CNA on 1/11/12 at 10:40 p.m., and Resident 1 was on the floor between the closet and the bed laying on her left shoulder. The Resident complained that it "hurt to be on the floor" and wanted to go back to bed.On 1/18/12 at 4:15 p.m., review of the admission sheet indicated that Resident 1 was admitted on 3/11/2009 to the facility. MDS quarterly assessment dated 11/11/12 indicated that Resident 1 needed extensive assistance for bed mobility, transfer, toilet use, dressing and Resident 1 did not walk in the room or corridor. Review of the 6/6/11 and updated 11/21/11 care plan for "Risk for falls" that was in place before the fall, indicated that Resident 1 was at risk for falls related to the lack of ability to transfer without assistance and medication side effects. The care plan indicated frequent checks throughout the day for whereabouts and to assess for needs and safety PRN (as needed). The 6/6/11 care plan also indicated that tab alarms were on at all times and a wanderguard was placed for occasional attempts to leave the facility. The care plan indicated that there would be frequent checks but there was no indication what frequent checks meant or documentation of the frequent checks before the fall. There was no updates on the care plan before the fall or interventions to address new resident behaviors that may result in falls or the potential need for additional preventive measures. On 1/23/12, at 7:20 a.m., review of the MDS (Material Data Set) annual assessment dated 5/20/2011, indicated in care areas that Resident 1 was delusional, believing events were happening when they were not and that frequent checks were to be done to anticipate her needs and to ensure her safety due to her cognitive defects.On 1/23/12 at 6:15 a.m., CNA C stated that the resident was not assigned to her, and she was walking down the hall to replenish the linen, saw the resident was not in her bed, and found her on the floor next to the closet. CNA C stated that Resident 1 was whispering and she could not hear her in the hallway. CNA C stated that Resident 1 rarely called out and did not get up to go to the bathroom. CNA C stated that when she found her, Resident 1 did not have the tab alarm on her. CNA C stated that the resident can take the alarm off and throw it on the floor and the alarm did not alarm when she did that. CNA C stated that Resident 1 had done that several times. On 1/23/12 at 6:43 a.m., during an interview, CNA D stated that she went in to help put Resident 1 back in bed after the fall and did not see a tab alarm on the bed. CNA D stated that Resident 1 had taken the tab alarms off in the past. CNA D stated that Resident 1 just unhooked them and they did not alarm. CNA D stated that she saw Resident 1 get out of bed before and saw her standing once and it was a good thing she passed by her room. CNA D stated that she thought that she told the nurse about it.During an interview on 1/26/12 at 6:41 a.m., CNA D, who gave an interview on 1/23/12 at 6:43 a.m., stated that Resident 1 stood up once in the last year and she usually used her call light or yelled "Help". CNA D stated that Resident 1 would sit on the edge of the bed. CNA D stated that she never saw the resident remove the alarm, but the time she saw the resident standing up, the alarm was unhooked so probably Resident 1 took the alarm off. CNA D stated that the CNAs did two rounds at night on all the residents and did a quick round when they come on shift. CNA D stated that she reported everything to the nurse. The night that Resident 1 fell she was helping another resident. CNA D stated that Resident 1 usually slept through the night and did not require frequent checks. CNA D stated that frequent checks would mean at least checking her four more times at night and the nurses would tell us if they needed that, as it would depend on the resident situation.During an interview on 1/26/12 at 7:30 a.m., The DON (Director of Nursing) stated as she reviewed the care plans for Resident 1, that "frequency" of checks depended on the care plan for the individual resident. The DON stated that staff did an MDS assessment and initiated the care plans from that. The "Routine Resident Checks" policy, for all staff, indicated to make rounds every 8 hours, but staff do it more frequently, and agreed that the care plan was not specific as to what frequency meant and how often residents are checked. The DON stated that the residents are checked every 2 hours once they go to bed. The DON stated that the checking of residents by staff is not documented anywhere specific. The DON stated that the CNAs documented on the ADL (Activities of Daily Living) sheet when they do care. Review of the ADL sheets, indicated checks for bed mobility, transfers, bowel movements, dressing, snacks. There were checks marked once a shift, but there were no checks for monitoring patient safety. Review of the "Routine Resident Check Policy" revised December, indicated 2 hour checks and that staff would make routine resident checks to help maintain resident safety. Documentation under policy interpretation; however, documented that staff would make a routine check at least once per 8 hour shift. The nursing supervisor was to keep documentation of the routine checks including time, identity of the person making checks and outcome of the checks. CNAs may also record the information and provide it to the charge nurse. The DON stated that the "Resident Check Policy" was not consistent with the interpretation of 2 hours versus 8 hours and stated that staff do rounds more frequently than just every 8 hours and also agreed that the care plan was not specific as to how often staff should monitor. The DON also stated that the nurses checked the tab pull alarms every shift to make sure the alarms were properly placed and working. On 2/15/12 at 3 p.m., Licensed Staff B stated that she never saw Resident 1 take her alarm off and the CNAs had never come to her to say that Resident 1 had. Licensed Staff B stated that when she checked a resident frequently that meant every time she walked by the room and she communicated to everyone, to check so maybe every 15 minutes, someone checks her but it is not written down. On 2/15/12 at 3:20 p.m., during an interview, the DON stated that the alarms were checked once per day, but are now checked once a shift to ensure alarms were working. The alarm check change was made on 1/14/12 after the fall. On 2/15/12, review of the care plan policy revised in 2006, indicated that the care plan was to be revised as changes in the resident's condition dictate. The facility's failure to assure a fall prevention care plan was revised to assure effective fall prevention measures were in place, had a direct relationship to the health and safety of Resident 1, who fell and sustained an injury to her neck resulting in hospitalization and immobilization due to neck fractures. |
| 010000066 |
Broadway Villa Post Acute |
110009281 |
B |
19-Sep-12 |
83R411 |
1272 |
1418.91(a) Health & Safety Code 1418 (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.1418.9 (b) Health & Safety Code 1418 (b) A failure to comply with the requirements of this section shall be a class "B" violation. The facility violated the regulation by failing to report an allegation of sexual abuse to the Department within 24 hours when Resident 3 reported that Resident 2 sexually abused Resident 1. This failure which had the potential that Resident 1 and other resident would be subjected to continuing abuse. An anonymous complaint was called to the Department on 3/15/12 regarding an allegation of sexual abuse. During an interview on 3/23/12 at 2:13 p.m., Administrator stated that on 3/9/12, Resident 3 came to him and reported she wanted to be transferred to another nursing facility because she was a witness to a rape. The Administrator could not state the rationale for not reporting an allegation of abuse within 24 hours.A review of the Abuse Investigation policy indicated: "All alleged abuses are to be reported immediately [sic] to the Ombudsman" and "reported to State Licensing Agency within twenty-four (24) hours." |
| 010000066 |
Broadway Villa Post Acute |
110009336 |
B |
15-Jun-12 |
J45811 |
2005 |
Health and Safety Code 1418.21 (a)(1)(A)(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. Health and Safety Code 1418.21 (a)(1)(C) (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: (C) An area used by residents for communal functions, such as dining, resident council meetings, or activities. Based on observation and staff interview, the facility failed to post the overall facility rating information in an area accessible and visible to members of the public and in an area used by residents for communal functions, such as dining, resident council meetings, or activities. This had the potential to prevent residents and the public from having access to the information. Findings: During the initial tour, on 5/15/12 at 9:30 a.m., the facility Five Star rating was posted in a back dining room, not utilized by the majority of residents, and in the rehabilitation/administrative hall, utilized by staff. Concurrent observation and interview, on 5/17/12 at 4:30 p.m., revealed the postings remained in the same areas. Management Staff Q stated that the front dining room was the area utilized by most residents and was used by the Resident Council, dining, and activities. He concurred that the hall where the rating was posted was not utilized by residents or visitors unless they went to rehabilitation or administrative offices. |
| 010000066 |
Broadway Villa Post Acute |
110010198 |
A |
04-Mar-14 |
INM411 |
11189 |
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 regulation by failing to ensure that Resident 1, who was at risk for falls and known attempts to get out of bed and the wheelchair unassisted, was provided adequate supervision by direct care staff and had effective revisions and implementation of Resident 1's nursing care plan to prevent further falls to keep Resident 1 safe. Resident 1 had six falls during a 30 day period from 8/26/11 to 9/16/11, with no effective interventions considered to prevent further falls from the bed and wheelchair. These failures contributed to Resident 1 sustaining a right femur fracture after falling while getting up unassisted from the wheelchair while outside on the patio. Resident 1 was admitted to the facility with diagnoses that included multiple falls at home. Resident 1's care plan/risk for injury dated 8/25/11 indicated poor balance, limited mobility, lack of awareness, poor safety awareness, and frequent falls/history of falls. The approaches were that the bed be kept in low bed position, a mat be on the floor beside the bed, use of nonskid socks, rounds every two hours, and a wheelchair alarm. The goal was that Resident 1 will have no injuries related to falls. The Nursing Notes dated 8/25/11 at 10:00 p.m., indicated that Resident 1 was alert and oriented to self. Resident 1 needed extensive assistance from one person to transfer Resident 1 from the bed to the wheelchair and for movement while in bed.First Fall: The Nursing Notes dated 8/26/11 at 1:45 a.m. indicated that Resident 1 was awake most of the night and had attempted to get out of bed several times. Resident 1 was forgetful and confused. The notes indicated that the alarm went off and the nurse found Resident 1 on the floor. Resident 1 was not able to recall what had happened.The Interdisciplinary Team Notes dated 8/26/11 at 9:30 a.m. indicated they determined that Resident 1 has poor safety awareness and made a recommendation for physical therapy and occupational therapy to screen, a low bed (the bed frame or mattress sits on the floor), and pharmacy review of Resident 1's medications. Resident 1's Nursing Plan of Care dated 8/26/11 indicated that Resident 1's alarms were to be checked every shift, encourage resident to use call light for needs and there was to be "frequent visual checks." The nursing plan of care lacked specificity about how a confused and forgetful resident would remember to use the call light to communicate his or her needs. There were no effective interventions to prevent falls for a resident who got up unassisted. During an interview on 3/7/12 at 11 a.m., Staff B stated that she did not know what "frequent visual checks" would entail. Second Fall: Nursing Notes dated 8/27/11 at 10:30 a.m., indicated that Resident 1 was found lying on the floor in his room. The notes indicated that Resident 1 stated, "I got up and fell down again." The notes do not indicate if the bed alarm sounded when Resident 1 got out of bed.The Nursing Post Fall Assessment dated 8/27/11 indicated that Resident 1 was in bed prior to the incident. The New Interventions indicated encourage using call light, increased observation as staff allows, and continue physical therapy and occupation therapy. These were the same interventions as the previous fall on 8/26/11. Resident 1's Nursing Plan of Care dated 8/27/11, indicated that Resident 1 was found on the floor from bed. The approaches/actions indicated physical therapy and occupational therapy treatment and evaluation as ordered. There were no new interventions considered for Resident 1 who attempted to get out of bed unassisted. The licensed staff did not evaluate the effectiveness of the previous interventions on the nursing plan of care dated 8/26/11. The staff did not implement the low bed on the nursing plan of care dated 8/26/11. During an interview on 3/7/12 at 11 a.m., Staff B stated that she did not know what "increased observation as staff allows" would entail. During an observation on 3/7/12 at 11:30 a.m., Resident 1's bed was in the low bed position that measured 16 inches from the floor to the top of the mattress. During an interview on 3/7/12 at 11 a.m., Staff B stated she was not aware of any intervention that would put the bed on the floor directly.During an interview by telephone on 3/12/12 at 11:30 a.m., Staff A stated that the facility will put a resident's mattress directly on the floor if indicated. Staff A stated that Resident 1 was a candidate to have his mattress directly on the floor but in his case the intervention was not implemented. When asked why the facility did not try placing Resident 1's mattress directly on the floor, Staff A was not able to provide an answer. Nurses' notes dated 8/29/11 at 6:00 a.m., indicated Resident 1 attempted to get out of bed unassisted without using the call light or asking for assistance. Nurses' notes dated 8/30/11 at 4:30 a.m., indicated Resident 1 made several attempts to get out of bed. Nurses' notes date 9/4/11 at 6:00 a.m., indicated Resident 1 made several attempts to get out of bed at night. Resident 1 had an unsteady gait and wandering behavior. Third Fall: The Nurses Notes dated 9/5/11 at 9:30 a.m. indicated that Resident 1 got up and fell from the wheelchair. Resident 1 was found lying on the floor. The Nurses Notes dated 9/5/11 at 1:45 p.m. indicated that Resident 1 complained of right hip pain. On 9/5/11 Resident 1 got an x-ray of the right hip which was negative for fracture.The Interdisciplinary Team Notes dated 9/6/11 at 9:45 a.m., recommended a room change near the nurses station. There were no further effective interventions considered for Resident 1 who got up out of the bed and wheelchair unassisted. Resident 1's Nursing Plan of Care dated 9/5/11 did not indicate any new approaches or interventions.Fourth Fall: The Nurses Notes dated 9/6/11 at 9:06 p.m. indicated that Resident 1 was found lying on the floor at 6:30 p.m. The nurses notes indicated Resident 1 was last seen in the wheelchair. The Nursing Post Fall Assessment dated 9/6/11 indicated previous interventions of bed and wheelchair alarms. The new interventions were increased observation as staff allows, encourage wife to visit during afternoon. The room change was supposed to be implemented on 9/5/11. The increased observation as staff would allow and the room change were the same interventions as indicated on the nursing plan of care dated 9/5/11.Resident 1's Nursing Plan of Care dated 9/6/11, indicated that Resident 1 was found on the floor. The approaches/actions indicated bed and wheelchair alarm, increased observation , encourage wife to visit on the evening shift, and room change close to the nurses station. The nursing plan of care lacked specificity regarding "increased observation as staff allows." There were no new effective interventions considered for adequate supervision for Resident 1 who had multiple falls and got up from the bed and wheelchair unassisted. Fifth Fall: The Nurses Notes dated 9/7/11 at 9:50 p.m. indicated a witnessed fall when Resident 1 stood up from the wheelchair and attempted to walk unassisted. The notes indicated that the staff were not able to get to Resident 1 in time to prevent the fall.The Nursing Post Fall Assessment dated 9/7/11 indicated previous interventions of low bed, mats, wheelchair and bed alarms, and observation by staff. The new intervention was that the Social Service Designee would talk to Resident 1's wife about medications to prevent sun downing episodes(episodes of confusion when the sun sets). The Nursing Post Fall Assessment indicated to continue current nursing plan of care. The nursing plan of care lacked specificity regarding increased observation by staff and there was no low bed implemented. There were no new effective interventions considered for adequate supervision for Resident 1 who had multiple falls and got up from the bed and wheelchair unassisted. Sixth Fall: The Nurses Notes dated 9/16/11 at 4 p.m. indicated that Resident 1 got up unassisted from the wheelchair and fell. Resident 1 was found outside, on the patio lying on his right side. The X-ray report from Community Mobile Diagnostics, Inc of the Right Hip for Resident 1 dated 9/17/11 indicated a fracture of the right femoral neck with displacement (top of the right thigh bone). The Nurses Notes dated 9/17/11 at 4:30 p.m. indicated that Resident 1 was transported to the hospital per the physician's order. Resident 1's nursing plan of care dated 9/16/11, indicated that Resident 1 had a fall. The approaches/actions indicated: x-ray as ordered, increase visual monitoring, make sure wanderguard and bed alarm in place and working. The nursing plan of care lacked specificity regarding increased observation by staff. There were no new effective interventions considered for adequate supervision for Resident 1 who had multiple falls and got up from the bed and wheelchair unassisted. During an interview on 3/7/12 at 11 a.m., Staff B stated that the facility could do 1:1 staffing when a resident was a fall risk. Staff B stated there was a program called Care Specialists that enabled CNAs to work extra hours assigned to a specific resident for 1:1 supervision. During an interview by telephone on 3/12/12 at 11:30 a.m., Staff A stated there was no specific times for "frequent monitoring". Licensed staff and CNAs check in on a resident and do a visual check anytime they are in the vicinity of a resident that is a known fall risk. The staff will check a resident anytime they are near that resident's room as well as on their regular rounds. Staff A stated that the facility will put a resident on 1:1 supervision if indicated. Staff A stated that she did not think that Resident 1 was a candidate for 1:1 supervision. Staff A were asked the criteria was for 1:1 supervision. Staff A was not able to provide an answer.The Fall Prevention Policy and Procedure dated 5/2007 did not include specific preventative measures regarding how facility staff would provide adequate supervision to prevent accidents.The facility violated the regulation by failing to ensure that Resident 1, who was at risk for falls and known attempts to get out of bed and the wheelchair unassisted, was provided adequate supervision by direct care staff and had effective revisions and implementation of Resident 1's nursing care plan to prevent further falls to keep Resident 1 safe. Resident 1 had six falls during a 30 day period from 8/26/11 to 9/16/11, with no effective interventions considered to prevent further falls from the bed and wheelchair. These failures contributed to Resident 1 sustaining a right femur fracture after the sixth fall while getting up unassisted from the wheelchair while outside on the patio. The violation of this regulation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 010000066 |
Broadway Villa Post Acute |
110011099 |
A |
13-Jan-15 |
ABPS11 |
10093 |
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 falls for one resident (Resident 1), when: 1. Resident 1's bed alarm was not activated per the care plan, and Resident 1 got out of bed, walked to the facility's main entrance, then fell without staff's knowledge. 2. Staff's failure to be alerted by a bed alarm and intercept Resident 1, resulted in Resident 1 sustaining a neck fracture and hematoma (collection of blood in a localized area after a trauma that looks similar to a bruise) to the right side of the face, humerus (upper arm) fracture, a rapid decline and death five days after the accident. On 9/26/14, review of Resident 1's admission documentation, dated 7/12/14 at 12:22 p.m., indicated the following:1. The facility admitted Resident 1, a 93 year old female, on 7/11/14. 2. Resident 1 arrived from the hospital for rehabilitation after a mechanical fall at home which resulted in a vertebral compression (spinal) fracture and herniated disc (bulging of the space between the spinal bones) of her lumbar area (low part of the back).3. Resident 1 had no respiratory distress, was alert and oriented times 2-3 with some confusion, had no problems swallowing, did not complain of pain, and had normal vital signs (the body's basic functions such as heart rate, blood pressure, breathing, temperature).4. The facility identified Resident 1 as a fall risk. The facility's "Fall Risk Evaluation", dated 7/11/14, indicated that Resident 1 scored a 10, which according to the facility's policy, "Fall Management System," made Resident 1 a high fall risk. Under "Gait/Balance/Ambulation", the evaluation indicated Resident 1 had a balance problem, decreased muscular coordination, change in gait when walking (i.e. shuffling), and required assistive devices when walking (forward walker, cane, wheelchair). The facility's policy, "Fall Management System", revised 6/2013, also indicated that the facility was dedicated to providing an accident-free environment that included adequate supervision, assistive devices and developed nursing care plans. Resident 1's care plan, initiated 7/11/14, indicated that Resident 1 was at risk for falls and injury related to gait and balance problems from a compression fracture of the lower lumbar (L1). The care plan goal indicated that Resident 1 would not sustain serious injury. Resident 1's fall prevention care plan interventions included: "Bed Alarm - To alert staff if resident attempts to get out of bed without assistance - check placement and function Q (every) shift." The intervention was identified in the care plan as a nursing responsibility. The facility's report, dated 9/15/14, indicated that Resident 1 had an unwitnessed fall on 9/14/14 at 4 a.m. that resulted in a bump on the forehead with slight bleeding, and complaint of pain in her right arm. During an interview and concurrent record review on 9/26/14 at 10:45 a.m., Administrative Licensed Staff A stated that Resident 1 had died on 9/19/14 at 2:25 p.m. (five days after the fall on 9/14/14). Administrative Licensed Staff A stated that on 9/14/14, at approximately 4 a.m., Resident 1 was found by staff lying on the lobby floor and an ambulance was called. The ambulance responded quickly and took Resident 1 to the hospital and she came back to the facility later that day. Administrative Licensed Staff A stated the Certified Nursing Assistant (CNA) assigned to Resident 1 on the date of the fall was Unlicensed Staff B. The nurse on duty had been Licensed Staff E, and two other CNA's (Unlicensed Staff C, Unlicensed Staff D) had been the first to discover Resident 1 on the floor. Interdisciplinary Team notes (IDT), dated 9/15/14 at 1:19 p.m., confirmed that Resident 1 returned to the facility on 9/14/14 at 11:40 a.m., with a hematoma to the right side of her face, a lump on her forehead, and a C-1, C-2 (cervical vertebrae in the neck) fracture and right arm fracture. Notes further indicated that Resident 1 was returned on comfort measures only.The death certificate, dated 9/19/14 at 2:25 p.m., documented the cause(s) of death were as follows:1. Acute Respiratory Failure 2. Cervical Spine Fracture 3. Mechanical Fall 4. Cerebrovascular Disease During an interview on 9/26/14 at 2:05 p.m., Resident 2 (Resident 1's roommate at the time of the fall) stated that on 9/14/14 at 2 a.m., Resident 2 awoke and went to the bathroom. Resident 2 stated that Resident 1 had been awake at that time. Resident 2 stated she went back to sleep after going to the bathroom and did not wake up until approximately 7 a.m. in the morning, when she noted that Resident 1 was not in her bed. Resident 2 stated during the night she did not hear a bed alarm going off. Telephone interviews on 9/29/14 with Unlicensed Staff B at 2:32 p.m., Unlicensed Staff D at 2:52 p.m., and Unlicensed Staff C at 3:02 p.m., indicated the following:1. Unlicensed Staff B stated that Resident 1 was his assignment on 9/14/14. Unlicensed Staff B stated he heard a scream at approximately 4 a.m. and ran to the lobby where he saw Resident 1 lying on the floor. Two other staff had arrived ahead of him. Unlicensed Staff B had no recall of hearing a bed alarm prior to hearing Resident 1 scream, and stated that it was part of Resident 1's care plan to have a bed alarm. Unlicensed Staff B could not recall whether the bed alarm had been set or not and why it had not alarmed. Unlicensed Staff B stated that Resident 1 was incontinent (loss of bowel and / or bladder control) of bowel and bladder, and he checked her a couple times a night. He recalled that he had last monitored Resident 1 before his lunch break at 3 a.m. 2. Unlicensed Staff D stated as she returned from her break at 4 a.m. on 9/14/14, she heard someone say, "Oh". Unlicensed Staff D stated she ran to the lobby and saw Resident 1 lying on her side and another CNA, Unlicensed Staff C, standing next to her. Unlicensed Staff D stated she did not hear a bed alarm prior, during, or at anytime of the fall. 3. Unlicensed Staff C stated on 9/14/14 at approximately 4 a.m., she had just exited another patient's room into the hall and heard someone yelling, "Help, help." Unlicensed Staff C stated she was the first to arrive and saw Resident 1 lying on her left side by the facility's information desk in the lobby. Unlicensed Staff C described Resident 1 as alert and awake but she said nothing, and had both of her hands up by her mouth, and had some swelling on her forehead with a little blood. Unlicensed Staff C stated the "only shocking thing is her lying there by the desk. How'd she get there?" During a follow up telephone interview on 9/30/14 at 8:48 a.m., Unlicensed Staff C stated she did not hear a bed alarm, which, "are loud and can be heard all over," and which required being turned off manually, once they alarmed. During a telephone interview on 9/30/14 at 8:09 a.m., Licensed Staff E stated on 9/14/14 at 4 a.m., she was doing a treatment on another patient with the door closed. She stated Unlicensed Staff C came and told her that a resident had fallen. Licensed Staff E stated she recognized Resident 1, and stated that Unlicensed Staff B had seen the resident approximately an hour prior (3 a.m.). Licensed Staff E stated she did not hear a bed alarm which would be loud and continuous until manually turned off. Licensed Staff E confirmed that Resident 1 was a fall risk and required an alarm, which she stated the CNAs were responsible for maintaining.During a family interview, on 9/29/14 at 11:58 a.m., Resident 1's family member stated Resident 1 had originally been admitted for rehabilitation after a fall at home that resulted in a fracture of the lower back. Resident 1 was switched to long term care after the hospital's physical therapist told the family that it was "a 100% chance" Resident 1 would fall again if taken back home. Resident 1's family member stated that Resident 1 had walked at home with a cane, had no dementia, enjoyed conversing, and her "vitals were strong." Resident 1's family member stated that the distance from Resident 1's bed to where she fell was "a long way" and he was surprised that she had been able to walk, unassisted, the distance to the main door on 9/14/14. He also stated that after the fall on 9/14/14, Resident 1 was in a lot of pain, declined rapidly, and did not speak again after 9/14/14.An observation of Resident 1's room on 9/26/14 at 1:48 p.m., noted the room was located close to a nursing station and the front lobby. The distance from Resident 1's bed to the spot which staff found her lying on the floor was at least 50 feet.During a telephone interview on 9/30/14 at 9:17 a.m., Licensed Staff G stated that, when asked, maintenance staff said that Resident 1's room was approximately 50 feet to the nursing station and 20 feet to the lobby. Resident 1 was found near the lobby front door, just short of the nursing station. Therefore, Resident 1 walked approximately 8-10 feet from her bed to the bedroom door, 20 feet from the bedroom door to the lobby, and an additional 20-30 feet to the lobby door. Licensed Staff G stated that Resident 1's bed had an alarm which was in working order and would be heard in the hallway.On 10/2/14 at 9:40 a.m., when interviewed, Physician F stated: "If not for the fall [Resident 1) would not be dead." Therefore, the facility failed to: 1. Follow Resident 1's nursing care plan and assure that Resident 1's bed alarm was activated and working on 9/14/14. 2. Intercept Resident 1 before she fell and sustained a neck fracture and hematoma to the right side of the face, humerus (upper arm) fracture, a rapid decline and death five days after the accident. 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. |
| 010001140 |
Brookdale Fountaingrove |
110012392 |
A |
1-Jun-17 |
ENC411 |
8140 |
T22 DIV5 CH3 ART3-72301(f)
(f) The facility shall ensure that all orders, written by a person lawfully authorized to prescribe, shall be carried out unless contraindicated.
The facility failed to ensure that all orders, written by a physician were carried out when: Resident 1, who had an order for oxygen per nasal cannula, was left unattended from 11:30-5:00 p.m., with an empty oxygen tank. This failed practice was the cause for delay in treatment in maintaining Resident 1's respiratory airway and had the potential to cause serious harm or death to Resident 1 due to not receiving oxygen.
Resident 1 was admitted from the acute care hospital on XXXXXXX15, with the admitting diagnosis of pneumonia. Resident 1's physician order, dated 4/3/15, indicated, "Oxygen via NC (nasal cannula) to keep sats (oxygen saturation) at 91% every shift."
During an interview on 8/8/15 at 4:05 p.m., Licensed Staff G stated that on 4/17/15, the Maintenance Supervisor took Resident 1 to the Assisted Living area dining room for lunch with the portable oxygen tank. On 4/17/15 at 5 p.m., Resident 1's family member arrived at the facility and found Resident 1 in the Assisted Living dining room with altered mental status (confused) with the oxygen tubing in his nose connected to an empty portable oxygen tank.
During an interview on 8/17/15 at 3:30 p.m., Resident 1's family member (Family Member 1) stated that on 4/17/15 at 5 p.m., she and another family member (Family Member 2) went to the facility to visit Resident 1. They found Resident 1 in the Assisted Living dining room. Family Member 1 further stated that Resident 1 did not look good and was not making sense. She noticed his oxygen tank was empty. She further stated that he had been downstairs in the Assisted Living (AL) dining room from 11:30-5:00 p.m., (AL lunch hour starts at 11:30) and that he had not been checked on or taken to the bathroom. Family Member 1 also stated they notified the Assisted Living Nurse of the condition they found Resident 1 in, and the Nurse in the Skilled Nursing area in charge of Resident 1's care was notified. The Nurse from the Skilled Nursing area brought down an oxygen tank. Family Member 1 also stated the two nurses were not able to set-up the oxygen tank because they did not have the proper attachments to start the oxygen. She asked Family Member 2 to bring an oxygen tank from Resident 1's room. Family Member 2 connected the attachments to the tank and started Resident 1 on oxygen. Family Member 1 further stated she spoke to Resident 1's care giver CNA F (Certified Nursing Assistant) about the incident and was told this also happened a week ago when the CNA F found Resident 1 sleeping in the Assisted Living area and his oxygen tank, "had run-out." Per Family Member 1, CNA F could not recall the exact date. Resident 1's family member notified the facility's Executive Director who acknowledged the incident and stated that it should have never happened.
On 8/12/15, during a review of Resident 1's clinical record Nursing Progress Notes, dated 4/16/15 at 10:37 a.m., a late entry indicated "Res. (resident) continues on oxygen 3L/min via nasal cannula...res. has an order to go to AL (assisted living) dining for lunch and dinner. Oxygen is checked regularly prior to leaving and also coming back from meals, res. uses the tank." The Nursing note, dated 4/17/15 at 13:36 p.m., late entry, revealed, "...Res. later went to the AL for lunch. Resident continues on ABT (antibiotic) for PNA (pneumonia) with no adverse drug consequences noted." No documentation was found in Resident 1's clinical records regarding the incident on 4/17/15, or Resident 1's oxygen saturation level when he was found by family members at 5 p.m., in the AL dining room with an empty oxygen tank.
During an interview on 8/12/15 at 1:10 p.m., Licensed Staff E stated she was called to the Assisted Living dining room, Resident 1's family members were present and concerned Resident 1 was lethargic and his oxygen tank was empty. Licensed Staff E further stated that she did not remember what Resident 1's oxygen level was at the time, and she would forward the information at a later time to CDPH. The documentation regarding Resident 1's oxygen saturation was not available in his clinical records and was not provided when requested from Director of Nursing, DON and Director of Staff Development, DSD.
During an interview on 8/12/15 at 1:25 p.m., CNA F stated about one to two days before this incident she was looking for Resident 1 and found him lying on the couch in the AL area with an empty oxygen tank. She brought him back to the Skilled Nursing area, and the nurse put him on oxygen. CNA F was not able to recall the Licensed Nurse's name and was not aware of any facility policy regarding residents going to the AL for meals.
During an interview on 8/18/15 at 4:05 p.m., Licensed Staff G stated that on the day of the incident, she had worked the day shift, and Resident 1 was having a bad day wanting to go home. The doctor had stated Resident 1 could go to AL for lunch, and the DON was notified. This was around 11:00-11:30 a.m., when the Maintenance Supervisor had taken Resident 1 to AL for lunch. She further stated this was reported to the evening nurse.
During an interview on 8/18/15 at 4:30 p.m., Licensed Staff D stated that on the day of the incident she had started her shift at 2:30 p.m. It was reported to her that Resident 1 was in the Assisted Living dining room having lunch with his friends. She further stated later that day she was notified that Resident 1's oxygen tank was empty, and she had put him back on oxygen. She also stated the next day the DON had told her, "fill out an incident report, but don't chart anything." When asked why the DON had stated not to chart anything she responded, "I don't know."
Review of Resident 1's physician orders on 8/12/15 at 2:10 p.m., dated 4/8/15, indicated, "Resident to go to AL for lunch and dinner, CNA will take him and AL caregiver will bring him back two times a day for socialization with peers in AL."
During a review, on 8/12/15, of the facility's job description for Unlicensed Staff, dated 11/2014, indicated, "Job Summary/Essential Functions: Makes room checks and verifies resident location at least every 2 hours."
Review of facility's Charge Nurse's job description, revised 4/2008, revealed, "Essential Functions: Meet with your assigned nursing staff, as well as support personnel, in planning the shifts' services, programs, and activities. Ensure that all nursing personnel are in compliance with their respective job descriptions. Chart nurses' notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident's response to the care. Perform routine charting duties as required and in accordance with established charting and documentation policies and procedures." Review of facility's Certified Nursing Assistant (CNA) job description under the title of Essential Functions, dated November 2014, indicated "6. Makes room checks and verifies resident location at least every 2 hours."
During a review of facility's policy and procedure titled "Charting and Documentation revised 4/2008 indicated "All incidents, accidents, or changes in the resident's condition must be recorded."
Facility policy titled Oxygen Administration, last revised October 2010, provided guidelines for safe oxygen administration however did not contain any information regarding regular monitoring of oxygen tank to ensure continued oxygen supply for residents.
The facility failed to ensure that all orders, written by a physician were carried out. The order, written on 4/8/15 was for Resident 1 to go to assisted living for lunch and dinner. CNA to take him and assisted living caregiver to bring him back two times a day for socialization with peers in assisted living.
These violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 010000066 |
Broadway Villa Post Acute |
110012774 |
B |
28-Dec-16 |
OUBI11 |
11099 |
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 assess and provide adequate supervision, for Resident 1, with a history of falls and a prior elopement, when Resident 1 left the facility on 7/22/16, without staff knowledge and was found by a family member at approximately 6 p.m. sitting on the seat of a four wheeled walker (FWW), at a busy intersection of a major highway, approximately 1/3 mile from the facility. This placed Resident 1 at high risk for a fall or an accident which could have led to serious injury or death. Resident 1's admission record documented Resident was 86 years old and was admitted to the facility xxxxxxx with diagnoses that included dementia with behavior disturbance and Parkinson's disease (a progressive motor system disorder) with anxiety and delusional disorders. According to the National Institute of Neurological Disorders, people with dementia lose their ability to solve problems and maintain emotional control, and they may experience agitation, delusions, and hallucinations. The four primary symptoms of Parkinson's Disease are trembling; rigidity; slowness of movement; and impaired balance and coordination. (http://www.ninds.nih.gov/disorders/parkinsons_disease/parkinsons_disease.htm; http://www.ninds.nih.gov/disorders/dementias/dementia.htm) A Nurse Practitioner note, dated 5/5/16, indicated a prior elopement when Resident 1 left the facility without staff and was found in a football field adjacent to facility. Resident 1 had demonstrated increased anxiety after spouse's illness, a Wanderguard (tracks the person using a wrist or ankle band and automatically alarms if the person moves outside a defined area without being accompanied by an authorized person) was ordered. A Risk/Consequences Notification form, not dated, indicated Resident 1's responsible party, Family Member 2, refused the Wanderguard, indicating it agitated Resident 1, which was noted as a discussion between licensed staff and Family Member 2. Family Member 2's signature was on the form, but it did not include the date signed or the date the form was initiated. Interdisciplinary Team (IDT) notes, dated 6/20/16, indicated Family Member 2 visited Resident 1 on 6/19/16 and did assist with calming Resident 1 after a day with behavior changes. Staff was aware that Resident 1 was becoming more agitated during care and in the evenings, and noted Resident 1 was working in the garden and ambulating all day long, which increased the behavior changes. Staff was to encourage rest periods and involve Family Member 2 in care and noted "...This is the single most common thread in stabilizing [Resident 1's] moods..." A Care Plan, dated as initiated 1/15/16, noted the problem: Resident 1 was at risk for impaired thought processes related to dementia and Parkinson's disorder, which hinders cognition (process of knowing). The interventions dated 1/15/16 included "provide a walking program that accommodates abilities, activity staff increased walking with Resident 1 at least twice a day." The care plan was updated on 6/19/16 noting on "6/19/16 Resident had an episode of increased agitation and unable to redirect or to calm with interventions," and included the intervention dated 6/20/16 for laboratory studies to rule out an infection. This care plan did not address the level of staff supervision for Resident 1. A Care Plan, dated initiated on 5/9/16, noted Resident 1 had potential behavior problem related to restlessness. This was updated on 6/19/16: "combative behavior with staff and confabulation (production of fabricated, distorted or misinterpreted memories) about staff taking clothes," and included the intervention of laboratory studies to rule out an infection. This care plan did not address the level of staff supervision for Resident 1. A Care Plan, dated initiated on 7/18/14, included: Resident was at high risk for falls and injury due to psychoactive (chemical substance that changes brain function and results in alterations in perception, mood, or consciousness) drug use, gait (manner of walking) / balance problems, chronic pain, and had episodes of walking outside the facility (parking lot / driveway) late in the afternoon, when dark or raining in spite of re-direction". Reported falls without injury were noted on 5/6/16 and 7/5/16. The most recent interventions, dated 5/10/16, included: "Encourage [Family Member 2] to say goodbye before leaving, keep [Resident 1] busy, redirect if possible to reduce anxiety," On 5/17/16, Resident 1 was enrolled in a fall prevention program. This care plan did not address the level of staff supervision for Resident 1. A Skilled Nursing Behavioral Health Care Follow up note, dated 7/12/16, indicated Resident 1 had a recent episode of behavior escalation which included combative behavior, striking staff and increased anxiety. "...Per [Family Member 2], Resident 1 continues to be very anxious and is concerned about anxious behavior... Discussed strategies to help decrease anxiety when [Family Member 2] is not present." A Physician order, dated 5/9/16, indicated Ativan 0.5 mg, give one tablet every 8 hours by mouth as needed for anxiety. (The most common side effects of Ativan: drowsiness, dizziness, weakness, and unsteadiness). The Medication Administration Record (MAR), noted that Resident 1 received Ativan 0.5 milligrams (mg) by mouth at 5:11 p.m. on 7/22/16, just prior to the elopement, reported as found at approximately 6 p.m. on 7/22/16 by Family Member 2. Nurses notes, dated 7/23/16 at 1:32 p.m., noted as a late entry for a change of condition on 7/22/16, indicated Family Member 2 called the facility at approximately 6 p.m. on 7/22/16 to notify staff that Resident 1 was found sitting on the four wheeled walker at a busy intersection. When Family Member 2 asked Resident 1 what he was doing, Resident 1 replied "waiting for you (Family Member 2)." Family Member 2 returned Resident 1 to the facility at 6:30 p.m. Resident 1 was alert but forgetful with confusion, and no signs of injury were noted. During an observation and concurrent interview, on 8/4/16 at 9:15 a.m., Resident 1 was standing in the doorway to his room, repeatedly looking up and down the hallway, with no staff present. When asked what he was doing, Resident 1 stated that physical therapy was supposed to take him for a walk and that they were late, again. When asked what time the walk was scheduled, Resident 1 stated "10 a.m.", and began to pace in the hallway outside the room. During an interview, on 8/4/16 at 10:50 a.m., Licensed Nurse (LN) A stated if staff saw Resident 1 display increased anxiety they would have a Certified Nursing Assistant (CNA)walk Resident 1 around, or do scheduled walks outside, to calm Resident 1 down. During an interview, on 8/4/16 at 3 p.m., LN B, who was on the 3 p.m. to 11 p.m. shift on 7/22/16 at the time of the elopement incident, stated prior to the elopement on 7/22/16, supervision of Resident 1 consisted of, "staff watching" the resident in the afternoons and evenings and Activity Staff had just taken Resident 1 for a short walk after dinner. LN B stated staff did not see Resident 1 leave the building and did not know Resident 1 was missing until Family Member 2 called and notified them. LN B stated on the day of the elopement, Family Member 2 had not been able to visit Resident 1 during the day, which staff knew increased Resident 1's agitation. During an interview, on 8/4/16 at 3:15 p.m., the Administrator stated Family Member 2's health had been failing and had been less able to spend time at the facility with Resident 1, which increased Resident 1's agitation level. When asked what the facility did to assess and ensure Resident 1's safety, the Administrator stated staff had changed Resident 1's walking schedule to late afternoon and evenings to accommodate Resident 1, who was more anxious in the afternoon and evenings. The Administrator stated staff did not see Resident 1 leave the building. Administrator also stated that a Risk-Benefit form had been signed by Family Member 2 after Resident 1 left the facility in May 2016. Family Member 2 asked the facility to remove the Wanderguard, as Family Member 2 felt it increased Resident 1's agitation and acknowledged that Resident 1 was at risk for safety endangerment. This form was not dated to indicate when initiated or signed. When asked what level of supervision the facility used to ensure Resident 1's safety, in the absence of the Wanderguard, the Administrator again stated that the increased walking schedule in the afternoon and evenings had been implemented to address Resident 1's increased agitation and restlessness. During an interview on 11/17/16 at 3:30 p.m., Director Of Nursing (DON) stated facility staff did try to take Resident 1 on walks outside at least twice a day but confirmed that the Care Plans did not include specific monitoring / supervision for Resident 1. DON stated "we try to promote their independence as much as possible." Review of facility policy "Wandering Residents - Wanderguard", dated 8/2015, indicated: "Policy: It is the policy of this facility to allow each resident as much physical freedom as safely possible in order to maintain the resident's optimum function...2. If the assessment of the resident shows there is wandering potential creating a safety issue, the DNS [Director of Nursing Services] or designee will discuss this issue with the family/responsible party. 3. Residents at risk for wandering shall have a Wanderguard...5. The family/responsible party shall be notified of the risk for wandering and that the Wanderguard has been placed on the resident..." Review of facility policy "Elopement", dated 10/2015, indicated the purpose of this policy was to ensure that residents at risk for elopement are properly monitored and to ensure that residents that do leave the facility are located quickly and safely. The procedure included: "1. Residents who are at risk for elopement will have an appropriate plan of care developed to address the risk. 2. When an elopement is suspected and the resident cannot be found, the Licensed Nurse will announce over the intercom "Code____ and residents name..." This policy does not address the type of supervision required to prevent elopements. The facility failed to assess and provide adequate supervision, for Resident 1, with a history of falls and a prior elopement, when Resident 1 left the facility on 7/22/16, without staff knowledge and was found by a family member at approximately 6 p.m. sitting on the seat of a four wheeled walker (FWW), at a busy intersection of a major highway, approximately 1/3 mile from the facility. This placed Resident 1 at high risk for a fall or an accident which could have led to serious injury or death. This had a direct relationship to the health, safety or security of patients / residents. |
| 010001140 |
Brookdale Fountaingrove |
110012907 |
A |
16-Feb-17 |
BBN311 |
9323 |
T22 DIV5 CH3 ART3-72315(f)
(f) Each patient shall be given care to prevent formation and progression of decubiti, contractures and deformities. Such care shall include:
The facility failed to ensure that one resident (Resident 1), who entered the facility without pressure ulcers, did not develop pressure ulcers, when Resident 1 developed two avoidable pressure ulcers. This failure resulted in Resident 1 developing cellulitis (bacterial infection of the inner layers of skin), delaying his discharge home, and not being able to reach his highest physical level of well-being.
During a telephone interview on 9/20/16 at 9:01 a.m., Complainant X stated she had visited Resident 1 on 9/16/16 in the facility. Complainant X stated Resident 1 was supposed to be discharged home on XXXXXXX16. Complainant X had noticed Resident 1's shoes were "bloody", and upon removing the shoes, noted his feet were "swollen", they "smelled bad" and his left heel was "slimy green." Complainant X stated Resident 1's family had arrived, and had been aware only of a "small blister" to his right foot. Complainant X stated the "head of nursing" (Administrative Staff B) was asked to come to Resident 1's room. Administrative Staff B agreed that it was a "bad ulcer", and stated she had not been aware of Resident 1's left heel ulcer. Complainant X and Resident 1's family had insisted on Resident 1's transfer to the acute care hospital for treatment of both feet.
On 9/21/16 at 2:30 p.m., review of a document titled "Admission Record" revealed Resident 1 was a 94 year-old male. Resident 1 was admitted to the facility on XXXXXXX16 with, among others, diagnoses of left Femur Fracture (broken hip bone), Generalized muscle weakness, and Dementia (progressive loss of memory). Resident 1's diagnosis did not indicate any clinical conditions making the development of pressure ulcers unavoidable.
A document titled" Progress Notes" dated 8/18/16, revealed "This is a nursing admission note..., pt (patient) will be turned every two hours. Heels are soft and elevated..." A document titled "BD Nursing Admission Data Collection" dated 8/19/2016 revealed in section 2 "Skin Integrity Review" no indication of pressure ulcers. A document titled "Minimum Data Set (MDS) Resident Assessment and Care Screening" (an assessment tool) dated as completed on 8/31/16, revealed in section M0510 the facility assessed Resident 1 as being at risk for developing pressure ulcers.
A document titled "Care Plan Conference Summary" signed by five facility staff and three members of Resident 1's family, dated 9/1/16, indicated under "Topics discussed"... Skin: "Surgical incision L (left) Femur (thigh bone)." There was no discussion of the fact Resident 1 was at risk for skin breakdown due to rubbing his heels on the mattress and removing interventions the facility put in place. A document titled "Collaborative Care Review" (a type of interdisciplinary review when team of staff members discuss resident concerns) dated 9/13/16, and signed by Administrative Staff B, revealed on page 9 of 11 in section J. Skin Integrity revealed a right heel stage 2 pressure ulcer which was in-house acquired. Administrative Staff B indicated the pressure ulcer was avoidable, and no other wounds were present. Resident 1's care plan was not updated. A document titled "Progress Notes" dated 9/14/16 signed by Licensed Staff D revealed "Resident noted with the blister to left of heel that is already burst and PU (pressure ulcer) with eschar/necrotic (dead tissue) to right outer lateral side of heel. Tx (treatment) applied as ordered. Heel is being floated."
A document titled "Progress Notes" dated 9/15/16 signed by Licensed Staff E revealed "Resident noted with the blister to left of heel that is already burst and PU (pressure ulcer) with eschar/necrotic (dead tissue) to right outer lateral side of heel. Tx (treatment) applied as ordered. Heel is being floated."
The documentation by Licensed Staff D on 9/14/16 and Licensed Staff E on 9/15/16 is identical.
Resident 1's Initial Care Plan provided by the facility on 10/14/16 dated "Target Completion Date: 8/22/16" revealed in the category titled "Focus" (Name) (Resident 1) has an ADL (Activities of Daily Living) Self care performance Deficit r/t (related to) dementia, weakness, abnormalities of gait/mobility, pain, s/p (status/post) (after) fall, femur fracture (broken thigh bone), agitation. The "interventions /tasks" category revealed "The resident requires SKIN inspection daily with care. Observe for redness, open areas, scratches, cuts, discoloration and report changes to the nurse."
Resident 1's Initial Care Plan provided by the facility on 12/6/16 and dated "Date Initiated 8/19/16" revealed under section titled "Focus" "(Name) (Resident 1) has potential for pressure ulcer development r/t (related to) weakness, incontinence (lack of bladder control), renal insufficiency (kidney disease), limited mobility, activity intolerance, confusion." The section titled "Goal" revealed "(Name) (Resident 1) will have intact skin, free of redness, blisters, discoloration by/through review date." The section titled "Interventions/Tasks" (interventions performed by staff to achieve the goals) did not include floating Resident 1's heels, or protecting Resident 1's heels with "booties". The Care Plan did not address revisions to address Resident 1's behavior of rubbing his feet on the mattress. A Care Plan addressing Resident 1's "actual impairment to skin integrity r/t (related to) laceration (cut) to forehead sustained in fall, s/p pinning to surgical site to left femur" had the intervention listed "Resident need heels floated."
A document titled "Progress Notes" dated 9/16/16 at 14:26, when Complainant X and family members were in the facility, was signed by Licensed Staff F. The "Progress Notes" revealed "R(right) heel pressure ulcer- unstageable (unable to determine depth of wound) measures at 5.5 cms in length and 4 cms in width at distal end and 3 cms at the proximal end, deep purple dry, hard to touch necrotic (dead tissue) wound base, surrounded by 10 cms x 11 cms redness with swelling noted... L (left) heel has a 2 cms x 2 cms and 0 depth, deep purple in color wound bed, unstageable..." Resident 1 was taken to the local acute care hospital on 9/16/16.
A local acute care hospital document titled "Emergency Department Report" dated September 16th, 2016 at 17:55 (5:55 p.m.) revealed "The extremity exam reveal stage II to III decubiti involving the heel right greater than left with the right area approximately 3-4 cm with central Afshar (sic) (Eschar) and surrounding erythema (redness of the skin) to the dorsal lateral (outer side) foot and proximal (inner side) ankle. The left heel reveals similar appearing ulcer 0.5 cm squared Afshar (sic) (Eschar) in the center with surrounding of erythema surrounding (sic)... Antibiotic therapy initiated regarding likely cellulitis secondary infection involving the right heel ulcer." The document revealed as "Primary Impression" "Decubitus ulcer to both feet." The document revealed as "Additional Impressions: Cellulitis of right heel."
A document titled "Progress Notes" dated 9/16/16 at 11:41 p.m. signed by Licensed Staff G revealed "Pt (patient) sent to hospital at 4 pm for evaluation of ulcers on both heels...Pt returned around 7:30 p.m....Pt came back with dx (diagnosis) of decubitus ulcer (bed sores) of both feet... and cellulitis (bacterial infection of the inner layers of skin) of right heel...Family with patient and was not happy with his condition..."
During an interview on 12/6/16 at 2:55 p.m., Licensed Staff D stated she had taken care of Resident 1, and he had been admitted without pressure ulcers. Licensed Staff D stated Resident 1 had been rubbing his feet on the bed and developed blisters on both heels. Licensed Staff D stated staff had attempted to "float" (put a pillow under the lower leg to keep the heels off the bed) Resident 1's heels, but it had not been helpful "at all" due to Resident 1 being too restless and removing the pillow. Licensed Staff D stated staff had tried "booties" (foam heel/foot covers) on Resident 1's heels but Resident 1 had removed them as well. When asked if the facility had tried anything else, Licensed Staff D stated "just floating the heels."
Review of the facility policy titled "BSL Skin and Wound Care Protocols/Guidelines" dated revised 6/2015" provided by the facility on 12/6/16, revealed interventions to prevent heel pressure ulcers which were not mentioned on Resident 1's care plan or implemented. Interventions included 1. skin prep (wipe used to toughen skin) q (every) shift to heels, 2. minimize exposure to pressure (skin sealant q (every) day, offload heels i.e. pressure relieving boots such as pillows, Prevalon Boot or Waffle Boot, 3. monitor area for any evidence of infection (erythema (redness), warmth, pain, swelling, fever, drainage, and notify physician per protocol...
Therefore, the facility failed to prevent a resident who was admitted without pressure ulcers, to develop avoidable pressure ulcers.
The above violation presented either imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result. |
| 010000066 |
Broadway Villa Post Acute |
110012996 |
B |
24-Aug-17 |
W1WE11 |
8156 |
F 323: 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 provide adequate supervision to prevent altercations for 1 of 4 sampled residents (Resident 1) when Resident 1, who had a history of resident to resident altercations, was punched by Resident 2 five times with a fist to the head in rapid succession.
This placed Resident 1 and other residents in the facility at risk for severe injury.
Resident 1's admission face sheet, dated 2/13/17, indicated Resident 1 was admitted to the facility on 4/12/16 with diagnoses that included left side paralysis following a stroke, disorientation, social and emotional deficits following the stroke and major depressive disorder.
Social Service Staff noted, on 2/13/17 at 12:39 p.m.: "As the IDT [interdisciplinary] team was doing their morning COC [change of condition] rounds, we were gathered around the South Station when movement down the hall drew attention. [Resident 2] was attempting to come out of a room but another resident [Resident 1] was moving down the hallway and was in front of the door that [Resident 2] was trying to exit. [Resident 2] was seen hitting a resident [Resident 1] in the head with his fist approximately five times in rapid succession..."
IDT notes, noted by Social Service Staff, dated 2/14/17 at 10:29 a.m., noted: "...Resident [2] is very proud and independent man who reports being frustrated with the patient [Resident 1] who wanders around saying 'help me.' Staff monitoring this resident's behavior as well as the other resident [Resident 1] who usually has a 1:1 [one to one observation] with agency attendant. The incident happened at 10:30 a.m. and his [Resident 1's] attendant comes at 11:00 a.m..."
Resident 1's Care Plan, date initiated 9/9/16, noted Resident 1 was involved in the following altercations with other residents:
On 8/9/16, Resident 1 was tapped by another resident when Resident 1 wandered into another resident's room.
On 9/8/16, Resident 1's ear was pinched and pulled and he was hit in the face with a closed fist by another resident.
On 2/13/17, Resident 1 was hit on the top of his head by another resident.
Interventions included:
Intervene as necessary, approach/speak to Resident 1 in a calm manner, divert attention, and remove Resident 1 from situation and take to alternate location.
On 9/16/16 an intervention was added for one on one care for Resident 1 provided by an outside agency for 30 days during waking hours and re-evaluate.
A medical consultation for behavioral issues was conducted on 9/15/16. The physician noted Resident 1 had intermittent altercations with residents due to Resident 1's poor recognition of boundaries, repeated intrusiveness, and loud repetitive phrases.
During an observation on 2/22/17 at 10 a.m., Resident 1 was seated in a wheelchair by his bed with no staff visible in the room or hallway. At 10:10 a.m., Certified Nursing Assistant (CNA) A entered the room wheeling another resident into the room following a shower. During a concurrent interview, CNA A stated she was assigned to Resident 1 that shift, along with other residents. CNA A stated when she was busy doing other duties with other residents she would tell the nurse, so they could keep an eye on Resident 1. CNA A stated Resident 1 could be cooperative at times and combative at others. CNA A stated Resident 1 frequently wheeled around the facility yelling, "help" all the time.
During an interview, on 2/22/17 at 10:30 a.m., Licensed Nurse (LN) B stated Resident 1 usually slept late and then sat in his wheelchair in the hallway to eat breakfast. LN B stated if Resident 1 was mellow and quiet, Resident 1 would sit in the wheelchair at the nursing station where the nurses watched him. LN B stated if Resident 1 was calm the CNA's would take him to the Activity Room before the (one to one) sitter arrived at 11 a.m. LN B stated that if Resident 1 started to wheel around the facility, nursing staff would ask for extra help from the CNA's.
During an observation and concurrent interview, on 2/22/17 at 11:20 a.m., Caretaker C was seated beside Resident 1 in the Activity Room while Resident 1 was sleeping in the wheelchair. Caretaker C stated Resident 1 was very sleepy that day, but usually wheeled constantly around the facility yelling "Help, Help," Caretaker C stated she followed Resident 1 and tried to decrease contact with other residents and keep Resident 1 out of other resident's rooms.
During an interview, on 2/2/17 at 1:15 p.m., LN D stated Resident 1 had difficult behaviors. LN D stated one minute Resident 1 would be sleeping and the next minute he would strike out. LN D stated Resident 1 constantly wheeled around the facility hollering "Help me," and when Resident 1 was agitated; all staff was to stop what they were doing and assist in keeping Resident 1 and other residents safe. LN D stated Resident 1 was on "line of sight" (staff maintains visual range of the resident) until the sitter came on duty.
During an interview, on 2/22/17 at 3:05 p.m., Social Service Staff E stated another agency provided a sitter / private caregiver for Resident 1 from 11 a.m. until 9 p.m., when Resident 1 was usually awake. When asked why Resident 1 did not have a 1:1 sitter prior to the agency provided sitter's arrival at 11 a.m., Social Service Staff E stated, "it's expensive." Social Service Staff E stated the facility had hoped to adjust Resident 1's medications so Resident 1 would not need one to one observation, but Resident 1's spouse was reluctant to use medications. Social Service E stated she had a conversation with Resident 1's spouse where she explained that Resident 1 was not popular at this facility with the other residents due to the roaming around the facility yelling help and going in and out of other resident's rooms. Social Service Staff E stated the facility had a large community, and other residents were tired of the yelling and Resident 1 going in and out of other resident's rooms and roaming around the facility. Social Service Staff E also stated that even when Resident 1 was on one to one observation Resident 1 would still holler "Help me" and strike without warning.
During an interview, on 2/22/17 at 3:35 p.m., Resident 3 stated Resident 1 was his roommate and would go non-stop for 1 or 2 nights and yell, "Help me, help me" and then would be quiet for a day or two. Resident 3 had a physician order, dated renewed on 2/17/17, indicating Resident 3 had the capacity to make all medical decisions.
During an interview on 2/22/17 at 3:50 a.m., LN F stated Resident 1 had a history of hollering and thrashing about and had grabbed his arm and it was difficult to get away from Resident 1, who had a very strong grip. LN F stated Resident 1 was unpredictable.
The facility failed to provide adequate supervision to prevent altercations for 1 of 4 sampled residents (Resident 1) when Resident 1, who had a history of resident to resident altercations, was punched by Resident 2 five times with a fist to the head in rapid succession.
This placed Resident 1 and other residents in the facility at risk for severe injury.
This had a direct relationship to the health, safety, and security of patients. |
| 120000464 |
Bethesda Lutheran Communities-Lake Superior |
120008044 |
B |
13-Jun-12 |
NZ1511 |
3124 |
W and I code 4502(h)It is the intent of the Legislature that persons with developmental disabilities shall have the 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 April 24, 2008 at 2:45 PM an unannounced visit was made to the facility to investigate a report of alleged client abuse. Based on interview and record review the facility failed to protect one client from repeated episodes of verbal abuse. Client A is a 64-year-old man admitted to the facility May 24, 1991. Client B is a 27-year-old woman admitted to the facility June 10, 2002. Client C is a 48-year-old man admitted to the facility May 5, 2005. On April 11, 2008 the facility reported an allegation of abuse by the day program bus driver (DPBD) toward Client A, involving yelling at the client and pushing him down into his seat. The DPBD also was alleged to curse around two other facility clients (Clients B and C). The facility report included two statements written by Direct Care Staff (DCS) 1, dated April 8, 2008 and April 11, 2008. The statement dated April 8, 2008 indicated the DPBD "was aggressive" with (Client A), yelling at him and physically putting her hands on him to sit him down." The statement dated April 11, 2008 indicated the DPBD spoke an expletive when she came to pick up the clients and a car was in the driveway. Also, the DPBD "put her two hands on (Client A's) shoulders and sat him down hard. (The DPBD) yells at (Client A) all the time."On January 14, 2009 at 4:00 PM DCS 1 stated during interview that one morning the DPBD pulled up to the facility and "started yelling and using curse words because she said my car was in the way...(the DPBD) was always aggressive with (Client A)."DCS 4, another witness to the allegations, was interviewed on January 16, 2009 at 1:57 PM and stated one day Client A drank the DPBD's soda, and the DPBD yelled at the client. According to DCS 4, the DPBD "would also push (Client A) down a little forcefully by the shoulders into his seat, a few times...(the DPBD) did yell quite a few times at (Client A)." During interview on January 16, 2009 at 2:35 PM a third witness to the allegations, DCS 3, stated the way the DPBD "talked to the clients was very loud and rude." The rudeness was mainly directed at Client A. DCS 3 indicated the DPBD would yell "You know you are not supposed to sit there" at Client A, but the client didn't understand. On March 27, 2009 at 2:09 PM the DPBD stated during interview Client A had bandages on his neck that were coming off, and while the DPBD was putting the bandages back on the client sat down. The DPBD, during interview on April 1, 2009 at 10:53 AM, could not explain why facility staff alleged the DPBD did this on more than one occasion, nor could the DPBD explain why facility staff alleged she cursed around the clients. Therefore the facility failed to protect one client from repeated episodes of verbal abuse. The above violation has a direct relationship to the health, safety or security of clients. |
| 120000464 |
Bethesda Lutheran Communities-Lake Superior |
120008046 |
B |
13-Jun-12 |
NZ1511 |
2659 |
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. (b) A failure to comply with the requirements of this section shall be a class "B" violation.The facility failed to report an allegation of abuse of a client within 24 hours. A second incident of alleged abuse then occurred. Client A was a 64-year-old man admitted to the facility May 24, 1991. He had a diagnosis of severe mental retardation with limited verbal abilities, (English).On April 11, 2008 the facility reported an allegation of abuse by the day program bus driver (DPBD) toward Client A, involving yelling at the client and pushing him down into his seat. The DPBD also was alleged to curse around two other facility clients (Clients B and C). The facility report included two statements written by a witness to the allegations, Direct Care Staff (DCS) 1, dated April 8, 2008 and April 11, 2008. According to the statements, April 8, 2008 and April 11, 2008 are the dates of two separate incidents. During an interview on April 24, 2008 at 2:45 PM, the QMRP stated there were two incidents of alleged abuse regarding the DPBD, but the QMRP didn't receive them until April 11, 2008. When asked why she wasn't informed of the first incident at the time it occurred, the QMRP replied DCS 1 forgot. On January 14, 2009 at 4 PM, DCS 1 also stated during an interview that there were two incidents of alleged abuse regarding the DPBD. "I believe I called [the Program Manager (PM)] right away," to report the allegations. The statement dated April 8, 2008 written by DCS 1 indicated DCS 1 told the PM about the allegation, and the PM told her to write a statement. DCS 4, another witness to the allegations, was interviewed on January 16, 2009 at 1:57 PM, and stated the staff had told the PM about incidents regarding the DPBD several times. During an interview on January 14, 2009 at 11:45 AM, the PM was asked if the first allegation dated April 8, 2008 was reported in a timely manner. The PM replied "I can't really tell you right now. I told (DCS 1) to write a statement. I'll have to dig up the paperwork." On January 16, 2009 at 2:22 PM the Program Manager (PM) was asked during an interview if she found any evidence the allegation dated April 8, 2008 was reported in a timely manner. The PM replied "I don't have any more information to go on." Therefore the facility failed to report an allegation of abuse of a client within 24 hours. The above violation has a direct relationship to the health, safety or security of clients. |
| 120001519 |
Bethesda Lutheran Communities-Westfield |
120008944 |
B |
20-Nov-12 |
XCRK11 |
2386 |
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 protect the rights of Client C when an employee verbally abused her during dinner. The clinical record for Client C was reviewed on 12/30/09 at 11 AM. Client C was described as being profoundly developmentally impaired, with quadriplegia, a seizure disorder, and an anxiety disorder. The record indicated she was able to communicate and understand when spoken to. In a Special Report written 7/29/09, by the Qualified Mental Retardation Professional (QMRP), it indicated Staff Member 1 (SM 1) had yelled at the client to eat or she would end up in a "home," and she, (SM 1), did not care. In a report written by the Regional Director (RD) on 7/30/09, SM 1 had admitted to her during an investigation on 7/24/09 that she, at one time, had yelled at Client C when the client would not eat dinner. The Special Incident Report submitted by the Central Valley Regional Center on 7/29/09 indicated, "On 7/24/09 during an interview between the RD and SM 1, SM 1 confessed to screaming at Client C. SM 1 stated that she yelled "you've got to eat your dinner, if you don't they will put you in a home and I don't care." The reporting care worker added that she talked to the QMRP about the fact that Client C recently had surgery on her bowel, removing a section of it due to cancer, and that this could be effecting her desire to eat all her dinner. Therefore, the facility failed to protect the rights of Client C when an employee verbally abused her during dinner. This violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety or other emotional trauma to the client. |
| 120001519 |
Bethesda Lutheran Communities-Westfield |
120008945 |
B |
20-Nov-12 |
XCRK11 |
3010 |
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 protect the rights of Client A when she was physically abused by a staff member, who hit her with a sandal. Client A was a nonverbal 48 year old female with profound mental retardation, anxiety disorder, social phobia, and behaviors of hitting herself and/or rubbing her head. On 7/9/09, the facility informed the Department that an incident of physical abuse had occurred when Staff Member (SM) 1 hit Client A with her (SM1's) sandal. During an interview with SM 2 on 7/10/09, at 2:30 P.M., she stated she witnessed SM 1 hit Client A on her arm. SM 2 stated, "Client A was rubbing her head and (SM 1) told her to stop. Client A did it worse and (SM 1) took off her sandal and hit Client A with it." When SM 2 was asked if she could put a date on this incident, SM 2 stated was on 6/4/09.During an interview with the Regional Director (RD) on 7/10/09, at 3:00 P.M., she stated she received two anonymous phone calls on 6/23/09, from a man who told her she "needed to so something. Staff were hitting people." The RD initiated an investigation, but concluded the accusations were unsubstantiated. Then on 7/1/09 the RD received a letter specifically identifying staff, clients, and alleged incidents. The RD stated that during a second investigation interview with SM 2 on 7/9/09, SM 2 related that she had witnessed SM 1 hit Client A on her arm with a sandal in an attempt to distract Client A from her behavior. A copy of the facility's investigative report dated 7/9/09 indicated: "SM 2 stated SM 1 would also remove Client A's shoe/slipper, hitting Client A on the arm and use the shoe/slipper to lead Client A to her room. SM 2 stated this sort of incident was on-going...." The "Final Follow-up on Allegation of Abuse regarding (SM 1) and (SM 2)", written by the RD, was reviewed. It read: "On 7/17/09 I met with (SM 1)...and the incident on 6/4/09 was determined to be substantiated. She did not respond to or deny this in any way."The facility failed to protect the rights of Client A when she was physically abused by a staff member, who hit her with a sandal. Therefore, the actions of SM 1 caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to Client A. |
| 120001519 |
Bethesda Lutheran Communities-Westfield |
120008946 |
B |
20-Nov-12 |
XCRK11 |
2241 |
Health and Safety Code Section 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 the section shall be a class "B" violation. The facility failed to report allegations of abuse against Client A in a timely manner, potentially leaving clients unprotected from further abuse in the facility. The client was a nonverbal 48 year old female with profound mental retardation, anxiety disorder, social phobia, and behaviors of hitting herself and/or rubbing her head.On 7/9/09, the facility informed the Department an alleged incident of physical abuse had occurred when Staff Member (SM) 1 hit Client A with her (SM1's) sandal. During an interview with SM 2 on 7/10/09, at 2:30 PM, she stated she witnessed SM 1 hit Client A on her arm. SM 2 stated, "Client A was rubbing her head and (SM 1) told her to stop. Client A did it worse, and (SM 1) took off her sandal and hit Client A with it." When SM 2 was asked if she could put a date on this incident, SM 2 stated it had occurred on 6/04/09.During an interview with the Regional Director (RD) on 7/10/09, at 3:00 PM, she stated she received two anonymous phone calls on 6/23/09, from a man who told her she "needed to do something. Staff were hitting people." The RD initiated an investigation, but concluded the accusations were unsubstantiated. Then on 7/01/09, the RD received a letter specifically identifying staff, clients, and incidents in which they were allegedly involved. The RD stated that during a second investigative interview with SM 2 on 7/09/09, SM 2 related that she had witnessed SM 1 hit Client A on her arm with a sandal, in an attempt to distract Client A from her behavior. SM 2 stated that hitting Client A's arm was an on-going physical abuse by SM 1. The Department was notified of the abuse allegations 16 days after the anonymous phone calls and 7 days after receiving the letter with specific allegations.Therefore, the facility failed to report allegations of abuse against Client A in a timely manner, potentially leaving clients unprotected from further abuse in the facility. |
| 120001519 |
Bethesda Lutheran Communities-Westfield |
120008947 |
B |
20-Nov-12 |
XCRK11 |
2458 |
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 protect one client from abuse when a staff member became frustrated, yelled at the client and hit her in the head with her hand. Client B was a 57 year old diagnosed as profoundly developmentally delayed with Down's Syndrome and dementia. She needed assistance with activities of daily living. During a facility investigation into multiple abuse allegations, an investigative report was faxed to the Department on 7/30/09. The report alleged SM 1 had struck Client B in the head during dinner on 6/30/09. The report also alleged that SM 1 said, "You need to slow down. Look at yourself. There is food all down your shirt." On 7/22/09, the facility received a written report from a previously terminated employee, (SM 2), that SM 1 had struck Client B on the head during dinner on 6/30/09. The Regional Director's (RD) written report to the Department, dated 7/30/09, indicated, "Under much emotional distress, SM 1 was asked if, during frustrating times, she ever hit anybody at the home. SM 1 admitted to hitting Client B in the head during dinner time...She demonstrated the severity of the strike which was hard enough to jar."During an interview with the RD on 8/6/09 at 9:30 AM, she stated that the facility determined that this physical abuse was substantiated. Both SM 1 and SM 2 had been terminated and were unavailable for interview by the Department.Therefore, the facility failed to protect one client from abuse when a staff member became frustrated, yelled at the client, and hit her in the head with her hand.The actions of SM 1 caused or occurred under circumstances likely to cause pain, significant humiliation, indignity, anxiety, or other emotional trauma to Client B. |
| 120001519 |
Bethesda Lutheran Communities-Westfield |
120008949 |
B |
20-Nov-12 |
XCRK11 |
1961 |
Health and Safety Code Section 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 the section shall be a class "B" violation.The facility failed to notify the California Department of Public Health within 24 hours of receiving an anonymous phone call regarding the abuse of one client. The first name of one of the clients, Client A, was mentioned in a telephone allegation of abuse on 6/23/09. She was a 54 year old female with profound mental disability and a seizure disorder. She was dependent upon staff for her care. During an interview with the Regional Director (RD) on 7/10/09, at 3:00 PM, she stated she received two anonymous phone calls on 6/23/09 from a man who told her she "...needed to do something. Staff were hitting people." The RD stated the caller hung up when she asked questions. The RD stated she received an anonymous letter on 7/1/09, which was reviewed by her on 7/2/09. The letter identified a specific abusive staff person, the specific client victim, described the incident, and that it occurred on 6/7/09 or 6/8/09. The RD stated she began her internal investigation, but did not report it to the Department until 7/9/09. The facility's "Investigation of Anonymous Phone Call" was reviewed on 7/10/09. The last paragraph read, "This initial telephone report was...not reported to any outside agency due to my conclusion of it being without merit was arrived at within 24 hours of receipt of the call." The RD reported the allegation of abuse to the Department 33 or 34 days after the alleged incident, 14 days after the phone calls and 7 days after the letter was received. Therefore, the facility failed to notify the California Department of Public Health within 24 hours of receiving an anonymous phone call regarding the abuse of a client. |
| 120001519 |
Bethesda Lutheran Communities-Westfield |
120008950 |
B |
20-Nov-12 |
XCRK11 |
1295 |
Health and Safety Code Section 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 with 24 hours. (b) A failure to comply with the requirements of the section shall be a class "B" violationThe facility failed to notify the California Department of Public Health of a suspected abuse of a client within 24 hours. The clinical record for Client C was reviewed on 12/30/09 at 11 AM. Client C was described as being profoundly developmentally impaired, with quadriplegia, a seizure disorder, and an anxiety disorder. The record indicated she was able to communicate and understand when spoken to. During a facility investigation into abuse allegations, a Special Incident Report was faxed to the Department on July 29, 2009, by the QMRP (Qualified Mental Retardation Professional). This report indicated that during an interview with the Regional Director (RD), on July 24, 2009, Staff 1 (SM 1) admitted she yelled at Client C who was not eating dinner. The QMRP's report was received by the Department on 7/29/09, five days after the interview. Therefore, the facility failed to notify the California Department of Public Health of a suspected abuse of a client within 24 hours. |
| 120001519 |
Bethesda Lutheran Communities-Westfield |
120009060 |
B |
20-Nov-12 |
XCRK11 |
1239 |
Health and Safety Code Section 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) (b) A failure to comply with the requirements of the section shall be a class "B" violation.The facility failed to notify the California Department of Public Health of an alleged abuse within 24 hours. Client B was a 57 year old diagnosed as profoundly developmentally delayed with Down's syndrome and dementia. She needed assistance with activities of daily living.During a facility investigation into abuse allegations, a Special Incident Report was faxed to the Department on 7/29/09, by the Regional Director (RD). This report indicated Staff Member (SM) 1 admitted to the RD during an interview on 7/24/09 that she hit Client B during dinner on 6/30/09. The notification of alleged abuse was 13 days after becoming aware of the incident. During an interview with the RD on 8/6/09 at 9:30 AM, she stated the facility determined that the physical abuse by SM 1 to Client B was substantiated. Therefore, the facility failed to notify the California Department of Public Health of an alleged abuse within 24 hours. |
| 120001395 |
Brookdale Riverwalk SNF (CA) |
120010453 |
A |
19-Feb-14 |
PPPD11 |
5923 |
F-309 483.25The facility must ensure that the resident obtains optimal improvement or does not deteriorate within the limits of a resident's right to refuse treatment, and within the limits of recognized pathology and the normal aging process.On April 22, 2013 an unannounced visit was made to the facility to investigate an entity-reported incident regarding a resident (Resident 1) who had critical laboratory results but the facility staff failed to notify his physician of the results immediately. The resident was transferred to an acute care hospital and died within a few hours of his arrival to the hospital.Based on interview and record review, the facility failed to ensure one resident's (Resident 1's) critical laboratory results were reported to the physician. This failure resulted in delay of treatment and ultimately, Resident 1's death.Findings: Resident 1 was a 75-year-old alert and oriented male with a history of cardiac disease, COPD (chronic obstructive pulmonary disease) chronic lung disease that can cause shortness of breath. On 4/22/13, Resident 1's clinical record was reviewed. Resident 1's physician, on 4/17/13, ordered a Complete Blood Count (CBC, a blood test that indicates anemia and infection) and a Basic Metabolic Panel (BMP, a test that indicates the status of the kidneys) to be done on the following day, 4/18/13. These laboratory test results were faxed by the laboratory to the facility on 4/18/13, at 2:58 PM. The results showed several critical laboratory values requiring immediate attention. These critical results included a white blood cell count (indicates infection) of 24.9 (normal range 4.0-10.5), hemoglobin (part of red blood cells) of 6.9 (normal range 13.5-18.0, a low value means anemia, a condition in which red blood cells are deficient), and hematocrit (used to measure the number of red blood cells in whole blood) of 22.2 (normal range 42-52, a low value could mean anemia).During a concurrent interview and record review with the Director of Nurses (DON) on 4/22/13, at 2 PM, the DON stated a Registered Nurse (RN 1) was responsible for reviewing all residents' laboratory results and notifying their physicians of critical results. The DON stated, on 4/18/13, RN 1 gave all residents' laboratory results received on that day to a Licensed Vocational Nurse (LVN 1) to review and notify physicians. The DON further stated LVN 1 did not review the laboratory results; instead, LVN 1 placed the abnormal laboratory results on a clipboard for the physician to review during the physician's routine visit. Resident 1's laboratory results were among the ones on the clipboard. Resident 1's physician (Physician A) did not come in to visit residents that day. On 4/19/13, Resident 1 was found non-responsive and was transferred to an acute hospital at 5:20 AM. During a review of Resident 1's "ED (emergency department) Physician Notes" on 4/22/13, a complete blood cell count was done as soon as the resident arrived at the emergency department. The results showed his white blood cell count was 49.1 (very critical value indicating systemic infection), hemoglobin was 5.8, and hematocrit was 19.3. Resident 1's diagnosis included anemia, renal insufficiency (loss of kidney functions), and septic shock (bacteria in the bloodstream that can lead to multiple organ failures including respiratory failure, and may cause rapid death). Resident 1 was unresponsive and had low blood pressure on arrival to the emergency department on 4/19/13, at 6:54 AM. He died in the emergency department within a few hours of arrival. The DON stated the licensed staff was not even aware of these critical laboratory results until Resident 1's physician came to the facility on 4/19/13, after Resident 1's death, to review the resident's records. Resident 1's physician took the critical laboratory results off the clipboard and showed them to the DON. The facility staff had not reviewed these results until then.During an interview with Resident 1's physician on 5/16/13, at 9:25 AM, he stated he had a meeting on 4/18/13, before the resident's critical laboratory results were received, with the DON and nurses on duty to call him or the physician on call for all laboratory results because there had been problems with the facility not notifying the physicians of laboratory results. The physician stated, "I told them you guys are going to kill somebody." Physician A verified he was the one who reviewed Resident 1's abnormal laboratory results after Resident 1 died in the hospital.The facility policy and procedure for "Lab (laboratory) and Diagnostic Test Results - Clinical Protocol," revised 4/07, was reviewed on 4/22/13. Under the section titled "Review by Nursing Staff," it read, "A nurse will review all results." Under the section "Deciding How Urgently to Contact the Physician," it read, "A nurse will identify the urgency of communicating with the Attending Physician based on physician request, the seriousness of any abnormality, and the individual's current condition." Furthermore, under the section of "Identifying Situations that Warrant Immediate Notification," It read: "Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: 1. The physician had requested to be notified as soon as a result is received..." These policies and procedures were not followed by the facility staff.The facility staff failed to follow its policy and procedure in notifying physicians of their patients' abnormal laboratory results timely. After the warning from Resident 1's physician, the facility staff did not change their practice. Resident 1's laboratory results were not reported to his physician. 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. |
| 120000320 |
Bakersfield Healthcare Center |
120010546 |
A |
24-Mar-14 |
D1PF11 |
4999 |
Title 22 72315(h) Nursing Services - Patient Care Each patient shall be provided with good nutrition and with necessary fluids for hydration. On 2/8/13 at 9:05 AM, an unannounced visit was made to the facility to investigate a complaint of Quality of Care/Treatment. Based on interview and record review, the facility failed to monitor one patient's (Patient 1) intake and output as planned which had caused Patient 1 to develop severe dehydration and related complications of fluid and electrolyte imbalance. Patient 1 was transferred to an acute hospital and died two weeks later, on 2/17/13, at 2:30 AM. During an interview with Certified Nursing Assistant 1 (CNA 1), on 4/23/13, at 10:30 AM, CNA 1 stated she remembered Patient 1 frequently would resist care. He would throw his meal trays, knock it out, and say "No, No." He also stated Patient 1 could drink a lot of fluids when he wanted to but, most of the time, Patient 1 would not. Patient 1's clinical record was reviewed on 2/8/13. Patient 1 was admitted to the facility on 1/8/13 after sustained a spinal cord injury that left him unable to control or feel his lower part of his body. Therefore, he had a urinary catheter (or Foley catheter) to relieve his urinary incontinence.During further review of Patient 1's nutritional assessment on 2/8/13, at 9:05 AM completed by the facility's registered dietician on1/14/13, Patient 1's fluids intake should be at a 1920 milliliters (ml) per day to meet his requirement. A plan of care, initiated on 1/10/13, titled "NUTRITIONAL STATUS," also included "monitor intake record" as one of the approaches the licensed staff, nursing assistants, and dietician should take. On the same care plan, it also indicated the staff were to monitor the patient for signs and symptoms of dehydration.During a concurrent interview with the Medical Records Director (MRD) and review of Patient 1's clinical record, on 2/8/13, at 10:30 AM, MRD stated the staff would normally document patients' intake and output on an "Intake and Output" form and a licensed nurse would review and assess patients' fluids status. However, she was unable to locate Patient 1's "Intake and Output" forms anywhere in the records. At 10:55 AM, the Administrator was made aware of the findings, she reviewed the records and was unable to locate any documents to indicate the licensed nursing staff had reviewed and assessed Patient 1's fluids status. At 12:45 PM, during an interview, the Director of Nursing (DON) verified the above findings and could not provide further documentation.Based on Patient 1's "CNA-ADL (Activities of Daily Living) TRACKING FORM" from 1/8/13 to 2/2/13, Patient 1 had an average of 480 to 1220 milliliters (ml) fluids intake per day which equated to 26 to 65 percent of his minimum daily fluid requirement of 1830 to 1890 ml. During further review of Patient 1's "DAILY SKILLED NURSE'S NOTE," from 1/9/13 to 1/30/13, the nursing staff consistently marked Patient 1 was incontinent of bladder control instead of catheter. In addition, the section under "SERVICES PROVIDED," the licensed staff consistently placed a check mark on "Monitor Fluids Intake to Prevent Dehydration" but failed to document the patient's fluids status. The facility policy and procedure titled, "Intake and Output" dated 5/08, at 12:45 PM, read in part..."The licensed nurse shall consider initiating intake and output for residents with the: Urinary Catheter, other factors identified by physician and/or nursing staff. The Nursing staff shall report any unusual variance in the intake and output to the physician including but not limited to the following: Intake less than amount determined necessary for resident. The licensed nurse shall review and document review of the intake and output record at least weekly to assess the resident's fluid status and determine if intake and output recording is still required." During a review on 3/11/13 of the acute care hospital Emergency Department Report, Patient 1 was assessed to have "an extremely dry mouth, low blood pressure, and tachycardia (rapid heart rate)." All were the symptoms of dehydration. The "ER (emergency room) COURSE," on the same report, read; "Clearly, the patient is very, very dehydrated and he has been bolused (a large dose of a substance given by injection for the purpose of rapidly achieving the needed therapeutic concentration in the bloodstream) now more than 3 liters. The Foley catheter was changed was found to be blocked, and so we did slowly get some urine output..."The facility staff failed to assess and monitor Patient 1's intake and output at least weekly and failed to monitor him for signs and symptoms of dehydration as prescribed in his care plan throughout his stay had caused him to be severely dehydration and eventually lead to his death.This violation had a direct relationship to the health and presented an imminent danger that serious harm would result or a substantial probability that serious physical harm would result. |
| 120001395 |
Brookdale Riverwalk SNF (CA) |
120010617 |
A |
08-May-14 |
3XXW11 |
13919 |
F 323 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.On 12/10/13, at 2:35 PM, an unannounced visit was made to the facility to investigate an entity reported incident regarding Resident 1's un-witnessed fall on 12/3/13, which resulted in a skin laceration (skin tear) on her head and subdural hematomas (areas of bleeding inside the head resulting from a traumatic injury). Resident 1 died on 12/5/13, two days after the fall incident at the facility. Based on observation, interview, and record review, the facility failed to place a pressure alarm pad (pressure-sensitive pads placed on the seat of a wheelchair and/or the surface of a bed which sets off a loud sound as the resident attempts to get up from the wheelchair or bed) on Resident 1's wheelchair as ordered by the physician and as indicated in her plan of care. This failure resulted in Resident 1's un-witnessed fall which caused a skin laceration to the head, subdural hematomas, and subsequently, Resident 1's death.Findings: Resident 1 was an 88 year old female resident who was diagnosed with Dementia (progressive deterioration of a person's intellectual functions such as memory), general muscle weakness, and difficulty in walking with a history of falls. Resident 1 sustained a Fracture (break in the bone) to the neck of the femur (upper part of the thigh bone that inserts into the hip socket) and a Fracture to the upper end of the humerus (the bone of the upper arm that inserts into the shoulder socket). During a review of Resident 1's clinical record, the Care Area Assessment for fall(s), dated 11/3/13, indicated Resident 1 was a high risk for falls. The Care Area Assessment for cognitive loss, dated 11/3/13, indicated Resident 1 had a BIMS (Brief Interview for Mental Status-brief screener that aids in detecting cognitive impairment) score of 7 out of 15 (BIMS Score of 0-7 indicates severe cognitive impairment), and had a very short attention span requiring supervision. The Care Plan Report dated 11/4/13, indicated Resident 1 had impaired short-term and long term memory wherein she was unable to recall and forgot information after 5 minutes. The resident's Medication Administration Record indicated she was taking Coumadin (a medication that thins the blood) for a condition called atrial fibrillation (abnormal or irregular heartbeats).During an interview with Certified Nurse Assistant (CNA) 1, on 12/13/13, at 9:53 AM, she stated on 12/3/13, before 11 AM, she had noticed Resident 1 sitting in her wheelchair in front of the nurse's station. CNA 1 stated the call light of another resident was activated and she responded to that call light and remained with the resident until she was done assisting. At 11 AM, after CNA 1 had finished helping the other resident, she saw the bathroom call light was activated for Resident 1. She stated as she approached Resident 1's bathroom, the resident was calling for help and knocking on the bathroom door. When CNA 1 entered the bathroom, she found the resident lying on the floor. CNA 1 stated she asked Resident 1 why she did not call for help, Resident 1 stated, "I don't know." When CNA 1 was asked if an alarm was in use during this time, CNA 1 stated she clipped a personal tab alarm (an alarm box that hangs at the back of the wheelchair and sounds a loud alarm when the clip hooked to the resident detaches from the box when the resident attempts to get up) to Resident 1's sleeve earlier that morning after she changed her briefs. CNA 1 verified after the fall, the alarm was not clipped to Resident 1's sleeve. CNA 1 did not mention a pressure alarm pad was used on Resident 1's wheelchair seat.During a concurrent observation of Resident 1's bathroom and interview with a Licensed Nurse (LN 1), on 12/10/13, at 3:06 PM, LN 1 stated she was one of the staff who assisted when Resident 1 fell in her bathroom on 12/3/13. LN 1 described how the resident was lying on the bathroom floor, her feet were by the toilet bowl, her head was against the bathroom wall across from the toilet bowl, and her wheelchair was in front of the sink by the door. On the floor, under the toilet bowl, were a few drops of urine. LN 1 stated Resident 1 had placed the detachable seat cushion of the wheelchair between her head and the wall. LN 1 stated she felt a lump on the area of the resident's head which was in contact with the wall and "it was bleeding." LN 1 stated she was alternating with another nurse applying pressure to the resident's head to stop the bleeding. When asked if an alarm was in use at that time, LN 1 stated she saw a tab alarm hanging on the wheelchair. She stated the alarm did not sound off because it was not clipped to Resident 1. LN 1 did not mention a pressure alarm pad was used on Resident 1's wheelchair seat.A review of the Nurse's Notes, dated 12/3/13, at 12:50 PM, written by LN 2 indicated she was notified of Resident 1's fall and also assisted the resident during this incident. LN 2 indicated in her notes Resident 1's brief was "halfway down" her legs, the resident's hands were noted with blood, and the resident was frequently touching her head. When the resident was asked by LN 2 what she had wanted to do, the resident stated, "I just needed to go to the bathroom." LN 2 documented Resident 1 had a personal (tab) alarm at the back of the wheelchair that was not sounding an alarm because it was "unhooked" from the resident. The notes also indicated Resident 1 was alert and oriented enough to unclip the personal tab alarm. A review of the Quality of Care Progress Notes, dated 12/6/13, written after the fall had occurred on 12/3/13, indicated Resident 1 removes her personal tab alarm and was noted several times attempting to transfer self from the wheelchair to the bed. She was also noted to be transferring herself to the toilet unassisted.During a review of the current physician's orders for Resident 1 for the month of 12/13, an order written on 7/6/10 indicated, "May use Pressure Alarm in bed and w/c (wheelchair) to alert staff of unassisted transfers".During a review of the Care Plan Report dated 11/4/13, one of the interventions indicated "Use pressure alarm in bed and w/c (wheelchair) to monitor attempts to rise." A handwritten note by an unknown staff at an unknown date was added to this intervention to also use a personal tab alarm in addition to the pressure alarms. During an interview with the Director of Nursing (DON) on 2/26/14, at 1:23 PM, she clarified the above physician's orders indicated that if Resident 1 was assessed to be a fall risk, then nursing staff was to use pressure alarm pads on both the resident's bed and on the seat of her wheelchair. The DON stated the nursing staff was instructed by her to sign and date new information added to a care plan. The DON stated she was unable to verify who added the handwritten notes to add the use of a personal tab alarm. When the DON was asked, what the nursing staff had done after learning Resident 1 knew how to remove the clip of the personal tab alarm from her sleeve and if any of the records indicated the pressure alarm pad was in use on the wheelchair seat during the time of the fall on 12/3/13, the DON responded she would have to review Resident 1's chart. No confirmation was received from the DON in response to these questions. During a review of the Nurse's Notes dated 12/3/13, at 12:50 PM, it indicated Resident 1 was transported to Hospital 1 via an ambulance on 12/3/13, at 12:45 PM, and was noted to be alert and verbally responsive upon transport.During a review of Hospital 1's Emergency Department (ED) Report dictated by Physician 1 on 12/3/13, at 3:30 PM, it indicated Resident 1 had a laceration (tear) to the lower back of the head and was complaining of a mild headache. Her vital signs included a temperature of 98 degrees Fahrenheit, pulse at 66 beats per minute, respirations at 16 breaths per minute, blood pressure at 137/58 (normal blood pressure is below 120/80) mm Hg (millimeter per Mercury), oxygen saturation level (amount of oxygen in the blood) of 92 percent (normal oxygen saturation is between 95-100 percent), and a 2 out of 10 level on the pain scale (0- no pain, 10- worst pain). Resident 1 had a Glasgow Coma Scale (Glasgow Coma Scale is a scoring system used to describe the level of consciousness in a person to assess the severity of a traumatic brain injury- 3 being the worst and 15 being the best) of 15. Physician 1 also indicated the resident was alert and oriented. Her pupils were at an equal size and reacting to light. A Computerized Tomography scan (scan showing detailed images of internal organs using a sophisticated X-ray device) of the brain showed a significant left subdural (area between the layers of tissue that surround the brain) hematoma (bleeding) with blood present in the front part of the brain, in the membrane that separates the brain hemispheres, on the left cavity in the middle part of the brain, and the internal base of the skull. There was also a small amount of blood in the subarachnoid (area between the brain and the thin tissues that cover the brain). Also found was a 5 mm (millimeter) shift of the brain from the left to the right side with some disappearance of the brain on the left side. Physician 1's notes dictated on 12/3/13, at 4:09 PM, indicated the resident's scalp laceration was closed with staples to control further bleeding. Also, at the request of the consulting Neurosurgeon 1 (physician who specializes in brain surgery), the resident was transferred in stabilized critical condition to the Intensive Care Unit at Hospital 2.During a review of Hospital 2's ED report dictated by Physician 2 on 12/3/13, at 6:29 PM, it indicated Resident 1 was received from Hospital 1 by ambulance on 12/3/13, at 5:35 PM, for completion of recommended treatment at the request of Neurosurgeon 1. Physician 2's notes indicated the resident was unresponsive with a GCS of 5, body temperature at 97.8 degrees Fahrenheit, pulse at 80 beats per minute, respirations at 16 breaths per minute, and blood pressure of 174/68 mmHg. Her right pupil measured 3 mm and the left pupil measured 5 mm (unequal pupil sizes after trauma to the head are indicative of severe brain injury). She had no response to any type of stimulation other than she was withdrawing from pain stimulation. Hospital 2 performed a repeat CT scan of Resident 1's brain and results relayed to Physician 2 by the Radiologist (physician who specializes in interpreting CT scan images) at 6:20 PM showed significant worsening of the subdural hematoma with shift of brain tissues due to the increasing bleeding.During a review of Neurosurgeon 1's consultation notes dictated on 12/4/13, at 8:06 AM, it indicated Resident 1's hematoma had multiple components: the first component was on the brain's left frontal area which was classified as an older hematoma; the second component was located further to the back of the head to the left frontal area which was classified as a newer hematoma; and the third component was located on the left lower back part of the brain which was described as having the most dramatic abnormality where there was a large bleeding that starts from the front to the back of the head. The resident's physical examination performed by Neurosurgeon 1 revealed her left pupil had become smaller at about 2 or 3 mm and her right pupil pinpoint. The resident was prepared for a procedure to surgically open the head to release pressure and removal of the subdural hematoma, with a likely poor outcome and a low likelihood of improvement. The procedure was performed on 12/4/13. The "Operative Report," dictated on 12/4/13, at 8:11 AM, indicated the resident was found to have a one centimeter tear in a large vein in the brain which was the source of the bleeding. This vein travels over the top portion of the skull, beginning at the top of the skull and moving to the back part of the skull. A review of Neurologist 1's (physician who specializes in the diagnosis of nervous system disorders) Evaluation Notes dictated on 12/4/13, at 8:55 PM, indicated the resident was "comatose" (in a state of unconsciousness and extreme unresponsiveness wherein even painful stimuli are unable to affect any response from a person) with very sluggish reactivity noted on her left pupil and an unreactive right pupil. She also did not respond to painful stimuli. The notes further indicated that she had deteriorated rapidly since the start of the hemorrhage, and that her prognosis was very grave. A review of Physician 3's "Discharge Summary," dictated on 12/5/13, at 12:08 AM, indicated Resident 1's condition did not improve after coming out of surgery. She was taken off life support and placed on a "Do Not Resuscitate" status, and subsequently died.The Certificate of Death indicated the resident's immediate cause of death was "Cardiorespiratory Failure" (inability of the heart and lungs to continue functioning) as preceded by "Intracranial Hemorrhage (bleeding inside the head) of Unknown Etiology." The facility staff, knowing Resident 1 had the behavior of removing the clip on her personal tab alarm, did not place a pressure alarm pad on the resident's wheel chair as prescribed by the physician and as indicated in the care plan. Resident 1 got up from her wheelchair unassisted and undetected by the facility staff. She walked inside her bathroom and fell. This fall had caused Resident 1 to have internal bleeding in the brain and eventually, death, two days after the resident fell. 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 and was a direct proximate cause of the death of the resident. |
| 120001395 |
Brookdale Riverwalk SNF (CA) |
120010847 |
A |
04-Aug-14 |
YOS411 |
8390 |
483.2 ( c ) Treatment/ SVCS 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. On 4/25/14 at 3:15 PM, an unannounced visit was made to the facility to investigate a complaint of Quality of Care/Treatment. The facility failed to ensure Resident 1's) pressure ulcer (according to the National Pressure Ulcer Advisory Panel [NPUAP] a pressure ulcer is a 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) was provided necessary treatment when:a. Licensed staff failed to perform treatments to Resident 1's sacrococcygeal (area involving the sacrum [triangular bone at the base of the spine] and the coccyx [tailbone]) area as ordered by the physician and failed to notify the physician for the renewal of the treatment orders on 4/7/14 to ensure continued treatment of the pressure ulcer. b. Licensed staff failed to perform a weekly wound assessment for Resident 1's pressure ulcer over the coccyx area on 4/7/14 to 4/8/14. This resulted in Resident 1's pressure ulcer to the sacrococcygeal area worsening.Resident 1 was a 77 year old male, who was admitted to the facility on 3/5/14. His diagnosis, upon admission to the facility, included a stage 1 pressure ulcer (the area is not opened; the skin is deep pink, red, or mottled. Digital pressure on the area will cause temporary blanching for up to 15 minutes after pressure is released), and paraplegia with impaired movement to both of his lower extremities.During a review of the clinical record, it was noted Resident 1 was admitted to the facility with a stage 1 pressure ulcer to his sacrococcygeal area (area involving the sacrum and tail bone.) A physician's order, dated 3/24/14, was obtained to treat the stage I pressure ulcer with Calmoseptine (topical skin protectant) ointment twice (in the morning and in the evening) daily and as needed for 14 days (from 3/24/14 to 4/7/14). No other physician's orders were noted to treat the sacrococcygeal pressure ulcer. There was no documented evidence that staff had contacted the physician for treatment orders after the initial treatment orders had expired. There was also no documentation found the wound had healed. During a review of Resident 1's clinical record, the 4/2014, Treatment Records were reviewed. The initials of the nursing staff performing the treatments to the sacrococcygeal area, for 4/5/14, 4/6/14, and 4/7/14, morning shift, were circled with documentation on the back of the treatment record stating "treatment not done". There was also no documentation that staff had contacted the physician for renewal orders after the order had expired on 4/7/14. During an interview with LN 2, on 6/3/14, at 3:45 PM, she indicated that on 6/7/14 Resident 1's pressure ulcer was not healed. She stated Resident 1's pressure ulcer "looked like an onion skin that was peeled off." During an interview with Licensed Nurse (LN) 1, on 6/7/14, at 2:10 PM, LN 1 stated "Resident 1's treatment(s) (were) not done on 4/5/14, 4/6/14, and 4/7/14 (morning shift), and I circled them as not done because (the) treatment nurse did not do them..." LN 1 indicated the treatment nurse performs the treatments for the residents who have pressure ulcers. She stated, she did not contact the physician...about the treatments not being performed for 3 days on the morning shift (4/5/14, 4/6/14, and 4/7/14) ...because "I was busy that day".She stated on 4/10/14 she noted the wound was opened ( an opened area indicates the wound has progressed.) However, Resident 1 was scheduled for an appointment so "I covered it with a bandage." The resident was then taken to his scheduled appointment. The facility policy and procedure titled, "Skin assessment and Wound Prevention", dated 3/09, read in part under the Policy Overview, "The purpose of the Skin Assessment is to observe the condition of the resident's skin...on a routine basis. This process...provides a system for Licensed Nurses to regularly assess each resident's skin condition..." Under the Policy Detail it read in part, "...Notify physician for treatment orders..." b. During a review of the clinical record for Resident 1, the initial, 3/24/14, "INTERIM PLAN OF CARE" indicated staff was to perform "Skin evaluation weekly". The "WOUND EVALUATION FLOW SHEET" was reviewed. The form was used to conduct skin evaluations of pressure ulcers weekly. On the form staff were to document the wound's stage, measurements, any additional treatment, preventative interventions in place, response to treatment and if the care plan was updated. The first entry was documented, on 3/24/14, (date of admission.) The documentation indicated Resident 1 had a stage I pressure ulcer. On 4/1/14, another entry was noted, and the wound size was documented as 2.1 cm x 2.2 cm. No other weekly entries were noted, documenting the weekly reassessment, which included the wound's stage, measurements, any additional treatment, preventative interventions in place, response to treatment, and if the care plan was updated. On 4/10/14, at 8 AM, a "DAILY SKILLED NURSE'S NOTE" indicated, "...Resident going to...Hospital (with) his son for surgery. Skin assessment done found Resident(s) (sacrococcygeal pressure ulcer) advance(d) to unstageable (according to NPUAP unstageable is full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough [yellow, tan, gray, green or brown dead tissue] and/or eschar [tan, brown or black] in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV...) from stage I..." The clinical record did not indicate the physician was notified about the pressure ulcer progressing to unstageable. During an interview with Licensed Nurse (LN) 1, on 6/7/14, at 2:10 PM, LN 1 stated, she did not contact the physician...about the wound worsening because "I was busy that day". During an interview with the DON, on 5/1/14, at 4:10 PM, after reviewing the "WOUND EVALUATION FLOW SHEET" for Resident 1, she acknowledged although the weekly reassessment of Resident 1's pressure ulcer should have been completed on 4/7/14 to 4/8/14, there was no documented evidence it was done. She provided no additional information. During an interview with the DON, on 4/14/14, at 3 PM, the DON stated Resident 1 had a Stage I pressure ulcer over the sacrococcygeal area upon admission on 3/24/14, and it was being treated. On 4/10/14, Resident 1 was taken to a physician's appointment and the resident did not return to the facility. Family Member (FM) 1 informed the facility, they were not notified the pressure ulcer to the sacrococcygeal area, had worsened and the family had decided to transfer him to another local nursing home.The facility policy and procedure titled, "Skin assessment and Wound Prevention", dated 3/2009, read in part under Policy Detail, "Weekly: The License Nurse will...Stage, measure, and document all pressure ulcers on Wound Evaluation Flow Sheet...Initiate treatment intervention..."The facility policy and procedure titled, "Change of Condition", dated 10/2006, read in part, "Procedure: All staff members shall communicate any information about resident status change to appropriate licensed personnel upon observation...Change in skin condition, color and/or integrity...When assessing and documenting Change of condition, the licensed nurse will follow through with: Call the physician and document in the nursing progress notes. Obtain physician orders for treatment..." Therefore, the facility failed to prevent the progression of Resident 1's stage 1 pressure ulcer, when staff failed to preform treatments to Resident 1's pressure ulcer, and failed to preform weekly wound assessments.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. |
| 120001519 |
Bethesda Lutheran Communities-Westfield |
120011039 |
A |
22-Dec-14 |
E4YA11 |
5132 |
42CFR 483.420(d)(1)(i) Staff of the facility must not use physical, verbal, sexual or psychological abuse or punishment. The facility failed to protect a client from physical abuse by staff which caused injury. An unannounced visit was made to the facility on 7/29/14, at 12 PM to investigate an allegation of staff to client physical abuse. Client A was a 31 year old male admitted to the facility on 7/1/14 with diagnoses of severe intellectual disability/development disorder, intermittent explosive disorder, severe recurrent major depressive disorder, hydrocephalus with shunt (fluid surrounding the brain with an internal tube that drains the fluid into the abdomen), and epilepsy (a seizure disorder). The American Academy of Family Physicians defined severe mental retardation as: "Intelligence quotient of 20-34; marked and obvious delays; little or no communication skills; may be trained in simple self-care; need direction and supervision." During a record review, an incident report dated 7/16/14 and written by a Registered Nurse (RN) read: "I heard (Client A) state that he hated someone and went to investigate. Noted (Client A) in his wheelchair being pushed into the dining room by staff. He was verbalizing that he wanted to go back and that he hated staff. Witnessed staff hit (Client A) on the back of the head with the phone and turn to walk away. I immediately went to (Client A), who was crying and upset. I attempted to calm (Client A) down and escorted him to his room. (Client A) was still crying and when I asked him to look at me I noted blood on his shirt. Assessed and noted bleeding from the right nares (nostril)."During an interview with the Area Director (AD) on 7/29/14, at 12:25 PM, she stated: "(RN) called me and told me what happened. (Direct Support Provider-DSP 1) came to my office and said "I'll resign. I am going to be arrested." During an interview with the Program Manager (PM) on 7/29/14, at 12:30 PM, he stated: "(DSP 1) called me saying she accidentally hit him with the phone and (RN) saw her." During an interview with RN on 8/13/14, at 1:53 PM, she stated: "They (the clients reside in the home) came back (from the day program) early. I was in the office and heard the door bell ring. (Client A) was saying "I want to go back." I was in the office and on the backside of the kitchen. (DSP 1) was pushing his chair alongside the dining room table. I came into the kitchen and as I walked through the kitchen, she thumped his head with the house phone. I think I gasped because she turned and said, "I'm sorry you had to see that." I said, 'I have to report this'. (DSP 1) said, 'I will quit'. I told her I still had to report it. (Client A) was crying and I pushed him into his room and I crouched down and noticed his nose bleeding....When (DSP 1) saw his nose bleeding, she said, 'Oh, my God!' If I had any doubt that it was an accident, I would not have reported it. (DSP 1) told me (Client A) had attacked her before and said he hated her." During a record review, the police report, dated 7/16/14, indicated: "(DSP 1) stated due to (Client A)'s program ending early he was upset. While removing (Client A) from the medical van, (Client A) became uncooperative by swinging his body around within his wheelchair. While (DSP 1) was pushing (Client A) in his wheelchair which he is confined to, he jerked his head backwards ultimately head-butting (DSP 1) in the mouth area...(DSP 1) stated the house was chaotic due to several residents acting out of control. While pushing (Client A's) wheelchair inside the home, the cordless phone rang. (DSP 1) answered the phone but as she did, she overheard another resident yelling for help so she turned immediately thus striking (Client A) in the back of the head with the cordless phone that was in her left hand. (DSP 1) stated she then observed that his nose began to bleed at which time (DSP 1) left (Client A) in the kitchen area...she stated he began to cry. (DSP 1) also confirmed that (Client A) did not have a bloody nose prior to her 'bumping' into him....Although I did not see any visible injuries to the back of his head nor to the nose area, he did complain of the pain to staff. After (Client A) was examined by the doctor's at the hospital I was informed that (Client A) was found to have contusions to the back of his head..."The facility's policy titled "Abuse/Neglect of Individual" dated 2/28/97 indicated: (Facility) shall ensure that individuals supported by (facility) are not subjected to neglect, physical, verbal, sexual, or psychological abuse, or punishment, or misappropriation of property and to inform employees of their responsibilities as mandatory reporters...Any form of abuse, neglect or exploitation shall not be tolerated and, if substantiated, shall result in corrective action up to, and including, termination of employment..." Therefore, the facility failed to protect a client from physical abuse by staff which caused injury. The above violation presented imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 120000320 |
Bakersfield Healthcare Center |
120011331 |
A |
18-Mar-15 |
QL5811 |
7107 |
F323-483.25(h) 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.On November 12, 2014, at 2:30 PM, an unannounced visit was made to the facility to investigate an entity reported incident of a resident fall. Based on observation, interview, and record review, the facility failed to provide adequate assistance for one of one sampled residents (Resident 1) while using a mechanical lift (used for transfer of residents). This failure resulted in Resident 1 having a fall which resulted in multiple fractures; femur (thigh bone), humerus (long bone of the arm), and iliac crest (top of the hip bone) that required surgery. Resident 1 was a 57 year old female with diagnoses of rheumatoid arthritis (chronic inflammatory disorder of the joints), acute cerebrovascular disease (a group of brain dysfunctions related to disease of the blood vessels supplying the brain), generalized anxiety disorder (unpleasant state of inner turmoil), hypertension (high blood pressure), pulmonary embolism and infarction (blockage of main artery of the lung and death of part of lung). She was admitted to the facility on July 14, 2014. She was alert and oriented and her own responsible party. During a concurrent observation and interview with the Administrator on, 11/12/14, at 2:45 PM, he stated Resident 1 was still in the hospital. He called to medical records for the clinical record. The Administrator stated, "Resident 1 has her own sling for the lift." The sling was a blue full body mesh with all straps intact. The Administrator stated, "During our investigation we found there was nothing wrong with the lift...it was operator error. Talking to Certified Nurse Aide (CNA 1) she knows that she messed up." During a review of the clinical record for Resident 1, the face sheet indicated she was admitted on 7/14/14. Resident 1 was alert, made her own decisions, and needed extensive assistance with her activities of daily living (ADL). The Fall Risk Evaluation, dated 7/15/14, indicated a score of 18. The form indicated "A resident who scores a 10 or higher is at risk, interventions should promptly be put in place." The resident care plan "Fall/Injury", dated 7/14/14, indicated risk factors: impaired balance and unsteady gait, poor muscle coordination, weakness, underlying health problems..., and Interventions: assist resident in ADL's, Anticipate needs..." During an interview with Licensed Vocational Nurse 1 (LVN 1), on 11/12/14, at 3:15 PM, she said she entered the room to assist Resident 1's roommate. LVN 1 stated "I saw CNA 1 with Resident 1, and she (Resident 1) was lying down in a shower chair. All of a sudden I hear a loud noise and Resident 1 screamed. I looked and she was on the floor." LVN 1 was asked if CNA 1 requested her help with the lift. LVN 1 stated, "She didn't ask for my help with the lift." During an interview with Registered Nurse 1 (RN 1), on 11/12/14, at 3:30 PM, she stated on the day of the fall she heard the call and went into Resident 1's room. RN 1 said "Resident 1 was lying on her left side yelling for a pillow and pain shot." RN 1 stated "She (CNA 1) had training on the lifts." During a concurrent interview with RN 1 and review of the facility training log sign-in sheet for: Accident/Safety Measure on 9/8/14 and Transfers via Hoyer Lift (2) persons on 10/14/14, CNA 1 did not attend. RN 1 stated "CNA 1 was on-call, and didn't attend training. She has her Restorative Nurse Aide (RNA), so she got training then." A review of CNA 1's Restorative Training certificate dated 11/22/11 indicated it was an 8-hour classroom/field work course.During a review of the clinical record for Resident 1, the Nurse Notes dated 11/7/14, at 10:20 AM indicated: "Resident encountered fall from lift. Resident heard to be yelling "my leg" and found to be leaning towards left side of body on floor... c/o (complaints of) pain 10/10 to left leg, left hip, left arm, and left shoulder. Resident transferred to hospital and left facility at approx. (approximately) 10:40 (AM)." During an interview with CNA 1, on 12/2/14, at 4:25 PM, she stated, "The resident told me to put the sling on backwards...I did what she asked." CNA 1 said when she was picking up Resident 1 with the lift when she slid from the sling and fell to her left side. CNA 1 said she had used a lift before. CNA 1 was asked if she is supposed to follow the residents' instructions instead of how she was trained, and stated "No." CNA 1 stated "I'm aware that I didn't use it properly, but she was alert and that's how she wanted it." CNA was asked if the lift requires two people and stated "Yes." During an interview with the Assistant Director of Nurses (ADON), on 12/3/14, at 3:30 PM, she was asked the amount of staff that was needed when using the mechanical lift. The ADON stated "It should always be two people." During a review of the clinical record for Resident 1, the hospital "Operative Report" dated 11/12/14 indicated the following operations were performed:1. Open Reduction Internal fixation (method of surgically repairing a fractured bone with the use of plates and screws), left femur 2. External Fixator (screws and pins that are inserted into the bone through the skin) of the left elbow, stabilizing the fracture and dislocation of the elbow During an observation and interview with Resident 1, on 12/3/14, at 4:30 PM, she was lying in bed with an External Fixator to the left elbow. Resident 1 was asked what happen the day of her fall. Resident 1 stated "The CNA put me on the shower bed. She used the sling...it was only her using the sling." Resident 1 was asked if she instructed the CNA how to use the sling. Resident 1 stated "No, I didn't tell her what to do. I don't think she put it on correct in the back. It was like once she did the back...I fell." Resident 1 was asked how she felt, and stated "I wake up crying at night...I think that I'm falling." During an interview with CNA 2, on 12/3/14, at 5 PM, she was asked how to use the mechanical lift. CNA 2 stated, "You have to use two people to use the lift. I never use it by myself...not supposed to." During an interview with CNA 3, on 12/3/14, at 5:10 PM, she was asked how to use the mechanical lift, and stated, "You always use two people when you use the lift." The facility policy and procedure titled "Mechanical Lift Usage," undated, indicated "Assess physical characteristics of the resident...determine if assistance is needed from another caregiver." The education module titled "Mechanical Lifts", approved curriculum-Unit 13, undated, and indicated "Enough assistance to assure safe transfer." Medline Owner's Manual with revised date 4/5/07 indicated, "Always fit the sling according to the instructions provided." Therefore, the facility failed to use the mechanical lift properly which presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 120000320 |
Bakersfield Healthcare Center |
120011525 |
B |
16-Jun-15 |
WC7D11 |
4926 |
F314 - Treatment/services to Prevent/heal Pressure sores - 483.25 The facility must ensure that resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that that they are 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 implement their care plan for one (12) resident to promote healing of the wound when: 1. A pressure reducing mattress was not provided to Resident 12 as indicated on the care plan.2. Resident 12 was not kept clean, dry at all times after episodes of incontinence as indicated on the care plan.These failures resulted in progression of Resident 12's wound to his right buttock.Findings:Resident 12 was a 70 year old male who was admitted to the facility on 8/15/14 with diagnoses of cerebrovascular disease (a condition that affect the circulation of blood to the brain), benign prostatic hypertrophy (a condition in men in which the prostate gland is enlarged), hypertension (blood pressure in the arteries is elevated), hemiplegia (total or partial paralysis of one side of the body), anxiety disorder, and major depressive disorder.During an observation on 3/23/15, at 10:20 AM, Resident 12 was in bed lying on his right side on a concave mattress (mattress with curve sides for safety).During a concurrent observation and interview with Certified Nursing Assistant (CNA) 7, on 3/24/15, at 9:25 AM, Resident 12 was up in a gerichair (recliner chair with a high back) by the hallway in front of his room. Patient12 was screaming. CNA 7 stated, "He has a big sore on his bottom where he is hurting".During a concurrent observation with Resident 12 and interview with the CNA 7, on 3/24/15, at 9:32 AM, CNA 7 stated "He has been screaming and hollering when we turned and touched him." Resident 12 was asked by CNA 7 if he wanted to go back to bed and Resident 12 stated "Yes". Resident 12 was put back to bed lying on his right side on a concave mattress. CNA 7 stated, "He prefers to stay on his right side. He would scream if he's being turned to his left side".During a subsequent interview with CNA 7, on 3/24/15, at 1:15 PM, she stated Resident 12 did not have a pressure reducing mattress. CNA 7 stated Resident 12 had a sore on his right buttock for a while and it was not getting any better.During an observation with Resident 12, on 3/24/15, at 1:20 PM, he was repositioned by CNA 7 to his left side. Resident 12 was screaming when he was being repositioned. Resident 12 was noted with an open wound to his right buttock with yellow slough (yellow tissue or accumulation of necrotic tissue/dead tissue) in the center of the wound bed.During an interview with Licensed Nurse (LN) 8, on 3/25/15, at 10:20 AM, he stated Resident 12's open wound on the right buttock started as a scratch. It had a yellow slough now.During a subsequent interview with LN 8, on 3/25/15, at 2 PM, he stated, "I just placed the roho cushion (pressure reducing mattress) yesterday (3/24/15) when the staff told me he didn't have a pressure reducing mattress. He added Resident 12 was scratching his right buttock when he got wet".During an interview with CNA 7, on 3/27/15, 10:40 AM, she was asked about Resident 12 being left wet and he was not changed promptly. CNA 7 stated, "I believe it's from the night shift. When I came in the morning the diaper was dry but the bed was wet".During a review of the clinical record for Resident 12, the document "WEEKLY WOUND CONDITION RECORD" dated 2/23/15 indicated "...Site Location: Right Buttock... Condition... Scratch...."measuring 3 cm (centimeters) in length, 1 cm in width, 0.1 cm in depth... Characteristics..."Partial Thickness", Wound Bed..."Dark pink/red tissue...". On 3/16/15 on the same site and location to the right buttock measuring 2.5 cm in length, 0.8 cm in width, and 0.1 cm in depth, "Partial Thickness", Wound Bed..."Pink, Pale tissue 100%"... On 3/23/15, on the same site and location to the right buttock indicated "MD was notified that wound deteriorated and now has 80 % granulation tissue and 20 % Slough..." measuring 3.5 cm in length, 1 cm in width and 0.2 cm in depth.The "BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK" dated 8/16/14 indicated a total score of 13 (Moderate Risk) for pressure sore. During a review of the clinical record for Resident 12, the plan of care was reviewed. The "PRESSURE ULCER/SKIN BREAKDOWN" plan of care dated 8/16/14 indicated in part "Provide pressure reducing mattress... Keep resident clean, dry at all times after episodes of incontinence..."Therefore, the facility failed to implement their care plan to promote healing of a wound for Resident 12 which had a direct relationship to the health, safety, or security of the patient |
| 120001395 |
Brookdale Riverwalk SNF (CA) |
120011661 |
A |
08-Sep-15 |
FN8T11 |
7912 |
F327-Hydration: The facility must provide each resident with sufficient fluid intake to maintain proper hydration and health. On 6/29/15 at 3:15 PM, an unannounced visit was made to the facility to investigate a complaint regarding the quality of care Resident 1 received from the facility. Based on interview and record review, the facility failed to provide adequate hydration (supplying fluid into the body) per Physician's order for one of one sampled resident (1) who was dependent on gastrostomy tube (tube inserted on the belly to provide nutrition for people who cannot obtain nutrition by mouth) which resulted in dehydration for Resident 1.Resident 1 was an 80 year old male with a history of septicemia (Systemic [body wide] illness with toxicity due to invasion of the bloodstream by virulent bacteria), pneumonia (inflammation of the lungs with congestion), malnutrition (a condition that develops when the body does not get the right amount of the vitamins, minerals, and other nutrients it needs to maintain healthy tissues and organ function), hypertension (high blood pressure), chronic airway obstruction (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), dependence on oxygen, difficulty walking, generalized muscle weakness, depressive disorder (a mental illnesses characterized by a profound and persistent feeling of sadness or despair), and congestive heart failure (the inability of the heart to keep up with the demands on it, with failure of the heart to pump blood with normal efficiency). During a review of the clinical record for Resident 1, the "Admission Record" indicated in the Diagnosis Information: "Attention to Gastrostomy and Malnutrition [lack of proper nutrition] of mild degree." (A gastrostomy includes a small, flexible tube inserted into the stomach from the outside of the skin and is required when nutrition and hydration is insufficient based on clinical signs and documented laboratory values. Water and liquid feeding are administered into the stomach for hydration and nutrition. The water helps to maintain body functions, as well as, relieve constipation, maintain bladder function and to help the lungs clear of infection.Both liquid feeding and water can support hydration).The "Order Summary Report", indicated in the physician diet order dated 4/22/15, NPO [nothing by mouth] and Flush with water 50 ml/hr (milliliter per hour) x (for) 20 hours [1000 milliliter per day]. The physician order dated 4/23/15 and renewed on 5/13/15, indicated Resident 1 was to receive liquid feeding 20 hours a day at the rate of 70 ml per hour for a total of 1400 ml per day.During a concurrent interview and record review with the Director of Nursing (DON), the "Input and Output Record", dated 5/11/15 to 5/27/15, indicated Resident 1's gastrostomy tube was not provided with the daily 1000 milliliter of water and the 1400 ml of liquid feeding on the following days:Amounts of Water given each day: 5/11/15, 400; 5/12/15, 900 ml; 5/13/15, 800 ml; 5/14/15, 400 ml; 5/15/15, 900 ml; 5/16/16, 600 ml, 5/17/15, 600 ml; 5/18/15, 400 ml; 5/19/15, 400 ml; 5/20/15, 400 ml; 5/21/15, 960 ml; 5/22/15, 700 ml, 5/23/15, 960 ml; 5/24/15, 800 ml; 5/25/15, none; 5/26/15, none; 5/27/15, 380 ml.Amounts of Liquid Feeding given each day: 5/11/15, none; 5/12/15, 1120 mil; 5/13/15, 1120 ml, 5/14/15, 560 ml; 5/15/15, 1120 ml; 5/16/15, 1400 ml; 5/17/15, 840 ml; 5/18/15, none; 5/19/15, 560 ml; 5/20/15, 560 ml; 5/21/15, 400 ml; 5/22/15, 840 ml; 5/23/15, 560 ml; 5/24/15, 280 ml; 5/25/15, none; 5/26/15, none; 5/27/15, none.During the above 17 days, Resident 1 should have received with the combination of water and liquid feeding, 40,800 ml of fluid. Per the above totals, Resident 1 received 19,060 ml of fluid, a deficit of 21,740 ml of fluid. The DON verified and confirmed the findings.During an interview with Licensed Vocational Nurse (LVN) 1, on 7/6/15, at 3:05 PM, she stated on 5/28/15, "Resident [1] was lethargic and unresponsive." When asked about Resident 1's input and output record, she stated, "We have a protocol that if a resident has gastrostomy tube, we have to record the input and output." When asked if she monitored and documented the input and output, she stated, "I don't remember doing the input and output." When asked how often they have to monitor and document the input and output, she stated, "We have to do it every shift."During a review of the clinical record for Resident 1, the "Nursing Progress Note", dated 5/28/15, at 10:15 AM, indicated, "Try to wake patient [Resident 1] noted patient is lethargic, O2 [oxygen] sat [saturation-level of oxygen in the blood] 84% (normal range is 95-100%), heart rate elevated to 130 (normal heart rate is 60-100 beats per minute), Temperature 97.9 [degrees Fahrenheit], respiration 22 (normal breathing rate is 12-18 breaths per minute). Assessed patient by RN [Registered Nurse] Supervisor. Place phone call to MD [doctor] and notified wife. [Resident 1 was transferred to the hospital]."The hospital "History and Physical", dated 5/28/15, indicated, "The patient arrived at the emergency room at 11:10 today morning with blood pressure [pressure exerted by circulating blood upon the walls of blood vessels] of 63/32 [normal adult blood pressure is 120/80] with DNR/DNI [Do Not Resuscitate/Do Not Intubate - Do not revive] status. The patient was given boluses of fluid, although patient was DNR/DNI. Laboratory Studies: BUN (Blood Urea Nitrogen-blood test indicating kidney health) 48 (normal adult BUN in the blood is between 6 to 20 milligram of urea nitrogen per 100 milliliter of blood), Creatinine (blood test that measures kidney function) 2.6 (normal creatinine in blood is 0.7 to 1.2 milligram per deciliter for men).[Elevated BUN and creatinine can indicate kidney disease and dehydration].The x-ray report for Resident 1, completed while he was at the facility, dated 5/12/15, indicated he had a small amount of fluid in the lower portion of his right lung. The x-ray report for Resident 1 completed while he was at the facility, dated 5/27/15, one day before he was admitted to the hospital, indicated he had pneumonia (inflammation of the lungs) in the left lower part and the right upper part of his lungs. The hospital emergency department physician's notes dated 5/28/15, read "Diagnoses: Severe sepsis due to pneumonia."The hospital "Discharge Summary", dated 5/28/15, indicated, "The patient was in septic shock (a potentially lethal drop in blood pressure due to the presence of bacteria in the blood and part of the treatment is to administer fluids into the blood stream via a catheter.) when evaluated in the emergency room. Patient was almost dead, but the family chose to continue with fluid resuscitation. The patient expired on 5/28/15 peacefully."The facility policy and procedure titled, "Intake Measuring and Recording", dated 10/2010, indicated, "General Guidelines: 5. At the end of your shift, total the amounts of all liquids the resident consumed. Documentation: The following information should be recorded in the resident's medical record, per facility guidelines: 3. The amount (in mls) of liquid consumed. Report other information in accordance with facility policy and professional standards of practice."The nursing manual titled "Lippincott Manual of Nursing Practice" ninth edition dated 2010, indicated the nurse was to administer the prescribed amount of enteral feeding (gastrostomy feeding) and water flushes. This manual read "Document type and amount of feeding, amount of water given, and patient tolerance of procedure. Monitor breath sounds, gastric distention, diarrhea or constipation, intake and output, daily weight, and serum chemistry results."Therefore, 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. |
| 630004101 |
Bethesda Lutheran Communities - Wren I |
120011978 |
B |
10-Feb-16 |
737N11 |
2529 |
Welfare and Institution Code 4502 (b)(8) - A right to be free from harm, including unnecessary physical, restraint, or isolation, excessive medication, abuse, or neglect. On 9/3/2015 at 4:45 PM, an unannounced visit was made to the facility to investigate an entity reported incident regarding an allegation of verbal abuse.Based on interview and record review, the facility failed to protect one sampled client (1) from verbal abuse. This failure resulted in Client 1 being verbally abused, and had the potential to cause Client 1 emotional distress.Client 1 is a 65 year old female; she is verbal and able to make her needs known. She has a history of becoming easily agitated, and may become physically and/or verbally aggressive. During a review of the facility report, dated 8/24/15, it read in part, on 8/20/15 at approximately 8:15 AM, the Qualified Individual Disabilities Professional (QIDP) received a call from Direct Support Professional (DSP 2) reporting that there had been an incident at the facility involving night shift DSP 1 and Client 1. DSP 2 heard Client 1 screaming, and when she entered the living room area she observed DSP 1 shaking his finger in Client 1's face and yelling at Client 1 to "Stop yelling and calm down!"During an observation and interview with Client 1, on 9/3/15, at 4:48 PM, Client 1 was observed answering the front door. When questioned regarding the incident of 8/20/15, Client 1 did not respond to questioning, and began talking about her day at her day program.During an interview with DSP 2, on 10/5/15, at 10:58 AM, she stated she was in the facility office whenshe heard Client 1 scream and heard DSP 1 yelling "Stop it." DPS 2 went to the living room and observed Client 1 seated in a recliner.DSP 1 was standing over Client 1 with his face close to Client 1, while he was pointing his finger at Client 1. DSP 2 stated Client 1 was upset, so she moved DSP 1 out of the way and took Client 1 to the office where she comforted her.The facility policy and procedure titled " Abuse, Neglect, Misappropriation and Mistreatment, of person served" dated 3/8/13, indicated the definition of abuse was the act or repeated acts by a person, towards another...that causes or could reasonably be expected to cause mental or emotional damage to a person, including harm to the person's psychological or intellectual functioningTherefore the facility failed to protect Client 1 from verbal abuse.The above violation has a direct relationship to the health, safety or security of the client. |
| 120000320 |
Bakersfield Healthcare Center |
120012036 |
A |
01-Mar-16 |
O9RB11 |
8947 |
F224-The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. Based on interview and record review, the facility failed to protect Resident 1 from neglect when staff did not promptly take necessary actions after Resident 1 was noticed to be lethargic (a lowered level of consciousness). This failure resulted in Resident 1 being transferred to the acute care hospital. An unannounced visit was made to the facility on 1/8/16 at 1:30 PM, to investigate an allegation of resident neglect by the staff. Resident 1 was an 83 year old female with diagnoses including urinary tract infection (bladder infection), generalized muscle weakness, dementia without behavioral disturbance (a syndrome which causes memory loss, decline in cognition, and difficulties with activities of daily living), and hypertension (high blood pressure).During a review of the clinical record for Resident 1, the Minimum Data Set (MDS- resident assessment tool), dated 12/11/15, indicated Resident 1 had severe cognitive impairment. Resident 1 required supervision with feeding, extensive assistance with bed mobility and total dependence with transfers.During a review of the clinical record for Resident 1, the nurse's notes, dated 12/15/15, at 1 PM, indicated "Resident alert and verbally responsive. Resident cont [continue] PT [Physical Therapy- A branch of rehabilitative health that uses specially designed exercises and equipment to help patients regain or improve their physical abilities.]/OT [Occupational Therapy- treatment to develop, recover and maintain daily living and work skills]."During a review of the clinical record for Resident 1, the nurse's notes, dated 12/15/15, at 9 PM, indicated "Res [Resident] alert and verbally responsive...Res were up in w/c [wheelchair] during dinner and activities. PT/OT ongoing. Tol [tolerated] well..."During a review of the clinical record for Resident 1, the nurse's notes, dated 12/17/15, at AM shift, indicated "Resident is alert. Participating in PT...Res are up in wheelchair. (No complaint of) pain, discomfort or distress..."During an interview with Family Member (FM) 1, on 1/8/16, at 10:07 AM, he stated on 12/18/15, Resident 1 was in her room with staff who tried to feed her but she would not eat. He stated Resident 1 was unresponsive and was slumped over in her wheelchair with her face almost on the plate. FM 1 stated a week earlier, she was talking, laughing, feeding herself and was able to hold a coffee cup. FM 1 told staff that Resident 1 needed to go to the emergency room. Staff had told him that he had to take Resident 1 to the hospital or he can call or go to the doctor's office as she was already discharged. FM 1 went to the doctor's office and found out the doctor was on vacation. FM 1 went back to the facility and saw Resident 1's belongings were all packed up. Resident 1 was in the activity room exhibiting labored breathing (abnormal respiration evidenced by increased effort to breathe). He told the staff to call 911 (the number intended for use in an emergency for emergency responders to be sent to the caller's location) and staff told him that Resident 1 was already discharged.During an interview with Staff 1, on 1/14/16, at 1:46 PM, she stated she noticed the change in Resident 1's level of consciousness (LOC- measurement of a person's responsiveness to stimuli from the environment) on 12/18/15 around 12 PM. She stated Resident 1 ate fine at breakfast and would not eat during lunch. Staff 1 stated Resident 1 was able to feed herself before. Resident 1 took a bite and fell asleep. She tried to wake Resident 1 up to eat and stated, "She is out of it." Staff 1 had notified the nurse (License Vocational Nurse 1- LVN 1) regarding the change in Resident 1's LOC. She stated the nurse was talking about discharge and she did not remember the nurse assessing Resident 1.During a review of the clinical record for Resident 1, the nurse's notes, dated 12/18/15, at 1 PM to 2:45 PM, indicated Resident 1 was transferred to the acute hospital after FM 1 notified the staff of a change of condition for Resident 1 and "Resident appeared in no distress". There was no indication Resident 1's vital signs were taken (vital signs include blood pressure, heart rate, pulse, and temperature) or that she was actually assessed by a nurse after FM 1 notified the facility staff of a change of condition in Resident 1 which as indicated in the nurse's notes above, was after 1 PM.During a concurrent interview with the Registered Nurse Supervisor (RNS) and review of Resident 1's clinical record on 1/8/16, at 3 PM, she stated Resident 1 was scheduled to be discharged that day but when the sons (FM 1) were all there, they did not want the resident to be transferred to the board and care home (special facilities designed to provide those who require assisted living services both living quarters and proper care with activities of daily living) because they felt that Resident 1 was not improving. The RNS stated the sons were upset with the insurance company and ordered that Resident 1 be sent to the emergency room. The RNS stated, "Resident (1) was alert but sleepy which was normal for her baseline (normal behavior). The RNS verified the above nurse's notes and verified no vital signs or assessment was completed after the FM 1 notified the staff of a change in condition for Resident 1.During an interview with LVN 1 on 1/14/16, at 12:44 PM, she stated Resident 1 went to therapy (PT/OT) and was confused but responsive. When asked about the incident with Resident 1 on 12/18/15, she stated she could not recall fully the incident and could not remember if Resident 1 was lethargic before going to the hospital.During an interview with the Physician Assistant (PA) in charge of Resident 1's medical care at the time of the incident (12/18/15) on 1/20/16, at 10:07 AM, she stated she had received a call from her office that family was concerned that Resident 1 had a change of condition. The PA stated, I called the nursing home and the nurses were saying resident was in and out that she had good days and bad days. Family told the office case manager that resident was up in a wheelchair and was unresponsive. I thought maybe the family saw something that the staff didn't like a mini stroke or something. I said to go ahead and send (Resident 1) to the ER (emergency room). Resident (1) was picked up by ambulance and sent to ER. A week later, I learned Resident (1) died."The hospital Emergency Department clinical record for Resident 1 was reviewed. Resident 1's clinical record indicated that she died approximately 3 hours after leaving the facility. The acute hospital Emergency Department Notes, dated 12/18/15, at 3:14 PM, indicated Resident 1 was immediately evaluated upon arrival in the emergency room. Resident 1 was hyper-lethargic and her blood pressure was 70/36 (severely low blood pressure-normal is considered to be around 120/80).The Emergency Department Critical Care Notes, dated 12/18/15, at 3:23 PM, indicated Resident 1 had agonal (gasping) respirations and was intubated (placement of plastic tube through the mouth into the windpipe to maintain an open airway).The Emergency Department Laboratory Results, dated 12/18/15, at 4:23 PM, indicated the elevation of her laboratory values was consistent with sepsis (whole body inflammatory response to infection).The Emergency Department Critical Care Notes, dated 12/18/15, indicated "At (4:47 PM Resident 1's) pulse could not be felt. CPR [Cardiopulmonary resuscitation - an emergency procedure performed in an effort to manually preserve intact brain and heart function] was started and was given a milligram (mg) of epinephrine [medication that causes the heart to contract] and bicarbonate [medication that increases the heart's ability to pump blood]. At (4:50 PM, Resident 1's) pulse and cardiac activity resumed and (Resident 1's) cardiac activity resumed."During a review of the clinical record for Resident 1, the Emergency Department Critical Care Notes, dated 12/18/15, indicated "At (5:16 PM Resident 1) once again became asystole [absence of any heartbeat ] with no pulse... At 5:34 PM, pulse returned as verified by an ultrasound [medical imaging] of the heart."During a review of the clinical record for Resident 1, the Emergency Department Critical Care Notes, dated 12/18/15, indicated "At (5:59 PM, Resident 1) once again went into asystole... CPR continued until the family requested that no further intervention be performed. (Resident 1) was therefore declared deceased at (6:10 PM)."The facility policy and procedure titled "Prohibition of Abuse, Neglect, Mistreatment and Misappropriation of Resident Property", dated 10/2012, indicated "Neglect is the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness." |
| 120000320 |
Bakersfield Healthcare Center |
120012086 |
B |
16-Mar-16 |
NM8711 |
3796 |
T22 72520(a)(b)(c) (a) If a patient of a skilled nursing facility is transferred to a general acute care hospital as defined in Section 1250(a) of the Health and Safety Code, the skilled nursing facility shall afford the patient a bed hold of seven (7) days, which may be exercised by the patient or the patient's representative. (b) Upon admission of the patient to the skilled nursing facility and upon transfer of the patient of a skilled nursing facility to a general acute care hospital, the skilled nursing facility shall inform the patient, or the patient's representative, in writing of the right to exercise this bed hold provision. No later than June 1, 1985, every skilled nursing facility shall inform each current patient or patient's representative in writing of the right to exercise the bed hold provision. Each notice shall include information that a non-Medi-Cal eligible patient will be liable for the cost of the bed hold days, and the insurance may or may not cover such costs. (c) A licensee who fails to meet these requirements shall offer to the patient the next available bed appropriate for the patient's needs. This requirement shall be in addition to any other remedies provided by law. Based on interview and record review, the facility failed, upon transfer to the acute hospital, to offer a seven day bed hold, offer the first available bed, and readmit one of one sampled resident (1). This resulted in a violation of Resident 1's admission agreement and Regulation. Findings:The clinical record for Resident 1 was reviewed. Resident 1's admission record indicated her pay sources included Medicare and Medicaid. A seven day bed hold was not documented in this record. During an interview with the Administrator, on 2/12/16, at 1:10 PM, she stated yesterday (2/10/16) the resident (Resident 1) was transferred to the acute hospital because of her behavior. The Administrator stated the resident was not offered a seven day bed hold and the facility decided not to readmit the resident back to the facility. During an interview with the acute hospital House Manager (HM), on 2/17/16, at 8:55 AM, she stated the resident was medically stable, but the resident was still at the hospital because the facility was refusing to readmit the resident.The facility provided the booklet titled "California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities" dated 5/11, as the admission agreement provided to all admitted residents. This Admission Agreement read "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 have 24 hours after receiving this notice to let us know whether you want us to hold your bed for you. If Medi-Cal [Medicaid] is paying for your care, then Medi-Cal will pay for up to seven days for us to hold the bed for you. If you are not eligible for Medi-Cal and the daily rate is not covered by your insurance, then you are responsible for paying $________ for each day we hold the bed for you. You should be aware that Medicare does not cover costs related to holding a bed for you in these situations. 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. You should also note that, if our Facility participates in Medi-Cal and you are eligible for Medi-Cal, if you are away from our Facility for more than seven days due to hospitalization or other medical treatment, we will readmit you to the first available bed in a semi-private room if you need the care provided by our Facility and wish to be readmitted." |
| 120001395 |
Brookdale Riverwalk SNF (CA) |
120012293 |
A |
06-Jun-16 |
K69M11 |
6331 |
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. Based on observation, interview, and record review, the facility failed to implement it's pain control policy and procedure for one of one sampled resident (Resident 1) which resulted in Resident 1 experiencing uncontrolled pain. An unannounced visit was made to the facility on 3/23/16, at 2:13 PM to investigate an allegation of unrelieved pain for Resident 1. Resident 1 was a 74 year old female with diagnoses including chronic obstructive pulmonary disease with acute exacerbation (a progressive disease that makes it difficult to breathe), congestive heart failure (a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues), generalized muscle weakness, difficulty walking, coronary artery disease (a blockage of one or more arteries that supply blood to the heart), hypertension (high blood pressure), angina pectoris (Chest pain due to an inadequate supply of oxygen to the heart muscle), major depressive disorder (a mental illness that involves the body, mood, and thoughts. It interferes with daily life and normal functioning), anxiety disorder (A chronic condition characterized by an excessive and persistent sense of apprehension), and, insomnia due to medical condition [difficulty sleeping- the presence of comorbid (the existence of more than one disorder or disease at the same time) medical conditions is a significant contributor to the increased prevalence of insomnia in the elderly]. During an interview with Resident 1 on 3/23/16 at 2:20 PM, Resident 1 stated because of her diagnoses, she was in constant pain. Resident 1 stated the doctor had ordered morphine (medication used for severe pain) in addition to Norco (medication used for moderate pain) for her extreme pain but she did not like taking the morphine because it made her very sleepy. She stated, "They tell me I'm dying. I will be going on hospice soon. I want to spend my last days with my family and not be too sleepy to be aware they are here." She stated the Norco was given to her every four hours but it only lowered her pain for about 30 minutes of those four hours. Resident 1 stated the facility staff had not told her of any other options for pain control except for the morphine. During this interview, Resident 1 was observed constantly shaking, she was very anxious while rubbing her stomach which was where she stated she had the most pain. Resident 1 stated she has been telling all the nursing staff that her pain was not controlled by the Norco alone. The electronic clinical record for Resident 1 was reviewed with the Director of Staff Development (DSD) on 3/23/16 at 2:48 PM. The Minimum Data Set (MDS-an assessment tool) dated 3/16/16, indicated Resident 1 had a score of 15 out of 15 which meant she was cognitively intact. The MDS pain assessment interview indicated Resident 1 had frequent pain that made it hard for her to sleep at night, limited her day-to-day activities, and was usually a 7 out of a possible 10 on the pain scale. A pain scale is a numeric rating scale from 0 through 10 for patients to self-report their level of pain. Zero means no pain, 1-3 means mild pain, 4-6 means moderate pain, and 7-10 means severe pain that is often disabling and patients are unable to perform activities of daily living (ADLs). The physician's orders for Resident 1 were reviewed and indicated Resident 1 was to received MS Contin (morphine), Norco, or acetaminophen (a pain medication used for mild pain) for pain control. No other pain medication was ordered for Resident 1. Resident 1's care plan for her chronic pain indicated staff was to observe and report changes in usual routine, sleep patterns, decrease in function abilities, decrease ROM (range of motion), withdrawal or resistance to care. Resident 1's care plan for pain medication indicated the staff was to monitor the efficacy of the pain medication and notify the attending doctor if the pain medication was not effective. The medication administration record for the month of March 2016, indicated Resident 1 was receiving Norco one tablet every four hours. The progress notes for Resident 1 were reviewed from 3/12/16 through 3/23/16. There was no progress notes indicating the attending doctor was notified concerning Resident 1's continued uncontrolled pain. The DSD verified the above findings during the record review. During an interview with the Licensed Nurse (LN) on 3/23/16 at 3:25 PM, she stated Resident 1 often complained to her about the pain medication decreasing the pain for about 30 minutes before the pain would increase back to a high level. The LN stated Resident 1 was always anxious and shaky. The LN stated Resident 1 had refused the morphine because it made her lethargic and she wanted to be awake to spend time with her family. The LN stated she had never called the attending doctor, notify other licensed nurses, or chart in the clinical record about Resident 1's continued unrelieved pain and refusal of the morphine. During an interview with the Assistant Director of Nursing on 3/23/16, at 3:30 PM, she stated she was unaware of Resident 1's pain issues and that licensed staff should call the attending doctor when Resident 1's pain was not controlled. The facility policy and procedure titled "Pain Management" dated 11/07, indicated "The purpose of the policy is to identify, treat, and manage the resident's pain levels....Pain management needs will be addressed on the resident's care plan and monitored by Interdisciplinary Team (IDT)....New or worsening pain will be identified as a Change of Condition." The facility policy and procedure titled "Clinical Status Change" dated 11/07, indicated "When a resident is assessed as having a clinical status change, the licensed nurse will follow through in documenting notification to family/responsible party, the physician and other licensed nurses in order to facilitate the appropriate plan of care." 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. |
| 120000320 |
Bakersfield Healthcare Center |
120013008 |
A |
15-Mar-17 |
1RY411 |
12502 |
F278
g) Accuracy of Assessments. The assessment must accurately reflect the resident's status.
(h) Coordination
A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals.
(i) Certification
(1) A registered nurse must sign and certify that the assessment is completed.
(2) Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment.
(j) Penalty for Falsification
(1) Under Medicare and Medicaid, an individual who willfully and knowingly-
(i) Certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment; or
(ii) Causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty or not more than $5,000 for each assessment.
(2) Clinical disagreement does not constitute a material and false statement.
Based on observation, interview, and record review, the facility failed to re-assess one of four sampled residents' ability to smoke independently (1) which resulted in Resident 1 catching on fire while smoking and then being transferred to a hospital for severe burns.
An unannounced visit was made to the facility on 1/10/17, at 9:23 AM, to investigate an incident involving a resident receiving burns while smoking.
Resident 1 was a 60-year-old female, with diagnoses of hemiplegia (loss of ability to move one side of the body), polyneuropathy (a disorder occurs when many nerves throughout the body malfunction simultaneously. It frequently affects the feet and hands causing weakness loss of sensation pins-and-needle sensations or burning pain), and nicotine dependence (an addiction to tobacco products).
The clinical record for Resident 1 was reviewed on 1/10/17. The "History and Physical" for Resident 1, dated 3/8/14, indicated Resident 1 had paralysis to her left arm and left leg. The Minimum Data Set (MDS- a comprehensive assessment tool), dated 12/5/16, indicated Resident 1's cognition was moderately impaired (a decline with mental processes of perception, memory, judgment, and reasoning).
The care plans for Resident 1 were reviewed. The care plan titled "SMOKING CARE PLAN", initiated on 9/30/16 and revised on 12/6/16, indicated Resident 1 "IS ABLE to smoke independently." One of the interventions listed was to "Assess resident for ability to smoke independently per facility policy."
The "Change of Condition" for Resident 1 dated 1/8/17, at 10:14 AM, indicated: "Resident was outside smoking when CNA (Certified Nursing Assistant 1) heard resident yell for help, (CNA 1) was in another patients room and saw resident catch [sic] fire thru patio door, (CNA 1) ran thru the patio door immediately to help resident while yelling for help. Licensed Nurse (LN 1) responded to (CNA 1) yells and helped put fire out while (CNA 2) also helped remove patient's burnt clothing, when questioned patient stated sparks from her cigarette were blown by wind onto her sweater causing the fire. 911 was called, Fire Department and ambulance responded and took patient to a local acute hospital Burn unit."
During an interview with CNA 2, on 1/10/17, at 9:47 AM, she stated, on Sunday (1/8/17), at approximately 10 AM, she was in the hallway when she heard a loud voice yelling for help. CNA 2 responded and went to the outside smoking patio and saw the fire on Resident 1's jacket. CNA 2 stated, "It's so bad; it's like what you see in the movie." CNA 2 stated she saw CNA 1 taking Resident 1's jacket off the resident's right arm, but the fire moved to the left arm. While another Licensed Nurse (LN 1) was reaching over from the resident's back and was also helping in removing Resident 1's jacket. But LN 1 realized the fire was so bad, and so LN 1 took the water hose and put the fire out. CNA 2 stated Resident 1 had burns to the right face, right arm, right breast, and right side of the body. CNA 2 stated Resident 1 was smoking independently but she always felt Resident 1 needed supervision in smoking, because Resident 1 was paralyzed to the left side of her body. CNA 2 stated Resident 1 smoked in the smoking patio all day long (everyday) and was keeping her own cigarettes and lighters.
During a concurrent observation and interview with Resident 2, on 1/10/17, at 10:58 AM, in the smoking area, Resident 2 stated Resident 1 needed a smoking apron and supervision while smoking because Resident 1 was not paying attention to what she was doing. Resident 2 stated, "Sometimes (Resident 1) falls asleep while she was smoking." Resident 2 stated he had informed the staff Resident 1 needed supervision while smoking over a month ago. Resident 2 stated in one incident, Resident 1 was smoking with her cigarette in her right hand and suddenly placed her right hand on top of her left chest and burned her clothes and created holes. Resident 2 stated when that happened; it was good thing he was there to put out the fire. Resident 2 stated he told a CNA about the incident, and the CNA told him Resident 1 should pay attention to what she was doing, and that he (Resident 2) was there to supervise Resident 1. Resident 2 could not recall the name of the CNA he talked to. Resident 2 stated he also informed the Activity Director (AD) about the same incident. Resident 2 stated he had informed the facility staff on several occasions that Resident 1 needed supervision while smoking but they (facility staff) did not listen. Resident 2 stated they (facility staff) expected him (Resident 2) to supervise Resident 1.
The clinical record for Resident 2 was reviewed. The Minimum Data Set for Resident 2, dated 11/28/16, indicated Resident 2 was cognitively intact (normal mental processes).
During an interview with the AD, on 1/10/17, at 11:20 AM, the AD stated he noticed Resident 1 had declined and could not properly hold her cigarettes anymore; the resident was having a problem with her balance while sitting in her wheelchair, and was usually leaning on her left side. The AD stated Resident 1 had burned her clothes on multiple occasions but Resident 1 did not like to wear a smoking apron. The AD stated he thought Resident 1 needed supervision while smoking. The AD stated he informed the Previous Director of Nursing (PDON) regarding Resident 1 burning her clothes and she could not smoke independently anymore. The AD could not provide further information if the facility staff had reassessed Resident 1's ability to smoke independently after his conversation with the PDON. The PDON's last day with the facility was 12/19/16.
During a concurrent observation in Resident 1's room and interview with CNA 3, on 1/10/17, at 2:50 PM, CNA 3 stated Resident 1 usually used a purple blanket to cover her lap when smoking outside. The purple blanket was on top of the bed and was noted with approximately 14 holes (each hole was measuring approximately 0.5 centimeters in diameter). CNA 3 stated Resident 1 would also place a square pillow on her left side to improve her positioning while sitting in the wheelchair. CNA 3 stated, "Here's the pillow." The square pillow was noted with two holes. CNA 3 stated the holes were from cigarette ashes that were dropping off onto Resident 1's blanket and pillow while she was smoking. CNA 3 stated she noticed, in the past weeks, Resident 1 was sleeping more in her wheelchair and stated Resident 1 needed supervision in smoking. CNA 3 stated she did not notify the licensed nurse the resident was sleeping more in her wheelchair because she (CNA 3) thought it was "Due to her meds (medications)."
During a further review of Resident 1's "SAFE SMOKING EVALUATION," dated 10/22/16, the summary of the evaluation deemed Resident 1"may smoke independently." On this form, under "OBSERVATIONS", it indicated Resident 1 was able to smoke safely by demonstrating "Does not allow ashes or lit material to fall while smiling, inhaling or holding smoking items. Remains alert and aware while smoking. Does not forget he/she is smoking or falls asleep holding them. Does not endanger self or others while smoking. Does not burn furniture, clothing, skin, self or others. Turns oxygen off prior to lighting cigarettes. Smokes only in designated area."
The facility "SAFE SMOKING EVALUATION" document indicated under "Directions: "For a resident who wishes to smoke (e.g., cigarettes, cigars, pipe) perform evaluation on admission, quarterly, annually, at a significant change, or if there has been an incident of unsafe smoking observed or reported (or per facility policy). Evaluate Resident Status and Potential Risk Factors and check YES or NO under the appropriate evaluation date..."
During a concurrent interview with the AD, and review of Resident 1's "SAFE SMOKING EVALUATION," on 2/9/17, at 2:33 PM, the AD reviewed the document and confirmed the document. AD stated the PDON was aware of Resident 1's unsafe smoking behavior and stated "I'm just waiting for her (PDON) to act." The AD stated the PDON told him she (PDON) was the "Leader" of the team and he could not perform the reassessment by himself.
During a concurrent interview with the Director of Nursing (DON), and review of the clinical record for Resident 1, on 2/9/17, at 3:05 PM, she stated she was the one who performed the "SAFE SMOKING EVALUATION" on 10/22/16, and Resident 1 was "Fine." The DON stated she was not aware of Resident 1's unsafe smoking behavior in the past few weeks.
The DON stated, on 12/29/16, she was included in the "CARE PLAN CONFERENCE" for Resident 1. The DON was asked if the IDT (Interdisciplinary Team- a group of people organized to do a task together) had discussed in the "CARE PLAN CONFERENCE" about Resident 1's smoking ability to smoke independently, with supervision, or discussion about smoking reassessment for Resident 1. The DON stated she could not recall if they (the interdisciplinary team) discussed the unsafe smoking behavior. The DON stated she could not say "Yes or No, because it was not documented."
During a review of Resident 1's emergency room record, dated 1/8/17, the emergency room report indicated: "She (Resident 1) apparently ignited herself and several team members had to put fire out essentially with her hands and with other implements. The patient now is screaming in pain. She has burns obviously over the face, neck, right breast and right hand. There is also mild left hand burns as well...predominantly 3rd degree burns (third degree burns is a full thickness burn. This type of burn destroys the outer layer of skin and the entire layer beneath) are present. The patient does have areas of second-degree burns (a second-degree burn affects the outer layer of skin and part of the inner layer of skin) over the trunk and over the right arm. The hand itself is 3rd, has 3rd degree burns contractures (a condition of shortening or hardening of muscles, tendons, or other tissue often leading to deformity and rigidity of joints) present on the right." Indicated under Impression: "Multiple second-degree and third-degree burns... The patient will require...endotracheal intubation (the placement of a flexible plastic tube into the windpipe to maintain an open airway and usually requiring ventilation of the lungs by a machine), central line placement (tubing inserted for continuous access to a chest vein for administering fluids and medicines) and admission to Burn ICU (ICU-intensive care unit)."
The facility policy and procedures titled "Smoking," dated 10/2012, indicated, under Action Steps, "In accordance with the state fire safety codes, the Executive Director/designee implements methods for the storage of smoking materials. The Interdisciplinary Team ensures an assessment is completed by the Licensed Nurse/designees at the time of admission, quarterly, annually and upon significant change. The community staff will make reasonable accommodations to assist residents identified through the Safe Smoking Evaluation as unsafe to smoke with supervision. The Interdisciplinary team/designee will document interventions related to safe smoking on the resident's individualized plan of care. Violations of the smoking rules will be addressed by the Executive Director/designee."
Several facility staff was aware of Resident 1's unsafe smoking behavior but failed to conduct a reassessment as required managing her increasing risk of injuring herself due to a change of mental alertness. |
| 220000041 |
BROOKSIDE SKILLED NURSING HOSPITAL |
220013025 |
B |
9-Mar-17 |
699N11 |
6844 |
F206 483.15(e)(1)(2) POLICY TO PERMIT READMISSION BEYOND BED-HOLD
(e)(1) Permitting residents to return to facility.
A facility must establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave. The policy must provide for the following.
(i) A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, returns to the facility to their previous room if available or immediately upon the first availability of a bed in a semi-private room if the resident-
(A) Requires the services provided by the facility; and
(B) Is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services.
(ii) If the facility that determines that a resident who was transferred with an expectation of returning to the facility, cannot return to the facility, the facility must comply with the requirements of paragraph (c) as they apply to discharges.
(e)(2) Readmission to a composite distinct part. When the facility to which a resident returns is a composite distinct part (as defined in ? 483.5), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there.
This REQUIREMENT is not met as evidenced by:
Based on interview and record review the facility failed to permit one Patient (Patient 1) to return to facility after Patient 1 was hospitalized on XXXXXXX16.
This failure had the potential to cause significant humiliation, indignity, anxiety or other emotional trauma for Patient 1 and the family of Patient 1.
Findings:
Patient 1 was admitted to the facilitXXXXXXX 3/8/13 with diagnoses that included bi-polar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), bacteremia (bacteria in the blood stream), and urinary retention (inability to empty the bladder).
During a review of the clinical record for Patient 1, the minimum data set (MDS, a Patient assessment tool) dated 1/5/16 indicated a brief interview for mental status (BIMS, a brief scanner to help in detecting cognitive impairment) score of 7 (BIMS score of 0 -7 indicates severe cognitive impairment). The behavior assessment of the MDS indicated Patient 1 had delusions, exhibited verbal behaviors, such as screaming, threatening, and cursing, toward others, and rejected or refused necessary care and treatments.
The care plan (a written or computerized guide that organizes information about the Patient ' s care) dated 6/10/14 with update 1/26/16 indicated interventions for infectious process, such as washing hands of Patient 1 before and after meals, and consider a private room if no proper roommate is possible.
On 2/5/16, Patient 1 was lethargic (drowsy having little energy) with blood pressure of 100/60 and heart rate of 40. Patient 1 was diagnosed with urinary tract infection and sepsis and transferred to an acute care facility.
On 5/11/16, Patient 1 was refused re-admission to the first available semi-private bed after being discharged from acute care facility.
Review of Interdisciplianry Team (IDT) Notes dated 5/11/16 indicated, "... After significant consideration and review of the information gathered and discussion with Infectious Disease experts, the (facility name) IDT team concluded that we will not be able to ensure excellent clinical care and services for ALL the (patients) entrusted to our care. On 5/11/15 (Administrator) notified the hospital that we would not be able to consider (Patient 1) for readmission."
During an interview with Administrator (Admin) on 1/18/17, at 1 PM, Admin stated the "behaviors" of Patient 1 posed a danger to other patients if Patient 1 was admitted to a semi-private room. When asked about the previous behaviors Admin stated Patient 1 would rummage through the linen cart, throw dirty linen, clothes, and food at staff in addition Patient 1 would yell at roommates and their visitors. When asked how the facility handled these behaviors in the past Admin stated Patient 1 was in a semi-private room without a roommate.
Admin stated the behaviors of Patient 1 would make it hard for facility to provide the recommended "enhanced standard precautions" (integration and consolidation of Center for Disease Control (CDC) recommendations for Standard Precautions, Transmission-based Precautions, and Intensified Interventions [Joint Infection Prevention and Control Guidelines - Enhanced Standard Precautions (ESP) - California Long-Term Care Facilities, 2010] needed for Patients colonized with VRE (bacteria are present but no symptoms of infection is present).
Review of the facility census record printed 1/18/17 indicated from 3/8/13 until 2/5/16 Patient 1 was in the same semi-private room.
Review of California Association of Health Facilities document titled Joint Infection Prevention and Control Guidelines - Enhanced Standard Precautions (ESP) - California Long-Term Care Facilities, 2010 indicated ...Process Measures - Admission Assessment
1. No request for long term care facility admission or readmission should be refused based on knowledge of a positive test for any multi-drug resistant organism (such as VRE)
2. No request for negative tests prior to inter-facility transfer should be made. New or returning Patients should be admitted based on the ability of the facility to provide supportive and restorative care.
3. Develop a Patient care plan, which takes into consideration the individual ' s risk of transmission or acquisition of infectious agents.
Review of acute hospital Progress Record Infectious Disease consult note dated 5/6/16, entered by Infectious Disease Physician indicated Patient 1 likely colonized with VRE and may grow this organism in the future, note indicated no treatment needed at this time.
Review of the facility policy and procedure titled "Admission, Transfer, and Discharge Rights" dated 5/1/15, indicated under section titled Bed Hold Rights" ..."When the Patient is ready for readmission to the facility ...the facility shall offer the next appropriate bed to the Patient."
Review of facility census indicated Patient 1 resided in the facility from XXXXXXX 13 until transfer to acute facility XXXXXXX 16 in a semi-private room without a roommate.
Therefore, the facility failed to permit one Patient (Patient 1) to return to the facility after Patient 1 was hospitalized on XXXXXXX16.
The violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients in the facility. |
| 240001552 |
Bethesda Lutheran Communities - Bochee |
240010602 |
B |
24-Apr-14 |
SV0611 |
4067 |
REGULATION VIOLATION: Title 22 76872 Developmental Program Services - Staffing and 76923 Unusual Occurrence 76872 (l) Direct care staff shall be in the facility whenever clients are present. AND 76923 (a) Occurrences such as but not limited to, epidemic outbreaks of any disease, prevalence of communicable disease, whether or not such communicable disease is required to be reported by Title 17, California Administrative Code, Section 2500 or infestation by parasites or vectors, poisonings, fires, major accidents, deaths from unnatural causes or other catastrophes which threaten the safety or health of clients, personnel or visitors are deemed to be unusual occurrences and shall be reported by the facility within 24 hours either by telephone, with written confirmation, or by telegraph to the local health officer and the Department.FINDINGS: The facility failed to ensure the health and safety of clients at all times by failing to have a staff present whenever there were clients in the facility. Six clients were left unsupervised on December 29, 2009, from 9:20 PM through 9:45 PM. The facility failed to report the unusual occurrence of leaving the clients unsupervised on December 29, 2009, from 9:20 PM to 9:45 PM, to the Department, as required. On February 1, 2010 at 10:20 AM, review of the "Special Incident Report" dated January 18, 2010, and other facility documents were conducted. Review of the facility's incident report dated January 18, 2010 showed that on December 29, 2009 at approximately 9:20 PM through 9:45 PM, the facility was left with no staff supervision for a total of six clients. The incident report also indicated that DCS (direct care staff) 3 arrived at the facility on December 29, 2010, prior to 9:45 PM and found that there was no other staff present. DCS 3 reported that one client (Client A) was awake. Client A was found at the kitchen having a snack while the other five clients were asleep. Also the kitchen oven was observed on at 400 degrees Fahrenheit, without food inside and the oven door slightly opened. In addition, the medication cabinet key was found on the counter in the kitchen. Client A was a 41 year old male who was admitted to the facility on May 18, 1991, with diagnoses that include Down's syndrome, mild-moderate mental retardation, dementia, and pacemaker insertion on July 2, 1999.During the interview with the QMRP (Qualified Mental Retardation Professional) on February 1, 2010 at 11:00 AM, the QMRP confirmed and stated that Client A was a highly functioning client. Review of the time sheet for December 29, 2009, revealed that DCS 1 had clocked out at 9:00 PM, DCS 2 had clocked out at 9:01 PM, and DCS 3 had clocked in at 9:45 PM. Review of DCS 1's written declaration dated January 20, 2010, revealed and confirmed that on December 29, 2009, she clocked out at 9:00 PM, but left the facility at 9:20 PM not realizing that she had left early, assuming another staff was talking to Client A, since Client A's room was lit. During an interview with the Program Manager on June 16, 2010 at 2:05 PM, she stated that as a "rule of thumb" the medication cabinet key is put back on the hook in the office after each use. However, the medication cabinet key was found on the kitchen counter by DCS 3, when she got to the facility on December 29, 2009 at 9:45 PM. The Program Manager was not able to give a clear answer as to why the medication cabinet key was found on the counter that evening. During an interview with the QMRP and the Program Manager on June 16, 2010 at 2:10 PM, both confirmed and stated that DCS 1 had admitted that she had set the oven to 400 degrees Fahrenheit and that action was a fire hazard. The facility's failure to provide client supervision on December 29, 2009 at 9:20 PM thru 9:45 PM; failure to ensure the oven was turned off and failure to secure the medication key placed all clients at risk for health and safety hazard, for a universe of 6 clients.These facility failures had direct or immediate relationship to the health, safety, or security of the patient. |
| 240001854 |
Bishop Care Center |
240013163 |
B |
2-May-17 |
UQP511 |
4604 |
72631 (b) Detachable extension cords shall be readily accessible to patient at all times.
The facility failed to implement policies and procedures to ensure an emergency call light in the bathroom was able to be reached for Patient A. This failure resulted in Patient A to experience a fall on March 18, 2017 and sustain a laceration (deep wound) of the forehead requiring sutures (stitches).
Finding:
An unannounced visit was made to the facility on March 22, 2017 at 4:45 PM, to investigate a complaint regarding quality of care.
During an observation on March 23, 2017 at 9:35 AM, in Patient A's room, the patient was lying in bed with bandages on top of his head.
During an interview with Patient A, on March 23, 2017 at 9:45 AM, he stated, "I fell...I couldn't reach the call light. I got dizzy. The toilet bowel was spinning and I fell down on the floor of the bathroom. There was a lot of blood. The door was shut. My roommate shouted and shouted and finally someone came."
During an observation on March 23, 2017 at 10 AM, in Patient A's bathroom in Room 109, the call light string was observed to be tied in knots, shortening the length of the cord.
During an interview with a Licensed Vocational Nurse (LVN 3), on March 23, 2017 at 10:15 AM, she stated, "The call light string is short. I don't know how long that has been like that. I would make it a little longer. He [Patient A] would have to reach for it which would throw him off balance." She confirmed the call light string was tied in knots shortening the length of the cord and stated, "It should not be like that."
During an interview with the Director of Nurses (DON) on March 23, 2017 at 10:45 AM, she confirmed the call light string was tied in a knot. The emergency call light string was measured. It measured 2 feet when tied in a knot and 2 feet 11 inches when untied. She stated, "It (emergency call string) should not be like that. Let me unknot it and make it longer."
A review of Patient A's clinical records, reflected Patient A was admitted to the facility on XXXXXXX 2015, with diagnoses which included: chronic obstructive pulmonary disease (a disease of the lungs), hypertension (high blood pressure), and heart failure (a disease of the heart).
A review of the physician's history and physical, completed on May 27, 2014, indicated Patient A does have the capacity to understand and make his own decisions.
A review of the Resident Assessment Instrument (RAI-a computerized assessment tool) section G, dated March 7, 2017, indicated Patient A required extensive assistance in toileting.
During a review of the clinical record for Patient A, the licensed nurse's progress notes dated March 18, 2017 at 8:17 PM, indicated, "Resident found on floor of bathroom. Staff was alerted to resident fall by his calling out. Resident stated that he was attempting to reach call string and then became dizzy. Was sent out to hospital at 7:35 PM."
A review of the Fall Risk Assessment dated March 9, 2017, indicated Patient A's fall risk score was 15, and Patient A was considered at risk for falls.
A review of Patient's A's "Fall" care plan, dated May 29, 2015, indicated the patient was at risk for falls. The intervention listed included "call light within reach."
During an interview with the certified nursing assistant (CNA 1), on April 14, 2017 at 4:35 PM, she stated, "I got him out of bed, and took him to the bathroom. I transferred him to the toilet. I left the room to provide privacy. I went next door. The next thing I knew, he had fallen." She confirmed she left Patient A unattended in the bathroom and stated, "Now I know that I should have not left him alone."
During an interview with a Licensed Vocational Nurse (LVN 1), on April 19, 2017 at 3:55 PM, he stated he was the charge nurse on duty when Patient A fell on March 18, 2017. He stated Patient A was left alone in the bathroom. Patient A was found by CNA 2 who happened to go to the room and find Patient A on the ground.
During a review of the policy and procedure titled, "Answering call light", dated October 2010, indicated under "Policy, the purpose of this procedure is to respond to the resident's requests and needs." In the same policy under "General Guidelines... 2. Demonstrate the use of the call light. 3. Ask the resident to return the demonstration...explain to the resident that a call system is also located in his/her bathroom. Demonstrate how it works."
These facility failures had a direct or immediate relationship to the health, safety, or security of long-term care health facility patients or residents. |
| 250001663 |
BENTLEY HOUSE |
250009594 |
B |
20-Nov-12 |
2IHE11 |
4799 |
W&I 4502 (h) HSC 1418.91 (a) (b) 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. 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 ensure Client A was free from verbal and physical abuse. The facility staff failed to report the incidents of abuse on September 14 and 17, 2008, immediately. The facility staff did not report the abuse incident to the administrative staff until September 20, 2008.An unannounced visit was made to the facility on September 22, 2008, at 2 p.m., for the purpose of investigating this self-reported incident. The record for Client A was reviewed on September 22, 2008. Client A, a 28 year old client was admitted to the facility on November 17, 2006, with diagnoses that included severe mental retardation.During an interview conducted with the FM (Facility Manager) on September 22, 2008, at 2 p.m., the FM stated she received a phone call from the RNC (Registered Nurse Consultant) on September 21, 2008, regarding DCS 1 and 2's (Direct Care Staff) allegations of abuse towards Client A. The FM stated DCS 3 witnessed DCS 1 and 2 abusing Client A on two separate occasions. She stated DCS 3 did not report the incidents to her. The FM stated when there is an allegation of abuse; it should be reported to two administrative staff. An interview was conducted with the RNC on September 22, 2008, at 2:15 p.m. The RNC stated she received a phone call from DCS 3 on September 20, 2008, informing her of an abuse incident toward Client A by DCS 1 and 2, on September 14 and 17, 2008. The RNC stated DCS 3 witnessed both incidents, but did not report the incidents until September 20, 2008. An interview was conducted with DCS 3 on September 22, 2008; at 2:45 p.m. DCS 3 stated on September 14, 2008, at approximately 4 p.m., she observed DCS 1 verbally abusing Client A. She stated she observed Client A sitting on a stool in the living room. She stated when Client A got up and tried to sit next to DCS 1, she heard DCS 1 telling Client A, "You're nasty, sick and hairy. Don't get near me." DCS 3 also stated on September 17, 2008, during dinner, she observed DCS 2 physically and verbally abusing Client A. She stated she observed Client A pushing his plate away when DCS 2 was trying to feed the client. She stated she observed DCS 2 getting upset at Client A, calling Client A a "dumb ass." She stated she observed DCS 2 smack Client A behind the head. She stated the smack was hard enough to make Client A's head move forward. When asked why she did not report the incidents right away, she stated she was afraid of the other staff and did not want to get in trouble too. She stated she did not report the incidents until September 20, 2008. A review of the facility policy and procedure for abuse indicated, "...staff are encouraged to report situations which are suspicious or when they suspect abuse may be occurring even if they have no observable proof. Determination of whether abuse has occurred will be the responsibility of the administrative staff including but not limited to the following: 1. Administrator 2. RN Supervisor 3. QMRP for specific consumer involved 4. RN Consultant for specific consumer involved When an employee suspects and/or observes consumer abuse they are to report their concerns to one of the four persons listed above immediately." The facility failed to ensure Client A was free from verbal and physical abuse. The facility staff failed to report the incidents of abuse on September 14 and 17, 2008, to the administrative staff until September 20, 2008. The facility staff's failure to report the abuse incidents' immediately to the administrative staff placed all clients' at risk for further abuse from DCS 1 and 2.The above violations caused or occurred under circumstances likely to cause significant humiliation, dignity, anxiety, or other emotional trauma to patients. |
| 250001745 |
BROOKDALE RANCHO MIRAGE |
250010204 |
B |
15-Oct-13 |
JRV011 |
6639 |
Title 22 72311 (a) (2) 72517 (a) (5) Class "B" CitationTitle 22 72311 (a) (2) Nursing Service - General (a) Nursing service shall include, but not limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated, and 72517 (a) (5) - Staff Development (a) Each facility shall have an ongoing educational program planned and conducted for the development and improvement of necessary skills and knowledge for all facility personnel. Each program shall include, but not limited to: (5) Accident prevention and safety measures. During the investigation of an entity complaint, initiated on 11/30/10, it was determined that the facility failed to: 1. Implement Patient A's care plan developed for Falls/Safety. This failure resulted in a fall that caused the patient to have a neck fracture, and 2. Ensure that facility personnel had the necessary knowledge and skills to operate the patient's HI/LO bed to maintain it in the low position per Patient A's care plan. The failure resulted in the patient's accidental fall from his bed while in the HI position.Patient A, a 91 year old male, was admitted to the facility on 10/26/10, with diagnoses that included: advanced Alzheimer's dementia, (impaired memory and judgment,) degenerative joint disease, congestive heart failure, (heart failing to be able to pump blood), and diabetes type II, (impaired carbohydrate, protein, and fat metabolism secondary to insufficient secretion of insulin.) The patient was described in the Nursing Admission Assessment and interdisciplinary progress notes, dated 10/26/10, as being alert/oriented to self and wife only, and was confused to time and place. A care plan, "Falls/Safety," dated 10/27/10, indicated that Patient A's bed was to be kept in a low position with mats on the floor next to the bed. On 11/5/10, Patient A's interdisciplinary progress notes indicated, "Pt. (patient) found lying on the ground beside his bed. The resident raised his bed and was discovered with the upper half of his body hanging over the side. When I (LVN Charge Nurse) arrived his whole body was in a side-lying position on the ground. The pt has an abrasion on the top of his head near the forehead, as well as an abrasion on the posterior (back) aspect of his L (left) shoulder. The pt. verbalized accidently raising his bed and that the pain felt was on his head. Pt wife and physician were contacted, no new orders received." There was no mention of mats being in place at the time of the fall. A late entry, dated 11/13/10, at 2:00 p.m., was written in the interdisciplinary progress notes as clarification for a note on 11/6/10. It read, "At 1445 (2:45 p.m.) two staff members from activities & PT (Physical Therapy) find the pt. falling out of his bed in a high position. While calling out for help, they attempted to prevent the fall but the pt. was already mid-fall. The attending physician was made aware of the incident, & that the pt. only c/o (complain of) pain to forehead r/t (related to) abrasion, and that the pt's v/s (vital signs) stabilized."On 11/12/10, seven days after his fall, Patient A was transferred to the hospital and admitted for his complaint of neck pain. A consultation report, completed in the hospital, dated 11/13/10, indicated that a "CT (computerized tomography) scan of patient's cervical spine (neck portion of the spine) shows a fracture of the spinous process (the piece of bone that projects away from the spine) and lamina (flat surface of a vertebra, a bone of the spine) and pars interarticularis (the region between the upper and lower surfaces of a vertebra that allows motion and is frequently the site of a fracture)." Patient A's discharge summary from the hospital indicated the patient's final diagnosis was, "Comminuted fracture of spinous process of C2 vertebrae (second neck bone), post (after) recent fall." This type of fracture is also known as a "hangman's fracture." (Stedman's Medical Dictionary defines hangman's fracture as, "A fracture or dislocation fracture of the cervical vertebrae near the base of the skull.") An inspection of the bed used by Patient A while in the facility, revealed a toggle switch (an on/off switch) located at the foot of the bed. The surveyor moved the switch to the off position and asked the charge nurse (CN) to raise the entire bed to its highest position from the floor, using the resident's hand held control pad. The bed would not rise. Then the surveyor moved the switch to the "on" position and the process was repeated. The bed then rose to its highest position from the floor. The CN confirmed that the on/off switch, located at the foot of the bed, controlled the height of the bed and further stated, "This was the type of bed used. I didn't know about this switch." An interview conducted with a certified nurse assistant (CNA) indicated that she was not aware of the switch that prevented the bed from lowering or rising until the facility's maintenance man told her about it after Patient A had fallen from the bed. She said, "I did not know about this switch." A review of the Arro 111 bed manual from CARROLL HEALTHCARE, the bed's manufacturer indicated: "A toggle switch on the 111 Junction Box just under the foot board activates the HILO pendant (hand held control) lock out feature, See DIA 69. When in the "off" position, theHILO function on the pendant will NOT operate. When in the "ON" position, all pendant functions will operate normally. The head function and knee-foot function on the pendant remain operational whether the lock out is activated or deactivated." Review of the facility's policy titled, "FALL PREVENTION PROGRAM," not dated, indicated under "Responsibility:"Educating resident and family of fall risk issues. Further review of the facility's policy indicated:"The following are suggested measures that can be utilized in the prevention of falls. This list is not all- inclusive. -Resident education in the use of the call light system to ask for assistance. -Educate in other specific safety measures as indicated. Policy did not indicate who to educate and did not mention teaching the patients and staff on the use of their electric bed. -Use of low beds, curved mattresses and/or floor mattresses." Therefore, the facility failed to ensure that Patient A's Fall/Safety care plan was implemented to prevent a fall that resulted in a neck fracture, and that the facility personnel had been educated to use the toggle switch to activate the HI/LO lock out feature of the patient's bed.These violations had a direct or immediate relationship to the health, safety or security of patients. |
| 250001745 |
BROOKDALE RANCHO MIRAGE |
250010604 |
A |
10-Apr-14 |
KVTY11 |
9860 |
Citation: A HSC 1424(d) 1424. Citations issued pursuant to this chapter shall be classified according to the nature of the violation and shall indicate the classification on the face thereof.(d) Class "A" violations are violations which the state department determines present 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. A physical condition or one or more practices, means, methods, or operations in use in a long-term health care facility may constitute a class "A" violation. The condition or practice constituting a class "A" violation shall be abated or eliminated immediately, unless a fixed period of time, as determined by the state department, is required for correction. Except as provided in Section 1424.5, a class "A" citation is subject to a civil penalty in an amount not less than one thousand dollars ($1,000) and not exceeding ten thousand dollars ($10,000) for each and every citation.If the state department establishes that a violation occurred, the licensee shall have the burden of proving that the licensee did what might reasonably be expected of a long-term health care facility licensee, acting under similar circumstances, to comply with the regulation. If the licensee sustains this burden, then the citation shall be dismissed. T22 DIVSS-Nursing Service-General 7231 (a) (1) (A) (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. The facility failed to develop a plan of care to provide consistent supervision of Patient 1's movements throughout the facility and grounds, which resulted in Patient 1 wandering, unescorted, into the parking lot area, falling from his wheelchair, and hitting his head on the driveway, causing subarachnoid (under the arachnoid membrane covering the the brain), subdural (under the dura membrane covering the brain), and intra-ventricular (fluid filled areas of the brain) hemorrhages. These injuries led to Patient 1 being admitted to an In-Patient Hospice Unit where he remained until his death. During a complaint investigation, initiated on September 30, 2010, it was identified the facility had no plan of care in place to supervise Patient 1 while he moved around the facility and grounds. The medical record for Patient 1 was reviewed on September 30, 2010. Patient 1, a 90 year old male, was admitted to facility on April 13, 2009, with diagnoses including cerebral vascular accident (CVA, stroke), insulin dependent diabetes, high blood pressure, and dementia. According to staff interviews, Patient 1 was able to answer yes/no questions and make his needs known. Patient 1 was able to self-propel himself in his wheelchair. The Minimum Data Set Assessment 2.0 tool, dated September 13, 2010, indicated Patient 1 had very unsteady standing balance but good sitting balance. He moved through the facility by moving his wheelchair with his legs. He was usually able to make his needs known and was improving in understanding what was said to him. The nursing care plans indicated Patient 1 was a "high risk for falls with poor safety awareness." Patient 1 had history of falls on July 15, September 5, and September 13, 2010. There was no documentation of a plan to monitor his activities on the grounds or monitor his exit through the front door. The "Interdisciplinary Progress Notes:, dated September 26, 2010, indicated, "Pt. (Patient 1) found on pavement of parking lot...Pt. assisted to wheelchair and brought back to his room...Laceration of area above left eye...abrasions: left frontal area (head)...ice pack placed on swollen left eye. Left forearm abrasion...Abrasion left knee...neurochecks (assessment used to detect early signs and symptoms of a brain injury) started...Pt. exhibiting nonverbal signs of pain...MD and family notified...Pt. sent to Emergency Room at 10:40 a.m., via ambulance." The Emergency Room record for Patient 1, dated September 26, 2010, was reviewed. The laceration above the left eye was sutured. "A CT scan (computed tomography scan uses x-rays to make detailed pictures of structures inside the body) of the brain showed that the patient had an acute bilateral frontal lobe subarachnoid hemorrhage (bleeding under the arachnoid membrane covering the brain front) actually due to parenchymal contusion (manifestation of direct injury to brain tissue). A small right subdural hematoma (bleeding under the dura membrane of the brain) and an intra-ventricular hemorrhage (bleeding into the fluid filled areas of the brain) were present... The ER (emergency room) physician, the on-call neurosurgeon, and the family discussed the CT findings and the fact that Patient 1 was not a surgical candidate due to his age and comorbidities (other health conditions), as well as his DNR/DNI (Do not resuscitate/Do not intubate) wishes..." Patient 1 was referred to hospice care.The hospice record was reviewed. Patient 1 was admitted to the in-patient hospice unit on September 26, 2010, and expired 14 days later on October 10, 2010. He remained lethargic, with altered level of consciousness, until death. The facility environment was observed on September 30, 2010. There was one centralized nursing station with a high counter in front of the desk area. This counter faced the front door down a small corridor. There was an open area in front of the desk, where patients frequently gathered. A patient and family lounge was to the left and across the hall from this counter. Anyone sitting at the desk must stand to observe activity in the lounge, hallway, and through the glass front door. Outside the front doors, a covered area had benches, tables, and flowers. A sidewalk led to the parking lot and another sidewalk turned left toward the adjacent Assisted Living Facility building. About 60 feet down the sidewalk, to the left, a wheelchair access ramp was cut into the curb. Patient 1 was found lying off the concrete sidewalk and on the asphalt driveway, near this ramp, by a visitor. During an interview, on September 30, 2010, at 10:10 a.m., with the Director of Nursing, she stated Patient 1 went to a church service every Sunday in the Assisted Living Facility. On September 26, 2010, at 9:30 a.m., she stated Patient 1 was left in the activity room to wait for personnel from the Assisted Living Facility to take him and other patients to the service. At 9:45 a.m., a visitor came into the facility and reported that a patient had fallen in the parking lot. She stated there was no one at the front desk and no one saw Patient 1 go outside. There were no witnesses to the fall outside. An interview was conducted with the Concierge on September 30, 2010, at 10:55 a.m. She stated her duties included sitting at the front desk by the front door of the facility to answer the phone and greet visitors to facility. She arrived at the facility at 9 a.m. Patient 1 was sitting in his wheelchair in front of the desk. She left the desk for a short time, around 9:15 a.m., and when she came back, Patient 1 was gone. She stated she did not look for him because she assumed the staff from the Assisted Living Facility (ALF) area had come to get Patient 1 for church service. A visitor came into the front door and reported Patient 1 was lying on the driveway in front of the facility, left of the entrance at the wheelchair access slope. During an interview with a certified nursing assistant (CNA), on September 30, 2010, at 2 p.m., she stated she was assigned to Patient 1 on September 28, 2010, during the day shift. About 8:45 a.m. she moved Patient 1 from the dining room into the hallway in front of the desk. The CNA further stated that Patient 1 would frequently go outside by himself. He was able to move very fast in the wheelchair by moving his legs, and knew how to push the button to open the front doors for wheelchair access. The CNA stated she had brought him back into the facility many times. On September 30, 2010, at 3:45 p.m., during an interview with LVN 1, she stated she had taken care of Patient 1 during previous night shift. She stated Patient 1 would try to get out of the building through the front doors. She further said that the staff had to "keep a close eye on him." During an interview with LVN 2, on September 30, 2010, at 4 p.m., she stated she had seen Patient 1 outside alone, every one or two days. She would go and bring him inside. The outside temperature was over 100 degrees Fahrenheit. She responded to a report of a patient had fallen out his wheelchair and was lying on the asphalt driveway. LVN 2 stated she found Patient 1 lying on his left side, entangled in the wheelchair. He was in the section of the sidewalk with a wheelchair access inset. He was returned to the facility and transported to the emergency room by ambulance. Therefore, the facility failed to develop a plan of care to provide consistent supervision of Patient 1's movements throughout the facility and grounds, which resulted in Patient 1 wandering, unescorted, into the parking lot area, falling from his wheelchair, and hitting his head on the driveway. These injuries led to Patient 1 being admitted to an In-Patient Hospice Unit where he remained until his death. 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. |
| 250000022 |
BLYTHE POST ACUTE LLC |
250011288 |
A |
05-Mar-15 |
8L2I11 |
11508 |
H&S Code 1425 1424.5. (a) In lieu of the fines specified in subdivisions (c), (d), (e), and (g) of Section 1424, fines imposed on skilled nursing facilities or intermediate care facilities, as specified in paragraphs (1) and (2) of subdivision (a) of Section 1418, shall be as follows:(1) A class "AA" citation is subject to a civil penalty in an amount not less than twenty-five thousand dollars ($25,000) and not exceeding one hundred thousand dollars ($100,000) for each and every citation. For a second or subsequent class "AA" citation in a skilled nursing facility or intermediate care facility within a 24-month period, the state department shall commence action to suspend or revoke the facility's license in accordance with Section 1294.(2) A class "A" citation is subject to a civil penalty in an amount not less than two thousand dollars ($2,000) and not exceeding twenty thousand dollars ($20,000) for each and every citation.(3) Any "willful material falsification" or "willful material omission," as those terms are defined in subdivision (f) of Section 1424, in the health record of a resident is subject to a civil penalty in an amount not less than two thousand dollars ($2,000) and not exceeding twenty thousand dollars ($20,000) for each and every citation. CFR 483.25(h)(1)(2) The facility must ensure that the resident environment remains as free of accidents and hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. Based on observation, interviews, and record review, the facility failed to provide adequate supervision for Patient A when the patient had wheeled herself out of the facility and was not discovered for two hours and 55 minutes in temperatures of 100 degrees Fahrenheit (F).This failure to provide supervision of Patient A caused her to become unresponsive, require an endotracheal tube (insertion of a tube into the windpipe to provide artificial respiration by way of a ventilator), admission to intensive care, and a burn to the right inner forearm. Findings: On June 5, 2014, at 8:20 a.m., an unannounced visit was made to the facility to investigate an entity reported incident that occurred on May 24, 2014, and indicated Patient A had wheeled herself outside the facility where the temperature reached at least 100 degrees F, developed altered level of consciousness, and was not discovered for two hours and 55 minutes. Patient A also developed a burn on her right inner arm.According to the "Weather History for Blythe, CA / Weather Underground," (an Internet weather history site) the recorded maximum temperature for May 25, 2014, was 100 degrees Fahrenheit.Patient A, a 75 year old female, was admitted to the facility on December 14, 2013, with diagnoses that included weakness, diabetes mellitus (abnormal blood sugar levels), and senile dementia (loss of cognitive abilities). On June 5, 2014, at 8:35 a.m., Patient A was observed sitting in her wheelchair in the main hallway. Further observation revealed a lap buddy (a removable cushion restraint) in place. In addition, a wheelchair alarm was applied to her sweater. Patient A's skin to her right inner arm was healed. On June 5, 2014, at 10:10 a.m., the Director of Nursing (DON) was interviewed. She stated that Patient A was more mobile after her Risperdal (a medication used off label to treat agitation associated with dementia; the medication is known to cause sedation) was changed to a lower dose. She stated they (IDT - Interdisciplinary Team) failed to recognize Patient A's increase in mobility after the medication dosage was reduced. The DON further stated that Patient A was able to move from one location to another using her feet to propel her wheelchair. On June 5, 2014, at 10:45 a.m., a phone interview was conducted with CNA (Certified Nursing Assistant) 1. She stated that she (CNA 1), received instructions from the charge nurse and off duty (a.m. shift) CNA prior to starting her duties on the p.m. shift of May 24, 2014. She further stated that she had no shift report from the morning CNA and had no instructions about Patient A's behavior of wandering off. In addition, CNA 1 stated, "We are suppose to watch our patients every time. The last time I saw her, I can't pinpoint the time. I saw her at the beginning of the shift (2 p.m.). We were so busy that day. For the most part she's very alert. I never know she goes out the back door. It was really hot that day. I didn't realize she was not around. I know of her, she (Patient A) roaming around in the facility. Typical of her being inside." In an interview with Laundry Staff 1, on June 5, 2014, at 11:35 a.m., she stated that Patient A could open both doors that lead to the staff patio. In an interview with CNA 2 on June 5, 2014, at 11:52 a.m., she stated that she had seen Patient A open the north door with no assistance. CNA 2 further stated, "She (Patient A) can open the door sitting in her chair." In a phone interview with Licensed Nurse (LN) 1 on June 5, 2014, at 12:10 p.m., she stated, "She (Patient A) can scoot around pretty good in her wheelchair." LN 1 further stated, "All of us are responsible to watch patients." There were no wandering/elopement assessments and no nursing care plan to indicate Patient A was a wanderer. The "LICENSED NURSES PROGRESS NOTES," dated May 25, 2014, at 5:30 p.m., indicated, "Discovered patient sitting in w/c (wheelchair) in (on) grass on west side of building was unresponsive to verbal stimuli & noted to have small emesis (vomit) & mucous on chin & chest aided into bed... O2 (oxygen) sats (saturation) 87% on room air (the amount of oxygen circulating in arterial blood; normal level is 96% or greater) ronchi (rhonchi) & wheezes (abnormal lung sounds) bilat. (bilateral - both lungs)..." Review of Patient A's physician telephone orders dated May 25, 2014, at 5:50 p.m., indicated, "Send to (Hospital 1's name omitted) ER (Emergency Room) for eval (evaluation)."On May 25, 2014, at 6:05 p.m., Patient A was transferred to Hospital 1's ER for evaluation.The Emergency Department record dated May 25, 2014, at 6:23 p.m., indicated "CHIEF COMPLAINT/HISTORY OF PRESENT ILLNESS: ...75 old F (female) that presented to the Emergency Department at 18:23 (6:23 p.m.) by AMB (ambulance) ... vital signs 99.6 (elevated temperature) PO (oral) 133 regular (heart rate), 28 (respirations) Unlabored." Chief Complaint-- ALTERED MENTAL STATUS...found outside, unknown time outside, altered , emesis on gown and possible aspirations... poorly responsive... She was in wheelchair at (facility name omitted). PHYSICAL EXAMINATION: ...Chest - rales ronchi bilaterally... CLINICAL IMPRESSION:2. Aspiration pneumonia - intubation (insertion of a tube into the windpipe to provide artificial respirations by way of a ventilator)."Review of the facility's portable upright chest x-ray indicated that there was "No significant acute abnormality."Review of the laboratory report dated May 25, 2014, at 7:10 p.m., indicated: "WBC (white blood count) 15.5 H (high) (4.6 - 10.2 normal) BUN (Blood Urea Nitrogen) 30 H (high) (.7 - 18 normal) CREATININE BLOOD 1.7 H (high) (0.6 - 1.5 normal)" (An elevated WBC is indicative of infection. Abnormal high results of the BUN and Creatinine could indicate dehydration and/or kidney disease). At 11:16 p.m., on May 25, 2014, Patient A was transferred by air ambulance to another hospital (Hospital 2). Transfer was initiated for, "SPECIALIZED RESPIRATORY." Patient A's diagnoses at the Hospital 2 were hypoxia (decreased oxygen level), aspiration of gastric contents, altered mental status, and failure to thrive. Review of the Hospital 2's emergency department (ED) report, dated May 25, 2014, at 1 a.m., indicated that Patient A remained intubated and had been placed on a ventilator. Further review of the ED report indicated that Patient A was on a cardiac (heart) monitor, received IV (intravenous) fluids, antibiotics and had a Foley catheter (a tube inserted into the bladder to drain urine). Patient A was then transferred from the ED to the Intensive Care Unit in critical condition. Review of the nurses progress notes titled, "Site Management ," from May 25, 2014 at 12:38 a.m., to June 3, 2014 at 4 a.m., indicated: "BLISTER (1) RIGHT INFERIOR) Side = RIGHT, Site ELBOW (...RN at 05/25/2014 10:36), Descriptors = INFERIOR [below] (... RN at 05/25/2014 10:36, Type = BLISTER ...Comments = looks like a blister that popped ... BLISTER (1) LEFT UPPER ARM Side = LEFT; Site = UPPER ARM (... RN at 05/27/2014 06:10); Type = BLISTER (...RN at 05/27/2014 06:10) Review of the Hospital 2's form titled, "PHYSICIANS PROGRESS NOTES," dated May 27, at 3 p.m., indicated, "Wound care - Pt. (patient) has 2 unroofed (uncovered) blisters of (R) (right) inner arm that family member says may have been due to a burn from the metal of her wheelchair. Blisters measure 6 x 7 x 0.1 cm (centimeters) (distal) and 2 x 5 x 0.1 cm (proximal) ..." Review of the facility's investigation report, completed on June 5, 2014, indicated under "Conclusion: Considering the condition the pt. (patient) was found in (extremely hot skin, unresponsive, possible vomiting and questionable aspiration) and the fact that the pt. had not been seen by staff members after 2-2:20 p.m., and that even if the assigned CNA had actually seen her in the facility an hour prior to finding her behind the facility the least amount of time the resident (patient) would have been exposed to extreme heat outdoors was an hour. However, the security cameras recording shows a pt. exiting the facility at 2:20 p.m. by the back door, going around the building toward back of the facility and does not show pt. returning from behind facility until she was wheeled back into back door at approximately 5:15 p.m. This makes this incident a confirmed abuse in the form of neglect by the CNA assigned to care for her because she (the CNA) did not check her pt. at least every 2 hours." Review of the facility's policy titled, "Preventing Hot Weather Injuries," undated, indicated: "POLICY: To prevent sunburn, heat exhaustion, dehydration, heat stroke and other injuries to residents (patients) from exposure to sun and hot weather (above 85*F) the nursing staff will adopt guidelines recommended by the CDC (Center For Disease Control). PROCEDURE: D. Limit time outside to 1 hr (hour) if temperature is below 100 degrees and limit time to 30 mins (minutes) if temp (temperature) exceeds 100. E. Place resident (patient) in shaded areas outside. DO NOT ALLOW EXPOSURE TO DIRECT SUNLIGHT." Review of the facility's form titled, "RESIDENT (patient) RIGHTS," undated, indicated under section, "In Summary ...The main point to remember is that the resident (patient) rights are protected. You are responsible for assuring that your assigned residents (patients) are properly cared for." Therefore, the facility failed to provide adequate supervision for Patient A when the patient had wheeled herself out of the facility and was not discovered for two hours and 55 minutes in temperatures of 100 degrees F causing her to become unresponsive, require an endotracheal tube (insertion of a tube into the windpipe to provide artificial respirations by way of a ventilator), admission to the intensive care unit, and a burn to the right inner forearm. 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 to the patient. |
| 250001663 |
BENTLEY HOUSE |
250011693 |
B |
28-Aug-15 |
ZLGU11 |
2421 |
CLASS B CITATION - PROTECTION OF CLIENT RIGHTS W0127 - 483.420(a)(5) The facility must ensure the rights of all clients. Therefore, the facility must ensure that clients are not subjected to physical, verbal, sexual or psychological abuse or punishment. The facility failed to protect Client 1's right to be free from physical abuse. On October 23, 2014, an unannounced visit was made for the purpose of investigating an entity reported incident. On October 22, 2014, Client 2 lay down on top of Client 1, held onto Client 1's wrist, and bit Client 1 on the left wrist and right hand, leaving bite marks in each location. On October 23, 2014, at 11:45 a.m., an interview was conducted with the Facility Manager (FM). The FM stated, on October 22, 2014, at approximately 5:30 a.m., she was giving medications. Client 1 was lying on the blue couch waiting for breakfast. Client 2 was walking toward Client 1, agitated, and he lay down on top of Client 1, biting him on the left wrist. Client 2 was also holding Client 1's left wrist while biting.The FM stated Client 2 had not bitten anyone for more than a year, although Client 2 had a history of biting others. On October 23, 2014, at 1:30 p.m., an observation was conducted of Client 1 at the day program. Client 1 was alert and able to talk using a slow, slurred speech. Client 1 had an injury to the right index finger that measured 0.9 cm (centimeter) by 0.6 cm (0.35 inches by 0.24 inches). A second injury was present to the left wrist that measured 5.4 cm by 3.2 cm (2.13 inches by 1.26 inches). A concurrent interview was conducted with Client 1. Client 1 stated Client 2 bit him. A review of the record of Client 2 on November 20, 2014, showed Client 2 had identified behaviors of emotional outbursts and/or agitation. The documented outbursts for the prior five months (May through September 2014) occurred more than 100 times (range of 115 to 227 times) each month. The Annual Individual Service Plan (ISP), dated April 14, 2014, indicated, "Monitor (Client 2) closely particularly when near peers, one in particular as he has occasionally bit him."The facility failed to protect Client 1 from client to client abuse. Client 2 lay down on top of Client 1, held onto Client 1's wrist, and bit Client 1 on the left wrist and right hand, leaving bite marks in each location. These violations had a direct relationship to the health, safety or security of clients. |
| 250000016 |
BANNING HEALTHCARE |
250012953 |
B |
23-Feb-17 |
CQMM11 |
9330 |
483.25 Quality of Care (F-309)
Each patient 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 April 1, 2015, at 5:10 p.m., an unannounced visit was conducted at the facility to investigate an entity reported incident regarding Patient A's fall and fracture that occurred on March 20, 2015, at 7:06 a.m.
It was determined that the facility failed to ensure one sampled patient (Patient A) remained free from falls and injuries when a staff member failed to get assistance from another staff member to help assist Patient A while the patient was in the bathroom. This failure resulted in Patient A sliding out of his wheelchair, falling to the floor, and sustaining a fracture (broken bone) to his right distal femur (thigh bone).
On April 1, 2015, at 5:10 p.m., Patient A was observed in his room sitting up in bed and eating his dinner meal. A pressure pad alarm (an electronic device attached to a resident that will alarm when the resident gets up unassisted) was in place, the bed was in low position, and there were padded floor mats on the floor. The patient was alert and confused but able to respond to simple direct communication. There was a visual identifier (star symbol) placed on the nameplate outside of the patient's room to alert staff that he was on a fall prevention program. Further observation of the patient's bathroom indicated it had an emergency call light system that could be activated by the patient or a staff member as needed to provide patient assistance while in the bathroom.
During a concurrent interview with the Director of Nurses (DON), she stated at the time of the fall on March 20, 2015, Patient A was in his wheelchair, with a wheelchair alarm in place, and his wheelchair was at the entrance door of the bathroom. The DON stated the patient was reaching over to the sink and washing his hands.
A review of the facility's investigation report indicated Patient A was attempting to wash his hands at the bathroom sink on March 20, 2015, at 7:06 a.m. Activity Assistant 1 (AA 1) was in the bedroom providing care to the roommate (Patient B). Patient A's wheelchair alarm sounded due to the patient leaning too far forward in the wheelchair. AA 1 went over to Patient A and reset the alarm, then went back to assist feeding Patient B. AA 1 did not seek other staff assistance to help Patient A, and Patient A continued to lean forward in his wheelchair trying to wash his hands. Patient A then slid out of the wheelchair onto the floor.
A second visit was made to the facility on April 2, 2015, at 9:05 a.m. Patient A's record was reviewed which indicated he was admitted to the facility on July 10, 2013, with diagnoses that included diabetes (delayed or reduced insulin response to blood sugar), osteoarthritis (degenerative joint disease), dementia (impairment of memory, judgment, and thinking), and a previous right hip fracture in the year 2013.
A review of the facility form titled, "History and Physical Examination," dated July 29, 2014, indicated Patient A did not have the mental capacity to understand and make his own decisions.
A review of a facility form titled "Fall Risk Assessment," dated January 20, 2015, indicated the Patient A was a high risk for falls.
A review of Patient A's Minimum Date Set (MDS, an assessment tool), dated January 20, 2015, indicated Patient A required extensive assistance of one staff for mobility, toileting, transferring, and hygiene care.
In an interview with Registered Nurse 1 (RN 1) on April 2, 2015, at 9:15 a.m., she stated AA 1 was in Patient A's room assisting Patient B. The wheelchair alarm for Patient A was activated (sounding) when Patient A was bending forward and overreaching from his wheelchair to the bathroom sink to wash his hands. RN 1 stated AA 1 went over to Patient A, reset the alarm to stop it from sounding, and went back to caring for Patient B. RN 1 stated Patient A continued to reach forward in the wheelchair to reach the sink and then slid forward onto the floor. RN 1 stated Patient B needed to be on 1:1 supervision by AA 1, that is why AA 1 left Patient A to go back and care for Patient B. RN 1 stated she asked Patient A what happened and Patient A stated while he was washing his hands the wheelchair backed up and he fell down. RN 1 further stated, "The wheelchair was not locked (to prevent the wheelchair from rolling backwards)."
Patient A had a care plan dated January 23, 2015, titled, "Potential for recurrent falls r/t (related to) hx (history) of falls, with poor safety awareness, unaware of self-limitations, with intermittent confusion r/t dementia, with poor balance, unsteady gait, with attempts to transfer self without assist, and medical diagnoses/conditions." The nursing interventions on the care plan for fall prevention included the following:
"Monitor resident's (Patient A?s) location as often as possible. Maintain vigilance at all times. Keep environment free of any health and safety hazards. Provide daily activities appropriate for the resident (patient). Provide adequate lighting. Call light within reach and answered promptly. Assist with ADLs (activities of daily living) and anticipate needs and attend well...apply tab alarm while up in wheelchair for safety..."
In an interview with the DON on April 2, 2015, at 10 a.m., she stated AA 1 was supposed to call another certified nursing assistant or charge nurse for help with Patient A when his alarm went off. The DON confirmed AA 1 re-attached the alarm device and went back to assisting Patient B.
In an interview with AA 1 on April 2, 2015, at 10:20 a.m., she stated she had to provide 1:1 supervision for Patient B and was feeding him breakfast. She stated Patient A's wheelchair was partially in the bathroom doorway as Patient A was trying to wash his hands. AA 1 state the patient was leaning "pretty far" forward to reach the sink. AA 1 stated Patient A's wheelchair alarm started to sound so she went to Patient A to and reset the alarm. AA 1 stated she then went back to caring for Patient B and shortly afterwards Patient A fell on the floor. AA 1 stated she was told by the nurse supervisor that she should have called for staff assistance to help Patient A. AA 1 stated Patient A would attempt to reach for things and the cord that attached to the patient from the alarm device would sometimes get disconnected causing the alarm to sound due to the patient reaching forward. AA 1 further stated, "We were told that when we hear the alarm, to go to the alarm right away to see what's going on and to help out with the situation."
In an interview with the DON on April 2, 2015, at 10:45 a.m., she stated when an alarm goes off all staff were to participate by answering the alarm promptly. The DON stated if a patient needed assistance that staff could not provide, then staff were to call for other staff to help the patient.
In an interview with the Activity Director (AD) on April 2, 2015, at 11:07 a.m., she stated when a patient's alarm goes off in the presence of an activity assistant, they are to reconnect the alarm and call the charge nurse or a certified nursing assistant immediately for assistance. The AD further stated the facility's concern was for the patient's safety.
A review of Patient A's nursing progress notes dated March 20, 2015, at 7:20 a.m. indicated, "ACTUAL FALL - PATIENT SLID OFF FROM WHEELCHAIR IN A SITTING POSITION, NO INJURIES NOTED AT THIS TIME."
Patient A's nursing progress note dated March 21, 2016, at 10:28 p.m., indicated the nurse informed the physician of the patient's swelling on the right leg and knee due to the fall, and of the patient's complaints of pain when his leg was touched. The note further indicated, "...referred back to x-ray results of right knee, hip and femur to MD (Medical Doctor) and clarified regarding mildly displaced fracture of the distal femur." Patient A was then transferred to the hospital for further evaluation.
A review of the physician order dated March 20, 2015, at 11:08 a.m., showed an order to x-ray Patient A's right knee, right hip, and right femur.
Patient A's x-ray report dated March 20, 2015, confirmed a right distal femur fracture.
On XXXXXXX 2015, at 9:55 p.m., Patient A was transferred to the hospital for further evaluation and treatment of the femur fracture. Patient A returned back to the facility on XXXXXXX 2015, at 2:30 a.m. with a splint (an immobilizer) on his right leg and awaiting surgery. On XXXXXXX 2015, at 1:48 p.m., Patient A was transferred again to the hospital for surgical repair of the fracture.
In an interview with the DON on April 2, 2015, at 11:45 a.m., she stated Patient A had surgery to repair his right femur fracture on March 25, 2015.
The facility's policy and procedure titled, "ACCIDENT PREVENTION/MONITORING ENVIRONMENTAL HAZARD," undated, was reviewed and indicated the patient?s wheelchair brakes were to be locked, and staff were to be trained on safe handling of patients during care.
The violation of this regulation had a direct relationship to the health, safety, or security of the patients. |
| 910000322 |
Beverly West Healthcare |
910007214 |
A |
25-Feb-13 |
CB2W11 |
6002 |
CFR 483.25(h) Accidents.The facility must ensure that ? 1. The resident environment remains as free of accident hazards as is possible; and 2. Each resident receives adequate supervision and assistance devices to prevent accidents. On February 18, 2010, an unannounced visit was made to the facility to conduct a recertification survey. Based on observation, interview, and record review, the facility's nursing staff failed to ensure Resident 22, who was totally dependent on the nursing staff for transfers, had her legs/feet properly positioned as to clear the bedside rails before transferring her from the bed to the shower chair. As a result, On May 6, 2009, Resident 22?s right leg/foot got stuck on the bedside rail while two nursing assistants were attempting to transfer her from the bed to a shower chair, causing her to sustain a fracture of the right lower leg (tibia - the inner bone of the two bones between the knee and ankle), requiring hospitalization. Resident 22, a 91 year-old female, was admitted to the facility on February 7, 2008, with diagnoses that included multiple pressure sores (areas of damaged skin caused by staying in one position for too long),anemia (decreased red blood cells), and degenerative joint disease. She was unable to bear weight (stand). A review of the Minimum Data Set (MDS), an assessment and care screening tool, dated March 24, 2009, indicated Resident 22 was severely impaired in cognition and was totally dependent on the staff for her activities of daily living (ADL) including transfers. She was unable to ambulate, and she required one person assist to move in bed. The MDS also indicated the resident required to be manually lifted for transfers.The Resident Assessment Protocol Summary, dated March 24, 2009, indicated ADL was triggered as an area of concern requiring further assessment and care planning. It indicated for the staff to be able to provide adequate assistance with Resident 22's ADL function. A facility investigation report, dated May 6, 2009, indicated that during the transfer of Resident 22 from the bed to the shower chair, the staff hit the resident's right leg on the bedside rail, causing swelling.A review of Resident 22?s X-ray results dated May 6, 2009, indicated two fracture lines in the mid-tibia (lower leg) area without displacement (the bone cracks either part or all of the way through, but maintains its proper alignment). A review of Resident 22?s medical record with the director of staff development failed to provide documentation by LVN 4 and/or CNA 8 or 10, describing the events surrounding Resident 22?s fractured leg. According to the general acute care hospital (GACH) History and Physical Examination dated May 7, 2009, Resident 22 was admitted with complaints of a right tibia-fibula fracture. It was indicated the resident got her leg stuck in one of the railings in her bed. Orthopedic consultation had been obtained and surgery was not required (no reason noted). A brace or a cast was placed.On February 23, 2010, at 9 am, Resident 22 was observed while two certified nursing assistants were transferring the resident from the bed to a Geri-chair using manual lift (carrying the resident using muscle force and without the use of a machine). Resident 22 was totally dependent on the staff and was not able to move her arms or legs independently. On February 24, 2010, at 3:10 pm, during an interview, the licensed vocational nurse (LVN 4), who was the charge nurse at the time, stated the certified nursing assistant (CNA 8) told her that on May 6, 2009, Resident 22's leg got stuck in the bedside rail while she and another CNA were trying to transfer the resident from the bed to the shower chair. LVN 4 stated while at the resident's bedside she noticed some swelling of the resident's right leg, but no discoloration. LVN 4 stated she reported the information to the registered nurse (RN) supervisor, but did not document anything. During an interview on February 24, 2010, at 3:25 pm, CNA 8 stated that on May 6, 2009, she helped Resident 22 sit up in the bed and swiveled her around in one motion to the edge of the bed. She held the resident on the left side, and CNA 10 held the resident on the right side and they placed a blanket under the resident's knees to help pull the resident up off of the bed. CNA 8 stated the bed had one long side rail and it was down at that time. While lifting the resident, she heard a snap, saw the resident grimace (a twisted expression on the face expressing pain), and saw the resident's leg begin to quickly swell. CNA 8 said that the resident?s leg got caught on the siderail. CNA 8 stated she reported the incident to the supervisor using a translator (CNA 9), and told the supervisor that Resident 22's foot got caught in the side rail. She stated it happened so fast she did not know how the resident's foot got caught in the side rail. When asked if she documented the events in the CNA notes, CNA 8 stated, "No."A review of CNA 8?s employee file indicated general safety rules, lifting techniques and injury reporting policies were included as part of the training and instruction during orientation. The orientation checklist was signed and dated by CNA 8 on July 20, 2007, indicating she received instructions in these areas. The facility's nursing staff failed to ensure Resident 22, who was totally dependent on the nursing staff for transfers, had her legs/feet properly positioned as to clear the bedside rails before transferring her from the bed to the shower chair. As a result, on May 6, 2009, Resident 22?s right leg/foot got stuck on the bedside rail while two nursing assistants were attempting to transfer her from the bed to a shower chair, causing the resident to sustain a fracture of the right lower leg (tibia - the inner bone of the two bones between the knee and ankle), requiring hospitalization. The above violation presented a substantial probability that death or serious physical harm would result to Resident 22. |
| 910000014 |
BERKLEY EAST CONVALESCENT HOSPITAL |
910008601 |
A |
02-May-12 |
7F1011 |
14448 |
72517(a)(1) Each facility shall have an ongoing educational program planned and conducted for the development and improvement of necessary skills and knowledge for all facility personnel. Each program shall include, but not be limited to: (1) Problems and needs of the aged, chronically ill, acutely ill and disabled patients. 72523(a)Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. 72523(b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the patient care policy committee. On December 8, 2010, an unannounced visit was conducted to investigate a complaint that Patient 1?s newly inserted GT had been accidently dislodged and replaced by the nursing staff, resulting in multiple complications, readmission to an acute care facility, and further surgery before the patient expired. Based on interview and record review the facility failed to provide the necessary care and services according to acceptable standards of practice for one of one sampled patients with a percutaneous endoscopic gastrostomy tube, (PEG or GT), a tube surgically placed directly into the stomach through which nutrition and medications can be administered, by failing to: 1. Ensure nursing staff notified the physician prior to reinserting a GT as outlined in the facility?s policy. 2. Establish patient care policy and procedure on GT reinsertion specifying when a GT could be replaced by nursing staff, and the degree of experience, training, and/or educational requirements for the nurse to perform the procedure based on standards of practice. Patient 1's PEG, was accidently dislodged when the facility staff transferred him from the wheelchair to the bed. The facility charge nurse inserted another tube into the fresh surgical opening without consulting a physician. As a result of this deficient practice Patient 1 experienced excruciating pain when the tube feedings were resumed and required a second transfer back to an acute care facility. A computerized tomography (CT) scan at the acute care hospital revealed: the G-tube was not in the stomach, extravasation (fluid leakage into tissue), and air in the peritoneal (stomach lining) cavity. Patient 1 remained in the acute care facility twelve days and required surgical replacement of the G-tube.Patient 1 expired on November 17, 2010. A review of the clinical record face sheet and undated Therapy Evaluation Intake form indicated Patient 1 was an 84 year old admitted to the facility on October 27, 2010, with diagnoses that included bladder cancer, weight loss, and failure to thrive. The Therapy Evaluation Intake sheet further indicated the Patient was alert, able to understand others at all times and always able to make himself understood.A review of the Discharge Summary by Patient 1's Primary Physician dated November 06, 2010 indicated the Patient had been admitted to the acute care facility on October 12, 2010 with loss of appetite for which he'd had a percutaneous gastrostomy tube (PEG) inserted on October 25, 2010. The discharge form further indicated the Patient was transferred to the facility from the acute care facility on October 27, 2010 where he was to have physical therapy and rehabilitation therapy. Upon discharge from the acute care facility the record indicated Patient 1 was tolerating tube feedings well.During an interview and record review with the facility Director of Staff Development (DSD) on December 8, 2010 at 1:43 p.m., she stated she did not know if the facility's policy allowed their nurses to replace G-tubes if a G-tube is dislodged. The DSD stated the licensed nurses employed at the facility do not receive any training on G-tube placement at the facility. When the DSD was asked to show the surveyor the skills checklist in RN 1's employee file indicating the facility had verified the RN could perform the skill, the DSD stated the facility did not do any specific skill level check with the licensed nurses they hired to verify the licensed nurse knew how to re-insert a dislodged G-tube. When the DSD was asked how RN 1 would have known how to re-insert a G-tube, the DSD stated she "could not answer that". During the same interview, the DSD stated when licensed nurses are hired they are given the facility policy and procedures to review, but that the facility could not go through each policy with the new staff.A review of the clinical record Licensed Personnel Progress Notes dated October 28, 2010, written by RN 1 indicated she'd inserted a new G-tube at 4:55 p.m., checked placement by listening for gastric sounds using a stethoscope, applied a gauze dressing to the site, then called and left a message for the MD. The note further indicated the RN spoke with Patient 1's daughter after the daughter was notified of the incident by the sitter. The narrative note further indicated the patient's daughter called the surgeon, who in turn called the RN and gave her an order to transfer Patient 1 to the acute care facility emergency room to check placement of the new tube.A review of the facility's undated policy titled "Gastrostomy Tube Insertion", indicated the following as "essential steps" the licensed nurse must follow prior to reinserting the G-tube: 1. Obtain the physician's order for replacement of the tube (RN 1 did not call the physician prior to replacing the dislodged G-tube) 2. Bring all equipment to the bedside 3. Explain procedure to the patient 4. Provide privacy and wash hands 5. Unless contraindicated, place Patient in semi-fowler's position. During an interview with RN 1 on December 8, 2010 at 3:30 p.m., she stated she immediately replaced the G-tube and spoke with two physicians after she'd replaced the G-tube.The January-March, 2008, on line "Journal of Minimal Access Surgery ", published by The National Institute of Health indicated the tract where a PEG was placed is usually well formed and mature in four to six weeks, therefore if dislodged the PEG tube can be changed, replaced or removed without complications. The article further stated removal or replacement of the tube before this time will cause extravasation of gastric contents and air into the peritoneal cavity.The article indicated if a PEG is accidently dislodged early after the PEG was placed it should be removed and the stomach repaired. If the patient still needs a gastrostomy tube, the early dislodged PEG should be replaced by laparoscopy (a surgical procedure that uses a thin lighted tube inserted through a cut in the belly to look at the abdominal organs) and any blind attempt to replace the PEG should be avoided.The California Board of Registered Nurses states a standardized procedure must specify any experience, training and/or education requirements for the nurse to perform the procedure and further states as a safeguard for the consumer (patient) there must be a requirement that the nurse be currently capable of performing the procedure. The facility did not have any documented proof of RN 1's ability to insert a G-tube.A review of the clinical medical record and interview with the Director of Nurses (DON) on January 14, 201,1 verified there were no physician?s orders in the medical record indicating what steps the nursing staff were to take in the event of G-tube dislodgement. The DON stated "what she did was act immediately but we all work under the physicians, so the physician should have been called." A review of the acute care facility's emergency department (ER) record dated October 28, 2010, indicated Patient 1 was brought to the ER via ambulance where an x-ray revealed the replacement tube was in proper position in the stomach. The patient was transferred back to the facility. A review of the nurse?s notes dated October 28, 2010 at 11:25 p.m., indicated the patient's physician had been called and gave an order for the feedings to be resumed.During an interview, with Patient 1's daughter on December 1, 2010 at 11:15 a.m., she stated when the feedings were resumed at the facility her father cried out in "excruciating pain", and said his pain was at a level 10, (pain scale: 1=lowest, 10=highest). A continued review of the nurses note dated October 28, 2010 at 11:25 p.m., indicated Patient 1's physician was called when the patient complained of abdominal pain with the resumption of the feedings and an order was given to transfer Patient 1 back to the acute care facility. A review the acute care facility's abdominal computerized tomography (CT) scan and History and Physical dated October 29, 2010, indicated the G-tube was not in the abdomen, and Patient 1 had a moderately large amount of free air in the peritoneal cavity, fluid throughout the abdomen and pelvic areas, and layering of contrast consistent with extravation. According to the American Society for Gastrointestinal Endoscopy (www.asge.org) maturation of the PEG tract usually occurs within the first seven to ten days. A PEG tube that is accidently removed during this period should be replaced endoscopically, (replaced using an endoscope for visualization), as the tract may be immature and the stomach and anterior abdominal wall can separate from each other, resulting in perforation. (Practical Gastroenterology, November 2004 pp73) "Nursing Care Plans", an on line nurse education site published an article titled "Nursing Care of Gastrostomy Tubes", dated December 2008. The article indicated an initial PEG device could be removed once the tract is well established (10 to 14 days after insertion). During a phone interview with Patient 1's primary physician on January 10, 2011 at 5:30 p.m., when asked if he would have expected the facility nurse to put the G-tube back in after it was dislodged he stated, " I would not have expected the nurse to put the G-tube back in herself. If she had called me first I would have told her to transfer the patient immediately to the ER. A new tube should not be blindly replaced, it needs to be replaced surgically." During the same interview, Patient 1's primary physician stated, "This patient had multiple health problems but he had the potential to have lived much longer. I can not say this caused his death, but I do believe it hastened his death." On January 14, 2011 at 11:30 a.m., when asked why the facility policy did not specify how old a G-tube site needed to be before a nurse replaced the tube, the DON stated "a G-tube is a G-tube, it is what it is, whether it is old or new. RN 1 stated on December 8, 2010 at 3:30 p.m., during a phone interview she received training on G-tube replacement by "watching other RN's". A review of an undated the job description for the DSD indicated the primary function of the DSD position was to plan, implement, direct and evaluate the educational program of all personnel in the facility. The DSD qualifications included maintaining an interest and awareness of changes and advancement in geriatric nursing and regulations. The job description indicated a specific responsibility of the DSD would be to direct and conduct the orientation of new employees according to regulations which included policies and procedures of the facility. The California Board of Registered Nurses published on it's web site "An Explanation of the Scope of RN Practice". The article outlines the legislative amended Section 2725 of the Nurse Practice Act (NPA) which amplified the role of the registered nurse. The article indicated the legislative intent of the amendment was to address the overlapping functions between registered nurses and physicians and the means to authorize performance of a medical function by a registered nurse. The California Board of Registered Nurses indicated standardized procedures developed through collaboration among registered nurse, physicians and administrators are to be used when registered nurses perform functions that overlap physician functions.The California Business and Professions Code Section 2725 defines a standardized procedure as policies and protocols developed by a licensed health facility through collaboration among administrators and health professionals, including physicians and nurses. On January 14, 2011, during a phone interview the facility Medical Director stated he would need to refer the surveyor to the DON regarding facility standardized procedures. The Medical Director further stated he did not know when the facility's G-tube replacement policy had been reviewed or updated because he did not have the policy in front of him.In 1998 the "Institute of Medicine" created the "Committee on the Quality of Health Care in America". The committee produced a report titled "Keeping Patients Safe: Transforming the Work Environment of Nurses". The report identified the need of all health facilities to provide ongoing learning and clinical decision making support to the nursing staff as one of the safeguards facilities could implement in order to protect patient safety. ("Practice Implications of Keeping Patients Safe", NCBI Bookshelf, of the National Library of Medicine, National Institutes of Health. ( www.ncbi.nlm.nih.gov/books/NBK2671) A review of the Discharge Summary dated November 15, 2010, indicated after readmission to the acute care facility on October 29, 2010, Patient 1 was placed on intravenous (IV) feedings until the damage from the leakage into his abdominal wall and cavity healed, then underwent another surgery to place another G-Tube. A review of Patient 1's Death Certificate indicated the cause of death was pulmonary embolus secondary to small bowel obstruction from surgical adhesions and bladder cancer. The facility failed to: 1. Ensure nursing staff notified physician prior to reinserting a GT as outlined in the facility?s policy. 2. Establish patient care policy and procedure on GT reinsertion specifying when a GT could be replaced by nursing staff, and the degree of experience, training, and/or educational requirements for the nurse to perform the procedure based on standards of practice. The above violation presented a substantial probability of death or serious physical harm to this resident. |
| 910000014 |
BERKLEY EAST CONVALESCENT HOSPITAL |
910008602 |
B |
09-May-12 |
7F1011 |
10559 |
72315(j)(2) 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 72311(a)(2) 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.On December 8, 2010, an unannounced visit was conducted to investigate a complaint that Patient 1 had not had any urine output for greater than eight hours resulting in the patient having an over distended bladder upon admission to an acute care facility. Based on observation, interview and record review, the facility failed to monitor urinary output for two of two sample Patients (1, 2) with indwelling urinary catheters. This deficient practice resulted in bladder distention (over full) for Patient 1 and had the potential of resulting in an inability to determine kidney function and provision of prompt interventions, hydration status and effectiveness of treatment for Patient 2. The facility failed to: 1. Identify Patient 1 did not have urine output for twelve and one half hours, resulting in the patient?s surgically altered neo-bladder becoming overly distended. Neo-bladder?s do not have the capability to contract. This deficient practice could have resulted in Patient 1?s total loss of bladder control had he lived. 2. Irrigate Patient 1?s urinary catheter in the event of occlusion (blockage) according to physician?s orders. 3. Accurately and consistently monitor Patient 2?s urinary output. 4. Implement the care plans for monitoring urinary output for Patient 1 and Patient 2.a. Patient 1 was transferred from the facility to an acute care facility for an x-ray to confirm placement of a G-tube. Upon admission to the acute care facility the Patient's bladder was noted on x-ray to be distended (over full) and required irrigating (flushing), resulting in 1,150 mililiters (ml.) of urinary output. Normal bladder capacity is 300 to 350 ml. Patient 1 had a neo bladder, a surgically altered bladder created from the Patient's intestine (bowel), over distention of a neo bladder can result in the loss of contraction ability of the neo bladder.A review of the clinical record face sheet, and undated Therapy Evaluation Intake form indicated Patient 1 was an 84 year old admitted to the facility on October 27, 2010 with diagnoses that included multiple therapies, bladder cancer, weight loss, and failure to thrive. The Therapy Evaluation Intake sheet further indicated the patient was alert, able to understand others at all times and always able to make himself understood. A review of the physicians orders, dated October 27, 2010, indicated Patient 1 was to have a "foley catheter to straight drainage" (a foley catheter is a tube which has been inserted into the bladder to drain urine). The physician's order also indicated the catheter was to be irrigated with 100 milliliters (ml.) of normal saline as needed for occlusion (partial or complete absence of urinary output due to blockage).During an interview on December 1, 2010 at 11:15 a.m., Patient 1's daughter stated when her father was transferred to an acute care hospital from the facility on October 28, 2010, she noticed he did not have any urine in the catheter drainage bag. Patient 1's daughter stated she was concerned because several years ago her father had bladder cancer and the surgeons had removed his bladder and replaced it with a neo bladder. Review of an article titled, "Neobladder Continent Urinary Diversion", published by The University of Wisconsin, (www.uwhealth.org) on May 8, 2010, indicated a neobladder operates like the bladder it replaced, but because it was made from part of the bowel, mucus can accumulate and result in a mucus plug. The University of Michigan, in an article titled "Care following Neobladder", (www.med.umich.edu), indicated the neobladder should not be allowed to over-extend because unlike a normal bladder, the neobladder does not contract (squeeze out the urine). The normal capacity of the bladder is 300 to 350 milliliters, Patient 1 had 1,150 milliliters of urine in his bladder when admitted to the acute care facility. . A review of the emergency room department (ER) record dated October 28, 2010, indicated upon admission, Patient 1's bladder was distended on x-ray and required irrigation. The record indicated when the catheter was irrigated by the acute care facility staff, a mucus plug was dislodged and 1000 ml. of yellow urine was released. The ER staff clamped the tube for fifteen minutes and then obtained an additional 150 ml. of urine.During an interview with Certified Nursing Assistant 1 (CNA) on December 8, 2010 at 2:58 p.m., she verified she was caring for Patient 1 on October 28, 2010, on the 3 p.m. to 11 p.m. shift. The CNA stated when she cared for Patient 1 on October 28, 2010, he did not have a urinary catheter. During another interview with CNA 1 at 4:30 p.m., one and one half hours later, the CNA stated she had forgotten during our earlier interview, but now she remembered, the Patient did have a urinary catheter, but she could not remember if there had been any urine in the bag when her shift started. A review of the facility's Licensed Personnel Progress Notes indicated Patient 1 had a urinary drainage catheter in place when admitted to the facility on October 27, 2010 at 6:00 p.m. A review of the facility's undated policy titled, "Intake and Output", indicated if a patient had a catheter, the CNA assigned to that patient would be responsible for seeing that the catheter drainage bag was emptied and the amount of output charted before she goes off duty.The Nursing Assistant Daily Flow Sheet for the October 28, 2011 night shift (11 p.m. to 7 a.m.) indicated Patient 1 had eight hundred milliters urinary output emptied from the drainage bag at 7 a.m. During an interview with the Director of Staff Development (DSD) on December 8, 2010 at 3:15 p.m., she verified there was no documentation of Patient 1's urinary output for the 7 a.m. to 3 p.m. shift in the medical record, in addition the DSD stated the staff had ?made a mistake? when they had documented on the CNA flow sheet that the patient was incontinent and did not have a urinary catheter. The DSD also verified there were no separate intake/output sheets on which the facility staff had documented any urinary output for Patient 1. There was no urinary output documented for Patient 1 after the night shift emptied the drainage bag of 800 ml. at 7 a.m. until Patient 1 was admitted to the acute care facility at 7:30 p.m.,( twelve and 1/2 hours), where it was discovered his bladder was over distended and required irrigation. A review of the October 28, 2010, Nursing Assistant Daily Flow Sheet for the 3 p.m. to 11 p.m. shift indicated two hundred ml. of urine was emptied from Patient 1's drainage bag at 11 p.m. During an interview on December 8, 2010 at 4:30 p.m., CNA 1 verified that the documented two hundred ml. was the Patients urinary output she emptied from the drainage bag after he returned from the acute care facility.A review of the facility's care plan for Patient 1 dated October 27, 2010, indicated he was at risk for urinary retention and the planned approaches included monitoring his intake and output and observing the appearance of his urine for any signs and symptoms of obstruction. b. Patient 2 was observed on December 8, 2010 at 4:15 p.m. with nine hundred ml. of urine in her urinary drainage bag. A review of Patient 2's medical record face sheet indicated she was an 83 year old admitted to the facility on November 21, 2010, with diagnoses that included right ankle fracture, status post fall, and multiple therapies. A review of the physician?s history and physical examination, dated November 20, 2010, Patient 2 also had renal insufficiency and chronic kidney disease. During an interview on December 8, 2010 at 4:45 p.m., Patient 2 stated she often had to remind the facility staff to empty her drainage bag.On December 8, 2010 at 4:50 p.m. the DSD was shown Patient 2's full drainage bag which was to have been emptied at 3 p.m. During this interview the DSD verified the following amounts were documented on the Nursing Assistant Daily Flow Sheets: a. December 4, 201011 p.m. to 7 a.m. shift= 900 ml7 a.m. to 3 p.m. shift=550 ml.3 p.m. to 11 p.m. shift = 200 ml. b. December 5, 201011 p.m. to 7 a.m. shift = Blank7 a.m. to 3 p.m. shift = 200 ml.3 p.m. to 11 p.m. shift = 500 ml. c. December 6, 201011 p.m. to 7 a.m. = 800 ml.7 a.m. to 3 p.m. = N/A3 p.m. to 11 p.m. = 800ml d. December 7, 201011 p.m. to 7 a.m. = 200 ml.7 a.m. to 3 p.m. =N/A3 p.m. to 11 p.m. = 500 ml. e. December 8, 201011 p.m. to 7 a.m. = 500 ml.7 a.m. to 3 p.m. = N/A * * During an interview with CNA 3 on December 8, 2010 at 4:55 p.m., when asked what ?N/A? indicated when written on the Nursing Assistant Daily Flow Sheet, he stated it meant the patient did not have a catheter. When asked why N/A would be written on Patient 2?s flow sheet when she did have a catheter he stated he did not know.A review the facility?s plan of care for Resident 2 identified the resident as being at risk for fluid volume deficit and/or electrolyte (salts and minerals that conduct electrical impulses in the body) imbalances.The facility?s plan of care indicated the resident?s urinary output would be observed and recorded as one approach to ensure Resident 2?s fluid and electrolyte balance was maintained. A review of the facility's undated "Intake and Output" policy indicated the purpose of documenting a patient?s fluid intake and urinary output is to serve as an aide to the physician in establishing a diagnosis and planning the treatment for the patient in addition to providing an accurate record of the fluid intake and output. The facility failed to: 1. Identify Patient 1 did not have urine output for twelve and one half hours, resulting in the patient?s surgically altered neo-bladder becoming overly distended. Neo-bladder?s do not have the capability to contract. This deficient practice could have resulted in Patient 1?s total loss of bladder control had he lived. 2. Irrigate Patient 1?s urinary catheter in the event of occlusion (blockage) according to physician?s orders. 3. Accurately and consistently monitor Patient 2?s urinary output. 4. Implement the care plans for monitoring urinary output for Patient 1 and Patient 2. The above violations had a direct relationship to the health safety or security of patients. |
| 910000017 |
Beachwood Post - Acute & Rehab |
910009007 |
B |
15-Feb-12 |
XF4N11 |
11036 |
22 CCR ? 72313 (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed.On October 8, 2010, the Department received an entity reported incident filed by the facility, alleging a licensed vocational nurse (LVN 1) documented the administration of medications to patients without actually administering some of the medications during his shifts.On October 25, 2010, at 8 a.m., an unannounced visit was made to the facility to conduct an investigation on the entity reported incident. Based on interviews and record reviews, the facility failed to ensure medications were administered as prescribed by the physician, as evidenced by not administering medications to 6 out of 35 patients on the fourth floor (East Wing) on October 3 and 4, 2010. On October 25, 2010, during an interview at 9:50 a.m., the administrator (ADM) stated the incident affected 20 of 35 patients who resided on the fourth floor (East Wing). The ADM stated LVN 1 had been suspended from work since October 4, 2010, as a result of the facility?s investigation.The facility first discovered, during the morning medication pass on October 3, 2010, that some medications for the morning doses were not administered on October 1 and 2, 2010. The facility identified LVN 1 was scheduled and responsible for medication passes on those dates, however, they failed to act on this discovery promptly to prevent a reoccurrence by allowing LVN 1 to continue to work and administer medications to patients on the evening shifts on October 3 and 4, 2010. The facility suspended LVN 1 from work duty in the evening of October 4, 2010, which was approximately 36 hours after the discovery of medication omissions. The facility?s failure resulted in 6 additional patients not receiving their medications, which included significant medications, as prescribed by their physicians. This failure had a potential for detrimental effects to the patients? health and safety, such as: sudden increase in blood pressure; increase seizure activity; changes in mental status or psychotic behavior; increase pain, in magnitude and/or frequency; and gastro-intestinal distress.At 11:25 a.m., during an interview, LVN 3 stated when she returned to work on October 5, 2010, evening shift, she noticed some of the evening medications for October 3 and 4, 2010, remained in the bubble packs. LVN 3 reported this finding to her supervisor who then reported to DON. LVN 3 stated the morning and evening meds were stored in separate drawers in the medication cart. She also stated ?this never happened before? and ?it was out of character for [LVN 1]?. A review of the Licensed Nurses Schedule October 2010 indicated LVN 1 was scheduled to work evening shifts on October 3 and 4, 2010. At 11:35 a.m., RN 2 stated LVN 3 from the evening shift on October 3, 2010, reported the possible omission of medications. RN 2 stated the ADM suspended LVN 1 on the evening of October 4, 2010, approximately 8 p.m. On October 26, 2010, during a telephone interview, at 11:57 a.m., LVN 1 stated the event happened on his first day back to work. LVN 1 could not remember what date it was, but stated he remembered ?the medications were out of sequence? during medication pass and notified the nursing supervisor. When he was questioned about cycle meds, LVN 1 stated he was never trained on bubble pack sequence of medications at this facility, but was trained at other facilities. However, a review of an In-service titled ?Medication Pass?, dated March 24, 2010, revealed LVN 1?s name and signature, which indicated he was in attendance. LVN 1 also stated he was passing the evening medications on October 4, 2010, around 9 p.m., when he was summoned by the ADM regarding the medication documentation errors and was relieved from work duty. A review of LVN 1?s personnel file revealed a Written Warning dated October 4, 2010, indicating LVN 1 was removed from schedule and received the warning at 10 p.m.On October 27, 2010, during a telephone interview, at 10 a.m., the director of nursing (DON), who had recently resigned (October 21, 2010), stated she was first informed of the incident by her staff on October 3, 2010. The DON stated after the facility investigated the incident, their evidence suggested LVN 1 did not administer the medications even though he initialed on the MAR. The DON also stated ?cycle meds? were usually changed or renewed on the tenth of each month and any unused medications at the end of the cycle would be taken out of the medication cart and given to supervisors for disposition.A review of the Interdisciplinary Team Meeting record, dated October 7, 2010, indicated the facility identified another 6 patients (Patients 2, 4, 6, 7, 9, and 20) who resided on the fourth floor that ?were possibly not given medications?. According to the meeting record, some of the medications for these 6 patients were not given because the medications remained in the bubble packs on October 3 and 4, 2010, for the evening doses. A review of the photocopies of these patients? bubble packs indicated 24 doses of medications were not administered.A review of the bubble packs photocopies individually labeled with the patient?s name indicated medications remained in the bubbles for the dates October 3 and 4. A review of these 6 patients? individual MAR for October 2010 revealed LVN 1 signed his initials on October 3 and 4, which indicated the medications were administered. The following patients were involved in the omission of medications: a. Patient 2 was an 83 year old female, who was admitted on September 24, 2010. She had diagnoses that included, but not limited to: hypertension (high blood pressure), muscle weakness, and seizure disorder. A review of the Minimal Data Set (MDS, a standardized assessment and care screening tool), dated October 13, 2010, indicated Patient 2 required limited to extensive assistance on her daily activities. According to the facility?s report, the medications that were not given to Patient 2 included: levetiracetam (Keppa, a medication to treat seizure disorder). b. Patient 4 was a 64 year old male, who was admitted on November 13, 2009. He had diagnoses that included, but not limited to: chronic pain syndrome and seizure disorder. A review of the MDS, dated September 29, 2010, indicated Patient 4 required limited assistance on his daily activities. According to the facility?s report, the medications that were not given to Patient 4 included: gabapentin (Neurontin, a medication to treat seizure disorder) and naproxen (a pain medication). c. Patient 6 was an 89 year old male, who was admitted on June 25, 2009. He had diagnoses that included, but not limited to: hypertension (high blood pressure), muscle weakness, hyperlipidemia (high cholesterol), ulcerative colitis (a type of inflammatory bowel disease that affect the large intestine and the rectum), and dementia (a serious loss of cognitive skills). A review of the MDS, dated October 4, 2010, Patient 6 was able to repeat 1 of 3 words after first attempt; he was not able to report the correct day of the week; and failed to recall 3 of 3 words after cueing. Under Section G, the MDS indicated Patient 6 required extensive assistance on his daily activities. According to the facility?s report, the medications that were not given to Patient 6 included: Namenda (a medication to treat dementia), Pentasa (a medication to treat inflammatory bowel diseases), Welchol (a medication to treat high cholesterol), and doxazosin (a medication to treat high blood pressure). d. Patient 7 was a 51 year old female, who was admitted on February 10, 2009. She had diagnoses that included, but not limited to: hypertension (high blood pressure), diabetes mellitus (high blood sugar), and seizure disorder. A review of the MDS, dated August 4, 2010, indicated Patient 7 had problems with both short and long-term memory. Her cognitive skills for daily decision-making were ?moderately impaired?. Under Section G, the MDS indicated Patient 7 required extensive assistance on some of her daily activities and was totally dependent on staff for other activities. According to the facility?s report, the medications that were not given to Patient 7 included: Dilantin (phenytoin, a medication to treat seizure disorder). e. Patient 9 was an 89 year old female, who was admitted on May 2, 2006. She had diagnoses that included, but not limited to: hypertension (high blood pressure), hypercholesterolemia (high cholesterol), and depression. A review of the MDS, dated August 12, 2010, indicated Patient 9 had problems with short-term memory. Her cognitive skills for daily decision-making were ?moderately impaired?. Under Section G, the MDS indicated Patient 9 required supervision and limited assistance on her daily activities. According to the facility?s report, the medications that were not given to Patient 9 included: Lipitor (a medication to treat high cholesterol), Remeron (mirtazapine, a medication to treat depression), lisinopril (a medication to treat high blood pressure), and gabapentin (Neurontin, a medication to treat seizure disorder and neuropathic pain). f. Patient 20 was a 59 year old female, who was admitted on May 24, 2006. She had diagnoses that included, but not limited to: muscle weakness, neuropathy (a functional disturbance or damage to the peripheral nervous system), and depression. A review of the MDS, dated July 14, 2010, under Section G, indicated Patient 20 was totally dependent on staff support for most of her daily activities and required extensive assistance for other. According to the facility?s report, the medications that were not given to Patient 20 included: gabapentin (Neurontin, a medication to treat seizure disorder and neuropathic pain) and baclofen (a medication to relax muscles).Many of the above mentioned medications, if omitted, could potentially affect the patient?s comfort level or jeopardize the patient?s health or safety, depending on the drug category. For example, according to Lexi-comp Online, a nationally recognized drug information resource for healthcare professionals, Dilantin (phenytoin, a medication to treat seizure disorder) can cause status epileticus (a life-threatening condition in which the brain is in a persistent seizure) if discontinue abruptly.During a telephone interview on October 26, 2010, at 12:40 p.m., the physician who participated in the facility?s interdisciplinary meetings after the incident stated that their investigation concluded that those patients did not receive their medications. She also concurred that some of the medication errors involved in the reported incident were significant. Therefore, the facility failed to ensure medications were administered as prescribed by the physician, as evidenced by not administering medications to 6 out of 35 patients on the fourth floor (East Wing) on October 3 and 4, 2010. These violations had a direct relationship to the health, safety, or security of patients. |
| 910000017 |
Beachwood Post - Acute & Rehab |
910009008 |
B |
14-Feb-12 |
XF4N11 |
20342 |
22 CCR ? 72313 (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed.On October 8, 2010, the Department received an entity reported incident from the facility, alleging a licensed vocational nurse (LVN 1) documented the administration of medications to patients without actually administering some of the medications during his shifts.On October 25, 2010, at 8 a.m., an unannounced visit was made to the facility to conduct an investigation on the entity reported incident. Based on observations, interviews and record reviews, the facility failed to ensure medications were administered as prescribed by the physician, as evidenced by not administering medications to 14 out of 35 patients on the fourth floor (East Wing) on October 1 and 2, 2010 for Patients 1, 3, 5, 8, 10, 11, 12, 13, 14, 15, 16, 17, 18 and 19. The facility?s failure resulted in 14 patients not receiving their medications, included significant medications, as prescribed by their physicians. This failure had a potential for detrimental effects to the patients? health and safety, such as: sudden increase in blood pressure; increase seizure activity; increase in blood sugar; changes in mental status or behavior; increase pain, in terms of magnitude and/or frequency; and dysrhythmia (a condition in which there is abnormal electrical activity in the heart, causing fast, slow, irregular heart beat, or life-threatening medical emergency). Once the facility identified the incident, they failed to act on it promptly to prevent a reoccurrence by allowing LVN 1 to administer medications to patients until approximately 36 hours after the time when LVN 2 first discovered some patients did not receive their medications. On October 25, 2010, during an interview, at 9:50 a.m., the administrator (ADM) stated LVN 2 was the first to notice that medications were remained in the bubble packs after signed given. ADM stated LVN 2 first notified RN 2 and RN 2 notified him. The ADM stated he received a text message from RN 2 about the incident on October 4, 2010, around 8 a.m. and he instructed RN 2 to make copies of all the bubble packs and MARs involved. He contacted the facility contracted pharmacy consultant (RPh) to perform an audit on all the floors. The ADM stated the audit concluded that the incident was found to be isolated on fourth floor only and affected about 20 of 35 patients on fourth floor.At 10:50 a.m., during an interview, LVN 2 stated there were three licensed nurses (LVN 1, LVN 3, and she) who administered medications on the fourth floor. LVN 2 stated she worked on October 3, 2010, morning shift (7 a.m. to 3 p.m.), after being off from work two days prior. LVN 2 stated LVN 1 covered those morning shifts (October 1 and 2) while she was off duty. LVN 2 also stated during the medication pass in the morning of October 3, 2010, she noticed some cycle medications for the past two days remained in the bubble packs. She explained that when administering cycle medications, she was trained to always push out the medication contained in the bubble pack that matches the date of the month. LVN 2 stated the only exception would be medications that were out of cycle. LVN 2 stated those bubble packs that had medications for October 1 and 2, 2010, were mostly cycle medications, which suggested those medication may not have been given to the patients. Thus, she notified her supervisor, RN 2. A review of the Licensed Nurses Schedule, dated October 2010, indicated LVN 1 was scheduled to work on the morning shifts on October 1 and 2, 2010. LVN 1 was also scheduled to work the evening shifts (3 p.m. to 11 p.m.) on October 3 and 4, 2010. During an interview on October 25, 2010, at 11:35 a.m., RN 2 confirmed that LVN 2 had notified her of the possible omission of medications for many patients on October 4, 2010. RN 2 stated she then contacted the DON and the ADM by telephone and text message respectively. RN 2 stated the ADM suspended LVN 1 on the evening of October 4, 2010. Furthermore, RN2 stated she later found out that the evening shift had also reported a similar incident happened on the evening shifts on October 3 and 4, 2010 while LVN 1 was on duty.On October 26, 2010, during a telephone interview, at 11:57 a.m., LVN 1 stated the event happened on his first day back to work. LVN 1 could not remember what date it was, but stated he remembered ?the medications were out of sequence? during medication pass and notified the nursing supervisor. When he was questioned about cycle meds, LVN 1 stated he was never trained on bubble pack sequence of medications at this facility, but was trained at other facilities. However, a review of an In-service titled ?Medication Pass?, dated March 24, 2010, revealed LVN 1?s name and signature, which indicated he was in attendance. LVN 1 also stated he was passing the evening medications on October 4, 2010, around 9 p.m., when he was summoned by the ADM regarding the medication documentation errors and was relieved from work duty. A review of LVN 1?s personnel file revealed a Written Warning dated October 4, 2010, indicating LVN 1 was removed from schedule and received the warning at 10 p.m.On October 27, 2010, during a telephone interview, at 10 a.m., the director of nursing (DON), who had recently resigned (October 21, 2010), stated she was first informed of the incident by her staff on October 3, 2010. The DON stated after the facility investigated the incident, their evidence suggested LVN 1 did not administer the medications even though he initialed on the MAR. The DON also stated ?cycle meds? were usually changed or renewed on the tenth of each month and any unused medications at the end of the cycle would be taken out of the medication cart and given to supervisors for disposition.A review of the Interdisciplinary Team Meeting record, dated October 5, 2010, indicated the facility identified 14 of 35 patients who resided on the fourth floor ?were possibly not given their medications.? Those 14 patients were Patients 1, 3, 5, 8, 10, 11, 12, 13, 14, 15, 16, 17, 18 and 19. According to the meeting record, some of the medications for these 14 patients were not given because the medications remained in the bubble packs on October 1 and 2, 2010, for the morning doses. A review of the photocopies of these patients? bubble packs indicated 73 doses of medications were not administered.A review of the photocopies of the bubble packs individually labeled with the patient?s name indicated medications remained in the bubbles for the dates October 1 and 2. A review of these 14 patients? individual MAR for October 2010 revealed LVN 1 signed his initials on October 1 and 2, which indicated the medications were administered. The following patients were involved in the omission of medications: a. Patient 1 was a 67 year old male, who was admitted on August 11, 2009. He had diagnoses that included, but not limited to: aftercare for fractures of shoulder and hip, osteoporosis (a disease of the bone that leads to an increased risk of fracture), and hypothyroidism (a condition in which the thyroid gland does not make enough thyroid hormones). A review of the Minimal Data Set (MDS, a standardized assessment and care screening tool), dated September 15, 2010, indicated Patient1 had problems with both short and long-term memory. His cognitive skills for daily decision-making were ?severely impaired?. Also, under Section G1, ADL (activities of daily life), the MDS indicated Patient 1 was totally dependent on staff?s assistance in most ADLs and needed extensive assistance in others. According to the facility?s report, the medications that were not given to Patient 1 included: levothyroxine (medication to treat hypothyroidism) and Cardizem (diltaizem, medication to treat high blood pressure). b. Patient 3 was an 87 year old female, who was admitted on August 8, 2007. She had diagnoses that included, but not limited to: hypertension (high blood pressure), and dementia (a serious loss of cognitive skills). A review of the MDS, dated July 19, 2010, indicated Patient3 had problems with both short and long-term memory. Her cognitive skills for daily decision-making were ?moderately impaired?. Also, under Section G1, ADL (activities of daily life), the MDS indicated Patient 3 required staff?s supervision when performing most of her activities. According to the facility?s report, the medications that were not given to Patient 3 included: Vasotec (enalapril, a medication to treat high blood pressure), Razadyne (galantamine, a medication to treat dementia), Depakote (divalproex, a medication for seizure and certain mood disorder). c. Patient 5 was an 80 year old female, who was admitted on April 26, 2007. She had diagnoses that included, but not limited to: hypertension (high blood pressure), and dementia (a serious loss of cognitive skills). A review of the MDS, dated September 20, 2010, indicated Patient 5 had problems with both short and long-term memory. Her cognitive skills for daily decision-making were ?moderately impaired?. Also, under Section G1, ADL (activities of daily life), the MDS indicated Patient 5 was totally dependent on staff?s assistance in performing all activities. According to the facility?s report, the medications that were not given to Patient 5 included: amlodipine (a medication to treat high blood pressure). d. Patient 8 was a 91 year old female, who was admitted on October 4, 2006. She had diagnoses that included, but not limited to: hypertension (high blood pressure), Parkinson?s disease (a degenerative disorder of the central nervous system that impairs motor skills, cognitive processes, and other functions), and dementia (a serious loss of cognitive skills). A review of the MDS dated, July 8, 2010, indicated Patient 8 had problems with both short and long-term memory. Her cognitive skills for daily decision-making were ?moderately impaired?. Also, under Section G1, the MDS indicated Patient 8 required extensive assistance from staff in most ADLs and was totally dependent on staff in other. According to the facility?s report, the medications that were not given to Patient 8 included: metoprolol (medication to treat high blood pressure), Sinemet (carbidopa-levodopa, medication to treat Parkinson?s disease). e. Patient 10 was a 74 year old male, who was admitted on August 27, 2010. He had diagnoses that included, but not limited to: hypertension (high blood pressure), atrial fibrillation (a form of [cardiac arrhythmia], abnormal heart rhythm, that involves the two upper chambers [atria] of the heart). A review of the MDS, dated September 7, 2010, under Section G1, indicated Patient 10 needed extensive assistance from staff in most activities. According to the facility?s report, the medications that were not given to Patient 10 included: metoprolol (medication to treat high blood pressure), digoxin (medication to treat abnormal heart rhythm). f. Patient 11 was a 59 year old female, who was admitted on January 17, 2006. She had diagnoses that included, but not limited to: hypertension (high blood pressure), and seizure disorder. A review of the MDS, dated September 22, 2010, indicated Patient11 had problems with both short and long-term memory. Her cognitive skills for daily decision-making were ?moderately impaired?. Also, under Section G1, ADL (activities of daily life), the MDS indicated Patient 11 was totally dependent on staff for all activities except bed mobility, in which she required extensive assistance. According to the facility?s report, the medications that were not given to Patient 11 included: Lopressor (metoprolol, a medication to treat high blood pressure), Norvasc (amlopidine, a medication to treat high blood pressure), and Neurontin (gabapentin, a medication to treat seizure disorders). g. Patient 12 was a 92 year old male, who was admitted on December 18, 2009. He had diagnoses that included, but not limited to: hypertension (high blood pressure), aphasia (a language disorder that may include difficulty in producing or comprehending spoken or written language), Parkinson?s disease (a degenerative disorder of the central nervous system that impairs motor skills, cognitive processes, and other functions), and dementia (a serious loss of cognitive skills). A review of the MDS, dated September 28, 2010, indicated Patient12 had problems with both short and long-term memory. His cognitive skills for daily decision-making were ?severely impaired?. Also, under Section G1, the MDS indicated Patient 12 was totally dependent on staff for all activities except bed mobility and personal hygiene, in which he required extensive assistance. According to the facility?s report, the medications that were not given to Patient 12 included: amlopidine (medication to treat high blood pressure), carbidopa-levodopa (a medication to treat Parkinson?s disease), Mirapex (another medication for the treatment of Parkinson?s disease). h. Patient 13 was a 90 year old male, who was admitted on April 1, 2010. He had diagnoses that included but not limited to: hypertension (high blood pressure), chronic atrial fibrillation (a form of [cardiac arrhythmia], abnormal heart rhythm, that involves the two upper chambers [atria] of the heart), and renal insufficiency. A review of the MDS, dated July 9, 2010, indicated Patient 13 had problem with short-term memory. His cognitive skills for daily decision-making were ?moderately impaired?. Also, under Section G1, the MDS indicated Patient 13 required supervision and limited assistance from staff in his daily activities. According to the facility?s report, the medications that were not given to Patient 13included: benazepril (medication to treat high blood pressure), Detrol LA (tolterodine, a medication to treat urinary problem). i. Patient 14 was an 88 year old female, who was admitted on May 5, 2010. She had diagnoses that included, but not limited to: hypertension (high blood pressure), diabetes mellitus (high blood sugar), and dementia (a serious loss of cognitive skills). A review of the MDS, dated July 12, 2010, indicated Patient 14 had problems with both short and long-term memory problem. Her cognitive skills for daily decision-making were ?moderately impaired?. Also, under Section G1, the MDS indicated Patient 14 required extensive assistance from staff in most of her daily activities. According to the facility?s report, the medications that were not given to Patient 14 included: carvedilol (medication to treat high blood pressure), Diovan (valsartan, medication to treat blood pressure), clonidine patch (medication to treat high blood pressure), Norvasc (amlodipine, medication to treat high blood pressure), and Januvia (sitagliptin, medication to treat diabetes). j. Patient 15 was a 66 year old female, who was admitted on May 1, 2006. She had diagnoses that included, but not limited to: Parkinson?s disease (a degenerative disorder of the central nervous system that impairs motor skills, cognitive processes, and other functions) and anemia (a condition in which the body does not have enough red blood cells). A review of the MDS, dated September 13, 2010, under Section G1, indicated Patient 15 required supervision in most of her daily activities. According to the facility?s report, the medication that was not given to Patient 15 included carbidopa-levodopa (a medication to treat Parkinson?s disease). k. Patient 16 was a 28 year old female, who was admitted on December 1, 2005. She had diagnoses that included, but not limited to: seizure, anemia (a condition in which the body does not have enough red blood cells), and subacute sclerosing panencephalitis (a rare, progressive brain disorder caused by an abnormal immune response to certain viruses). A review of the MDS, dated September 6, 2010, indicated Patient 16 had problems with both short and long-term memory. Her cognitive skills for daily decision-making were ?severely impaired?. Also, under Section G1, the MDS indicated Patient 16 was totally dependent on staff in all of her daily activities. According to the facility?s report, the medications that were not given to Patient 16 included: Neurontin (gabapentin, a medication to treat seizure disorders), and folic acid (a medication to treat anemia due to folate deficiency). l. Patient 17 was an 85 year old female, who was admitted on July 21, 2006. She had diagnoses that included, but not limited to: diabetes mellitus (high blood sugar), and dementia (a serious loss of cognitive skills). A review of the MDS, dated August 4, 2010, indicated Patient 17 had problems with both short and long-term memory. Her cognitive skills for daily decision-making were ?moderately impaired?. Also, under section G1, the MDS indicated Patient 17 was totally dependent on staff for most of her daily activities. According to the facility?s report, the medication that was not given to Patient 17 included Glucophage (metformin, a medication to treat diabetes) m. Patient 18 was an 87 year old female, who was admitted on July 30, 2010. She had diagnoses that included, but not limited to: hypertension (high blood sugar), status post fall (accident), and dementia (a serious loss of cognitive skills). A review of the MDS, dated August 11, 2010, indicated Patient18 had problems with both short and long-term memory. Her cognitive skills for daily decision-making were ?moderately impaired?. Also, under Section G1, the MDS indicated Patient 18 required extensive assistance from staff for most of her daily activities. According to the facility?s report, the medication that was not given to Patient 18 included Motrin: (ibuprofen, a medication to relieve pain and/or inflammation), and folic acid (a medication to treat anemia due to folate deficiency). n. Patient 19 was an 84 year old male, who was admitted on July 30, 2010. He had diagnoses that included, but not limited to: Vancomycin-resistant Enterococci in urine (a type of urine infection), renal mass, and seizure disorder. A review of the MDS, dated August 12, 2010, under section G1, indicated Patient 19 required some assistance from staff in most of his daily activities. According to the facility?s report, the medication that was not given to him included: Flomax (tamsulosin, a medication to treat benign prostatic hyperplasia [enlarged prostate] or promote urine flow). Many of the above mentioned medications, if omitted, could potentially affect the patient?s comfort level or jeopardize the patient?s health or safety, depending on the drug category. For example, digoxin is considered a ?high alert medication? (medications that bear a heightened risk of causing significant patient harm when they are used in error) by the Institute of Safe Medication Practices. According to a drug information piece from WebMD (http://www.webmd.com/drugs/drug-4358-Digoxin+Oral.aspx?drugid=4358&drugname=Digoxin+Oral), ?some condition may become worse if [digoxin] is suddenly stopped?. Another example, a patient whose pain is controlled may develop an episode of pain if a dose of pain medication is missed. A review of the Resident Monitoring Tool for Medication Omission, which was developed after the incident, indicated the facility monitored the possible side effects on the 14 patients involved. The side effects that were being monitored included, but not limited to: sudden increase in blood pressure; increase seizure activity; increase in blood sugar; changes in mental status or psychotic behavior; increase episodes of pain; and dysrhythmia.During a telephone interview on October 26, 2010, at 12:40 p.m., the physician who participated in the facility?s interdisciplinary meetings after the incident stated that their investigation concluded that those patients did not receive their medications. She also concurred that some of the medication errors involved in the reported incident were significant. Therefore, the facility failed to ensure medications were administered as prescribed by the physician, as evidenced by not administering medications to 14 out of 35 patients on the fourth floor (East Wing) on October 1 and 2, 2010 for Patients 1, 3, 5, 8, 10, 11, 12, 13, 14, 15, 16, 17, 18 and 19.These violations had a direct relationship to the health, safety, or security of patients. |
| 910000322 |
Beverly West Healthcare |
910009168 |
A |
21-Mar-12 |
ZCBV11 |
12840 |
72311(a)(3)(B) Nursing Service-General (a) Nursing service shall include, but not be limited to, the following: (3) Notifying the attending physician promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. 72313(a)(2) Nursing Service-Administration of Medications and Treatments (a) Medication and treatments shall be administered as follows: (2) Medication and treatments shall be administered as prescribed. Based on interview and record review the facility?s nursing staff failed to: 1. Ensure Patient A?s physician was notified on June 29, 2008, July 7, 17 and 20, 2008, August 9, 16-17, 23-24 and 25, 2008, when the patient?s blood sugar was above 500 milligrams (mg)/deciliter (dl).2. Administer medication (insulin) as prescribed, when Patient A?s blood sugar was above 500 mg/dl. On July 7 and 17, 2008, August 9, 16-17 and 25, 2008, Patient A?s blood sugar was above 500 mg/dl. 15 units of insulin was administered to the patient, however, the prescribed order indicated 20 units of insulin was to be administered. On August 27, 2008, a Complainant was contacted regarding a complaint she filed through the Ombudsman?s office. The Complainant indicated Patient A was transferred to an acute care facility, because her blood sugar level was high. On August 25, 2008, at 1:00 a.m., Patient A was found on the floor. A blood sugar level was obtained; it registered ?hi? (indicating, her blood sugar was over 600 mg/dl). According to Registered Nurse 1 (RN 1), the recommended amount of insulin was administered to the patient; however, the physician was not notified. The same day at 6:30 a.m., another blood sugar level was obtained; it also registered ?hi?. 15 units of regular insulin was administered to the patient, however, the sliding scale (a progressive increase in insulin dosage that is defined by the individual's blood glucose range) indicated the Patient should have received 20 units of regular insulin). The physician was notified and the patient was sent to a general acute care hospital (GACH) for evaluation. A review of Patient A?s Admission Records indicated she was a 58 year-old female who was admitted to the facility on November 16, 2006, with diagnoses that included diabetes mellitus, cerebrovascular accident (stroke) with left sided hemi paresis (weakness), congestive heart failure (when the heart can't pump enough blood to meet the body's needs), hypertension and she had a pacemaker. According to the Minimum Data Set (MDS) Assessment (a standardized comprehensive assessment of the patient?s problems and conditions), dated May 23, 2008, Patient A had modified independence in her decision-making ability and experienced an acute episode or flare-up of a recurrent or chronic problem. A Care Plan, dated November 5, 2007, indicated Patient A had a potential for fluctuation in blood sugar levels due to diabetes mellitus. The goal was for the patient to be free from signs and symptoms of a hyperglycemic (high blood sugar) reaction and for her blood sugar to be between 80-120 mg/dl. Approaches indicated nursing staff would be alert for signs and symptoms of hyperglycemia such as a blood sugar levels above 200 mg/dl and to administer medication as ordered. A Facility Transfer Report, from the General Acute Care Hospital (GACH), where Patient A was transferred from, dated November 16, 2006, indicated to give Patient A 20 units of regular insulin for a blood sugar level of 500 mg/dl or greater and then to call the physician. However, recapitulated (recapped) physician?s orders did not indicated to call the physician. Recapped Physician?s Orders, for August 2008, indicated Patient A had an order, dated November 16, 2006, for a finger stick to obtain a blood sugar level before breakfast and at bed time. Regular insulin was to be administered subcutaneously (beneath the skin), according to the following sliding scale: Less than 60- Give orange juice or glucagon (used to increase blood sugar levels) 1 mg IM (intramuscularly) 60-150 = no coverage 151-200 = 2 units 201-250 = 4 units 251-300 = 6 units 301-350 = 8 units 351-400 = 10 units 401-450 = 12 units 451-500 = 15 units Greater than 500 = 20 units Continued review of the Recapped Physician?s Orders did not reflect what the Facility Transfer Report, dated November 16, 2006, indicated, which was to give 20 units of insulin for blood sugar levels greater than 500mg/dl and to call the medical doctor. A review of the Medication Record and Profile indicated the following: 1. June 29, 2008, at 11:30 a.m., Patient A?s blood sugar level registered ?hi?, 20 units of regular insulin was administered, to the patient, as prescribed. Documentation did not indicate the physician was notified. 2. July 7, 2008, at 6:30 a.m., Patient A?s blood sugar level was 564 mg/dl. 15 units of regular insulin was administered to the patient. (The sliding scale indicated 20 units of insulin should have been administered). Documentation did not indicate the physician was notified. 3. July 17, 2008, at 4:30 p.m., Patient A?s blood sugar level was 510 mg/dl,15 units of regular insulin was administered to the patient. (The sliding scale indicated 20 units of insulin should have been administered). Documentation did not indicate the physician was notified. 4. July 20, 2008, at 11:30 a.m., Patient A?s blood sugar level registered ?hi?, 20 units of regular insulin was administered, to the patient, as prescribed. Documentation did not indicate the physician was notified. 5. July 29, 2008, at 6:30 a.m., Patient A?s blood sugar level registered ?hi?, 20 units of regular insulin was administered, to the patient, as prescribed. Documentation did not indicate the physician was notified. 6. August 9, 2008, at 6:30 a.m., Patient A?s blood sugar level was 538 mg/dl, 15 units of regular insulin was administered to the patient.(The sliding scale indicated 20 units should have been administered). Documentation did not indicate the physician was notified. 7. August 16-17, 23-25, 2008, at 6:30 a.m., Patient A?s blood sugar registered ?hi?, 15 units of regular insulin was administered to the patient. (The sliding scale indicated 20 units of insulin should have been administered) Documentation did not indicate the physician was notified). Licensed Personnel Progress Notes, dated August 25, 2008, at 1:00 a.m., indicated Patient A was found on the floor. Documentation indicated the patient?s blood sugar level registered ?hi?. Per documentation the recommended amount of insulin was administered to the patient. The physician was not notified of the patient?s blood sugar level until on the same day at 6:30 a.m., another blood sugar level was obtained, which also registered ?hi?. 15 units of regular insulin was administered to the patient. (The sliding scale indicated 20 units of regular insulin should have been administered). The physician was notified and the patient was transferred to a GACH for evaluation. A review of the Medication Record and Profile, dated August 25, 2008, at 1:00 a.m., indicated there was no documented evidence of how many units of regular insulin was administered to the patient. Patient A?s blood sugar was not re-checked until 6:30 a.m., five hours after the patient?s initial blood sugar reading registered ?hi?. A Diabetes Flow sheet, dated August 25, 2008, at 8:14 a.m., from the GACH, where Patient A was transferred to for evaluation, indicated her blood sugar was 548 mg/dl. An Emergency Room Report, obtained from the GACH, where Patient A was transferred to for evaluation, dated August 25, 2008, indicated Patient A was admitted for elevated blood sugars and altered mental status. The report indicated the patient?s blood sugar level was 543 mg/dl. Patient A?s course of treatment while she was in the emergency department, from 8:00 a.m. until 4:25 p.m., included observation, frequent accu-checks (a blood sugar monitoring system), aggressive hydration with intravenous (in a vein) fluids and intravenous insulin. Patient A was placed on an insulin infuser (a medical device used for continuous administration of insulin). On July 10, 2009, at 11:35 a.m., during a telephone interview, the Director of Nursing (DON) stated if the patient?s blood sugar level registered ?hi? the patient should have been administered the amount of insulin that was prescribed and another blood sugar level should have been obtained in an hour using a different glucometer (medical device for determining the approximate concentration of glucose in the blood). She stated there was no literature on the glucometer regarding what a reading of ?hi? meant. On July 10, 2009, at 11:55 a.m., during a telephone interview, a representative from the company, who made the glucometers the facility was currently using, stated the glucometer did not register number above 600 and a reading of ?hi? meant the blood sugar levels were over 600 mg/dl. On July 13, 2009, at 10:15 a.m., during a telephone interview, Licensed Vocational Nurse 3 (LVN 3) stated the physician usually wrote orders for parameters indicating when to call if the blood sugar readings were above or below a certain number. She was instructed to give Patient A the maximum dosage of insulin that was prescribed if her blood sugar level registered ?hi?, obtain another blood sugar level in an hour and call the physician if the reading was still ?hi?. LVN 3 stated the glucometers they were currently using were new. She did not recall if there was an in-service given on the use of the glucometers. On November 20, 2009, at 6:45 a.m., during an interview, RN 1 stated he found Patient A on the floor, took her blood sugar and gave the recommended amount of insulin (he did not document how much insulin he gave on the Medication Record Profile or in the Licensed Nurses Notes). He stated the patient was stable and did not think it was necessary to document specifically on her condition (level of consciousness, skin condition, etc). RN 1 stated he did not call the physician because the patient had no injuries, from being on the floor, and the normal procedure was give the patient insulin as prescribed, re-take the patient?s blood sugar (no specific time frame), and call the physician if it was still high.A review of the Medication and Record Profile and the Licensed Nurse?s Notes, dated August 25, 2008, at 1:00 a.m., indicated no documented evidence that new blood sugar levels were obtained within an hour of a ?hi? blood sugar level reading. Patient A?s blood sugar was re-checked at 6:30 a.m., which was over five hours after the first reading of ?hi?.A review of the facilities policy and procedure titled, ? Nursing care of the Adult Diabetes Mellitus Patient? revised August 2002, indicated documentation should reflect the carefully assessed diabetic patient and include the following: level of consciousness, assessment of the skin, which should include the color, turgor, temperature, any dryness or diaphoresis (sweating), any irritation, abrasions and/or pruritus (itching). Emotional reactions, moods, assessment of pain, restlessness, discomfort and/or paresthesia (numbness, tingling) should include the location, intensity, description/type, duration and aggravating/alleviating factors. Assessment should also include motor weakness, urinary retention, incontinence and orthostatic hypotension (low blood pressure that happens when you stand up from sitting or lying down).An additional facility policy titled ?Obtaining a Finger Stick Glucose Level? revised August 2002, indicated the person performing this procedure should record the following information in the patient?s medical record: blood sugar results following facility policies and procedures for appropriate nursing interventions regarding blood sugar results (if the patient is on sliding scale coverage, and/or physician intervention is needed to adjust insulin or oral medication dosages). Report the results promptly to the supervisor and the attending physician. Report other information in accordance with facility policy and professional standards of practice.Therefore, the facility failed to: 1. Ensure Patient A?s physician was notified on June 29, 2008, July 7, 17 and 20, 2008, August 9, 16-17, 23-24 and 25, 2008, when the patient?s blood sugar was above 500 milligrams (mg)/deciliter (dl).2. Administer medication (insulin) as prescribed, when Patient A?s blood sugar was above 500 mg/dl. On July 7 and 17, 2008, August 9, 16-17 and 25, 2008, Patient A?s blood sugar was above 500 mg/dl. 15 units of insulin was administered to the patient, however, the prescribed order indicated 20 units of insulin was to be administered. These violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 970000127 |
BURLINGTON CONVALESCENT HOSPITAL |
910009583 |
B |
06-Nov-12 |
6YVZ11 |
5447 |
Code of Federal Regulations - 483.70 (h)(4) F469 The facility must maintain an effective pest control program so that the facility is free of pests and rodents.The facility failed to maintain an effective pest control program so that the facility was free of pests and rodents by having an active infestation of cockroaches and evidence of rodents in the kitchen, resident rooms and storage spaces.On October 26, 2012, from 6:45 a.m. to 10:45 a.m., during a tour of the facility, the evaluator, in the presence of Employee A, observed evidence of cockroaches (live cockroaches, fecal focal points, and egg cases) and evidence of mice (old/fresh droppings about 1/8 inch long and pointed on both ends) in the following areas: 1. There were seven live nymph German cockroaches and four live adult German cockroaches by the low temperature dish wash machine.2. There was one dead cockroach on the wall underneath the electrical outlet and there were three dead cockroaches on the floor near the dish-machine. 3. There were two live nymph German cockroaches on the floor by the six door reach-in refrigerator.4. There was a live nymph German cockroach in the janitorial closet room in the kitchen.5. There were three rodent droppings on the wall surface next to the knife holder.6. There were two live adult German cockroaches on the shelf in the janitorial closet room in the kitchen.7. There were three rodent droppings inside the storage cabinet connected to the steam table.8. There were six rodent droppings on the floor in the dry food storage room.9. There were 10 to 15 rodent droppings in the storage cabinet connected to the steam table.10. There was one live adult German cockroach inside the storage cabinet connected to the steam table.11. There were two live adult German cockroaches inside the vinyl base-cove in the ice machine room.12. There was one live adult German cockroach in the floor in the dry food storage room.13. There were 40 to 50 rodent droppings inside the storage cabinet in the dietarysupervisor?s office.14. There were three dead cockroaches on the storage shelf below the food spice containers.15. There was a live adult German cockroach and 15 rodent droppings on the storage shelf below the food spice containers. 16. There were two live adult German cockroaches on the floor by the white reach-in refrigerator.17. There were 10 to 15 rodent droppings inside the back space located at the bottom of the white reach-in refrigerator.18. There were 10 to 15 rodent droppings on the floor beneath the wardrobe drawer in Room 4.19. There was one dead cockroach in the cabinet in the medication room by nurse?s station 1.20. There was one dead cockroach on the floor in the housekeeping closet by Room 15.21. There were two dead cockroaches on the floor in the beauty shop.22. There were 10 rodent droppings on the floor beneath the wardrobe drawer in Room 19.23. There were five rodent droppings on the floor beneath the wardrobe drawer in Room 22.24. There was one live nymph German cockroach, four dead cockroaches and fecal spotting on the wall in the housekeeping closet by Room 28.25. There was a live adult German cockroach on the floor in the maintenance shop in the basement.26. There were ten rodent droppings and three dead cockroaches on the shelf used for the storage of the emergency water in the basement.27. There was one live adult German cockroach on the wall in the emergency water and emergency food storage room in the basement.During an interview with Employee A, at 7 a.m., during the time of the observation, he stated that the pest control company services the kitchen once a month, and he stated that he had seen cockroaches over the last three months in the kitchen. He also stated that the pest control company indicated that there was a rodent problem two weeks ago.During an interview with Employee B at 7:10 a.m. during the time of the observation, he stated that he had seen cockroaches in the kitchen three weeks ago.A review of the pest control service reports from November 15, 2011 to October 17, 2012, revealed that there was pest activity found each month, and cockroach activity was found in the kitchen and rooms on November 15, 2011, December 19, 2011, January 10, 2012, February 9, 2012, April 18, 2012, May 21, 2012, September 20, 2012, and October 17, 2012.Also, the pest control service reports did not identify that there were any structural deficiencies (holes, gaps, unsealed cracks and crevices), and indicated that the general sanitation was good.However, during a kitchen observation tour from 6:45 a.m. to 8 a.m., on October 26, 2012, the evaluators observed insanitary conditions (food debris, dirt build-up food splatter) on the walls/floors and equipment throughout the kitchen. In addition, there were holes, gaps and crevices throughout the kitchen and in the facility. There was a 1/4-inch gap beneath the exit doors by the northwest side of the facility by the kitchen.During an interview with Employee C, on October 26, 2012, at 11:15 a.m., he stated that he was unaware of the pest and rodent problem because he was never told by the pest control service person that there was an ongoing problem with cockroaches and rodents.Failure of the facility staff to maintain an effective pest control program in order to maintain the facility free of cockroaches and rodents had a direct relationship to the health and safety of all residents living in the facility. |
| 910000009 |
BAY CREST CARE CENTER |
910009897 |
B |
15-May-13 |
GIYX11 |
10285 |
Title 22 Section 72311 (a)(2) Nursing Service ? General Nursing service shall include, but not be limited to the following: Implementing of each patient?s care plan according to the methods indicated. Each patient?s care shall be based on this plan. A complaint allegation was made to the Department on June 3, 2009, alleging a patient (Patient A) fell out of his bed, because a certified nursing assistant (CNA) left the bed rail down and proceeded to step out of the room during the time the rail was down. The complainant indicated the patient fell on his head, resulting in a large hematoma/bruise (ruptured blood vessel) on the right side of his head above the right eye.On June 12, 2009, at 3 p.m., an unannounced visit was made to the facility to conduct a complaint investigation with the following results: Based on observation, interview, and record review the facility failed to: 1. Implement Patient A?s care plan to keep both side rails up and secure while the patient was in bed and to put the patient?s bed in the lowest position. These failures resulted in Patient A falling, sustaining head and bilateral knees injuries, requiring transfer to a general acute care hospital (GACH). On June 12, 2009, at 4 p.m., Patient A was observed lying in bed with both side rails up, however, the lower part of his left leg was hanging over the side rail. In addition, Patient A's bed was not in a low position as per the patient?s plan of care. On June 12, 2009, at 4 p.m., the director of nursing (DON) stated Patient A moves around a lot while in the bed and when sitting in the Geri-chair (medical reclining chair). She stated both side rails were to remain up while the patient was in bed to assist the patient with turning/repositioning and for safety measures. The DON stated Patient A's bed should be kept in the lowest position, and could not explain why it was not in a low position at the time of the incident. On July 20, 2010, at 2:15 p.m., the licensed vocational nurse (LVN 1) stated she was on duty during Patient A?s fall incident and she heard the patient calling out "help, help." LVN 1 stated she found the patient on the floor, face down and the side rail was down on the right side of the bed. She stated the patient was always putting his arms and legs out of the bed and he moved around a lot. LVN 1 stated CNA 1 had just picked up Patient A's breakfast tray, and CNA 1 was assisting another patient by the time she entered and saw the patient lying on the floor. LVN 1 stated CNA 1 "claimed" she had put Patient A's side rail up before she left his room. A review of Patient A?s Admission Sheet, indicated the patient was a 77 year-old male who was admitted to the facility on January 31, 2009, with diagnoses including altered mental status, dementia (intellectual deterioration) and hypotension (low blood pressure). The Minimum Data Set (MDS) assessment, a standardized assessment and care screening tool, dated February 12, 2009, indicated Patient A was severely impaired in his cognitive skills for daily decision-making and required extensive to total care with his activities of daily living, bed mobility and transfers. According to the MDS, Patient A was assessed as not having any limitations in range of motion to his extremities and was able to use both side rails for bed mobility and/or transfers. A review of a Resident Assessment Protocol Summary (RAPS), dated February 12, 2009, indicated falls triggered as an area of concern for Patient A due to a previous fall at home. The RAPS indicated the patient continued to be at risk for falls or injury due to his cognitive deficit and physical functioning deficit. According to a Fall Risk Assessment, dated April 1, 2009, Patient A had a score of an eight indicating he was not considered a high risk for falls in contrast to the patient being considered a high risk on the RAPS. However, the licensed nurse who assessed Patient A?s status failed to include an existing diagnoses that would have increased the score to a 10 resulting in the patient being considered a high risk for falls. Patient A had hypotension which was a predisposing factor, contributing to the patient?s increased risk for falls. A score of 10 or higher was an indication a patient should be considered a high risk for falls.A patient care plan dated, April 1, 2009, addressed Patient A being at risk for falls as manifested by poor safety awareness, putting his legs over the side rails, and being totally dependent on the staff for transfers and locomotion. The goal included to keep Patient A free from injuries and falls for the next 90 days. The nursing approaches included keeping the patient?s bed in the lowest position and keeping the side rails up at all times while the patient was in the bed.However, CNA 1 failed to put the patient?s bed in the lowest position and put the side rails up before leaving Patient A?s bedside, resulting in a fall. Another care plan, dated April 1, 2009, addressed the concern of physical restraints/side rail use with a goal including the prevention of falls for Patient A. The nursing approaches included monitoring the patient frequently; however, the frequency of the monitoring was not specified. Patient A was not monitored by the staff when the side rails were left down and the patient fell out of the bed. Patient A?s care plan, dated May 20, 2009, addressed the concern of the patient?s mobility while in bed. The nursing approaches included frequent visual checks and increased monitoring by supervision. However, there were no time frames specified for the staff to conduct the visual checks or increased monitoring of Patient A. A review of the facility?s policy on Care Plans (not dated) indicated the purpose of the care plan development was to maintain a patient?s highest practical and physical functioning. Although a plan of care was developed for Patient A, it was not implemented.A review of a Physical Restraint Device Assessment for Patient A, dated May 19, 2009, indicated the patient required assistance with mobility and would benefit from both side rails being up to use as an enabler. A review of another facility?s policy on Physical Restraints, dated October 10, 2007, indicated restraints were to be used for the safety and protection of the patient during treatment or for safety/positioning. According to the licensed nurse daily/shift charting, written by LVN 1, dated May 31, 2009, at 8:20 a.m., indicated the licensed nurse heard Patient A calling for help and rushed into his room. It was documented Patient A was found on the floor and noted with one side rail down. The patient was assisted back to bed using a mechanical lift.While conducting a body check, the licensed nurse noted Patient A had a bump on the right side of his forehead measuring 5 centimeters (cm) x 5.5 cm, a 1 cm x 1 cm abrasion with discoloration to the left knee and a 1 cm x 1 cm abrasion with redness to the right knee. The licensed nurse daily shift charting, dated May 31, 2009, and timed at 9:30 a.m., indicated Patient A?s family wanted the patient transferred to a general acute care hospital (GACH) for an evaluation. The licensed nurses progress notes, dated May 31, 2009, indicated Patient A was transferred to the GACH per the family?s request. A review of the disciplinary action record, dated May 31, 2009, indicated Patient A experienced a fall incident due to being left unattended after being fed breakfast, with the bed side rail down. The record indicated the employee (CNA 1) stated she was feeding Patient A, went to check on another Patient outside of the door when Patient A fell out of the bed. It was documented the nursing assistant "believed" Patient A's side rails were up. A facility Investigative Report, dated June 1, 2009, indicated the DON interviewed the CNA assigned to Patient A during the fall incident. The description of the alleged incident as documented indicated Patient A was heard calling for help, found lying on the floor face down and was noted with a bump to the right forehead. The result of the investigation as documented indicated the CNA fed the patient, picked the food tray up, pulled the side rail up and attended to another patient. Further review indicated the right side rail was not pulled up securely, and Patient A had episodes of putting his legs over the side rails and was mobile while in bed. It was indicated that the patient turned toward the right side, fell, landed on the floor and sustained the injuries to his forehead and lower extremities.A review of Patient A?s history and physical from the GACH, dated May 31, 2009, indicated the patient had a contusion (bruise) to the head status-post a mechanical fall while in the skilled nursing facility. While in the GACH, a contrast (dyes used to highlight specific areas) Computerized Tomography (CT scan/ a procedure that assists in diagnosing tumors, fractures, bony structures, and infections in the organs and tissues of the body) of the patient?s brain was conducted. The test results indicated Patient A sustained a hematoma (semisolid mass of blood) to the right frontal scalp area. According to a "Notice of Termination of Employment" dated June 5, 2009, CNA 1 had two incidents within a six-month period regarding the safety of patients, both resulting in the patients falling to the floor. It indicated CNA 1 did not follow the safety protocols in both instances and was reprimanded in both cases. Injury was sustained by Patient A in the fall incident.The facility failed to implement Patient A?s plan of care to ensure the side rails were up at all times, as stipulated in the patient?s care plan to prevent him from falling to the floor and sustaining injuries. As a result, Patient A sustained a contusion and a 5 cm x 5.5 cm hematoma to the right side of his forehead and abrasions to the right and left knee. The facility failed to: 1. Implement Patient A?s care plan to keep both side rails up and secure while the patient was in bed and to put the patient?s bed in the lowest position . These failures resulted in Patient A falling, sustaining head and bilateral knees injuries, requiring transfer to a general acute care hospital (GACH). This violation had a direct relationship to the health, safety or security of Patient A. |
| 910000009 |
BAY CREST CARE CENTER |
910009904 |
B |
15-May-13 |
None |
6263 |
CFR 483.25(h) F323 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 September 10, 2009, a complaint investigation was conducted regarding a resident (Resident A), who managed to exit the facility, unnoticed, through an emergency exit door that was not alarmed and fell down the stairs. Resident A sustained injuries including skin lacerations and abrasions.The facility failed to ensure the residents? environment was safe from accident hazards when they did not check the delayed egress emergency door was alarmed and operating correctly. Resident A, while in his wheelchair, exited through the disarmed emergency exit door. He was found sitting on the ground after falling down the stairs, and was still attached to his wheelchair by his soft belt restraint. As a result, he sustained a skin laceration to his right eyebrow measuring approximately 1.2 centimeters (cm) x 0.7 cm with a moderate amount of bleeding, abrasions to the right side of his nose and right knee, and redness to his right inner hand. [When pressure is applied to the delayed egress hardware (bar) and held for 1 to 3 seconds, the door alarm sounds, and within 15 to 30 seconds, the door will unlock, giving staff time to respond to the alarm].Resident A was an 82 year-old male, who was admitted to the facility on June 29, 2008, with diagnoses including history of falls, general muscle weakness, debility, osteoporosis (weak bones) of the lumbar (lower back) spine and altered mental status. According to a Minimum Data Set (MDS), an assessment and care screening tool, dated July 9, 2009, Resident A had short term memory problem, had ?modified independence? (some difficulty in new situations only) in daily decision making, required limited assistance (some help provided by staff) for locomotion off the unit (moving to and from distant areas on the floor) and used a wheelchair as his primary mode of locomotion. The MDS indicated Resident A sustained a fall in the facility in the last 30 days. The Fall Risk Assessments, conducted monthly from April 9, 2009, to August 21, 2009, identified Resident A to be a high risk for falls. On September 10, 2009, at 8 a.m., during a telephone interview with an anonymous caller, she stated she witnessed a resident exit the facility?s double doors without activating the alarm, roll down the stairs, and fell and hit his head on the ground.On September 10, 2009, at 10:15 a.m., during an interview, the Director of Nursing (DON) stated that on August 21, 2009, Resident A was found outside an emergency exit door that was equipped with an alarm.The last time the resident was seen, by staff, was at approximately 1:20 p.m. on August 21, 2009. She stated there were two steps outside the door. The DON stated the emergency exit?s alarm did not activate (sound) when the resident opened the door. She stated the resident?s room was on the other side of the building and he had to travel a good distance to reach the door. The resident ?s fall was unwitnessed by staff and he was found at the bottom of the steps at approximately 2:35 p.m. No staff noticed him going towards or out of the door.The Facility Investigation Report, dated August 21, 2009, indicated a certified nursing assistant (CNA) found Resident A in a sitting position, with his wheelchair and soft waist belt still attached to him. The wheelchair was tilted behind him. The resident was able to ?open the exit door and fell with his wheelchair to the ground??The report indicated Resident A was alert, verbally responsive with confusion and disorientation.The report assessment indicated Resident A sustained a small cut to his right eyebrow, measuring approximately 1.2 centimeters (cm) x 0.7 cm with a moderate amount of bleeding, an abrasion to the right side of his nose, measuring 0.5 cm x 0.5 cm, an abrasion to his right knee, measuring 1.0 cm x0.5 cm and redness to his right inner hand.In addition, this incident was not reported to the Department as required, and a thorough investigation was not completed. The investigation report did not indicate the facility was at fault for the incident when the emergency exit door delayed egress and alarm were not activated so that the alarm would sound and alert staff 15 to 30 seconds before the door unlocked and opened, allowing the resident to propel himself out of the door.On September 10, 2009, at 10:35 a.m., during an interview, the Maintenance Supervisor stated there were three keys to alarm the emergency exit. He stated he has one key, one for his assistant and one for the charge nurse. He did not know who shut the alarm off. He usually does visual checks of the door but only documented the status of the door about every two weeks.He stated he was the only one who documents in the log book and he was not at the facility the day Resident A exited the door in his wheelchair and fell. An undated facility policy titled ?Logbook Documentation Doors, Locks and Alarms: Test operation of door and locks daily? indicated staff were to test the operation of the delayed egress doors and locks daily, and document the results of the inspection in the log book. Any discrepancies were to be documented.A review of the maintenance log book dated August 2009, revealed there was no documentation that the delayed egress operation had been monitored or checked, daily.The facility failed to ensure the residents? environment was safe from accident hazards when they did not check the delayed egress emergency door was alarmed and operating correctly. Resident A, while in his wheelchair, exited through the disarmed emergency exit door. He was found sitting on the ground after falling down the stairs, and was still attached to his wheelchair by his soft belt restraint. As a result, he sustained a skin laceration to his right eyebrow measuring approximately 1.2 centimeters (cm) x 0.7 cm with a moderate amount of bleeding, abrasions to the right side of his nose and right knee, and redness to his right inner hand.The above violation had a direct relationship to the health, safety, or security of Resident A. |
| 910000017 |
Beachwood Post - Acute & Rehab |
910010100 |
B |
22-Aug-13 |
None |
5150 |
Title 22 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 facility failed to ensure that each patient was treated with dignity and respect and not subjected to verbal and physical abuse of any kind. This resulted in an injury to the right eye. A complaint investigation was initiated on August 31, 2010, of an alleged abuse incident against Patient A.During an interview with Patient A?s family member on August 30, 2010, at 2:02 p.m., it was stated that when she arrived at the facility on August 28, 2010, she noticed Patient A?s right eye was red and swollen. She stated she asked Patient A if his eye hurt, and did he hurt himself. Patient A shook his head no. When asked if someone else hurt him, Patient A nodded yes. Patient A shook his head no, when the family member asked him if it was a male who had hurt him, but nodded yes, when asked if it was a female who had hurt him, and that she was Hispanic. The family member stated she reported the incident to the charge nurse (Registered Nurse 1). The charge nurse told the family member there were three Hispanic nurses were on duty that day and when the nurses came into the room Patient A identified the nurse he accused of hurting him. The family member stated she called the Police and they interviewed the patient and his story never changed. Patient A was observed lying in bed August 31, 2010 at 9:50 a.m., the patient had redness to the right eye and upper eyelid. The Evaluator attempted to interview Patient A at that time and the patient just looked at the evaluator and did not respond.A review of the medical record revealed Patient A is a 46 year old male, readmitted to the facility on May 18, 2010 with diagnoses that included chronic respiratory failure, status post intracranial bleed ( bleeding within the skull), sepsis ( infection in the bloodstream), and tracheotomy.The Minimum Data Set (MDS) (a resident assessment and care screening tool) dated May 13, 2010, indicated Patient A was assessed as being in a coma and unable to make his needs known. The patient was assessed as having no behavioral problems and was totally dependent on staff for his care needs.During an interview with the Director of Nurses (DON) on August 31, 2010 at 11:17 a.m., she stated on August 28, 2010, (could not remember the time), the charge nurse called her on her cell phone and left a message that Patient A?s family was accusing the staff of hitting the patient. None of the staff noticed or reported the bruise on Patient A and there had been no problems with the family in the past. She stated the patient tends to nod yes and no but he is not consistent and has involuntary movements and might have hit himself. She stated Employee 1 was suspended pending the investigation. However there was no documentation in Patient A?s medical record of any bruises or skin assessment in the Licensed Nurses Progress notes. Additionally, Patient A had no involuntary movement documented in his medical record. The Evaluator went back to Patient A?s room August 31, 2010 at 1:30 p.m., to attempt to interview the patient again. This time Patient A responded by nodding his head when asked a question. During the interview, Patient A was asked to raise his right arm, which he was able to do. His right arm was steady without any involuntary movement, indicating he understood what was being said to him. When asked what happened to his eye and was he hit, Patient A nodded yes. When asked if it was a nurse? He nodded yes. The Evaluator asked Patient A if he knew the nurse?s name and he whispered Employee 1?s name to the Evaluator.An interview was conducted on September 14, 2010 at 9:20 a.m., Employee 1 stated she made rounds that morning and did not notice the bruise. When she went back to the room formorning care she noticed redness to the right side of Patient A?s face and right eye. She stated she was ready to tell a supervisor around 9:30 a.m., when someone asked her to help put another patient in the chair and she forgot to report the bruise to the supervisor. Employee 1 stated around 2:20 p.m., the same day she was confronted by the patient?s family and they accused her of hitting Patient A. Employee 1 denied hitting Patient A and stated she did not know how he got the bruise. A review of the Santa Monica Police Report disclosed on August 28, 2010 at approximately 7:37 p.m., the police officer arrived at the facility. The officer went to Patient A?s room and observed redness and mild bruising to the right eye. The officer documented that it appeared as if he (Patient A) sustained physical trauma. The officer questioned Patient A and he (Patient A) was consistent with his story and when asked if it was Employee 1, Patient A became visibly excited and started nodding his head very rapidly.The facility failed to protect Patient A from physical abuse by the facility nursing staff. This resulted in an injury to the right eye. This violation had a direct or immediate relationship to the health, safety, or security of Patient A. |
| 910000322 |
Beverly West Healthcare |
910010265 |
A |
10-Dec-13 |
8TO011 |
7009 |
F309 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. The nursing staff failed to develop a comprehensive nursing assessment and plan of care to address Resident A's right arm contractures (a permanent tightening or shortening of a body part such as a muscle, tendon, or the skin), and the approaches to utilize when providing daily care, especially when dressing the resident. The certified nursing assistant (CNA) lifted Resident A's right arm while dressing her, which resulted in a fracture of the distal humerus (one type of elbow fracture).On April 27, 2012, at 3:11 p.m., during an interview, the complainant stated he received a telephone call from a nurse at the facility stating they were transferring Resident A to the general acute care hospital (GACH), but did not have any details. He stated the resident is totally dependent on the staff for her care needs and she is bedridden. He has been caring for her at home and when she developed a decubitus ulcer, the acute hospital sent her to the skilled nursing facility (SNF) for treatment and once it healed, he would be taking the resident home. He also stated the resident has a contracted right arm, and the facility's staff told him that while a certified nursing assistant (CNA) was changing the resident's gown, the right arm was lifted and she heard a snap. The complainant stated the resident could not lift, move, or raise her right arm and feels the CNA forced her arm and broke it.A review of the Admission Record indicated Resident A was readmitted to the facility on March 30, 2012, with diagnoses including decubitus ulcer of the coccyx and late effects of cerebral vascular accident (stroke). A review of the Admission Assessment form dated March 30, 2012, revealed no documentation to indicate that the resident had a contracted right arm, and the area that addressed contractures was blank. A review of the Licensed Personnel Progress Notes forms from March 30, 2012, to April 17, 2012, revealed there was no documentation of the resident having contractures to her upper or lower extremities.A review of the discharge transfer from the GACH to the SNF titled, "Warm Handoff From KP Hospital To SNF" dated March 30, 2012, listed the resident as having right upper extremity contracture. The Transfer to Nursing Facility form dated March 30, 2012, in the Musculoskeletal Assessment section indicated Resident A was ?contracted? in her right upper and lower extremities.The Minimum Data Set (MDS), an assessment and care screening tool, dated April 13, 2012, revealed the resident had short and long term memory problems, her decisions were poor,and she was totally dependent on staff for dressing, requiring one-person physical assistance. Section G, functional limitations,indicated the resident was assessed with functional limitations in range of motion (full movement potential of a joint, range of flexion and extension) to both upper and lower extremities (arms and legs).The Licensed Personnel Progress Notes documentation dated April 17, 2012, at 10:15 a.m. indicated that when the CNA raised the right arm of the resident to change her gown, she heard an "unusual click sound." The resident was assessed and was noted to be moaning and grimacing when her right hand was moved. The physician was contacted and ordered an emergency X-ray to the right upper arm to rule out a fracture. The results were acute (new) fracture involving the distal half of the right humerus with significant overriding of the fracture fragments. The physician was notified of these results and gave an order for the resident to be transferred to the GACH for an evaluation. Resident A was readmitted to the SNF at 9 p.m. with a splint to the right arm. On April 27, 2012, at 4 p.m., during an interview the staff developer stated the CNA was trained on how to care for a resident with contractures, and to carefully move the resident with assistance. She stated she did not think the CNA asked for help and when she was dressing the resident she was putting a gown on the resident. The staff developer stated the CNA knows how to handle a resident with contractures and she was told to use a snap-on gown on the resident because it would be easier. The CNA had been caring for the resident since she was admitted to the facility on March 30, 2012. During an interview on May 11, 2012, at 9 a.m., the administrator stated that the involved CNA was suspended April 17, 2012, pending the completion of their investigation. She was terminated Arpil 24, 2012, with the last day actually worked Arpil 17, 2012, for violating safety, health or facility rules. He stated that the CNA was putting a gown on a resident that had a severely contracted arm when the incident occurred. In an interview with the director of nurses on May 11, 2012, at 9:15 a.m., she stated she was sure the resident had been assessed for the right arm contracture. She was observed looking in the Licensed Nurses Progress notes, admission assessment and plan of care, and was unable to locate documentation or a care plan to address the right arm contracture.At 11:17 a.m., during an interview the restorative nursing assistant (RNA) stated she was caring for a resident in the next bed at the same time that the CNA was providing care to Resident A. The RNA stated she did not hear anything, no crack, and the resident did not yell out. The RNA stated the resident's right arm was severely contracted and she could not lift her arm by herself, and it had to be gently lifted for her. The RNA stated the Physical Therapist had instructed her on how to handle Resident A, and stated the range of motion was very difficult and you had to take your time.During an interview with the Physical Therapist on November 20, 2013, at 2:15 p.m., he stated that they don?t always train the CNAs specifically for each resident that has contractures, but the CNAs and RNAs learn that during their course training.On July 9, 2012, at 12:50 p.m., the involved CNA stated she cleaned the resident pretty good and raised the resident's right hand a little bit to put the gown on, and heard a snap. She stated Resident A had a lot of contractures, and she was working by herself without help, trying to put a snap-on gown on the resident. She said she reported the incident to the charge nurse. Therefore, the nursing staff failed to develop a comprehensive nursing assessment and plan of care to address Resident A's right arm contractures, and the approaches to utilize when providing daily care, especially when dressing the resident. The certified nursing assistant lifted Resident A's contracted right arm while dressing her, which resulted in a fracture of the distal humerus. The above violation presented either imminent danger that death or serious harm would result to Resident A. |
| 970000125 |
BONNIE BRAE CONVALESCENT HOSPITAL |
910010325 |
A |
14-Jan-14 |
WYJH11 |
9847 |
F323 483.25(h) 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. On December 15, 2011, at 3:40 p.m., an unannounced visit was made to the facility to investigate a complaint alleging, that on admission to a general acute care hospital (GACH), ?it looked as if the resident was dragged across the floor.?Based on observation, interview, and record review, the facility?s nursing staff failed to ensure a resident who was assessed at risk for falls/injury, with a history of falls and episodes of restlessness and wandering, was adequately supervised by staff in accordance with his plan of care and the facility policy. As a result, on December 1, 2011, between 4:30 a.m. and 5 a.m., Resident A exited the facility, unsupervised, and wandered into an unsafe storage area that was not supposed to be accessible to residents. He was found lying on the ground at approximatly 5:20 a.m., and assessed with swelling to his right eye, scratches to both of his knees and right elbow. The resident was transferred to a GACH for evaluation and treatment of multiple contusions/abrasions and right eye trauma, where he was hospitalized until December 9, 2011.A review of Resident A?s Admission Records indicated he was an 81 year-old male, who was admitted to the facility on April 22, 2011, with a diagnosis of dementia (progressive loss of mental ability) and lung disease. A Minimum Data Set (MDS) Assessment, a standardized assessment and care screening tool, dated November 5, 2011, indicated Resident A?s cognitive skills for daily decision-making were severely impaired. He was assessed with a behavior of wandering, was not steady when he walked, required extensive assistance to walk and had a functional limitation in range of motion [(ROM) the distance and direction a joint can move to its full potential] to one of his lower extremities. A Care Plan dated April 23, 2011, and revised October 2011, indicated Resident A was at risk for falls/injury related to impaired vision, impaired cognition, poor body balance/control, poor safety awareness/judgment, and a history of falls. The goal was for Resident A to be free from injury due to falls daily for the next three months. Approaches used included to provide a safe and clutter-free environment, and visibly observing the resident frequently, but did not indicate how frequent. Another Care Plan dated August 5, 2011, and revised November 2011, indicated Resident A had episodes of restlessness and wandering, but was not specific as to where he wandered or how frequent. The goal was for Resident A to be safe and free from falls/injuries and will accept redirection for 90 days. The approaches used included redirecting the resident to his room. Licensed Personnel Weekly Progress Notes dated December 1, 2011, at 5:20 a.m., indicated Resident A was found on the ground (no specific location) with swelling to his right eye, and scratches to the back of his knees and right elbow. There was no documented evidence of the frequency of Resident A's wandering behavior, or where he wandered to.An Incident Report dated December 1, 2011, indicated Resident A was found on the patio ground, with swelling to his right eye, and scratches to the back of his knee and right elbow. A diagram indicated Resident A had right peri-orbital (situated around the eye) swelling, abrasions to both of his anterior (front) knees, his right posterior (back/behind) knee and right elbow. Physician?s Orders dated December 1, 2011, at 5:45 a.m., indicated to transfer Resident A to a GACH for evaluation of right eye swelling. The GACH Urgent Care Center Physician?s Report dated December 1, 2011, indicated Resident A had scattered trauma after falling, his right eye was ecchymotic (bruised) and closed shut, he had scattered abrasions over his knees, feet and right elbow, and his right lower extremity was swollen and discolored. A brain computer tomography (CT) scan was done. The diagnosis indicated Resident A presented with confusion, pneumonia, right orbit (the eye socket; the bony part of the skull that houses and protects the eyeball) trauma, and multiple contusions/abrasions ?consistent with a direct blow and dragging.? On December 15, 2011, at 3:58 p.m., during an interview the registered nurse (RN) supervisor stated a certified nursing assistant (CNA1) found Resident A on the ground outside an unlocked gate that led to an area where old equipment was stored. He stated no one saw the resident fall but when they found him, he had sustained bruising around his right eye, abrasions to both of his elbows, both of his knees, and his toes. He was not sure how long the resident was outside before he was found, but rounds were normally conducted at 1 a.m. and 5 a.m. He stated the resident was unable to give details of the fall.According to the RN supervisor, Resident A was found outside of the patio gate in the area used to store shower chairs, wheel chairs, and other equipment, where residents are not supposed to have access to. He stated although the gate had the capability of being locked, to his knowledge it never had been locked. He stated Resident A had a behavior of wandering, started to act out after 3 p.m. (sundowning), and would go outside through the gate to urinate, so he was supposed to be supervised one-on-one at night. He stated there were usually four staff working during the 11 p.m. to 7 a.m. shift, and they either stayed in the dining room, which was located near the entrance of the facility away from Resident A?s room and took turns answering call lights, or they were stationed at the end of each hallway. He stated the charge nurse usually sat at the nursing station, located near the entrance of the facility, which had a view of each hallway. He was not sure how the resident got past the nursing staff and stated the facility used video surveillance to monitor the hallways and common areas. He stated he was not the person responsible for, nor did he have access to the video equipment.On December 15, 2011, at 4 p.m., Resident A?s room was observed at the end of a hallway approximately 20 feet from a door that led outside to a fenced patio area that had a latched but unlocked gate. This gate led to an area that stored wheel chairs, shower chairs, and other equipment. This area was not supposed to be accessible to residents, as stated by the RN Supervisor. There was no lock present on the gate when observed. On December 16, 2011, during telephone interviews with the licensed vocational nurse (LVN) and the certified nursing assistant (CNA1), between 12:11 p.m. and 1:18 p.m., they stated the last time Resident A was observed on December 1, 2011, was at 4:30 a.m., when the CNA changed Resident A?s adult briefs. It was stated Resident A had a behavior of wandering on the day shift, and in the evening would verbalize he wanted to go home to Mexico. He often got out of the facility door and through the outer gate that led to the unlocked storage area. Together they conducted a search and eventually found the resident outside on the ground some time after 5 a.m.During interviews with the director of nursing (DON) on June 19, 2012, at 6:10 a.m. and June 21, 2012, at 6:35 a.m., she stated there were three CNAs scheduled on the 11 p.m. to 7 a.m. shift on December 1, 2011. Each of them was assigned areas to monitor along the hallways. She stated CNA1 was assigned to the hallway near Resident A?s room. CNA1 and the other CNAs assigned were suspended for three days for failure to monitor their assigned areas. The DON stated the only doors in the facility that were alarmed were the front door and the door immediately down the 1st hallway, left of the entry. The door near Resident A?s room was not alarmed, but would be locked at night so no one could enter from the outside, but would allow exit. She stated there was no actual time the doors should be locked and/or alarmed, just at some point during the night. She stated she had access to the video equipment, that the recording is continuous, and unless viewed, are recorded over about every three days. The DON stated that no one viewed the video because the feed was taped over before there was an opportunity to view it, and she was on vacation when the incident occurred.An undated facility policy on Securing the Building indicated the facility will maintain a safe and secure building at all times. An undated facility Policy Statement indicated it is the policy of the facility to ensure the safety of all residents in its care. The facility has alarms on the front and the back door to alert staff in the event of a resident attempting to wander outside of the facility. The policy did not address the door that Resident A exited.Therefore the facility?s nursing staff failed to ensure a resident who was assessed at risk for falls/injury, had a history of falls and episodes of restlessness and wandering, was adequately supervised by staff in accordance with his plan of care and the facility policy. As a result, on December 1, 2011, between 4:30 a.m. and 5 a.m., Resident A exited the facility, unsupervised, and wandered into an unsafe storage area that was not supposed to be accessible to residents. He was found lying on the ground at approximatly 5:20 a.m., and assessed with swelling to his right eye, scratches to both of his knees and right elbow. The resident was transferred to a GACH for evaluation and treatment of multiple contusions/abrasions and right eye trauma, where he was hospitalized until December 9, 2011.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. |
| 910000017 |
Beachwood Post - Acute & Rehab |
910010472 |
B |
14-Feb-14 |
S5TL11 |
7797 |
483.12 (a)(3)?(7)F202 When the facility transfers or discharges a resident under any of the circumstances specified in paragraph (a)(2)(i) through (v) of this section, the resident's clinical record must be documented. The documentation must be made by the resident's physician when transfer or discharge is necessary under paragraph (a)(2)(i) or paragraph (a)(2)(ii) of this section; and a physician when transfer or discharge is necessary under paragraph (a)(2)(iv) of this section. F203 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 when specified in paragraph (a)(5)(ii) 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. F204 A facility must provide sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. 483.20(l)(1)&(2) F283 When the facility anticipates discharge a resident must have a discharge summary that includes a recapitulation of the resident?s stay; and a final summary of the resident?s status to include items in paragraph (b)(2) of this section, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or legal representative. A complaint investigation was conducted on July 12, 2010, regarding an inappropriate transfer/discharge (T/D) of Resident A to another facility (Facility B), without approval from or notification of the responsible party. The California Department of Public Health (CDPH) held a T/D appeal hearing on July 23, 2010, regarding the inappropriate discharge of Resident A. Based on a review of the medical record and the results of the CDPH hearing decision documents, the facility failed to issue a proper notice of T/D to Resident A, or the resident's representative, and failed to provide sufficient preparation and orientation to Resident A to ensure a safe and orderly T/D. Resident A was abruptly transferred from Facility A to Facility B on July 9, 2010. As a result, Resident A complained that she wanted to return to Facility A because she missed her friends, the food, and her primary language, which was spoken there. Resident A, a 79-year-old female, was admitted to Facility A on December 31, 2008, with diagnosis of dementia (a decline in mental abilities), degenerative joint disease, and psychosis (loss of contact with reality).The Minimum Data Set Assessment and Care Screening tool dated April 20, 2010, indicated the resident had memory problems, modified independence in cognitive skills, and required limited assistance with activities of daily living. Section E, Mood and Behavior Patterns indicated the resident wandered one (1) to three (3) times in the last seven (7) days of the assessment.A review of the Care Conference Review form dated June 29, 2010, indicated the facility interdisciplinary team and attending physician were present at the conference. It was documented that on June 25, 2010, a notification of the care plan conference was sent, however the form was blank in the area of how the notification was sent, and who had been notified of the care plan conference. Under comments/follow up/additional notes, documentation indicated the facility discussed transferring the resident to a locked unit for safety, due to the resident's wandering behavior.A review of the Social Work Progress Notes for June and July 2010, revealed documentation that Facility A had discussed with the resident?s responsible party, a possible T/D to a locked facility (B) for the resident?s safety on July 9, 2010. According to the documentation, the social worker contacted the attending physician and the resident's daughter regarding the transfer to Facility B.The Licensed Nurses' Progress Notes dated July 9, 2010, at 11 a.m. had documentation by the licensed nurse that the resident was transferred to Facility B in a taxi accompanied by a staff member. There was no evidence presented that a written transfer notice was given which included the appropriate reason and completion of documentation in the medical record, timely and appropriate notification of the T/D action, identifying the reason for and effective date of the T/D, the location the resident was to be transferred or discharged to, a statement of the resident?s or representative?s right to appeal the T/D action, the name, address and telephone number of the State long term care Ombudsman, and orientation to ensure a safe and orderly T/D.There was no documentation in the medical record to indicate the facility staff gave sufficient preparation and orientation for Resident A to ensure a safe and orderly transfer.A review of the Discharge Summary document dated July 8, 2010, revealed no information regarding the course of the resident?s stay at the facility, no recap of the stay, nor any other information relative to the resident?s medical condition addressing the resident?s care needs, activity of daily living routines, activity interests, or her psychosocial needs. There was no post-discharge plan of care to ensure that the resident?s care needs would be appropriately met after T/D to Facility B. The recapitulation of the resident's stay in the facility was incomplete and the reason for the transfer was blank. Therefore, the facility failed to issue a proper notice of T/D to Resident A, or the resident's representative, and failed to provide sufficient preparation and orientation to Resident A to ensure a safe and orderly T/D. Resident A was abruptly transferred from Facility A to Facility B on July 9, 2010. As a result, Resident A complained that she wanted to return to Facility A because she missed her friends, the food, and her primary language, which was spoken there. The above violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to Resident A. |
| 910000009 |
BAY CREST CARE CENTER |
910011918 |
B |
24-Dec-15 |
BNOW11 |
5828 |
CFR 483.15 (h) (6)The facility must provide comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 - 81ø FOn 9/14/15 at 1:30 p.m., an unannounced visit was made to the facility to investigate a complaint regarding Quality of care and Physical Environment.Based on observation and interview, the facility failed to provide comfortable and safe temperature levels in the resident environment by failing to: Provide safe and comfortable ambient temperatures between 71 and 81 degrees Fahrenheit (F). The ambient temperature in the residents? area located in Nursing Station 1, including the entrance lounge, the nursing station, and the residents residing in Rooms 5, 6, 8, 11, 15, and 16, ranged from 82 to 83 degrees F, placing the residents at risk of heat exhaustion and dehydration. On 9/14/15, at 3:30 p.m., during the inspection of Nursing Station 1's general environment, in the presence of the maintenance supervisor, he stated the facility had been waiting a couple of years for a replacement air conditioning (AC) unit for Nursing Station 1. The maintenance supervisor explained the Nursing Station 1 area was very hot because the AC was not working and they were utilizing fans distributed throughout the facility, including a portable AC unit the hallway and a portable AC unit in the activity room.During the tour of Nursing Station 1 hallway, the AC unit was shut off. The maintenance supervisor stated when the water collects and overflows at the bottom of the unit, it shuts off automatically, if not emptied on a regular basis. He then emptied the water and turned the AC unit back on. It took approximately eight minutes for the unit to start to circulate 78 - 79 degrees F air.On the same day during the tour, the maintenance supervisor while using a digital infrared thermometer gun (device that measures the temperature from a distance) indicated the temperatures were as follows:Station 1 - 83 F. Front entrance lounge - 83 F. Room 5 - 82 F. Room 6 - 83 F. Room 8 - 82 F. Room 11 - 83 F. Room 15 - 83 F. Room 16 - 83 F.During the tour of the Nursing Station 1 residents' rooms, Resident 2 was sitting in the room with two fans blowing directly at her and she stated she was very uncomfortable for several days because of the heat and humidity. Resident 2 complained she could not open the sliding glass door because the residents smoked outside of her room and opening the windows would not help anyway because it was just too hot. According to the resident, the fans only circulated the hot air.On the same day at 3:50 p.m., Resident 1 was observed sitting in her room. A fan in her room was blowing at a half drawn privacy curtain around her bed. Resident 1 stated it had been too hot and uncomfortable for several days and requested to get another fan and more ice water. Once she got an additional small fan, she stated no matter how many fans are placed in her room, it was just blowing the hot air around.On the same day at 5 p.m., during an interview, Certified Nursing Assistant 2 (CNA 2) stated Station I had been very hot and humid.The All Health Care Facilities letter (from the Licensing and Certification (L&C) Program to health facilities that are licensed or certified by L&C which may include changes in requirements in healthcare, enforcement, new technologies, scope of practice, or general information that affects the health facility) titled Hot Summer Weather Advisory dated 6/1/15, reminded health care facilities to implement recommended precautionary measures to keep individuals safe and comfortable during extremely hot weather. One of the recommendations to the facility administrators was to monitor weather predictions for fluctuation in extreme temperatures and take extra precautions to be sure appropriate air conditioning equipment is well maintained and operating effectively. According to the Accuweather.com (provides hourly and minute by minute weather forecast) for the month of September 2015, on Monday 9/14/15, the local temperatures (Los Angeles area) was registered at 86 degrees F. The average temperature from 9/1 thru 9/13/15 was 85 degrees F.A document dated 12/31/10, from the Office of Statewide Health Planning and Development (OSHPD - which regulates the design and construction of healthcare facilities to ensure they are safe and capable of providing services to the public), indicated a building permit for a new heating, ventilation, and air conditioning (HVAC) was approved. The letter indicated to notify OSHPD in writing of the start date prior to commencing construction and include the name and address of the contractor, and contract price. The letter indicated the building permit was going to expire unless it was started by 12/31/11.On 9/14/15 at 6:10 p.m., in an interview with the administrator, she stated the HVAC project was delayed due to several factors, one being an ownership change. The administrator further stated there was no official date for the project completion. The facility's architectural HVAC plans provided by the administrator dated 6/17/15 did not indicate a completion date. The facility failed to provide comfortable and safe temperature levels in the resident environment by failing to: Provide safe and comfortable ambient temperatures between 71 and 81 degrees Fahrenheit (F). The ambient temperature in the residents? area located in Nursing Station 1, including the entrance lounge, nursing station, and the residents residing in Rooms 5, 6, 8, 9, 11, 15, and 16, ranged from 81 to 83 degrees F, placing the residents at risk of heat exhaustion and dehydration.The above violation had direct or immediate relationship to the health, safety, or security of the residents. |
| 910000073 |
BRENTWOOD HEALTH CARE CENTER |
910011924 |
B |
24-Dec-15 |
LMKQ11 |
6117 |
CFR 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.On 9/25/15, at 7 a.m., an unannounced visit was made to the facility to investigate a complaint related to Admission and Discharge Rights.Based on interview and record review, the facility failed to ensure its Bed-hold policy was followed by failing to: Provide Resident 1 and a family member with a written notice specifying the duration of the bed-hold policy at the time of transfer for hospitalization or within 24 hours of the transfer. On 9/17/15, Resident 1 was transferred to a general acute care hospital (GACH) for psychiatric evaluation and on 9/21/15, when the resident was ready for discharge from the GACH and within seven days from day he was transferred from the facility, the facility refused to readmit Resident 1.As a result, Resident 1 was not allowed to exercise his right to seven day bed-hold, became upset he could not return to the facility and had to go to another skilled nursing facility (SNF) that accepted his admission 9/24/15.A review of Resident 1's clinical record indicated the resident was admitted to the facility on 4/27/15, with diagnoses including right hip fracture secondary to a fall and schizoaffective behavior [mental health condition including schizophrenia (delusions) and mood disorder symptoms]. The Minimum Data Set (MDS - standardized assessment and care planning tool) dated 9/9/15, indicated the resident was alert, oriented, had daily verbal outbursts directed towards others, required limited to extensive assistance with toilet use, personal hygiene, and transfers. Resident 1 used a walker and/or wheelchair for assistance with ambulation.A care plan dated 4/27/15, developed for Resident 1's constant yelling and screaming, included in the approaches encouraging activity attendance and focusing on the positive.A licensed nursing progress note dated 6/11/15 timed at 7:01 p.m., indicated Resident 1 was yelling and screaming in the hallway at dinner time because he was not served hot dogs. A licensed nursing progress notes dated 6/15/15 timed at 11:55 p.m. indicated that at 10 p.m., Resident 1 was yelling about his new roommate, the roommates' caregiver and was complaining there was not enough room.Further record review disclosed the resident had multiple episodes of yelling, using profanities, getting easily angry and being verbally abusive to others, including staff, residents and visitors. According to a Change of Condition note dated 9/17/15, at 10:32 a.m., the resident attempted to strike out at the director of nursing (DON) and the Psychiatric Emergency Team (PET) was called. At 2:45 p.m. Resident 1 was transferred to a GACH for psychiatric evaluation.A document in Resident 1's clinical record dated 9/21/15 and signed by the administrator indicated the administrator had visited Resident 1 at the GACH as the resident was ready for discharge. The administrator felt since the resident was not taking his medications and the facility staff was afraid of the resident and his outburst, did not feel re-admitting the resident to the facility was appropriate.According to a document provided by the GACH titled, ?Patient Return Agreement Letter,? which the administrator signed on 9/17/15, indicated the agreement to accept the resident back to the facility as soon as the resident was stable for transfer from the GACH.According to the GACH Discharge Summary dated 9/24/15, the resident was doing well and there was no reason for him to stay at the GACH, however the facility refused to take the resident back even if Licensing (and Certification) would give the facility a fine. The note also indicated the resident was upset he was not going back to the facility. Resident 1 was discharged to another SNF. On 12/23/15 at 1:40 p.m., during an interview, the Administrator confirmed there was no order for bed-hold and could not find evidence Resident 1 was provided with a seven day hold notice. The administrator stated all residents are given a seven day bed-hold when transferred to a GACH and there is no need to obtain a physician's order. A review of the facility's undated policy and procedure on Transfer/Discharge/Bedhold policy indicated the facility will automatically hold the bed for seven days for all Medi-Cal residents transferred out the facility. The facility failed to ensure its bed-hold policy was followed by failing to: Provide Resident 1 and a family member with a written notice specifying the duration of the bed-hold policy at the time of transfer for hospitalization or within 24 hours of the transfer. On 9/17/15, Resident 1 was transferred to a general acute care hospital (GACH) for psychiatric evaluation and on 9/21/15, when the resident was ready for discharge from the GACH and within seven days from day he was transferred from the facility, the facility refused to readmit Resident 1.As a result, Resident 1 was not allowed to exercise his right to seven day bed-hold, became upset he could not return to the facility and had to go to another SNF that accepted his admission on 9/24/15. The above violation had direct or immediate relationship to the health, safety, or security of Resident 1.1 |
| 910000017 |
Beachwood Post - Acute & Rehab |
910012623 |
B |
6-Oct-16 |
DXK811 |
11762 |
F223
483.13 Resident Behavior and Facility Practices
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.
On August 16, 2016, during the annual recertification survey, the survey team investigated allegations regarding resident abuse.
Based on observation, interview, and record review, the facility failed to implement their abuse policy and procedures to prevent and protect Resident 13 from physical, verbal and psychological abuse, mental anguish and neglect by four facility staff by failing to:
1. Ensure Certified Nursing Assistant (CNA) 1 did not physically abuse Resident 13 by scratching her left arm causing her to bleed.
2. Ensure CNA 2 did not physically abuse Resident 13 by hitting her between her eyes with an open hand.
3. Ensure LVN 11 reported Resident 13's allegation of being physically abused (hit) by CNA 2 to the DON and administrator.
4. Implement interventions to immediately suspend and or reassign CNA 1 and CNA 2, after Resident 13 had voiced allegations of physical, psychological, mental and verbal abuse by CNA 1 and CNA 2 to the DON and Administrator. This resulted in Resident 2 experiencing intense fear for her life and anxiety, which had the potential to cause an exacerbation of the resident's post traumatic stress disorder (A mental health issue triggered by a terrifying event).
5. Ensure Licensed Vocational Nurse (LVN) 6 did not verbally abuse Resident 13 by speaking to her in a rude harsh manner, calling her a liar and retaliating against the resident by shoving paper in her face because she shared her concerns in front of the surveyor. This resulted in Resident 13 feeling neglected and uncared for.
These deficient practices resulted in Resident 13 feeling fearful, afraid, and neglected and had the potential to place other residents at risk for ongoing physical, verbal, and psychological abuse.
A. During an initial tour of the facility on August 16, 2016, at 2:45 p.m., Resident 13 stated in the presence of licensed vocational nurse (LVN 3) that she was afraid of CNA 1 and CNA 2. She was afraid because CNA 1 told her he would kill her and scratched her on the left arm a few weeks prior causing her to bleed. CNA 2 hit her between her eyes the previous day on August 15, 2016, with an open hand.
Resident 13's admission record indicated Resident 13 was admitted to the facility on XXXXXXX 2014, with diagnoses that included Parkinson's disease (disease of the central nervous system which causes shaking, stiffness, slowness of movement, and difficulty walking), osteoarthritis (joint disease causing joint pain and stiffness), post-traumatic stress disorder (mental health condition that develops after a terrifying event), and contractures (condition that causes stiffness to joints restricting normal movement) to both arms and feet.
A review of Resident 13's Minimum Data Set (MDS - a standardized resident assessment and care screening tool), dated February 17, 2016, indicated the resident was cognitively intact but required total assistance from facility staff in all activities of daily living such as eating, bathing, toileting, and transferring.
A review of Resident 13's History and Physical dated April 4, 2016 indicated the resident had the capacity to understand and make decisions.
During an observation, on August 16, 2016 at 2:47 p.m., Resident 13 showed the surveyor a reddish-brown discoloration measuring half an inch to the left upper arm.
During an interview, on August 16, 2016, at 3:03 p.m. accompanied by the the administrator and the DON, in the presence of the surveyor, Resident 13 stated CNA 1 scratched her left arm causing her to bleed. CNA 2 hit her between the eyes with an open hand and called her a "white bitch." Resident 13 stated she informed LVN 11 that she was hit by CNA 2 on August 15, 2016. Resident 13 further stated she felt scared because her life was threatened by CNA 1. CNA 1 also waved his closed fist in her face and forced her to watch Spanish television (Resident 13 speaks english) He also told the resident she was "cuckoo and no one would believe her." During the interview, the administrator and DON assured Resident 13 both CNA 1 and CNA 2 would not take care of her any longer.
During the interview on August 16, 2016, at 3:06 p.m., The surveyor observed the DON assess Resident 13's left upper arm and confirmed the resident had a "purple mark the size of a penny." The facility did not assess the residents bruises prior to the survey.
On August 17, 2016, at 11:21 a.m., during an interview Resident 13 stated CNA 2 came into her room, that morning, after being told she would not be there anymore by administration on August 16, 2016, yesterday. The resident stated that she started screaming for help because she was scared and feared for her life.
During an interview on August 17, 2016, at 12:00 p.m., the surveyor alerted the administrator that CNA 2 had contact with Resident 13 this morning. The administrator stated the facility could not get a hold of CNA 2 via telephone the previous day August 16, 2016, to inform her of her suspension.
During an interview, on August 17, 2016, at 12:05 p.m., with the registered nurse (RN) consultant he stated he suspended and sent CNA 2 home at the start of the shift, sometime around 7 a.m., on August 17, 2016, at which time, he informed CNA 2 not to return until the completion of the ongoing abuse investigation.
During an interview, on August 17, 2016, at 12:07 p.m., the DON stated the plan was to ask the RN consultant to intercept CNA 2 before the start of the shift to inform her of the investigation and suspension. The DON stated, "I was here all night until 4 a.m., perhaps I should have been here until 7 a.m. to intercept CNA 2." The RN consultant then stated CNA 2 was sent home around 8:15 a.m.
During an interview, on August 17, 2016, at 12:55 p.m., RN supervisor 1 stated CNA 2 arrived to the floor at 7 a.m. and saw her near Resident 13's room between 7:45 a.m. and 8 a.m., but no later than 9 a.m. RN supervisor 1 stated LVN 3 made the assignment in the morning.
A review of the CNA work assignment for the 7-3 shift on August 17, 2016 indicated CNA 2 was assigned to Resident that morning.
During an interview, on August 22, 2016, at 3:11 p.m., LVN 3 stated she made the assignment on August 17, 2016. CNA 2 was scheduled for the day and was not happy about her assignment. LVN 3 stated CNA 2 was assigned to Resident 13 that morning but was unsure if she went inside the resident's room. LVN 3 was unaware of CNA 2's pending suspension.
During an interview, on August 19, 2016, at 9:21 a.m., Resident 35 stated CNA 2 had a short temper, had called the resident a liar, and she was scared of CNA 2 because of her short temper. RSR 35 recalled a time in which CNA 2 called her roommate a liar and stated to her roommate, "You are not blind, you are not fooling anybody, and you are a liar." RSR 35 stated she went without pooping for two days because she is afraid of having CNA 2 assigned as her nurse. RSR 35's roommate was hospitalized at the time of the interview.
A review of the facility's Resident Abuse Investigation Report Form indicated the CNA 1 and 2 were terminated on August 19, 2016 after further investigation for a lack of remorse, dishonesty, and attitude It further indicated LVN 11 received oral counseling and a written warning on August 18, 2016 for failure to report abuse.
A review of the facility's Corrective/Disciplinary Action Form dated August 18, 2016, indicated LVN 11 was informed by Resident 13 on August 15, 2016 that CNA 2 hit her in the nose. LVN 11 assessed the resident and did not see any signs or symptoms of injury and did not report it to the administrator.
A review of the facility's revised December 2006 policy and procedure titled "Resident Behavior and Facility Practices - Abuse Prevention" indicated the following:
a. Employees accused of participating in the alleged abuse will be immediately reassigned to duties that do not involve resident contact or will be suspended until the findings of the investigation have been reviewed.
b. Should the employee(s) be reassigned to non-resident care duties, such assignment will not be in any part of the building, which the resident frequents.
c. Should a resident be observed with unexplained injuries (including bruises, abrasions, and injuries of unknown source), the nurse supervisor on duty must complete an accident/incident form and record such information into the resident's clinical record.
d. Employees, facility consultants and/or attending physicians must immediately report any suspected abuse or incident of abuse to the DON. In absence of the DON such reports may be made to the nurse supervisor on duty.
During an observation, on August 17, 2016, at 4:25 p.m., LVN 6 returned to Resident 13's room with a full water pitcher. After giving Resident 13 a sip of water, the resident asked again the name of her assigned nurse. LVN 6 grabbed the Nurse Assignment Sheet from the medication cart and returned to the room. Resident 13 then stated her nails were too long and asked LVN 6 when he was going to clip her nails. Resident 13 continued, stating that she had asked LVN 6 last week and he told her he did not have time to trim her nails. LVN 6 replied to Resident 13 that she was making up stories and that the trimming of her nails was news to him.
During an observation, on August 17, 2016, at 4:28 p.m., LVN 6 the surveyor observed LVN 6 shoving the Nurse Assignment Sheet back and forth inches away from Resident 13's face while stating, "Have I been bad to you, say it now, I'm confronting you in front of the surveyor." LVN 6 swiftly walked out of the room.
During an interview, on August 17, 2016, at 4:30 p.m., LVN 6 stated Resident 13 was the only resident lying to the surveyors by telling all kinds of stories about the nurses. LVN 6 stated because the surveyor asked for his name when he returned to the room that Resident 13 might have said something behind his back when he left the room to refill the resident's water pitcher.
During an interview with the DON on August 17, 2016, at 4:44 p.m., the DON was informed of the encounter between LVN 6 and Resident 13. The DON stated he would take disciplinary action because LVN 6 has had attitude issues before. There were no prior written disciplinary notices regarding LVN 6 in his employee file.
During an interview with Resident 13 on August 17, 2016, at 5:56 p.m., the resident stated LVN 6 was rude to her and called her a liar. Resident 13 stated LVN 6 does not pay much attention to her and does not like to do anything when asked making her feel neglected.
A review of the facility's Licensed Vocational Nurse Job Description indicated nurses must demonstrate knowledge of, and respect for, the rights, dignity and individuality of each resident in all interactions.
A review of the facility's Corrective/Disciplinary Action Form dated August 17, 2016 indicated LVN 6 was terminated from the facility because the incident happened in the presence of a surveyor.
A review of the facility's revised December 2006 policy and procedure titled "Abuse Prevention Program" indicated the facility's residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion.
These violations had a direct relationship to the health, safety, or security of residents. |
| 920000071 |
BURBANK HEALTHCARE AND REHABILITATION CENTER |
920009039 |
A |
01-Jun-12 |
8NY511 |
15636 |
Code of Federal Regulations Section 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.Based on interview and record review, the licensed nursing staff failed to effectively manage Resident 1?s bowel hygiene and dietary needs, to prevent constipation or its progression to a fecal impaction [a solid, immobile bulk of feces that can develop in the rectum or the colon (large intestine) as a result of chronic constipation and prolonged retention of feces], that resulted in complications and death for Resident 1 by failing to:1. Consistently and accurately assess and document the resident?s bowel habits, and monitor the characteristics of the resident's stool, including the frequency, the color, the amount, the odor, and the consistency of the stool, as indicated in the care plan. 2. Provide and ensure the consumption of adequate fluids as indicated in the nutritional assessment. 3. Implement the care plans that identified alteration in bowel patterns and immobility as problem areas that may lead to constipation, with specific interventions that incorporated the resident?s specific dietary needs, and specific interventions to increase activity. 4. Implement and monitor the effectiveness of the physician's order to administer stool softeners, laxatives, or enemas to evacuate feces and to prevent the prolonged retention of feces that led to fecal impaction.On January 10, 2011, the Department received a complaint that alleged Resident 1 vomited a large amount of reddish brown liquid, had a largely distended abdomen that was hard to the touch. The nurse performed a rectal exam and found a large fecal mass of stool in the resident's rectum. On January 10, 2011, an unannounced visit was initiated to investigate the above allegations.Resident 1 was admitted to the facility on April 28, 2010, with diagnoses that included atrial fibrillation, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), hypertension (high blood pressure), and dementia.The Admission Assessment dated April 28, 2010, indicated Resident 1 was continent of bowel, had a urinary catheter, was alert, answered questions reluctantly, had quick comprehension, and was oriented. The discharge evaluation plans were to have a short term stay in the facility, and return home with his wife and a caregiver. The Medication Reconciliation Facility Transfer Medication Orders dated April 28, 2010, for discharge from the general acute care hospital (GACH) to the skilled nursing facility (SNF) listed current scheduled medications to continue that included: Dulcolax for constipation twice a day as needed, Colace for constipation daily as needed.The resident had physician's orders in the SNF dated April 28, 2010, that included the following:1. Colace 100 milligrams (mg) by mouth daily as necessary for constipation. 2. Dulcolax 10 mg suppository, insert one suppository per rectum daily asneeded (PRN) for severe constipation. 3. Fleets enema one per rectum every two days PRN if Dulcolax is ineffective for severe constipation. 4. Milk of Magnesia 30 cubic centimeters (cc) by mouth at night PRN for constipation. 5. Regular mechanical soft diet. 6. HPN (high protein nutrition) 4 ounces at 10 a.m. for 90 days. 7. Demadex 20 mg daily (causes increased excretion of fluids, used for hypertension and congestive heart failure). The Minimum Data Set (MDS) assessment dated May 4, 2010, indicated the resident had long and short-term memory problems, was moderately impaired in cognitive skills for daily decision-making, had a height and weight of 71 inches and 156 pounds, required extensive assistance from staff for bed mobility, transfers, dressing, and personal hygiene. The MDS indicated he was totally dependent on staff for toilet use, was usually continent of bowel, and had pain of moderate intensity less than daily.The Nutritional Assessment Screening Section dated April 30, 2010, signed by the Dietary Supervisor (DS), listed diagnoses that included atrial fibrillation, dementia, and renal insufficiency. There were no food or beverage preferences indicated, and the DS had documented that the resident was at risk for dehydration. On May 4, 2010, the Registered Dietician (RD) evaluated the resident?s caloric needs to be 2357 calories, 85 grams protein, and 2127 cubic centimeters (cc) of fluids per day. The RD assessed the level of care as high risk for the potential or presence of malnutrition.The ?Goals? section indicated ?for care plan? , with no explanation or other documentation noted.There was a care plan initiated on April 28, 2010, reviewed on May 10, 2010, for ?Elimination, Alteration in Bowel Patterns.?The goal was for the resident to be adequately emptied without complications as evidenced by regular bowel movement, and no abdominal distention, daily, for ninety days. The interventions included to monitor and document bowel patterns, consistency, frequency, color, odor; to monitor for abdominal distension; to administer laxatives as ordered and to indicate and monitor for effectiveness;and to encourage optimal activity to stimulate bowel elimination (non-specific activity given). There was another care plan initiated April 28, 2010, reviewed May 10, 2010, for the potential for ?Constipation Related to Reduced Mobility.? The goal was to be free from signs and symptoms of constipation as evidenced by no abdominal pain, no distention, no nausea/vomiting, and regular bowel movements without complications daily for 90 days. The interventions included to evaluate for bowel sounds and abdominal distention; to monitor elimination patterns; to increase physical activity and fluid intake to promote optimal bowel function (non-specific as to how this was to be accomplished); to maintain ?adequate? nutrition and hydration (non-specific); and to administer medications as ordered. The above care plans did not have specific interventions as to how the facility was to accomplish the increase of physical activity, the increase in fluid intake, and the provision of ?adequate? nutrition and hydration. The care plan did not include input or interventions from the RD, who was part of the interdisciplinary team, even though the RD had indicated on the May 10, 2010, Nutritional Assessment, that the nutritional/hydration problems identified were to be care planned.For example, the resident was ordered a mechanical soft diet. However, there was no indication the RD had considered foods such as fruits and vegetables, prune juice, and/or other foods with natural laxatives and rich in fibers, to prevent excessive straining when having a bowel movement, or to prevent constipation.A review of the Intake and Output (I&O) Flow Sheet from April 28, 2010, to May 13, 2010, revealed nursing staff did not consistently monitor the resident?s I&O in order to ensure they provided ?adequate? hydration as indicated in the care plans. The I&O records revealed Resident 1 received less than the RD?s assessed hydration needs per day, according to the documentation that was available. For example, from May 3, 2010, to May 13, 2010, the resident received 1,000 cc to 1,800 cc of fluids per day. This was less than Resident 1?s daily required volume of fluids by a range of 327 cc to 1,127 cc per day, as evaluated by the RD, leading to the potential for dehydration and constipation. A review of the Certified Nursing Assistant ADL Sheet records from April 28, 2010, to May 13, 2010, revealed the resident was bedfast, was continent of bowel, and consumed 20 percent (%) to 90% of his breakfast, 15% to 80% of lunch, and 40% to 100% percent of his dinner. The Bowel Movement section was not consistent in documentation, and there were no written notes describing the characteristics of the bowel movement that included the color, odor, and the consistency of the stools, as stated on the care plan.On January 18, 2011, at 10:45 a.m., during an interview with the Director of Nursing, she stated licensed staff should have implemented the care plans. She also stated the CNAs should have documented accurately on the CNA forms.A review of the Licensed Nurse Record documents from April 28, 2010, to May 13, 2010, revealed the resident was bedfast, alert, able to follow direction, and was on a "soft diet." Unlike the Certified Nursing Assistant (CNA) notes that indicated the resident was always continent of bowel, the licensed notes indicated the resident had thirteen episodes of bowel incontinence during the same period of time. There was no documentation that the licensed nurses evaluated the characteristics of the bowel movements, including the color, consistency, or odor of the stool, as indicated in the plan of care. There was no documentation to indicate that licensed staff had assessed and documented the reasons for the bowel incontinence, which would be a change from their initial assessment ?continent of bowel.?The documentation, indicated by check marks, revealed that the resident?s bowel continence habits started to change on or about May 4, 2010.However, there was no documented evidence that indicated the licensed nurses had assessed the resident?s abdomen for distention, or for the presence or absence of bowel sounds, as indicated in the care plan, until the resident experienced a change in condition on May 14, 2010. Prompt assessment would have enabled licensed staff to detect the early signs of constipation in order to intervene timely before the resident's constipation progressed to fecal impaction.According to the literature, astute observations regarding the frequency, color, amount, and consistency of the stool can provide the nurse with guidance for action. The nurse should also be alert for any signs and discomfort associated with the process of elimination.American Journal of Nursing, April 1967 Pages 785- 787).Although the resident had physician orders dated April 28, 2010, for stool softeners, laxatives, and enemas, as needed, a review of the Medication Records for the months of April 2010 and May 2010 revealed the resident did not receive any of the laxatives or stool softeners ordered by the physician to prevent constipation. Only after a licensed nurse observed the resident with symptoms associated with fecal impaction on May 14, 2010, manifested by vomiting a large amount of reddish brown liquid, and having a largely distended and hard to touch abdomen, enemas were ordered.The License Nurse Record documents dated May 13, 2010, 11 p.m. to 7 a.m. shift, and May 14, 2010, 7 a.m. to 3 p.m. shift, revealed the resident had a change of condition characterized by a large red brown liquid emesis (vomit) reported by CNA 1. The resident stated he became sick all of a sudden. Vital signs were measured as blood pressure 100/54, temperature 98.8, pulse 98, respiratory rate 22, and oxygen (O2) saturation was 95 percent (%) on room air. The resident?s skin was pale, warm and dry, the abdomen was largely distended, hard to the touch, and painful with light palpation (touch), with scattered bowel sounds in four quadrants. CNA 1 reported that the resident had ?three large soft bowel movements liquid stools? during the shift (11 p.m. to 7 a.m.). A digital rectal exam was done and found a large firm mass of stool felt high in the rectum. O2 was administered at 2 Liters per minute (2 L/min) via nasal cannula (tube in the nose).Enemas were given three times per the Licensed Nurse Record notes as follows: 1. Fleets enema was given at 6:40 a.m., fecal mass down low in the rectum; small amount of stool loosened and removed from the rectum with a large amount of flatus (gas). 2. Fleets given at 6:55 a.m. to ?further relieve retained stool.? The physician was called at 7:15 a.m., the blood pressure was rechecked and measured 100/56. New orders were given for Fleets and tap water enema, communicated to the next shift.The resident complained of nausea, and his abdomen was slightly distended, with bowel sounds present in all four quadrants. The resident denied abdominal pain, and the abdomen was non-tender to touch. Vital signs were taken, with the blood pressure measured at 140/70, pulse was 80 beats per minute, respiratory rate was 20 breaths per minute, the temperature was 98.6, and O2 saturation was 96% on room air. 3. Tap water enema was given at 7:30 a.m., while the resident was in bed, that resulted in a large bowel movement. At 8 a.m., the resident refused to eat, and stated he felt full and nauseated. At 8:30 a.m., the resident stated he felt like he had to have another bowel movement. CNA 1 assisted him to the toilet, and the resident had a bowel movement, was noted to have clammy skin, and he stated he felt weak. The resident?s respiratory rate was 24, and his pulse was 58 beats per minute. He was returned to bed, his respiratory rate was measured at 12, and his pulse was faint. O2 was initiated at 2 L/min. The licensed nurse initiated CPR and the paramedics were called, who arrived at 9:06 a.m., and continued the CPR. The paramedics were unsuccessful to resuscitate the resident, who was pronounced dead on May 14, 2010, at 9:16 a.m. According to "Evidence Based Clinical Practice" by Nolan O. Aludino, MD, the major complications associated with fecal impaction include partial or complete obstruction of the large intestine. The reliable signs and symptoms (more than 90 percent certainty) of obstruction of the large intestine are abdominal distention and fecaloid (resembling feces) vomits. Patient 1 had experienced these signs and symptoms on May 14, 2010, at 6:30 a.m.According to the Certificate of Death, the immediate cause of death was cardiopulmonary arrest, and arteriosclerotic cardiovascular disease. There was no autopsy performed, according to this certificate. The facility?s Procedure: Bladder & Bowel Retraining Program, indicated that nursing assistants are to ?accurately document? the resident?s bowel elimination on the ADL or CNA forms. The licensed nursing staff failed to effectively manage Resident 1?s bowel hygiene and dietary needs, to prevent constipation or its progression to a fecal impaction, that resulted in complications and death for one out of one sample residents by failing to: 1. Consistently and accurately assess and document the resident?s bowel habits, and monitor the characteristics of the resident's stool, including the frequency, the color, the amount, the odor, and the consistency of the stool, as indicated in the care plan. 2. Provide and ensure the consumption of adequate fluids as indicated in the nutritional assessment. 3. Implement the care plans that identified alteration in bowel patterns and immobility as problem areas that may lead to constipation, with specific interventions that incorporated the resident?s specific dietary needs, and specific interventions to increase activity. 4. Implement and monitor the effectiveness of the physician's order to administer stool softeners, laxatives, or enemas to evacuate feces and to prevent the prolonged retention of feces that led to fecal impaction.The violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would and did result to Resident 1. |
| 970000005 |
BRIER OAK ON SUNSET |
920009752 |
B |
21-Feb-13 |
74RX11 |
10214 |
F 157 42 CFR 483.10(b)(11) Notification of changes 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). The facility must also promptly notify the resident and, if known, the resident's legal representative or interested family member when there is a change in room or roommate assignment as specified in ?483.15(e)(2); or a change in resident rights under Federal or State law or regulations as specified in paragraph (b)(1) of this section. The facility must record and periodically update the address and phone number of the resident's legal representative or interested family member. The Department received a complaint allegation that the facility?s staff did not act timely when a resident (Resident 1) had a change of condition and the resident?s blood pressure dropped low requiring a transfer to the hospital.On February 11, 2013 at 7:30 a.m., an unannounced visit was conducted to continue a complaint investigation. Based on interviews and closed record review, the facility failed to follow their policy and procedure and the plan of care that had been developed for Resident 1 regarding change of condition by not: 1. Notifying the primary physician and family member when Resident 1?s, blood pressure dropped to 84/63 when his heart rate was at 38 beats per minute. This resident had a history of high blood pressure and congestive heart failure. 2. Closely monitoring the resident?s vital signs after the blood pressure and heart rate had dropped to a life-threatening level.These failures resulted in a delay in evaluation and treatment for Resident 1, and as his condition continued to deteriorate, ultimately requiring a transfer to a general acute care hospital (GACH). A review of Resident 1?s closed clinical record indicated the resident was a 79 year-old male who was admitted the facility on August 19, 2010. The resident had several re-admissions back to the SNF during a four-month period. The last re-admission to the SNF was on October 30, 2010. The resident?s diagnoses included hypertension (high blood pressure) with a history of a cerebral vascular accident (CVA),congested heart failure (the pump is inadequate to deliver oxygen rich blood to the body), atrial fibrillation (cardiac arrhythmia/irregular heart beat), multiple pressure ulcers (opened skin breaks after something rubbing or pressing against the skin), diabetes mellitus (a chronic disease in which high levels of glucose (sugar) build up in the bloodstream), and a small bowel obstruction (mechanical or functional obstruction of the intestines, preventing the normal transit of the products of digestion), status-post an exploratory laparotomy surgery (a laparotomy is a large incision made into the abdomen and is used to visualize and examine the structures inside of the abdominal cavity) with a strangulated bowel repair. A review of an initial nursing assessment, dated August 21, 2010, indicated the resident was alert with his memory intact, able to make needs known and understand others, and required assistance with transfer and mobility. A review of a Minimum Data Set (MDS), a standardized assessment and care screening tool, dated November 1, 2010, indicated the resident was non-ambulatory, required extensive assistance with bed mobility, dressing, eating, personal hygiene, and totally dependent in all other activities of daily living. The resident had the ability to understand and be understood by others. The resident?s re-admission physician?s orders included Diltiazem (used to treat high blood pressure, angina and certain heart rhythm disorders) 30 milligram (mg) by mouth every six hours for hypertension and Metoprolol (used to treat angina [chest pain] and hypertension) 25 mg. one tablet by mouth twice a day, but to hold if SBP (systolic blood pressure) is less than 100 or heart rate less than 60. A review of a Code Status, dated November 2, 2010, indicated Resident 1 was a ?Do Not Resuscitate (DNR).? However, the resident?s family members met with facility staff and changed the code status to full code, on December 10, 2010 at 2:20 p.m., which included CPR (cardio pulmonary resuscitation), transfer to hospital, nasogastric/GT tube and IVFs. There was also a telephone physician?s order, dated December 10, 2010, indicating the resident?s status changed from DNR to Full Code. A review of a care plan titled, Heart Disease, dated November 1, 2010, indicated the resident had potential for shortness of breath and chest pain secondary to his history of heart disease/hypertension. The staff approaches included report abnormal vital signs. Another care plan dated on November 1, 2010, titled, ?Weakness? indicated the resident would be free of weakness within 90 days. The nurses? plan of approaches included notifying the physician of any change in condition. On December 6, 2010, Resident 1 was seen by a physician with orders written for intravenous fluids (IVF/ administered directly into the circulatory system via a needle) to be infused three times a week (MWF) at 125 milliliter (ml) an hour, for a total of 500 ml for hydration and low blood pressure to run over three-four hours. A review of a ?Daily and Q-Shift Charting? dated December 12, 2010, on the 7-3 p.m. shift, indicated the resident?s vital signs were within normal limits at T=97.7, HR=70, RR=18, and blood pressure 126/70 (normal reference range for T= 97.8 - 99.1 degrees; HR=60-100; RR= 12-18 breaths per minute; B/P=90/60-120/80). However, on December 12, 2010, on the 11 p.m. to 7 a.m. shift, the resident?s blood pressure and heart rate were low at 84/63 and 38 respectively. The nurse documented the resident was asleep and verbally responsive when awakened and the IVF was tolerated well. There was no documentation of notification to the resident?s physician or family of the resident?s change in condition with a low B/P and extremely low HR. On February 12, 2013, at 11:20 a.m., the director of nursing (DON) reviewed Resident 1?s closed record. She stated the nurse documented on December 12, 2010, on the night-shift, that the resident?s B/P and HR were low and there was no documentation the physician was notified. The DON stated the nurse should have called the resident?s physician, especially since his code status had recently changed. She stated, ?I would have called the physician and continued to monitor the vital signs.? She stated the nurse should have called ?911? with the resident?s low B/P and HR. The DON stated the resident?s vital signs were not taken again until eight hours later, on December 13, 2010, on the 7-3 p.m. shift. Resident 1?s condition changed again on December 14, 2010 at 12:30 p.m., according to a Daily and Q-Shift Charting and a physical therapist note, the resident?s B/P dropped again to 80/60 than to 55/47 with a low oxygen saturation of 62 percent (%) on room air (RA) while the physical therapists were getting him up in a Geri-chair (Normal oxygen saturation on RA is between 97 and 100 %), the nurse?s note indicated the resident was awake and responsive. The physician was called and ordered to transfer the resident to the GACH. Resident 1 left the facility (SNF) at 1:08 p.m. A review of the GACH emergency room record, dated December 14, 2010, at 1:35 p.m., indicated the resident was brought in secondary to decreased oxygen saturation and level of consciousness. The resident was diagnosed with rapid atrial fib (irregular heart beat), anemia (a condition in which the body does not have enough healthy red blood cells) acute dehydration (excessive loss of body water, with an accompanying disruption of metabolic processes), renal failure (a rapid loss of kidney function), and acute chronic obstructive pulmonary disease (COPD/a sudden worsening of symptoms such as shortness of breath, quantity and color of phlegm, that typically lasts for several days). The resident received IVFs, blood transfusions, breathing treatments, and emergency cardiac drugs in the emergency room. Resident 1 was transferred to a cardiac care unit (CCU) for further care and treatment. According to Medicine Net.com., low blood pressure that causes inadequate flow of blood to the body?s organs can cause strokes, heart attacks, and kidney failure. It also indicated other common causes of low blood pressure include a reduced volume of blood, heart disease, and medications. A review of the facility?s policy, titled, ?Physician Notification of Change in Resident Condition? dated April 2004 and revised November 2005, indicated the physician should be notified of any sudden and marked adverse change in the resident?s condition which is manifested by signs and symptoms different than usual denoting a new problem. According to the policy, changes in vital signs, that are abnormal findings, is an example of a change. The facility failed to follow their policy and procedure and the plan of care that had been developed for Resident 1 regarding change of condition by not: 1. Notifying the primary physician and family member when Resident 1?s blood pressure dropped to 84/63 when his heart rate was at 38 beats per minute. This resident had a history of high blood pressure and congestive heart failure2. Closely monitoring the resident?s vital signs after the blood pressure and heart rate had dropped to a life-threatening level. The above violation had a direct relationship to the health, safety, or security of Resident 1. |
| 970000005 |
BRIER OAK ON SUNSET |
920011177 |
B |
24-Dec-14 |
YXP111 |
5227 |
72315. Nursing Services ? Patient Care 72315 (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 Department received an entity reported incident (ERI) on September 28, 2012, alleging a patient (Patient 2) witnessed another patient (Patient 1) being slapped in the face by a certified nursing assistant (CNA/Employee A). Patient 2 observed Employee A slapping Patient 1 on September 16, 2012.On September 28, 2012, at 1:45 p.m., an unannounced complaint investigation was conducted and on November 21, 2014, a follow-up investigation was conducted.Based on interview and record review of the two complaint investigation visits, the facility failed to: 1. Ensure Patient 1 was free from physical abuse by Employee A.2. Supervise and monitor Patient 1?s care being rendered by Employee A.These failures resulted in the physically assault of Patient 1 and had the potential for harm to other patients under Employee A?s care.Patient 2 reported to the administrator (ADM) on September 19, 2012, she observed Employee A in Patient 1?s room feeding her, and slapped her in the face. Patient 2 stated Patient 1 was spitting and screaming at the time. During a tour, on November 21, 2014, at approximately 1 p.m., Patient 1 was observed sitting up in the wheelchair sleeping, but alert when spoken to, but would only bow her head and look away. According to Employee B, a registered nurse (RN), the assessment indicated Patient 1 was non-interviewable, due to the diagnosis of dementia and being Spanish speaking.On September 28, 2012, at 2:45 p.m., during an interview, the ADM, stated Employee A was interviewed and from facial gestures knew it was about the incident. The ADM stated Patient 2, who witnessed the incident, was interviewed. The ADM stated Patient 2 stated in an interview, she was in her wheelchair passing by the door of Patient 1?s room and saw Employee A slap Patient 1.On November 21, 2014, at 9:30 a.m., during another interview with the facility?s ADM, the ADM stated the incident was reported to the Department as investigated; Employee 1 was on suspension from September 19, 2012 (three days after the incident occurred) and terminated on September 26, 2012, after the full internal investigation was completed.A review of Patient 1?s face sheet indicated in 2012 the patient was an 84 year-old female who was admitted to the facility with an admitting diagnosis of Diabetes Mellitus Type II (a metabolic disorder), multiple other diagnoses included dysphagia (swallowing difficulties), dementia, psychosis (a serious mental disorder), late effect cardio-vascular disease (involve the heart and/or blood vessels) . A review of Patient 2?s face sheet indicated the patient was a 29 year-old female, admitted to the facility on September 6. Patient 2?s admitting diagnoses included pyelonephritis (a potentially serious kidney infection), difficulty in walking and muscle disuse atrophy.According to the Licensed Nursing Notes, dated September 6, 7, 15, and 16, 2012; the Licensed Nurses Weekly Summaries, dated September 12 and 19, 2012, and the Social Service Assessment, dated September 6, 2012, indicated the patient was alert, verbally responsive and was able to make needs known and her own decisions. According to the facility?s investigative report, provided to the Department, the allegation was substantiated. Patient 2 the only witness was interviewed on September 19 and 20, 2012 by different interviewers and gave a written statement, dated September 21, 2012, for consistency of her report. The report indicated Patient 2 was very detailed and consistent with her report. The facility report indicated Patient 1 could not be questioned about the incident due to confusion, impaired cognition secondary to dementia with psychosis. The facility?s report indicated they viewed a video camera filming on the date, time, and location in questioned reported by Patient 2, on September 16, 2012 between the hours of 5 to 6 p.m., by Station B. On the video, Patient 2 was observed in her electric wheelchair passing by Station B several times. Patient 2 appeared to be looking inside Patient 1?s room, substantiating the report given by Patient 2.The facility?s investigative report concluded in a follow-up letter to the Department, dated September 24, 2012, ??that there was an abuse. The employee to be terminated immediately.?A review of the facility?s policy with a revision date of July 1, 2005 and titled, ?Abuse Prevention,? indicated each resident has the right to be free from ?physical abuse?and residents must not be subjected to abuse by anyone?the facility would protect its residents from acts of abuse and prevent mistreatment, neglect and abuse of residents and misappropriation of residents? property. The facility failed to: 1. Ensure Patient 1 was free from physical abuse by a staff member. 2. Supervise and monitor Patient 1?s care being rendered by Employee A.The above violations jointly, separately, or in any combination presented a substantial probability that death or serious physical or mental harm would result. |
| 920000071 |
BURBANK HEALTHCARE AND REHABILITATION CENTER |
920011898 |
A |
22-Dec-15 |
JHC511 |
9917 |
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.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 8/11/15, at 9 a.m., an unannounced visit was made to the facility to investigate a complaint regarding Resident 1 sustaining a fall at the facility which resulted in a back fracture. Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as possible and that Resident 1, who was assessed as risk for falls, received adequate supervision and assistance devices to prevent accidents including: 1. Failure to ensure Resident 1 was supervised and assisted while sitting on the toilet. 2. Failure to implement the plan of care interventions to provide assistance with toilet use and provide a safe environment As a result, Resident 1 suffered a fall on 7/29/15, with a fractured thoracic vertebra (T-12 - the mid-back spine), when she got up from the toilet, after being left unattended and nobody responded to her calls for assistance. Resident 1 developed severe pain to the mid-back area, was transferred to an acute care hospital on 7/30/15 and returned to the facility on the same day requiring log rolling technique (method of turning when the spine must be maintained in alignment. Two persons use a sheet to turn the patient as a unit) for repositioning.A review of the clinical record indicated the Resident 1 was re-admitted to the facility on 6/12/15, with diagnoses including end stage renal disease (ESRD) on hemodialysis treatments, lack of coordination, generalized muscle weakness, and unspecified anemia (not enough healthy red blood cells to carry adequate oxygen to the tissues and may cause lethargy and weakness). The Quarterly Minimum Data Set (MDS - standardized assessment and care planning tool) dated 6/22/15, indicated Resident 1 usually had the ability to understand others with some difficulty communicating some words; required extensive assistance with one-person assist transferring from bed to chair and using the toilet; was not steady with moving from seated to standing position and moving on and off the toilet; and was only able to stabilize with staff assistance. A review of Resident 1's Fall Risk Assessment form, dated 6/12/15, indicated the resident was assessed at a high risk for falls. A review of Resident 1's Rehabilitation Fall Risk Assessment form completed by a physical therapist (PT) on 6/13/15 and 7/9/15, indicated the resident required extensive assistance with transfers, did not use the call bell properly, was unable to demonstrate proper safety while using assistive devices, and was unable to show proper sitting or standing balance or sufficient strength and correct posture in sitting and standing. A care plan revised on 6/22/15, developed for Resident 1's risk for falls/injury related to poor balance, poor safety awareness/judgment, and history of falls, included in the interventions to observe the resident frequently, keep call light within easy reach, provide safety instruction regarding ambulation, transfers and activities of daily living (ADLs).A care plan revised on 6/22/15, developed for Resident 1's self-care deficits, and need of extensive assistance with transfers, toilet use, and personal hygiene, included in the approaches to provide a safe environment, and assist with ADLs as needed. According to the Change of Condition form dated 7/29/15, timed at 10:10 a.m., Resident 1 was up in a shower chair with a seat belt with the assigned Certified Nursing Assistant (CNA 1), who wheeled the resident to the bathroom. The resident was instructed by CNA 1 to call while CNA 1 went to get linen. CNA 1 walked away to answer a call light in another room. At 10:24 a.m., a visiting hospice nurse found Resident 1 lying on the floor in the bathroom. A Registered Nurse supervisor (RN 1) assessed the resident and the resident denied pain. At 10:32 a.m., the resident was given a shower and taken back to room at 10:47 a.m. and Tylenol 325 milligrams (mg) two tablets were given to the resident for comfort. The physician was notified and ordered an X-ray of the back.A nursing note, dated 7/29/15, timed at 5 p.m., indicated the X-ray reported an acute moderate compression fracture of T-12. The director of nursing (DON) called the physician's office about the x-ray result and the secretary took the message for the on call physician. At 7:30 p.m., the on call physician called back and ordered to transfer the resident to a general acute care hospital (GACH) for evaluation; but the family decided to have the resident transferred the following day.According to the medication administration record (MAR) on the day of the fall, 7/29/15, Resident 1 at 5 p.m., complained of back pain rated 10/10 (scale of zero to 10, zero indicating no pain and 10 indicating the worst possible pain) and was given two tablets of Tylenol 325 mg. At 9 p.m., Resident 1 complained of back pain rated 10/10 and was given two tablets of Tylenol 325 mg.The MAR further indicated that on 7/30/15, at 2 a.m., the resident had back pain (not rated) and was two tablets of Tylenol 325 mg. At 9 a.m. the resident had back pain rated 8/10 and was given two tablets of Tylenol 325 mg.On 7/30/15, at 10:45 a.m., Resident 1 was transferred to the GACH. A review of the x-ray report from the GACH dated 7/30/15 indicated T-12 compression fracture and 50% wedging deformity of T-12. The same day, 7/30/15, the resident returned to the facility at 6:45 p.m. requiring log rolling technique (a method of turning patients when the spine must be maintained in alignment. Two persons use a sheet to turn the patient as a unit) for repositioning.On 8/11/15, at 11:04 a.m., during an interview, PT 1 stated Resident showed no signs of improvement from the therapy. On 8/11/15, at 11:39 a.m., during an interview, CNA 1 stated on the day of Resident 1's fall incident (7/29/15), she took the resident to the bathroom on a shower chair (a wheeled chair with a toilet shaped seat that can fit over a toilet) and stayed with the resident for about two minutes, she then heard a call light (from another room) and walked out of Resident 1's room, leaving the resident alone. CNA 1 went to a room across the hall to attend to another resident. While CNA 1 was in the other resident's room, she heard another CNA (CNA 2) call out to her telling her Resident 1 was found on the floor. CNA 1 stated she was not supposed to leave Resident 1 in the restroom alone, but was concerned the other resident across the hall needed help also. On 8/11/15, at 12:05 p.m., during an interview, CNA 2 stated she was making a resident's bed when someone down the hall called out that Resident 1 was on the floor. CNA 2 then told CNA 1 Resident 1 fell. CNA 2 stated residents were not to be left alone while sitting in the shower chair and there should always be one person with the resident, even if another call light is ringing. On 8/11/15, at 12:11 p.m., during an interview, LVN 1 stated she was told Resident 1 was on the floor and found the resident lying between the doorways of the bathroom. RN 1 was already in the room. The resident was responsive and had no visible injuries. LVN 1 gave the resident Tylenol 650 milligrams for possible pain. LVN 1 further stated a nurse should always be with the resident while the resident is sitting in a shower chair. On 9/10/15, at 1 p.m., an interview and observation with Resident 1 was conducted with the assistance of a translator. Resident 1, who was alert and was able to recall the details of the fall incident, stated the nurse (CNA 1) left her alone and left the restroom door open, When she was done in the restroom, she yelled out for help several times, but no one came. After yelling out for help, she stood up, grabbed the grab bar along the wall, felt dizzy and fell back on the floor, hitting her back and buttocks on the floor. The resident further indicated she grabbed a pink pitcher and started banging it on the floor to get someone's attention. The resident denied having a seat belt while in the shower chair. The resident was asked to demonstrate to release a seat belt but did not know how to remove it. Resident 1 stated this was the first time she was left alone in the restroom.The facility failed to ensure that the resident environment remained as free of accident hazards as possible and that Resident 1, who was assessed as risk for falls, received adequate supervision and assistance devices to prevent accidents including: 1. Failure to ensure Resident 1 was supervised and assisted while sitting on the toilet. 2. Failure to implement the plan of care interventions to provide assistance with toilet use and provide a safe environment As a result, Resident 1 suffered a fall on 7/29/15, with a fractured thoracic vertebra (T-12 - the mid-back spine), when she got up from the toilet, after being left unattended and nobody responded to her calls for assistance. Resident 1 developed severe pain to the mid-back area, was transferred to an acute care hospital on 7/30/15 and returned to the facility on the same day requiring log rolling technique (method of turning when the spine must be maintained in alignment. Two persons use a sheet to turn the patient as a unit) for repositioning.The above violation 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 1. |
| 970000005 |
BRIER OAK ON SUNSET |
920012216 |
A |
01-May-16 |
TP4J11 |
9108 |
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.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 1/29/16, at 4 p.m., an unannounced visit was made to the facility to investigate an entity reported incident regarding Resident 1 sustaining a fall outside the facility which resulted in a dislocation and fracture (break) of a previously fractured left shoulder. Based on observation, 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 and failed to ensure Resident 1, who was assessed as high risk for falls due to history of falls and fractures, physical limitations, unstable balance, diagnoses, and in need of one-person assistance for transfer and walking, was provided with supervision, assistance, and an environment free of accident hazards as possible to prevent fall and injuries by failing to: 1. Provide supervision during ambulation as per care plan and physical therapy recommendation 2. Provide assistance during walking as necessary as per care plan and physical therapy recommendation 3. Implement the facility?s policy on Transportation and Escort outside the facility to ensure safety.On 1/20/16 Resident 1 was sent unaccompanied to an appointment at a medical office building and at the end of the appointment approximately at 4 p.m., while walking alone outside the building waiting for the transportation, Resident 1 missed two steps and fell on her left side sustaining a left humeral neck fracture, a left shoulder dislocation, an abrasion of the right knee, bruising of the left eyebrow, discoloration on the left shoulder, and had pain on the right knee, left side of the face, and left shoulder.According to the Admission Face Sheet, Resident 1 was admitted to the facility on 11/16/15, with diagnoses including history of falls, difficulty walking, generalized muscle weakness, and previous fractures of the left shoulder, the right radius (forearm), left humerus (the long bone on the upper arm), and dislocation of an unspecified shoulder joint.A review of the Fall Risk Review dated 12/1/15 indicated Resident 1 had unsteady gait/balance due to lower extremity weakness, history of falls in the last 30 days, factures due to falls, and diagnoses of hypertension and urinary tract infection. The Fall Risk Review indicated Resident 1 was at high fall risk.The Minimum Data Set (MDS - a care planning and assessment screening tool) assessment dated 12/10/15 indicated Resident 1 had no memory problem and was able to make decisions, required limited assistance with one-person physical assistance for transfer and walking, and used a wheelchair as a mobility device.The care plan dated 12/14/15 developed for the resident?s risk for falls had a goal for the resident not to have falls with injury. The interventions included assisting Resident 1 with ambulation and the use of a walker.The resident had physical therapy from 12/1/15 to 12/31/15. According to the Physical Therapy Discharge Summary dated 12/31/15, Resident 1 was to safely ambulate on level surfaces, with supervision. Physical therapy referred the resident to the restorative nursing program for maintenance.The Restorative Nursing Referral dated 12/31/15, indicated to provide Resident 1 restorative nursing services for supervised ambulation as tolerated five times a week without the use of an assistive device.The physician?s order and nursing notes indicated on 1/20/16 at 2 p.m., Resident 1 had an appointment at an outside facility for a CT (computerized tomography- radiologic test) scan of the left shoulder. A Transportation Service Request Form for the CT scan appointment, indicated in the section Information for Transportation Set Up Resident 1 was ambulatory (no assistance or supervision when walking was indicated), did not need assistive devices (wheelchair or walker), and was able to transfer self safely (no assistance during transfers was indicated).According to the nursing note documentation on the SBAR (Situation Background Assessment Request) Post Fall form dated 1/21/16 timed at 11 a.m., Resident 1 reported that on 1/20/16 (the day before) at 4 p.m., she fell on the concrete outside the building where she had the appointment. The resident stated she walked outside the building, missed two small steps, fell to the concrete and hit the left side of her face and left shoulder. Resident 1 stated she was assisted by a stranger to get up. The assessment indicated the resident sustained injuries including abrasion of the right knee, bruising of the left eyebrow, discoloration on left shoulder, and had pain on the right knee, left side of the face, and left shoulder. Physician 1 was informed and ordered x-rays of the left shoulder, right knee and face.According to the Radiology Detail Report dated 1/22/16, Resident 1 had an anterior (frontal) shoulder dislocation (joint out of position). A nursing note dated 1/22/16, timed at 11 p.m., indicated Physician 1 was informed of the x-ray results and ordered transfer to a general acute care hospital (GACH) for further evaluation of the left shoulder. Resident 1 was transferred to the GACH on 1/23/16 at 2:25 a.m. On 1/23/16, x-ray to the left shoulder performed at the GACH indicated the resident had in addition to the left shoulder dislocation, an acute fracture of the surgical neck of the humerus. On 1/29/16, at 3 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated that on 1/20/16, Resident 1 went out of the facility to an appointment, unaccompanied by a transportation van. LVN 1 stated upon the resident's return from the appointment she was medicated for complaints of pain in the left shoulder and went to bed.During an observation, on 1/29/16, at 3:30 p.m., Resident 1 was observed ambulating in the hallway with an unsteady gait, her left arm was noted in a sling, and a light green discoloration was noted above the resident's left eye. During a concurrent interview, Resident 1 stated she was at the imaging center for an appointment, waiting alone for transportation. As the resident walked to go check for transportation, she tripped over two small steps, and fell to the ground, hitting her left shoulder, face, and knee. Resident 1 stated a person passing helped her up from the ground and the pain in her left shoulder and right arm became worse. Resident 1 stated she noticed a scrape over her left eye later, after she returned to the facility.During an interview, on 2/4/16, at 11:45 a.m., Physical Therapist 1 (PT 1) stated Resident 1 was able to ambulate around 200 feet on a level surface with supervision. PT 1 stated the resident had stair training with the hand rail and supervision. PT 1 also stated Resident 1 should have been supervised when ambulating.A review of the facility's policy titled, "Transportation and Escort: Patient," dated 9/1/13, indicated the staff may escort patients, if needed, to assure patient safety.the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being and failed to ensure Resident 1, who was assessed as high risk for falls due to history of falls and fractures, physical limitations, unstable balance, diagnoses, and in need of one-person assistance for transfer and walking, was provided with supervision, assistance, and an environment free of accident hazards as possible to prevent fall and injuries by failing to: 1. Provide supervision during ambulation as per care plan and physical therapy recommendation 2. Provide assistance during walking as necessary as per care plan and physical therapy recommendation 3. Implement the facility?s policy on Transportation and Escort outside the facility to ensure safety.On 1/20/16 Resident 1 was sent unaccompanied to an appointment at a medical office building and at the end of the appointment approximately at 4 p.m., while walking alone outside the building waiting for the transportation, Resident 1 missed two steps and fell on her left side sustaining a left humeral neck fracture, a left shoulder dislocation, an abrasion of the right knee, bruising of the left eyebrow, discoloration on the left shoulder, and had pain on the right knee, left side of the face, and left shoulder.The above violation presented either (1) imminent danger that death or serious harm to the resident of the Skilled Nursing Facility would result therefrom, or (2) substantial probability that death or serious physical harm to the resident of the Skilled Nursing Facility would result therefrom. |
| 920000021 |
BROADWAY MANOR CARE CENTER |
920012323 |
A |
14-Jun-16 |
8UCX11 |
6910 |
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. 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 March 11, 2016, at 1:30 p.m., an unannounced visit was made to the facility to investigate a complaint regarding Resident 1 sustaining a bump (swelling) on the back of the head from unknown origin.Based on interview and record review, the facility failed to provide the necessary care and services and ensure the resident environment remained as free of accident hazards as possible and that Resident 1, who was assessed as requiring extensive assistance during transfers and required two-person assistance with the use of a stand up machine/lift device, received adequate supervision and assistance devices to prevent accidents, including: 1. Failure to provide support of two-person physical assistance during transfers using the stand-up machine/lift device. 2. Failure to revise the plan of care reflecting the use of the stand-up machine/lift device and the need of two-person assistance when transferring Resident 1, to reduce risks and prevent accidents 3. Failure to implement the facility?s policy and procedure on Resident Lifting/Assisting Transfer. As a result, Resident 1 hit the back of her head with the back rest of the shower chair when Certified Nursing Assistant 1 (CNA 1), without the help of another staff, transferred the resident from the stand-up machine/device to the shower chair. Resident 1 sustained swelling with discoloration on the right dorsal parietal (right-back side) area of the head.According to the admission record, Resident 1 was initially admitted to the facility on June 3, 2013, and re-admitted on December 14, 2016, with diagnoses including anemia (a reduced number of red blood cells accompanied by paleness, weakness and breathlessness), dementia (severe impairment or loss of intellectual capacity and personality integration), and abnormalities of gait and mobility. The Minimum Data Set (MDS ? standardized assessment and care planning tool) dated December 17, 2015, indicated Resident 1 was able to express ideas and wants and able to understand verbal communication from others. The MDS indicated Resident 1 required extensive assistance with activities of daily living (ADLs) such as transfers, bed mobility, personal hygiene and bathing.A care plan was developed on July 16, 2014, last revised on August 28, 2015, addressing Resident 1?s self-care deficit and requiring extensive assistance with ADLs. The interventions included assisting the resident with ADLs and providing the resident a safe environment. The care plan did not include the use of the stand-up device when transferring Resident 1. The care plan was not revised since August 28, 2015, five months prior to the head injury. According to the situation background assessment (SBAR) form, completed by registered nurse (RN) 1 on February 25, 2016, at 10 a.m., Resident 1 was assessed at 8:50 a.m.., with a right dorsal parietal swelling with discoloration. An ice pack was applied to the site and RN 1 called and left a message to the attending physician. RN 1?s documentation did not include size/measurement of the swelling. Resident 1 was placed on 72 hours neurology monitoring (level of consciousness, motor and sensory assessment) from February 25, 2016, until February 28, 2016, at 8:45 a.m., a total of three days.According to the facility's investigation of the incident, on February 25, 2016, at 8:50 a.m., CNA 1 transferred Resident 1 from the stand up machine to the shower chair without the help of another staff member. During the transfer, Resident 1's head bumped on the back of the shower chair. On March 11, 2016, at 2:30 p.m., during an interview, the morning shift RN Supervisor (RN 1) stated Resident 1 required total care and needed a two person assist when using the stand-up machine, in accordance with the facility?s policy.On March 15, 2016, at 2:30 p.m., during a telephone interview, CNA 1 stated on February 25, 2016, at 8:50 a.m., she used the stand-up machine to transfer Resident 1 to the shower chair. CNA 1 stated during the transfer Resident 1 accidentally bump her head at the back of the shower chair. CNA 1 stated she discovered the swelling when she was combing the resident's hair after the shower. CNA 1 stated she should have called for help when she transferred the resident..A review of the employee file indicated CNA 1 was suspended for five days starting February 25, 28, 29 and March 1 and 2, 2016, as a result of the incident with Resident 1. A review of the facility's policy titled, "Resident Lifting/Assisting Transfer," updated on February 26, 2014, indicated no resident lift or assisted transfers would be attempted without using a Vander Lift, an Invacare Lift, or a Hoyer Lift.The facility failed to provide the necessary care and services and ensure the resident environment remained as free of accident hazards as possible and that Resident 1, who was assessed as requiring extensive assistance during transfers and required two-person assistance with the use of a stand up machine/lift device, received adequate supervision and assistance devices to prevent accidents, including: 1. Failure to provide support of two-person physical assistance during transfers using the stand-up machine/lift device. 2. Failure to revise the plan of care reflecting the use of the stand-up machine/lift device and the need of two-person assistance when transferring Resident 1, to reduce risks and prevent accidents 3. Failure to implement the facility?s policy and procedure on Resident Lifting/Assisting Transfer. As a result, Resident 1 hit the back of her head with the back rest of the shower chair when CNA 1 without the help of another staff, transferred the resident from the stand-up machine/lift device to the shower chair. Resident 1 sustained swelling with discoloration on the right dorsal parietal area of the head.The above violation presented either (1) imminent danger that death or serious harm to the resident of the Skilled Nursing Facility would result therefrom, or (2) substantial probability that death or serious physical harm to the resident of the Skilled Nursing Facility would result therefrom. |
| 970000005 |
BRIER OAK ON SUNSET |
920012324 |
B |
14-Jun-16 |
5PHO11 |
8398 |
F-223 483.13 (b) Free from Abuse/Involuntary SeclusionThe 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.On 4/26/16, at 10:20 a.m., an unannounced visit was made to the facility to investigate an entity self-reported incident of verbal abuse. Based on interview and record review, the facility failed to ensure Resident 1 had the right to be free from verbal abuse by Escort 1 during a visit to a doctor?s office on 4/19/16. As a result, Resident 1 was shaking, crying, and afraid of Escort 1.A review of Resident 1's clinical record indicated an admission to the facility dated 2/2/16, with diagnoses including low back pain, muscle wasting and atrophy (complete or partial wasting away of a part of the body), difficulty walking, and anxiety (nervousness) disorder.The resident?s medication regimen included Xanax (used anxiety and panic disorder) 2 milligrams (mg) twice a day, Amlodipine (to treat high blood pressure) 5 mg daily, acetaminophen (analgesic to treat pain) 650 mg every four hours as needed for moderate pain, and Tramadol (narcotic to treat pain 50 mg every six hours as needed for severe pain. A review of Resident 1's admission Minimum Data Set (standardized assessment and care planning tool) dated 2/14/16, indicated Resident 1 was able to hear adequately, able to understand others and be understood. Resident 1's memory was intact and did not display any verbal or physical behaviors toward others. Resident 1 was independent or required only supervision and setup help for activities of daily living (ADLs).According to a written report by the administrator of an interview with Resident 1 on 4/19/16, Escort 1's inappropriate behavior started at the facility, when Resident 1 needed to sit at front, next to the driver of the transportation van. Escort 1 was upset about sitting in the back of the van and began yelling at Resident 1. Once they arrived at the medical office, Escort 1 yelled at Resident 1 in the elevator and continued into the medical office. Escort 1 continued to yell at Resident 1, which caused the medical office staff to come and tell Escort 1 to leave.During an interview, on 4/26/16, at 10:30 a.m., the social services designee (SSD) stated Resident 1 reported to her that Escort 1 was rude and yelled at her in front of other people during the medical appointment on 4/19/16. The SSD stated Escort 1 was provided by a contracted agency which provided transportation, drivers, and escorts as needed by the facility.A review of the Client Financial and Services Agreement form, dated 2/10/16, indicated the contracted agency, which employed Escort 1, and the skilled nursing facility, where Resident 1 resided, entered into an agreement where the agency was to provide qualified personnel for protective supervision, escort, and wheelchair transportation.A review of the contracted agency's Caregiver Job Description, undated, indicated an essential job function was transportation and to drive the client to his /her doctor?s appointment and to ensure the client rights were well-respected and maintained. The Job Description form indicated employees must possess the ability to deal tactfully and respectfully with staff co-workers and clients, and must display courteous behavior towards clients and fellow caregivers.On 4/26/16, at 2:45 p.m., during an interview, Resident 1 stated she was upset about sitting in the back of the van and requested to sit in the front seat of the transportation van. Resident 1 stated Escort 1 started cursing at her when they were in the elevator of the medical office building. When she returned to the waiting area from one of the doctor?s appointments, she mentioned to the medical office staff she did not want to return to the facility with Escort 1. Resident 1 stated at that time Escort 1 stood over her while she was in her wheelchair and started screaming and cursing at her. The doctor?s office staff told Escort 1 to leave and took Resident 1 back into the office area. Resident 1 stated she was scared and was shaking after the incident. Resident 1 stated the medical office arranged for another transportation van to take her back to the facility. During a telephone interview, on 4/26/16, at 1:50 p.m., Escort 1 stated the driver of the van assisted Resident 1 out of the van and into her wheelchair and pushed her into the building. Escort 1 stated there was a little disagreement with the driver and herself (Escort 1), about the driver not wanting to give his telephone number to call once the appointment ended. Escort 1 stated the medical office staff heard the disagreement, but there was no yelling. Escort 1 stated there was some problem setting up another medical appointment for Resident 1 and she stepped out of the office to bring down the situation. While outside she heard Resident 1 tell the office staff that she (Escort 1) was stupid. Escort 1 staid she went back in the office to clarify the situation and Resident 1 told the office staff she did not want to go back with Escort 1. The office staff took Resident 1 back into the office area and Escort 1 stated she left.On 4/27/16, at 10:50 a.m., a telephone interview was conducted with Medical Office Manager 1 (Manager 1). Manager 1 stated when Escort 1, Resident 1, and the driver, first entered the office, she saw there was tension between Escort 1 and the driver. Escort 1 was yelling at the driver to give her his telephone number and grabbed at his badge. The driver appeared nervous, and Manager 1 intervened and told Escort 1 they would call for transportation after the appointments were completed. Escort 1 waved her off and stated, ?I?m glad you think you have it figured.? Escort 1 sat down mumbling, while Resident 1 entered for the medical appointment.Manager 1 stated after Resident 1 finished one of her doctor?s visits, the resident went to the waiting area. While in the waiting area, Resident 1 told Escort 1 she did not want to be in the car with her. Escort 1 told Resident 1 she would be waiting for her downstairs and you figure out how to get down there. Resident 1 stated to the office staff that Escort 1 was calling her names and at that point Escort 1 comes back in the office and pushes the door open and almost hits Resident 1's wheelchair. Manager 1 stated they both started yelling and screaming at each other. Escort 1 yelled at Resident 1, asking, ?What are you going to do? What are you going to do?? mocking Resident 1. Escort 1 was waving her arm and posturing, like she was going to do something. Manager 1 stated another office staff had to get in between them because they look like they might start to fight.Manager 1 stated Escort 1 told Resident 1 while laughing, ?I'll wait for you downstairs, we will see.? Manager 1 told Escort 1 to leave, and security was called. Manager 1 stated Resident 1 was crying, and that she did not want to go back with Escort 1. The office staff took Resident 1 out a different exit and called for another transport to take her back to the facility.A review of the facility policy and procedure titled, "Transportation and Escort: Patient," revised 9/1/13, indicated the facility would contract for transportation services to provide transportation of patients for scheduled appointments. The policy indicated the purpose was to assure patient?s safety.A review of the facility policy and procedure titled, "Abuse Prohibition," revised 5/1/16, indicated abuse was the willful infliction of mental anguish or the willful deprivation by a caretaker of services which are necessary to maintain mental health. The policy indicated verbal abuse was any use of oral or gestured language that willfully included disparaging and derogatory terms to patients regardless of their age, ability to comprehend, or disability.The facility failed to ensure Resident 1 had the right to be free from verbal abuse by Escort 1 during a visit to a doctor?s office on 4/19/16. As a result, Resident 1 was shaking, crying, and afraid of Escort 1. The above violation had direct or immediate relationship to the health, safety, or security of Resident 1. |
| 970000005 |
Brier Oak on Sunset |
920013109 |
A |
12-Apr-17 |
4FGV11 |
12650 |
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.
On February 16, 2017 at 10 a.m., during an unannounced annual recertification survey made to the facility, Resident 1?s wound treatment to the scalp (skin covering the head) on the upper/front area of the head was observed.
Based on observation, interview and record review, the facility failed to ensure its residents 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, and failed to ensure residents with diagnoses of malnutrition, muscular atrophy, and vascular diseases, received and were provided with the necessary care and prompt interventions to prevent complications, including:
1. Failure to conduct ongoing accurate assessments of the resident?s skin condition to the scalp and report those changes to the registered nurse (RN 1) and the physician in a timely manner.
2. Failure to implement Resident 1?s plan of care for skin breakdown.
3. Failure to follow the facility's Job Description for the position of Dietitian Category III, revised August 9, 2012, for the dietitian to assesses the residents? nutritional status, monitor and evaluate effectiveness of nutritional interventions, and recommend interventions and follow-up.
4. Failure to implement the facility?s policy, dated March 1, 2016, titled, "Nursing Documentation,? to document and communicate pertinent and accurate information of the residents? condition.
5. Failure to identify origin of a skin injury, scratching and itchiness, in order to develop and implement interventions to prevent further skin problems and promote wound healing.
As a result, by February 18, 2017, Resident 1?s wound to the frontal scalp deteriorated, increased in size, and developed infection requiring additional treatment.
On February 16, 2017 at 10 a.m., a wound care observation for Resident 1 with Licensed Vocational Nurse 3 (LVN 3) was conducted. Resident 1?s frontal scalp wound dressing had a small amount of blood stain; the wound had a red scab measuring eight (8) centimeters (cm) in length by 8 cm in width (8x8); there was no hair around the scab area and the bald area measured approximately 15x15 cm. Part of the exposed scalp was yellowish with dry skin lifting off the scalp.
According to the admission record, Resident 1 was readmitted to the facility on XXXXXXXX, 2012, with diagnoses including muscle wasting and atrophy (decrease in muscle mass), protein-calorie malnutrition (lack of balance diet), chronic (long term) peripheral venous insufficiency (veins cannot pump enough blood back to the heart).
A review of the Minimum Data Set (MDS - comprehensive assessment and care-planning tool) dated December 8, 2016, indicated Resident 1 was able to make herself understood and understand others, and required extensive assistance from staff for bed mobility, transfer, dressing, personal hygiene and toilet use. The assessment indicated the resident did not have any skin tear.
On November 4, 2016, a plan of care was developed for the problem of actual skin breakdown related to a skin tear on the top of the resident's head, had a goal for the wound would heal in 14 days as evidenced by decrease in size, absence of erythema (redness) and drainage, and presence of granulation (new tissue in the healing surface of a wound). The interventions included evaluating the wound area daily including surrounding tissue for presence or absence of drainage/infection, and wound pain; monitoring effectiveness and/or side effects of medication; reporting to the physician as indicated; obtaining dietitian consult as needed/ordered; and conducting and weekly wound assessment to include measurements and description of wound status.
A Change in Condition - Skin report dated November 4, 2016, indicated the resident had a skin tear on the top of the head, no skin measurement, medications did not appear to be contributing to a change in condition, and the resident was assessed with no complaints of pain. The physician was made aware and orders were received to cleanse with normal saline, pat dry, apply hydrogel, and cover with dry dressing daily. There was no documentation to indicate the possible causes of the injury and there was no interview with the resident regarding the origin of the wound.
There was no documented evidence Resident 1?s wound treatment order was modified (changed) from November 4, 2016 to February 16, 2017.
A review of Resident 1's Non-Pressure Ulcer Weekly Skin and Wound Report for the scalp skin tear indicated the following:
-From November 11, 2016 to December 2, 2016, the skin tear measured 2x2 cm.
-From December 9, 2016 to December 30, 2016, the skin tear measured 1x1 cm with no infection or bleeding.
-From January 6, 2017 to February 10, 2017 - the skin tear was not measured. On January 6, 2017, the report indicated the wound was healing.
A review of Resident 1?s Physician Progress Notes from January 2016 to January 2017 had no documentation addressing the resident?s skin condition.
The Non-Pressure Ulcer Weekly Skin and Wound Reports had no ongoing description of the wound bed, surrounding tissues, color, presence or absence of drainage, progress, and response to treatment.
A review of Resident 1's Pre-Albumin level (indicator of nutritional status and a preferred marker for malnutrition) dated April 7, 2016, indicated 13 milligrams/deciliter (mg/dL), below the reference range 17 - 34 mg/dL.
Resident 1?s Nutritional Assessment dated December 15, 2016, completed by a registered dietitian (RD), indicated the skin problem field of the assessment was left blank. The summary field indicated Resident 1 was receiving a protein supplement daily, there was no skin breakdown noted, and there were no recent laboratory tests to assess and no further assessment was needed.
On February 16, 2017 at 11:05 a.m., during an interview and review of Resident 1?s Non-Pressure Ulcer Weekly Skin and Wound Reports from January 6, 2017, to February 10, 2017, with LVN 3, she stated the documentation did not reflect Resident 1's scalp wound condition. LVN 3 stated "Yes, measurements are important; it will tell if the wound is healing."
On February 16, 2017 at 12:30 p.m., during an interview, the Director of Nursing (DON) stated the Interdisciplinary Team's (IDT, a group of health care professionals from diverse fields working in a coordinated fashion toward a common goal for the resident) the last care plan conference meeting for Resident 1 was on February 17, 2016 and the resident's skin condition was not discussed and no one was supervising wound care at that time.
On February 16, 2017 at 4:40 p.m., during an interview, RD 1 stated the assessment dated December 15, 2016, was based on weekly reports generated by the treatment nurses, electronic charting and review of the hard copy of the chart. RD 1 stated she had not seen or spoken to the resident. RD 1 stated that the resident did not have a current Pre-albumin level to identify if the Pre-Albumin level of 13 mg/dL dated April 7, 2016 had improved and/or to identify if the protein supplement was effective.
On February 16, 2017 at 5:25 p.m., during an interview with both the DON and RD 1, the DON stated that, "Unfortunately the facility has issues with poor assessments." As the DON was reading Resident 1's Weekly Skin Progress Notes, she stated, the notes do not say too much. The DON stated the IDT should have notified the physician. RD 1 stated she should have recommended laboratory tests to evaluate the resident?s nutritional status.
A review of Resident 1?s Surgical Consult (Physician 2) dated February 18, 2017, indicated the reason for the consult was to manage Resident 1's burn tissue to left frontal scalp with a skin lesion (wound). According to the Consult the resident reported she had been scratching her (head) with the use of her remote control. The wound consult indicated the resident had a left frontal scalp burn, with purulent (forming pus) drainage, with smooth pink granulated (new formation) tissue present, connected by a bed of epithelial (one or more layer of cells) tissue to unstable black eschar (a dry scab) beneath a shaven scalp area, with mild purulent drainage, no odor, non-erythematous (no redness of the skin), with 15% granulation 15% eschar, and 70% epithelial tissue. The wound measured 5.5 cm in length, 9.6 cm width, 0.1 cm depth, 52.8 cm wound area. The scalp condition included seborrheic dermatitis (a skin disorder affecting the scalp, face, and torso), crusts, dry, scaly scalp tissue that is non-erythematous.
Physician 2 ordered:
1. Cleanse left frontal scalp burn with normal saline, pat dry, apply Silvadene cream (antibiotic used to treat or prevent infections on areas of burned skin), 1% cover with dry dressing daily times 14 days.
2. Selenium Sulfide (an anti-infective agent, relieves itching and flaking of the scalp) 2.25 % shampoo-wash scalp three times per week times one month.
3. Hydroxyzine Hydrochloride 25 milligrams (mg - to treat itching caused by allergies) orally twice daily for 30 days.
The plan of treatment goals were wound stabilization, prevention of wound decline, creation of a wound healing bed and reduction of infected tissues.
On February 28, 2017, at 8:15 a.m., during a telephone interview with Resident 1?s physician (Physician 1), when asked about the lack of reference regarding the scalp wound in the progress notes, Physician 1 stated he was being told by the facility licensed staff that the resident?s wound condition was progressing well.
A review of the facility's Job Description for the position of Dietitian Category III, revised August 9, 2012, indicated the dietitian assesses the nutritional status of residents per standards of practice, monitors and evaluates effectiveness of nutritional interventions, ensures appropriate and timely documentation of nutrition assessment tools, recommended interventions and follow-up. Addresses appropriate nutrition concerns with all members of the interdisciplinary team.
A review of the facility's policy and procedure, reviewed on March 1, 2016, titled, "Nursing Documentation," indicated nursing documentation will follow the guidelines of good communication and be concise, clear, pertinent, and accurate. The purpose of the documentation is to communicate patient's status and provide accurate accounting of care and monitoring provided.
The facility failed to ensure its residents 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, and failed to ensure residents with diagnoses of malnutrition, muscular atrophy, and vascular diseases, received and were provided with the necessary care and prompt interventions to prevent complications, including:
1. Failure to conduct ongoing accurate assessments of the resident?s skin condition to the scalp and report those changes to the registered nurse (RN 1) and the physician in a timely manner.
2. Failure to implement Resident 1?s plan of care for skin breakdown.
3. Failure to follow the facility's Job Description for the position of Dietitian Category III, revised August 9, 2012, for the dietitian to assesses the residents? nutritional status, monitor and evaluate effectiveness of nutritional interventions, and recommend interventions and follow-up.
4. Failure to implement the facility?s policy, dated March 1, 2016, titled, "Nursing Documentation,? to document and communicate pertinent and accurate information of the residents? condition.
5. Failure to identify origin of a skin injury, scratching and itchiness, in order to develop and implement interventions to prevent further skin problems and promote wound healing.
As a result, by February 18, 2017, Resident 1?s wound to the frontal scalp deteriorated, increased in size, and developed infection requiring additional treatment.
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. |
| 970000005 |
Brier Oak on Sunset |
920013110 |
A |
12-Apr-17 |
4FGV11 |
10616 |
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(i) Nutrition
Based on a resident?s comprehensive assessment, the facility must ensure that a resident--
?483.25(i) (1) Maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident?s clinical condition demonstrates that this is not possible; and
?483.25(i) (2) Receives a therapeutic diet when there is a nutritional problem.
Based on interview and record review, the facility failed to ensure its residents 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, and failed to ensure residents maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident?s clinical condition demonstrates that this is not possible and receive a therapeutic diet when there is a nutritional problem, including:
1. Failure to conduct ongoing nutritional assessment of Resident 1?s nutritional condition and nutritional needs to prevent weight loss.
2. Failure to review and revise Resident 1?s plan of care to develop effective interventions to prevent further weight loss.
3. Failure to provide Resident 1?s assistance with eating as indicated in the comprehensive assessment.
4. Failure to implement the facility?s policy, dated November 18, 2016, titled, "Nutrition Care Progress,? to routinely assess residents? nutritional condition to ensure each resident receives timely, individual, and consistent nutritional care.
5. Failure to follow the physician?s order to monitor Resident 1?s weekly weights.
As a result, Resident 1 sustained an unplanned severe weight loss of 10 pounds (9.0 %) in one month (from August to September 2016) and a progressive weigh loss for a total of 19 pounds in six months from August 2016 to February 2017).
On February 15, 2017, at 9:30 a.m., during an unannounced annual recertification survey made to the facility, Resident 1 was observed in her bed able to communicate in a foreign language.
On February 24, 2017, at 7:55 a.m., Resident 1 was in bed having breakfast independently. At the time of the observation, the resident stated her family visited at times, but did not remember how often.
According to the admission record, Resident 1 was initially admitted to the facility on XXXXXXXX 2016, and readmitted on XXXXXXXX 2016, with diagnoses including anemia (blood lacks enough healthy red blood cells to carry oxygen), diabetes mellitus (a chronic condition of high blood sugar), and dysphagia (difficulty swallowing).
A review of the Nutritional Assessment dated February 8, 2016, completed by the registered dietitian (RD) indicated Resident 1 had an order for a consistent carbohydrate (one of several substances, such as sugar or starch, that provide the body with energy) diet with texture of dysphagia advanced (diet used with people who have problems with chewing and swallowing. This food should be moist and in bite-sized pieces). The Ideal Body Weight (IBW) ranged was 110 pounds to 130 pounds. The resident?s weight was 118 pounds upon admission. The Nutritional Assessment indicated the resident did not have swallowing problems, did not have weight gain or loss, and had poor to good oral intake. Resident 1 daily nutritional calorie needs were 1327 (kilocalorie ?kcal) and the protein needs were 64 - 75 grams. The oral intake was meeting 80% of the resident's estimated calorie needs and 50 - 60% of the resident?s protein needs.
A review of Resident 1's Weight Log indicated the following:
1. August 1, 2016 - 111 lbs.
2. September 9, 2016 - 101 lbs.
3. October 1, 2016 - 101 lbs.
4. November 1, 2016 - 99.2 lbs.
5. December 1, 2016 - 99 lbs.
6. January 8, 2017 - 93 lbs.
7. February 1, 2017 - 92 lbs.
According to the Centers for Medicare and Medicaid Services (CMS), the suggested parameters for evaluating significance of unplanned and undesired weight loss are:
Interval Significant Loss Severe Loss
1 month 5 % Greater than 5 %
3 months 7.5 % Greater than 7.5 %
6 months 10 % Greater than 10 %
A review of Resident 1?s Nutrition Progress Note dated September 15, 2016 completed by RD 1 indicated the resident lost 10 pounds (9%) in one month. The oral intake shows improvement, 75 - 100% in the past few days and previously 25 - 50 %. According to the note the resident was receiving a dysphagia puree diet and as per the family the resident disliked it. The note indicated house supplement would be added three times daily with meals. The note indicated the resident received Lasix (medication to decrease fluid accumulated in the body through urine) 40 mg daily for high blood pressure, and weight fluctuations was expected/potentially unavoidable, and continue monitoring. RD 1 did not address the resident?s food dislike and what strategies to utilize to increase the intake.
Resident 1 continued to progressively lose additional seven pounds resulting in significant weight loss by February 1, 2017, when the resident weighed 92 pounds, a total of 19 pounds since August 1, 2016 and 17 % weight loss in six months.
A review of the Minimum Data Set (MDS ? comprehensive assessment and care planning tool) dated February 6, 2017, indicated Resident 1?s cognitive (thinking, reasoning, or remembering) skills for daily decision-making were intact, required extensive assistance from the staff with eating, and had a weight loss and was not on weight loss regimen. However, on February 24, 2017, at 7:55 a.m., Resident 1 was observed having breakfast without staff assistance.
A care plan initially developed on February 8, 2016, for the resident?s nutritional risk problem and updated on November 7, 2016, due to the resident?s unintentional weight loss (10.8 pounds weight loss in three six months), poor oral intake of most meals, and requiring assistance with feeding, had a goal for the resident to consume at least 75% of the three meals daily. The interventions included to evaluate for proper consistency of diet, encourage resident to chew and swallow each bite, weigh weekly, times four weeks and alert the dietitian and physician to any significant loss or gain, monitor for changes in nutritional status (change in intake, ability to feed self, unplanned weight loss/gain, abnormal labs), and report to food and nutrition/physician as indicated, monitor intake at all meals, offer alternate choices as needed, alert dietitian and physician to any decline in intake.
A review of Resident 1's Activity of Daily Living Record for the month of August 2016 indicated the average meal percentage consumption for breakfast was 76%, for lunch 73%, and for dinner 60%. For the month of September 2016, the average meal percentage consumption for breakfast was 60%, for lunch 56%, and for dinner 60%.
Further record review revealed no documented interventions by nursing, RD or the interdisciplinary team (IDT) addressing the progressive weight loss, the continued poor intake, the resident?s need for assistance and/or cuing during meals, and the need for nutritional interventions to improve meal consumption and prevent further weight loss.
On February 24, 2017, at approximately 4:20 p.m., during an interview, the Director of Nursing (DON) stated a Change of Condition report had not been completed on September 9, 2016, when Resident 1 had a ten- pound weight loss. The DON stated that the nurse's notes were not clear if Resident 1's physician (Physician 1) was made aware of the weight loss. The DON, after reviewing the nursing notes, indicated that on January 12, 2017 (approximately four months after Resident 1 was identified with a severe weight loss) the physician was made aware of the resident?s weight change.
On January 17, 2017, Physician 1 ordered to monitor Resident 1?s weight weekly; however, by February 24, 2017, there was no documented evidence the resident?s weight were monitored weekly as ordered.
A review of the facility's policy and procedure, revised November 28, 2016, titled, "Nutrition Care Process," indicated residents are visited and assessed upon admission and routinely thereafter, to assure that each resident receives timely, individualized, and consistent nutritional care. Care plans are evaluated and updated a minimum of quarterly or as scheduled according to established policies.
The facility failed to ensure its residents 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, and failed to ensure residents maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident?s clinical condition demonstrates that this is not possible and receive a therapeutic diet when there is a nutritional problem, including:
1. Failure to conduct ongoing nutritional assessment of Resident 1?s nutritional condition and nutritional needs to prevent weight loss.
2. Failure to review and revise Resident 1?s plan of care to develop effective interventions to prevent further weight loss.
3. Failure to provide Resident 1?s assistance with eating as indicated in the comprehensive assessment.
4. Failure to implement the facility?s policy, dated November 18, 2016, titled, "Nutrition Care Progress,? to routinely assess residents? nutritional condition to ensure each resident receives timely, individual, and consistent nutritional care.
5. Failure to follow the physician?s order to monitor Resident 1?s weekly weights.
As a result, Resident 1 sustained an unplanned severe weight loss of 10 pounds (9.0 %) in one month (from August to September 2016) and a progressive weigh loss for a total of 19 pounds in six months from August 2016 to February 2017).
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. |
| 920000071 |
BURBANK HEALTHCARE AND REHABILITATION CENTER |
920013204 |
B |
17-May-17 |
None |
6938 |
F-224
? CFR 483.12 (b) (1-3) Prohibit mistreatment/neglect/misappropriation
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,
On 9/11/15, at 10 a.m., an unannounced visit was made to the facility to investigate a complaint and an Entity Reported Incident (ERI) regarding certified nursing assistant 1 (CNA 1) taking money and property from Resident 1.
Based on observation, interview, and record review, the facility failed to ensure its residents have the right to be free from misappropriation of resident property and exploitation and failed to implements its policy on abuse prevention including:
1. Failure to ensure CNA 1 was not making Resident 1 give her money and using Resident 1?s personal items.
2. Failure to ensure the facility?s policy on Abuse and Mistreatment of Residents by not adequately supervising and monitoring CNA 1 to identify occurrence of inappropriate behavior.
As a result, Resident 1 felt pressured by CNA 1 in giving her money, guilty about giving CNA 1 money that was never returned, manipulated and taken advantage of by CNA 1
Resident 1 was admitted to the facility on XXXXXXX14, with diagnoses that included anxiety, insomnia (difficulty sleeping), and depressive disorder (a persistent feeling of sadness and loss of interest).
A review of the resident's History and Physical (H&P) examination, dated by the attending physician on 9/26/14, indicated the resident had the capacity to understand and make decisions.
A review of the Minimum Data Set (MDS ? standardized assessment and care planning tool) dated 6/21/15, indicated Resident 1 was assessed with the ability to understand, and express ideas and wants with clear comprehension, with intact short and long-term memory.
According to the facility?s reported incident to the Department, Resident 1 reported on 9/8/15 that CNA 1 called her to the resident?s cellular telephone asking to borrow money.
On 9/11/15, at 10:08 a.m., during an interview, Resident 1 stated that at the end of April or early May 2015, CNA 1 visited her often in the resident's room, to talk. CNA 1 confided in the resident and shared stories about CNA 1's personal life. The resident stated CNA 1 told the resident she was having financial problems and did not have enough money to feed her family. Resident 1 felt bad and gave CNA 1 $20.00. Resident 1 thought CNA 1 would repay her but CNA 1 did not return the money. Resident 1 stated they exchanged cellular telephone numbers. CNA 1 made a call to the resident to tell her that she (CNA 1) was being evicted from her home. CNA 1 also told the resident she wanted to buy a gift for her boyfriend, but did not have any money to buy a gift. The resident felt badly and gave CNA 1 another $20.00.
Throughout the month of June, Resident 1 stated that CNA 1 (who was not assigned to care for her) visited almost every night, and used her personal facial moisturizer, body lotion, and body mist; products delivered from the resident's family. The resident stated CNA 1 started asking for more money that ended up being a total of about $100. In August 2015, CNA 1 asked for money from the resident to buy school uniform for her son. Resident 1 stated she became uncomfortable having CNA 1 in her even when the resident wanted to sleep. The resident then stated sometime early September 2015, CNA 1 asked for the resident's coin jar. The resident's coin jar contained quarters, dimes and nickels. CNA 1 then opened the resident's bedside drawer and took a dollar coin.
Throughout the interview, Resident 1 was observed to be teary-eyed and stated she felt guilty for giving CNA 1 money that was never returned and felt manipulated and taken advantage of.
On 10/9/15, at 9:50 a.m., an interview was conducted with Registered Nurse 1 (RN 1) who stated in the last six months, she witnessed Resident 1 and CNA 1 talking to each other during CNA 1's break. CNA 1 would be sitting and talking to Resident 1 and neglecting other residents. RN 1 stated she informed the DSD (Director of Staff Development) and the administrator in writing regarding CNA 1's actions. RN 1 stated Resident 1 approached her at the end of her shift, sometime early September 2015, regarding CNA 1 taking money from her and RN 1 informed the DSD right away.
On 9/11/15, at 1:50 p.m., during an interview, the DSD stated CNA 1 was terminated on 9/10/15.
A review of CNA 1's personnel file indicated no disciplinary actions against her, until the CNA was terminated on 9/10/15. Attempts were made to contact CNA 1 via telephone regarding the above incident, but there was no response.
A review of the facility's policy and procedure for Abuse and Mistreatment of Residents indicated the facility Administrator and/or designee shall ensure adequate supervision and monitoring of staff to identify any occurrence of inappropriate behaviors. Department Supervisors shall ensure that adequate supervision is being given and appropriate assistance extended to residents in need when performing their daily monitoring and rounds.
A review of the facility's policy and procedure for Abuse and Mistreatment of Residents indicated the facility Administrator and/or designee shall ensure adequate supervision and monitoring of staff to identify any occurrence of inappropriate behaviors. Department Supervisors shall ensure that adequate supervision is being given and appropriate assistance extended to residents in need when performing their daily monitoring and rounds.
The facility failed to ensure its residents have the right to be free from misappropriation of resident property and exploitation and failed to implements its policy on abuse prevention including:
1. Failure to ensure CNA 1 was not making Resident 1 give her money and using Resident 1?s personal items.
2. Failure to ensure the facility?s policy on Abuse and Mistreatment of Residents by not adequately supervising and monitoring CNA 1 to identify occurrence of inappropriate behavior.
As a result, Resident 1 felt pressured by CNA 1 in giving her money, guilty about giving CNA 1 money that was never returned, manipulated and taken advantage of by CNA 1
The above violation had direct or immediate relationship to the health, safety, or security of Resident 1. |
| 970000005 |
Brier Oak on Sunset |
920013217 |
A |
21-Jul-17 |
4FGV12 |
16014 |
F151
42 CFR ?483.10(a) Resident rights. The resident has a right to a dignified existence, self-determination, and communication with and access to person and services inside and outside the facility, including those specified in this section.
F224
42 CFR ?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.
42 CFR ?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,
42 CFR ?488.301 Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.
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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:
(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.
F501
?483.75(i) Medical Director
(1) The facility must designate a physician to serve as medical director.
(2) The medical director is responsible for ?
(i) Implementation of resident care policies; and
(ii) The coordination of medical care in the facility.
On April 25, 2017, at 7:40 a.m., during first revisit recertification survey Resident 1 condition status was investigated.
Based on observation, interview, and record review, the facility failed to ensure Resident 1 who was under hospice care (care designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure) was free of neglect and received sufficient care to alleviate suffering, by:
1. Failure to implement the Hospice Interdisciplinary Care Plan by not maintaining the Resident 1?s pain at a comfortable level through the administration of morphine sulfate (narcotic ? powerful pain medication) as ordered; and by not promoting optimal nutrition/hydration by evaluating alternative means when Resident 1 was unable to eat.
2. Failure to have interdisciplinary (IDT - a group of health care professionals from diverse fields) care conference to address Resident 1?s care needs due to swallowing difficulty and unable to eat or drink for six days.
3. Failure to implement the facility?s policy on Pain Management by not assessing, treating and evaluating Resident 1?s pain and restlessness.
4. Failure to provide oral (mouth) hygiene to Resident 1, who was unable to care for himself.
5. Failure to honor Resident 1?s wishes as indicated in his POLST (Physician Orders for Life-Sustaining Treatment) to allow natural death and comfort-focused treatment.
6. Failure to coordinate Resident 1?s care with the medical director to provide further clinical guidance and oversight of resident?s care when the resident continued to be nothing per mouth (NPO) from April 19 to 26, 2017 and there was no alternative nutritional intervention to ease the resident hunger and thirst.
As a result, Resident 1suffered undignified treatment, unnecessary abdominal pain, discomfort, signs and symptoms of dehydration (not sufficient body fluids) such as cracked lips, thick saliva, dried flakey white substance around the mouth and jaw, poor oral hygiene and thirst, instead of receiving comfort care at the end of life. Resident 1 expired in the facility on XXXXXXX17 at 1:40 a.m.
On April 25, 2017 at 7:55 a.m. during the initial tour of the facility, accompanied by Registered Nurse Supervisor 1 (RNS 1), Resident 1 was observed lying on a bed, wearing only an incontinent brief, and fidgeting around the bed (restless, not able to keep still in one position for one minute). The call light was hanging on the right side of the bed, not within the reach of the resident. Resident 1 was observed with cracked dry lips, and had a dried flakey white substance covering the left side of the mouth to his left lower jaw area. While Resident 1 was talking, very thick saliva was observed inside his mouth.
During an interview at the time of the observation Resident 1 stated he wanted to drink water. RNS 1 stated Resident 1 was under hospice care. RNS 1 stated the resident could verbalize his needs and follow simple commands. RNS 1 stated Resident 1 had an order for NPO and the resident could not have water. RNS 1 also stated that oral care should have been provided to the resident.
According to the Admission Record, Resident 1 was admitted to the facility on XXXXXXX 2017, with diagnoses that included pneumonia (lung inflammation caused by bacterial or viral infection), prostate (gland around the male bladder) cancer, and dysphagia (difficulty of swallowing).
According to the Admission Nursing Assessment dated April 19, 2017, Resident 1 was confused, had minimal difficulty in hearing, was unable to make significant changes in position independently, and needed extensive assistance from staff with bed mobility and transfer.
A review of Physician Order for Life-Sustaining Treatment (POLST) dated April 20, 2017, and signed by Resident 1?s responsible party, indicated to allow natural death and comfort-focused treatment.
A review of Resident 1?s Physician?s order dated April 19, 2017, indicated NPO diet and Piperacillin (antibiotic, a medicine that inhibits the growth of or destroys microorganisms) 3.375 gram intravenously every eight hours for pneumonia for one week.
A review of Resident 1's Physician's Order dated April 20, 2017, indicated the following:
1. NPO until further order.
2. Acetaminophen (pain medication) Suppository 650 milligrams (mg) every 6 hours as needed for general discomfort.
3. Lorazepam (for anxiety or nervousness) 0.5 mg by mouth every 4 hours as needed for restlessness.
4. Morphine Sulfate 5 mg sublingually (under the tongue) every 2 hours as needed for pain.
A review of the Hospice Interdisciplinary Care Plan dated April 20, 2017, indicated the goal was for the resident?s pain to remain at a comfortable level by the use of morphine sulfate every two hours as needed.
The plan of care also included promoting the resident?s optimal nutrition/hydration as the resident was NPO, but there were no interventions to obtain optimal nutrition/ hydration. There were no interventions to provide fluids for comfort, relieve signs and symptoms of impending dehydration, and hunger pain resulting from the resident?s inability to eat or drink due to swallowing problems.
A review of Resident 1's Hospice care plan developed by skilled nursing facility staff member initiated on April 25, 2017, indicated a goal for the resident to experience the highest practical quality of life throughout life journey in the next 90 days. The interventions included to assess for pain, restlessness, agitation, constipation and other symptoms of discomfort, medicate as ordered and evaluate effectiveness, and provide non-pharmacological approaches to aide in decreasing discomfort.
On April 25, 2017, at 2:00 p.m. during an interview with hospice registered nurse (HRN), HRN stated she admitted Resident 1 under hospice care on April 20, 2017. HRN stated that she is not aware if the hospice, family and the facility had a care plan meeting regarding Resident 1 plan of care. HRN stated she did not evaluate the NPO status of Resident 1 since April 20, 2017, and she will call the hospice case manager to arrange Resident 1 care conference.
On April 25, 2017, at 2:15 p.m. during an interview, RNS 1 stated Resident 1 was not receiving anything by mouth for six days and did not know why the resident did not have an intravenous fluid therapy (IVF - is the infusion of liquid substances directly into a vein, may be used for fluid administration) for hydration. RNS 1 further stated Resident 1 was receiving antibiotic through IV. RNS 1 stated she had called the resident's physician regarding IV fluid therapy or diet for Resident 1 but was unable to provide documentation of the call and the response from the physician.
On April 26, 2017 at 9:17 a.m., Certified Nursing Assistant 1 (CNA 1) was observed at Residents 1?s bed side. CNA 1 stated that resident kept moving and asking for water, but his NPO. Resident 1 was observed in fetal position (a body position in which the body lies curled up on one side with the head bowed and the legs and arms drawn in toward the chest) holding his abdominal area and restless. Resident 1 complained of having abdominal pain and was asking for water. The resident was observed with dried lips and tongue, and had thick saliva.
On April 26, 2017 at 10:15 a.m., Resident 1 was still complaining of abdominal pain and upon interview, was unable to quantify the level of pain for zero (no pain) to 10 (worst pain possible).
A review of the Medication Administration Record (MAR) from April 20 to 26, 2017 was reviewed with RNS 1. There was no documentation Resident 1 received or was administered any pain medication (acetaminophen or morphine) or lorazepam for the resident?s restlessness as ordered by the physician since April 20, 2017, a total of six days.
On April 26, 2017 at 9:24 a.m., during an interview, the Medical Social Worker (MSW) stated an IDT meeting was done on April 25, 2017, in the afternoon and was attended by nursing, social services, business office staff, and RP 1, who participated via telephone. The MSW stated the IDT discussed hospice and insurance coverage but hospice agency staff did not participate. The MSW stated the IDT meeting should have been conducted when the resident was placed on hospice care (April 20, 2017).
On April 26, 2017 at 10:43 a.m. during an interview, Responsible Party 1 (RP 1) stated she had a meeting with the facility staff via telephone and there was discussion about the insurance coverage but she did not remember discussing hospice or palliative treatment. RP 1 stated she was not well informed about hospice and palliative treatment, and wished someone in the facility explained it to her better. RP 1 stated she just wanted her husband to be comfortable and die peacefully.
On April 26, 2017, at 1:06 p.m. during an interview, Physician 1 (P1) stated that he is the hospice and the attending physician of Resident 1. P1 stated that Resident 1 was admitted at general acute care hospital (GACH) due to sepsis and pneumonia. P1 stated while Resident 1 was at GACH the resident was hydrated and had congested hydration overload and that is why the resident had no order for IV. P1 stated that Resident 1 was not in distress and will order a swallow evaluation and present this to family if the family still wants the resident to have food or water even though the resident might aspirate.
On April 26, 2017, at 3:30 p.m., during an interview, the Director of Nursing (DON) stated she expected the licensed nurses to assess the resident for pain and comfort. The DON stated a pain medication should have been given to Resident 1. The DON stated there was no care plan to address the resident?s NPO status.
A review of facility policy titled "Pain Management" revision date November 28, 2016, indicated the purpose of the policy was to maintain the highest possible level of comfort for patients by providing a system to identify, assess, treat, and evaluate pain. Center staff will report any observation or communication of pain to the nurse responsible for that patient (resident).
A review of Resident 1?s Certificate of Death indicated Resident 1 expired on April 29, 2017, at 1:40 a.m., and the immediate cause of death was cardiopulmonary arrest.
On June 28, 2017, at 12:20 p.m., during an interview with the facility?s Medical Director (MD), she stated she was called by the facility but not sure if the call was before or after the survey regarding an unclear concern about a hospice resident. MD stated she was in the facility (MD was not sure of the date) when the hospice physician walks in in the facility, she thought that everything was fine.
A review of October 4, 2016, revised facility?s Medical Director Job Responsibilities, stipulated Coordination of Medical Care ? direct and coordinate facility ? wide medical care. Resolve issues related to continuity of care and transfer of medical information between the facility and other care settings. Review individual resident cases as requested or indicated, including consultation recommendation.
A written agreement for the use of the outside resource hospice care provider was requested from the Administrator. The facility had no written agreement with the hospice agency providing care to Resident 1 in order to determine the responsibilities of each of the care providers (the skilled nursing facility and the hospice agency) and to integrate these care to ensure Resident 1 was provided with necessary comfort measures at the end of his life.
The facility failed to ensure Resident 1 who was under hospice care was free of neglect and received sufficient care to alleviate suffering, by:
1. Failure to implement the Hospice Interdisciplinary Care Plan by not maintaining the Resident 1?s pain at a comfortable level through the administration of morphine sulfate as ordered; and by not promoting optimal nutrition/hydration by evaluating alternative means when Resident 1 was unable to eat.
2. Failure to have interdisciplinary care conference to address Resident 1?s care needs due to swallowing difficulty and unable to eat or drink for six days.
3. Failure to implement the facility?s policy on Pain Management by not assessing, treating and evaluating Resident 1?s pain and restlessness.
4. Failure to provide oral hygiene to Resident 1, who was unable to care for himself.
5. Failure to honor Resident 1?s wishes as indicated in his POLST (Physician Orders for Life-Sustaining Treatment) to allow natural death and comfort-focused treatment.
6. Failure to coordinate Resident 1?s care with the medical director to provide further clinical guidance and oversight of resident?s care when the resident continued to be nothing per mouth (NPO) from April 19 to 26, 2017 and there was no alternative nutritional intervention to ease the resident hunger and thirst.
As a result, Resident 1 suffered undignified treatment, unnecessary abdominal pain, discomfort, signs and symptoms of dehydration such as cracked lips, thick saliva, dried flakey white substance around the mouth and jaw, poor oral hygiene and thirst, instead of receiving comfort care at the end of life.
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. |
| 940000047 |
BEL TOOREN VILLA CONVALESCENT HOSPITAL |
940009289 |
B |
09-May-12 |
IIYI11 |
8172 |
72311(a) (2) 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.On 6/20/11, at 10:15 a.m., an unannounced visit was made to the facility to investigate a complaint regarding an inappropriate transfer of Patient 1 from a chair to the bed resulting in a fractured right wrist. Based on observation, interview, and record review, the facility failed to implement Patient 1?s plan of care according to the methods indicated by failing to:1. Provide two persons physical assist during transfer from a recliner chair (Geri-chair) to the bed, as assessed and as documented in the plan of care. 2. Stop giving care when the patient was upset and attempt again when the patient was calm as stated in the plan of care. On 2/23/11, while Patient 1 was combative and refusing to be transferred from the chair to her bed and was holding her right hand inside an opening below the armrest of the Geri-chair, Certified Nursing Assistant (CNA) 1 transferred the patient resulting in the patient sustaining a right wrist fracture.On 9/7/11, at 5:40 p.m., Patient 1 was observed sitting in a Geri-chair unable to participate in an interview. On 9/7/11, a review of the clinical record revealed Patient 1 was a 79 years old female, initially admitted to the facility on 6/28/10, and readmitted on 11/17/10, with diagnoses including history of femur fracture, toe amputation, end stage renal disease on hemodialysis treatment, diabetes mellitus and dementia (loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior). The Minimum Data Set (MDS ? standardized assessment and care planning tool) dated 2/2/11, indicated the patient was disoriented, had memory problems, needed extensive assistance with one person physical assist with bed mobility, toilet use, personal hygiene and walking. The patient was assessed as requiring extensive assistance and two or more persons physical assist with transfers (between surfaces including to or from bed, chair or wheelchair).The patient?s medication regimen included the psychotropic (mind-altering) medications Namenda 5 milligrams (mg) orally twice a day for mental disorder dated 12/27/10, Trazodone 50 mg at bedtime for depression manifested by inability to sleep dated 11/30/11, and Ativan 0.5 mg every six hours as needed (PRN) for anxiety manifested by restlessness dated 11/17/10.A plan of care dated 1/24/11, developed for the patient?s episodes of resistance to care manifested by refusal to be cleaned, changed, eat and take medications, included the approaches to always approach the patient calmly and unhurriedly, stop giving care when the patient is upset and attempt again when the patient is calm. A plan of care dated 11/17/10, developed for the patient?s altered thought process due to dementia and confusion, included in the approaches to provide reality orientation as needed and provide a calm, therapeutic environment and structured routine. Another plan of care dated 11/17/10, revised on 2/2011, developed for the patient?s risk for injury/falls/restraints, included in the approaches to assist the patient as necessary, anticipate needs and remove hazards from the environment. Another plan of care dated 11/17/10, developed for the patient?s ADLs self-care deficit requiring extensive assistance with transfers included in the approaches to provide assistance with ADL care as needed and two-person assists during transfers.According to a nurse?s note dated 2/23/11, timed at 2 p.m., while the patient was being assisted by CNA 1, the patient placed her right wrist into the opening area of the side of the Geri-chair. When attempting to remove the right wrist from the Geri-chair, the wrist became caught and was noted to be swollen with redness. The physician was notified and ordered an x-ray and to apply an ice pack to the area. Another nurse?s note dated 2/23/11, timed at 3 p.m., documented the patient became resistive and combative during care and her right arm moved toward the side of the reclining chair. A splint was placed on the patient?s right wrist for immobilization of the area. A nurse?s note dated 2/23/11, timed at 8:30 p.m., indicated the x-ray revealed an acute non-displaced distal right radial (one of the two bones of the forearm at the wrist) fracture. Further record review revealed the patient was evaluated by an orthopedist on 2/25/11, who applied a cast to the right wrist. On 3/25/11, the cast was removed and replaced with a splint.According to the Incident Follow-up and Recommendation Form dated and signed by the director of nursing and the executive director on 2/23/11, the patient was in her room in the reclining chair and the CNA needed to attend to her and clean her but the patient was resistive and did not want to be transferred to her bed. The CNA left the patient in the recliner and after several minutes came back to clean and change the patient but she became resistive again. The patient grabbed the side of the chair while being attended to and sustained swelling and redness on the right wrist. The recommendations/actions taken indicated to have a two-person assist if the patient becomes combative/resistive during ADLs. The follow-up documention indicated not to continue the care, pause for few minutes, get help from other staff members, then approach again in a calm manner, explaining the purpose of the care.A facility's policy and procedure titled, "Lifting Techniques- General Information," revised 10/2004, indicated the purpose of this procedure was to use proper lifting techniques when lifting or moving a patient to prevent injury. The policy further stated to encourage the patient to assist as much as possible, try not to lift more than you feel comfortable lifting because this is dangerous for you and the patient and should the patient feel weak or faint during moving or positioning cease the procedure and summon the staff/charge nurse.On 9/9/11, at 2:15 p.m., during an interview, CNA 1 stated on 2/23/11, the patient was sitting in the Geri-chair in front of the nursing station, upset, demanding to go home and attempting to get out of the Geri-chair. Licensed Vocational Nurse (LVN 1) asked CNA 1 to assist the patient to bed and the patient screamed she did not want to go to bed. The patient continued to be angry in her room, said she did not want to go to bed and placed her right arm between the metal frame under the side armrest in order to stay in the Geri-chair. CNA 1 stated she attempted to lift the patient and remove the patient?s hand from the armrest without assistance from other staff members. While transferring the patient, CNA 1 told the patient repeatedly to, ?Let it go?. Then CNA 1 removed the patient?s hand from gripping the armrest. CNA 1 further stated she had assisted the patient to the floor so she could call for help. At that time, she noticed the patient was holding her wrist and complaining of pain.On 9/9/11, at 2:47 p.m., during an interview, the director of nursing stated CNA 1 was supposed to get help before transferring the patient and had to wait for the patient to calm down. The facility failed to implement Patient 1?s plan of care according to the methods indicating by failing to:1. Provide two persons physical assist during transfer from a recliner chair (Geri-chair) to bed, as assessed and as documented in the plan of care. 2. Stop giving care when the patient was upset and attempt again when the patient was calm as stated in the plan of care. On 2/23/11, while Patient 1 was combative and refusing to be transferred from the chair to her bed and was holding her right hand inside an opening below the armrest of the Geri-chair, Certified Nursing Assistant (CNA) 1 transferred the patient resulting in the patient sustaining a right wrist fracture. The above violation had direct or immediate relationship to the health, safety or security of Patient 1. |
| 940000047 |
BEL TOOREN VILLA CONVALESCENT HOSPITAL |
940009447 |
B |
20-Aug-12 |
W3YY11 |
7660 |
F203 ?483.12 (a) (4) Notice Before Transfer 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 when specified in paragraph (a)(5)(ii) 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.On 9/6/11, at 6:44 p.m., an unannounced visit was made to the facility to investigate a complaint regarding Resident 1?s transfer to another skilled nursing facility without a 30-day notice. Based on interview and record review, the facility failed to ensure Resident 1 and Family Member A were given a notice of transfer/discharge at least 30 days before the resident was transferred by failing to: Provide an advanced notice of transfer/discharge before discharging the resident to another skilled nursing facility. Resident 1 and Family Member A were provided with a written discharge notice dated 8/8/11, which was the day prior to the resident?s discharge to another facility.According to Family Member A, she was told Resident 1 had to be transferred to another skilled nursing facility due to the completion of the resident?s rehabilitation therapy and lack of further Medicare coverage. Family Member A and Resident 1 were not given a 30-day notice and did not agree with the transfer but the resident was transferred on 8/9/11. On 9/7/11, a review of the closed clinical record revealed Resident 1 was an 99-year old female admitted to the facility on 7/5/11, with diagnoses that included rehabilitation procedure, difficulty walking, muscle weakness, status post right hip fracture, atrial fibrillation (irregular heartbeat), and hypertension (high blood pressure). The Face Sheet listed Family Member A as the resident?s responsible party.The physician?s history and physical examination dated 7/8/11 indicated the Family Member A was the resident?s surrogate decision maker.The Minimum Data Set (MDS ? standardized assessment and care planning tool) dated 7/11/11, indicated the resident had short-term memory problem, modified independence with cognitive skills with decision-making, required extensive assistance with transfers, dressing and personal hygiene and used a wheelchair as mobility device.According to the physician?s orders and rehabilitation documentation, the resident had occupational therapy from 7/6/11 to 8/2/11 and physical therapy from 7/6/11 to 8/5/11. The physician ordered on 8/4/11, to transfer the resident on 8/9/11, to another skilled nursing facility. The Social Service Progress Notes dated 8/1/11, indicated the social service designee (SSD) informed Family Member A regarding the resident?s local coverage determination (LCD - insurance coverage of a service) was dated 8/4/11. The SSD further documented Family Member A requested a list of skilled nursing facilities in the area and a copy was provided.Another Social Service Progress Notes dated 8/4/11, indicated Family Member A requested the SSD to call a staff member from another skilled nursing facility. The note further indicated the SSD communicated with the staff member from the other facility and faxed all the records requested. The Initial Discharge Planning dated 7/7/11, revealed the SSD documented there was no plan for discharge at that time. The Discharge Plan Review dated 8/8/11, indicated the SSD met with the family member, communicated with the other facility and the resident?s discharge was set for 8/9/11. Family Member 1 offered to provide the transportation. A review of the Notice of Resident Transfer or Discharge form revealed the notice was dated 8/8/11, with a discharge date of 8/9/11, and the reason for discharge was, ?Off rehabilitation.?The notice was signed by Family Member A on 8/9/11, the same day of discharge.A nurse?s note dated 8/9/11, timed at 2 p.m., documented the resident?s discharge to another skilled nursing facility with all belongings accompanied by Family Member A. The facility?s policy and procedure on Admission, Transfer, and discharge Procedures, revised 6/2010, indicated the definition of discharge was to leave the facility without plans or intention to return (e.g., discharge to home, a lower level of care, or another long-term care facility) and to give a copy of the Notice of Transfer or Discharge as required. According to the facility?s Admission Agreement signed by Family Member A, the facility will notify the resident/representative at least thirty (30) days in advance of any involuntary transfer or discharge.On 9/7/11, at 12:30 p.m., during an interview, the SSD confirmed that on 8/1/11, she informed Family Member A of the need to discharge Resident 1 because the Medicare coverage was ceasing and would need to change over to MediCal coverage. The SSD further indicated Family Member A requested for the resident stay at the facility.On 9/7/11, at 1:54 p.m., during an interview, the administrator was asked about the lack of provision of the discharge notice at least 30-day before the resident?s discharge as stated in the facility?s Admission Agreement. The administrator explained Resident 1 and Family Member A were told since admission the resident?s stay in the facility was short-term.The facility failed to ensure Resident 1 and Family Member A were given a notice of transfer/discharge at least 30 days before the resident was transferred by failing to: Provide an advanced notice of transfer/discharge before discharging the resident to another skilled nursing facility. Resident 1 and Family Member A were provided with a written discharge notice dated 8/8/11, which was the day prior to the resident?s discharge to another facility.The above violation had direct or immediate relationship to the health, safety, or security of Resident 1. |
| 940000047 |
BEL TOOREN VILLA CONVALESCENT HOSPITAL |
940010146 |
B |
12-Sep-13 |
BSWW11 |
7391 |
F226-?483.13 ?The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property.On 8/15/13 at 12:05 p.m., an unannounced complaint investigation was conducted at the facility regarding an incident of alleged resident to resident physical abuse (Resident 2 punched Resident 1 in the mouth).Based on interview and record review, the facility failed to implement its abuse policies and procedures by failing to: 1. Protect the right of the resident from any form of abuse. 2. Investigate the alleged abuse immediately. On 8/15/13 at 1:10 p.m., during an interview, Resident 1 stated at the end of June 2013 (he couldn?t remember the exact date) Resident 2 walked into Resident 1's room to use the restroom. When Resident 1 told Resident 2 to go back and use his own restroom, Resident 2 punched him in the mouth with a closed fist. Resident 1 stated that a certified nursing assistant (CNA1) was in the room when the incident happened, however she did not witness the actual punching because she was busy fixing his roommate's bed. Resident 1 further stated that he told CNA1 that Resident 2 punched him in the mouth. Resident 1 stated that he was scared and defenseless and was unable to block the punch because he was sitting in his wheelchair and he some personal items in his hand that he needed to get ready for his shower. Resident 1 further stated he was scared because Resident 2 was a big guy with big hands and a big head. Resident 1 stated if Resident 2 punched him a little harder, his lips would have bled and his teeth would have fallen out. Resident 1 stated that he was upset because he had told two staff members about the incident but the facility had not done anything about it. Resident 1was able to identify the female staff (CNA 1) who was present in the room at the time of the incident but was unable to identify the male staff to who he had reported the incident.A review of Resident 1's medical record indicated that the resident was admitted to the facility on 7/31/12 and was re-admitted to the facility on 9/23/12 with diagnoses including hemorrhage (bleeding) of gastrointestinal (stomach and intestines) tract, tachycardia (fast heart rate), and diabetes mellitus (a metabolism disorder that affects the body's ability to use blood sugar). The Minimum Data Set (MDS, a resident assessment and care screening tool), dated 5/6/13, indicated that Resident 1 had no memory problem, was independent in making decisions regarding tasks of daily life, and required limited (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance) to extensive assistance (weight bearing support and at times requires full staff performance) from staff for bed mobility, transferring, walking, and toilet use. On 8/15/13, a review of the Investigation Follow Up dated 7/16/13, indicated (according to Resident 1), that he was hit on the left cheek by Resident 2 while the CNA (CNA 1) was getting him ready for a shower. According to CNA 1, Resident 2 entered Resident 1?s room to use the bathroom and witnessed when Resident 2 attempted to hit Resident 1. CNA1 told someone about the incident, but could not recall who she told about the incident because it happened almost a month ago.On 8/15/13 at 1:30 p.m., during an interview, the director of nursing (DON) stated on 7/16/13 Resident 1 told the ombudsman that Resident 2 hit him in the mouth. The DON stated that when she interviewed Resident 1 on 7/16/13, Resident 1 did not respond to her question, but asked her to talk to CNA1 because CNA1 was in the room when the incident happened, and that he told CNA1 about what happened. The DON stated during a telephone conversation that CNA1 told her that Resident 2 attempted to hit Resident 1 in the mouth, but Resident 2's hand never touched Resident 1's mouth. The DON further stated CNA1 was currently out of the country for vacation and she would not be back until next week.On 8/15/13 at 2:30 p.m., during an interview, CNA 2, (Resident 1's assigned CNA) stated if Resident 1 had told her that he had been punched by Resident 2, she would have reported the incident to the charge nurse whether or not she actually witnessed the incident. CNA 2 stated that if Resident 2 had attempted to punch Resident 1, she would have reported the incident to her supervisor so that the facility staff could investigate the root cause of the incident and take the necessary steps to prevent future incidents from reoccurring. On 8/15/13 at 2:50 p.m., during an interview with CNA 3, (Resident 2's assigned CNA) she stated that if Resident 1 had told her that he had been punched by Resident 2, she would have reported the incident to the charge nurse even if she had not witnessed the actual incident so the facility could investigate whether or not the incident happened. CNA 3 further stated if Resident 2 had only attempted to punch Resident 1, she would report the incident to her charge nurse to investigate what triggered Resident 2's violent behavior so that the facility can could come up with a plan to prevent it from happening to other residents in the facility.On 8/15/13 at 4 p.m., during an interview, the administrator stated that facility staffs were encouraged to follow the chain of command, and to report all alleged incidents of abuse regardless of whether or not they actually witnessed the abuse event. The administrator stated that by reporting the abuse incidents, the facility would have the chance to investigate the incident, and come up with a solution (e.g. plan of care), based on the results of the investigation. On 8/22/13 at 10:55 a.m., during a telephone interview, CNA1 stated in June 2013, she witnessed Resident 2 go to Resident 1's room, wanting to use Resident 1's restroom, and attempted to urinate on the floor. CNA 1 stated that she reported the incident to her charge nurse/licensed vocational nurse (LVN 1) on the same day, because it was her job to report any allegation of abuse, however, she did not follow up.On 8/22/13 at 3:20 p.m., during a telephone interview, the DON stated LVN 1 was out of the country for a family emergency. The DON further stated she did not know when LVN 1 would be back.Upon further review of Resident 1?s medical record (investigation report, nursing progress notes), there was no documented evidence that LVN 1 assessed Resident 1 immediately after being notified about the incident, reported the alleged abuse incident to her supervisor, a thorough investigation was conducted, and reported the incident to the Department according to the facility?s policy.A review of the facility's undated policy and procedure titled, "Protection of Residents: Reducing the Threat of Abuse & Neglect" stipulated that the facility is to fully protect the rights of the residents from any form of abuse and initiates an investigation of the alleged abuse event immediately. The facility failed to implement their abuse policies and procedures by failing to: 1. Protect the right of the resident from any harm or form of abuse. 2. Investigate the alleged abuse event immediately. The above violation had a direct or immediate relationship to the health, safety, or security of Resident 1. |
| 940000047 |
BEL TOOREN VILLA CONVALESCENT HOSPITAL |
940010149 |
B |
16-Sep-13 |
BSWW11 |
5092 |
1418.91Reports of incidents of alleged abuse or suspected abuse of residents (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. On 8/15/13 at 12:05 p.m., an unannounced complaint investigation was conducted at the facility regarding an incident of alleged resident to resident physical abuse (Resident 2 punched Resident 1 in the mouth).Based on interview and record review, the facility failed to implement its abuse policies and procedures by failing to: 1.Notify the Department (State survey and certification agency) regarding the abuse allegation within 24 hours of the allegation of abuse in accordance with the facility?s policy. On 8/15/13 at 1:10 p.m., during an interview, Resident 1 stated at the end of June 2013 (he couldn?t remember the exact date) Resident 2 walked into Resident 1's room to use the restroom. When Resident 1 told Resident 2 to go back and use his own restroom, Resident 2 punched him in the mouth with a closed fist. Resident 1 stated that a certified nursing assistant (CNA1) was in the room when the incident occurred, however she did not witness the actual punching because she was busy fixing his roommate's bed. Resident 1 further stated that he told CNA1 that Resident 2 punched him in the mouth. Resident 1 stated that he was scared and defenseless and was unable to block the punch because he was sitting in his wheelchair and had some personal items in his hand that he needed to get ready for his shower. Resident 1 further stated he was scared because Resident 2 was a big guy with big hands and a big head. Resident 1 stated if Resident 2 punched him a little harder, his lips would have bled and his teeth would have fallen out. Resident 1 stated that he was upset because he had told two staff members regarding the incident but the facility had not done anything about it. Resident 1was able to identify the female staff (CNA 1) but was unable to identify the male staff member to whom he had reported the incident. On 8/15/13, a review of the facility?s investigation report and follow up, dated 7/16/13, indicated that, according to Resident 1, that he was hit on the left cheek by Resident 2 while the CNA (CNA 1) was getting him ready for a shower. According to CNA 1, Resident 2 entered Resident 1?s room to use the bathroom; however she did not witness the actual punching incident. CNA1 told someone about the incident, but could not recall who she told about the incident because it happened almost a month ago. There was no documented evidence that the facility staff reported the abuse allegation to the Department within 24 hours according to the facility?s policy.On 8/15/13 at 4 p.m., during an interview, the administrator stated that facility staff were encouraged to follow the chain of command, and to report all alleged incidents of abuse regardless of whether or not they actually witnessed the abuse. The administrator stated that by reporting the abuse incidents the facility would have the chance to investigate the incident, and come up with a solution (i.e. plan of care), based on the results of the investigation. On 8/22/13 at 10:55 a.m., during a telephone interview, CNA1 stated in June 2013, she witnessed Resident 2 go to Resident 1's room, wanted to use Resident 1's restroom, and attempted to urinate on the floor. Resident 1 asked Resident 2 to go back to his bathroom. CNA 1 further stated that she did not witness the actual punching event, but Resident 1 reported to her that Resident 2 punched him. CNA 1 stated that she reported the incident to her charge nurse/licensed vocational nurse (LVN 1) on the same day, because it was her job to report any allegation of abuse, however, she did not follow up.On 8/22/13, at 3:20 p.m., during a telephone interview, the DON stated LVN 1 was out of the country for a family emergency. The DON further stated she did not know when LVN 1 would be back.Upon further review of Resident 1?s medical record (investigation report, nursing progress notes) there was no documented evidence that LVN 1 reported the incident to the Department within 24 hours of the allegation of abuse according to the facility?s policy.A review of the facility's undated policy and procedure titled, "Protection of Residents: Reducing the Threat of Abuse & Neglect" stipulated that the facility is to fully protect the rights of the residents from any form of abuse, initiates an investigation of the alleged abuse immediately, and reported incidents of abuse to the Department immediately or within twenty four (24) hours.The facility failed to implement their abuse policies and procedures by failing to: 1. Notify the Department (State survey and certification agency) about an abuse allegation within 24 hours of the allegation of abuse in accordance with the facility?s policy.The above violation had a direct or immediate relationship to the health, safety, and/or security of Resident 1. |
| 940000005 |
BROADWAY BY THE SEA |
940011067 |
A |
04-Dec-14 |
DE8911 |
16081 |
Title 22 ? 72315. Nursing Service ? Patient care (h) Each patient shall be provided with good nutrition and with necessary fluids for hydration.On 5/11/12 at 11:30 a.m., an unannounced visit was made to the facility to investigate a complaint regarding quality of care. Based on interview and record review, the facility failed to ensure Patient 1, who was identified as being at risk for dehydration (a complex condition resulting in a reduction in total body water), received the necessary care and services to prevent dehydration by failing to: 1. Re-assess the patient for increased risk of becoming dehydrated when there were changes in her condition.2. Monitor an accurate hydration and fluid balance by not measuring the urine output in a quantifiable amount in milliliters (ml).3. Follow the facility's policy and procedure on hydration program and intake and output.This deficient practice resulted in Patient 1's hospitalization due to septic shock (a serious condition that occurs when an overwhelming infection leads to life-threatening low blood pressure), dehydration, and acute (sudden) renal (kidney) failure. Patient 1 was intubated (insertion of a tube into the windpipe to maintain an open airway) and was admitted in the Intensive Care Unit (ICU).A review of the clinical record indicated Patient 1 was admitted to the facility on 2/24/12 with diagnoses that included dementia (loss of brain function that occurs with certain diseases and affects memory, thinking, language, judgment, and behavior), dysphagia (difficulty swallowing), and failure to thrive (a state of decline with manifestations including weight loss, decreased appetite, poor nutrition, and inactivity).According to the Minimum Data Set (MDS, an assessment and care screening tool), dated 3/2/12, Patient 1 was able to make her needs known and able to understand others sometimes, required extensive assistance (weight bearing support and at times requires full staff performance) when eating with one person physical assist. The MDS indicated the patient's weight was 159 pounds.A review of the Physician Orders for Life-Sustaining Treatment (POLST), signed by the patient's legal representative on 2/28/12, indicated the patient was to receive full treatment or medical intervention, which included the use of antibiotics and IV (intravenous) fluids and transfer to a hospital. A review of the Dehydration Assessment dated 2/24/12 identified Patient 1 as being moderately at risk of developing dehydration. There was no other re-assessment conducted after 2/24/12. A review of the plan of care, dated 2/24/12, addressing the patient?s risk for dehydration indicated a goal for the patient to consume 50% to 100% of her meals and for staff to promptly identify signs and symptoms of dehydration. The approaches included monitoring the patient's intake by mouth, observing for changes in level of consciousness, and notifying the physician immediately. The dehydration care plan was updated on 2/26/12 and the approaches included monitoring for change in mental state and urine output. There was no further revision of the care plan after 2/26/12. A review of the Nutritional Assessment Screening by the registered dietitian (RD), dated 3/1/12, indicated Patient 1 was alert, verbal with confusion, had dysphagia, and had a history of poor intake by mouth and failure to thrive. It also indicated the patient was at risk for weight loss and dehydration due to dementia, use of cardiovascular (pertaining to heart and vessels) agents, and ?po? intake (intake by mouth) of less than 75%. Patient 1?s average percentage of meals eaten was 57% and the patient's fluid estimated requirement per day (24 hours) was 1800 cc [cubic centimeter or milliliter (ml)]. A review of the Weekly Intake and Output Evaluation reports indicated the following: 1) From 2/25/12 to 3/2/12, the average 24 hour fluid intake was 1182.8 ml (617.2 ml less than the fluid requirement or fluid intake deficit); 2) From 3/3/12 to 3/9/12, the average 24 hour fluid intake was 1200 ml (600 ml fluid intake deficit);3) From 3/10/12 to 3/16/12, the average 24 hour fluid intake was 1254 ml (546 ml fluid intake deficit); 4) From 3/17/12 to 3/23/12, the average 24 hour fluid intake was 1271.4 ml (528.6 ml fluid intake deficit); 5) From 3/24/12 to 3/30/12, the average 24 hour fluid intake was 1511 ml (289 ml fluid intake deficit); 6) From 3/31/12 to 4/6/12, the average 24 hour fluid intake was 1262.8 ml (537.2 ml fluid intake deficit); 7) From 4/7/12 to 4/12/12, the average 24 hour fluid intake was 1220 ml (580 ml fluid intake deficit); 8) From 4/13/12 to 4/19/12, the average 24 hour fluid intake was 1210 ml (590 ml fluid intake deficit); and 9) From 4/20/12 to 4/22/12, the average 24 hour fluid intake was 1247 ml (553 ml fluid intake deficit).From 2/25/12 to 4/22/12, there was no documented evidence the urine output was measured in a quantifiable amount in milliliters (ml). There was no accurate evaluation of Patient 1?s fluid balance (a balance between the amount of fluid intake as compared to the amount of fluid lost from the body).A review of the SBAR (Situation-Background-Assessment-Recommendation) Change of Condition Documentation dated 3/8/12 indicated Patient 1 developed a moist cough. A plan of care was developed with approaches which included offering and assisting the patient with increased fluid intake every shift and as needed. There was no documented evidence Patient 1 was re-assessed for increased risk of dehydration when she had a change of condition and continued fluid intake deficit.A review of the Weight Flow Sheet indicated that on 3/13/12, Patient 1 weighed 148 pounds, an 11-pound weight loss from an admission weight of 159 pounds. The interdisciplinary team (IDT) documented on the Resident Weight Change Evaluation on 3/14/12 that the patient's fluid intake (1200 cc daily on an average) did not meet her fluid needs and her meal intake average was 64% in the last seven days.According to the IDT?s Weight Variance Meeting report dated 3/21/12, the patient's meal percentage improved compared to previous week's percentage; there was no more edema present; and the patient's fluid intake did not meet her fluid requirements. The report indicated to continue the one-to-one supervision during meals and the plan of care. There was no documented evidence the IDT re-assessed the patient for increased risk of dehydration. The Dehydration Risk Assessment was not updated.A review of the psychiatric notes dated 3/21/12 indicated ?Patient is barely able to keep eyes open or answer questions. She apparently is more alert in the AM (morning) but afternoons and evenings she is lethargic. I see no medication that can cause this degree of lethargy. Can?t be certain if depression plays a part but clearly she is down.? There was no documented evidence the facility re-assessed the patient for increased risk of dehydration since the patient was showing signs of lethargy (abnormal drowsiness).A review of the SBAR Change of Condition Documentation dated 4/5/12 indicated the patient's urinalysis (urine test) was not within normal limits. A plan of care for the patient?s urinary tract infection (UTI) was developed with approaches that included encouraging fluid intake by mouth and to call the physician for any changes. The plan of care did not indicate to measure the urine output accurately to determine fluid balance. The Dehydration Risk Assessment was not updated to determine if the patient's risk for dehydration had increased due to presence of the infection.According to the article titled ?Dehydration and Dysphagia: Challenges in the Older Adult? and published in the Journal of Medical Speech-Language Pathology in 2010, Volume 18, Number 3, page 2, dehydration, in general, is known to contribute to urinary tract infections, constipation, fecal impaction, cardiovascular symptoms, heatstroke, and delirium . A review of the Weight Flow Sheet indicated Patient 1?s weight was 152.4 on 4/4/12. According to the IDT?s Resident Weight Change Evaluation report dated 4/11/12, 47 days after admission, the patient's meal intake average was 70%; her fluid intake did not meet her fluid intake needs; and her weight loss was expected secondary to infection.According to the Licensed Nurses Progress Notes dated 4/23/12 and timed 5 a.m., 59 days after admission, the patient was noted to be unresponsive to verbal or tactile (sense of touch) stimuli, her oxygen saturation (a measure of how much oxygen the blood is carrying as a percentage of the maximum it could carry) was 80% (normal oxygen saturation values are 97% to 99%), her blood pressure was 98/60 millimeters of mercury or mm Hg (optimal blood pressure is 120/80 mm Hg), her pulse rate was 82 beats per minute (normal pulse ranges from 60 to 100 beats per minute), her respiratory rate was 42 breaths per minute (normal respiration rates range from 12 to 16 breaths per minute), and her temperature was 99.1 degrees Fahrenheit (normal body temperature range from 97.8 degrees Fahrenheit to 99 degrees Fahrenheit. The physician was paged and an order was received to transfer the patient via 911 emergency services to the acute hospital for further evaluation.According to the Emergency Department Report dated 4/23/12, Patient 1's physical examination indicated her oxygen saturation was 90% on high flow oxygen; her blood pressure was 82/53 mm Hg; her pulse rate was 103 beats per minute; her respiratory rate was 15 breaths per minute; and her temperature was 96 degrees Fahrenheit. The report indicated the patient was in severe distress, hypoxic (inadequate oxygenation of the blood), hypotensive (low blood pressure), and looked extremely dry. Further review of the Emergency Department (ED) Report indicated Patient 1 was started on peripheral intravenous line and she was given two (2) liters of normal saline (salt solution) bolus (a large dose of a substance given by injection for the purpose of rapidly achieving the needed therapeutic concentration in the bloodstream) and four different kinds of antibiotics. The report also indicated the patient had leukocytosis (an increase in the white blood cell count which was a sign of infection and inflammation), hypernatremia (high sodium level), hyperchloremia (high chlorine level), and renal failure. The patient's urine color was very cloudy. Patient 1 was intubated and admitted in the ICU.Patient 1?s laboratory results, dated 2/20/12, prior to her admission to the facility was compared to the hospital?s laboratory results. The patient?s sodium and chloride (tests to determine electrolyte and fluid balance) and BUN and creatinine (test to determine kidney function) were within the reference ranges. A Nephrology Consultation was also performed on 4/23/12 due to presence of acute (rapid onset) kidney injury. According to the consultation report, the patient?s creatinine was 3.9 mg/dL upon arrival to the emergency department. The patient was significantly dehydrated and aggressively fluid volume resuscitated with over five (5) liters of IV (intravenous) fluids.The Discharge Summary indicated the patient's primary discharge diagnosis included septic shock, urinary tract infection, pneumonia, dehydration, acute kidney injury, and azotemia (elevation of BUN and serum creatinine level).On 5/11/12 at 1:30 p.m., during an interview, CNA 1 stated Patient 1 required assistance in feeding and was able to say simple words, such as ?I drink? when she wants to drink. CNA 1 stated, ?You need to keep going back to her to encourage her to drink.? According to CNA 1, the CNAs monitored the patient?s fluid intake by documenting her meal percentages which was a combined percentage for both food and fluid.On 8/26/13 at 11 a.m., during an interview, the director of nursing (DON) stated the process of determining a patient's risk for dehydration included the following: 1) Evaluating the patient's risk factors within 14 days of admission; 2) Developing a plan of care to prevent dehydration; 3) Monitoring and recording the patient's fluid input and output; 4) Monitoring the patient's laboratory tests for any electrolyte (e.g. sodium, potassium, chloride) imbalances; and 5) Consulting with the registered dietitian (RD) for the initial nutritional assessment which included determining the patient's daily calorie and fluid requirements. The DON stated the patient's dehydration risk should have been re-assessed, the care plan revised, and patient-centered interventions implemented. The DON explained that during the patient's stay, the facility did not have a policy and procedure to re-assess the patient when a change of condition occurred. However, the DON stated the facility's policy and procedure had been revised as of 8/2012 and the hydration risk evaluation was done on each patient at admission, change of condition, and on a quarterly basis since the revision. When asked why the IDT did not make any new recommendations after their meetings on 3/14/12, 3/21/12, and 4/11/12 when the patient's fluid intake was not meeting her fluid needs, the DON could not give an explanation. Instead, the DON stated the IDT should have indicated why the plan of care needed to be continued when the patient's fluid intake was not meeting her fluid needs. The DON stated that if the patient was not taking enough fluids by mouth, then she could have received hydration via IV (intravenous) administration. The DON did not give an explanation as to why IV hydration was not administered to the patient. According to the facility's undated policy and procedure titled, "Hydration Program Policy," patients risk for dehydration will be assessed on admission, quarterly, annually, and as needed.A review of another facility's undated policy and procedure titled, "Intake and Output," indicated the following: 1. The licensed nurse monitors and documents all fluid (in milliliters) consumed by the patient from diet trays, water pitcher at bedside, and during medication pass on the I&O (Intake and Output) sheet each shift. 2. Record total output in the I&O sheet each shift. 3. At the end of each 24 hours cycle, record on the I&O shift sheet the total intake and output for the whole 24-hour period.A review of the article in Nursing Standard titled, "The importance of fluid balance in clinical practice," dated 7/30/08, volume 22, number 47, pp. 50-57, indicated the symptoms of dehydration only occur when the reserve of interstitial fluid (liquid found between the cells of the body) is already depleted and the patient is in a negative balance of several liters. Altered vital signs and elevated renal chemistry are late signs of dehydration and careful attention to fluid balance charts could alert staff to fluid imbalances before symptoms occur. Fluid balance records are an essential part of the patient care and the responsibility for maintaining fluid balance charts rests with the nurses. Nurses should be able to perform comprehensive hydration assessment to plan and deliver the care that patients require. Staff should be trained to complete fluid balance charts and should view the fluid balance chart with the same importance as a medication prescription. The facility failed to ensure that Patient 1, who was identified at risk for dehydration, received the necessary care and services to prevent dehydration by failing to: 1. Re-assess the patient for increased risk of becoming dehydrated when there were changes in her condition.2. Maintaining an accurate fluid balance record by not measuring the urine output in a quantifiable amount in milliliters (ml).3. Follow the facility's policy and procedure on hydration program and intake and output.The above violation jointly, separately, or in any combination presented either an imminent danger that death or serious physical harm would result or substantial probability that death or serious physical harm would result. |
| 940000013 |
BELLFLOWER POST ACUTE |
940011184 |
B |
18-Dec-14 |
None |
6063 |
72315. Nursing Service ? Patient Care. (f) Each patient shall be given care to prevent the formation and progression of decubiti, contractures and deformities. Such care shall include: (3) Maintaining proper body alignment and joint movement to prevent contractures and deformities. On April 5, 2013, the Department received a complaint alleging a patient (Patient A) was not receiving restorative care as prescribed by the attending physician. On July 2, 2014, at 1:35 p.m., an unannounced visit was made to the Facility (2) to conduct a complaint investigation. The Facility (2) failed to meet the intent of this regulation by not: 1. Conducting an initial and ongoing assessment of Patient A?s upper and lower extremities. 2. Providing range of motion exercises to Patient A?s right and left upper and lower extremities as order by the attending physician. The failure of a physical therapist (PT) to assess and the restorative nursing assistant (RNA) to continue to provide range of motion (ROM) exercises, as prescribed by the physician at Facility 2, put the patient at risk to develop further contractures and a decline at her weaken muscles of the lower and upper extremities. A review of Patient A?s medical record from Facility 2 identified the patient as being a 68-year old female admitted to the facility on December 7, 2010, from another skilled nursing facility (Facility 1). The patient?s diagnoses included hypertension (high blood pressure), diabetes mellitus type 1 (high levels of blood sugar, lifelong chronic disease), Parkinson?s disease (chronic and progressive movement disorder), rheumatoid arthritis (inflammation of the joints and surrounding tissues), and congenital artery anomaly (malformation of the heart vessels). There was a physician?s telephone order, dated February 2, 2013, for ROM exercises to be provided to Patient A?s upper and lower extremities daily as tolerated. On March 3, 2013, a new physician?s telephone order was received to increase the patient?s ROM exercises from once a day to twice a day as tolerated. The RNA documentation, recorded from March 2013 to June 2014, was reviewed. The medical record contained a pre-printed/timed record for recording the a.m. and p.m. (9 a.m. and 5 p.m.) ROM exercises. However, the documentation for Patient A?s 5 p.m. ROM exercises was left completely blank. The DON was questioned about the 5 p.m. ROM exercises, and stated on several occasions she observed the evening staff providing ROM exercises to the patient. On September 2, 2014, at 2:29 p.m., an interview was conducted with Patient A. The patient was asked if she was receiving ROM exercises she stated, ?Sometimes.? When asked about the evening ROM exercises she stated there were no evening exercises provided. At 3:05 p.m., on September 2, 2014, an interview was conducted with the director of nursing (DON) at Facility 2. When asked about the physical therapy (PT) assessment for Patient A, the DON stated there was no PT assessments completed for the patient. Facility 2 did not have a copy of the PT assessment completed from the previous SNF (Facility 1) where Patient A was transferred from on December 7, 2010.An admission care plan from Facility 2, dated December 9, 2010, identified the patient as having contractures. However, the area(s) of contractures were not documented. The Minimum Data Set (MDS/from Facility 2), an assessment and care screening tool, dated December 20, 2012 and September 20, 2014, under Section O-titled physical therapy, was reviewed. This section on each MDS was left blank. A review of Patient A?s PT assessment was obtained from the previous SNF (Facility 1). According to the PT assessment, the patient was described as having rheumatoid arthritis and muscle weakness (generalized). The short term goal was to increase the patient?s strength 4/5 (opportunities for improvement, with 5 being the highest improvement possible) in the right and left lower extremities in order to facilitate the patient?s ability to perform transfers with the use of an assistive device. The PT?s assessment baseline, dated September 6, 2010, from Facility 1, for the patient?s right lower extremity strength was 3/5 (part moves through full range against gravity without added resistance; muscle holds test position ? no added pressure). The patient at this time was able to transfer with maximal assistance. The PT discharge assessment, dated December 6, 2010, was 3+/5 (part moves through full range against gravity, takes minimum resistance then breaks/relaxes suddenly: muscle holds test position against slight pressure). The patient at this time was able to transfer with minimal assistance. A second baseline assessment from Facility 1, dated September 6, 2010 for the left lower extremity was 3/5 (part moves through full range against gravity without added resistance; muscle holds test position-no added pressure). The patient was able to transfer with maximal assistance. The PT discharge assessment from Facility 1, dated December 6, 2010, one day prior to being transferred to Facility 2, showed improvement of 3+/5 (part moves thru full range against gravity, takes minimal resistance then breaks/relaxes suddenly; muscle holds test position against slight pressure). The patient was able to transfer with minimal assistance. The above assessment showed an improvement in Patient A?s level of performance. The discharge prognosis and recommendations indicated the patient?s prognosis was excellent with consistent of staff support. The recommendation was to facilitate the patient by maintaining the current level of performance in order to prevent a decline. The Facility failed to: 1. Conduct an initial and ongoing assessment of Patient A?s bilateral upper and lower extremities. 2. Provide ROM exercises to the patient?s upper and lower as ordered by the attending physician. The above violation jointly, separately, or in any combination had a direct or immediate relationship to patient A?s health, safety or security. |
| 940000011 |
BELL CONVALESCENT HOSPITAL |
940011417 |
B |
24-Apr-15 |
5URS11 |
7484 |
F225 - 42 CFR 483.13(c)(1)(2) Reporting/Response: The facility must ensure that all alleged violations involving mistreatment, neglect, 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). F226 - 42 CFR 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. 42 CFR 483.13(c)(3). Investigation: Have procedures to investigate different types of abuse and identity the staff members responsible for initial reporting, investigation of alleged violations and reporting of results to proper authorities 42 CFR 483.13(c)(3). Protection: Have procedures to protect residents from harm during an investigation. On 3/11/15, at 10:30 a.m., during the recertification survey, an entity-self reported incident, which involved an alleged altercation between Resident 12 and 13, was investigated.Based on interview and record review, the facility failed to implement its abuse policy and procedures by failing to: 1 Thoroughly investigate an allegation that Resident 12 went into Resident 11?s room (a female resident?s room) and other female residents? rooms, and asked the female residents to flash their breasts at him2. Protect female residents from Resident 12 during an investigation. 3. Report the alleged sexual abuse by Resident 12 to the administrator, the State licensing and certification agency (the Department), the Long Term Care Ombudsman, and the local enforcement agency. A review of Resident 13's clinical records indicated she was admitted on 12/21/11, with diagnoses that included depression (feelings of intense sadness including feeling helpless, hopeless, and worthless). The Minimum Data Set (MDS, a comprehensive assessment of each resident's functional capabilities which helps nursing home staff identify health problems), dated 12/26/14, indicated Resident 13 was alert and oriented. A review of Resident 12's clinical records indicated he was admitted on 10/18/13, with diagnoses which included paraplegia (impairment in motor or sensory function of the lower extremities). The MDS assessment, dated 10/16/14, indicated Resident 12 was alert and oriented. A review of Resident 11's clinical records indicated she was admitted on 7/26/13, with diagnoses which included left-sided hemiplegia (weakness of the entire left side of the body). The MDS assessment, dated 8/1/14, indicated Resident 11 was alert and oriented. On 3/11/15 at 10:30 a.m., Resident 13 was interviewed regarding the alleged resident to resident altercation that occurred on 2/27/15, between herself and Resident 12, a male resident. Resident 12 and 13 were arguing on the patio when Resident 13 threw a book and a wheelchair?s foot rest at Resident 12. The wheelchair?s foot rest hit Resident 12?s pointer finger, but he did not sustain any injury. During the interview, Resident 13 stated she heard from her friend that Resident 12 was going into female rooms and asking the female residents to pull up their blouses so he could see their breasts. Resident 13 stated she informed the social service designee (SSD) but nothing was done about Resident 12. On 3/11/15 at 11:25 a.m., during an interview, the SSD stated, while interviewing Resident 13 about the alleged altercation with Resident 12 that occurred on 2/27/15, Resident 13 informed the SSD that Resident 12 went into female rooms and asked the female residents to pull up their blouses so he can see their breasts. The SSD stated Resident 13 did not mention names of the affected residents, but later stated it was one of her friends (Resident 11). The SSD stated she asked Resident 11 if the allegation was true but Resident 11 stated, "No."During the review of the SSD notes, the evaluator was unable to locate any documented evidence regarding Resident 13's allegation of Resident 12's sexual abuse/conduct towards other female residents, which included Resident 11. The SSD was asked if she informed the administrator about the allegation of sexual abuse of Resident 12 and she stated, "No." The SSD was asked if there were any interviews with the other residents and staff members to ensure a thorough investigation was done, the SSD stated, "No," because Resident 11 denied the allegation. The SSD was asked if there was any documented evidence to show that the facility reported the allegation to the Department and the Ombudsman?s office, the SSD stated, "No." There was also no documented evidence to show that the SSD engaged in any reasonable efforts to prevent the residents from harm during the investigation process. On 3/11/15 at 1:30 p.m., during an interview, the administrator stated he was not informed about Resident 13's sexual abuse allegation against Resident 12 and that the SSD was currently investigating it. On 3/11/15 at 2 p.m., during an interview, Resident 11 denied the sexual abuse allegation. On 3/11/15 at 3 p.m., during an interview, Resident 12 denied the sexual abuse allegation. A review of an undated facility's policy and procedures titled ?Policy and Procedure on Patient Abuse and Prevention,? indicated the facility shall establish system to prevent patient abuse including those practices and omissions, neglect and misappropriation of property that if left unchecked, may lead to abuse. The definition of sexual abuse includes, but is not limited to, sexual harassment, or sexual coercion.The facility?s policy and procedure indicated the facility shall ensure thorough and extensive investigation of incidents that may constitute abuse. The facility shall identify a staff member who would be responsible for the initial investigation of alleged violations and reporting of results to facility administrator. The facility administrator shall be responsible for ensuring thorough investigation, utilizing such measures as interview of staff, visitors, residents or other individuals who may have knowledge of alleged violations. The facility shall make reasonable efforts to prevent the residents from harm during an investigation process.The facility's policy and procedure indicated the facility shall ensure reporting of all alleged violations to the Department within 24 hours of knowledge of such incident, followed by a letter explaining the circumstances surrounding the incident. The administrator and director of nurses shall report incidents of suspected abuse to the Long Term Care Ombudsman and the local enforcement agency or police department, within 24 hours of occurrence. Therefore, the facility failed to implement its abuse policy and procedures by failing to: 1 Thoroughly investigate an allegation that Resident 12 went into Resident 11?s room (a female resident?s room) and other female residents? rooms, and asked the female residents to flash their breasts at him2. Protect female residents from Resident 12 during an investigation. 3. Report the alleged sexual abuse by Resident 12 to the administrator, the State licensing and certification agency (the Department), the Long Term Care Ombudsman, and the local enforcement agency. The above violations had a direct or immediate relationship to the health, safety, and security of patients. |
| 940000020 |
BUENA VENTURA POST ACUTE CARE CENTER |
940011546 |
A |
11-Jun-15 |
KWEW11 |
11294 |
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. On 7/1/14, the Department investigated a complaint about the lack of patient care services provided to Resident 1. The complainant alleged that Resident 1 was paralyzed on her right side and that on 6/28/14, the complainant found Resident 1 lying on her left side suffocating on a pillow on her face while a staff was standing right beside her at that time. Resident 1 was taken to the hospital and sustained brain damage.Based on interview, and record review, the facility failed to provide Resident 1 with the necessary care and services by failing to follow the facility?s policy and procedure for Cardio-pulmonary Resuscitation/and Basic Life Support and the American Heart Association Adult Basic Life Support for Healthcare Providers. The facility?s failure to provide necessary care and services also includes:1. Failure to immediately follow Resident 1?s Physician Orders for Life-Sustaining Treatment (POLST - a form created for specific medical orders to be honored by health care workers during a medical crisis), 2. Failure to immediately activate the emergency response team by calling a code as designated by the facility?s protocol, when Resident 1 was first found unresponsive. Instead LVN1 went to the nurses? station to page a registered nurse, 3. Failure to designate a staff person to call 9-1-1 (emergency number). Instead, RN 1 left the room to check Resident 1's code status in the clinical record, which indicated full code. That is when 9-1-1 was called. 4. Failure to immediately open the resident?s airway when Resident 1 was found unresponsive, 5. Failure to utilize a bag-mask device method which forces the oxygen in to the lungs instead of administering oxygen through a regular mask, when Resident 1 was found unresponsive with a weak pulse, as recommended by the American Heart Association Adult Basic Life Support for Healthcare Providers.These failures resulted in lack of oxygen to Resident 1. Resident 1 expired at the general acute care hospital with the cause of death listed as anoxic brain injury (brain damage due to lack of oxygen).A review of the clinical records indicated Resident 1 was admitted to the facility on 6/21/14, with the diagnoses that included cerebrovascular accident (stroke - happens when blood flow to a part of the brain stops, and if stopped for longer than a few seconds the brain cannot get blood and oxygen, which leads to brain cells dying, causing permanent damage) with right sided hemiparesis (weakness on one side of the body), and a pacemaker (an artificial device for stimulating the heart muscle and regulating its contractions) placement.The Minimum Data Set (MDS - standardized assessment and care planning tool) assessment dated 7/3/14, indicated Resident 1 had short term memory loss, and was severely impaired in cognitive skills for daily decision making.The POLST dated 6/25/14, indicated Resident 1's legal decision maker wanted full CPR to be performed in case of an emergency. A review of the facility?s policy and procedure titled, ?Cardiopulmonary Resuscitation and Basic Life Support? revised December 2006, indicated to check the victim?s pulse and respirations. If they are absent, attempt to arouse the individual. If the victim is unresponsive, activate the emergency response team, initiate CPR, and call a code as designated by facility protocol. The policy indicated to designate a staff person to call 9-1-1, open the airway, check breathing, administer rescue breaths, check for pulse, and give chest compressions.According to facility?s list of employees trained for CPR by an American Heart Association representative indicated that staff members, including LVN 1 were both trained at the facility on 3/21/14. RN 1?s CPR card indicated she was certified on 11/5/12 and that it was valid until 11/2014. The American Heart Association Adult Basic Life Support for Healthcare Providers manual dated 2010 - 2011, indicated that when a resident is unresponsive with no breathing or no normal breathing, the first thing is to activate emergency response system (call for help or send someone to get help). The manual also indicated that a bag-mask device (a hand-held device commonly used to provide positive pressure ventilation [forcing the oxygen in to the lungs] to patients who are not breathing or not breathing adequately) was the most common method of delivering rescue breaths versus only administering oxygen through a regular mask. A review of the Licensed Personnel Weekly Progress Notes dated 6/28/14 at 6:45 p.m., indicated Resident 1 was found unresponsive to both verbal and tactile (touch) stimuli. Resident 1?s vital signs were ?hardly appreciated but with weak pulse?. At 6:50 p.m., 9-1-1 and staff were called to the room for assistance. Resident 1 was placed on oxygen at 15 liters per minute and the head of the bed was elevated. At 6:55 p.m., paramedics arrived and continued with the CPR already in progress. At 7:15 p.m., Resident 1 was transferred to the hospital and was intubated (the insertion of an artificial airway to assist in breathing). On 7/7/14, Resident 1 expired at the hospital with the cause of death listed as anoxic brain injury. On 7/1/14 at 8 a.m., in an interview with LVN 1 as she was reading her notes, she stated on 6/28/14 at around 6:45 pm, she was in the room attending to Resident 1. LVN 1 stated before she repositioned Resident 1, she noticed half of the resident's face was on the pillow and the pillow was wet with saliva (watery liquid secreted into the mouth). LVN 1 stated almost at the same time Resident 1?s visitors entered the room and told her the resident ?looked funny.? LVN 1 then asked Resident 1 if she was all right, but Resident 1 did not open her eyes or respond. LVN 1 stated she took Resident 1's pulse and it was weak. LVN 1 stated she went to the Nurse?s Station in order to call the registered nurse (RN) 1 on the intercom for assistance. On 7/1/14 at 9:20 a.m., in a phone interview with RN 1, she stated LVN 1 paged her to Resident 1's room and when she got there, Resident 1 was unresponsive and her vital signs could not be obtained. RN 1 stated she left the room to check Resident 1's code status in the clinical record, which indicated full code (the provision of a full cardio-pulmonary resuscitation comprising of rescue breathing with chest compressions). RN 1 stated that was when she called 9-1-1 for assistance, and began copying the papers for the paramedics, so she could not assist in the actual CPR prior to the Paramedics arrival. When RN 1 was asked how she assessed Resident 1 when she first saw her, she stated she just checked the resident's pulse but the resident did not open her eyes. When asked for how long she took Resident 1's pulse and what the rate was, she could not recall. RN 1 was asked if she could have instead called other staff members for assistance to ensure timely initiation of CPR, she did not answer. RN 1 stated shortly after she instructed the facility staff to start the CPR, the paramedics arrived and took Resident 1 to the hospital. According to RN 1, she could not recall the exact time the CPR was initiated.On 10/9/14 at 4:06 p.m., in an interview, LVN 1 stated she took Resident 1?s pulse for about 45 seconds to a minute, which was ?weak.? LVN 1 could not remember what the pulse rate was. When asked about the resident?s breathing, LVN 1 stated she did not see the resident?s chest rising. LVN 1 stated when she came back to Resident 1?s room after calling RN 1; she attempted to take Resident 1's pulse rate again but was unable to find it. LVN 1 stated when RN 1 came to the room; she brought the crash cart (a wheeled container sometimes carrying medicine and equipment for use in emergency resuscitations). They administered oxygen through a face mask at 15 liters per minute. LVN 1 stated RN 1 could not obtain any of the vital signs. LVN 1 stated that was when she started CPR. When LVN 1 was asked how she ensured Resident 1 was getting enough oxygen when using a face mask instead of a bag-mask device which is commonly used when administering CPR, she did not answer. On 7/1/14 at 9:55 a.m., in an interview with the director of nursing (DON), she stated if the resident was found with a change of condition, the staff should check the vital signs. If the resident was not breathing, they should administer oxygen.A review of the paramedic report indicated on 6/28/14, the paramedic was dispatched at 18:56 (6:56 pm), arrived at the facility at 19:00 (7 pm). The report indicated that upon arrival, Resident 1 was seen lying supine (on her back) in bed and CPR was in progress. Resident 1 was in cardiac arrest. Procedures used included CPR; defibrillation (a process in which an electronic device gives a controlled electric shock to the heart to allow restoration of normal cardiac rhythm), cardioversion (a process that aims to convert an arrhythmia [abnormal heart rhythm] back to normal sinus rhythm), medication therapy including epinephrine administration (a medication used to restore cardiac rhythm), intubation (a placement of an artificial airway to assist in breathing), and oxygen therapy.On 7/3/14 at 2 p.m., a review of Resident 1's hospital History & Physicals dated 6/28/14 indicated Resident 1 was intubated. A review of the death certificate dated 8/1/14 indicated Resident 1 expired on 7/7/14 due to anoxic brain injury. The facility failed to provide Resident 1 with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, including:1. Failure to immediately follow Resident 1?s Physician Orders for Life-Sustaining Treatment (POLST - a form created for specific medical orders to be honored by health care workers during a medical crisis), 2. Failure to immediately activate the emergency response team by calling a code as designated by the facility?s protocol, when Resident 1 was first found unresponsive. Instead LVN1 went to the nurses? station to page a registered nurse, 3. Failure to designate a staff person to call 9-1-1 (emergency number). Instead, RN 1 left the room to check Resident 1's code status in the clinical record, which indicated full code. That is when 9-1-1 was called. 4. Failure to immediately open the resident?s airway when Resident 1 was found unresponsive, 5. Failure to utilize a bag-mask device method which forces the oxygen in to the lungs instead of administering oxygen through a regular mask, when Resident 1 was found unresponsive with a weak pulse, as recommended by the American Heart Association Adult Basic Life Support for Healthcare Providers.These failures resulted in lack of oxygen to Resident 1. Resident 1 expired at the general acute care hospital with the cause of death listed as anoxic brain injury (brain damage due to lack of oxygen).These violations resulted in substantial probability of death or serious physical harm to Resident 1. |
| 940000013 |
BELLFLOWER POST ACUTE |
940011609 |
B |
09-Jul-15 |
KOFO21 |
4118 |
F-323 CFR 483.25(h) Accident 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 must ensure that ? 1. The residents? environment remains as free from hazards as is possible.On 6/8/15, an unannounced visit was made to the facility to conduct a standard recertification survey which was completed on 6/12/15.Based on observation, interview, and record review, the facility failed to ensure that the residents? environment remained as free from hazards as is possible by failing to:Provide safe hot water temperatures below 120 degrees Fahrenheit (øF) in residents? common bathrooms and shower rooms which placed residents at risk for burn and scalding.During the general environmental inspection of the facility in the presence of the maintenance supervisor on 6/8/15, at 9:30 a.m., the evaluator noted that the temperatures of the hot water delivered to plumbing fixtures in resident bathrooms and in shower rooms were as follows: 1. Residents' common bathroom next to Station 1 was measured at 125.5 øF. 2. Residents ' common bathroom next to Room 5 was measured at 125.1 øF. 3. Residents ' bathroom #B-6 next to Oxygen room was measured at 128.2 øF 4. Residents ' shower room #S-3 was measured at 121.1 øF. 5. Residents ' bathroom in Room #17 was measured at 123.3 øF. 6. Residents ' bathroom in Room #22 was measured at 128.3 øF. According to the U.S. Consumer Product Safety Commission (http://www.cpsc.gov/) and (http://inspectapedia.com/plumbing/Scalding_Temperatures.htm), indicated that most adults will suffer third-degree burns if exposed to 130 degrees F for 30 seconds. A temperature of 120 øF for five minutes of exposure could result in third-degree burns. The U.S. Consumer Product Safety Commission urges to all users to lower their water heaters to 120 degrees F to prevent scalding, injuries, and death in elderly.There were a total of 18 residents in the affected rooms and 10 of the 18 residents were able to use the hand washing sinks independently. The other eight residents required assistance by staff to use the hand washing sinks. Three of the 10 ambulatory residents were diagnosed with cognitive impairment. The unsafe hot water temperature placed the residents at risk for burns and scalding. On 6/8/15 at 10:55 a.m., during an interview, the maintenance supervisor stated the high temperatures could be related to a malfunctioning circulation pump (temperature control valve that regulates the temperature of the hot water delivered to the plumbing fixtures used by the residents) located in the boiler room. The maintenance supervisor said that he kept a record of water temperature and had no prior problem with the water temperature. A review of the monthly temperature log did not indicate that hot water temperature reading were taken at the residents? bathrooms in May, 2015 and neither was there any hot water temperature readings recorded for shower rooms in June 2015. On 6/8/15 at 12:05 p.m., during an interview, the administrator stated a plumber would be called immediately to repair the problem. The facility's undated policy and procedure on Water Temperature indicated that water heaters that serviced resident rooms, common bathrooms, and tub/shower areas shall be set to temperatures of no more than 115 øF or the maximum allowed temperature per State regulation. The review of the plumber?s invoice dated 6/8/15, at 2:28 p.m., indicated that the circulation pump and the high water temperature were evaluated and set to a required temperature of 115 øF. The facility failed to ensure the resident environment remained as free from hazards as is possible by failing to: Provide safe hot water temperatures below 120 degrees Fahrenheit (F). in bathroom hand washing sinks used by residents which placed residents at risk of burns and scalding. The above violation had direct or immediate relationship to the health, safety, or security of the residents. |
| 940000069 |
BROOKFIELD HEALTHCARE CENTER |
940011766 |
B |
30-Oct-15 |
ZDUZ11 |
7368 |
?F 323 ? 483.25 (h) 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. The Department received a complaint on 7/31/14 that indicated a resident (Resident 1), who was confused, left the facility without a physician?s order and went missing. The police was notified and brought the resident back, three days later, on 7/21/14. The facility failed by not: 1. Supervising Resident 1 after he requested his debit card and indicated he was going shopping. 2. Implementing its policy for having a physician?s order to go out on pass. 3. Implementing its policy regarding reporting a missing resident to the Department.The facility?s failure to adequately supervise and implement the facility?s policy put Resident 1 at risk for harm and resulted in the resident not being supervised and not receiving his prescribed medications for three days.On 8/14/14 at 7 a.m., an unannounced visit was made to investigate allegations of quality of care issues, which included patient safety.The director of nursing (DON) stated during an interview on 8/14/14 at 8:25 a.m., that on 7/18/14, at approximately 5 p.m., the facility?s staff noticed Resident 1 was not in the facility. The DON stated the staff called her the next day (7/19/14) to report that Resident 1 went missing and stated she (DON) instructed the staff to call the police. She stated because of the staff?s delay in notifying her, the staff was given a written warning. The DON stated the resident was missing for three days and the facility did not know where he was. When the DON was asked if it was reported to the Department, she stated the incident of the resident going missing was not reported to the Department of Public Health.A review of an electronic nursing progress note, dated 7/18/19, and timed at 8:22 p.m., indicated Resident 1 could not be found. The note indicated Resident 1 did not have an ?out on pass? physician?s order and the resident did not sign out as being out on pass. According to the note, staff did not see the resident leave the facility. The note indicated the charge nurse who endorsed over nursing responsibilities to the next shift staff (11-7 shift) was supposed to notify the DON and the social service director (SSD) if the resident did not come back that night.On 8/14/14 at 10:06 a.m., during a telephone interview, Resident 1's friend stated the resident asked a facility?s staff (unknown) to call her so they could speak and they did. Resident 1?s friend stated she came to the facility on 7/18/14 to visit the resident, per his request. Resident 1?s friend stated while at the facility the resident asked her to assist him with banking and shopping and she agreed. She stated the resident then asked the social service director (SSD) for his debit card and the SSD jokingly told them Resident 1 and friend not to spend all the money.Resident 1?s friend stated the SSD did not ask any further questions. Resident 1?s friend stated after the outing, the resident did not want to return to the facility instead he wanted to be helped on to the train (Blue Line), which Resident 1?s friend stated she helped the resident to get on the train. The friend stated the facility had her telephone number, but did not call her until the next morning to inquire about the resident?s whereabouts.At 10:40 a.m., on 8/14/14, Resident 1 was observed dressed sitting in a wheelchair, with a left leg above the knee amputation (AKA). The resident was asked about the incident of going missing, but was unable to recall the incident.A review of the facility's policy titled, "Resident out of Pass," revised 5/2007, indicated the staff would obtain a physician's order for a resident to go out on pass with a responsible party.A review of Resident 1's clinical records indicated the resident was a 68 year-old non-ambulatory male, who was admitted to the facility on 3/25/14. His diagnoses included diabetes (high levels of blood sugar), hypertension (high blood pressure), atrial fibrillation (abnormal heartbeat), one-sided weakness due to a prior stroke ([CVA] cerebral vascular accident), history of deep vein thrombosis (DVT/a blood clot that forms in a vein deep in the body), and a left AKA amputation.A review of a Minimum Data Set (MDS), an assessment and care screening tool, dated 4/3/14, indicated the resident had memory problems, required extensive assistance from staff for bed mobility, transferring, dressing, toilet use, personal hygiene, and was incontinent (no control) of both bowel and bladder functions.According to physician's orders the resident was receiving the following medications for high blood pressure; Carvedilol 25 milligram (mg) twice a day, Hydralazine HCl 100 mg three times a day and Isosorbide Mononitrate 120 mg at bedtime. The resident also received Clopidogrel Bisulfate 75 mg for DVT control and Warfarin Sodium 3 mg in the afternoon for CVA prophylaxis. Resident 1 did not receive the above medications for three days, after he left the facility without a physician?s order. A review of Resident 1's care plan, dated 4/3/14, indicated the following problems and interventions; impaired cognitive function/dementia or impaired thought process related to disease process requiring supervision and assistance with all decision making. The plan of care also indicated the resident was at risk for activities of daily living (ADL) self-care performance deficit related to disease process requiring staff assistance for all ADL care.On 8/14/14, at 11:08 a.m., the SSD and DON were questioned about the resident?s elopement. The SSD was asked if she knew Resident 1 and his friend were leaving the facility to go shopping after she gave them his debit card, she did not answer. The SSD was also asked if the resident had a physician?s order to go out on pass, but the SSD would not answer. The DON stated it was unsafe for the resident to have been out on the streets wandering around for several days without supervision, food, and medications. The DON stated the staff should have supervised him closer, especially once they were aware he wanted to go shopping.An electronic progress note, dated 7/21/14, and timed at 3:30 a.m., indicated the police found the resident wandering around in his wheelchair in another local city area and brought him back to the facility.According to the facility's policy and procedure titled, "Missing Resident," dated 7/2007, indicated the facility?s staff will immediately search for the resident. If the resident was not located, the police department, the administrator and the DON would be notified that a resident was missing. The facility's policy and procedure also indicated that a family member or responsible party listed on the resident?s chart would also be called.The facility failed by not: 1. Supervising Resident 1 after he requested his debit card and indicated he was going shopping. 2. Implementing its policy for having a physician?s order to go out on pass. 4. Implementing its policy regarding reporting a missing resident to the Department. The above violation had a direct relationship to the health, safety, or security of Resident 1. |
| 940000011 |
BELL CONVALESCENT HOSPITAL |
940012186 |
A |
21-Apr-16 |
1E3211 |
21834 |
F309 ?483.25 PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING 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. F 327 ? 483.25(j) SUFFICIENT FLUID TO MAINTAIN HYDRATION The facility must provide each resident with sufficient fluid intake to maintain proper hydration and health. 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 that a resident received sufficient fluid to maintain proper hydration to prevent dehydration and fecal impaction, including but not limited to: 1. Failure to follow its undated policy and procedure, titled, ?Hydration,? for Resident 7 who had history of dehydration (deficit of total body water). 2. Failure to assess and document the actual amount of fluid intake and output for Resident 7, per the facility's policy. 3. Failure to provide fluids and ensure fluids were accessible for Resident 7, who was at risk for dehydration and required an extensive assistance in eating and drinking, to ensure hydration was maintained for fluid balance. 4. Failure to implement Resident 7?s plan of care to increase fiber and fluid intake. 5. Failure to adequately assess Resident 7?s bowel patterns and consistency of bowel movements especially after the first diagnosis of fecal impaction (hard stool in colon unable to pass), after the resident did not have a bowel movement for five days. These failures resulted in Resident 7 complaining of abdominal tenderness/pain due to not having regular bowel movements and requiring two transfers to a general acute care hospital (GACH) and being diagnosed with fecal impaction (mass of dry, hard stool that cannot pass out of the colon or rectum). Resident 7 had to be digitally dis-impacted (manual removal of feces or stool from the rectum) on 6/4/15 and 11/19/15. As a result of these deficient practices, Resident 7 required three transfers to a GACH,all related to hydration on 6/4/15, 11/19/15, and 12/12/15. Resident 7 was diagnosed with fecal impaction on the first two GACH transfers, requiring a large amount of intravenous ([IV], into the vein) fluids, oral laxatives (substances that loosen stools and increase bowel movements) and manual extraction of the stool. During the third transfer to the GACH, Resident 7 was diagnosed with an acute renal failure (a sudden and often temporary loss of kidney function [kidneys remove waste and help balance fluids and electrolytes in your body]) often related to dehydration and urosepsis (a life-threatening bacterial infection of the blood; urosepsis is sepsis that complicates a urinary tract infection), requiring IV fluids for dehydration and IV antibiotics for the urosepsis. Resident 7?s GACH?s laboratory results were as follows: white blood cell count at 16.32 per microliter ([WBC] normal reference range [NRR] =4.5-11), creatinine 2.3 (NRR= .6-1.2 mg/dl) sodium 151 (NRR=135-145 meq/L) and a BUN of 89 ([blood urea nitrogen] NRR=7-20 mg/dl.).On 3/17/16 at 7 p.m., during the facility?s initial tour, Resident 7 was lying on a low bed, sleeping, with two half side rails up. A water pitcher, dated 3/18/16, with NTL (nectar thickened liquid) written on it, was observed on a night stand located at the far left of the resident's head of the bed, while the bed was positioned in its lowest position making it difficult for Resident 7 to reach. On 3/18/16 at 8:30 p.m., during another observation and a concurrent interview, Resident 7 was lying on a low bed with two half-side rails up. There was a pitcher, dated 3/19/16, with NTL ([nectar thickened liquid] liquids that have been thickened to a consistency that coats and drips off a spoon, similar to unset gelatin) written on it, placed on the night stand at the far left of the resident's head of the bed. There was no cup near the pitcher. The bed remained at its lowest position making it difficult to reach if Resident 7 wanted to drink. Resident 7 was asked if he speaks English, and stated, ?Poquito (meaning a little in Spanish).? Resident 7 was asked if he was thirsty, and he stated, "Yes."On 3/18/16, at 9:10 p.m., during a concurrent interview and record review, Resident 7's Intake and Output Record, dated 3/1/16 to 3/17/16, indicated documentation of Resident 7's fluid intake by mouth for all three shifts (7 a.m. to 3 p.m., 3 p.m. to 11 p.m., and 11 p.m. to 7 a.m.). The total fluid intake for Resident 7 every 24 hours averaged between 500 to 700 cubic centimeters (cc). The DON stated the facility only monitors Resident 7?s fluids taken by resident during medication pass and fluids offered by nurses every time the resident was encouraged to drink. The DON further stated the facility monitors Resident 7?s fluid intake, because the resident had urinary retention (inability to urinate) and required in and out catheterizing (removal of urine from the bladder through the use of a rubber catheter) every shift if he does not urinate. The DON stated the facility did not monitor the fluids provided and taken by Resident 7 during meals (breakfast, lunch, and dinner).A review of an Initial Nutritional Assessment, dated 12/4/15, written by the facility's RD, indicated Resident 7's daily fluid requirements was 1,848 cubic centimeters (cc).A review of Resident 7's Face Sheet (admission record) indicated the resident was a 58 year-old male who was initially admitted to the facility on 9/3/14, and last readmitted on 12/16/15. The resident's diagnoses included urinary calculus (a stone in the urinary tract), anemia (the red blood cell count [RBC] or hemoglobin [oxygen carrying capacity] is less than normal), diabetes (a group of metabolic diseases in which there are high blood sugar levels over a prolonged period), and fecal impaction. A review of Resident 7's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 3/1/16, indicated Resident 7 had impaired communication skills and required extensive assistance (resident involved in activity, staff provide weight-bearing support) in bed mobility, and was totally dependent on staff with transferring. The Licensed Nurse Weekly Summary, dated from 12/1/15 to 3/14/16, indicated Resident 7 required extensive assistance in eating. A review of the Licensed Nurses Progress Notes indicated the following: On 5/30/15 at 2 p.m., the resident (Resident 7) had no bowel movement. Medication was provided. On 5/30/15 at 9:40 p.m., Resident 7 had no bowel movement. Encouraged resident to consume meal, but refused dinner. Provided the resident oral fluid intake, as tolerated.On 5/31/15 at 4 p.m., a new order for bowel management, was received and carried out. On 6/1/15 at 10:30 a.m., an ultrasound of the abdomen was done and reported to the physician with no new orders at 3:30 p.m. On 6/1/15 at 3:40 p.m., Resident 7 complained of mild nausea and ate 40 % of lunch. "Abdominal distention noted but improved from a few days ago." No bowel movement during the day. On 6/3/15 at 4 p.m., laboratory result reported to the physician with no new orders. On 6/4/15 at 9 a.m., Resident 7 was lethargic (inactive; slow). Did not eat breakfast and complained of general weakness with a slight headache. Abdominal distention was continuously noted, but had a small amount of bowel movement three days in a row (but was not documented by the certified nurse assistants on the ADL form). The physician was notified and Resident 7 was transferred to the hospital. There was no documented evidence that the licensed nurses checked Resident 7 for a fecal impaction, after not having an adequate bowel movement and complaining of abdominal distention and nausea (motion sickness; feeling sick or queasy) for five days.A review of Resident 7's physician's orders, dated 6/4/15, indicated the resident was transferred to a GACH on 6/4/15, for diagnoses of failure to thrive and possible sepsis (life threatening infection/severe blood infection that can lead to organ failure and death). According to the physician's telephone orders, dated 6/9/15, Resident 7 was readmitted back to the facility on 6/9/15 (five days later) with diagnoses of fecal impaction and urinary tract infection ([UTI] an infection that affects part of the urinary tract). A review of the GACH's history and physical (H/P), dictated on 6/5/15, indicated Resident 7 was admitted for further care and treatment for an acute UTI and fecal impaction. During Resident 7?s hospital stay the resident received intravenous fluids, IV antibiotics (treatment of infection), and was digitally dis-impacted. A review of an untitled facility form that certified nurse assistants (CNA) records residents' ADLs (activities of daily living) performance, for the month of 6/2015, indicated Resident 7 had no bowel movements recorded from 5/30/15 to 6/3/15. The form did not have a method for the CNAs to record and document a residents' stool consistency, to ensure a resident was having regular bowel movements. The CNAs only recorded the number of bowel movements per shift and if a resident was incontinent of bowel (inability to control bowel movement).There was no documented evidence that the licensed nurses monitored or recorded Resident 7's bowel patterns with regard to the amount and consistency.A review of Resident 7's Medication Administration Record (MAR) for the month of 6/2015, indicated a physician's order, since 9/8/14, for milk of magnesia ([MOM] a laxative) 30 cubic centimeters (cc) orally as needed (PRN) once a day for constipation. The MAR did not have any documented evidence that MOM was given to Resident 7 when the resident complained of abdominal pain/tenderness and did not have a bowel movement for five days from 5/30/15 to 6/3/15.A review of an online article by the National Center for Biotechnology Information (NCBI) titled, "Fecal Impaction: A Cause for Concern?? indicated fecal impaction was a result of chronic or severe constipation, mostly found in the elderly population. The article indicated the three most important risk factors were bowel hypomotitlity (slow movement of bowels), inadequate dietary fiber and water intake. The article indicated treatment is aimed at relieving the major complaint and correcting the underlying fecal impaction to prevent reoccurrence. Also after removal of the impaction, the resident should be placed on additional stool softeners and laxatives for bowel management. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3348734/ A review of another telephone physician's order for Resident 7, dated 11/19/15, indicated Resident 7 was transferred to the GACH again due to abdominal tenderness and pain. Resident 7 was re-admitted to the facility on 11/27/15, with diagnoses that included fecal impaction (second one). A review of the GACH's abdominal CT Scan (computed tomography (X-ray CT) or computerized axial tomography scan [CAT scan]), performed on 11/19/15, indicated Resident 7 had a large amount of stool within the colon, particularly within the rectum (the concluding part of the large intestine that terminates in the anus) with distention (occurs when substances, such as stool, air (gas) or fluid, accumulate in the abdomen causing its outward expansion beyond the normal girth [ measurement around the middle of something, especially a person's waist]). A review of Resident 7's preprinted care plan, initiated on 11/28/15, and titled, ?At Risk for Dehydration," indicated Resident 7 was at risk for dehydration related to being dependent on staff for fluid intake, laxatives, and impaired cognition. The staff's approaches included monitoring intakes, weights, encouraging oral fluid intake, and offering fluids frequently. The care plan did not specify how the facility would monitor Resident 7's intake. There was no documented evidence the facility had a method on how to monitor intake from both nursing and dietary department to ensure Resident 7 was hydrated.A review of Resident 7's Hydration Assessment, dated 11/28/15, indicated the resident's medical factors and conditions did not have an impact on the resident's dehydration and fluid maintenance status. A handwritten entry, dated 11/28/15, indicated Resident 7 was able to reach fluid at bedside [sic].Another handwritten entry, dated 12/17/15, indicated a reevaluation of the resident's hydration assessment, which indicated the resident had no signs and symptoms of dehydration, but had a poor appetite and refused to drink water at times, despite constant recommendation for hydration [sic]. There was no documented evidence that these concerns were included in the Resident 7's care plans.A review of Resident 7's preprinted care plan, dated 11/29/15, and titled, "Patient Care Plan Sheet," indicated Resident 7 was at risk for constipation related to medication, decreased physical activity, and had a history of fecal impaction. The staff's approaches included offering foods high in fiber, monitoring and recording Resident 7's bowel patterns, and assessing for fecal impaction if no bowel movement in three days. The care plan did not specify how the facility's staff would assess Resident 7 for fecal impaction and constipation. There was no documented evidence the facility had a method on how to conduct an assessment for constipation, such as describing the consistency of the stool as hard or soft, and that the facility had offered foods high in fiber and incorporated it in the resident's diet. A review of an undated facility's policy and procedure titled, "Policy and Procedures on Hydration," indicated that CNAs shall ensure provision of water pitchers by the residents' bedside, unless contraindicated, with a clean cup in reach for the resident's use. The policy stipulated the residents who were dependent on staff for performance of ADLs, fluid will be offered at least once every two hours. The policy also indicated residents at high risk for dehydration shall be placed on a 72 hour monitoring of intake and output to obtain baseline data of hydration status to identify any problems of poor hydration. There was no documented evidence that Resident 7 was offered fluids at least once every two hours and how much fluids Resident 7 consumed.A review of another telephone physician's order, dated 12/12/15, indicated Resident 7 was transferred to the GACH due to poor oral intake, altered level of consciousness (ALOC), and urolithiasis (the formation of urinary calculi (urinary stones), which are calculi formed). Resident 7's was readmitted on 12/16/15, with diagnoses of dehydration (a deficit of total body water), urosepsis, and acute renal failure (kidney not functioning well [filtering waste from the blood]). A review of the GACH's history and physical (H/P) for Resident 7, dated 12/13/15, indicated Resident 7 was admitted to the GACH with metabolic encephalopathy (temporary or permanent damage to the brain that happens when the body's metabolic processes are seriously impaired), dehydration, urosepis, and acute renal failure. A review of the GACH's physician's progress note, dated 12/15/15, indicated Resident 7 received intravenous fluids (IVF) because of hypernatremia of 151 mEq/L ([milliequivalents per liter] an elevated sodium level in the blood, specifically a serum level above 145 mEq/L [ normal reference range 135-145]) consistent with free water deficiency. A review of a handwritten nurse?s entry, dated 1/3/16, indicated Resident 7 continuously refused to eat or drink. The note indicated the facility will continue to offer extra fluids and monitor.According to the skilled nursing facility's Medication Administration Record (MAR) for Resident 7, dated 3/1/16 to 3/18/16, Resident 7 was receiving a diet of pureed consistency (soft, smooth, thick paste consistency similar to a thick pudding) and nectar thickened liquids every meal. A handwritten nurse's note, dated 3/4/16, indicated Resident 7 had poor oral intake at times, but was still within the ideal body weight (IBW). The note further indicated Resident 7 had no signs and symptoms of dehydration at that time, but the nurse documented they would continue to monitor. There was no documented evidence that a care plan was developed for Resident 7's poor appetite and refusal to eat and drink water. There was also no documented evidence that Resident 7's plan of care was revised for the concerns of the resident's risk for dehydration. On 3/19/16, at 10:20 a.m., during an interview, the dietary supervisor (DS) stated she was too busy to attend the facility's IDT Resident Care Conferences. The DS stated that she writes progress notes and reviews resident's weight records, meal intakes, and the physician's orders. The DS could not answer when asked how the facility was ensuring that Resident 7 was receiving the daily fluid requirements.A review of the facility's interdisciplinary (IDT) Resident Care Conference Reviews, dated 6/8/15, 6/22/15, 9/4/15, 12/4/15, 1/15/16, and 3/4/16, indicated lack of attendance of the dietary supervisor (DS) and registered dietitian (RD) during some of the conferences. There was no documented evidence that an IDT approach was utilized to address Resident 7's clinical conditions to develop a plan of care for Resident 7, who had recurrent urinary tract infections, fecal impaction, and dehydration given the risk factors of poor oral intake, poor mobility, requiring extensive assistance in eating/drinking, refusal to drink, having dysphagia and receiving pureed diets with thickened liquids, weight loss, and renal disease. A review of Resident 7's Nutritional Progress Note, dated 3/4/16, indicated the DS documented the resident had poor oral intake averaging between 30 to 60 percent (%) per meal with weight loss. The DS further documented that Resident 7 was receiving pureed diet with nectar thick liquids and had a recent urinary tract infection on 2/22/16. The DS written recommendations indicated the plan was to improve Resident 7's appetite and to continue with the same diet with "good intake."A review of the Nutritional Progress Note, written by the RD, dated 3/17/16, indicated a high protein nourishment drink was ordered on 3/9/16 to be given twice daily.A review of an undated facility's policy and procedure titled, "Policy and Procedures on Hydration," indicated that CNAs shall ensure provision of water pitchers by the residents' bedside, unless contraindicated, with a clean cup in reach for the resident's use. The policy stipulated the residents who were dependent on staff for performance of ADLs, fluid will be offered at least once every two hours. The policy also indicated residents at high risk for dehydration shall be placed on a 72 hour monitoring of intake and output to obtain baseline data of hydration status to identify any problems of poor hydration.There was no documented evidence that Resident 7 was offered fluids at least once every two hours and the staff documented the amount of fluids Resident 7 consumed. There was also no documented evidence that other recommendations were made by the RD, DS, or IDT, after Resident 7 continued to refuse to eat and drink.On 3/20/16 at 3:30 p.m., during a telephone interview, the facility's RD was asked what interventions were implemented to ensure that Resident 7 met his fluid requirements to maintain good hydration. The RD acknowledged that the fluids consumed by the resident from dietary were not included in the monitoring of Resident 7's intake to ensure the resident met the fluid requirements of 1,848 cc per day. The RD also agreed that the DS should have been present at all the facility's IDT Care Conferences, especially since Resident 7 had continuing problems with refusing to drink, eat, and had a high risk for dehydration. The RD stated Resident 7's poor hydration may lead to another urinary tract infection and fecal impaction. The RD further stated either she or the DS can develop care plans for the residents nutritional and hydration problems.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 that a resident received sufficient fluid to maintain proper hydration to prevent dehydration and fecal impaction, including but not limited to: 1. Failure to follow its undated policy and procedure, titled, ?Hydration,? for Resident 7 who had history of dehydration (deficit of total body water). 2. Failure to assess and document the actual amount of fluid intake and output for Resident 7, per the facility's policy. 3. Failure to provide fluids and ensure fluids were accessible for Resident 7, who was at risk for dehydration and required an extensive assistance in eating and drinking, to ensure hydration was maintained for fluid balance. 4. Failure to implement Resident 7?s plan of care to increase fiber and fluid intake. 5. Failure to adequately assess Resident 7?s bowel patterns and consistency of bowel movements,especially after the first diagnosis of fecal impaction (hard stool in colon unable to pass), and after the resident did not have a bowel movement for five days. 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. |
| 940000011 |
BELL CONVALESCENT HOSPITAL |
940012187 |
B |
21-Apr-16 |
1E3211 |
3357 |
?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.The facility failed to follow its policy to post the accurate and most recent star rating, determined by the Federal Centers for Medicare and Medicaid Services (CMS): 1. In areas accessible and visible to members of the public. 2. Used for employee?s break. 3. Used by patients for communal activities including a dining area or activities room. On 3/17/16 through 3/19/16, a recertification survey was conducted. During several observations, the facility?s overall star rating information was only posted in the facility?s dining room/activities room. The posting indicated the facility had "five stars," there was no star rating information posted in the employee?s lounge or the facility?s lobby. According to CMS (Center for Medicare/Medicaid Services), the Star Posting must be in at least the following locations: an area accessible and visible to the public; an area used for employee breaks and an area used by residents for communal functions and activities. On 3/19/16, at 4 p.m., the administrator provided a copy of an updated print-out of the facility's STAR rating from CMS. The print-out indicated the facility had "three stars."At 4:30 p.m., on 3/19/16, during an interview, the administrator stated the facility received a letter from CMS indicating the facility?s overall star rating was three stars for the year 2015. The administrator stated the 5 star rating for the year 2014 information was posted in the facility?s dining room, because the facility?s owner stated to leave it that way. The administrator stated the facility did not post the current three stars rating in two more areas, such as the employee lounge and the lobby, as stipulated in the facility?s policy and by CMS. On 3/19/16, at 4:45 p.m., during an interview, the director of nursing (DON) stated he was not aware that the current three stars rating information was supposed to be posted in three areas. The DON stated he thought it was supposed to be posted only in the residents? dining room/activities room.A review of the facility's undated policy and procedure titled, "Star Rating (5 Star Rating)," indicated that it was the policy of the facility to ensure the public was informed about the facility?s current star rating according to the California regulations. The policy further stipulated that the star rating should be posted on the following locations: lobby, dining/activity area, and nursing lounge. The facility failed to follow its policy to post the accurate and most recent star rating, determined by the Federal Centers for Medicare and Medicaid Services (CMS): 1. In areas accessible and visible to members of the public. 2. Used for employee?s break. 3. Used by patients for communal activities including a dining area or activities room. |
| 940000013 |
BELLFLOWER POST ACUTE |
940012352 |
A |
28-Jun-16 |
OO2K11 |
16379 |
F250 ?483.15(g) (1) Provisions of Medically Related Social Service The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. 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. F 323 ? ?483.25 (h) 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. The Department received two entity reported incidents (ERI) and a complaint. The facility initially left a voice message on 10/26/15, indicating a resident (Resident 1) left the facility and got hit by a car sustaining minor abrasions. A follow-up ERI, dated 10/26/15, indicated Resident 1 was struck by a car, but sustained more serious injuries and was transferred to a general acute care hospital (GACH). A complaint was received on 10/30/15, alleging Resident 1, who had dementia with a cognition decline with psychosis, was struck by a car sustaining multiple injuries requiring hospitalization. The facility failed to ensure medically-related social services were provided to attain and maintained the highest practicable mental and psychosocial well-being and the residents environment remains as free from accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents, including but not limited to: 1. Failure to follow the physician?s orders for a psychiatric consult for Resident 1, who had dementia (loss of memory and other mental abilities severe enough to interfere with daily life) and was exhibiting delusional behavior (a type of serious mental illness in which a person cannot tell what is real from what is imagined). 2. Failure to provide supervision for Resident 1, who expressed she wanted to leave the facility. 3. Failure to prevent Resident 1 from leaving the facility unsupervised within minutes, after she left out of the facility unsupervised and was brought back. These deficient practices resulted in Resident 1 not receiving an evaluation and treatment to manage her problematic behaviors, such as delusions (a type of serious mental illness in which a person cannot tell what is real from what is imagined), which resulted in Resident 1 leaving the facility on 10/24/15 unsupervised twice in one day, running across a busy street in front of the facility and was struck by a car. Resident 1 was transported to a GACH after the accident and was diagnosed with multiple injuries that included bleeding in the brain (subdural hemorrhage [SDH] with a left skull hematoma [a localized collection of blood outside the blood vessels, usually in liquid form within the tissue]), a collapse lung ([pneumothorax] a buildup of air in the space between the lung and the chest wall (pleural space) and an injury of the spine. Resident 1 was admitted to the GACH for nine days. An unannounced complaint/ERI investigation was conducted on 10/27/15. A review of Resident 1's admission record indicated that Resident 1 was a 77 year-old female who was initially admitted to the facility on XXXXXXX. Resident 1's diagnoses included dementia (loss of memory and other mental abilities severe enough to interfere with daily life) and anxiety disorder (excessive worry or fear). At 11 a.m. on 10/27/15, during an interview, the director of nursing (DON) stated Resident 1 was sent to a GACH after the incident on 10/24/15. The DON stated at approximately 7 p.m., on 10/24/15, Resident 1 went out of the facility using the front door and the facility's staff went after Resident 1 and redirected Resident 1 back to the facility. According to the DON, the staff took Resident 1 back to her room but "after a few minutes,? Resident 1 went outside again unsupervised. The DON stated two licensed vocational nurses (LVNs A and B) and one certified nursing assistant (CNA A) had to run after Resident 1 when the resident went out of the facility the second time. Per the DON, Resident 1 was telling the staff, who ran after her, to leave her alone and for the staff to go away. The DON stated, "Suddenly she ran across the street." The DON stated the incident happened all of a sudden and it was unexpected. The DON stated Resident 1 had no prior behavior of wandering or elopement. On 10/27/15 at 12:15 p.m., during a telephone interview, Resident 1's family member (FM 1) stated Resident 1 was admitted to the facility under hospice care (a program that helps people who are dying to have peace, comfort, and dignity). FM 1 stated that Resident 1 had dementia and ?she sees and imagines things." According to FM 1, Resident 1's condition had not advanced drastically so she was discharged from hospice care. During the interview, FM 1 stated a nurse from the facility called him on 10/24/15, at approximately 10 p.m., and stated the nurse sounded very distraught and told him that a car "bumped" Resident 1 when she crossed the street. FM 1 stated the nurse had explained to him that Resident 1 was saying she was going to meet him across the street. FM 1 stated he had not arranged to meet with Resident 1 across the street. FM 1 stated, "She's (Resident 1) imagining things and they know that." FM 1 stated, ?The facility's staff knew that she (Resident 1) says weird stuff like she bought the building across the street (from the facility)." FM 1 stated, ?She (Resident 1) was supposed to have a psych (psychiatric) consult, but they never did anything." A review of a licensed nurses? progress note, dated 7/5/15, and timed 7 a.m. to 3 p.m. shift, indicated Resident 1 displayed periods of confusion and disorientation. Per the nurses? note, Resident 1 gets easily irritated and preferred to be left alone. A review of Resident 1's Minimum Data Set (MDS), an assessment and care screening tool, dated 9/18/15, indicated the facility staff did not identify Resident 1 as having potential indicators of psychosis (occurs when a person loses contact with reality. The person may have false beliefs about what is taking place, or see or hear things that are not there). The MDS indicated that Resident 1 did not manifest behavioral symptoms and did not exhibit refusal of care. According to the MDS, Resident 1 was ambulatory and only required oversight when moving to and from distant areas. A review Resident 1's Medication Administration Records (MARs), for the months of September and October 2015, indicated Resident was not receiving any antipsychotic/psychotropic medications (used for treatment of mental illness). A review of Resident 1's social work progress note, dated 8/12/15, and timed at 10:30 a.m., indicated Resident 1 had become more confused and disoriented. The social service designee (SSD) documented, "Resident (Resident 1) confused again this morning. She says she bought the building across the street." According to the SSD's note, Resident 1 stated, "I am going across the street to take a shower and I will be back." A review of the licensed nurse weekly summary, dated 8/24/15 indicated Resident 1 had delusions of "people stealing her money." The note further indicated that Resident 1 was resistive with nursing care. A review of Resident 1's "Activity Assessment" conducted by the SSD, dated 9/17/15, indicated Resident 1 was known to refuse care, was irritable, yelled at others, and can become combative (striking out). The SSD documented that Resident 1 displayed, "No real change. On 10/27/15 at 1:58 p.m., during an interview, the SSD stated that it was not necessary to address Resident 1's prior behavior of wanting to go to the building across the facility. When the SSD was asked if the psychiatrist had seen and examined Resident 1, the SSD stated, while reviewing Resident 1's record, she could not find documented evidence that it was done. A review of Resident 1's physician's progress note, dated 8/22/15, the physician documented, "Very agitated, loud, using foul language and refuses to be examined or give her medical history." The physician indicated that a psychiatric consultation was advised for Resident 1. A review of Resident 1's physician's orders, dated 8/22/15, indicated an order for a psychiatric (diagnosis, prevention, study and treatment of mental disorders) consultation. Resident 1's physician's orders for the months of September and October 2015 also indicated a "Psychiatric Consult as needed." A review of Resident 1's care plan titled, "Mood States and Cognitive Loss/Dementia," dated 10/1/15, did not identify Resident 1 as having behavioral symptoms of having false beliefs, yelling, and rejection of care. The care plan area to describe Resident 1's behavior manifestations was left blank and did not indicate Resident 1's actual behaviors. During an interview on 10/27/15 at 3 p.m., LVN A stated she was on-duty on the day of the incident (10/24/15). LVN A stated she was passing medications when she noticed Resident 1 pacing in and out of the room and to the restroom located in the front hallway. LVN A stated Resident 1 exited the facility through the front door and she asked CNA A to "keep an eye on the resident" after they had brought Resident 1 back to her room after leaving the building the first time. According to LVN A, CNA A had to help another resident and was not able to watch and Resident 1 left the facility again. LVN A stated she was unable to convince Resident 1 to come back in the facility and thought it was "abuse" if she had persisted to ask Resident 1 to come back in the facility. LVN A stated Resident 1 was yelling back at them and did not want to come back inside the facility. At 3:30 p.m., on 10/27/15., during an interview, a licensed vocational nurse (LVN B) stated he went after Resident 1 when she exited the facility on 10/24/15. LVN B stated he was surprised about the incident because it was only his third day on the job. LVN B stated they were "discussing what to do with the resident and trying to get her to go back in." According to LVN B, Resident 1 walked toward the sidewalk and ran into the street. A review of a progress note written by LVN A, dated 10/24/15, and timed at 7:30 p.m., indicated the resident abruptly begin to run from the staff entering the street and onto incoming traffic flow. The progress note indicated Resident 1 fell in the street on the left side. LVN A documented that Resident 1's head was bleeding from a laceration (a deep cut or tear in skin or flesh) and Resident 1 was assisted onto a wheelchair and brought back inside the facility. LVN A documented, "Asked resident why she ran across the street and she stated, 'My son is across the street and taxi is waiting.' LVN A documented that she had spoken with Resident 1's family member (FM 1) and that FM 1 denied being at the facility and/ or making arrangements to be with Resident 1 that day. According to Resident 1's progress note, dated 10/24/15, and timed at 7:40 p.m., indicated that 911/paramedics were called and arrived at the facility and took the resident to a general acute care hospital (GACH). A review of the facility's policy and procedure titled, "Care for Residents with Dementia" dated 8/2015, indicated that the IDT will review the treatment plan of a resident with dementia to address the physical, psychological, behavioral symptoms and underlying causes. The IDT will monitor the effectiveness of interventions and provide an ongoing assessment as to whether they (the residents) are improving or stabilizing the resident's status or causing adverse consequences. The policy stipulated additional approaches for care included the following: - Activities that divert resident's attention. - Ensure that staff establish familiarity with residents and are aware of resident's preferences regarding care. - The physician must be immediately consulted when there is significant change in the resident's physical, mental, or psychosocial status. On 10/27/15 at 5:30 p.m., during an interview, the director of nursing (DON) stated that there was no documentation of an interdisciplinary team meeting conducted to discuss Resident 1's care (since admission 7/2015). The DON stated she was not aware why Resident 1 never received a psychiatric consultation and stated, "We are still in the process of cleaning up the facility." At 5:45 p.m., on 10/27/15, during an interview, the assistant DON (ADON) stated she reviewed and revised Resident 1's care plans. The ADON stated that she used information on the MDS, MARs, and input from the interdisciplinary team (IDT) to update Resident 1's care plans. When asked about the IDT meetings for Resident 1, the ADON was unable to provide documentation of one occurring. A review of Resident 1's psychiatric consultation note from the GACH, dated 10/30/15, indicated Resident 1 had visual hallucinations and poor judgement. A review of the facility's policy and procedure titled, "Care for Residents with Dementia" dated 8/2015, indicated that individuals with dementia may also have underlying mental disorders or other conditions causing or contributing to impaired cognition and problematic behavior. These residents will be assessed by the physician or referred for psychiatric consultation for proper diagnosis. A review of Resident 1's discharge summary from the GACH, dated 11/4/15, indicated the resident was brought to the emergency room via paramedics with final diagnoses of ?Auto versus Pedestrian." The record indicated Resident 1 sustained a small intracranial brain hemorrhage (bleeding into the brain), a small left pneumothorax (lung collapse), a transverse process fracture of the left lumbar ([L1 through L4] break in the lower bones in the spine), and a hematoma in the left psoas muscle (solid swelling of clotted blood in the muscles of the left side of the spine) after being struck by a car, rolling on the car's hood and falling to the ground. Resident 1 received a battery of exams and test and required nine days of hospital admission, which included intensive care and neurology (the branch of medicine or biology that deals with the anatomy, functions, and organic disorders of nerves and the nervous system) monitoring, pain medications, and trauma, psychiatry (devoted to the diagnosis, prevention, study and treatment of mental disorders), and neurology consults to stabilize Resident 1 prior to discharge. A review of a GACH's psychiatry consultation, dated 10/30/15, indicated Resident 1 had poor insight and judgment, and exhibiting visual hallucinations. The psychiatrist recommended social service involvement regarding the resident's psychosocial (pertaining to or involving both psychic [relating to the soul or mind] and social aspects) issues with a possible placement needed in a locked facility. The psychiatrist ordered for Resident 1 to start on Haldol (antipsychotic medication [a class of psychiatric medications primarily used to manage psychosis]). The facility failed to ensure the residents environment remains as free from accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents, including but not limited to: 1. Failure to follow the physician?s orders for a psychiatric consult for Resident 1, who had dementia (loss of memory and other mental abilities severe enough to interfere with daily life) and was exhibiting delusional behavior (a type of serious mental illness in which a person cannot tell what is real from what is imagined). 2. Failure to provide supervision for Resident 1, who expressed she wanted to leave the facility. 3. Failure to prevent Resident 1 from leaving the facility unsupervised within minutes, after she left out of the facility unsupervised and was brought back. 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. |
| 940000011 |
BELL CONVALESCENT HOSPITAL |
940012354 |
B |
24-Jun-16 |
NUG411 |
11118 |
F205 ?483.12(b) (1) & (2) Notice of Bed-Hold Policy Before/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. The Department received a complaint on 5/30/14, alleging that the facility refused to honor Resident 1's 7-day bed hold and would not readmit Resident 1. According to the complaint, on 5/22/14 (three days after admission), a case manager from a general acute care hospital (GACH) attempted to transfer Resident 1 back to the facility, but was told by the director of nurses (DON) the facility was unable to take care of Resident 1 and refused to readmit her. The facility failed to ensure residents who transfer to a hospital or go on a medical leave are provided with written information regarding the bed-hold policy under the State plan and the resident is permitted to return and resume residence in the nursing facility as stipulated in its policy, including but not limited to: 1. Failure to provide Resident 1?s family member or legal representative written notice, which specified the duration of the bed-hold policy. 2. Failure to permit Resident 1 to return and resume residence in the facility during the 7 day bed-hold period. This deficient practice resulted in Resident 1 being displaced and transferring to another skilled nursing facility (SNF 2), without proper preparation and notice, which had the potential to result in unnecessary anxiety. On 5/30/14, at 12:30 p.m., an unannounced complaint investigation was conducted to investigate the facility's refusal to re-admit Resident 1 from a GACH. A review of Resident 1's Admission Face Sheet indicated Resident 1 was a 43 year-old male who was admitted to the facility on XXXXXXX. Resident 1's admitting diagnoses included gastrointestinal hemorrhage (relating to the stomach with bleeding) , attention to gastrostomy ([GT] a surgical procedure for inserting a tube directly into the stomach through the abdomen wall incision for administration of food, fluids, and medications), anemia (a decrease in the amount of red blood cells), mental retardation (a condition in which your brain does not develop properly or function within the normal range), and cerebral palsy (disorder of movement, muscle tone or posture that is caused by an insult to the immature, developing brain, most often before birth). On 5/30/14 at 12:30 p.m., during an interview, the director of nursing (DON) stated she was not refusing to re-admit Resident 1, but stated the facility was unable to care for Resident 1 because he needed a sub-acute care (a level of treatment that is between chronic [e.g. skilled nursing facility) and acute [e.g. acute care hospital]). On 5/30/14, at 1:30 p.m., during an interview, the administrator (ADM 1) stated that he was aware of the regulations. The administrator stated he felt seven days had elapsed and that Resident 1 would be considered a new admission and the facility had a right to refuse residents they could not care for. On 6/14/16, at 10:56 a.m., a follow-up complaint investigation was done, during an interview, Administrator 2 (ADM 2) stated Resident 1 was discharged, but she could not remember the date and why Resident 1 was not re-admitted. A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 4/10/14, indicated Resident 1 had short and long-term memory problems and Resident 1's cognitive skills for daily decision-making was severely impaired. A review of Resident 1's physician's order, dated 5/19/14 indicated Resident 1 was transferred to the GACH on 5/19/14, for displacement of the GT tube with gastrointestinal bleeding. The physician ordered a seven (7) day bed hold. A review of Resident 1's GACH emergency department report, dated XXXXXXX, and timed at 6:18 p.m., indicated Resident 1 had a gastric GT dislodgment and was admitted to the GACH. A review of the GACH's records, Resident 1's physician's note, dated 5/20/14, and timed at 9:39 p.m., indicated to consult intervention radiology ([IR]providing minimally invasive image-guided diagnosis and treatment of diseases in every organ system) for Resident 1's new gastric tube placement. According to Resident 1's discharge summary, dated 5/20/14, Resident 1's GT tube placement was done by IR. A review of Resident 1's GACH nursing note, documented by a case manager (CM 1) from the regional center, dated 5/22/14, and timed at 9:09 a.m., indicated that CM 1 sent a referral for placement in the facility (skilled nursing facility [SNF1]) and was waiting for a response. A review of another nursing note, dated 5/22/14, and timed at 1:56 p.m., written by the case manager (CM 2) from the GACH, indicated CM 2 called SNF 1 and talked to ADM 1 and was told they were not able to take Resident 1 back. According to the note, ADM 1 stated Resident 1 required a level one for care, which included to receive two antibiotics and they did not have 24 hours of registered nurses (RNs) in their facility. A review of CM2's note, dated 5/22/14, and timed at 2:51 p.m., indicated Resident 1 was not being accepted back to SNF 1. CM 2 documented requests for placement referrals for Resident 1 was sent to other facilities and was waiting for a response. A review of the GACH's medicine progress note disposition, dated 5/24/14, and timed at 10:59 a.m., indicated Resident 1 required placement at a SNF (skilled nursing facility) given the resident's inability to care for self. A review of CM2's nursing note, dated XXXXXXX, and timed at 11:41 a.m., indicated Resident 1 was discharge to another SNF (SNF 2). On 6/14/16, at 11:21 a.m., during an interview, the facility's (SNF 1) social worker designee (SSD) stated Resident 1 did not sign the admission agreement, which included the seven day bed hold and the admission transfer and discharge notice. The SSD stated Resident 1 was not able to sign the admission agreement upon admission and stated she had tried to call the regional center and the responsible party, but never received a call back. The SSD stated she did not document the calls attempted in Resident 1's record. On 6/14/16 at 11:33 a.m., during a subsequent interview, ADM 2 stated Resident 1 was discharge from the facility to a GACH on 5/19/14. ADM 2 stated, "I think maybe the reason why Resident 1 was not re-admitted to the facility was because of too many medical problems and his diagnosis of mental retardation." ADM 2 stated Resident 1 was previously under the care of the regional center for his mental disabilities. ADM 2 stated if a resident was discharged to a hospital there is a seven-day bed hold policy and during the seven days they will re-admit the resident. On 6/14/16, at 11:41 a.m., during an interview, the director of medical records (DMR) stated that a seven-day bed hold notice was signed during the time of discharge. The DMR stated that an admission, transfer, and discharge notice should be signed by the resident or responsible party within 24 hours of the resident being discharged. The DMR stated the bed-hold notice; transfer and discharge notice for Resident 1 was not signed by Resident 1 or the responsible party. The DMR stated she failed to follow-up. At 11:52 a.m., on 6/14/16, during an interview, ADM 2 stated the SSD mailed an admission agreement to the regional center, but the regional center never mailed it back to the facility. However, after reviewing the record with ADM 2, she stated there was no documentation in Resident 1's record indicating an admission agreement was mailed to the regional center. On 6/14/16, at 11:54 a.m., during an interview, the SSD stated the process of the admission agreement was for residents to read and sign the document if the residents were able to. The SSD stated if a resident was not able to sign the admission agreement; the responsible party would sign the agreement. The SSD stated if the responsible party was not available during the time of admission, the SSD would call and make arrangements for the responsible party to sign the admission agreement. On 6/14/16, at 12:09 p.m., ADM 2 stated if they cannot re-admit a resident to the facility, they call the GACH's case manager and physician to explain the reason for not re-admitting the resident. ADM 2 stated she cannot remember if she called the physician. ADM 2 stated the facility had RNs on duty around the clock ([ATC] on all three shifts) and that they administer IV antibiotics. The facility's undated policy and procedure titled, "Policy and Procedure on Transfer and Discharge,? indicated: 1. The resident and/or responsible party/ legal representative shall be notified in writing of the transfer or discharge and the reason for such move. 2. The written notices should be given to the resident and/or responsible party within thirty days. The facility's undated policy and procedure titled, "Policy and Procedures on Bed-hold,? indicated: 1. The facility must inform the resident, family member or legal representative (includes Public Guardian or Conservator) in writing of their right to exercise this bed-hold, upon admission and upon transfer to a general acute care facility or therapeutic leave. 2. In case of an emergency transfer notice "at the time of transfer? means that the family, surrogate, or representative is provided with written notification within 24 hours. 3. If for certain reasons, the resident's family, surrogate or legal representative cannot be reached i.e. via telephone, any attempts made to reach the family; surrogate or legal representative shall be documented in the resident's medical record followed with written notice. The facility failed to ensure residents who transfer to a hospital or go on a medical leave are provided with written information regarding the bed-hold policy under the State plan and the resident is permitted to return and resume residence in the nursing facility as stipulated in its policy, including but not limited to: 1. Failure to provide Resident 1?s family member or legal representative written notice, which specified the duration of the bed-hold policy. 2. Failure to permit Resident 1 to return and resume residence in the facility during the 7 day bed-hold period. The above violation had a direct relationship to the health, safety, or security of Residents 1. |
| 940000069 |
BROOKFIELD HEALTHCARE CENTER |
940012602 |
A |
30-Sep-16 |
5D4R11 |
12741 |
483.25 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. F 279 483.20 (d) 483.20(k) (1) Develop comprehensive Care Plans. A facility must use the results of the assessment to develop, review and revise the resident's comprehensive plan of care. 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 August 18, 2015 at 12 p.m., an unannounced visit was conducted at the facility to investigate a complaint that Resident 1 had fallen on 08/10/2015, at the facility and sustained a right hip fracture. Resident 1 was observed, on 08/18/2015, dozing in her wheelchair outside the Physical Therapy (PT) room, with her right leg elevated. The resident was returned to her room and transferred to bed with the aid of two certified nurse assistants CNAs. The facility failed to provide Resident 1 adequate supervision and assistance devices and revise the care plan to prevent Resident1?s falls from a wheelchair. As a result Resident 1 sustained a hip fracture from a fifth fall and was transferred to the general acute care hospital (GACH) for a surgical repair of the fracture, and administration of pain management. After that fall, Resident 1 experienced a decline in her condition that included decreased mobility. A review of Resident 1's Admission Record, indicated the resident, who was 95 years old, was initially admitted to the facility on February 26, 2014, with diagnoses that included status post fall at home, which resulted in bilateral arm fractures, and loss of one eye due to injury during the fall; diabetes mellitus (a condition that causes blood glucose (sugar) levels to rise higher than normal); and Alzheimer's Disease (an irreversible, progressive brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest tasks). The resident was readmitted to the facility on August 14, 2015. A review of the Minimum Data Set (MDS- a standardized resident assessment tool), dated August 3, 2015, indicated Resident 1 was severely cognitively impaired in her daily decision-making skills, had highly impaired vision, and required extensive to total staff assistance with all of her daily living activities. The section of the MDS that addressed balance, indicated Resident 1 was not steady, only able to stabilize with staff assistance for moving from seated to standing position; walking with assistive device; turning around; moving on and off toilet; and surface-to-surface transfer (transfer between bed and chair or wheelchair). The resident used a wheelchair and walker for mobility. A review of the Physician Orders for August 2015 indicated Resident 1 received three anti-hypertensive (high blood pressure) medications daily: losartan, amlodipine, and atenolol. There was also an order for lorazepam (anti-anxiety medication) 0.5 mg by mouth every eight hours PRN (as necessary) for anxiety manifested by inability to relax (ordered October 23, 2014). According to the online government pharmaceutical website, daily.com (dailymed.nlm.nih.gov/), potential side effects for the anti-hypertensive medications included dizziness, light-headed, and low blood pressure. It also indicated that patients who are over 65 years of age and receiving lorazepam may have a greater incidence of central nervous system depression (decreased level of brain functioning that can result in lowered breathing rate and decreased heart rate), that can lead to confusion and dizziness, impaired memory, and impaired motor coordination. A review of the PRN Psychotropic Assessment Flow Sheets for June 2015, and July 2015 indicated Resident 1 received a dose of lorazepam 0.5 mg with her daily anti-hypertensive medications at 9 a.m. for restlessness, on the following dates: -June 24, 2015, June 29, 2015, July 4, 2015, July 5, 2015, July 10, 2015, July 24, 2015, and July 29, 2015. On July 24, 2015, the resident received a total of three doses of lorazepam within a 24 hour period. A care plan for fall risk, dated February 24, 2014, indicated Resident 1 was at risk for falls related to history of falls, poor safety awareness, confusion, psychoactive (mind-altering) drug use, gait/balance problems, cardiovascular medications, and potential side effects of multiple medications. The Care plan interventions included to anticipate and meet the resident's needs, ensure the call light was within reach, bed bolster (a mattress that helps keep patients centered and reduces the gaps between mattress and side-rail) for comfort and positioning, and bed level in lowest position. A review of a fall incident, dated January 14, 2015, indicated Resident 1 was found on the floor lying against a wheelchair in the hallway at 2 p.m. that afternoon. A reddish-purple discoloration was noted on the resident's left lower back area. A revised care plan for fall risk, dated January 17, 2015, indicated to continue interventions included in the at-risk care plan, floor mat at bedside, and to determine and address causative factors. There were no care plan revisions to prevent falls from the wheelchair. A review of a fall incident, dated April 20, 2015, indicated Resident 1 was sitting in her wheelchair across from the nursing station, when the resident abruptly stood, stumbled over the wheelchair leg rest, and fell onto her left side. No injuries were identified, and the resident denied any pain. A care plan, dated April 21, 2015, indicated the same interventions documented on the January 17, 2015 care plan. There were no care plan revisions to address the falls from the wheelchair. A review of the Pharmacist's Monthly Drug Regimen Review for recommendations between April 1, 2015 and April 23, 2015, indicated Resident 1 had a recent fall during that month without resulting injuries. The report also indicated that all cardiovascular drugs may increase the risk of falls because they alter BP, pulse, and slow cardiac response time, resulting in orthostatic hypotension (a drop in BP due to a sudden change in position). The report further indicated the benefits of the resident receiving the medications outweighed the risks, and that all the resident's medications reviewed at that time were at an effective dose, in order to decrease risk of falls. A review of a fall incident, dated July10, 2015 at 4:50 p.m., indicated the certified nursing assistant (CNA) had witnessed Resident 1 standing by her wheelchair, turning around quickly and losing her balance. Following the fall, the resident complained of left knee and left fifth finger discomfort, no redness or swelling was noted. A review of the PRN Psychotropic Assessment Flow Sheet indicated Resident 1 had received a dose of lorazepam 0.5 mg on July 10, 2015 at 4:30 p.m., 20 minutes prior to her fall. A care plan, dated July 10, 2015, indicated interventions that included: to ensure bed was in the lowest position, check the resident's range of motion, continue interventions on the at-risk plan, and to obtain therapy consult for strength and mobility. There were no revisions to address the falls from the wheelchair or adequate monitoring of Resident 1. A review of a fall incident, dated August 1, 2015 indicated Resident 1 suddenly stood up from her wheelchair, lost her balance, and slid down to the floor. The resident sustained a one by one centimeter (cm) skin tear on the left knee. A review of the August 2015 Medication Administration Record (MAR), indicated that on August 1, 2015, Resident 1 received a dose of lorazepam 0.5 mg at 3:24 p.m., 20 minutes prior to the fall. A review of a fall incident, dated August 10, 2015 at 4:45 p.m., indicated Resident 1 had her alarm pad on, was severely agitated, stood up unassisted from her wheelchair, struck out at staff members, and tripped and fell onto her right side, striking her head. Immediately following the fall, the resident complained of right hip and leg pain, and was unable to move her right leg. The physician was notified, and ordered to transfer the resident to the GACH for further evaluation. A review of the GACH clinical record, indicated Resident 1 was diagnosed with a right hip fracture, and minor contusion (bruising) to the head, and that the resident had low blood pressure readings. The resident required a surgical repair of her right hip, pain management, and two blood transfusions for a low blood count. A care plan, dated August 10, 2015, included an interdisciplinary (IDT) recommendation to continue the current plan of care, continuously monitor for mood lability (mood swings), place resident close to the nursing station, and obtain pharmacy consult to evaluate the resident's current medications. The plan further indicated that if all interventions failed, and the resident behavior could not be controlled, to consider transferring the resident for more appropriate placement who could provide one-to-one monitoring, or restraints to prevent any fall occurrence. On August 18, 2015 at 12:50 p.m., during an interview, CNA 1 stated Resident 1 had been confused most of the time, and, became more confused during the afternoon, attempted to get up, and continually asked for her baby. CNA 1 further stated the resident also struck out at the staff, and attempted to get up to the bathroom in the morning, without using her call light. The CNA then stated that there was a sensor alarm on the resident's bed and wheelchair, and that the resident was in the hallway in her wheelchair most of the time, so that the staff could see her. On August 18, 2015 at 1:05 p.m., during an interview with the licensed vocational nurse (LVN) 1, she stated Resident 1 was alert and oriented to person only, and became increasingly agitated when family members left. On August 18, 2015 at 1:15 p.m., during an interview and review of the Incidents Log for January 2015-August 2015, the DON stated that in March, 2015, there were a total of 12 resident fall incidents, and that the facility had started increasing the use of sensor pads, increased frequency of staff rounds of resident rooms, as well as bowel and bladder training. The DON then stated that after Resident 1's first fall in January 2015, the resident was placed near the nursing station for closer monitoring, and was transferred to a Gero-Psychiatric (a subspecialty of psychiatry dealing with the study, prevention, and treatment of mental disorders of old age) facility for evaluation, due to increased confusion and agitation. On August 18, 2015, and August 19, 2015 during interviews with the DON and administrator, both stated that restraints were not used at the facility. The DON responded that she recalled that the resident had a Lap Buddy restraint during April, 2015. The DON further stated that the resident had also had a sitter (a staff member that is one-to-one with a resident), but was unable to find documented evidence of a physician order for a sitter in the clinical record, and was unable to locate any documentation of a sitter in the licensed nurses notes. The DON further indicated that staff members who had taken care of the resident were also assigned fewer residents, in order to monitor Resident 1 more closely, but was unable to substantiate this when she reviewed the staffing assignments for the last year. The facility failed to provide Resident 1 adequate supervision and assistance devices and failed to revise the care plan to prevent Resident 1?s falls from a wheelchair. As a result Resident 1 sustained a hip fracture from a fifth fall and was transferred to the general acute care hospital (GACH) and had surgical repair of the hip fracture. After the fall, Resident 1 experienced a decline in her condition that included decreased mobility. These violations presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious harm would result. |
| 940000011 |
BELL CONVALESCENT HOSPITAL |
940012870 |
A |
23-Mar-17 |
391J11 |
17537 |
?483.10 Resident Rights
(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 --
(B) 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);
?483.20 Resident Assessment
(k)(3) The services provided or arranged by the facility must?
(i) Meet professional standards of quality and;
?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.
On 3/26/16, at 11:35 a.m., an unannounced visit was conducted at the facility to investigate an allegation that the facility failed to provide medical interventions and implement emergency procedures for Resident 1 on 3/24/16. The allegation indicated that Resident 1 died at the facility on XXXXXXX16, at approximately 7 p.m.
Based on interviews and record review, the facility failed to ensure that Resident 1, who exhibited a significant change in condition, manifested by weakness, refusal to eat, and water being given by a teaspoon spilled from the resident?s mouth, was provided with necessary care and services, including but not limited to:
1. Failure to ensure that a registered nurse supervisor (RNS) on duty on 3/24/16 had the ability to manage nursing service concerns, coordinate transfer procedures, and immediately initiate lifesaving measures, including cardiopulmonary resuscitation (CPR, a life-sustaining emergency procedure for persons in cardiac arrest), as indicated in the facility?s job summary for a nursing supervisor.
2. Failure to assess and identify the cause of Resident 1?s weakness, which included Resident?s refusal to eat, water spilling from the Resident?s mouth while Resident was given sips of water, and failure to notify the physician immediately, as indicated in the facility?s Change of Condition policy and procedures.
3. Failure to transfer Resident 1 to a higher level of care in a timely manner and monitor Resident 1 prior the transfer pursuant to the facility?s Change of Condition policy and procedures.
4. Failure to initiate CPR, pursuant to the physician?s progress notes stating that Resident 1 was a ?Full Code? (meaning to do everything possible and necessary to save the life of a person) when Resident 1 was found pulseless and not breathing on 3/24/16, at 6:50 p.m., pursuant to the facility?s CPR policies and procedures.
These failures resulted in progressive worsening of Resident 1?s condition at the facility on 3/24/16. Resident was not transferred to a general acute care hospital (GACH) and did not receive immediate medical intervention for acute myocardial infarction (commonly known as a heart attack, occurs when blood flow stops to a part of the heart causing damage to the heart muscle) that led to cardiopulmonary arrest. Resident 1 was pronounced dead at the facility on XXXXXXX16, at 6:55 p.m.
According to the Admission Record, Resident 1 was a 65-year-old male, admitted to the facility on XXXXXXX15 with diagnoses that included cerebrovascular accident (stroke) with hemiplegia (paralysis on one side of the body), hypertension (high blood pressure), and diabetes mellitus (high blood sugar).
A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/5/16 indicated Resident 1 had the ability to understand others and make self-understood, The resident's cognitive skills for daily decision-making were moderately impaired and the resident required extensive assistance to total dependence from the staff with activities of daily living. The MDS indicated Resident 1 required extensive assistance from the staff with eating.
A review of the Physician's Progress Notes dated, 9/20/15, 11/15/15, 12/7/15, 1/19/16, and 2/27/16 indicated that Resident 1 was a full code.
A review of the Licensed Nurse Weekly Summary (Condition of the resident for the past week) dated 3/17/16, one week prior to the resident?s death, untimed indicated that Resident 1?s blood pressure (BP is the pressure exerted by circulating blood upon the walls of blood vessels) reading was 134/66 millimeters of mercury or mmHg (reference range is 120/80 mmHg), pulse rate (PR is the speed of the heartbeat measured by the number of contractions of the heart per minute (bpm) ) was 78 bpm (reference range 60 to 100 bpm), respiratory rate 20 (RR, resting respiratory rate 12 to 20 breaths per minute), 0/10 pain level (no pain). The notes indicated that the resident average meal intake consumption for the past week was 100 percent (%), and there was no swallowing difficulty.
A review of the Licensed Nurse Weekly Summary dated 3/24/16, untimed indicated that Resident 1?s BP reading was 134/66 mmHg, PR was 72 bpm, RR 18 breaths per minute, 0/10 pain level (no pain). The notes indicated that the resident average meal intake consumption for the past week was 10 to 100 percent, and no swallowing difficulty. The note indicated that the resident was alert, able to follow simple directions, sit in a wheelchair and attends group activities.
A review of the Licensed Nurses Progress Notes dated 3/24/16, at 11 a.m., indicated that Resident 1's BP reading was 105/66 mmHg, PR was 83 bpm, RR rate was 20,, 0/10 pain level (no pain), and oxygen saturation (a measure of how much oxygen the blood is carrying) rate was 99 % (normal is 95 to 100 %), no documentation if the resident was receiving oxygen. The notes indicated the resident had poor oral (by mouth) intake and that the resident refused to eat breakfast. The notes indicated RNS helped feed the resident and 60 cubic centimeters (cc) of thickened water was provided.
A review of the Licensed Nurses Progress Notes dated 3/24/16, at 12:30 p.m., indicated Resident 1's BP reading was 111/65, PR 86 bpm, RR 21 breaths per minute, and oxygen saturation reading was 98 %. The notes indicated that Resident 1 refused lunch and was given 150 cc of thickened water by teaspoon.
A review of the Licensed Nurses Progress Notes dated 3/24/16, at 5 p.m., indicated Resident 1?s BP reading was 106/72, PR 89 bpm, RR 21 breaths per minute, 0/10 pain level, and oxygen saturation reading was 98 %. The documentation indicated that Resident 1 refused dinner and was given 90 cc of thickened water.
A review of Resident 1?s medical record did not indicate an assessment by the licensed nurses as to why Resident 1 refused to eat breakfast, lunch, and dinner. There was no documented evidence that Resident 1's primary care physician was notified about resident's refusal to eat the whole day.
A review of the Licensed Nurses Progress Notes dated 3/24/16, at 5:50 p.m., indicated Resident 1's BP reading was 100/68, PR was 87 bpm, RR was 21 breaths per minute, 0/10 pain level, and oxygen saturation reading was 96 %. The notes indicated the resident had mild fever of 100 degrees Fahrenheit (Reference range 97.8 to 99 degrees Fahrenheit). The documentation indicated that gurgling sounds were noted from the resident. There was no documentation that Resident 1's respiratory (lungs/throat) status was assessed. The notes indicated that the resident?s primary care physician (Doctor 1) was notified and Doctor 1 ordered to transfer the resident for further evaluation.
A review of the Licensed Nurses Progress Notes dated 3/24/16, at 6:10 p.m., indicated that staff arranged Resident 1?s transfer to a GACH. The notes indicated that transfer documents were prepared and that Resident 1 will be monitored until ambulance transport arrived. There was no documented evidence that facility staff had assessed and monitored Resident 1 while waiting for the ambulance to transfer resident to the general acute care hospital (GACH).
A review of the Licensed Nurses Progress Notes dated 3/24/16, at 6:50 p.m., indicated that the charge nurse called RNS and reported to RNS that Resident 1's condition ?dramatically changed.? The notes indicated that RNS ran into the room with a phone to call 911 in emergency situation. The notes indicated Resident 1 was found pulseless, no heart rate, no breathing noted. There was no BP reading or manual BP measuring device and no oxygen saturation reading on oximetry (a device to check how much oxygen is in the blood). There was no documented evidence of calls for emergency assistance via 911 and no documentation that staff initiated CPR.
During an interview and record review of Resident 1's clinical record with RNS on 3/26/16, at 1 p.m., he stated Resident 1 refused breakfast, lunch, and dinner on 3/24/16. RNS stated, "I just assumed that Resident 1 was dehydrated." RNS stated that he gave the resident water during the breakfast meal but the water kept spilling out of the resident's mouth. RNS stated at approximately 6:50 p.m., on 3/24/16, licensed vocational nurse 2 (LVN 2) found Resident 1 unresponsive. RNS stated that if a resident was a full code, ?We have to do CPR and call 911.? RNS stated that Resident 1 was a full code but he did not initiate a CPR, because the resident was "dead."
During a follow-up interview with RNS on 3/26/16, at 4:38 p.m., he stated that he called the administrator about Resident 1's condition because he was initially unable to contact Doctor 1. RNS stated that he did not try to call an alternate physician. RNS stated that the administrator, who was not in the facility, coordinated Resident 1's transfer to the GACH.
During an interview with the administrator on 3/26/16, at 6:19 p.m., she stated that the staff should have initiated CPR on Resident 1 because the resident was a full code. On a subsequent interview with the administrator on 6/14/16, at 1:48 p.m., she stated that on 3/24/16, she received a phone call from RNS notifying her that Resident 1 had a fever. The administrator stated that RNS was unable to get in contact with Doctor 1 and she had to coordinate Resident 1?s transfer herself. According to the administrator, she was not at the facility at that time and was at a store. The administrator stated that she called Doctor 1?s assistant from her cellphone to arrange Resident 1?s transfer to the GACH.
During an interview with LVN 1 on 6/9/16, at 9:55 a.m., she stated that she took care of Resident 1 in the morning shift (7 a.m. - 3 p.m.) on 3/24/16. LVN 1 stated that she let Resident 1 stay in bed that morning because Resident 1 appeared weak and refused to eat breakfast. LVN 1 stated that Resident 1 did not eat lunch as well, "He did not even open his mouth." LVN 1 indicated that she did not think Resident 1 was exhibiting a change in condition, "I thought he was just having a bad day." LVN 1 stated that she reported the situation to RNS but she did not notify Resident 1's doctor.
During an interview with Doctor 1 on 6/9/16 at 3:10 p.m., he stated that he was not notified that Resident 1 refused all his meals on the day that Resident 1 died. Doctor 1 further stated, "A prudent thing to do is try to find out what's going on with the resident and monitor the resident?s vital signs. Doctor 1 stated if a resident is a full code and had no pulse and no blood pressure, the nurse has to call 911. Doctor 1 stated ?I guess RNS took it on himself not to do CPR."
During an interview with LVN 2 on 6/14/16, at 10:30 a.m., LVN 2 stated that Resident 1 looked tired when she did her rounds at 3 p.m., the beginning of her shift on 3/24/16. LVN 2 stated that she gave Resident 1 Tylenol by mouth at 5:30 p.m., for fever. LVN 2 stated that at 6:50 p.m., she noted that Resident 1's body was blue so she left Residents 1's room to call the other nurses. LVN 2 stated that it was her first time to see a resident who was unresponsive and no one directed her to begin CPR on Resident 1. LVN 2 stated that she and another licensed nurse checked the resident's breathing, pulse, oxygen saturation and the resident was completely dead, "So we didn't do CPR."
A review of RNS, LVN 1 and LVN 2?s copies of Healthcare Provider card indicated that RNS, LVN 1 and LVN 2 had an active CPR card. The Healthcare Provider card indicated that this certifies that the above individual had successfully completed the cognitive and skills evaluations in accordance with the curriculum of the American Heart Association BLS (Basic Life Support) for Healthcare providers (CPR and AED, automated electrical device) Program.
According to Resident 1?s "Certificate of Death?, the date of death was XXXXXXX16 at 6:55 p.m. The document indicated that Resident 1's immediate cause of death was cardiopulmonary arrest, and the secondary cause of death was acute (new) myocardial infarction.
A review of the facility's undated "Job Summary for a Nursing Supervisor," indicated that the person assigned would provide direction, supervision, and evaluation of all resident care. The document titled ?Performance Standards? for a nursing supervisor indicated some of the following requirements:
* Implement established performance standards of nursing practice and facility policies and procedures.
* Demonstrate consistent ability to manage nursing service concerns, emergency situations, and immediately initiate lifesaving measures as necessary in the absence of a physician.
* Perform nursing skills, demonstrating knowledge and competence.
* Implement facility admission, discharge, and transfer procedures and supervises coordination with other departments, physicians, residents, families and community agencies.
A review of the facility?s ?Orientation Checklist,? dated 10/2/15 the date that RNS was hired, indicated that RNS received his job description and work assignment.
A review of the facility's undated policy and procedures (P&P) on "Change of Condition Notification" indicated the following: If a resident's primary care physician does not respond within a reasonable amount of time, it is the responsibility of the licensed nurse to notify alternate physician of resident's change in condition. If resident?s condition requires immediate physician intervention, (and primary care physician and/or alternates are not available within a reasonable amount of time), licensed nurse shall be responsible from calling for emergency assistance, as such, 911 or Paramedics. It is standard operating procedure to immediately consult with the primary care physician on drastic changes and/or lack of progress or improvement in the resident?s condition.
A review of the facility?s undated policy and procedures on ?911 Calls? indicated that emergency assistance via 911 should be sought to meet emergency medical needs of a resident including potentially life-threatening conditions such as cardiac arrest.
According to the 2015 update of American Heart Association's Adult Cardiac Arrest Algorithm (Basic Life Support Healthcare Provider), the healthcare provider will begin CPR for a victim who is not breathing/only gasping and does not have a pulse.
According to the 2007 Emergency Management Strategies for Acute Myocardial Infarction, indicated the time interval between the onset of acute myocardial infarction and the initiation of reperfusion therapy (medical treatment that restores blood flow through blocked arteries) is a major determinant of patient (resident) outcome. An acute myocardial infarction is a medical emergency requiring immediate intervention.
The facility failed to ensure that Resident 1, who exhibited a significant change in condition, manifested by weakness, refusal to eat, and water being given by a teaspoon was spilling from the resident?s mouth, was provided with necessary care and services, including but not limited to:
1. Failure to ensure that a RNS on duty on 3/24/16 had the ability to manage nursing service concerns, notify an alternate physician, coordinate transfer procedures, and immediately initiate lifesaving measures, including CPR, as indicated in the facility?s job summary for a nursing supervisor.
2. Failure to assess and identify the cause of Resident 1?s weakness, which included Resident?s refusal to eat, water spilled from the Resident?s mouth while Resident was given sips of water, and failure to notify the physician immediately, as indicated in the facility?s Change of Condition policy and procedures.
3. Failure to transfer Resident 1 to a higher level of care in a timely manner and monitor Resident 1 prior the transfer pursuant to the facility?s Change of Condition policy and procedures.
4. Failure to initiate CPR, pursuant to the physician?s progress notes stating that Resident 1 was a ?Full Code? when Resident 1 was found pulseless and not breathing on 3/24/16, at 6:50 p.m., pursuant to the facility?s CPR policies and procedures.
These failures resulted in progressive worsening of Resident 1?s condition at the facility on 3/24/16. Resident was not transferred to a GACH when the change of condition should have been recognized and did not receive immediate medical intervention for acute myocardial infarction that led to cardiopulmonary arrest. Resident 1 died at the facility on XXXXXXX16, at 6:55 p.m.
These violations presented a substantial probability of death or serious physical harm to Resident 1. |
| 940000047 |
BEL TOOREN VILLA CONVALESCENT HOSPITAL |
940012943 |
A |
17-Feb-17 |
Y5FG11 |
11524 |
?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.
Based on interview and record review, the facility staff failed to ensure Resident 1 who sustained a fracture (broken bone) of the left wrist after a fall incident received necessary care and services by failing to:
1. Follow the fall management policy and procedures for Resident 1 to receive prompt medical attention after a fall with fracture.
2. Identify the need to involve the interdisciplinary team that includes the facility's medical director to discuss the appropriateness of Resident 1's care after a fall with fracture.
3. Coordinate and arrange Resident 1?s orthopedic appointment with the necessary X-ray result of the left wrist.
These deficient practices resulted in Resident1?s delayed necessary surgery for an open reduction internal fixation (surgical repairing of a bone) of the left distal radius (bone fracture by the forearm), and ulna (one of two bones that give structure to the forearm) with mild displacement for seven (7) days after a fall with fracture of left wrist. Resident 1 experienced unnecessary pain and received 22 tablets of controlled pain medication. The delay in surgery placed the resident at risk of malunion (Incomplete union or union in a faulty position after a fracture or wound.) of the bone, and infection.
A review of Resident 1's Admission Record indicated the resident was admitted to the facility on XXXXXXX13 and readmitted on XXXXXXX13 with diagnoses that included osteoporosis (thinning bone), and dementia (a progressive deterioration of mental and physical functioning).
A review of the Minimum Data Set (MDS, an assessment and care screening tool) dated 6/7/13, indicated that Resident 1 was able to recall with cues, usually had the ability to understood and understand others. The MDS indicated that the resident required one staff assistance for bed mobility, transfer, ambulation, dressing, personal hygiene, was occasionally incontinent (minimal control) of bowel and bladder functions and no toileting program for bowel and bladder was currently used.
A review of the nurses' Progress Notes dated 10/15/13, at 4:25 a.m., indicated at 2:25 a.m., certified nurse assistant (CNA) heard a noise and went to Resident 1's room. The CNA found the resident sitting on the floor by the side of her bed. The resident stated that she wanted to go to the bathroom and she slid. The resident was assessed and swelling of the resident left wrist was noted. The resident complained of pain on a scale 8/10 (8, severe pain [a pain scale of 1 to 10, 10 being the worst pain a person can experience]) when the wrist was touched. At 2:35 a.m., the resident's physician was notified and an order of STAT (at once) X-ray was placed for the left wrist. The notes further indicated that the physician ordered to apply a splint (strip of rigid material used for supporting a broken bone) to immobilize resident's left wrist. The note further indicated that a suggestion was made to transfer the resident to emergency room for further evaluation and the physician stated to do the X-ray first and call her with the result.
A review of Resident 1's diagnostic imaging report dated 10/15/13, read at 4:18 a.m., indicated that "There is a fracture involving the distal radius (define) and ulna (define) with mild displacement. There is associated soft tissue swelling."
The nurses' Progress Notes dated 10/15/13, at 7:28 a.m., indicated that the physician was called and provided with the X-ray result. The notes indicated that a suggestion was made to transfer Resident 1 to the hospital and the physician stated "No, just orthopedic (the branch of medicine dealing with the correction of deformities of bones or muscles) consult."
The nurses' Progress Notes dated 10/15/13, at 11:03 a.m., indicated that the resident complained of pain on a scale of 6 out of 10 (6/10-moderate pain) to the left wrist and was given pain medication. After 30 minutes the pain scale was 3/10 (mild pain) and within one hour the pain scale was 0/10 (no pain) per resident statement.
The nurses' Progress Notes dated 10/15/13, at 5:24 p.m., indicated that the physician ordered orthopedic consult for 10/17/13.
A review of nurses' Progress Notes dated 10/17/13, at 1:05 a.m. documented by a registered nurse indicated that at 7 p.m., resident's family member was requesting to send Resident 1 to the hospital due to left wrist dislocation. The notes indicated that the physician was aware of the X-ray result and declined to transfer the resident to the hospital. The notes further indicated that it was explained to the resident's family member that an orthopedic consult was ordered. The documentation indicated that the residents' family insisted to have the resident transferred to the hospital. The physician was called and notified of resident's family member request. The notes indicated that the resident's physician did not want to transfer the resident to the hospital because they (hospital) will only keep the resident for two (2) hours, just to immobilize the arm/wrist and the resident will then be sent back to the facility. The documentation further indicated that this was why she (physician) ordered the orthopedic consult, and sending the resident to the emergency room would cause her (resident) to lose the opportunity for an orthopedic authorization for the consult. The notes indicated that the physician spoke to the resident's family member and the resident's family member agreed to what the physician said.
A review of Resident 1's Medication Record indicated a physician's order dated 10/16/13 for Vicodin (narcotic, controlled pain medication) 5/500 (combination of hydrocodone bitartrate and acetaminophen) milligram (mg) two (2) tablets per oral (by mouth) every six hours as needed (PRN) for severe pain, not to exceed (NTE) four grams per 24 hours.
A review of Resident 1's physician order dated 10/17/13, indicated Vicodin 5/500 mg one (1) tablet by mouth every eight (8) hours PRN for moderate pain, NTE four grams/24 hours.
A review of Resident 1's Pain Flow Sheet from 10/15/13, at 2:30 a.m., to 10/21/13, at 6:00 p.m., indicated that the resident received Vicodin 5/500 mg two tablets for severe pain (pain scale 8/10) 12 times, and Vicodin one tablet for moderate pain (pain scale 6/10 and 7/10) 10 times. The resident received a total of 22 tablets for six days after the fall incident where she sustained the left wrist fracture.
A review of the nurses Progress Notes dated 10/17/13, at 4:16 p.m., indicated that Resident 1 was unable to see the orthopedic doctor due to not having the X-ray result available. The orthopedic appointment was rescheduled on 10/21/13, and Resident 1 went back to the facility accompanied by a family member.
A review of the nurses Progress Notes dated 10/18/13, at 9:38 a.m., the notes indicated the resident will be admitted to the hospital on 10/21/13, for open reduction internal fixation (ORIF, a two part surgery used to fix broken bones. First, the broken bone is reduced or put back into place. Next, an internal fixation device is placed on the bone). The documentation included the resident?s pre-surgery preparation such as: nothing per mouth (NPO, nothing to eat by mouth) after the midnight of 10/20/13.
A review of the nurses' Progress Notes dated 10/21/13, at 4:10 a.m., indicated that Resident 1 was sitting in a wheelchair, had a splint intact and secured to left wrist. The notes indicated that the resident was picked up by her family member for scheduled surgery appointment.
The nurses' Progress Notes dated 10/21/13, at 2:42 p.m., indicated that the scheduled surgery was cancelled due to over booking of surgery candidates to be done 10/21/13. The notes indicated that Resident 1?s surgery was rescheduled for 10/22/13, and the resident should be NPO by midnight of 10/21/13.
A review of the Operative Record obtained from the GACH dated 10/22/13 indicated pre-operative diagnosis was displaced left distal radius fracture. The operation performed indicated ORIF, of left radius fracture. A discharge order dated on 10/23/13 at 10:30 a.m. indicated to transfer resident to skilled nursing facility (SNF).
On 9/8/16, at 4:07 p.m., during an interview with director of nurses (DON), she stated that the resident's physician orders were to immobilize the resident's left wrist, give pain medication and wait for the orthopedic consult. The DON stated it was not the appropriate treatment for Resident 1 because the facility usually sends residents to the hospital when the interventions of the resident's physician were not appropriate. The DON stated the facility should follow the facility's "Falls Management" policy and procedures.
On 9/8/16, at 4:35 p.m., during a telephone interview with Resident 1's current physician, he stated "With a mild displacement of the wrist, Resident 1 should have been sent to the hospital."
On 9/20/16, at 4:17 p.m. during an interview with the DON, the DON stated that the facility?s medical director will be consulted when the facility consider that the order of resident?s primary care physician are not appropriate. The DON stated that the facility?s medical director was not consulted.
A review of the undated facility's policy and procedures titled, "Falls Management," indicated the following:
- Residents who experience a fall will receive prompt medical attention.
- If initial assessment denotes fracture, the affected area will be immobilized and comfort will be provided until the arrival of emergency medical services (EMS).
According to an article dated 11/1/02, Orthopedic Proceedings titled "Management of complication of distal radius and ulna fractures," indicated tendon complications following distal radius fractures, range from minor adhesions to complete rupture. This complication can be avoided with a proper cast techniques allowing full range of motion to the digits. Complications may involve soft tissue (tendon, nerve, arterial or fascial complication, reflex sympathetic dystrophy) or bone and joint (malunion, nonunion, osteoarthritis).
The facility staff failed to ensure Resident 1 who sustained fracture of the left wrist after a fall incident received necessary care and services by failing to:
1. Follow the fall management policy and procedures for Resident 1 to received prompt medical attention after a fall with fracture.
2. Identify the need to involve interdisciplinary team that includes the facility's medical director to discuss the appropriateness of Resident 1's care after a fall with fracture.
3. Coordinate and arrange Resident 1 orthopedic appointment with the necessary X-ray result of left wrist.
These deficient practices resulted in Resident 1?s delayed necessary surgery for an open reduction internal fixation of the left distal radius, and ulna with mild displacement for seven days after a fall with fracture of left wrist. Resident 1 experienced unnecessary pain and received 22 tablets of controlled pain medication. The delay in surgery placed the resident at risk of malunion of the bone, and infection.
These violations presented a substantial probability of death or serious physical harm to Resident 1. |
| 950000277 |
Brookdale San Dimas |
950009632 |
B |
29-Nov-12 |
D74711 |
5413 |
F371 483.35 (i) (1) The facility must - (1) Procure food from sources approved or considered satisfactory by Federal, State or local authorities; and 483.35 (i) (2) Store, prepare, distribute and serve food under sanitary conditions Based on observation, interview, and record review, the facility failed to store and serve food under sanitary conditions by failing to:1. Ensure that sliced ham, a potentially hazardous food (PHF) was held in the steam table during the breakfast food service at 135 degrees Fahrenheit . Hot holding temperature (135 degrees F) prevents the growth of pathogenic bacteria that may be present in or on these foods. 2. Ensure that the kitchen as well as kitchen equipment, walls and floors were kept clean and free from encrusted food debris. This condition predisposes the facility to risks that are associated with foodborne illness and food safety hazards. 3. Ensure that dietary staff maintained and wore kitchen aprons that were clean and neat while preparing and serving food. Wearing clean and intact aprons in good condition and that are changed when necessary will help reduce the spread of microorganisms and consequently help in preventing foodborne illness.During the initial kitchen tour of the facility during a re-certification survey on November 8, 2012, at 8 a. m., the evaluator made an unannounced visit to the kitchen facilities and made the following observations:1.The cook in the presence of the evaluator measured the breakfast food items (consisting of sausage, scrambled eggs, cream of wheat, thin liquid eggs and sliced ham) placed in the steam table and noted, that all of the food items in the steam table were maintained at 150 degrees Fahrenheit except for the steam table pan-filled with sliced ham (8-inch pan) that measured 98 degrees Fahrenheit. The cook offered to re-heat the ham in the oven for 15 minutes. At 8:25 a. m., the cook stated that the ham was ready to be served. The cook in the presence of the evaluator measured the temperature of the ham to be at 130 degrees Fahrenheit. The cook and the director of dietary services decided to dispose of the entire steam pan-filled ham and grilled frozen ham instead for the residents? breakfast meal.2. The ventilation device located directly above the High-temperature ?Inferno? dishwashing machine was missing thereby, exposing the inner ceiling and beams supporting the roof structure.3. There were removable thick blackish stains on the dishwasher as well as an accumulation of dirt and numerous thick black lint materials that were hanging all around the area of the missing vent and vent grill.4. The drain pipe underneath the High-temperature ?Inferno? dishwashing machine was leaking water when in use to wash dishes. 5. The drain pipe underneath the High-temperature ?Inferno? dishwashing machine that was piped to drain into a floor sink was observed embedded or enclosed inside the floor sink that was filled with dirt and removable food debris. The director of dietary services admitted that the drain pipe should have been raised at least 1-1/2 inches above the floor sink to prevent back-flow (back-siphonage) of waste and waste water into the dishwashing system.6. There were dried, encrusted, and removable food debris as well as removable stains in the following areas:a. At the back and behind of the ?South bend Griddle Top, the oven and deep fryer.b. Inside and around the deep fryer. c. Inside the reach-in refrigerator and inside the counter top Reach-in dispense refrigerator by the food preparation table next to the steam table. d. Behind the entire wall of the cooking equipment, the wall where the K-Fire Extinguisher was installed and the entire floor of the kitchen and dishwashing areas. e. Inside and around the stainless hand-washing sink, with encrusted and wet food debris lodged in between the cold and hot water knobs.7. There were loose ceiling tiles above the steam top machine. 8. There were dried, encrusted, and removable food debris as well as removable white and brown stains and white powder on the entire front section of the cook?s apron, while the cook was preparing and serving food.9. Thee garbage disposal at the dishwashing area of the kitchen that was being used to dispose food scrapes and other kitchen waste did not have a cover.The facility failed to store and serve food under sanitary conditions by failing to:1. Ensure that sliced ham, a potentially hazardous food (PHF) was held in the steam table during the breakfast food service at 135 degrees Fahrenheit. Hot holding temperature (135 degrees F) prevents the growth of pathogenic bacteria that may be present in or on these foods.2. Ensure that the kitchen as well as kitchen equipment, walls and floors were kept clean and free from encrusted food debris. This condition predisposes the facility to risks that are associated with foodborne illness and food safety hazards.3. Ensure that dietary staff maintained and wore kitchen aprons that were clean and neat while preparing and serving food. Wearing clean and intact aprons in good condition and that are changed when necessary will help reduce the spread of microorganisms and consequently help in preventing foodborne illness.These violations had a direct or immediate relationship to the health, safety or security of the residents in the facility. |
| 950000277 |
Brookdale San Dimas |
950009633 |
B |
29-Nov-12 |
D74711 |
5284 |
F-323 ?483.25(h) Accidents. The facility must ensure that ? (1) The resident environment remains as free from accident hazards as is possible; Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free from accident hazards as was possible by failing to: 1. Maintain the facility?s hot water at a temperature not to exceed 117 degrees Fahrenheit, as stipulated by the facility?s policy, at the bathroom faucets in all of the residents? rooms during the environmental observation on November 8, 2012, between9:30 a. m. and 9:45 a. m.2. Adhere to the facility?s policy that required that hot water temperatures in residents? rooms be maintained between 105 and 120 degrees Fahrenheit (State Specific-California). Hot water temperatures in resident rooms 104, 106, 110, 114, 115, 122, 124, and 131, were measured at unsafe temperatures above 120 degrees Fahrenheit that placed residents at an increased risk for burns caused by scalding.During the environmental tour of the facility on November 8, 2012, between 9:30 a.m. and 9:45 a.m., the maintenance supervisor, in the presence of the evaluator tested the hot water temperature in faucets in residents? bathrooms, using a probe thermometer. The following readings were obtained:Room #Temperature (Degrees Fahrenheit) 104 131 106 131 110 130 114 128 115 131 122 132 124 132 131 131 On November 8, 2012 at 9:45 a. m, the maintenance and the administrator were made aware of the unsafe hot water temperature readings. The maintenance supervisor measured the temperatures at the rest of the residents? rooms and stated that the hot water temperatures in all of the residents? rooms were above 130 degrees Fahrenheit. Most adults will suffer third-degree burns if exposed to 150 degree water for two seconds. Burns will also occur with a six-second exposure to 140 degree water or with a thirty second exposure to 130 degree water. Even if the temperature is 120 degrees, a five minute exposure could result in third-degree burns.(http://www.accuratebuilding.com/services/legal/charts/hot_water_burn_scalding_graph.html) During an interview with the administrator on November 8, 2012 at 9:50 a. m. she stated that two residents in rooms 103 and 124 that ambulated independently had been kept safe and away from the bathroom immediately the facility was made aware of the unsafe hot water temperature readings in the residents? bathrooms and would be allowed to return only when it was safe to do so.On November 8, 2012 at 10:10 a. m, the maintenance supervisor immediately disposed of the hot water in both of the boilers, refilled the boilers with fresh water and re-ignited the burnt out burner.The maintenance supervisor further stated that the unsafe water temperatures in the resident rooms were due to a malfunction of one of the two water boilers. The maintenance supervisor stated that the burner to one of the two boilers went out and the remaining and functioning burner, continued to function and over-compensated for the burnt out burner, which resulted in the unsafe water temperatures at the faucets in the residents? bathrooms. On November 8, 2012 at 10:45 a. m, the temperature of the hot water in the residents? bathroom faucets were measured at 115 degrees Fahrenheit.During an interview with the maintenance supervisor on November 8, 2012 at 11 a. m., he stated that it was the facility's practice to maintain the temperature range of the hot water in the resident hand sinks from 105 to 120 degrees Fahrenheit. He also stated that he checked the temperature of the resident hand washing sinks on a daily basis.A review of the temperature monitoring log sheet for August, September, October, and November, 2012, provided by the maintenance supervisor indicated that hot water temperatures in the resident rooms ranged from 110 to 118 degrees Fahrenheit.A review of the facility policy on ?Checking Hot Water Temperature? revealed that ?The Maintenance Director must check the hot water temperature in residents rooms every week. The water temperature must not exceed 117 degrees?. Also, ?State Specific-California-Communities shall maintain hot water delivered to public and resident care areas at a temperature between 105-120 degrees Fahrenheit?The facility failed to:1. Maintain the facility?s hot water at a temperature not to exceed 117 degrees Fahrenheit, as stipulated by the facility?s policy at the bathroom faucets in all of the residents? rooms during the environmental observation on November 8, 2012, between 9:30 a. m. and 9:45 a. m.2. To adhere to the facility?s policy that required that hot water temperatures in residents? rooms be maintained between 105 and 120 degrees Fahrenheit (State Specific-California). Hot water temperatures in resident rooms 104, 106, 110, 114, 115, 122, 124, and 131, were measured at unsafe temperatures above 120 degrees Fahrenheit that placed the residents at an increased risk for burns caused by scalding.The above violations had a direct relationship to the health, safety or security of the residents in the facility. |
| 950000277 |
Brookdale San Dimas |
950009849 |
B |
03-Jul-13 |
D74711 |
10715 |
F- 329 483.25 (l)-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. F 505 ? Laboratory Service - 483.75 (j)(2)(ii) - The facility must promptly notify the attending physician of the findings. On November 8, 2012 at 7:30 a.m., an unannounced visit was made to the facility to conduct a Recertification survey. Based on observation, interviews and record reviews the facility failed to ensure that a resident was not administered potassium in the presence of adverse consequences which indicate the dose should be reduced or discontinued by failing to: 1. Develop a care plan to address appropriate use of potassium chloride (a mineral that is essential for conduction of nerve impulses to the heart and is often administered while Lasix, a diuretic is used), to include monitoring/assessing for an increase in Resident 7?s potassium blood levels.2. Ensure that the nursing staff monitored/assessed the resident?s potassium laboratory blood level results to ensure that potassium chloride was administered only when necessary in order to prevent increasing / worsening of hyperkalemia, (a greater than normal amount of potassium in the blood).3. Notify the physician promptly that Resident 7 had an elevated potassium, creatinine and blood urea nitrogen laboratory blood test result that indicated kidney function was worsening, which required prompt medical intervention/attention.As a result Resident 7 had a delay in treatment for hyperkalemia, and was administered three unnecessary doses of potassium chloride, likely worsening the resident's high potassium blood level, which can lead to cardiac arrhythmias (irregular heart beat) or arrest (a life threatening condition).According to the Geriatric Dosage Handbook 12th Edition, Page 1265: Older adults may require less potassium than younger adults due to decreased renal function. According to the article titled "Hyperkalemia" (elevated potassium blood level), based on the relative decline in renal function with age, monitoring of potassium levels is important for patients receiving potassium because hyperkalemia is a potentially life-threatening metabolic problem.A review of the acute hospital history and physical, dated October 9, 2012, indicated that Resident 7 had a past history of mitral valve replacement, aortic stenosis, and atrial fibrillation.The admission face sheet for Resident 7 indicated that the resident was a 93 year old female that had been initially admitted to the skilled nursing facility on November 5, 2012, with diagnoses that included hypertension (high blood pressure); and hyperlipidemia (elevated levels of any or all lipids and/or lipoproteins in the blood).The quarterly Minimum Data Sets (MDS), a standardized assessment and care screening tool, dated November 12, 2012, indicated the resident was understood and understands others, required extensive assistance with bed mobility and toilet use and used a diuretic (a medication used to reduce the swelling and fluid retention caused by various medical problems) medication 7 days over the last 7 days.A review of the clinical record revealed that a nursing care plan to address the use of potassium was not developed. According to the Mosby?s Nursing Drug Reference 23rd Edition, Page 44, Nursing considerations in the use of diuretics include: ?assess:? electrolytes, potassium, sodium, chloride, include blood urea nitrogen, blood glucose, complete blood count.The physician orders were as follows: 1. November 5, 2012, administer Lasix 40 milligrams (mg) one tablet every day for edema. (Lasix is used to reduce the swelling and fluid retention caused by various medical problems) 2. November 5, 2012, administer potassium chloride 40 mEq one tablet every day for hypokalemia (low potassium).3. November 8, 2012, complete blood count and a comprehensive metabolic panel (laboratory blood studies to monitor medical conditions, to monitor for any kidney- or liver-related side effects of specific medications being used, or to monitor a response to treatment). Resident 7's Diagnostic Laboratory results were as follows: November 8, 2012 at 7:25 a.m.: a. Estimated Glomerular Filtration Rate (eGFR), 30 ml/min/1.73 m2 (a laboratory study indicating that the resident had moderately reduced kidney function), reference range of 90 or more is normal.b. Potassium (K+), 5.0 milliequivalents (mEq) per liter mEq/L, normal with a reference range of 3.5 mEq/L - 5.1 mEq/L. c. Creatinine (Cr) 1.61 milligrams/deciliter (mg/dL), High, with a reference range of 0.60 mg/dL-1.20 mg/dL (a high serum creatinine level may indicate that your kidneys are not working well), according to Mosby?s Diagnostic and Laboratory Test Reference, 9th Edition, Page 316. d. Blood urea nitrogen (BUN) 39 mg/dL, High, in a reference range of 7 mg/dL ? 25 mg/dL (a high blood urea nitrogen can indicate that your kidneys are not working properly), according to Mosby?s Diagnostic and Laboratory Test Reference, 9th Edition, Page 954.Resident 7?s diagnostic laboratory results on November 12, 2012, at 4:06 p.m. were as follows: a. Potassium, 5.4 mEq/liter (L), (High), with a reference range of 3.5 mEq/L - 5.1 mEq/L b. Creatinine 1.99 mg/dL, (High), with a reference range of 0.60 mg/dL-1.20 mg/dL c. BUN 51 mg/dL, High, with a reference range of 7 mg/dL ? 25mg/dL. The Laboratory Report of November 12, 2012, indicated that the SNF received the laboratories results by fax on November 12, 2012 at 4:10 p.m.Although Resident 7?s potassium laboratory result was elevated as evidenced by the laboratory report of November 12, 2012, the Medication Administration Record (MAR), dated November 2012, indicated the licensed nurses administered potassium chloride 40 mEq to the resident on November 13, 14, and 15, 2012, for the morning medication dose at 9 a.m., likely further increasing the resident?s potassium blood level.Additionally, even though Resident 7?s potassium, CR, and BUN laboratory results of November 12, 2012, were abnormal, and indicated possible worsening of the resident?s kidney function, there was no documented evidence on November 12, 13, or 14, 2012, that the physician was notified of the resident?s high potassium, Cr, or BUN blood levels.During an interview with the director of nursing (DON), on November 15, 2012, at 10:40 a.m., she stated she was unaware of Resident 7's elevated potassium, Cr, or BUN laboratory blood levels for an unknown reason. The DON further mentioned that there was no documentation that the physician was aware of the resident's elevated laboratory blood levels, because there was no entry in the resident's clinical record or electronic medical record, and the laboratory report of November 12, 2012, at 4:06 p.m., was not signed or noted by the physician. During an interview with the medication nurse-licensed vocational nurse (LVN 1), on November 15, 2012, at 10:40 a.m., she stated she was unaware of Resident 7's elevated potassium, Cr, or BUN laboratory blood levels because she had not checked the resident?s chart, but was supposed to.The facility policy dated March 14, 2012, titled ?Laboratory Services? indicated that abnormal results need to be called and faxed in to the physician. If there is no response by the physician within 4 hours, the physician needs to be page or called. This process needs to be repeated until the physician has been notified of the abnormal results.On November 15, 2012, at 10:37 a.m., after the surveyor inquired about Resident 7?s laboratory report of November 12, 2012, (three days earlier), the DON reported by telephone to the physician the elevated potassium blood level. At the same time, the physician ordered to discontinue the potassium, and to do a potassium blood level for Resident 7. The potassium laboratory test was collected on November 15, 2012 at 1:10 p.m. and completed on the same date at 10:20 p.m. with the following results: a. Potassium, 5.7 mEq/liter (L), High b. Creatinine 2.21 mg/dL, High c. BUN 50 mg/dl, High The physician order of November 15, 2012 at 10:30 p.m., indicated to administer Kayexelate (a medication used to treat high potassium in the blood), 30 grams, one dose tomorrow in AM (November 16, 2012), to the resident, and to monitor for signs and symptoms of hyperkalemia?every shift for 7 days.The MAR indicated that on November 16, 2012 at 6:26 a.m., the resident was administered 30 grams (gm) one dose of Kayexelate, as the physician ordered.Resident 7?s Diagnostic Laboratory results dated November 17, 2012 at 5:10 a.m., after the resident was administered Kayexelate, indicated while the BUN and Cr remained high, the potassium blood level was restored, as follows: a. Potassium, 4.4 mEq/L, (normal) b. Creatinine 1.97 mg/dL, High c. BUN 51 mg/dl, High The facility policy and procedure titled "Laboratory Services" dated March 14, 2012, indicated the nurse shall document the time when laboratory results were reported and the physician's response in the resident's medical record.The facility failed to ensure that a resident was not administered potassium in the presence of adverse consequences which indicated the dose should be reduced or discontinued by failing to: 1. Develop a care plan to address appropriate use of potassium chloride to include monitoring/assessing for an increase in Resident 7?s potassium blood levels.2. Ensure that the nursing staff monitored/assessed the resident?s potassium laboratory blood level results to ensure that potassium chloride was administered only when necessary in order to prevent increasing/worsening of hyperkalemia,3. Notify the physician promptly that Resident 7 had an elevated potassium, creatinine and blood urea nitrogen laboratory blood test result that indicated kidney function was worsening, which required prompt medical intervention/attention.As a result Resident 7 had a delay in treatment for hyperkalemia, and was administered three unnecessary doses of potassium chloride, likely worsening the resident's high potassium blood level, which can lead to cardiac arrhythmias (irregular heart beat) or arrest (a life threatening condition).The above violations either jointly, separately, or in any combination presented a substantial probability that serious harm would result to Resident 7. |
| 950000030 |
BROADWAY HEALTHCARE CENTER |
950010234 |
A |
10-Dec-13 |
XHIM11 |
11631 |
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 On May 25, 2012, the Department received a complaint alleging a resident (resident 1) was having phlegm and a cough which required suctioning. A family member made several requests for the resident to be suctioned and for the physician to be notified, however the facility staff failed to suction the resident and the physician was never contacted. Six hours later the resident was found unresponsive. A code blue was called, the resident expired shortly after. On June 8, 2012, an unannounced visit was made to the facility to conduct a complaint investigation. Based on interview and record review the facility failed to ensure resident 1 received the necessary care and services by not: 1. Notifying the on-call physician or medical director of a change of condition after the resident?s primary care physician was unable to be located.2. Providing suctioning for the resident after family informed facility staff, several times throughout the day, the resident was congested. These failures resulted in delay of treatment for the resident, who later expired. Review of an admission face Sheet on June 26, 2012 at 2 p.m., indicated the resident was admitted to the facility on November 5, 2010. Diagnosis included paralysis (loss of muscle function in one or more muscles), muscle weakness, and dysphagia (difficulty swallowing). A Minimum Data Set (MDS), a standardized assessment and care screening tool, dated November 13, 2011, indicated the resident spoke Chinese, was usually able to make himself understood and usually able to understand others. The resident required extensive assistance with activities of daily living (ADL?s) such as transfers, dressing, toilet use and personal hygiene. The care plan for dysphagia, risk for choking, aspiration or pneumonia dated 1/6/12 and updated on 2/3/12, included interventions to monitor the resident for signs and symptoms of aspiration - shortness of breath, respiratory distress, congestion, and temperature elevation, and to notify the MD (physician promptly if signs and symptoms occur. Review of the ?Certified Nursing Assistant (CNA) Flow Sheet-Day Shift?, dated February 24, 2012, indicated the resident had a change of condition (COC) ?Needs more help for everything?. The Social Work progress note dated February 24, 2012, indicated the director of nursing (DON) and charge nurse were notified the resident?s son had stated he noticed the resident had a change of mood and a lot of saliva secretions since the day before (February 23, 2012). A licensed nursing note dated February 24, 2012 at 9:15 p.m., (a late entry) indicated the director of nursing (DON) was informed by the resident?s son at 9:30 a.m. on February 24, 2012, that the resident, did not look good. The DON observed the patient sitting upright in his wheelchair and the resident?s skin was very pale. The DON informed the resident?s son that the physician would be notified of his ?Concern?.At approximately 5:20 p.m. the resident was found unresponsive and the nursing supervisor called a code blue (an emergency code used when a resident requires emergency resuscitation). The Paramedics arrived at approximately 5:23 p.m. and took over resuscitation of the resident but the resident expired at 5:34 p.m. According to the nursing note on February 24, 2012 at 8:47 p.m., the resident?s physician called and the DON updated the physician about the resident?s change of condition (COC) that was identified in the morning.According to the DON, the physician stated he was out of town and had not received the message until after his office closed.Review of another licensed nursing note dated February 25, 2012 at 8:13 a.m., (a late entry written the day after the COC) indicated LVN 2 observed the resident on February 24, 2012 at 9:50 a.m., looking pale and weak with a runny nose. The vital signs were blood pressure (BP) 130 (no diastolic indicated), respirations (R) 20, pulse (P) 101, temperature (T) 98.6 and a oxygen saturation level of 95% (an indicator of the percentage of hemoglobin saturated with oxygen at the time of the measurement. Vitals from the previous two days were as follows: February 22, 2012, BP 130/78, R 20, P 72, T 98.4, February 23, 2012, BP 120/70, R 18, P 72, T 97.4. The LVN asked the resident how he was feeling and he said he did not feel good and pointed to his head and said again that he had a headache and felt dizziness. The LVN called the physician?s office at 10 a.m. on February 24, 2012, and left a message with the physician?s secretary. The licensed note also indicated at 11:10 a.m., on February 24, 2012, the son expressed another concern that the resident had chest congestion and asked if the resident could be suctioned (the removal of secretions that may have collected in the pharynx [throat]). According to the note the LVN stated she could not suction the resident without a physician?s order. Review of a licensed nursing note dated February 24, 2012 at 9:49 p.m.,(a late entry) indicated LVN 1, charge nurse for the day shift 7 a.m. ? 3 p.m., had been advised by the DON to check on the resident that morning due to concerns from the patient?s son that the resident looked pale and was dizzy. According to the nurse?s note a blood pressure taken during a medication pass was 128/78, no other vital signs were indicated. The LVN called the resident?s physician at approximately 11:30 a.m. and left a message. The nursing note also indicated the LVN observed the resident at lunch time and advised the resident?s son to not give the resident any milk as a safety precaution. Review of licensed nursing note dated February 25, 2012 at 12:02 a.m., indicated Registered Nurse 1 (RN 1) received a call from the resident?s son at approximately 5:15 p.m. on February 24, 2012. The resident?s son asked if the physician had ever called back. According to the nursing note, the RN then called the resident?s physician and left a message saying she would suction the resident?s oral secretions and for the physician to call back if there was any other orders otherwise the RN would continue to provide suctioning for the resident. The RN then went to see the resident and found him unresponsive a code blue was called at that time. In an interview, on June 26, 2012 at 2:55 p.m., Certified Nursing Assistant 1 (CNA 1) stated she was assigned to the resident on February 24, 2012. The CNA stated the resident was coughing and was weaker than usual. According to the CNA, the resident was usually able to assist while being transferred from the bed to the wheelchair, however, that day the resident was unable to provide any assistance. On June 26, 2012 at 3:35 p.m., the director of nursing (DON) was asked what the facility?s policy is when a resident has a change of condition. The DON stated if the change is not an emergency the physician is notified of the change of condition. The DON stated if the physician is unable to be located the on-call physician is the next in line to be notified. If the on-call physician is not located the medical director is notified. According to the DON neither the on-call physician nor the medical director were notified of the resident?s change of condition even after the patient?s primary physician failed to return the staff members phone calls and even though the resident?s son repeatedly notified the nursing staff that his father was pale, did not feel good, was having episodes of dizziness, and required suctioning for congestion. In an interview on June 26, 2012 at 3:50 p.m., LVN 2 stated the DON had asked her to assess the resident on the morning of February 24, 2012. According to the LVN, the resident stated he did not feel good and the resident?s son stated the resident needed suctioning. The LVN stated she called the resident?s physician and left a message with the secretary. The LVN was asked what the facility?s policy is if there is a change of condition and the resident?s physician is unable to be located. The nurse stated, ?We have a medical director we are supposed to call.? The nurse was asked if the medical director was called, the LVN stated the medical director was not called. The LVN also stated the resident was not in distress. When asked what was done to address the resident?s complaints of headache and dizziness, the LVN stated nothing was done for the complaints of headache and dizziness. During a phone interview on June 27, 2012 at 2:14 p.m., the speech therapist stated the resident had problems with speech and swallowing. According to the speech therapist, the resident always had a lot of phlegm in his throat. In an interview on June 28, 2012 at 2:30 p.m., the DON stated nurses are allowed to suction a resident without a physician?s order if the nurse assesses a resident as requiring suctioning. According to the DON, she was unaware the resident had been complaining of a headache and dizziness. The DON also stated there was documentation the resident?s son had stated the resident was having episodes of dizziness, however, it was not clear if there was any assessment done by the nursing staff. The DON was asked if she acknowledged the resident had a change of condition on the morning of February 24, 2012, the DON stated, ?Yes?. During a phone interview on June 29, 2012 at 9:40 a.m., LVN 3 stated he had been the charge nurse for the evening shift (3 p.m. - 11 p.m.) on February 24, 2012. According to LVN 3, he was told by LVN 1 the resident?s physician had been called because the resident had some congestion; however, the physician had not called back. LVN 3 was asked if he made another attempt to contact the resident?s physician, the LVN stated he had not. LVN 3 stated he observed the resident in bed asleep during his shift however he could not remember at what time. LVN 3 was also asked why he had not made any documentation in the licensed nursing notes regarding the resident the LVN stated, ?The other nurses documented, they stayed late.? A review of the facility?s undated policy titled, ?Change of Condition Management Guideline?, indicated if a change of condition is not life threatening the licensed nurse will notify the primary physician, family, and resident?s responsible party. If there is no response from the primary physician, contact alternate physician, and if no response from the alternate physician, the medical director should be contacted. The policy also indicated a change of condition may be subtle and slow to develop examples include: pain or change in level of pain, dizziness, and respiratory distress. The policy also indicated licensed nurse will document resident response and progress to treatment interventions every shift until stabilized. The facility failed to ensure resident 1 received the necessary care and services by not: 1. Notifying the on-call physician or medical director of a change of condition after the resident?s primary care physician was unable to be located.2. Providing suctioning for the resident after the family informed facility staff, several times throughout the day, the resident was congested. These violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result for resident 1. |
| 950000277 |
Brookdale San Dimas |
950012058 |
A |
16-Mar-16 |
6TR011 |
15362 |
Based on interview, and record review, the facility failed to provide treatment and services to prevent the development of pressure sores to Resident 1 by failing to: 1.Notify the physician immediately and promptly obtain treatment orders when Resident 1 developed an open sore on the coccyx. 2.Accurately and thoroughly assess Resident 1?s pressure sore as a basis for the initiation of interventions to promote healing.3.Revise Resident 1's plan of care to include additional interventions to prevent worsening of the pressure sore. These failures resulted in Resident 1 developing an avoidable Stage 3 to 4 pressure sore on the coccyx with foul smelling discharge and resulted in a delay in care and services necessary for treatment of a worsening pressure sore. On December 4, 2014, at 12:30 p.m., an unannounced visit was conducted at the facility to investigate a complaint regarding quality of care and resident neglect involving Resident 1.A review of the admission record indicated Resident 1 was admitted to the facility on September 4, 2014, with diagnoses that included dementia (a chronic disorder of the mental processes), renal (kidney) failure, and orthopedic (branch of medicine that deals with the prevention and correction of injuries of the skeletal system and associated muscles, joints, and ligaments, often by surgery) aftercare. According to the admission assessment dated September 4, 2014, Resident 1 had no pressure sores upon admission.Resident 1's assessment for Predicting Pressure Sore Risk dated September 4, 2014, indicated Resident 1 was a high risk for developing pressure sores.Resident 1's Minimum Data Set (MDS), a standardized assessment and care planning tool, dated September 11, 2014, indicated Resident 1 was able to complete the brief mental status interview, understands others and was able to make herself understood, required extensive assistance with most activities of daily living and had no pressure sores.Resident 1's care plan dated September 12, 2014, indicated the resident had the potential to develop pressure sores related to weakness and bed mobility. The care plan goal indicated the resident would have intact skin, be free of redness, blisters or discoloration. The listed nursing interventions included to follow facility policies and protocols for prevention and treatment of skin breakdown, apply moisturizer to the skin and massage over bony prominences (any point on the body where the bone is immediately below the skin surface), and use mild cleansers for peri-care (cleaning of the genitals, rectum, and buttocks) washing.A review of Resident 1's nurse's note dated September 19, 2014, at 2 p.m., indicated the resident was assessed with mild redness on the coccyx (tailbone). The same day the physician ordered to apply Calmoseptine ointment (acts as a barrier to protect skin from moisture and irritating substances) to the coccyx topically (apply to a body surface) every shift for 14 days for mild redness (October 3, 2014 would end the 14 days). Intact skin with non-blanchable redness of a localized area, usually over a bony prominence, is a Stage I pressure sore (Medical-Surgical Nursing, Lewis, Dirksen, Heitkemper, Bucher, Ninth Edition, page 185). According to Resident 1's Licensed Nurse Weekly Summary dated September 22, 2014, at 10:05 p.m., the resident was assessed with a skin tear on the coccyx. The documentation did not include a detailed description of the skin tear as indicated in the facility's policy and procedure. There was no documented evidence that the resident's physician was notified of the change in the resident's skin condition, so as to promptly obtain treatment orders to promote healing of the skin tear. The treatment record of September 2014, indicated Calmoseptine ointment treatment continued to be applied to the coccyx topically every shift even after the resident?s skin condition worsened from September 19, 2014, when the resident was assessed with mild redness on the coccyx to September 22, 2014, when the resident was assessed with a skin tear on the coccyx. There was no plan of care developed to address the resident's skin tear. A review of Resident 1's nurse's note dated September 23, 2014, at 4:25 a.m., indicated the resident was being monitored for an open sore to the coccyx, which is indicative of a Stage II pressure sore (partial - thickness loss of dermis (skin) presenting as a shallow open ulcer with red or pink wound bed and may also present as an intact or open/ruptured blister). There was no documented evidence on September 23, 2014, to indicate that the physician was notified of the resident's Stage II pressure sore on the coccyx, so as to promptly obtain treatment orders and initiate interventions based on the characteristics of the sore to promote healing of the pressure sore.The treatment record of September 2014, indicated the treatment nurses continued to apply Calmoseptine ointment to the coccyx every shift from September 23, 2015, through September 30, 2014, even after the resident developed the Stage II pressure sore. The plan of care was not revised to include additional measures to prevent worsening of the open sore such as systematically assessing the skin at least once a day (Nursing Care Ready Reference: Resident Assessment Protocols, Ross, November 1997, Page 63). Once a pressure sore has developed, interventions should be initiated based on the characteristics of the sore e.g., stage, size, location, amount of exudate, type of wound, presence of infection or pain and the resident's general status (Medical-Surgical Nursing, Lewis, Dirksen, Heitkemper, Bucher, Ninth Edition, page 186). A review of the Medicare/PPS (prospective payment system) of Daily Charting dated September 25, 2014, at 9:26 p.m., indicated the resident had excoriation (a raw and open break in the skin surface usually caused by scratches, burns, or abrasion) on the coccyx. The charting did not include a thorough assessment of the resident's coccyx and it did not contain documented evidence that the resident's physician was notified of a change in the resident's skin condition.According to the treatment record for September 2014, the resident continued to receive Calmoseptine ointment on her coccyx every shift for mild redness from September 19, 2014 to September 30, 2014. Resident 1's plan of care dated September 25, 2014, indicated the resident had an actual impairment to skin integrity, unstageable pressure sore (unable to determine [UTD] stage due to coverage of wound bed by slough [dead tissue in the process of separating from viable portions of the body] and/or eschar [thick, leathery, dead, devitalized tissue]), related to fragile skin. The care plan nursing interventions indicated to evaluate the resident's skin condition on a daily and weekly basis. A review of the resident' s clinical record did not contain an accurate and detailed evaluation of the resident's skin condition for three days, from September 26, 2014 through September 28, 2014, as indicated on the resident's care plan dated September 25, 2014. As such, the status of the unstageable pressure sore was not determinable from the documentation.A review of Resident 1's treatment record for September 2014, indicated the treatment was changed on September 26, 2014. The treatment indicated to cleanse coccyx with normal saline (salt solution), pat dry, and to apply calmoseptine ointment on the coccyx topically and cover with a dry dressing every shift. A review of the treatment record for September 2014, indicated the calmoseptine ointment treatment continued to be applied to the resident's coccyx for mild redness from September 25, 2014 through September 30, 2014, even though the resident's pressure sore had worsened on September 25, 2014, to an unstageable pressure sore. There was no documented evidence the physician was notified immediately to obtain treatment orders for the resident's worsening unstageable pressure sore on the coccyx from the time it was identified by the facility on September 25, 2014, until September 29, 2014.The nurse's note dated September 29, 2014, at 2:55 p.m., indicated the resident's physician was notified about the resident's progressing excoriation and an order for a wound care surgeon consult was received. The nurse?s notes did not include an accurate and detailed assessment of the progressing excoriation to include the stage, length, and width, and depth, presence of exudates or necrotic tissue, as a basis for initiating interventions based on the characteristics of the sore. On September 30, 2014, the physician ordered to cleanse the unstageable pressure sore (UTD) with normal saline, pat dry, apply santyl (topical medication that helps to break up and remove dead skin and tissue) and cover with dry dressing every day and as needed until the follow-up with the wound surgeon. The physician's order for santyl, was obtained after a delay of five days, from when on September 25, 2014, the facility identified the resident had an actual unstageable pressure sore. Santyl is an FDA approved prescription medicine that removes dead tissue from wounds so they can start to heal. Healthcare professionals have prescribed Santyl ointment for more than 20 years to help clean many types of wounds including chronic dermal ulcers.A review of a plan of care dated September 30, 2014, indicated the resident was at risk for complications/injury to unstageable pressure sore related to the resident scratching at her pressure sore, pulling off the dressing, and noncompliance with not touching the wound. The care plan goal indicated the resident will not have further complications from the unstageable pressure sore. The listed nursing interventions included to encourage good hygiene and replace dressing to sacrum as necessary.According to Resident 1's nurse's note dated October 1, 2014, at 3:23 p.m., the resident was found with altered level of consciousness and chest pain and was transferred to the general acute care hospital due to a change in condition.The acute hospital Emergency Department (ED) Stat Admit (immediate admission) record, dated October 1, 2014, indicated the resident was assessed with a stage 3 (full thickness skin loss involving damage to or necrosis [tissue death] of subcutaneous [third of the three layers of the skin containing fat and connective tissue that houses larger blood vessels and nerves] tissue that extend down to, but not through, underlying fascia [sheet of connective tissue binding together body structures] to stage 4 (full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures; may include undermining [tissue destruction underlying intact skin along wound margins] and tunneling [pathway that can extend in any direction from the wound, resulting in dead space]) sacral pressure sore, measuring two to three centimeters (cm) with foul smelling discharge and had a temperature of 100.5 degrees. The acute hospital emergency room physician notes further indicated the resident had diagnoses that included severe sepsis and urinary tract infection.According to Mayo Clinic, signs of an infected pressure sore include; fever, drainage or a foul odor from a sore, and increased heat and redness in the surrounding skin (http://www.mayoclinic.org/diseases-conditions/bedsores/basics/symptoms/con-20030848). A review of the GACH's (general acute care hospital) Assessment Report by the ED registered nurse (RN) dated October 1, 2014, at 3:28 p.m., indicated the resident had a foul smelling open wound on the coccyx, stage 3 to 4, with eschar covering and around the edges.During an interview on December 4, 2014, at 2:45 p.m., Licensed Vocational Nurse (LVN) 1 stated that the resident was receiving calmoseptine ointment for the excoriation on her coccyx. LVN 1 further stated that the resident's excoriation got worse so fast due to the resident scratching the area and taking off the dressing. On March 26, 2015, at 2:40 a.m., during an interview, the director of nursing (DON) reviewed the clinical record and was unable to find accurate and detailed assessments of the resident's skin condition and wound progression from September 22, 2014 through September 30, 2014. The DON further stated that there were some inconsistencies in the licensed nurses' documentation.On April 22, 2015, at 12:45 p.m., during a telephone interview, LVN 1 stated that the resident's unstageable pressure sore worsened and had gotten bigger when she saw it on September 30, 2014. LVN 1 stated that she never measured the resident's wound and the attending physician had not seen the resident's wound.A review of the facility's policy and procedure titled "Pressure Ulcer/Skin Breakdown - Clinical Protocol" dated October 2010, indicated the nursing staff and attending physician will assess and document an individual's significant risk factors for developing pressure sores. In addition, the nurse shall assess and document the following: full assessment of pressure sore including location, stage, length, width, and depth, presence of exudates or necrotic tissue. During resident visits, the physician will evaluate and document the progress of wound healing, especially for those with complicated, extensive, or non-healing wounds.According to the US Department of Health and Human Services publication: "Clinical Practice Guideline for Pressure Ulcer Treatment" dated December 1994, pressure ulcers should be uniformly described to facilitate communication among staff and to ensure adequate monitoring of the progress toward healing. To monitor progress or deterioration of the lesion, the examiner must accurately measure the length, width, and depth of the ulcer and describe sinus tracts, tunneling, undermining, necrotic tissue, exudate, and the presence or absence of granulation tissue and epithelization (the regrowth of skin over a wound). To determine the adequacy of the treatment plan, it is essential to monitor pressure ulcers at consistent intervals. Assessment and documentation should be carried out at least weekly, unless there is evidence of deterioration, in which case both the pressure ulcer and the patient's overall management must be reassessed immediately. The facility failed to provide treatment and services to prevent the development of pressure sores to Resident 1 by failing to: 1.Notify the physician immediately and promptly obtain treatment orders when Resident 1 developed an open sore on the coccyx. 2.Accurately and thoroughly assess Resident 1?s pressure sore as a basis for the initiation of interventions to promote healing.3.Revise Resident 1's plan of care to include additional interventions to prevent worsening of the pressure sore. These failures resulted in Resident 1 developing an avoidable Stage 3 to 4 pressure sore on the coccyx with foul smelling discharge and resulted in a delay in care and services necessary for treatment of a worsening pressure sore.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. |
| 950000054 |
Beacon Healthcare Center |
950012210 |
A |
14-Jul-16 |
QZKS11 |
4448 |
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. Based on interview and record review, the facility?s staff failed to follow the physician?s order to raise Resident 1?s side rails up for safety. As a result, Resident 1 fell out of bed while under CNA 1?s care, causing four (4) fractured ribs and a puncture wound in the back. Findings: Record review of the admission face sheet revealed Resident 1 was admitted to the facility on 1/16/13 with diagnoses that included diabetes mellitus (a disease in which there are high blood sugar levels over a prolonged period), chronic kidney disease, osteoporosis (a progressive bone disease that weakens bones and makes them susceptible to bone fractures), and dementia (also known as senility, a broad category of brain diseases that cause a long term and often gradual decrease in the ability to think and remember that is great enough to affect a person's daily functioning). The most recent Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 10/14/13, indicated Resident 1 had short- and long-term memory problems and severely impaired decision-making skill; Resident 1 needed extensive assistance, requiring one person physical assist with daily activities that included bed mobility, transfers, eating and personal hygiene. A care plan dated 1/16/13 indicated Resident 1 had the following concerns/problems: 1) Altered thought processes related to memory loss, confusion, 2) Impaired verbal communication, 3) Potential for injury, 4) Self-care deficit, and 5) Inability to follow directions. Some of the listed goals included: a) Resident will not have any injury, and b) Resident will be assisted by staff in performing daily activities which cannot be met by the resident. A physician?s order dated 1/16/13 indicated, ?Side rails up in bed for safety, improve mobility, and increase independence.? A licensed nurse?s progress notes, dated 1/14/14, at 5:35 a.m., indicated that the resident fell out of bed. Upon assessment by the licensed nurse, Resident 1 was noted with a bleeding bump on the back of the body on the right side closer to the ribs. Resident 1 was grimacing and moaning. The resident was transferred to the acute hospital via 911 services on 1/14/2014 for a stay to 1/17/2014. During an interview on 2/25/14, at 2:45 p.m., the Director of Nursing (DON) stated that a certified nursing assistant (CNA 1) was providing care to the resident when the resident fell. The DON stated that CNA 1 reached for supplies that were at the foot of the bed and this was when the resident rolled out of bed. The DON stated that CNA 1 failed to raise the side rails which caused Resident 1 to roll and fall out of bed. The Employee Warning Record, dated 1/15/14, indicated, ?The resident fell out of the bed accidentally when the CNA (CNA 1) forgot to put the side rail up when he turned around to get his stuff.? Hospital records (x-rays) revealed Resident 1 sustained fractures on the right 7th, 8th, 9th and 10th ribs, and a puncture wound on the back, as a result of the fall. The resident?s pain level reached a level of 6 in a scale of 0-10 (0 = no pain, 1 ? 3 = mild pain, 4 ? 6 = moderate pain, 7 ? 10 = severe pain). During the stay at the acute hospital from 1/14/14 to 1/17/14, the Resident 1 received a total of five (5) tablets of APAP/Hydrocodone 750 milligrams/7.5 milligrams. ?Hydrocodone/APAP is a combination medication commonly used to treat short-term pain that is moderate to moderately severe. The drug is taken every four to six hours for pain, there is a narcotic component in it. The possible side effects include constipation, drowsiness, and nausea? (http://pain.emedtv.com/hydrocodone-apap/hydrocodone-apap.html). The facility?s staff (CNA 1) failed to provide safety measures by not having the side rails up during care of Resident 1. As a result, Resident 1 fell out of bed and sustained four (4) fractured ribs and a puncture wound in the back and had a three day stay at the hospital. The above violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 970000194 |
BRIGHTON CONVALESCENT CENTER |
950012230 |
A |
03-Jun-16 |
F2X311 |
11959 |
F223 483.13(b) 483.13(c)(1)(i) Free from physical abuse/involuntary seclusion. The resident has the right to be free from verbal, sexual, or physical abuse, corporal punishment, and involuntary seclusion.The facility must not use verbal, sexual, physical abuse, corporal punishment, or involuntary seclusion. Based on observation, interview, and record review, the facility failed to ensure that one of one sample resident, Resident A, was free from being physically and verbally abused by Employee 1. Resident A was struck on the head by Employee 1 using Resident A's own shoe that resulted in a sustained small red mark on top of his head; Resident A stated, ?It hurt so much."Resident A also stated he endured great pain when his left arm was pulled by Employee 1 during his attempt to transfer Resident A from the wheelchair to the bed. Resident A also suffered humiliation from verbal abuse, Employee 1 told Resident A, ?Shut up Bitch? and also used the ?f word? when addressing Resident A.Findings: Resident A is a 72 year-old male who was first admitted to the facility on August 29, 2014, with a diagnosis of Cellulitis. A review of his MDS (minimum data set) from his medical record dated September 8, 2014, indicated Resident A was understood, could understand, and had no memory problems, delirium, hallucinations, or delusions. He also had additional active diagnoses including Arthritis, Osteoporosis, Seizure Disorder, and generalized muscle weakness. During an interview with Resident A on September 5, 2014, at 11:00am, he stated, last night (on September 4, 2014), he was in his bedroom being helped to bed from his wheelchair by Employee 1. He stated Employee 1 grabbed him by his left arm which caused him great pain. He explained to Employee 1 to grab him by the back of his pants instead to transfer him to his bed. Resident A then stated after Employee 1 grabbed him by his pants and helped him to bed; he then proceeded to slap Resident A five times on his head with an open hand. Employee 1 then grabbed resident A's shoe and hit him on the head with the shoe. Resident A stated: "It hurt so much."During a review of Resident A's medical record (Licensed Nurses weekly progress notes), an entry dated September 4, 2014, at 9:30 pm indicated a pink and moist skin tear measuring one centimeter on the left parietal area of the head. The note indicated Resident A informed the RN supervisor that Employee 1 hit him, the police were called and Employee 1 was taken off the floor and ushered to the employee lounge to be questioned by the supervisor and later by the police when they arrived to investigate the allegation of abuse. The same progress notes indicated Resident A said, ?I was in my wheelchair when this aide grabbed my arm and I told him to grab or pull my pants so he did. I was on my bed when he suddenly hit me in the face with an open hand, then took my shoes off and hit me on my head."The documentation indicated that the police officers left the facility taking Employee 1 with them.On September 5, 2014, at 11:15 am it was observed that Resident A had a small red mark on the top of his head. On September 5, 2014, at 11:30 am, during an interview, Resident B (roommate) stated that last night (September 4, 2014,) he was in the same room with Resident A. He said he saw Employee 1 transfer Resident A to bed sometime after dinner and he heard Employee 1 say to Resident A, "Shut up bitch!?, and saw him hitting Resident A on the head with his hand. He then grabbed Resident A's shoe which he used to hit the resident on his head. Resident B said another employee entered the room and when Employee 1 saw the 2nd employee, he stopped hitting Resident A and quickly walked out of the room. A review of Resident B?s medical record indicated he was a 68 year-old male, admitted to the facility on September 4, 2014, with diagnoses including: Chronic airway obstruction, unspecified hypothyroidism, diabetes type II without complications, unspecified schizophrenia, nondependent cocaine abuse, depressive disorder, unspecified epilepsy without mention interact epilepsy , unspecified essential hypertension, coronary atherosclerosis unspecified type vessel native/graft, cardiomegaly, esophageal reflux, and cardiac pacemaker. Resident B?s physician orders sheet dated September 4, 2014, indicated that resident B is capable of understanding rights and responsibilities and /or able to participate in his treatment plan.A review of his Minimum Data Set dated September 16, 2014, indicated Resident B had adequate hearing and vision, clear speech, was able to make himself understood and had the ability to understand others, and had no signs or symptoms of delirium in his cognitive patterns.During an interview with Employee 2 (CNA) on September 8, 2014, at 3:30 pm, she stated that on September 4, 2014, at 8:30 pm, she saw Employee 1 go into Resident A's room. She was in the room next door taking care of a resident when she heard Employee 1 using "the f-word."She then heard Resident A say "Don't beat me!"Employee 2 went across to Resident A's room and saw Employee 1 holding his hand up as if to strike Resident A then Employee 1 walked out of the room. Employee 2 then said she reported the incident to Employee 3 (LVN).In addition to this incident, Employee 2 stated she saw an interaction between Resident A and Employee 1 earlier in the evening at 6:30 pm. She saw Employee 1 enter the bedroom of Resident A and heard Resident A tell him, ?No! I don't want you." She then saw Employee 1 leave the room. During different times that evening Employee 2 stated she observed Employee 1 talking loud and appeared like he could not keep his balance. Employee 1 was observed by Employee 2, staggering as she saw him knock down a linen barrel filled with soiled linen in front of room 36. During an interview with Employee 3 (LVN) on September 8, 2014, at 4:27 pm, she stated that on September 4, 2014, she was informed by Employee 2 that Resident A was hit by Employee 1. She went to speak to Employee 4 (RN) who called the Director of Nurses. Employee 3 was told to take Employee 1 off the floor (off work assignment with no further contact with residents). Employee 3 then called the police.An interview with Employee 4 (RN) on September 8, 2014, at 4:45 pm, revealed that on September 4, 2014, at 9:15 pm, she went to Resident A's room and he told her, Employee 1 hit him. She then spoke to the roommate, Resident B who verified that Resident A was hit by Employee 1. Employee 4 then spoke to Employee 1 in the employees lounge. He stated he did not hit Resident A and that Resident A is crazy. Employee 4 stated the police arrived at 10:30 pm and interviewed Employee 1 and Residents A & B; afterward the police left the facility with Employee 1 at 11:30 pm. During an interview with Employee 5 (LVN) on September 9, 2014, at 3:30 pm, she stated that on September 4, 2014, Employee 1 said that he didn't hit Resident A. Then Employee 5 stated she, Employee 4, and Employee 7, all took Employee 1 to the employee lounge and told him he could not work the floor anymore that evening. Employee 5 stated Employee 1 denied hitting Resident A and indicated Resident A was crazy and implied we were trying to nail him down. Employee 5 did a body assessment of Resident A and stated when the police came at about 10 pm, Employee 1's face looked red and he smelled of alcohol. During an interview with Employee 6 (CNA) on September 8, 2014, at 4:47 pm, he stated that later in the evening at 8:00 pm, he heard Resident A saying to Employee 1 that he wanted to go to the bathroom. Employee 6 stated Employee 1 replied by teasing Resident A saying, "Oh Yeah? Oh Yeah??After passing bedtime snacks about 8:30 pm, Employee 6 stated Resident A told him, "Hey! Your friend hit me with an open hand and with my shoe!" Employee 6 stated Employee 1 appeared drunk as he was sleeping instead of assisting patients. He also said he saw Employee 1 fall on the floor while taking linen out of room 37 at 8:00 pm. During an interview with Employee 7 (RN) on September 9, 2014, at 3:30 pm, he stated on September 4, 2014, in the evening after he and Employees 4 & 5 took Employee 1 to the employee lounge for questioning, Employee 7 asked Employee 1 if he had been drinking and Employee 1 replied "whatever man!" During an interview with Employee 1 on September 10, 2014, at 4:35 pm, he stated that on September 4, 2014, at 9:30 pm, he was assisting Resident A to bed. Employee 1 stated he transferred Resident A from his wheelchair to his bed. He stated he grabbed him by the back of his pants and lifted him to the bed. He said Resident A was upset. Employee 1 stated he did not hit resident A that night with either his hand nor with the resident's shoe. He stated no one could see him transfer the resident to the bed because he had drawn the privacy curtain around himself and Resident A before beginning the transfer. He stated he had not been assigned to Resident A before that evening of September 4, 2014. When asked if he had been drinking earlier that evening, Employee 1 stated, no, but he had been drinking the day before during a family function on September 3, 2014, from midnight till 4 am in the morning. He said he was getting over a hangover but still felt well enough to work and he worked from 7am till 3pm during the day at another facility on September 4, 2014, and then continued to work from 3pm till 11pm in the evening at the current facility. A review of the facility's policy on abuse prevention (revised 05/08/13) indicated that the facility will protect the rights, safety and wellbeing of each resident for whom they provide care and treatment against any and all forms of physical, verbal, mental abuse , neglect, financial abuse, abandonment, isolation/involuntary seclusion, abduction, corporal punishment, any form of mistreatment, or any other treatment that would result in physical harm, pain, or mental suffering, including the deprivation by a care custodian of goods/services that are necessary to avoid physical harm and to attain/maintain physical mental, and psycho-social well-being of the residents. A review of the facility?s policy on Substance Abuse dated September 2003 indicates that the work environment must be free from the effects of drugs, alcohol, or other intoxicating substances. The policy further states that any employee reporting to work under the influence of alcohol, drugs, or other intoxicating substances will not be permitted to work his/her assigned shift, or should an employee be discovered under the influence of alcohol, drugs, or other intoxicating substances while on duty, the employee will be relieved of his/her assigned tasks and be asked to leave the premises.During an interview with the current administrator of the facility on May 9, 2016, he stated the facility employee handbook became effective May 1, 2013. A review of the employee handbook on May 9, 2016, indicated in the Drug and Alcohol Abuse section of the handbook that the use of alcohol whether on or off the job can detract from an employee?s work performance, efficiency , safety, and health, and therefore seriously impair the employee value to the company. It further states that the use or possession of this substance on the job constitutes a potential danger to the welfare, and safety of other employees. The facility?s failure to ensure Resident A was not physically abused resulted in a wound to Resident A?s head and pain in his arm; failed to ensure Resident A was not verbally abused, caused Resident A humiliation from being hit on the head with his shoe and being called a ?bitch?. 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. |
| 970000194 |
BRIGHTON CARE CENTER |
950012561 |
B |
2-Sep-16 |
VD6M11 |
4732 |
F322 ? 483.25(g) (2) NG Treatment/services - Restore eating skills 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. On 6/1/15, at 7:26 a.m., an unannounced visit was made to the facility to conduct the annual recertification survey. Based on observations, interviews and record reviews, the facility failed to ensure the head of the bed was elevated to 30 degrees for Residents 3 and 9 while they were receiving G-tube feedings. This had the potential of the feeding formula to back up and enter the lungs which could result in aspiration pneumonia. 1.Resident 3 was readmitted to the facility on 4/30/15 with diagnoses that included muscle weakness, diabetes mellitus, encephalopathy (a general term that means brain disease, damage, or malfunction), and dementia. The MDS dated 5/27/15 indicated the resident was cognitively impaired and was fully dependent on staff to perform daily activities, such as transfers, dressing and personal hygiene. The resident was fed and medicated through a G-tube. On 6/1/15, at 2:54 p.m., Resident 3 was observed in bed with the G-tube feeding pump at 66 milliliters per hour. The resident's head-of-bed (HOB) was low, at 15 degrees. LVN 1 was in the room and asked why the HOB was low. LVN 1 quickly raised the HOB. There were a plastic pitcher with water and a plastic cup on the resident's nightstand located on the right side of the bed. A physician's order, dated 4/30/15, indicated to keep the HOB (head of bed) elevated at least 30 degrees at all times. A care plan dated 5/1/15 indicated the resident was at risk for aspiration. One of the care plan goals was for the resident to be free from aspiration, with an approach to elevate the HOB at all times if the feeding pump was being used. The facility's Policy and Procedures, Enteral Feedings - Safety Precautions, revised June 2015, indicated, "Always elevate the head of the bed (HOB) at least 30-45 degrees during tube feeding and at least 1 hour after." 2. The Admission Record (Face Sheet) for Resident 9 indicated Resident 9 was originally admitted to the facility on 7/26/13, and readmitted on 4/24/15, with diagnoses that included attention to gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food or medications), convulsions (when a person's body shakes rapidly and uncontrollably), and atrial fibrillation (irregular and often very fast heart rate). A review of Resident 9's minimum data set (MDS, a comprehensive assessment and care planning tool), dated 5/15/15, indicated Resident 9 had the ability to sometimes understand others and sometimes make self-understood, and scored 10 (moderately impaired) on his Brief Interview for Mental Status (BIMS). The MDS also indicated Resident 9 did not have any range of motion impairment on both sides of his upper and lower extremities, and was being fed by a gastric feeding tube (G-tube). Care Plans related to Resident 9 having G-tube feeding, dated 4/25/15, indicated a diagnosis of dysphagia (difficulty in swallowing), and was at risk for aspiration. On 6/1/15, at 3:10 PM, Resident 9 was observed lying in bed. A feeding formula (Isosource 1.5) was running thru the G-tube at 60 cubic centimeters (cc) per hour. There were a pink pitcher with water and a plastic cup on top of the resident's over bed table by the foot of the bed. Resident 9's head of the bed was not raised to an angle of at least 30 degrees or more, to prevent aspiration, as ordered by the physician on 4/25/15. During an interview with the Quality Assurance Designee (LVN 8) on 6/1/15, at 3:10 PM, he confirmed Resident 9's head of the bed was low. LVN 8 stated the resident's head of the bed should be raised to at least 30 to 45 degrees while receiving tube feeding to prevent aspiration. LVN 8 further stated he will bring this information to the charge nurse's attention. The facility's policy and procedures, Enteral Feedings - Safety Precautions, revised June 2015, indicated, "Always elevate the head of the bed (HOB) at least 30-45 degrees during tube feeding and at least 1 hour after." The facility failed to ensure that the head of the beds (HOB) were elevated at least 30 degrees for residents receiving feeding through the G-tubes. These failures placed the residents at risk for aspiration pneumonia and/or complications of aspiration. The above violation had a direct relationship to the health, safety or security of the residents. |
| 970000194 |
BRIGHTON CARE CENTER |
950012562 |
B |
2-Sep-16 |
VD6M11 |
12200 |
F322 ? 483.25(g) (2) NG Treatment/services - Restore eating skills 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. On 6/1/15, at 7:26 a.m., an unannounced visit was made to the facility to conduct the annual Recertification survey. Based on observations, interviews and record reviews, the facility failed to: Ensure Residents 2, 5, 9, 12, 20, 21 and 22 who had G-tubes (stomach tubes usually used for feeding and medications) and were NPO (nothing by mouth) and had difficulty swallowing, were not provided water pitchers at their bedside tables. 1.Resident 12 was readmitted to the facility on 4/3/15 with diagnoses that included dysphagia (difficulty in swallowing) and left-sided weakness secondary to a stroke (a sudden disabling attack or loss of consciousness caused by an interruption in the flow of blood to the brain, especially through thrombosis). Resident 12 was fed and medicated through a G-tube (gastric tube) and was on NPO status. A care plan dated 4/6/15 indicated the resident was at risk for aspiration. The Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 5/15/15 indicated the resident had cognitive (acquiring knowledge and understanding) and decision-making difficulties and required assistance with transfers, dressing, and personal hygiene. On 6/1/15, at 4:10 p.m., Resident 12 was observed lying in bed. The G-tube pump, on the left side of the bed, was infusing (dripping through the tube) at 70 milliliters per hour. On the right side of the bed there was a plastic pitcher with water in it and a plastic cup placed on the movable bedside table. When Resident 12 was asked if he was able to reach the water pitcher, Resident 12 stated "yes." The resident also stated he was able to pour water into the cup and drink from it and stated he just drank a full glass of water about 15 minutes ago. On 6/1/15, at 4:15 p.m., the licensed vocational nurse (LVN 1) who was at Resident 12's room, also saw the water pitcher and cup on the bedside table on the right side (along the wall) of the resident's bed. LVN 1 asked Resident 12 if he were able to reach the water pitcher and he stated "yes" and that he was able to pour water from the pitcher into the cup and drink the water. LVN 1 stated he was not aware the resident was able to pour and drink water by himself. During a follow-up interview in the presence of another surveyor on 6/1/15, at 5:45 p.m., Resident 12 stated that he has been pouring and drinking water on his own on a daily basis, about a cup four times each day and stated nobody from the facility had told him that he could not drink water, although he knew he should not "because the water wants to come out." He added that he just forces the water in his throat each time he drinks During an interview with another licensed vocational nurse (LVN 2) on 6/1/15, at 5:56 p.m., she stated she was not aware that Resident 12 was able to pour and drink water on his own. She stated Resident 12 was on NPO status and should not be drinking. LVN 2 indicated the resident had weakness on the left side, but had full range of motion on the right side (arm, hand, fingers). She stated that the water pitcher should be out of the resident's reach. When asked if the resident was taught NPO restrictions due to G-tube placement, LVN 2 stated "no." LVN 2 also stated she placed the bedside table on the resident's left side of the bed while flushing the G-tube, then placed the bedside table (with the water pitcher and cup) on the right side of the bed, along the wall, when she finished. During an interview on 6/1/15, at 6:20 p.m., a certified nursing assistant (CNA 1) from the 3-11 p.m. shift stated that when she's on duty, she fills water pitchers for the residents assigned to her, and today she was assigned to Resident 12. For Resident 12, she stated the water pitcher and cup are always placed along the wall (on the resident's right side) and she was not aware Resident 12 was able to pour and drink the water. During an interview on 6/1/15, at 6:35 p.m., the Director of Staff Development (DSD) stated she conducted an in-service training to nursing staff on 10/14/14 and 1/8/15, regarding NPO residents being at risk for aspiration and there should be absolutely no water pitchers at their bedside. A review of the in-service Education Records dated 10/14/14 and 1/8/15 revealed no documented evidence LVN 2 and CNA 1 attended the in-service training. The Joint Mobility Assessment, dated 4/15/15, indicated Resident 12 had full range of motion on his right shoulder, right elbow, right wrist, right hand and fingers, right hip, right knee and right ankle. During an interview on 6/4/15, at 9:08 a.m., a restorative nursing assistant (RNA 1) stated she provided exercises to Resident 12 five times weekly. RNA 1 stated Resident 12 was strong on the right side of the body and had no limitations of his right arm, hand, and fingers. She stated the resident had the ability to pour water and drink from a cup. During an interview on 6/4/15, at 9:28 a.m., the facility's Minimum Data Set (MDS) coordinator (assists with resident assessments and in completing the MDS assessment forms) stated the resident's right hand grasp was very strong and that the resident would be able to grasp, pour water from the pitcher, and drink, if these items were positioned close enough to the resident. 2. The Admission Record (Face Sheet) for Resident 9 indicated the resident was originally admitted to the facility on 7/26/13, and readmitted on 4/24/15, with diagnoses that included: attention to gastrostomy (stomach tubes for food or medications), convulsions ( rapid and uncontrollable shaking), and atrial fibrillation (irregular and often very fast heart rate). Resident 9's minimum data set (MDS, a comprehensive assessment and care planning tool), dated 5/15/15, indicated Resident 9 had the ability to sometimes understand others and sometimes make self-understood, and scored 10 (moderately impaired) on his Brief Interview for Mental Status (BIMS). The MDS also indicated Resident 9 did not have any range of motion impairment on either side of his upper and lower extremities, and was being fed through an abdominal or gastric feeding tube (G-tube). A review of Resident 9's Joint Mobility Assessment, dated 4/27/15, indicated the resident had full range of motion of his right and left elbows, wrists, and fingers. The G-Tube feeding Care Plan, dated 4/25/15, indicated the resident had a diagnosis of dysphagia (difficulty in swallowing), and was at risk for aspiration. On 6/1/15, at 3:10 PM, Resident 9 was observed lying in bed. Isosource (brand of feeding formula) 1.5 formula was infusing thru the G-tube at 60 cubic centimeters (cc) per hour. There was a pink pitcher with water and a plastic cup on top of the resident's over-bed table by the foot of the bed. The head of the bed was not elevated to an angle of at least 30 degrees or more, to prevent aspiration (Aspiration results from the abnormal entry of material from the mouth or stomach into the trachea and lungs), as ordered by the physician on 4/25/15. During an interview, with Resident 9 on 6/1/15, at 5:40 PM, he stated he drank a cup of water today from the water pitcher when a female person offered it to him. The resident was unable to identify the female person. 3. Resident 2 was readmitted to the facility on 5/22/15 with diagnoses that included pneumonia, muscle weakness, dementia and dysphagia. The MDS assessment dated 5/29/15 indicated the resident had short-and long-term memory problem and was dependent on staff to perform daily activities, such as transfers and personal hygiene. The resident was on NPO status and was fed and medicated through the G-tube. On 6/1/15, during multiple observations at 8:55 a.m. and 2:53 p.m., a water pitcher and a plastic cup were observed on the bedside table. During these times, Resident 2 stated he was thirsty and was asking if he could have some water. 4. Resident 5 was re-admitted to the facility on 3/1/15, with diagnoses that included adult failure to thrive (a condition when there are symptoms of weight loss, decreased appetite, poor nutrition, and inactivity), kidney disease and gastrostomy tube. The Minimum Data Set (MDS- standardized assessment and care planning tool) dated 3/19/15, indicated the resident had severe cognitive (mental) impairment, was totally dependent in all activities of daily living and the resident was receiving tube feedings. The Care Plan dated 3/2/15 indicated Resident 5 was on tube feedings and was at risk for aspiration. One of the resident's care plan goals was, to maintain a patent (open) airway which would be free from signs and symptoms of aspiration daily. During observation on 6/1/15, at 8 a.m. and 4 p.m., there were a plastic pitcher with water and a plastic cup observed at the resident's bedside table. During an interview with Certified Nurse Assistant (CNA) 2 on 6/1/15, at 4:30 p.m., he confirmed he fills the resident's water pitcher at the beginning of the shift. 5. Review of Resident 20's clinical records indicated the resident was re-admitted to the facility on 12/5/12, with diagnoses that included cerebrovascular disease (a condition that affects the circulation of blood to the brain, causing limited or no blood flow to affected areas of the brain), dysphagia (difficulty in swallowing) and diabetes mellitus (high sugar level in the blood). The Minimum Data Set (MDS-a standardized assessment and care planning tool) dated 3/2/15, indicated the resident sometimes made self-understood, and usually understood others, required extensive assistance in bed mobility, was totally dependent with other activities of daily living and was on a feeding tube. The care plan dated 6/1/15 indicated Resident 20 was at risk for aspiration. During observation on 6/1/15, at 8 a.m. and 4:30 p.m., Resident 20 was observed in bed with a G-tube feeding of Diabetic Source infusing at 70 ml per hour. There was a plastic pitcher with water and a plastic cup at the resident's bedside. 6. Resident 21 was re-admitted to the facility on 4/20/15, with diagnoses that included gastrostomy tube, dementia (problems with thinking and memory), and anxiety. According to Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 4/16/15, the resident had short and long-term memory problems, was severely impaired in his cognitive skills for daily decision making, sometimes able to understand others and make himself understood, and required total assistance with activities of daily living and was being fed by a feeding tube. A review of the care plan dated 6/1/15 indicated Resident 21 was at risk for aspiration. On 6/1/15, at 8:10 a.m., and 4:30 p.m., Resident 21 had a plastic pitcher and a plastic cup on the bedside table. 7. Resident 22 was admitted to the facility on 2/3/15, with diagnoses that included pneumonia (infection of the lungs), dysphagia, and gastrostomy tube. The Minimum Data Set (MDS- a standardized assessment and care planning tool) dated 5/19/15, indicated the resident usually made self-understood, usually understand others, was totally dependent for all activities of daily living and was being fed by a feeding tube. A Care Plan dated 6/1/15 indicated Resident 22 was at risk for aspiration. During observation on 6/1/15, Resident 22 had a plastic water pitcher with and plastic cup at the bedside. On 6/1/15, the interim DON confirmed the findings relating to all the residents. The facility failed to ensure that water pitchers were not accessible to residents who were on NPO status. This failure placed the residents at risk for aspiration pneumonia and/or complications of aspiration. The above violation had a direct relationship to the health, safety or security of the residents. |
| 960001713 |
BEST CARE HOME I, INC. |
960009630 |
B |
29-Nov-12 |
G24011 |
4066 |
Welfare and Institution Code 4502 (b) 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:(b) A right to dignity, privacy, and habilitation services and supports in the least restrictive environment. Treatment and habilitation services and supports shall be provided in natural community settings.Based on observation, interview and record review, the facility staff failed to ensure Client 4 was given privacy by failing to: 1. Close the bathroom door while Client 4 sat on the toilet wearing a white, tank undershirt and no pants in full view of anyone who walked past the bathroom.Client 4 was admitted to the facility on June 1, 1995 with diagnoses that included profound mental retardation (cognitive ability that is markedly below average level- less than one fifth of chronological age- incapable of self-care) and dependent on staff for activities of daily living.On September 21, 2012 at 6:20 a.m., during a fundamental survey observation, Client 4 was sitting on the toilet eliminating with the bathroom open to a bedroom and family room. The client had on a white tank top, no pants and would occasionally clap his hands. The bathroom was en suite to Client 2's bedroom. Staff A stood outside the bathroom door with the door open.The lead staff (Staff L) walked into the bedroom and saw the client on the toilet and was not observed trying to close the door to give the client privacy. Neither staff closed the bathroom door. On September 25, 2012 at 10:10 a.m., during an interview, the qualified mental retardation professional (QMRP) stated that was a big privacy issue. She stated she goes over privacy issues with the staff all the time.On September 25, 2012 at 10:15 a.m., during an interview, Staff L stated the bathroom door was left open so staff can see what the client is doing in the bathroom. She stated the client keeps moving and clapping his hands. She stated Client 4 would be quiet and not touch anything if you watched him. She stated staff are not able to go into the bathroom with the client because they did not have enough staff, therefore, they always leave the bathroom door open to watch the client on the toilet.She stated she was aware of the client's right to privacy, but did not have enough staff available to be in the bathroom with the client.A review of the client's functional assessment dated February 20, 2012, indicated the client was capable of sitting on the toilet for 3 to 5 minutes. The client was cooperative during toileting and goes to the toilet when taken and when given verbal directions among other toileting skills.A review of the undated Direct Care Staff job description indicated their duties include assisting and teaching toileting skills.A review of the facility's undated policy indicated person with developmental disabilities shall have rights including, but not limited to a right to dignity, privacy, and humane care. A right to make choices in their lives, including but not limited to, the way they spend their time, and leisure. This policy was in Client 4's chart signed the QMRP August 30, 2010. The facility staff failed to provide Client 4 privacy by not closing the bathroom door while the client sat on the toilet wearing only a tank undershirt and no pants on in full view of anyone who walked pass the bathroom. The above violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to clients. |
| 960001713 |
BEST CARE HOME I, INC. |
960009680 |
B |
17-Dec-12 |
G24011 |
9519 |
Title 22 ? 76862. Developmental Program Services-Program Elements. (a) The facility shall have the capability to provide program services to those developmentally disabled clients it serves. These program services shall be based on the client's specific needs as identified through the individual client assessment and include as appropriate: (3) Behavior management program.Based on observation, interview and record review, the facility's staff failed to: 1. Ensure Client 1 received appropriate behavior management for his aggressive behavior. Client 1 physically forced, pushed and pulled Client 2 to Client 2?s room and onto his bed repeatedly.On September 25, 2012, a review of Client 2?s medical record indicated the client was admitted to the facility on September 29, 1993 with diagnoses that included profound mental retardation (cognitive ability that is markedly below average level- less than one fifth of chronological age- incapable of self-care) and Down Syndrome (a set of mental and physical symptoms that result from having an extra copy of chromosome 21). The client was incapable of understanding his rights, expressed himself with sign language, actions and facial expressions. Client 2 depended on staff for activities of daily living.On September 25, 2012, a review of Client 1's medical record indicated the client was admitted to the facility on March 27, 1995 with diagnoses that included profound mental retardation, Down?s syndrome and self-injurious behavior. The client's only objective provided to the staff in the data collection book was communication. The QMRP located two more objectives in the client?s chart related to the client?s self-injurious behavior and wandering, that were set June 16, 2011, that had not been communicated to staff.On September 24, 2012 at 5:40 p.m., after dinner in the family room, the lead staff had all the clients remove their socks and shoes. Client 1 refused. Shortly thereafter, Client 1 repeatedly pushed Client 2 from the family room into Client 2's bedroom. Client 2 looked upset and attempted to resist, however, Client 1 was persistent. The lead staff told Client 1 to stop and stood in between Client 1 and 2, preventing Client 1 from touching Client 2. The lead staff then assisted Client 2 back to the family room to a sofa. Client 1 grabbed Client 2 by his left arm, pulled Client 2 up from a sitting position by his left arm and again forced Client 2 into his room again. Client 1 had succeeded in pushing Client 2 into his room a second time, he removed Client 2's blanket from his bed and pushed the client onto his bed, then forced him to lie down. Whenever Client 2 attempted to get up, Client 1 would push or hold him down. The lead staff made Client 2 remains lying down in the bed to appease Client 1. Client 2 looked confused and sad, but he cooperated with the staff. Client 1 remained in Client 2's room and made sure Client 2 remained in his bed. When Client 2 was taken out of bed by staff for his shower, Client 1 pushed Client 2 towards the en suite bathroom. When Client 2 was in the bathroom showering, Client 1, still dressed in the clothes he had worn that day, laid down on Client 2's bed on top of the sheets.Staff A, the qualified mental retardation professional (QMRP) and Staff Bill observed the incident and did not protect Client 2 from Client 1.They all left the lead staff to handle Client 1. Staff A was in the kitchen washing dishes when Client 1 continuously pushed Client 2. Staff A was observed watching, but did not know what to do. Staff B took Client 3 to a different bathroom and showered her. The QMRP went into the middle office area where the RN was sitting.On September 24, 2012 at 5:50 p.m., during an interview, the lead staff stated sometimes Client 1 was allowed to sit on Client 2's bed. Client 1 usually guides Client 2, but she had never seen Client 1 push client 2. She stated Client 1 was allowed to boss Client 2 around because he was like a brother to him.Client 1 showers after Client 2 and usually Client 1 stands in Client 2's room and waits for his turn to shower.On September 24, 2012 at 6 p.m., during observations, after Client 2 showered and exited the bathroom to his family room, Client 1 was taken inside that bathroom and was showered by staff. Once Client 1 exited the bathroom, he went over to Client 2, grabbed him by his arm and pulled him up from a sitting position and pushed him to his room and bed again.Non-verbal, Client 2 pulled the opposite direction attempting to resist, but again Client 1 succeeded.Staff told the client ?No?, however, Client 1 continued and staff took no further actions. On September 24, 2012 at 6:10 p.m., during an interview, the QMRP stated Client 1 usually leads Client 2 to his bedroom. Client 1 did not behave in that manner every day.The QMRP stated the clients usually relax in the family room after their showers.On September 24, 2012 at 6:25 p.m., during medication pass observations, while Client 2 was sitting in a chair in the medication area, Client 1, passed by Client 2, on his way to his room grunting and making sounds with his mouth. Client 2 flinched and appeared intimidated by Client 1 while he passed.A review of Client 1's physician order recap dated September 1, 2012, through September 30, 2012, indicated the client was prescribed Gabapentin 300 mg capsule by mouth twice a day for aggressive behavior since December 3, 2001, and Quetiapine Fumarate 200 mg tablet by mouth twice a day for aggressive behavior since November 12, 2007.On September 25, 2012 at 8:45 a.m., during an interview, the lead staff, Staff A and Staff B, all agreed, they were not able to handle the situation involving Client 1 and 2, therefore, they allowed Client 1 to have his way with Client 2. They concurred Client 2 communicates with sign language and expressions. Staff A stated Client 1 puts Client 2 into his room to hide him when new people are around like a big brother. All three staff concurred Client 1 was allowed to direct Client 2. Staff B stated Client 2 takes Client 1 away from Client 4 (who exhibited aggression towards Client 2 as well) like a big brother. The lead staff stated Client 1, like a big brother, forced Client 2 to his bedroom and bed because that was their routine.On September 25, 2012 at 9:10 a.m., during an interview, the QMRP stated Client 1 usually physically prompts Client 2 by tapping his elbow and bosses Client 2 around like his buddy. Client 1 got pretty aggressive yesterday and staff allowed him to guide and boss Client 2. The more you stop him the more he escalates. ?We said no, sit down, but he was already in the behavior.?Client 1's behavioral assessment dated April 15, 2012 indicated the client has a behavior of self-injurious behavior and wandering. His primary behavioral deficit was in the area of communication. He has issues with effective communication and an inability to comply appropriately with staff requests or adequately express himself. He does not have the ability to speak and his language consists of pointing and leading others by the hand which makes it difficult for him to appropriately express his needs. This may lead to the escalation of the above noted behavior. A report created by Regional Center (private contracting with the State of California for the provision of services to persons with developmental disabilities) dated April 23, 2009 stated that Client 1 had a history of being aggressive toward himself, aggressive toward others, property destruction and self-injury. A report dated May 5, 2009 by the Department of Developmental Services stated the client exhibited aggressive social behavior, disruptive social behavior, self - injurious behavior, wandering and emotional outbursts." There was no behavioral plan located in the client?s record or provided by the facility to address Client 1?s aggressive behavior.A review of the incident report generated by the QMRP October 3, 2012 indicated on "September 24, 2012 at approximately 6 p.m., immediately after dinner, Client 1 prompted Client 2 into his room. It was not time for bed yet so the lead staff prompted Client 2 back into the living room. Client 1 was agitated and did not like Client 2 being in the living room so he forcefully led Client 2 back into his room. The lead staff tried to intervene; however, Client 1 got aggressive and then pulled Client 2 into his bedroom again. Staff was not sure how to handle the situation so she just separated the two after the third time when Client 1 tried putting Client 2 into the bedroom. Client 2 and 1 showed no signs of bruising and pain. The behavior has not happened since."According to the facility's undated abuse policy, persons with developmental disabilities shall have rights including, but not limited to a right to dignity, privacy, and humane care. A right to make choices in their lives, including but not limited to, the way they spend their time, and leisure. This policy was in Client 2's chart signed by the QMRP August 30, 2010.The facility's staff failed to ensure Client 1 received appropriate behavior management for his aggressive behavior. Client 2 was physically forced, pushed and pulled to his room and to his bed by Client 1 repeatedly.These violations resulted in or occurred under circumstances likely to cause, anxiety, or other emotional trauma to Client 2. |
| 630013538 |
Beechwood Park, Inc. |
960009778 |
B |
07-Mar-13 |
L32111 |
4011 |
Welfare and Institution Code 4502 (b) 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:(b) A right to dignity, privacy, and habilitation services and supports in the least restrictive environment. Treatment and habilitation services and supports shall be provided in natural community settings.Based on observation, interview and record review, the facility's staff failed to ensure Client 3 was given privacy by failing to:1. Close the privacy curtain during care of Client 3?s personal needs.2. Allowing Client 2 to remain in the room and watch as Staff A and B removed Client 3?s diaper, leaving him totally nude while transferring him onto a bedside commode.This failure violated the client?s rights and had the potential to result in embarrassment, and emotional harm to the client. Client 3 was admitted to the facility October 24, 2005, 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), flexion contractures of the lower extremities, gastrostomy tube (g-tube, placed through an opening that allows food and medicine to be given directly into the stomach instead of through the mouth), seizure disorder (epilepsy, a brain disorder involving repeated, spontaneous convulsions) and constipation. During observations, on December 8, 2012, at 7:08 a.m., in Clients 2 and 3's bedroom; Staff A and B removed Client 3's diaper while he was lying in the bed having a bowel movement, stood him up as he continued to pass stool from his bare buttocks, transferred him onto a bedside commode without an attached pail, then draped and transported him to the bathroom as he continued to drop stool on the floor. The privacy curtain remained open in full view of Client 2.During observations, on December 8, 2012, at 7:30 a.m., in Clients 2 and 3's bedroom, after Client 3 was showered, Staff B diapered and dressed Client 3 with the privacy curtain closed.During an interview with Staff A and B, on December 8, 2012, at 12:55 p.m., regarding privacy, Staff B stated, the privacy curtain was supposed to be closed. Staff A stated they were in a hurry because the client was having a bowel movement. Staff B stated the privacy curtaingets stuck on occasion. During an interview with the qualified mental retardation professional (QMRP), on December 8, 2012, at 1:55 p.m., she stated staff are oriented upon hiring regarding client?s rights and trained every December or whenever needed if a privacy issue is noted.A review of the undated "Certified Nursing Assistant" (direct care staff at this facility) job description indicated they are to preserve dignity and respect for clients at all times and ensure client rights to privacy. The undated facility policy and procedure titled ?Privacy for Clients While in Their Bedrooms?, indicated clients have a right to privacy and staff will assure visual privacy by closing all curtains (door if necessary) completely when giving care to clients in their bedrooms. The facility staff failed to provide Client 3 privacy by not closing the privacy curtain during care of the client?s personal needs and allowing Client 2 to watch. The above violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to clients. |
| 960001702 |
BIXBY KNOLL PLACE |
960010217 |
B |
17-Oct-13 |
RBPF11 |
4804 |
Welfare and Institution Code 4502 (b) 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:(b) A right to dignity, privacy, and habilitation services and supports in the least restrictive environment. Treatment and habilitation services and supports shall be provided in natural community settings. On May 8, 2013, an unannounced visit was made to the facility to conduct a fundamental survey.Based on observation, interview and record review, the facility staff failed to ensure Client 6 was given privacy by failing to: 1. Close the bedroom door and privacy drape while Client 6 laid on her bed with an open diaper in her bedroom in view of Client 5 and anyone who walked past the bedroom.These breeches of privacy had the potential to result in anxiety and humiliation for all clients involved.Client 6 was admitted to the facility May 18, 1994 with diagnoses that included moderate intellectual disability (developmentally functions at one third of chronological age and can learn elementary health and safety habits), spina bifida (a condition that occurs when a baby is in the womb and the spinal column does not close all of the way), and now has a neurogenic bowel and bladder (malfunctioning urinary bladder/ bowel due to neurologic dysfunction or insult resulting from internal or external trauma, disease, or injury) and Client 6 was dependent on staff for activities of daily living. During observations, on May 8, 2013, at 5:45 a.m., Client 6 was lying on her bed with her diaper opened revealing her genitalia to anyone who passed by the bedroom door. Client 6?s roommate (Client 5) was present in the room and had full view of client 5. The bedroom door and the privacy drape between her and Client 5 were opened. Client 5 looked on as Client 6 was diapered.During an interview, on May 8, 2013, at 5:47 a.m., the licensed vocational nurse (LVN) stated, "I just finished her catheterization" as he returned to the client and finished diapering the client. During an observation, on May 8, 2013, at 6 a.m., the house leader (Staff A) arrived and was overheard stating, "Close the door at all times" to the staff that were present. During an interview, on May 8, 2013, at 12 noon, the LVN stated he had finished catheterizing Client 6, when he heard the doorbell ring and was rushing to answer the door. He stated he was about to open the front door, but Staff B let the surveyor in the facility. He stated the drapes were not properly closed because he forgot to close it back after opening the drape to answer the door. He stated he was aware of the privacy policy.During an interview, on May 8, 2013, at 12:45 p.m., the qualified intellectual disability professional (QIDP) stated staff had privacy training in July, October, December 2012. A review of the in-service training titled "Client's Rights/ Privacy/Confidentiality" dated July 15, 2012 and October 15, 2012, indicated the importance of providing the clients their right to privacy, dignity and humane care. The training titled "Protecting Client Confidentiality and Privacy" dated December 14, 2012; indicated staff were to always keep bedroom doors shut when clients are not fully clothed or when assisting the clients with hygiene and grooming. When you have two clients in a bedroom, make sure that they are not being changed in front of each other.The undated facility policy titled "Protecting Client Privacy" indicated it is the obligation of facility staff to protect the privacy of clients at all times. Client protections include but are not limited to physical privacy. Staff must utilize privacy screens or curtains to maintain client privacy during any personal hygiene that may expose a client in a private nature. Bedroom doors must remain closed whenever a client is being changed or in any stage of undress. The facility staff failed to provide Client 6 privacy by not closing the bedroom door and privacy drape while Client 6 lay on her bed with an open diaper in her bedroom in view of Client 5 and anyone who walked past the bedroom.The above violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to clients. |
| 960001702 |
BIXBY KNOLL PLACE |
960013098 |
B |
30-Mar-17 |
7VIF11 |
2953 |
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 March 6, 2017 at 6 a.m., an unannounced visit was made to the facility to conduct an annual recertification survey.
The facility failed to:
Ensure fingerprint clearance for one direct care staff (Staff A) working in the facility was completed prior to contact with all 6 clients residing in the facility. This failure had the potential of not ensuring the safety and well-being of the clients.
During a review of the ?Client Roster Information? dated March 6, 2017, indicated 1 client with a diagnosis of profound intellectual disability (significant developmental delays in all areas and incapable of self-care), 2 clients with diagnoses of severe intellectual disability (considerable delay in development and require daily supervision and support), and 3 clients with moderate intellectual disability (developmentally functions below chronological age and can learn elementary health and safety habits) were residing in the facility.
During a review of Staff A's employee file on March 6, 2017, indicated there was no documented evidence of criminal clearance from the California Department of Public Health (CDPH) through the Department of Justice (DOJ). The employee file indicated a hire date of March 3, 2016.
On March 6, 2017 at 1:35 p.m., a call was made to the Interactive Voice Response Unit for Criminal Clearance. The automated response system disclosed there was no record on file for criminal background clearance regarding Staff A. The Interactive Voice Response Unit also disclosed the certified nurse assistant (CNA) certification for Staff A had expired, and that Staff A must retrain in order to obtain valid certification.
During a review of Staff A?s CNA certification, indicated an effective date of September 29, 2010, through October 2, 2014.
During an interview with the qualified intellectual disability professional (QIDP), on March 6, 2017 at 2:14 p.m., she stated Staff A remains employed and usually works the weekend night shifts. The QIDP stated she did not follow-up with obtaining a confirmation fingerprint clearance number from CDPH because she thought the DOJ clearance letter, dated February 5, 2015, brought to the facility by Staff A at the time of hire was sufficient. Further interview, on March 9, 2017, at 11:34 a.m., the QIDP stated the facility has no policy and procedure for the fingerprint clearance screening of new employees.
The facility failed to ensure fingerprint clearance was completed for Staff A prior to contact with all 6 clients residing in the facility.
This failure had a direct relationship to the health, safety, and security of the clients. |
| 630004441 |
Bailey Care Home 1 |
960013223 |
B |
23-May-17 |
82W011 |
3497 |
Title 22: 76845
The securing of criminal records shall be accordance with the provisions of Section 1265.5 of the Health and safety Code.
1265.5 (f)
(f) Upon the employment of any person specified in subdivisions (a), and prior to any contract with clients or residents, the facility shall submit fingerprint cards to department for the purpose of obtaining a criminal record check.
On 4/22/17, an unannounced visit was made to the facility to conduct an annual re-certification survey.
The facility?s administrative staff failed to:
Ensure the criminal record clearance (pre-employment criminal background check) for two staff members (Staff A and Staff B) were submitted to the Department of Justice (DOJ) prior to providing care for 6 clients (Clients 1, 2, 3, 3, 5 and 6), who reside in the facility. This failure had the potential for not ensuring the safety and well-being for the clients.
During an observation, on 4/22/17, at 8:20 am, the facility's population consisted of 6 clients (4 males and 2 females) who depend on staff for assistance in the basic activities of daily living.
A review of the Clients? medical records indicated Clients 1 and 3 were diagnosed with mild intellectual disabilities (slower than typical in all developmental areas). Clients 2 and 5 were diagnosed with severe intellectual disabilities (considerable delays in development). Client 4 was diagnosed with profound intellectual disabilities (significant developmental delays in all areas). Client 6 was diagnosed with moderate intellectual disabilities (noticeable developmental delays). All six clients required supervision and/or depended on staff for activities of daily living including walking, transferring, eating and toileting.
A review of new employee files, on 4/24/17, at 10 am, indicated Staff A was hired as a direct care staff (DCS, non-license care giver) on 2/28/16 and Staff B was hired as a DCS on 12/11/16.
Further review of the new employee files, indicated there were no fingerprints clearance letters from the DOJ for Staff A and B available for review.
On 4/24/17, at 10:47 a.m., an Interactive Voice Response Unit (IVRU) was called to check for criminal clearance for Staff A and B. The IVRU indicated Staff A?s and Staff B?s live scan were not on record (not submitted).
On 4/24/17, at 12:35 a.m., during an interview with the facility?s Qualified Intellectual Disabilities Professional (QIDP) regarding Staff A?s and Staff B?s fingerprint cards, she stated she just called the IVRU and found out that Staff A?s and B?s live scan were not submitted.
A review of the facility?s employee weekly schedule, dated 4/24/17 to 4/30/17, indicated Staff A was scheduled to work from Monday to Friday and Sunday and Staff B was scheduled to work from Monday to Friday.
A review of the facility's policy and procedure titled "Incidents and Abuse Reporting," indicated as pre-employment requirements, applicants for employment have to submit the required fingerprinting for the purpose of criminal record clearance.
The facility?s administrative staff failed to ensure the criminal record clearance for Staff A and Staff B were submitted to the DOJ prior to providing care for six clients, who reside in the facility. This failure had the potential for not ensuring the safety and well-being for all clients residing in the facility.
The above violation had a direct relationship to the health, safety and security of clients. |
| 960001055 |
BEACH AVENUE HOUSE |
960013264 |
B |
7-Jun-17 |
5HDZ11 |
3418 |
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 January 24, 2017 at 5:45 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 direct care staff (Staff A) working in the facility was completed prior to contact with all 6 clients residing in the facility. This failure had the potential of not ensuring the safety and well-being of the clients.
During a review of the ?Client Roster Information? dated January 24, 2017, indicated 3 clients with diagnoses of profound intellectual disability (significant developmental delays in all areas and incapable of self-care), 2 clients with diagnoses of severe intellectual disability (considerable delay in development and require daily supervision and support), and 1 client with mild intellectual disability (slower in developmental areas but able to learn practical life skills and able to function in daily life) were residing in the facility.
During a review of Staff A's employee file on January 26, 2017, indicated there was no documented evidence of criminal clearance through the Department of Justice (DOJ). The employee file indicated a re-hire date of November 5, 2016.
On January 26, 2017 at 2:37 p.m., a call was made to the Interactive Voice Response Unit for Criminal Clearance. The automated response system disclosed there was no request received for criminal background clearance regarding Staff A.
During a telephone interview with the program representative from the Criminal Clearance Unit, on January 26, 2017 at 3:04 p.m., he stated Staff A did not complete the clearance process, was not cleared to work in the facility, and would need to apply.
During an interview with the administrator, on January 26, 2017 at 3:30 p.m., she stated Staff A works as a fill-in for other staff taking off or on vacation. The administrator also stated Staff A reported for work today. Further interview at 5:07 p.m., the administrator stated it was her responsibility to follow-up with ensuring criminal clearance was completed, and the follow-up was not done.
During an interview with Staff A, on January 26, 2017, at 3:45 p.m., she stated she has been working in the facility as a fill-in for staff.
The facility policy and procedure titled "Company Policies and Procedures" undated, indicated the administrator has the responsibility and authority for the verification of criminal background clearance.
The facility policy and procedure titled "Abuse Policy" undated, indicated all employees are required to submit fingerprints when they are hired. These are submitted to the DOJ for criminal record clearance, and an employee who does not receive clearance was subject to immediate termination.
The facility failed to:
Ensure fingerprinting clearance was completed for one direct care staff (Staff A) working in the facility was completed prior to contact with all 6 clients residing in the facility. This failure had the potential of not ensuring the safety and well-being of the clients.
The above violation had a direct relationship to the health, safety or security of the clients. |
| 630014963 |
Belagio in the Desert |
980012538 |
A |
7-Sep-16 |
7ZPQ11 |
14511 |
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 May 4, 2016, an unannounced visit to the facility was made to investigate a complaint regarding Patient 1 being admitted to the facility, and was removed from her ventilator (mechanical breathing aid) for short period of time. When the staff reconnected the patient to the ventilator, the ventilator malfunctioned, and Patient 1 turned blue. EMTs (emergency medical technicians) bagged (manual ventilation with an ambu bag) the patient until she was transferred to a general acute care hospital, where she was placed back on a ventilator. Based on record review and interview, the facility failed to implement its policies and procedures titled, ?Client Admission? and ?Respiratory Initial Assessment? by failing to ensure Patient 1 was admitted with physician orders for the ventilator, ventilator settings, and oxygen. Patient 1 was admitted to the facility on April 29, 2016, and connected to a ventilator without a physician's order for such treatment. Twenty-four (24) hours after admission, Patient 1 was removed from the ventilator, without a physician's order, on April 30, 2016 at 2 p.m., and immediately desaturated (low blood oxygen concentration causing bluish skin and lips, changes in mental status, and respiratory distress which could end in death) to 82 percent. When Patient 1 was reconnected to the ventilator, the blood oxygen concentration remained dangerously low at 42 percent and 911 (medical telephone emergency) was called. The paramedic staff arrived at the facility at 2:22 p.m., Patient 1 was unresponsive, provided the patient with 15 liters of oxygen, and the patient?s oxygen saturation rose to 100 percent (%) at 2:30 p.m. The facility?s deficient practice resulted in Patient 1 being transferred to the general acute care hospital (GACH), where she was admitted to a progressive care unit and was discharged on May 16, 2016, (16 days later) to a subacute unit of another GACH. According to http://www.mayoclinic.org/symptoms/hypoxemia, oxygen is carried in the blood attached to hemoglobin (red blood cells) molecules. Oxygen saturation is a measure of how much oxygen the blood is carrying as a percentage of the maximum it could carry. The blood oxygen level can be determined using a pulse oximeter - a small device that clips on the finger. Normal pulse oximeter readings range from 95 to 100 percent, under most circumstances. Values under 90 percent are considered low. Hypoxemia is a below-normal level of oxygen in the blood and a sign of breathing or circulation problem and may result to shortness of breath. A review of the admission face sheet indicated Patient 1 was admitted to the congregate living health facility on April 29, 2016, from GACH 1 with diagnoses including altered mental status, extreme leukocytosis (frequently a sign of inflammatory response, elevated white blood cells), encephalopathy (disease or malfunction of the brain), and left lobe pneumonia (infection in one or both lungs). According to the History and Physical Examination report from GACH 1, dated March 28, 2016, Patient 1 presented to the emergency department with alteration in mental status. The patient's respiratory status declined and the patient required endotracheal intubation (placement of flexible plastic tube into the windpipe through the nose or mouth to maintain open airway). The Admission Orders & Plan of Care from the congregate living health facility, dated April 29, 2016 at 12 p.m., indicated there were medications orders, but there were no orders for the use of ventilator, ventilator settings, and oxygen. The Admission Evaluation and Interim Care Plan (Section) dated April 29, 2016 at 2:25 p.m., indicated Patient 1's vital signs included blood pressure of 159/60, respiration was 29 per minute and pulse was 98 per minute. Section B of the Admission Evaluation and Interim Care Plan dated April 29, 2016 indicated Patient 1 had a tracheostomy (surgical opening into the windpipe when breathing is impaired or obstructed, or when mechanical ventilation is needed), was lethargic, receiving tube feeding, had an indwelling catheter, and was on oxygen at 5 liters per minute via the tracheostomy tube. Patient 1's respiratory status was identified as having irregular respiration, cough and inspiration wheezing (high pitched sound while breathing in). The Daily Skilled Nurse's Note dated April 29, 2016 (day shift), signed by Licensed Vocational Nurse (LVN) 2 documented: "Head to toe assessment done after pt (patient) arrived (new admit) to facility at 1430 (2:30 p.m.). Suctioned as needed, gave oxygen via nasal cannula." There was no documentation regarding whether or not the patient was connected to a ventilator. The Nurses Notes dated April 29, 2016 at 7:30 p.m., signed by Registered Nurse 1 indicated Patient 1 was admitted to the facility with a tracheostomy and ventilator. Patient 1 was noted with inspiratory wheezes and decreased breath sounds to right and left lungs (may mean air or fluid in or around lungs). Patient 1 was drowsy and answered to yes or no questions or nod head to communicate. There was no documentation regarding whether or not the patient was connected to a ventilator, the ventilator settings and was receiving oxygen. The Daily Skilled Documentation form dated April 29, 2016, during 7 p.m. to 7 a.m. shift, signed by LVN 3, documented Patient 1 was breathing room air, oxygen saturation was 96%, had no cough, shortness of breath, or difficulty breathing. There was no documentation the patient was suctioned during the 12 hour shift. There was no documentation to indicate whether or not the patient was connected to the ventilator or why she was breathing room air. The Daily Skilled Documentation form dated April 30, 2016, during 7 a.m. to 3 p.m. shift, signed by LVN 3, documented Patient 1 was breathing room air, had an oxygen saturation of 95%, had no cough, shortness of breath, or difficulty breathing, and was not suctioned during the shift. The narrative charting indicated Patient 1's tracheostomy tube was intact and the patient was on ventilator support settings per the medication administration record (MAR). However, a review of the MAR did not include any information regarding the use of the ventilator, the ventilator settings or oxygen use. Untimed entries in the narrative charting from the Daily Skilled Documentation form dated April 30, 2016, during the 7 a.m. to 3 p.m., indicated: "Pt (Patient) placed on oxygen concentrator at 4 liters (per minute) to be checked after 10 minutes. Pt rechecked oxygen levels dropped at 82% Pt placed back on ventilator support to be monitored closely. Pt oxygen levels rechecked oxygen saturation dropped considerably after a short period to 42%. LVN supervisor notified of situation, instructed to call 911 and send Pt to hospital. Emergency personnel on the scene. Pt put on oxygen support and oxygen levels checked at 52% and rising. Oxygen saturation peaked at 86% and was fluctuating. As a precautionary measure, Pt sent to AV (Antelope Valley) hospital at 1430 (2:30 p.m.). Family members notified. " A review of the Fire Department Emergency Medical Services Report Form (Run Sheet) dated April 30, 2016, at 2:22 p.m., indicated "PT's ventilator malfunctioned and staff took her off it for 15 minutes-replacing it with nasal cannula. According to PT's daughter, PT can be off the ventilator for short period." At 2:24 p.m., Patient 1's pulse was 100 per minute, respirations of 40 per minute, her blood pressure was 140/70, and oxygen saturation was 71%. The patient was unresponsive. The patient was provided with oxygen at 15 liters by bag-valve mask (assisted ventilation). At 2:30 p.m., Patient 1's oxygen saturation rose to 100%. At 2:32 p.m., the paramedics left the facility and transferred Patient 1 to the general acute care hospital. At 2:38 p.m., Patient 1's blood pressure was 104/54, her pulse was 114 per minute and respiration was 38 per minute. At 2:44 p.m., the patient arrived at GACH 2. According to the History and Physical Examination from GACH 2 dictated on May 1, 2016, Patient 1 was admitted on April 30, 2016, had a tracheostomy, and history of ventilator dependent respiratory failure. The patient was transferred from the facility due to malfunctioning of the ventilator. The paramedics transferred the patient to GACH 2 while the patient was bagged until she was placed on ventilator. The patient's vital signs were blood pressure of 116/65, pulse of 83 per minute, respirations at 18 per minute, oxygen saturation at 100%. The physician impressions included ventilator malfunction, urinary tract infection, and chronic ventilator-dependent respiratory failure. The plan included to admit the patient to the Progressive Care Unit, to continue on respiratory breathing treatments, and to start on intravenous Rocephin antibiotic for urine infection. The Patient Transfer form and the Patient Transfer and Referral Record from GACH 2 indicated Patient 1 was discharged on May 16, 2016 to a subacute unit of another GACH with primary diagnosis of respiratory failure with pneumonia. During an interview on May 9, 2016 at 3:30 p.m., LVN 1 (supervisor) stated on April 29, 2016, Patient 1 arrived at the facility from the general acute care hospital, and was connected to a ventilator. She stated the patient arrived without any orders for ventilator use, ventilator settings, and no orders for oxygen use. She confirmed telling LVN 3 that the patient could be off the ventilator, placed on oxygen, and that she had obtained that information from the patient's family. LVN 1 confirmed there were no physician's orders in the medical record regarding ventilator use, the settings or oxygen use. During an interview with LVN 3 at 2:05 p.m. on May 9, 2016, he stated he had started his shift at 7 p.m. the previous night and stayed on duty when the 7 a.m. shift nurse called off. LVN 3 had been on duty for 19 straight hours when the nursing supervisor called at around 2 p.m., and said it was okay to take Patient 1 off the ventilator and just put her on oxygen. So he did, and 10 minutes later the patient's oxygen saturation was 82%. LVN 3 stated he put the patient back on the ventilator, and after 10 minutes, her saturation dropped to 42%. LVN 3 called the LVN Supervisor back and was instructed to call 911. LVN 3 stated he took the patient off the ventilator at 2 p.m. per instructions from the LVN Supervisor, who told him the patient could be off the ventilator and placed on oxygen only. During an interview on May 9, 2016 at 2:50 p.m., Certified Nursing Assistant (CNA) 1 stated around 2:30 p.m. on April 30, 2016, he checked Resident 1's oxygen saturation and it was 40-42%. He stated he notified LVN 3, who came to the patient's room, re-checked the saturation level and it was 38-40%. The CNA stated LVN 3 then called the nursing supervisor while the CNA called 911. CNA 1 stated the EMTs (emergency medical technicians) arrived and had LVN 3 removed the patient from the ventilator and they began bagging her (artificial ventilation with an ambu bag). CNA 1 reiterated that Patient 1 had not been off the ventilator since he started his shift at 7 a.m. that morning. A review of the medical record indicated there were no physician's orders or care plans regarding ventilator settings and use. A care plan titled, "Pneumonia" initiated on April 30, 2016, indicated to administer oxygen as ordered if shortness of breath or respiratory distress present. However, there was no documented evidence of a physician order for the use of oxygen in the medical record. A review of the facility's undated policy and procedure titled, "Client Admission," indicated each client would have written and signed physician's orders on admission. The facility's undated policy and procedure titled, "Respiratory Initial Assessment," indicated the respiratory care provider would establish clinical responsibility for the patient's respiratory status and would be responsible for an initial and weekly clinical evaluation and assessment for each patient being serviced by the respiratory department. The respiratory care provider should be notified as soon as possible, preferably two (2) to four (4) hours prior to admission, of a patient's admission to the subacute unit. The respiratory care provider would, prior to admission, set-up the room with the necessary equipment. The therapist would clinically assess the patient within two (2) hours post admission when possible. The respiratory care provider would confirm the transfer orders with the transferring crew upon admission to assure the patient would remain stable during the admission process. The patient would be initially placed on therapy according to the transfer orders until the respiratory care provider could assess the patient and confirm the treatment orders with the attending physician. The facility failed to implement its policies and procedures titled, ?Client Admission? and ?Respiratory Initial Assessment? by failing to ensure Patient 1 was admitted with physician orders for use of ventilator, ventilator settings, and oxygen. As a result, Patient 1 was admitted to the facility and connected to a ventilator without a physician's order. Twenty-four hours after admission, when Patient 1 was removed from the ventilator, without a physician's order, Patient 1 immediately desaturated (low blood oxygen concentration causing bluish skin and lips, changes in mental status, and respiratory distress which could end in death) at 82 percent. When Patient 1 was reconnected to the ventilator, the blood oxygen concentration remained dangerously low at 42 percent, and 911 (medical telephone emergency) was called. The paramedic staff arrived at the facility, provided the patient with 15 liters of oxygen, and the patient?s oxygen saturation rose to 100%. Patient 1 was transported to the general acute care hospital (GACH), where she was admitted to a progressive care unit and was discharged on May 16, 2016, (16 days later) to a subacute unit of another GACH. The above violation presented an imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result to Patient 1. |
| 630014963 |
Belagio in the Desert |
980012643 |
B |
13-Oct-16 |
RB9511 |
8411 |
T22 DIV5 CH3 ART5-72523(a) 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 8/6/16, at 12 p.m., an unannounced visit was made to the facility to investigate a complaint regarding the discharge of Patient 1 to the general acute care hospital (GACH). The patient was brought to the GACH?s emergency room with no condition requiring emergency treatment. Following the examination, Patient 1 was cleared to return to the facility where she resided, but the facility refused to take Patient 1 back. Based on record review and interview, the facility failed to implement its policies and procedures regarding transfer/discharge for Patient 1. For Patient 1, who was transported and discharged to the emergency room of GACH 1, the facility failed to provide a discharge notice, reason for discharge, discharge orientation, and a post-discharge plan. This deficient practice resulted in the patient lying on a gurney in the emergency room of GACH 1 for over 48 hours which caused emotional distress to both the patient and her family. A review of the admission face sheet indicated Patient 1 was admitted to the facility on 7/12/16 with diagnoses including an infected unstageable pressure sore (Stage IV open wound on her back which had recently been debrided - damaged tissue removed), multiple sclerosis (autoimmune disease in which the protective covering of nerves is destroyed), and urinary tract infection. A review of a Daily Skilled Nurse's Note dated 8/3/16 indicated Patient 1 had an appointment to GACH 1 on 8/4/16 to re-fill Patient 1's Baclofen (muscle relaxer, prevents spasms) pump. A review of the facility's Interdisciplinary Progress Notes dated 8/1/16 indicated Case Manager (CM) 1 discussed with Patient 1?s family member, regarding a follow-up appointment of the patient?s wound on 8/4/16. The facility's Interdisciplinary Progress Notes dated 8/3/16 indicated the patient's family member wanted an appointment to evaluate Patient 1's wound. CM 1 informed Patient 1?s family member that Patient 1would be picked up by an ambulance on 8/4/16 at 9 a.m. for the appointment and an order would be obtained from the patient?s physician. A review of a Telephone Orders dated 8/3/16 at 7 p.m., received by Skilled Nurse (SN) 1 indicated a physician?s order to discharge Patient 1 to GACH 1 on 8/4/16. During an interview with SN 1 on 8/6/16 at 4 p.m., she stated the facility administration had informed her that Patient 1 would not be coming back to the facility after Patient 1 was discharged on 8/4/16 to GACH 1. The Physician Telephone Orders dated 8/4/16 at 9:20 a.m., indicated an order to transfer Patient 1 to GACH 1 for a wound evaluation. A review of a Daily Skilled Nurse's Note dated 8/4/16 at 9:20 a.m., indicated Patient 1 was sent out for a medical appointment for a wound evaluation. The Interdisciplinary Progress Notes dated 8/5/16 at 2:20 p.m., indicated CM 1 left a voice mail message to the patient?s family member to check on the progress and outcome of the appointment. At 3:30 p.m., the physician did not see the patient and the patient?s wound appointment needed to be re-scheduled. At 4 p.m., the facility?s Director of Operations would contact GACH 1 to get an update on the patient?s appointment. The Interdisciplinary Progress Notes dated 8/5/16 at 4 p.m. indicated the Intake Coordinator notified CM 1 that Patient 1 would not return to the facility due to the change of insurance, and the patient had been admitted to GACH 1. During an interview on 8/8/16 at 5 p.m., Patient 1's family member stated Patient 1 was not admitted to GACH 1. The family member stated the patient had been lying on a gurney in the emergency room of GACH 1 for 48 hours until on 8/7/16, when she was transferred and admitted to another GACH. Patient 1?s family member stated this had caused emotional distress to him and Patient 1. In an interview with the Social Worker from GACH 1on 9/28/16 at 3:15 p.m., she stated Patient 1 presented to the emergency room on 8/4/16 at 12:30 p.m. and Patient 1 was still in the emergency room on 8/6/16 at 8 p.m. During an interview with CM 1 on 8/6/16 at 5:15 p.m., she stated Patient 1 had missed the appointment with the wound specialist on 8/1/16. CM 1 stated the family was anxious for Patient 1 to be seen for wound evaluation. CM 1 stated when the patient arrived at GACH 1 to refill her Baclofen pump, the physician was not there, so Patient 1 was taken to the emergency room of GACH 1 for a wound evaluation. CM 1 stated after the wound was evaluated, the acute hospital staff contacted the facility staff member, who was in a meeting. CM 1 stated at that time, the Director of Operations stated the patient could not come back to the facility because of insurance issues. The Director of Operations spoke with the case manager at the acute hospital and explained the facility would not take the patient back because of insurance issues. A review of the Final Licensed Nurses Progress Notes dated 8/4/16 indicated Patient 1 was discharged to GACH 1 on 8/4/16. The reason for discharge was left blank. There was no documented evidence in the medical record the facility provided Patient 1 and the family member a discharge notice, reason for discharge, discharge orientation, and a post-discharge plan. An interview was conducted with the supervisor of the ambulance company on 8/9/16 at 12:42 p.m. He stated an arrangement had been made on 8/3/16 to transport the patient to the hospital and drop her there. The arrangement did not include a return trip back to the facility. On 8/8/16, the evaluator requested to interview the facility administration, and they were not available. The facility's policy and procedure titled, "Transfer or Discharge Orientation," revised April 2013, indicated the facility shall prepare a resident for a transfer or discharge. When a resident is scheduled for transfer or discharge, the business office would notify the nursing services of the transfer or discharge so that appropriate orientation procedures could be implemented. A post-discharge plan is developed for each resident prior to his/her transfer or discharge. This plan would be reviewed with the resident, and/or his/her family, at least 24 hours before the resident's transfer or discharge from the facility. The purpose of the orientation is to provide the resident and family with sufficient preparation and to ensure a safe and orderly transfer or discharge from the facility. The facility's policy and procedure titled, "Transfer or Discharge, Preparing a Resident for," revised April 2014, indicated the facility shall prepare a resident for transfer or discharge and Nursing Services would be responsible for preparing the discharge summary and post-discharge plan. The facility's policy and procedure titled, "Discharge Summary and Plan," revised April 2013, indicated when the facility anticipates a resident's discharge to another nursing care facility, a post-discharge plan would be developed which assist the resident to adjust to his or her new living environment. The post-discharge plan would be developed by the Care Planning/Interdisciplinary Team with the assistance of the resident and family and would contain as a minimum: A description of the resident's and family's preferences for care; A description of how the resident and family will access such services; A description of how the care should be coordinated if continuing treatment involves multiple caregivers; The identity of specific resident needs after discharge (i.e., personal care, sterile dressings, physical therapy, etc); and A description of how the resident and family need to prepare for the discharge. The Social Services Department would review the plan with the resident and family 24 hours before the discharge is to take place. The facility failed to implement its policies and procedures regarding transfer/discharge for Patient 1. For Patient 1, who was transported and discharged to the emergency room of GACH 1, the facility failed to provide a discharge notice, reason for discharge, orientation and a post-discharge plan. This violation had a direct relationship to the health and safety of Patient 1. |
| 250000016 |
BANNING HEALTHCARE |
250013627 |
B |
29-Nov-17 |
WECU11 |
8587 |
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
On October 4, 2017, at 9:18 am, an unannounced visit was made to investigate an anonymous complaint regarding an incident of alleged restraint of a resident (Resident 1).
During the investigation it was determined the facility failed to report to the California Department of Public Health (CDPH) an incident where one resident (Resident 1) had been tied with a bed sheet to her wheelchair. Failure to notify CDPH had the potential to place all the patients in the facility at risk for harm from physical abuse.
Resident 1 was a 91 year old, female, admitted to the facility on May 1, 2017, with diagnoses including dementia (condition causing confusion and memory loss) and unsteadiness on her feet. Resident 1 had a history of getting out of bed without requesting assistance and had fallen at home prior to admission.
On October 4, 2017, at 11:02 am, an interview was conducted with Administrator 1 (ADM 1). ADM 1 stated on May 25, 2017, she saw on the video surveillance monitors in her office, a resident go by in a wheelchair with something white around her waist. When she had the video played back, she saw the resident was tied to her wheelchair with a sheet. The ADM 1 stated she immediately started an investigation and placed the staff involved on suspension. ADM 1 could not remember exactly who was suspended, but she believed it was two Certified Nurse Assistants (CNAs), a Licensed Vocational Nurse (LVN), and a Registered Nurse (RN). ADM 1 stated she called her corporate office to report the incident and her actions to suspend the involved staff. ADM 1 stated she was told by corporate to not report the incident to the state. ADM 1 stated later that day she became ill and was off work for a month. ADM 1 stated an interim Administrator (ADM 2) was appointed by the corporate offices to oversee the facility in her absence. ADM 1 stated she believed ADM 2, the Director of Nurses (DON), and the Director of Staff Development (DSD) knew of the bed sheet being used as a restraint.
On October 4, 2017, at 11:15 am, an interview was conducted with the DSD. The DSD stated she was not aware of any allegation regarding a resident being tied with a sheet. The DSD at first stated only one CNA was suspended recently and that was for an alleged slapping of a resident incident which was reported. The DSD later stated there was additional staff suspended but she did not have the documentation of the suspensions. The DSD stated the DON would have the documentation of the licensed staff that was suspended. The DSD stated those suspensions were for the alleged slapping of a resident incident.
On October 4, 2017, at 3:10 pm, an interview was conducted with CNA 1. CNA 1 stated she tied Resident 1 with the sheet to prevent her from falling. CNA 1 stated she was suspended for five days.
On October 4, 2017, at 3:20 pm, an interview was conducted with LVN 1. LVN 1 stated she was aware of Resident 1 being tied with a sheet to her wheelchair. LVN 1 stated that morning she was tired because she had worked a double shift. LVN 1 stated she knew the CNAs were having trouble keeping Resident 1 in bed. LVN 1 stated while she was at the medicine cart during change of shift, Resident 1 came by with the sheet tied around her to keep her in the wheelchair. LVN 1 felt she should have paid more attention to what the CNAs were telling her. LVN 1 stated she was told she would be suspended, but was called the next day and told there would be no suspension.
On October 4, 2017, at 3:37 pm, an interview was conducted with CNA 2. CNA 2 stated she helped to tie Resident 1 to the wheelchair with a sheet. CNA 2 stated LVN 1 and RN 1, both knew about it. CNA 2 stated they had asked RN 1 if he could call the doctor for medication, because Resident 1 was so restless getting up and down continually. CNA 2 stated she was suspended for five days after that incident.
On October 4, 2017, at 4 pm, an interview was conducted with the DON. The DON stated she was not aware of an incident regarding Resident 1 being tied to a wheelchair using a bed sheet. The DON stated she was aware some staff was suspended but she believed the suspension was over another allegation regarding slapping a resident. The DON denied having any documentation regarding the suspension of either the LVN or RN. The DON stated the DSD would have that documentation.
No documentation of the suspension of either the RN or LVN was found as the DON and DSD both denied having the documentation.
On October 16, 2017, at 11 am, a phone interview was conducted with ADM 2. ADM 2 stated he was the interim administrator for the facility after ADM 1 became ill. ADM 2 denied any knowledge of Resident 1 being tied with a bed sheet while he was the interim administrator. ADM 2 stated he first learned of the incident when he had heard an investigation was begun recently. ADM 2 stated he was not involved with any suspensions of staff and did not know how the decision to have the staff return to work occurred.
On October 16, 2017, at 1:35 pm, a phone interview was conducted with RN 1. RN 1 stated he was aware of Resident 1?s behavior, but he did not know the CNAs had tied her to a wheelchair with a sheet. RN 1 stated he learned about it when ADM 1 called him to tell him he was on suspension while an investigation was done. RN 1 stated he told ADM 1 he did not know anything about Resident 1 being restrained. RN 1 stated at the same time there was an incident of a resident supposedly slapped by a CNA. RN 1 stated there was more talk about the slapping incident and he thought that was why they were all suspended. RN 1 stated he was called to come back to work the next day.
On October 16, 2017, at 2:20 pm, a phone interview was conducted with the Assistant (ASST) to ADM 1. ASST stated he was in ADM 1?s office when the video surveillance monitors displayed Resident 1 roaming around and it looked like she had a cloth wrapped around her waist. ASST stated, he and ADM 1 both saw it. ASST stated ADM 1 immediately said they needed to see what was going on. ADM 1 suspended the CNAs and he thought the LVN and RN too. ASST stated ADM 1 called the consultant right after the suspensions. ADM 1 stated the consultant said it was not considered reportable. The consultant said it was a failure in the method they used to restrain the resident. The consultant stated they should consult with the doctor and get a recommendation.
On October18, 2017 at 1:12 pm, a phone interview was conducted with the Corporate Consultant. The Corporate Consultant stated his actual job title was Quality Assessment and Risk Management Consultant (QARMC). The QARMC stated he did not speak to ADM 1 regarding the incident of Resident 1 being tied with a bed sheet to her wheelchair. The QARMC stated he first heard about the incident two weeks ago when he heard an investigation was being done. The QARMC stated he was aware the staff was having problems with Resident 1?s behavior and he recommended they have an Interdisciplinary Team (IDT) Meeting. The QARMC stated the staff could then explain to the family the problem and get a recommendation from the physician. The QARMC stated he was only aware of an allegation regarding a resident being slapped. The QARMC stated again there was no discussion regarding a sheet being used as a restraint. The QARMC stated if a bed sheet was used as a restraint, it should be reported.
On October 4, 2017, the undated facility policy and procedure (P&P) titled, ?Abuse Program?, was reviewed. The P&P indicated, ?11. If the abuse is in violation of the mandated reporting requirement, as implemented effective July 1st, 2002,the incident shall be reported to the appropriate agencies as specified by local and federal law and regulations (i.e. DHS, Ombudsman, local police, and/or APS.?
Therefore it was determined the facility failed to report to CDPH, an incident involving Resident 1 when she was restrained with a bed sheet to her wheelchair. Failure to notify CDPH had the potential to place all the patients in the facility at risk for harm from physical abuse.
The above violation jointly, separately, or in any combination, had a direct or immediate relation to the health, safety, and security of patients. |
| 940000010 |
Bel Vista Healthcare Center |
940013691 |
B |
13-Dec-17 |
957T11 |
4310 |
F 226 ? 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,
? 483.95
(c) Abuse, neglect, and exploitation. In addition to the freedom from abuse, neglect, and exploitation requirements in ? 483.12, facilities must also provide training to their staff that at a minimum educates staff on-
(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at ? 483.12.
(c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property
(c)(3) Dementia management and resident abuse prevention.
The Department received an entity reported incident (ERI) on 8/25/17, two days after an alleged abuse of a resident (Resident 1) being slapped by the resident?s private caregiver
Based on interview and record review the facility failed:
1. To report to the Department of Public Health (DPH), within 24 hours, of an allegation of abuse towards Resident 1.
This deficient practice had the potential to put Resident 1 at risk for harm and other residents at risk for abuse.
On 9/5/17, an unannounced ERI investigation was conducted.
A review of Resident 1's Admission Record indicated the resident was a 86 year-old female admitted to the facility on 7/11/17 with diagnoses that included dementia (progressive memory loss), major depression (mental health disorder characterized by persistently depressed mood or loss of interest in activities), anxiety disorder (a mental health disorder characterized by feelings of worry or fear strong enough to interfere with one?s daily activities), and generalized muscle weakness.
A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 7/20/17, indicated Resident 1's cognition was severely impaired. The MDS indicated Resident 1 required an extensive one-person physical assist for all activities of daily living (ADLs).
During an interview, on 9/5/17, at 1:10 p.m., the Administrator stated during a resident council meeting, Resident 1's Roommate (Resident 2) informed the Activity Director (AD) that Resident 1's private caregiver slapped her during the night shift. The Administrator stated Resident 2 told her, she heard the slap, but the curtain was closed. The Administrator stated no one from the evening/night shift reported the incident to her.
During a telephone interview, on 9/5/17, at 1:45 p.m., CNA 2 indicated she saw Resident 1's Caregiver (CG 1) push Resident 1's head as she walked past her bed. When asked what she did, CNA 2 stated she told the Assistant Administrator about the incident when she returned back to work the following day. CNA 2 stated the incident happened on her first day of work, after being off, and could not believe what she saw. CNA 2 further stated any incidents of abuse should be reported immediately.
A review of CNA 1's Written Statement, dated and signed on 8/24/17, indicated CNA 1 saw CG 1 pushing Resident 1's head back.
A review of CNA 2's Written Statement, dated and signed on 8/25/17, indicated CNA 2 saw CG 1 roughly pushing Resident 1's head back on the bed to make her lay down.
A review of the Assistant Administrator's Written Statement, dated 8/26/17, indicated CG 1 stated she may have "accidentally" hit Resident 1 while slapping her hands away from her to prevent Resident 1 from biting her.
A review of the facility's policy and procedures titled, "Preventing Resident Abuse," dated 8/2011, indicated the facility encouraged all personnel, residents, family members, visitors, etc., to report any signs or suspected incidents of abuse to facility management immediately.
Based on interview and record review the facility failed to:
Follow its policy in notifying the Department of Public Health (DPH) timely, within 24 hours, of an allegation of caregiver abuse towards Resident 1.
The above violation had a direct relationship to the health, safety, or security of the residents in the facility. |
| 910000322 |
Beverly West Healthcare |
910013520 |
B |
28-Sep-17 |
ULTT11 |
7846 |
F-241
? CFR 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.
F-279
?CFR 483.21 (b) Comprehensive Care Plans 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.
(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.
On 8/17/17, an unannounced visit was made to the facility to investigate complaints regarding Quality of Life, Quality of Care, and Nursing Services.
Based on observation, interview, and record review, the facility failed to treat and care for each resident in a manner and in an environment that promotes maintenance of his or her quality of life recognizing each resident?s individuality and failed to implement the plan of care for Resident 1, including:
1. Failure to treat Resident 1 with dignity and respect when Certified Nursing Assistant 1 (CNA 1) lowered the head of the bed and repositioned Resident 1 in bed, without first communicating to Resident 1 the procedure.
2. Failure to provide care in an unhurried manner when opening and closing the privacy curtain around Resident 1.
3. Failure to prevent mistreatment of Resident 1, when Registered Nurse 1 (RN 1) did not direct CNA 1 to promote Resident 1?s self-esteem and self-worth.
4. Failure to implement Resident 1?s plan of care related to self-care deficit in bed mobility, by not encouraging Resident 1 to participate with turning and repositioning in bed.
5. Failure to implement Resident 1?s plan of care to speech problem by not speaking to Resident 1 clearly, making eye contact, encouraging use of nonverbal communication techniques, and using short questions that only require Yes or No answers.
As a result, on 8/17/17, at 8:30 a.m., Resident 1, who was sleeping, awoke startled and frightened (hands rose up in the air and his body slightly jolted forward) as CNA 1 lowered the head of the bed. Resident 1 was hit in the face and body when CNA 1 closed the privacy curtain. RN 1 did not stop further mistreatment of Resident 1 when she observed CNA 1 entering the room without announcing himself and started lowering Resident 1?s head of the bed.
On 8/17/17 at 8:29 a.m., while inside Resident 1?s room, accompanied by RN 1, CNA 1 was observed as he quickly walked inside the room without knocking on the door or announcing himself. Resident 1 was asleep in his bed and the head of the bed was at 30-45 degree angle and the resident was halfway down towards the bottom of the bed leaning on his right side, on the upper side rail. CNA 1 did not speak to Resident 1 or anyone else in the room. CNA 1, without awakening Resident 1, to communicate his intention, proceeded to elevate the head of the bed by using the bed adjustment level, located at the foot of the bed. Resident 1 woke up startled, and his hands rose up in the air and his body slightly jolted forward. CNA 1 then, pulled the privacy curtain fast and hard around Resident 1. CNA 1, without talking to Resident 1 repositioned him in bed, by pulling him up in a rushed manner. After CNA 1 repositioned Resident 1, without talking to the resident, CNA 1 pulled the privacy curtain back (open) in a fast manner and the fabric curtain hit Resident 1's face and body. CNA 1 exited the room without communicating with Resident 1. Resident 1 did not speak during the time CNA 1 was in the room or after CNA 1 left.
RN 1, who was with the Evaluator observing CNA 1 carrying out the activity, did not direct CNA 1 to not lower the bed without first awakening Resident 1 to explain the procedure and obtain permission to do it. RN 1 did not check on Resident 1 after the curtain hit his face and body and did not comfort Resident 1.
During an interview on 8/17/17 at 8:32 a.m., RN 1 stated CNA 1 should have communicated with Resident 1.
A review of the Admission Record indicated Resident 1 was admitted to the facility on 6/25/10 with diagnoses including Down syndrome (genetic disorder causing developmental and intellectual delays).
A Care Plan dated 7/9/16, developed for Resident 1's self-care deficit in bed mobility, included in the approaches assisting and encouraging Resident 1 with turning and repositioning in bed and allowing and encouraging Resident 1 to participate with activities of daily living (ADLs ? transfers, locomotion, eating, personal hygiene, and toilet use).
A Care Plan dated 7/13/17, developed for Resident 1's problem with speech due to weak or low voice, included in the approaches speaking to Resident 1 clearly, making eye contact, encouraging use of nonverbal communication techniques, and using short questions that only require Yes or No answers.
A review of the Minimum Data Set (MDS - standardized assessment and care planning tool) dated 7/13/17, indicated Resident 1's cognition (reasoning, knowledge) was severely impaired and was total dependent on staff for bed mobility, transfers, dressing, eating, toilet use and personal hygiene.
On 8/22/17 at 3:30 p.m., an interview was conducted with CNA 1, regarding his interaction with Resident 1, in the presence of the Director of Staff Development/ Assistant Administrator (DSD/AADM). CNA 1 made minimal eye contact during the interview and stated, "You people (the Evaluators) follow me and try to get me in trouble." CNA 1 did not acknowledge any wrongdoing.
On 8/25/17 at 5:09 p.m., during an interview regarding the observation on 8/17/17 of CNA 1 mistreatment of Resident 1, RN 1 acknowledged not counseling CNA 1.
The facility failed to treat and care for each resident in a manner and in an environment that promotes maintenance of his or her quality of life recognizing each resident?s individuality and failed to implement the plan of care for Resident 1, including:
1. Failure to treat Resident 1 with dignity and respect when CNA 1 lowered the head of the bed and repositioned Resident 1 in bed, without first communicating to Resident 1 the procedure.
2. Failure to provide care in an unhurried manner when opening and closing the privacy curtain around Resident 1.
3. Failure to prevent mistreatment of Resident 1, when RN 1 did not direct CNA 1 to promote Resident 1?s self-esteem and self-worth.
4. Failure to implement Resident 1?s plan of care related to self-care deficit in bed mobility, by not encouraging Resident 1 to participate with turning and repositioning in bed.
5. Failure to implement Resident 1?s plan of care to speech problem by not speaking to Resident 1 clearly, making eye contact, encouraging use of nonverbal communication techniques, and using short questions that only require Yes or No answers.
As a result, on 8/17/17, at 8:30 a.m., Resident 1, who was sleeping, awoke startled and frightened (hands rose up in the air and his body slightly jolted forward) as CNA 1 lowered the head of the bed. Resident 1 was hit in the face and body when CNA 1 closed the privacy curtain. RN 1 did not stop further mistreatment of Resident 1 when she observed CNA 1 entering the room without announcing himself and started lowering Resident 1?s head of the bed.
The above violation had direct or immediate relationship to the health, safety, or security of Resident 1. |
| 910000322 |
Beverly West Healthcare |
910013558 |
B |
20-Oct-17 |
ULTT11 |
6184 |
F226 ? 42 CFR ? 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.
?483.95(c) Abuse, neglect, and exploitation.
In addition to the freedom from abuse, neglect, and exploitation requirements in ? 483.12, facilities must also provide training to their staff that at a minimum educates staff on?
?483.95(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at ? 483.12.
Based on observation, interview, and record review, the facility failed to follow its abuse prevention policy by failing to:
1. Conduct background checks for employees prior to hire.
2. Report a certified nursing assistant (CNA 1) to the administrator for rough handling Resident 3.
This deficient practice had the potential to result on hiring staff with history of abuse, placing the residents at risk of been subject to abuse.
1. On 8/23/17 at 2:06 p.m., a review of the facility's policy and procedure on abuse prevention and a random review of employees' files were conducted with the Director of Staff Development (DSD), who was also Assistant Administrator (DSD/AADM).
A review of the facility's policy and procedure titled "Abuse Prevention Program," with a revised date of 8/2006, indicated that the residents had the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. The Abuse Prevention Program policy indicated that the facility was committed to protect the residents and that the facility conducted background checks and would not knowingly employ any individuals who had been convicted of abusing, neglecting, or mistreating individuals.
The following staff members were identified without background checks prior to hiring and this was confirmed by the DSD/AADM:
1. The facility's Administrator (ADM).
2. Four certified nursing assistants - CNA 1, CNA 2, CNA 3, CNA 4, and CNA 8.
3. Four Licensed Vocational Nurses (LVNs) - LVN 1, LVN 2, LVN 3, LVN 4.
A review of the facility's "Active Employees List," dated 8/23/17, indicated that 143 facility?s staff members did not have background checks.
On 8/23/17 at 2:10 p.m., the DSD/AADM stated the aforementioned staffs did not have background checks and the DSD/AADM could not explain the reason. The DSD/AADM stated that according to the facility?s policy all staff members were supposed to have background checks prior to being hired.
2. During an initial tour of the facility, on 8/17/17 at 8:29 a.m., with Registered Nurse 1 (RN 1), CNA 1 was observed to quickly walk inside Resident 3's room. Resident 3 was asleep in his bed
at a 30-45-degree angle halfway down towards the bottom of the bed, leaning to his right side on the upper side rail. The CNA 1 did not speak to Resident 3 or anyone else in the room. CNA 1, without awakening Resident 3 and explaining his intention, used the head and leg adjustment level of the bed, located at the foot of the bed, and proceeded to lower the head of the bed, causing Resident 3 to wake up startled, and his hands to rise up in the air and his body slightly jolting forward. CNA 1 then pulled the fabric privacy curtain fast and hard around Resident 3. The CNA 1 repositioned Resident 3 by pulling and tugging in a rushed manner. After CNA 1 repositioned Resident 3, without talking to the resident, CNA 1 pulled the privacy curtain back in a fast manner that the fabric curtain hit Resident 3's face. CNA 1 exited the room without communicating with Resident 3.
A record review of Resident 3's Admission Record indicated he was admitted on 6/25/10.
Resident 3's History and Physical (H&P) examination, dated 7/12/16, indicated the resident had diagnoses that included Down syndrome (mental and physical growth delay).
A review of Resident 3?s Minimum Data Set (MDS - standardized assessment and care planning tool), dated 7/13/17, indicated Resident 3's cognition (reasoning, knowledge) was severely impaired and was total dependent on staff for bed mobility, transfers, dressing, eating, toilet use and personal hygiene.
On 8/22/17 at 3:30 p.m., an interview was conducted with CNA 1, regarding his interaction with Resident 3, in the presence of the DSD/AADM. CNA 1 made minimal eye contact during the interview and stated, "You people (the evaluators) follow me and try to get me in trouble." CNA 1 did not acknowledge any wrongdoing.
On 8/25/17 at 5:09 p.m., during an interview with a registered nurse (RN 1) regarding the observation on 8/17/17 of CNA 1?s treatment of Resident 3, she stated CNA 1 slung the curtain to where it hit Resident 3's face and body, and CNA 1 did not communicate with Resident 3. RN 1 stated she was not okay with the incident, but acknowledged not reporting the incident to anyone or counseling CNA 1. RN 1 stated she believed the DSD/AADM already knew about it.
During an interview, on 8/25/17, at 5:15 p.m., the DSD/AADM indicated RN 1 did not make a report about CNA 1's treatment of Resident 3, within 24 hours as per facility's policy on abuse reporting.
A review of the facility's policy on Abuse Investigation, revised April 2014, indicated all reports of abuse shall be promptly and thoroughly investigated by the facility. Should an incident or mistreatment be reported, the Administrator or designee will appoint a member of management to investigate the alleged incident. The Administrator will provide results of all abuse investigation to the State within five working days as required by state law.
The facility failed to follow its abuse prevention policy by failing to:
1. Conduct background checks for employees prior to hire.
2. Report a certified nursing assistant (CNA 1) to the administrator for rough handling Resident 3.
The above violations had a direct or immediate relationship to the health, safety, or security of the residents. |
| 910000322 |
Beverly West Healthcare |
910013559 |
B |
20-Oct-17 |
ULTT11 |
8801 |
F495 ? 42 CFR ?483.35(d) Requirement for facility hiring and use of nurse aides
?483.35(d)(3) Minimum Competency
A facility must not use any individual who has worked less than 4 months as a nurse aide in that facility unless the individual?
(i) Is a full-time employee in a State-approved training and competency evaluation program;
(ii) Has demonstrated competence through satisfactory participation in a State- approved nurse aide training and competency evaluation program or competency evaluation program; or
(iii) Has been deemed or determined competent as provided in ?483.150(a) and (b).
F497 ? 42 CFR ?483.35(d)(7) Regular in-service education.
The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of ?483.95(g).
On 8/22/17 at 7 a.m., an unannounced visit to the facility was conducted to investigate a complaint regarding the certified nursing assistants (CNAs) competency and training.
Based on observation, interview, and record review, the facility failed to implement its policy and procedure by failing to:
1. Ensure two certified nursing assistants (CNAs 2 and 4) completed the nursing aide program prior to being hired and assigned to care for residents.
2. Ensure CNA 2 and 4 received a thorough competency evaluation to perform as nursing assistants and to train nursing aide students.
3. Ensure new CNAs received pertinent residents' care information before the beginning of the shift.
4. Evaluate the skills performance of CNA 1 and 8 yearly.
These deficient practices had the potential for the residents to receive inappropriate care.
a. During an observation, on 8/22/17 at 7:42 a.m., CNA 2 was walking fast. CNA 2 stated, during an interview, that she had eight residents assigned to her and she was not familiar with the residents' care. CNA 2 stated she did not receive enough information regarding the residents' conditions from the licensed nurses.
During an observation, on 8/22/17 at 8:15 a.m., Resident 7 was lying in bed awake and stated the licensed nurses did not teach the CNAs about her care and some of the CNAs did not know how to provide personal care. Resident 7 stated the administrator ignored her concerns.
A review of Resident 7?s Admission Record indicated Resident 7 was admitted to the facility on 12/6/16 and was readmitted on 2/7/17 with diagnoses including difficulty in walking and multiple sclerosis ([MS] a potentially disabling disease of the brain and spinal cord [central nervous system]).
A review of Resident 7?s Minimum Data Set (MDS - standardized assessment and care planning tool), dated 6/13/17, indicated Resident 7 was cognitively intact for decision making and was total dependent on staff for transfer requiring two or more staff and required extensive assist for personal hygiene.
During a telephone interview, on 8/24/17 at 8:08 a.m., CNA 4 stated she was a new CNA and the licensed nurses did not supervise her while providing care to Resident 1 on 8/19/17 along with two other nursing aide students. CNA 4 stated she did not pass the written portion of the State nursing assistant exam.
During a telephone interview, on 8/24/17 at 10 a.m., Licensed Vocational Nurse 8 (LVN 8) stated he was the charge nurse on 8/19/17 and he did not supervise CNA 4. LVN 8 stated that the ratio for the CNA and nursing aide student when the CNA was teaching the nursing aide student was supposed to be one CNA to one nursing aide student.
During a telephone interview, on 8/24/17 at 10:05 a.m., Registered Nurse 2 (RN 2) stated that she was the RN supervisor working on 8/19/17 and Family Member 1 complained that new CNAs (CNA 4) along with nursing aide students were providing care for Resident 1 without supervision from a licensed nurse. RN 2 stated she did not supervise CNA 4 or the nursing aide students because LVN 8 was supposed to be supervising the CNA 4 and the nursing aide students.
A review of Resident 1?s Admission Record, indicated Resident 1 was admitted to the facility on 7/10/15 and was readmitted on 2/24/16 with diagnoses of chronic kidney disease stage 3 (moderate kidney damage) and unspecified dementia (decline in mental ability severe enough to interfere with daily life).
A review of Resident 1?s MDS, dated 7/20/17, indicated Resident 1 was moderately impaired in cognitively (knowledge and reasoning) skills. The MDS indicated that Resident 1 required extensive assistance for bed mobility requiring one person to assist and was total dependent with transfers requiring two or more people to assist.
On 8/23/17, at 2:28 p.m., during a review of the personnel files of CNAs 2 and 4 with the Director of Staff Development/Assistant Administrator (DSD/AADM), there was no documentation CNA 2 and 4 completed the nursing aide program. The DSD/AADM stated she did not have any information to confirm CNA 2 and 4 were qualified to be working with the residents and stated, "I go by their word."
During an interview, on 8/23/17 at 2:40 p.m., the DSD/AADM stated CNA 4 did not have any other job experience and was assigned to care for Resident 1 on 8/19/17. The DSD/AADM did not know how many nursing assistant students were assigned to CNA 4 and did not know CNAs should only be paired with one nursing aide student.
During a telephone interview, on 8/24/17 at 10:12 a.m., the director of nursing (DON 2) stated CNA 4 and the nursing aide students needed to be supervised to ensure they were competent to provide care to residents.
A review of the facility's policy and procedure titled, "Nurse Aide Qualifications and Training Requirements," with a revised date of 9/2011, indicated that nurse aides must undergo a State-approved training program and that the facility required the individual to demonstrate competence through satisfactory participation in a state-approved nurse aide training competency evaluation program.
A review of the facility's Nurse Assistant Training Program (NATP) Clinical Site Agreement, dated 12/6/16, indicated that the facility staff was not to be used to proctor, shadow, or teach the training program students.
A review of the facility's undated RN Supervisor Job Description indicated that the facility required RNs to conduct rounds throughout the center to assure work performance of all center staff and to identify any problem areas.
A review of the facility's policy and procedure titled "Changes in Status, Personnel Records," with a revised date of January 2008, indicated that the facility should maintain organized, up to date personnel records under the direction of the Director of Staff Development.
b. During an observation, on 8/22/17 at 8:55 a.m., CNA 1 was giving personal hygiene to Resident 10. CNA 1 stated, "You want me to go by the book?" or "Do you want me to do it my way, because if I do it my way, you will report me."
During an interview, on 8/22/17, at 2:35 p.m., Licensed Vocational Nurse 4 (LVN 4) stated CNA 1 did not need supervision and stated CNA 1, "Knows what he is doing."
During an interview, on 8/22/17 at 3:06 p.m., the DSD/AADM stated CNA 1 was supposed to provide care his way.
During a review of CNA 1's employee file, on 8/23/17 at 2:06 p.m., the DSD/AADM stated CNA 1 did not have the yearly skills competency evaluation up to date and CNA 1 needed to have a current competency evaluation.
During a review of CNA 8's employee file, on 8/23/17 at 2:52 p.m., the DSD/AADM stated CNA 8 did not have the yearly skills evaluation up to date and CNA 8 needed to have a current skills evaluation. The DSD/AADM stated CNA 8 had one disciplinary action regarding alleged abuse.
A review of the undated facility's job description titled, "Staff Development, Director" indicated the facility required the DSD to conduct departmental performance evaluations in accordance with the facility's policies and procedures.
The facility failed to implement its policy and procedure by failing to:
1. Ensure two certified nursing assistants (CNAs 2 and 4) completed the nursing aide program prior to being hired and assigned to care for residents.
2. Ensure CNA 2 and 4 received a thorough competency evaluation to perform as nursing assistants and to train nursing aide students.
3. Ensure new CNAs received pertinent residents' care information before the beginning of the shift.
4. Evaluate the skills performance of CNA 1 and 8 yearly.
These deficient practices had the potential for the residents to receive inappropriate care.
The above violations had a direct or immediate relationship to the health, safety, or security of the residents. |
| 940000012 |
BRIARCREST NURSING CENTER |
940013518 |
A |
2-Oct-17 |
6G0K11 |
17829 |
F315
(?483.25(e) Incontinence
(1)The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.
(2) For a resident with urinary incontinence, based on the resident?s comprehensive assessment, the facility must ensure that?
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident?s clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident?s clinical condition demonstrates that catheterization is necessary and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.
(3) For a resident with fecal incontinence, based on the resident?s comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.
The Department received a complaint on 8/17/17 that alleged a resident (Resident 1) was not receiving adequate care resulting in bedsores and trauma to his penis.
The facility failed to provide residents with the necessary care and services ensure that residents who did not have a medical justification for an indwelling catheter (a tube inserted into the bladder via the urethra [a tube that transports urine from the bladder to the outside of the body]) was not catheterized, including but not limited to:
1. Failure to ensure Resident 2 was not catheterized unless clinically necessary.
2. Failure to ensure Residents 1, 2, and 3 receive the necessary care and services to prevent urinary tract infections (UTI), a disease caused by microorganisms that invade the tissue of the kidneys, bladder, or urethra.
3. Failure to ensure the catheter tubing were secure and stabilized to prevent trauma to the urethra/urinary meatus.
4. Failure to follow its policy regarding the care of urinary catheters.
5. Failure to implement the resident?s plan of care in caring for the indwelling urinary catheters.
Resident 1 had multiple UTIs (2/15/17, 3/21/17, 5/24/17, and 6/23/17), and trauma to the urinary meatus (the external urinary opening) of the posterior penile area due to staff inappropriately handling the catheter.
Resident 2 had no clinical indication to have an indwelling urinary catheter. The catheter bag was observe at the level of the bladder, with the potential for urinary backflow, without a stat lock device (a stabilization device) in place to hold the catheter in place.
Resident 3, who had an UTI on 7/6/17 and 8/5/17, was observe to have the indwelling urinary bag positioned above the resident's bladder during a wound care treatment observation.
These deficient practices resulted in Resident 1 developing a wound to the urinary meatus (the point where urine exits the urethra in males) of the penis. Residents 1 and 2 developed repeated UTIs with pain. Resident 1 required a transfer to a general acute care hospital (GACH) receiving antibiotics (drugs that kill bacteria), these frequent reoccurrences of UTI had the potential to lead to sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs) and death.
a. A review of Resident 1's Admission Record Face Sheet indicated the resident was a 54 year-old male who was originally admitted to the facility on 4/16/14, and last readmitted on 12/16/16. Resident 1's diagnoses included paraplegia (a medical condition involving impairment in motor or sensory function of the lower extremities), sepsis, UTI, and neuromuscular dysfunction of the bladder ([as neurogenic bladder], a dysfunction of the bladder due to disease of the central nervous system or peripheral nerves involved in the control of urination).
A review of Resident 1's History and Physical Examination (H/P), dated 12/19/16, indicated the resident had the capacity to understand and make decisions.
A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 6/28/17, indicated Resident 1 was able to report the correct year, month, and day of the week. The MDS indicated the resident's memory was intact, and had a clear comprehension of understanding others and had the ability to express needs and wants. The MDS indicated Resident 1 was totally dependent (full staff performance every time) with two or more staff for physical assistance with bed mobility and transferring between surfaces and a one-person physical assist with toilet use and bathing. The MDS indicated the resident had an indwelling urinary catheter and was always incontinent (inability to control) of bowel movements. The MDS indicated Resident 1 had moisture associated skin damage (MASD), and was receiving antibiotics during the last two days.
A review of Resident 1's wound assessment and the physician's progress note from the GACH, dated 12/13/16, and timed at 7 p.m., indicated the resident had a wound present on admission, to the posterior head of the resident's penis with dimensions size of 2 centimeters (cm) in length, 1.5 cm in width, and 0.2 cm in depth. The physician's progress note indicated the posterior head of the resident's penis had an eroded (gradually destroy) open area, secondary to the use of the indwelling urinary catheter. The progress note indicated the wound was red and moist, with full thickness tissue loss (actual depth is completely obscured) in the wound bed without no odor.
A review of Resident 1's Care Plan titled, "UTI Prevention/Indwelling Catheter," dated 12/16/16, indicated the resident was at risk for UTI. The care plan indicated the staff's interventions included to position the urine catheter bag below the resident's bladder and to provide good perineal (the area in front of the anus extending to vagina in female; and scrotum in the male) hygiene for comfort and skin management.
A review of Resident 1's Laboratory Report titled, "Urine Culture," (a test to find germs, such as bacteria, in the urine that can cause an infection). A collection dated 2/19/17, and timed at 12:50 p.m., 3/21/17, and timed at 1:35 p.m., 5/24/17 and timed at 5:03 a.m., and 6/23/17 and timed at 6:30 a.m., the resident's urine was positive for bacteria in the urine.
A review of Resident 1's Change of Condition (COC) record, dated 2/15/17, indicated the resident experienced burning sensation of the bladder with white sediment (abnormal cells matter that settles to the bottom of a liquid) in the indwelling urinary catheter.
A review of Resident 1's Medication Administration Record (MAR) for the month of February 2017, indicated the resident had an order to receive Ciprofloxacin (antibiotic) 500 milligrams (mg), orally twice a day, for 10 days for the burning sensation in the bladder from 2/16/17 to 2/20/17. The MAR indicated the resident had a diagnosis of UTI and Ceftriaxone, two grams (gm), was ordered to be given via intramuscular (into the muscle [IM)] via an injection), daily for 10 days (2/21/17 to 3/2/17).
A review of Resident 1's Transfer Record, dated 3/22/17 and timed at 10 a.m., indicated the resident was transferred to the GACH for UTI.
A review of Resident 1's MAR for the month of March 2017, indicated the resident received Nitrofurantoin (an antibiotic used to treat urinary tract infections) 100 mg one tablet orally twice a day for seven days (3/24/17 to 3/30/17) for the diagnosis of UTI.
A review of Resident 1's Laboratory Report titled, "Urinalysis," collection, dated 5/24/17 , and timed at 5:03 a.m., indicated the resident had many bacteria present with blood and Leukocyte Esterase (white blood cells in urine associated with infection) in the urine.
A review of Resident 1's COC record, dated 5/27/17 and timed at 3 p.m., indicated the resident had a UTI and had new physician's orders to receive Ciprofloxacin ([Cipro]an antibiotic) 500 mg orally, twice a day for ten days.
A review of Resident 1's Laboratory Report titled, "Urinalysis," collection dated, 6/23/17 and timed at 6:03 a.m., indicated the resident had few bacteria with blood and Leukocyte Esterase present in the urine.
A review of Resident 1's COC record, dated 6/27/17, and timed at 2:15 p.m., indicated the resident had a UTI, and had new orders to received Bactrim (sulfa antibiotic) one tablet, orally twice a day.
A review of Resident 1 physician's order, dated 7/19/17 and timed at 8 a.m. indicated an order to discontinue the indwelling urinary catheter "for now" for "indication."
On 8/22/17, at 8:10 a.m., during a concurrent observation and interview, Resident 1 stated the facility resident's UTIs could be prevented. Resident 1 stated the certified nursing assistants (CNAs) would turn and reposition him, without repositioning the indwelling urinary catheter, which resulted in trauma from the catheter tubing pulling and injuring the urinary meatus of the penis. Resident 1 stated in the beginning, he would not feel the pain because of the trauma to the penis due to the lack of sensation to the lower half of the resident's body (paraplegia).
On 8/22/17, at 9:22 a.m., during a telephone interview, Resident 1's family member (FM 1), stated Resident 1 initially did not feel the sensation of the urinary meatus splitting, but FM 1 stated the staff would forcefully re-insert the indwelling urinary catheter, which resulted in the meatus ripping and becoming worse.
On 8/22/17, at 11:50 a.m., during an observation, with CNA 1, Resident 1's urinary meatus was observed split in the middle after CNA 1 retracted (draw or be drawn back or back in) the resident's penis.
On 8/23/17, at 8:55 a.m., CNA 2 stated Resident 1 told her several times that the resident's indwelling urinary catheter was pulling at the urinary meatus. CNA 2 also stated per Resident 1, the facility's nurses would also try to reinsert the indwelling urinary catheter multiple times, unsuccessfully, causing trauma to the posterior head of the penile area.
b. A review of Resident 2's Admission Record Face Sheet indicated the resident was a 66 year-old male who was admitted to the facility on 8/5/17. Resident 2's diagnoses included UTI, chronic kidney disease (progressive loss in kidney function over a period of months or years), and benign prostatic hyperplasia ([BPH] enlargement of the prostate) with lower urinary tract symptoms.
A review of Resident 2's H/P, dated 8/6/17, and timed at 5:18 p.m., indicated the resident was alert and had the capacity to understand and make decisions. The H/P indicated the resident recognized and recalled daily routine, and people without prompts or repetition to self.
A review of Resident 2's note signed by the Nurse Practitioner (NP), dated 8/17/17 and timed at 4:44 p.m., indicated the resident had a UTI while in the GACH. The Progress Note indicated the resident had an indwelling urinary catheter and requested to keep the catheter inserted until discharged home. The Progress Note indicated the resident informed the NP that he would urinate on himself, and that frequent changing would "burden the CNAs" and affect the resident's skin. According to the NP's Progress Note, Resident 1 required minimal assistance for transferring and was able to stand with maximum assistance of a two-person assist.
A review of Resident 2's Care Plan titled, "Foley Catheter," dated 8/5/17, indicated staff's interventions included to position the urinary catheter bag and tubing below the level of the bladder and keep away from the entrance room door.
On 8/22/17 at 10:38 a.m., during an observation and interview, Resident 2 was observed lying supine (face up) in bed with the urinary drainage bag at the level of the resident's bladder. The urinary drainage bag was placed on top of the middle of the resident's bariatric (large bed to accommodate larger residents) bed frame, at the foot of the resident. CNA 3 stated the urinary drainage bag was resting on the foot of the bed frame because the resident had an oversized mattress that did not have an area on the side rails to hang the urinary drainage bag below the resident's bladder. Resident 2 stated that sometimes the staff was able to hook the urinary drainage bag at the bottom of the middle of the bed frame to keep it lower than the bladder. Resident 2 was observed without a leg strap to secure the catheter tubing to prevent trauma and secure the tubing. Resident 2 stated he never had anything used to secure his catheter tubing.
On 8/22/17 at 4:11 p.m., during an interview, CNA 5 stated the urinary drainage bag should never be placed on the resident's bed, and should hang low on the sides of the resident's bed frame, always below the resident's bladder at all times.
At 4:20 p.m., on 8/22/17, during an interview, Resident 2 stated sometimes during repositioning and transferring from the bed to chair and/or vice versa, the staff would cause the urinary catheter to pull on his urinary meatus resulting in pain.
c. A review of Resident 3's Admission Record Face Sheet indicated the resident was a 69 year-old female who was originally admitted to the facility on 9/30/13, and last readmitted on 1/24/17. Resident 3's diagnoses included a Stage IV sacral pressure ulcer (a wound which extends into the underlying bone and muscle), and quadriplegia (paralysis of all four limbs; motor and/or sensory function).
A review of Resident 3's H/P, dated 1/25/17, indicated the resident did not have the capacity to understand and make decisions.
A review of Resident 3's MDS, dated 7/10/17, indicated Resident 3 had memory problems with severe impairment in cognitive skills for daily decision-making. The MDS indicated the resident was totally dependent on two or more staff for physical assistance with bed mobility and transferring. The MDS indicated Resident 3 required assistance from one staff with eating, toilet use, and personal hygiene. The MDS indicated Resident 3 had impairment on both sides of the lower and upper extremity, had an indwelling urinary catheter, and was always incontinent of bowel.
A review of Resident 3's COC record, dated 7/6/17, and timed at 5:30 p.m., indicated the resident had dark colored foul smelling urine.
A review of Resident 3's physician's order, dated 7/6/17 and timed at 5:30 p.m., indicated to administer Ciprofloxacin (an antibiotic) 500 mg, twice a day for 10 days, via the gastrostomy tube ([G-tube] a feeding tube placed through the abdomen into the stomach to deliver nutrition and medications), for the diagnosis of UTI.
A review of Resident 3's Nursing Note, dated 8/5/17, and timed at 12:56 p.m., indicated the resident had moderate hematuria (blood in the urine).
A review of Resident 3 physician's order, dated 8/5/17 at 12:30 p.m., indicated to administer Macrobid (an antibiotic that treats and prevents UTI), 100 mg, one tablet, via gastrostomy tube, twice a day for 10 days, for the diagnosis of UTI.
A review of Resident 3's Care Plan titled "UTI Prevention/Indwelling Catheter," dated 1/24/17, indicated the resident was at risk for UTI due to advanced age, history of UTI, and an indwelling urinary catheter use. The Care Plan indicated the staff's plan of approach included to position the urinary bag below the level of the resident's bladder at all times.
On 8/22/17, at 1:59 p.m., during an interview, CNA 6 verified she placed Resident 3's urinary bag on top of the resident's bed between the resident's legs during the wound care treatment, and that was incorrect. CNA6 stated the urinary bag should have been placed on the side of the bed in a low position.
A review of the facility's Policy and Procedure titled, "Catheter Care, Urinary," revision dated 10/2010, indicated to maintain an unobstructed urine flow by ensuring the urinary drainage bag be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. The policy and procedure indicated to ensure the catheter remained secured with a leg strap to reduce friction and movement at the insertion site (catheter tubing should be strapped to the resident's inner thigh).
The facility failed to provide residents with the necessary care and services ensure that residents who did not have a medical justification for an indwelling catheter (a tube inserted into the bladder via the urethra [a tube that transports urine from the bladder to the outside of the body]) was not catheterized, including but not limited to:
1. Failure to ensure Resident 2 was not catheterized unless clinically necessary.
2. Failure to ensure Residents 1, 2, and 3 receive the necessary care and services to prevent urinary tract infections (UTI), a disease caused by microorganisms that invade the tissue of the kidneys, bladder, or urethra/urinary meatus.
3. Failure to ensure the catheter tubing were secure and stabilized to prevent trauma to the urethra.
4. Failure to follow its policy regarding the care of urinary catheters.
5. Failure to implement the resident?s plan of care in caring for the indwelling urinary catheters.
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. |
| 920000310 |
Brookdale Northridge |
920013490 |
A |
29-Sep-17 |
OJBN11 |
16735 |
F309
? 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.
F-327
? 483.25(g) 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?
(2) Is offered sufficient fluid intake to maintain proper hydration and health;
On August 22, 2017, during an unannounced recertification visit, a review of Resident 1?s clinical record was conducted.
Based on observation, interview, and record review, the Department determined the facility failed to provide its residents with treatment and care in accordance with the comprehensive assessment, professional standards of practice, the comprehensive person-centered care plan, and the residents? choices, and failed to ensure its residents are provided with assisted hydration and are offered sufficient fluids to maintain proper hydration and health, including:
1. Failure to ensure Resident 1, who had a history of dehydration (a fluid imbalance caused by too little fluid taken in or too much fluid lost or both) and acute renal failure (occurs when your kidneys suddenly become unable to filter waste products from your blood), was monitored for fluid intake during breakfast, lunch, and dinner, as the physician had ordered.
2. Failure to follow the facility?s policy on Food and Mealtime Preferences - Meal service/Food Preferences, by not offering Resident 1?s fluid of preference.
3. Failure to follow the facility?s policy on Resident Hydration and Prevention of Dehydration, by not document Resident 1's fluid intake to ensure the resident consumed sufficient fluid as indicated in the facility's policy.
4. Failure to follow the recommendation from the Registered Dietitian (RD) to provide Resident 1?s minimum fluid needed.
5. Failure to develop a comprehensive care plan addressing Resident 1's hydration and fluids needs.
As a result, on August 24, 2017, Resident 1 was transferred to a General Acute Care Hospital (GACH) where she received hydration and antibiotic therapy to treat a urinary tract infection (UTI- an infection in any part of the urinary system, the kidneys, bladder or urethra) and manage her hypernatremia (elevated sodium in the blood) and acute kidney injury (an abrupt decrease in kidney function).
According to the Admission Record, Resident 1 was admitted to the facility from a GACH on April 28, 2017, with diagnoses including muscle weakness and dysphasia (difficulty swallowing).
A review of Resident 1's History and Physical (H&P) examination report completed at the GACH on April 21, 2017, indicated the clinical impressions included dehydration, renal failure, and hypernatremia.
A review of a GACH Consultation Report dated April 21, 2017, indicated Resident 1 was admitted with severe dehydration. The physician's impression included acute renal failure due to volume depletion (reduction), not drinking enough fluids and hypernatremia due to volume depletion.
A review of Resident 1's H&P examination report from the facility dated April 29, 2017, indicated the resident was confused, was not responding to verbal stimulus, and the diagnoses included dehydration, hypernatremia, and renal failure.
A review of the Physician's Orders dated April 29, 2017, included the following:
1. Pureed diet, nectar liquids consistency.
2. Monitor fluid intake, 640 milliliters (ml) for breakfast, lunch, and dinner for dehydration prevention.
3. Health Shake with lunch and dinner.
A review of the Minimum Data Set (MDS - standardized assessment and care planning tool) dated May 5, 2017, indicated Resident 1 usually understood others and made her-self understood, required extensive one-person physical assistance with transfer, eating, and toilet use, was receiving a mechanically altered diet (required change in texture of food or liquids).
A review of the care plans indicated no documentation of a care plan developed addressing Resident 1's fluid order to provide the resident with 640 ml each meal. This was confirmed on August 23, 2017 at 9:20 a.m. by the Director of Nursing (DON).
A review of the Nutritional Risk Assessment dated May 4, 2017, completed by the RD, indicated Resident 1 had an estimated daily fluid needs of 2,318 milliliters (ml) in 24 hours.
A review of Resident 1's laboratory results dated May 30, 2017, indicated the following:
1. BUN (blood urea nitrogen - a test that measures the amount of nitrogen waste in the blood) 14 milligram per deciliter (mg/dl) within the reference range 7-25 mg/dl.
2. Creatinine (Cr) 0.75 mg/dl, within the reference range 0.60-1.20 mg/dl.
3. Sodium (NA-salt) of 144 milliequivalent per liter (mEq/L), within the reference range 136-145 mEq/L.
4. Potassium (K) of 4.0 mEq/L, within the reference range 3.5-5.1 mEq/L.
5. BUN/Cr ratio of 18.7 within the reference range 10.0-20.0.
6. Estimated glomerular filtration rate (eGFR) of 73 mL/min/1.73m2, reference range equal or greater than 60. An eGFR is a test to measure the level of kidney function and determine the stage of kidney disease.
On August 22, 2017, at 12 p.m., an observation of Resident 1's meal card indicated the following meal preferences: health shake with meal (4 ounces-oz. or 120 ml.), 8 oz. of milk nectar thick (240 ml), and four oz. of orange juice nectar thick (120 ml), for a total of 480 ml. The meal card did not include the ordered 640 ml per meal.
On August 22, 2017 from 12:05 p.m. to 12:40 p.m., during a dining observation in the presence of the Dietary Services Supervisor (DSS), Resident 1 was sitting in her wheelchair at a dining table and was sleeping at times. The meal tray contained 120 ml of apple juice (not the preferred orange juice written in the meal card). Resident 1 did not receive the 640 ml ordered. The health shake (120 ml) and the thickened milk (240 ml) were not served during lunch. The resident was not served 640 ml fluid intake during lunch as the physician's order indicated. Resident 1 did not eat her lunch meal.
Resident 1 was provided 4 oz. of apple juice, instead of the resident's preference to have orange juice. The physician order indicated to monitor 640 ml fluid intake during lunch but Resident 1 refused to eat her meal.
On August 22, 2017 at 12:40 p.m., during an interview, the DSS stated fluid preferences should be provided with meals. The DSS also stated the nectar thick milk, the orange juice and the health shake should have been provided to Resident 1, as indicated on the tray card.
A review of the meal intake report for August 22, 2017, indicated Resident 1 consumed 51 percent (%) to 75 % of her lunch meal, but Resident 1 was observed not to eat her lunch. There was no documentation of the amount of fluid the resident consumed.
A review of the Medication Administration Record (MAR) for August 2017, indicated by a checkmark, Resident 1 was monitored for 640 ml of fluid intake for breakfast, lunch, and dinner. The licensed nurses checked the MAR for the 640 ml each meal without specifying the actual amount of fluid the resident consumed to ensure her fluid/hydration needs were met.
On August 23, 2017 at 9:20 a.m., during an interview and concurrent record review, the DON stated the physician's order to monitor Resident 1's intake of 640 ml of fluid for breakfast, lunch, and dinner was not communicated to the dietary services to provide 640 ml of fluids to Resident 1 and to reflect this order on the meal card and to be served on the meal tray. The DON reviewed Resident 1's MAR and nursing notes and stated she could not determine how much fluid Resident 1 consumed during breakfast, lunch, and dinner. The DON stated a care plan addressing hydration/dehydration was not developed because the nursing staff did not accurately process the physician's order. The DON stated the licensed nurses did not monitor the resident's consumption of fluids.
On August 23, 2017 at 10:05 a.m., during an interview, the DSS stated the facility was using the point system to determine the amount of food consumed. The DSS stated she observed Resident 1 ate about 25 percent or less of her lunch meal on August 22, 2017.
On August 23, 2017 at 10:25 a.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 had variable fluid intake. LVN 1 reviewed Resident 1's MAR for the month of August 2017 and was unable to determine how much fluid Resident 1 consumed during breakfast, lunch, and/or dinner. LVN 1 stated she monitored Resident 1's fluid intake by adding the resident's fluid intake from breakfast, snacks, medications, and fluids offered during shift. LVN 1 was unable to provide documented evidence of monitoring the resident's fluid intake to ensure the specific amount of fluid ordered by the physician, was consumed, during her shift.
A review of the documentation by the Certified Nursing Assistants (CNAs) for the month of August 2017 indicated the amount of fluid Resident 1 consumed was not included.
A review of Resident 1's meal intake report, indicated the resident refused dinner five evenings from August 15, 2017 to August 22, 2017.
On August 23, 2017 at 11:05 a.m., during an interview, Medical Record staff 1 (MR 1) stated she reviewed Resident 1's CNAs documentation and could not find a specific amount of fluid entered in the record by the CNAs.
On August 23, 2017 from 12:10 p.m. to 12:34 p.m., during dining observation, Resident 1 did not consume the milk nectar (240 ml) or orange juice (120 ml). Resident 1 consumed less than 25 percent of the health shake (120 ml).
On August 23, 2017 at 1 p.m., during an interview, Restorative Nursing Assistant 1 (RNA 1) stated Resident 1 refused to eat breakfast and lunch on the same day and she notified LVN 1.
On August 24, 2017 at 7:30 a.m., during an interview, the DON stated Resident 1 was transferred to the GACH on August 24, 2017 at 1:26 a.m. for further evaluation due to abnormal laboratory results.
A review of Resident 1's laboratory results dated August 24, 2017 and timed 12:58 a.m., indicated the following:
1. BUN of 44 mg/dl (above the reference range 7-25 mg/dl).
2. Creatinine of 1.59 mg/dl (above the reference range 0.60-1.20 mg/dl).
3. Sodium of 156 mEq/L (above the reference range 136-145 mEq/L).
4. Potassium of 5.3 mEq/L (above the reference range 3.5-5.1 mEq/L).
5. BUN/Cr ratio of 27.7 (above the reference range of 10.0-20.0). A BUN/CR ratio greater than 20 is an indicator for impending dehydration (American Journal of Nursing June 2006, Volume 106, Number 6, and Page 47).
6. eGFR of 31 (below the reference of equal or greater than 60, a range of 30 to 59 indicates moderately reduced kidney function).
There are laboratory values that may indicate signs of dehydration: Elevated BUN, (reference range 5-20 mg/dL) when the body is dehydrated the kidneys will reabsorb water to compensate the loss; with water, BUN is also reabsorbed passively in the kidney tubules thus increasing the BUN level. When fluid volume is diminished - as it is during dehydration - the renal tubules increase their re-absorption of waste, which in turn increases the re-absorption of urea (a substance normally cleared from the blood by the kidney into the urine). The result is an increased BUN. Elevated sodium may support dehydration, as sodium is retained to conserve water. (AJN May 1999- Vol. 99-Issue 5 PP 66-69).
Water depletion (reduced quantity) in the elderly is characterized by hypernatremia. (Journal of National Medical Association, 1987- Vol. 79-Issue 10 PP 1033-1038).
Dehydration is a condition in which the total body's fluids (intra and extra vascular) volume is reduced or depleted due to several causes including insufficient fluid consumption. The clinical signs of dehydration included fever and altered level of consciousness. Delayed treatment or delayed hydration may lead to acute renal failure, which is a sudden decrease in renal function which, if uncorrected, can lead, to irreversible tubular necrosis (AJN May 1999, Vol. 99, Issue 5, Pp. 66 - 69).
On August 24, 2017 at 8:45 a.m., during an interview, Resident 1's family member (FM 1) stated Resident 1 had been slowly declining for a week and a half. FM 1 stated Resident 1 had become less talkative and had a decreased appetite.
On August 24, 2017 at 11:05 a.m., during an interview, the RD stated if the fluids (health shake, milk nectar, and orange juice) were not on the resident's meal tray and the meal intake documentation was inaccurate, it was possible Resident 1 was not meeting her estimated fluid intake needs.
A review of the GACH Emergency Room report dated August 24, 2017, indicated Resident 1 was in serious condition and was to be admitted to the telemetry unit (a hospital unit with patients under continuous electronic monitoring). The diagnosis included severe sepsis (a potentially life-threatening complication of an infection that occurs when chemicals released into the bloodstream to fight the infection trigger inflammatory responses throughout the body) secondary to complicated UTI, hypernatremia, and acute kidney injury.
A review of the MAR from the GACH, indicated Resident 1 received 2500 ml bolus (rapid infusion) of normal saline on August 24, 2017 from 2:30 a.m. to 5:35 a.m. in the Emergency Department and 9000 ml of fluids (0.45 percent normal saline with 20 mEq/L potassium chloride at 75 ml per hour) from August 26, 2017 to August 31, 2017.
A review of the facility's revised policy and procedure dated December 2011, titled "Resident Hydration and Prevention of Dehydration" indicated the facility will endeavor to provide adequate hydration and to prevent and treat dehydration. Minimum fluid needs will be calculated and documented on initial, annual, and significant change assessments, using current standard of practice. The dietitian will include resident preference in distribution of allowed fluid. Nursing will assess for signs and symptoms of dehydration during daily care. Nurses' aides will provide and encourage intake of bedside, snack, and meal fluids, on a daily and routine basis as part of daily care. Intake will be documented in the medical records. Aides will report intake of less than 1200 ml/day to nursing staff. If potential inadequate intake and/or signs and symptoms of dehydration are observed, intake and output monitoring will be initiated and incorporated into the care plan.
A review of the facility's revised policy and procedure dated February 2017, titled "Food and Mealtime Preferences-Meal service/ Food Preferences" indicated that food and meal preference information is gathered from the residents for use in meeting their personal tastes and nutritional needs.
The facility failed to provide its residents with treatment and care in accordance with the comprehensive assessment, professional standards of practice, the comprehensive person-centered care plan, and the residents? choices, and failed to ensure its residents are provided with assisted hydration and are offered sufficient fluids to maintain proper hydration and health, including:
1. Failure to ensure Resident 1, who had a history of dehydration and acute renal failure, was monitored for fluid intake during breakfast, lunch, and dinner, as the physician had ordered.
2. Failure to follow the facility?s policy on Food and Mealtime Preferences - Meal service/Food Preferences, by not offering Resident 1?s fluid of preference.
3. Failure to follow the facility?s policy on Resident Hydration and Prevention of Dehydration, by not document Resident 1's fluid intake to ensure the resident consumed sufficient fluid as indicated in the facility's policy.
4. Failure to follow the recommendation from the RD to provide Resident 1?s minimum fluid needed.
5. Failure to develop a comprehensive care plan addressing Resident 1's hydration and fluids needs.
As a result, on August 24, 2017, Resident 1 was transferred to a GACH where she received hydration and antibiotic therapy to treat a urinary tract infection (UTI) and manage her hypernatremia and acute kidney injury.
The above violation presented a substantial probability that serious physical harm would result to Resident 1. |